Does BRIARCREST NURSING CENTER have any serious inspection findings?

Yes, BRIARCREST NURSING CENTER has 6 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 106 total deficiencies from recent inspections.

What are the staffing levels at BRIARCREST NURSING CENTER?

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

Where is BRIARCREST NURSING CENTER located?

BRIARCREST NURSING CENTER is located in BELL GARDENS, CA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does BRIARCREST NURSING CENTER have?

BRIARCREST NURSING CENTER has 135 certified beds.

Who owns BRIARCREST NURSING CENTER?

BRIARCREST NURSING CENTER is a for profit - partnership facility and is part of the CAMBRIDGE HEALTHCARE SERVICES chain.

What questions should families ask when visiting BRIARCREST NURSING CENTER?

Families visiting BRIARCREST NURSING CENTER 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 BRIARCREST NURSING CENTER compare to other nursing homes?

BRIARCREST NURSING CENTER 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.

BRIARCREST NURSING CENTER

Name: BRIARCREST NURSING CENTER
Address: 5648 EAST GOTHAM STREET, BELL GARDENS, CA, 90201, US
Telephone: (562) 927-2641
Rating: 1.0

5648 EAST GOTHAM STREET, BELL GARDENS, CA 90201 · (562) 927-2641

For profit - Partnership 135 Beds CAMBRIDGE HEALTHCARE SERVICES Data: November 2025 6 Immediate Jeopardy citations

Trust Grade

0/100

#988 of 1155 in CA

Share this report:

BRIARCREST NURSING CENTER nursing home in BELL GARDENS, CA - Photo 1 of 3

BRIARCREST NURSING CENTER nursing home in BELL GARDENS, CA - Photo 2 of 3

Photo by thomas Penn

View 360° on Google Maps

Last Inspection: March 2025

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

Overview

Briarcrest Nursing Center has received a Trust Grade of F, indicating significant concerns about its quality of care. It ranks #988 out of 1155 facilities in California, placing it in the bottom half of all nursing homes in the state, and #280 out of 369 in Los Angeles County, meaning only a few local options are better. While the facility's trend is improving, with issues decreasing from 36 in 2024 to 24 in 2025, it still faces serious challenges, including $102,711 in fines, which is higher than 87% of California facilities. Staffing is a relative strength, with a turnover rate of 27%, well below the state average, but the overall staffing rating is below average at 2 out of 5 stars. Recent inspections revealed critical issues, such as failing to maintain safe room temperatures for residents and not implementing proper infection control measures, which could put residents' health at risk.

Trust Score: F
In California: #988/1155
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 27% annual turnover. Excellent stability, 21 points below California's 48% average. Staff who stay learn residents' needs.
Penalties: $102,711 in fines. Lower than most California facilities. Relatively clean record.
Skilled Nurses: Each resident gets 32 minutes of Registered Nurse (RN) attention daily — about average for California. RNs are the most trained staff who monitor for health changes.
Violations: 106 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★★★★☆

4.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 36 issues

2025: 24 issues

The Good

4-Star Quality Measures · Strong clinical quality outcomes
Low Staff Turnover (27%) · Staff stability means consistent care
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover is low (27%)
21 points below California average of 48%

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

The Bad

1-Star Overall Rating

Below California average (3.1)

Significant quality concerns identified by CMS

Federal Fines: $102,711

Well above median ($33,413)

Significant penalties indicating serious issues

Chain: CAMBRIDGE HEALTHCARE SERVICES

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 106 deficiencies on record

6 life-threatening 2 actual harm

Aug 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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the facility's medical records were complete and accurately documented for one of two sampled residents (Resident 2) by not ensuring licensed nurses1. Documented the number of behavioral episodes on the Medication Administration record (MAR);2. Monitored Resident 2 for behavioral episodes (period or event marked by unusual, disruptive, or problematic behavior);3. Had the knowledge to complete monitoring section in the MAR; and4. Licensed nurses documented Resident 2' s return to the facility.These deficient findings could potentially place other residents in the facility at risk to Resident 2's behavioral episodes. These deficient findings created miscommunication on when and at what time Resident 2 returned to the facility.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE]. Resident 2's diagnosis included schizophrenia (a mental illness that is characterized by disturbances in thought) and anxiety (intense, excessive and persistent worry and fear about everyday situations).During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 5/24/2025, the MDS indicated Resident 2's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 2 required moderate assistance (helper does less than half) with oral hygiene, toileting hygiene, lower body dressing and putting on/taking off shoes. The MDS indicated Resident 2 required maximal assistance (helper does more than half the effort) with shower/bathing and personal hygiene.During a review of Resident 2's H&P dated 8/8/2025, the H&P indicated Resident 2 could make needs known but could not make medical decisions.During a review of Resident 2's Order Summary Report dated 8/8/2025, the order summary report indicated Resident 2 had an order for quetiapine (helps regulate mood, behavior and thoughts) oral tablet 100 milligrams (mg- metric unit of measurement), one tablet at bedtime for manic (mental state of an extreme highs or depressive lows) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs).During a review of Resident 2's Medication Administration record (MAR), dated 8/7/2025, the MAR indicated there was an order to monitor Resident 2 for agitation and aggressive behavior every shift for use of quetiapine. The MAR indicated for the shifts of 8/8/2025 from 7 a.m. to 3 p.m. and 3 p.m. to 11 p.m., and for 8/9/2025 from 7 a.m. to 3 p.m., the monitoring for those shifts was not done.During a review of Resident 2's Nursing Progress notes, dated 8/10/2025 at 10:58 p.m., Progress Note indicated Resident 2 displayed mild agitation.During a review of Resident 2's MAR, dated 8/9/2025, the MAR indicated there was an order to monitor Resident 2 for extreme mood swings with intense irritability for the use of quetiapine. The MAR indicated on 8/10/2025, Resident 2 did not display any behavioral episodes (period or event marked by unusual, disruptive, or problematic behavior). The MAR indicated on 8/11/2025 from 7 a.m. to 3 p.m., the word yes was documented under number of episodes of behavior. The MAR indicated for 8/11/2025 from 3 p.m. to 11 p.m., the behavioral monitoring for that shift was not done.During a review of Resident 2's MAR, dated 8/11/2025, the MAR indicated there was an order to monitor Resident 2 every shift for screaming and yelling for the use of quetiapine. The MAR indicated for 8/11/2025 from 3 p.m. to 11 p.m., the behavioral monitoring for that shift was not done. The MAR indicated on 8/12/2025 from 3 p.m. to 11 p.m., the letter n was documented under number of episodes of behavior.During a review of Resident 2's Nursing Progress notes, dated 8/11/2025 at 6:45 p.m., the Progress Note indicated Resident 2 displayed frustration regarding smoking break policy. The nursing progress note indicated Resident 2 became argumentative with staff. The nursing progress notes indicated Resident 2 voiced concerns in an elevated tone.During a review of Resident 2's Nursing Progress notes, dated 8/11/2025 at 9:15 p.m., Progress Notes indicated Resident 2 became hostile, raised his voice and said demeaning comments to staff.During a review of Resident 2's Order Summary Report dated 8/11/2025, the order summary report indicated Resident 2 had an order for Ativan (slows the activity of the brain and nerves) oral tablet 0.5 mg, every six hours as needed for anxiety.During a review of Resident 2's MAR, dated 8/11/2025 at 4:21 p.m., MAR indicated there was an order to monitor Resident 2 every shift for anxiety manifested by restlessness and agitation while using Ativan. The MAR indicated on 8/11/2025 from 3 p.m. to 11 p.m., behavioral monitoring was not done. The MAR indicated on 8/12/2025 from 7 a.m. to 3 p.m., Resident 2 had two behavioral episodes, and indicated No for behavioral episodes.During a review of Resident 2's Nursing Progress notes, dated 8/12/2025 at 11:30 a.m., Progress Notes indicated Resident 2 had a physical altercation with another resident.During a review of Resident 2's medical record, Resident 2's progress note indicating Resident 2 returned to the facility after leaving the facility was not located.During a concurrent interview and record review on 8/19/2025 at 3:26 p.m. with the Director of Nursing (DON), Resident 2's Medication Administration Record (MAR), dated August 2025 was reviewed. The MAR indicated on 8/8/2025, 8/9/2025, and 8/11/2025 monitoring for behavioral episodes was not performed. The DON stated Resident 2 should have been monitored on those days. The DON stated it was important for residents to get monitored because it was important to know if the medication was working. The DON stated residents must be monitored to inform their doctors if there was a change in their behavior.During a concurrent interview and record review on 8/19/2025 at 3:44 p.m. with the DON, Resident 2's MAR, dated August 2025, was reviewed. The MAR indicated on 8/11/2025 and 8/12/2025 licensed nurses did not accurately document the number of behavioral episodes on the MAR. The DON stated licensed staff must document the number of behavioral episodes and not write the word yes or the letter n. The DON stated if the numbers of episodes were not documented, there was no way of knowing how often the behavioral episodes occurred.During a concurrent interview and record review on 8/19/2025 at 4:00 p.m. with the DON, Resident 2's Nursing progress notes, dated 8/8/2025, were reviewed. The progress notes indicated licensed nurses did not document Resident 2's return to the facility. The DON stated licensed nurses must document when residents return to the facility to set a baseline as to how a resident entered the facility. The DON stated looking at the progress notes there was no way of knowing when Resident 2 returned to the facility. The DON stated licensed nurses must document resident's whereabouts because it served as communication for other licensed nurses.During a review of facility's Policy and Procedures (P&P) titled admission Notes dated 9/2012, the P&P indicated residents' information would be documented upon resident's admission to the facility.During a review of facility's P&P titled Charting and Documentation dated 7/2017, the P&P indicated it was the facility's policy for all services provided to the resident, any changes in resident's medical, physical, functional or psychosocial condition shall be documented in residents' medical record. The P&P indicated documentation in the medical record would be objective (not opinionated or speculative), complete, and accurate/During a review of facility's P&P titled Antipsychotic Medication Use dated 7/2022, the P&P indicated staff would gather and document information to a clarify a resident' s behavior, mood, function, medical condition, specific symptoms, and risks to the resident and others.

Aug 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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop an individualized resident care plan for one of six sampled residents (Resident 1), who had a diagnosis of dementia (a progressive state of decline in mental abilities).This deficient practice had potential to result in the nurses not being able to provide quality care and could affect in maintaining the highest practicable physical, mental and psychosocial well-being of the resident. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including unspecified dementia (a progressive state of decline in mental abilities,) epilepsy (a neurological disorder characterized by recurrent seizures, which are caused by abnormal electrical activity in the brain,) generalized anxiety disorder (excessive, ongoing anxiety and worry that are difficult to control and interfere with day-to-day activities.)During a review of Resident 1's History and Physical (H&P) dated 6/27/2025, the H&P indicated Resident 1 had fluctuating mental capacity to understand and make medical decisions.During a review of Residents 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/16/2025, the MDS indicated Resident 1 was maximal assistance with staff with activities of daily living (ADL) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side).During a review of Resident 1's Psychiatric notes, dated 6/20/2025, the psychiatric notes indicated Resident 1's affect (an observable and outward expression of emotions) was blunt/constricted (a reduction in the range and intensity of emotions displayed) and judgement, concentration and attention span (length of time for which a person is able to concentrate mentally) was impairments.During an interview on 8/7/2025 at 12:10 p.m. with Licensed Vocational Nurses (LVN) 2, LVN 2 stated Resident 1 had periods of confusion and was moody (shift towards negative emotions like sadness, anger, or irritability). LVN 2 stated it was important for the facility to develop an individualized care plan for Resident 1's dementia diagnosis to provide nurses with the right interventions and to be able to provide proper care for Resident 1. During a concurrent interview and record review on 8/7/2025 at 3:02 p.m. with Registered nurses (RN) 1, Resident 1's care plan for dementia was to be reviewed. RN 1 stated there was no care plan created for Resident 1's dementia. RN 1 stated Resident 1 should have a care plan for dementia with interventions developed to guide nurses on how to provide proper care for Resident 1 to improve outcome. During a review of facility's Policies and Procedures (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022 the P&P indicated a comprehensive, person-centered care plan should be developed and implemented for each resident and include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. The P&P indicated care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop a comprehensive, resident-centered care plan for one of three residents (Resident 1), who had a physician's order for fluid restriction (the amount of water the resident can drink in a day). This failure had the potential to result in Resident 1 not receiving the care and services the physician had ordered and placed the resident at risk to worsening clinical condition. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. The admission Record indicated Resident 1 had a history of edema (swelling, abnormal accumulation of fluid in body tissues), chronic heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and chronic kidney disease (kidneys malfunctioning over a prolonged period, sometimes resulting in fluid retention). The admission Record indicated Resident 1 was discharged on 5/14/2025. During a review of Resident 1's History and Physical (H&P), dated 5/6/2025, the H&P indicated Resident 1 was able to understand and make medical decisions. During a review of Resident 1's Physician Orders, dated 5/6/2025, the Physician Orders indicated fluid restriction of 1.5 liters (L - metric unit of measurement, for liquids) per 24 hours. During a review of Resident 1's Physician Orders, dated 5/8/2025, the Physician Orders indicated fluid restriction of 1500 milliliters (ml, a unit of measurement) a day, indicating the following: for dietary= 1,020 ml/ day (breakfast-420 ml; lunch= 240 ml; dinner= 360 ml). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/11/2025, the MDS indicated Resident 1 had moderate cognitive impairment. The MDS indicated Resident 1 required supervision (helper provides verbal cues and/or touching/steadying and or contact guard assistance to complete the activity) to eat (the ability to bring and/or liquid to the mouth and swallow food and/or liquid). During a review of Resident 1's Change of Condition Evaluation (COC), dated 5/11/2025 at 3:34 p.m., the COC indicated Resident 1 was observed with peripheral (referring to arms and legs) edema, abnormal lung sounds, weight gain of three pounds, and vesicles (small, fluid-filled sacs) on the skin of the right and left lower legs. During a review of Resident 1's Physician Orders, dated 5/12/2025, the Physician Orders indicated Resident 1's fluid restriction was reduced to 1 Liter of fluids per day. The Physician Orders indicated Resident 1 was ordered to have a condom catheter (external urine collection device) for intake and output (I&O - monitoring of fluids moving in and out of the body). During a review of Resident 1's COC, dated 5/14/2025, the COC indicated Resident 1 developed respiratory distress and severe back pain. The COC indicated Resident 1 was breathing at 30 breaths per minute (normal breathing rate is 12-20 breaths per minute) with an oxygen saturation level (O2 sat- a measurement of how much oxygen the blood is carrying as a percentage. Normal range is 95-100%) of 89%. The COC indicated 911 (emergency services) was notified and Resident 1 was transferred to the hospital via 911 due to respiratory distress. During a concurrent interview and record review on 6/16/2025 at 3:48 p.m. with Registered Nurse (RN 1), Resident 1's Physician Orders dated 5/6/2025 and 5/12/2025, all active and revised care plans were reviewed. RN 1 stated the Physician Orders indicated Resident 1's fluid restriction was decreased from 1.5 L on 5/6/2025 to 1 L on 5/12/2025. RN 1 stated there was no care plan for the fluid restrictions. RN 1 stated a care plan should have been created to provide safe care to Resident 1. RN 1 stated Resident 1 was at risk of not adhering to his fluid restrictions and was at risk of being hospitalized for fluid overload and respiratory distress if the fluid restriction was not followed. During a concurrent interview and record review on 6/25/2025 at 10:40 a.m. with the Licensed Vocational Nurse (LVN 1), Resident 1's active and revised care plans, and the facility's P&P titled Care Plans, Comprehensive, Person-Centered dated 3/2022, were reviewed. LVN 1 stated Resident 1's physician-ordered condom catheter should have been care planned to ensure Resident 1 had a condom catheter applied, education, and monitoring. During a concurrent interview and record review on 6/25/2025 at 2:45 p.m. with the Director of Nursing (DON), Resident 1's COC dated 5/11/2025, Physician Orders for 5/2025, active and revised care plans, and the facility's P&P titled Care Plans, Comprehensive, Person-Centered dated 3/2022, were reviewed. The DON stated the P&P indicated Resident 1's care plan should have been created and updated to address the Resident 1's care need. The DON stated the physician orders indicated Resident 1 should have a condom catheter and 1 L fluid restriction. The DON stated the facility did not create a care plan for Resident 1's fluid restriction nor a care plan revised to address Resident 1's new symptom (peripheral edema, abnormal lung sounds, weight gain of three pounds, and vesicles on the skin of the right and left lower legs, respiratory distress and severe back pain) and orders from 5/11/2025 and 5/12/2025. The DON stated other Resident 1's care plan were not specific and resident centered. During an interview on 6/26/2025 at 4:30 p.m. with the DON, the DON stated Resident 1 had no additional care plans existed. During a review of the facility's P&P titled Care Plans, Comprehensive Person-Centered dated 3/2022, the P&P indicated every resident must have person-centered care plans that include measurable objectives and timetables to meet a resident's physical and functional needs. The P&P indicated care plans must describe all services that are to be furnished to attain and maintain the resident's highest practicable well-being. The P&P indicated assessments must be revised as information about the residents and the residents' conditions change.

May 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

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the food allergies (abnormal response after a certain food is eaten) for one of four sampled residents (Resident 1) by serving Resident 1 fish, who was allergic to seafood. This deficient practice resulted in Resident 1 having an allergic reaction and had the potential to cause Resident 1 to have an anaphylactic shock (severe, potentially life-threatening allergic reaction) the reaction may include itchy skin, edema, collapsed blood vessels, fainting, difficulty in breathing, and death). Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE]. The admission Record indicated Resident 1's diagnoses included Dysphagia (difficulty swallowing) and gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). The admission Record indicated Resident 1 was allergic to caffeine, cheese, citrus products, milk, seafood and white bread. During a review of Residents 1's Minimum Data Set (MDS – a resident assessment tool), dated 5/2/2025, the MDS indicated Resident 1 did not have cognitive (ability to think and reason) impairment. The MDS indicated Resident 1 substantial/maximal assistance (staff does more than half the effort) for activities of daily living (ADLs) such as bed mobility (how resident moves from lying to turning side to side), upper body dressing and personal hygiene. During a review of Resident 1's Physician Orders dated 5/23/2025, the Physician's orders indicated to provide Resident 1 with a Regular, no added salt diet, pureed texture (soft, blended, semi solid foods with a smooth consistency that requires no chewing), thin consistency and no white bread, milk, citrus, cheese caffeine nor seafood. During a review of Resident 1's Change of Condition (COC) dated 5/23/2024, the COC indicated Resident 1 complained of itching on her head and neck after eating lunch. The COC indicated Resident 1 ate fish and had an allergy it. The COC indicated, the doctor was notified and ordered to administer diphenhydramine hydrochloride ([Benadryl] medication used to treat allergy symptoms), oral tablet 50 milligrams via gastrostomy tube every 8 hours as needed for allergic reactions. During an interview on 5/24/2025 at 8:06 a.m. with Resident 1, Resident 1 stated, she was allergic to all kinds of seafood. Resident 1 stated on 5/23/2025, staff (unidentified) brought her lunch tray which had 3 small containers; one with green vegetables, one with peach puréed and another container with a food item that was white in color. Resident 1 stated, she thought the food item was chicken, so she tasted it. Resident 1 stated Certified Nurse Assistant (CNA)1 told her, the white food item was fish. Resident 1 stated she developed and allergic reaction to the fish, felt numbness to her lower lip and was administered Benadryl and medication for her stomach (not specified) with relief. During an interview on 5/24/2025 at 9:00 a.m. with the Dietary Supervisor (DS), the DS stated during the tray line procedure (system where meals are prepared and assembled on trays and delivered to residents) the kitchen assistant (KA) would read the tray card (used to identify special diets and allergies of residents), and the cook would plate the food. The DS stated on 5/23/2025 Resident 1 received pureed fish by mistake. The DS stated Resident 1's tray card showed the resident's allergies, which included seafood, in small letters and was not written with a pen. During an interview on 5/24/2025 at 9:37 a.m. with KA, the KA stated tray card usually included resident's dislikes and food allergies written in pen with big to alert staff. The KA stated on 5/23/2025, Resident 1's tray card included the resident's allergy to seafood however was written in small letters and was not written with a pen, so she (KA) did not see it. The KA stated serving Resident 1 food, she was allergic to placed her in danger from an allergic reaction. During an interview on 5/24/2025 at 11:45 a.m. with Licensed Vocation Nurse (LVN) 1, LVN 1 stated when passing out food trays, two licensed nurses should check the trays before the CNAs pass them out to Residents. LVN 1 stated CNAs should also check for the diet, residents name and room number. LVN 1 stated on 5/23/2025, Resident 1 received a food tray with pureed fish which caused the resident to have redness to the forehead and chest and was given Benadryl. LVN 1 stated on 5/23/2025, she did not check Resident 1's food tray because she had to pass medications. LVN 1 stated it was very important to check the trays for any allergies to food. LVN 1 also stated, giving the wrong food to Resident 1 could cause the resident to have an anaphylactic shock which could lead to hospitalization. During an interview on 5/24/2025 at 1:10 p.m. with the Director of Nursing (DON) the DON stated staff should double check the food trays before they are served to residents to prevent the resident's from experiencing any allergic reactions which could lead to hospitalization. The DON sated It was very important to make sure residents received the correct tray and for staff to follow the allergies as indicated on the tray card. During a review of the facility's policy and procedures (P&P) titled, Tray card dated 2017, the P&P indicated tray cards should list residents' name, room number, diet order, location or meal services and food preferences. During a review of the facility's P&P titled, Food nutritional services aide dated 2017, the P&P indicated the Food and Nutrition Services Aide checks resident's trays for proper and accurate food items.

May 2025 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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to implement its infection prevention and control measures for two of four sampled residents (Residents 2 and 4) by failing to: 1. Ensure Licensed Vocational Nurse (LVN) 1 and Restorative Nursing Assistance (RNA) 1 wore personal protective equipment (PPE-specialized clothing or equipment such as gloves and gown worn to minimize exposure to serious illness) while providing care to Residents 2 and 4, who was on Enhanced Barrier Precautions (EBP-an approach to the use of to reduce transmission of Multidrug-Resistant Organisms [MDRO- bacteria that are resistant to multiple antibiotics].) 2.Ensure clear signage was posted to inform staff of the EBP to be followed when providing care to Resident 4. This deficient practice had the potential to result in potential transmission of a disease-causing organisms leading to illness and a delay in wound healing for Residents 2 and 4. Findings: During an observation on 5/22/2025 at 10:00 a.m. a signage for EPB and isolation cart was at the entrance of Resident 2's room. LVN 1 and RNA 1 was observed entering Resident 2's room without an isolation gown. LVN 1 proceeded with performing wound dressing change for the resident with RNA 1's assistance. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] and re-admitted on [DATE]. The admission Record indicated Resident's diagnoses included Pressure Ulcer stage 4 (full-thickness tissue loss with exposed bone, tendon, or muscle), quadriplegia (completely unable to move all four limbs), and unspecified lack of coordination (difficulty coordinating movements). During a review of Resident 2's History and Physical (H&P) dated 1/20/2025, the H&P indicated Resident 2 had fluctuating mental capacity to understand and make medical decisions. During a review of Residents 2's Minimum Data Set (MDS-a resident assessment tool) dated 3/29/2025, the MDS indicated Resident 2 had moderate cognitive (ability to think and reason) impairment. The MDS indicated Resident 2 was dependent on staff for activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). During a review of Resident 2' Physicians Order dated 4/1/2025, the Order indicated to place Resident 2 on EBP due to open wounds. During a review of Resident 2' Physicians Order dated 5/17/2025, the Order indicated to cleanse Resident 2's sacrum pressure injury with normal saline (NS), pat dry, apply hydrogel (material to provide a moist wound environment) and cover with foam dressing daily for 30 days every day. During an observation on 5/22/2025 at 10:50 a.m. no EPB signage nor isolation cart was observed at the entrance of Resident 4's room. LVN 1 and RNA 1 was observed not wearing an isolation gown while performing wound dressing change for Resident 4. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] and re-admitted on [DATE]. The admission Record indicated Resident 4's diagnoses included osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of the left ankle and foot, hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction (loss of blood flow to a part of the brain) and muscle weakness and Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and wound healing) . During a review of Resident 4's H&P dated 12/20/2024, the H&P indicated Resident 4 had fluctuating mental capacity to understand and make medical decisions. During a review of Residents 4's MDS dated [DATE], the MDS indicated Resident 4 had severe cognitive impairment. The MDS indicated Resident 4 was dependent on staff for ADLs such as dressing, toilet use, personal hygiene, transfer and bed mobility. During a review of Resident 4' Physicians Order dated 5/27/2025, the Order indicated to cleanse Resident 4's diabetic ulcer (open sore or wound) of the right great toe with NS, pat dry, swab with betadine (antiseptic used for skin disinfection) and cover with dry dressing daily. During an interview on 5/22/2025 at 11:07 a.m. with LVN 1, LVN 1 stated he forgot to use a gown. LVN 1 stated, nurses should wear PPE such as a gown and gloves when entering residents' rooms on and performing any procedures for residents on EBP. LVN 1 stated it was important to follow EBP to prevent the spread of any infection to other residents. During an interview on 5/22/2025 at 11:10 a.m. with RNA 1, RNA 1 stated she forgot to use a gown. RNA 1 stated staff needed to wear PPE when coming into direct contact with residents to prevent any transmission of infection from one patient to other. During an interview on 5/22/2025 at 4:00 p.m. with The Director of Nursing (DON), the DON stated EBP precautions should be followed for residents with foley catheter and wounds to prevent transmission of MDRO. The DON stated nurses must wear an isolation gown with any contact with Residents in EBP precautions. During a review of the facility's policy and procedures (P&P) titled, Enhance Barrier Precautions , dated 8/2022, the P&P indicated EBPs are used as an infection prevention and control intervention to reduce the spread of multi-drug-resistant organisms (MDROs) to residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include wound care (any skin opening requiring a dressing).

May 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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN 1) supervised the medication administration for one of three sampled residents (Resident 2), who had not been assessed by the Interdisciplinary Care Team (IDT- a group of healthcare professionals who work together to manage the resident ' s care) for medication self-administration. This failure placed Resident 2 at risk for medication errors including delayed doses or missed doses and could lead to adverse drug events for the resident. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated Resident 2 ' s diagnoses included osteoarthritis (a progressive disorder of the joints, caused by gradual loss of cartilage) of the left hip, hypertensive urgency (a significantly elevated blood pressure [normal pressure is 120/80 millimeter of mercury ([mmHG], a unit of pressure]) and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 2 ' s Minimum Data Set (MDS- a resident assessment tool), dated 2/27/2025, the MDS indicated Resident 2 had no cognitive (the ability to think and reason) impairment. The MDS indicated Resident 2 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying as resident completes activity) for Activities of Daily Living (ADLs) such as eating and oral hygiene. During a concurrent observation and interview on 5/6/2024 at 10:44 a.m. with Resident 2 at the resident ' s bedside, Resident 2 was observed holding a small plastic disposable medicine cup with approximately 5 medications: one small black, circular pill, one orange capsule, one white oval shaped pill with the number, 145, and two white pills. No licensed nurse was observed present with the resident. Resident 2 stated the pills were medications she was taking for blood pressure and blood sugar. During a concurrent observation and interview on 5/6/2025 at 10:47 a.m. at Resident 2 ' s bedside with Licensed Vocational Nurse (LVN) 1, LVN 1 stated the medications inside the medicine cup with the Resident 2 were Colace (a stool softener to treat constipation) and Pradaxa (a medication that prevents blood clots from forming). LVN 1 stated the medications were scheduled to be administered to Resident 2 at 9:00 a.m. and she (LVN 1) left the medications with the resident because the resident preferred to take the medications on her own. During a review of Resident 2 ' s Order Summary Report dated 5/6/2025, the Report indicated the following physician orders for Resident 2: On 2/4/2025, the physician ordered to administer amlodipine besylate (medication to treat high blood pressure) 5 milligrams (mg.- unit of measurement) give 1 tablet by mouth one time a day, ascorbic acid (supplement) 500 mg. 1 tablet by mouth one time a day, bisoprolol fumarate (medication to treat high blood pressure) 5 mg. give 1.5 tablet by mouth one time a day with food, docusate sodium (colace) 250 mg. give 1 capsule by mouth one time a day, ferrous sulfate (iron supplement) 325 mg. by mouth one time a day, every other day, gabapentin (medication to treat nerve pain) 400 mg. by mouth three times a day and hydralazine (medication to treat high blood pressure) 50 mg. give 1 tablet by mouth three times a day. On 3/6/2025, the physician ordered to administer Pradaxa 110 mg. 1 capsule by mouth two times a day. During an interview on 5/6/2025 at 12:01 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she observed a medication cup with Resident 2 ' s medications left on top of Resident 2 ' s bedside table in the morning (no time specified). CNA 1 stated she should have informed the charge nurse but had forgotten to do so. During an interview on 5/6/2025 at 1:31 p.m. with Registered Nurse (RN) 1, RN 1 stated, it was not acceptable for medications to be left unattended at a resident ' s (Resident 2 ' s) bedside without a licensed nurse. RN 1 stated, a licensed nurse should be present with the resident when administering medications, to ensure that all medications were taken and to ensure safety of the resident. During an interview on 5/6/2025 at 3:30 p.m. with the Director of Nursing (DON), the DON stated residents should first be evaluated by the IDT prior to the resident self-administering medication, to ensure the resident was able to safely do so and after a care plan had been initiated. The DON stated that an IDT had not been done for Resident 2 until about 30 minutes ago. The DON also stated medications for Resident 2 should not have been left unattended earlier in the morning, for the resident to take by herself because there was no physician ' s order, and an IDT had not yet been conducted. During a review of facility ' s undated policy and procedure (P&P) titled, Self-Administration of Medications, the P&P indicated, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The P&P also indicated, As part of the evaluation comprehensive assessment, the IDT assesses each resident ' s cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. The P&P indicated, the IDT considers the following factors when determining whether self-administration of medications is safe and appropriate for the resident: a. the medication is appropriate for self-administration b. the resident is able to read and understand medication labels c. the resident can follow directions and tell time to know when to take the medication d. the resident comprehends the medication ' s purpose, proper dosage, timing, signs of side effects and when to report these to staff e. the resident has the physical capacity to open medication bottles, remove medications from a container and to ingest and swallow (or otherwise administer) the medication f. the resident is able to safely and securely store the medication.

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess and notify Resident 1 ' s Medical Doctor (MD) when one of three residents (Resident 1), had tachycardia (heart rate faster than normal) and tachypnea (rapid breathing) on 2/17/2025. This failure resulted in delayed treatment and the resident's transfer to a general acute care hospital (GACH) for evaluation. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. The admission Record indicated Resident 1 had a history of chronic respiratory failure (chronic lung disease causing difficulty breathing), tracheostomy (a surgically placed breathing tube) status, pneumonia (an infection/inflammation in the lungs), and sepsis (a life-threatening blood infection). During a review of Resident 1 ' s History and Physical (H&P), dated 2/13/2025, the H&P indicated Resident 1 was not able to make medical decisions. During a review of Resident 1 ' s Physician progress notes, dated 2/15/2025, the progress notes indicated Resident 1 ' s mental status was altered. The progress notes indicated Resident 1 had no purposeful movement, and was awake, unable to follow commands or track. During a review of Resident 1 ' s Minimum Data Set (MDS – resident assessment tool), dated 2/17/2025, the MDS indicated Resident 1 ' s decision making was severely impaired. During a review of Resident 1 ' s Respiratory Rate flowsheet, dated 2/17/2025, the flowsheet indicate Resident 1 ' s respiratory rate was 30 breaths per minute or above (normal rate is 12-20 breaths per minute) , from 9:49 a.m. to 3:30 p.m During a review of Resident 1 ' s Pulse (heart rate) flowsheet, dated 2/17/2025, the flowsheet indicated Resident 1 ' s heart rate was over 100 beats per minute (normal rate is 80-100 beats per minute), from 6:56 a.m. to 3:25 p.m During a review of Resident 1 ' s progress notes, dated 2/17/2025, the progress notes indicated Resident 1 had tachypnea throughout the shift. The tachypnea did not indicate Resident 1 ' s MD was notified. During a review of Resident 1 ' s eInteract SBAR (situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents) Form, dated 2/17/2025, the SBAR indicated Resident 1 was tachycardic and tachypneic with coffee brown gastric residual and was transferred to a GACH for evaluation. During a review of Resident 1 ' s progress notes, dated 2/17/2025, the progress notes indicated Resident 1 was transferred to GACH 1 at 4:00 p.m. with a pulse of 120 beats per minute and respiratory rate of 34 breaths per minute. During a concurrent interview and record review on 4/21/2024 at 1:30 p.m. with Registered Nurse (RN 1), Resident 1 ' s progress notes dated 2/17/2025, Assessments dated 2/17/2025, Respiratory Rate flowsheet dated 2/17/2025, and Pulse flowsheet dated 2/17/2025, were reviewed. RN 1 stated the flowsheets indicated Resident 1 was tachycardic and tachypneic since 6:56 a.m. on 2/17/2025. RN 1 stated LVN 1 informed her about Resident 1 ' s elevated pulse and respiratory rate at approximately 11:47 a.m. on 2/17/2025. RN 1 stated she was concerned about Resident 1 ' s high pulse and respiratory rate but was too busy to address the situation until 3:00 p.m RN 1 stated she called Resident 1 ' s MD at 3:00 p.m. to notify the MD about Resident 1 ' s high pulse and respiratory rate. RN 1 stated LVN 1 did not call Resident 1 ' s MD earlier. During a concurrent interview and record review on 4/21/2025 at 4:00 p.m. with the Director of Nursing (DON), Resident 1 ' s Progress Notes dated 2/17/2025, Respiratory Rate flowsheet dated 2/17/2025, and Pulse flowsheet dated 2/17/2025, were reviewed. The DON stated Resident 1 ' s vital signs were abnormal and were monitored from 6:56 a.m. until Resident 1 was transferred to the hospital at 3:30 p.m The DON stated the nursing staff should have notified the Resident 1 ' s MD earlier in the morning of 2/17/2025, after Resident 1 ' s tachycardia and tachypnea was sustained. During a concurrent interview and record review on 4/21/2025 at 4:45 p.m. with RN 1, the facility ' s P&P titled Acute Clinical Changes- Clinical Protocol, dated 3/2018, was reviewed. RN 1 stated the policy indicated the LVN 1 gather pertinent data from the resident ' s chart and assess Resident 1 to notify the MD. RN 1 stated the MD should have been called within minutes of tachycardia and tachypnea onset. RN 1 stated the P&P was not followed because Resident 1 ' s nurse did not call the MD and discuss possible causes of the change of condition when it occurred in the morning of 2/17/2025. RN 1 stated, as a result, the MD was unable to provide orders and instructions to manage Resident 1 ' s condition because the MD was not notified. During a concurrent interview and record review on 4/22/2025 at 2:40 p.m. with LVN 2, Resident 1 ' s Respiratory Rate flowsheet, dated 2/17/2025, and Pulse flowsheet, dated 2/17/2025, and the facility ' s P&P titled Resident Examination and Assessment dated 2/2014, were reviewed. LVN 2 stated the Pulse flowsheet indicated Resident 1 ' s pulse was over 100 beats per minute. LVN 2 stated the high pulse rate should have prompted the LVN or RN to immediately perform a head-to-toe assessment on Resident 1 and notify the MD. LVN 1 stated Resident 1 ' s elevated pulse and respiratory rate were signs of respiratory distress. LVN 1 stated the nurses should have been more vigilant in calling Resident 1 ' s MD due to Resident 1 ' s tracheostomy dependence and history of respiratory failure and sepsis. LVN 1 stated delayed assessment and MD notification could lead to worsening health status, complications, and hospitalization. During a review of the facility ' s P&P titled, Resident Examination and Assessment, dated 2/2014, the P&P indicated resident examinations and assessment for abnormalities in health status will provide the basis for the care plan. The P&P indicated pulse, respiration rate, cardiovascular status, and respiratory status are part of resident assessment. The P&P indicated the physician must be notified of any abnormalities such as abnormal vital signs. During a review of the facility ' s P&P titled, Acute Clinical Changes- Clinical Protocol, dated 3/2018, the P&P indicated nursing staff should have collected pertinent details from the resident ' s current symptoms/status and medical chart after a change in condition. The P&P indicated the MD and nursing staff should discuss possible causes of the condition change, and the MD will identify and authorize appropriate treatments.

Mar 2025 15 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 66's admission Record, the admission Record indicated Resident 66 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 66's admitting diagnoses included generalized muscle weakness, reduced mobility, and age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). During a review of Resident 66's MDS, dated [DATE], the MDS indicated Resident 66 had moderately impaired cognition. The MDS indicated Resident 66 required substantial to maximal assistance from staff to roll left and right in bed and was fully dependent on staff to transition from sitting to lying, and lying to sitting positions, and chair/bed-to-chair transfers. During a review of Resident 66's care plan titled The resident is at risk for unavoidable falls, created 7/6/2024, the care plan indicated goals of care were Resident 66 being free from falls and associated injury. Care plan interventions indicated staff were to ensure Resident 66's call light was within reach. During a review of Resident 66's care plan titled [Resident 66] has had an actual fall .with serious injury, created 7/6/2024, the care plan indicated goals of care were Resident 66 not having any additional fall incidents. Care plan interventions indicated staff were to ensure Resident 66 had fall mats on both sides of her bed. During a review of Resident 66's Post-Fall Review assessment, dated 1/7/2025, the assessment indicated Resident 66 had an unwitnessed fall on 1/7/2025. The assessment indicated Resident 66's care plan was reviewed after the fall on 1/7/2025. The care plan indicated Resident 66 was to have floor mats to both sides of her bed and be encouraged to request for assistance. During a review of Resident 66's Quarterly Risk Data Collection Tool assessment, dated 1/17/2025, the assessment indicated Resident 66 was at risk for falls and had fallen one to two times in the last six months. During an observation on 3/11/2025 at 11:48 AM, at Resident 66's bedside, Resident 66 was observed lying in a left-facing position, with a blanket and sheet draped over her right arm. Resident 66's call light was placed on her bedside table, on her right side. When asked to demonstrate reaching for the call light, Resident 66 was unable to reach. During a concurrent observation and interview on 3/11/2025 at 1:13 PM, with Resident 66, at Resident 66's bedside, no fall mats were observed at Resident 66's bedside. Resident 66 stated she had a fall. During an observation on 3/12/2025 at 8:29 AM, at Resident 66's bedside, no fall mats were observed. During a concurrent observation and interview on 3/12/2025 at 11:53 AM, at Resident 66's bedside, with CNA 1, no fall mats were observed. CNA 1 stated Resident 66 did not have fall mats to either side of her bed. CNA 1 stated the purpose of the fall mats was to lessen or prevent injury from a fall. CNA 1 stated the fall mats were softer than the floor, and stated that without the mat, there was increased potential for injury. During a concurrent observation and interview, on 3/12/2025 at 11:56 AM, at Resident 66's bedside, with CNA 2, CNA 2 stated she provided care to Resident 66 for the last month. CNA 2 stated that in the last month, she did not observe fall mats at Resident 66's bedside. During a concurrent interview and record review, on 3/12/2025 at 12:07 PM, with LVN 1, Resident 66's care plan titled [Resident 66] has had an actual fall .with serious injury, dated 7/6/2024, was reviewed. LVN 1 stated the care plan indicated Resident 66 required fall mats to both [NAME] of her bed. LVN 1 stated Resident 66 was high risk for falls and the fall mats would minimize potential for injury if Resident 66 fell. During an observation on 3/13/2025 at 9:31 AM, at Resident 66's bedside, no fall mats were observed. During an interview on 3/13/2025 at 9:38 AM, with LVN 1, LVN 1 stated it was important for a resident's call light to be within reach. LVN 1 stated that if the call light was not within reach, the resident's needs might not be met, or they might attempt to get up unassisted and could fall and sustain injuries. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, revised 7/2017, the P&P indicated the facility would strive to make the environment as free from accident hazards as possible. The P&P indicated resident safety and supervision and assistance to prevent accidents are facility-wide priorities. During a review of the facility's P&P titled Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated a comprehensive, person-centered care plan, was to include includes measurable objectives and timeframes and describe the services that staff were to furnish to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. During a review of the facility's P&P titled, Falls and Fall Risk Managing, revised 2/7/2024, the P&P indicated the facility nursing staff would identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling based on previous evaluations and current data. The P&P indicated that air surface support mattress (i.e. Low air loss mattress /Pressure redistribution optimization mattress) was identified as an environmental risk factor that contributes to the risk of falls. The P&P indicated cognitive impairments, lower extremity weakness, poor grip strength, functional impairments, incontinence, heart failure, anemia, neurological disorders, and balance and gait disorders contributed to the risk of falls. The P&P indicated staff were to implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for at risk residents and those with a history of falls. Based on observation, interview, and record review, the facility failed to ensure the following for two of four sampled residents (Resident 23 and Resident 66). 1. Certified Nursing Assistant (CNA) 4 used a two person assist when performing perineal care ([peri care] the washing of the genitals and anal area) and repositioning for Resident 23. 2. The call light was within reach and fall mats were provided for Resident 66. This failure resulted in Resident 23 falling from the bed, sustaining a bilateral (pertaining to both sides) femur fractures (broken thighbone, a serious injury, often requiring surgery and extensive rehabilitation, and is typically caused by high-impact trauma like car accidents or falls) which required surgical intervention at a general acute care hospital (GACH). This failure also resulted in Resident 23 undergoing a right and left right femur open reduction internal fixation surgery (a surgical procedure used to treat severe fractures or dislocations by realigning the broken bones and stabilizing them with internal hardware, such as screws, plates, or rods) and required the transfusion of three units of packed red blood cells (a medical procedure where concentrated red blood cells (RBCs) are infused into a patient's bloodstream). This failure also placed Resident 66 at risk for falls and subsequent fall-related injuries. Findings: During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 23's diagnoses included fracture of the left and right femur, morbid obesity (a severe form of obesity characterized by an excessive amount of body fat that significantly impacts health and well-being), contracture of muscle multiple sites (a permanent or prolonged shortening of muscles, tendons, or other soft tissues that results in limited range of motion and stiffness), functional quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), neuromuscular dysfunction of the bladder (poor bladder control), dementia (a progressive state of decline in mental abilities), and anxiety (a feeling of uneasiness). During a review of Resident 23's Minimum Data Set ([MDS], a resident assessment tool), dated 12/29/2024, the MDS indicated Resident 23's cognitive skills (ability to think and reason) for daily decision making was moderately impaired. The MDS indicated Resident 23 had an impairment on both sides of her lower extremities (legs). The MDS indicated Resident 23 was dependent on staff (helper does all the effort, resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) for toileting hygiene (ability to maintain perineal hygiene), showering or bathing, upper and lower body dressing, and performing personal hygiene. The MDS indicated Resident 23 required substantial or maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) for rolling to the left and right side of the bed. During a review of Resident 23's Physical Therapy Discharge summary, dated [DATE], the discharge summary indicated Resident 23 was assessed as total dependence with attempts to initiate for bed mobility. During a review of Resident 23's Fall Risk Assessment, dated 12/27/2024, the Risk Assessment indicated Resident 23 was at risk for falls. During a review of Resident 23's Certified Nursing Assistant (CNA) Task Flowsheet, dated December 2024, the flowsheet indicated Resident 23 was assessed as dependent for the task of rolling to the left and right side of the bed, on the 7 a.m. to 3 p.m., shift, for 21 out of the 31 days in the month of December 2024. The flowsheet indicated Resident 23 was assessed as dependent for the task of toileting hygiene, on the 7 a.m. to 3 p.m. shift, for 24 out of the 31 days in the month of December 2024. During a review of Resident 23's Change of Condition Note, dated 12/31/2024, timed at 9:30 a.m., the Change of Condition Note indicated on 12/31/2024 at 9:30 a.m., while CNA 4 was changing Resident 23, CNA 4 turned Resident 23 to the right side Resident 23 reached and grabbed on to the call light slid off the bed and landed on her back. During a review of Resident 23's Situation, Background, Assessment, Recommendation (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents), dated 12/31/2024 (untimed), the SBAR indicated on 12/31/2024 at 9:30 a.m., Resident 23 fell. The SBAR indicated Registered Nurse (RN) 1 assessed Resident 23 on the floor. The SBAR indicated Resident 23's Physician ordered a STAT (without delay) right hip and right femur x-rays (imaging that creates pictures of the inside of your body) , and for Resident 23 to be transferred to a GACH. During a review of Resident 23's Physician Progress Note, dated 12/31/2024, timed at 12:42 p.m., the note indicated Resident 23 had a right anterior (the front or front surface of a structure or body part) thigh deformity (not having the normal or natural shape or form) with concern for a fracture. The note indicated Resident 23 complained of left hip and right leg pain. During a review of Resident 23's Radiology (a medical specialty that uses imaging technology to diagnose and treat diseases) Results Report, dated 12/31/2024, timed at 12:53 p.m., the Radiology Results Report indicated the following: 1. Left hip x-ray indicated Resident 23 sustained a displaced (when the broken bone snaps into two or more pieces and the ends are no longer aligned) acute fracture to the proximal (near the center of the body) femur. 2. Left femur x-ray indicated Resident 23 sustained a displaced acute subtrochanteric (a break in the femur that occurs below the lesser trochanter, a bony prominence located at the top of the femur) fracture. 3. Right femur x-ray indicated the presence of a fracture to the mid shaft femur. During a review of the GACH Internal Medicine History and Physical Note, dated 12/31/2024, timed at 9:27 p.m., the note indicated Resident 23's blood pressure was 53/39 millimeters of mercury ([MM HG]- unit of measurement that describes the amount of force blood uses to get through the vessels of the body [normal range of 120-129 [top number] and 80-84 [bottom number]). The note indicated Resident 23's oxygen saturation (the percentage of oxygen in a person's blood) was 88 percent (%) (normal range 93-100%) on room air. The note indicated Resident 23's x-ray of the bilateral femurs and bilateral hips indicated Resident 23 sustained the following: 1. A comminuted (a fracture where a bone is broken into multiple pieces or fragments) medial angulated fracture (a fracture that results when one piece of the bone points in an inward direction) of the right femur mid shaft (a break in the middle portion of the femur) with 3.5 centimeter (cm- a unit of measurement) overlap of fracture fragments. 2. A comminuted, mildly medically displaced fracture of the left femoral proximal shaft (the upper, long part of the femur bone) with extension into the lesser trochanter (a small, bony prominence located on the inner side of the femur). During a review of the GACH Operating Room Note, dated 1/2/2025, timed at 9:29 a.m., the note indicated Resident 23 underwent a right and left femur open reduction internal fixation surgery (a surgical procedure used to treat severe fractures or dislocations by realigning the broken bones and stabilizing them with internal hardware, such as screws, plates, or rods). During a review of the facility's Post Fall Review, dated 1/9/2025, timed at 10:30 a.m., the review indicated on 12/31/2024, Resident 23 suffered an assisted fall and slid off the bed while being changed and turned. During a review of the GACH Principal Discharge Diagnosis with Brief Summary Note, dated 1/16/2025, timed at 12:50 p.m., the note indicated Resident 23 was admitted the GACH on 12/31/2024 for hypovolemic shock (a life-threatening condition that occurs when there is a significant loss of blood or fluids in the body, leading to inadequate blood circulation and oxygen delivery to organs) due to blood loss and bilateral thigh hematomas (a localized collection of blood outside of blood vessels that forms due to injury or trauma) secondary to bilateral femoral fractures while receiving anticoagulation (blood thinning) medication. The GACH Note indicated Resident 23 received three units of blood. During a concurrent observation and interview on 3/10/2025 at 10:10 a.m. with Resident 23, in Resident 23's room, Resident 23 was lying on her back in bed. Resident 23's eyebrows were furrowed as the resident stated, I just wish I could be repositioned more often. During an interview on 3/11/2025 at 12:19 p.m. with Resident 23's family member ([FM] 1), FM 1 stated on 12/31/2024, Resident 23 fell and sustained a fracture to both of her femurs and right hip while CNA 4 cleaned Resident 23 in bed. During an interview on 3/11/2025 at 12:20 p.m. with Resident 23, in Resident 23's room, Resident 23 stated on 12/31/2024, while being changed she suggested CNA 4 grab another nurse for help because she felt CNA 4 could not change her alone. Resident 23 stated CNA 4 replied no and proceeded to clean Resident 23. Resident 23 stated CNA 4 rolled her to her side and she (Resident 23) fell off the bed to the ground. Resident 23 stated after the fall, she suffered excruciating pain all over Resident 23 stated she did not recall reaching for a call light. During an interview on 3/11/2025 at 2:40 p.m., with Registered Nurse (RN) 2, RN 2 stated on 12/31/2024 at 9:30 a.m., CNA 4 informed her that Resident 23 fell. RN 2 stated she (RN 2) observed Resident 23 on the floor to the right side of the bed. RN 2 stated Resident 23 was able to hold onto to the grab bars (a small railing place on the side of the bed ) on her bed during repositioning and peri care. RN 2 stated Resident 23 had poor core strength (a group of muscles that include the abdominal muscles, back muscles and the muscles around the pelvis) when assisting with repositioning or turning in bed. RN 2 stated Resident 23 had broken her leg after seeing a large deformity to the resident's right leg. RN 1 stated CNA 4 reported that while cleaning Resident 23, CNA 4 repositioned the resident away from her (CNA 4's) body. RN 1 stated CNA 4 stated that Resident 23 tried to grab the call light to break her fall as the resident slipped off the air mattress. RN 1 stated CNA 4 should have had a second nurse assist with repositioning and cleaning Resident 23 to maintain safety and to prevent falls. During an interview on 3/11/2025 at 3:20 p.m., with CNA 4, CNA 4 stated on 12/31/2024 she was the assigned CNA for Resident 23 for the 7 a.m. to 3 p.m. shift. CNA 4 stated on 12/31/2024, at approximately 9:00 a.m., she provided peri care for Resident 23. and positioned the resident on her right side in preparation for Resident 23's wound treatment. CNA 4 stated the wound nurse was at the door and she (CNA 4) did not intend on leaving Resident 23 on her right side for a long time. CNA 4 stated Resident 23 attempted to grab an area of the bed to hold on to. CNA 4 stated Resident 23's legs fell first off, the bed, and the rest of the resident's body followed. CNA 4 stated she did not ask another nurse for help because she did not usually need help with Resident 23's repositioning or peri care. CNA 4 stated the normal process to determine each resident's level of performance and the number of staff needed to perform the task was to refer to the Kardex (a type of platform (paper or electronic) that nurses use to quickly reference key patient information for care planning). CNA 4 stated no one there was no information provided about Resident 23's bed mobility in the Kardex. CNA 4 stated there was only information about the number of staff needed to perform a transfer from the bed to chair for Resident 23. CNA 4 stated Resident 23's fall may have been prevented if she asked another nurse for help before providing peri care and repositioning the resident alone. During a concurrent interview and record review on 3/11/2025 at 4:00 p.m. with Minimum Data Set Nurse (MDSN) 1, Resident 23's MDS Section GG (an assessment that evaluates the need for assistance with self-care and mobility activities, functional limitations in range of motion, and current and prior device use), dated 12/29/2024, was reviewed. MDSN 1 stated the MDS indicated Resident 23 was dependent on staff for toileting hygiene. MDSN 1 stated Resident 23's MDS Section GG indicated Resident 23 required substantial, maximal assistance when rolling left and right in bed. During an interview on 3/11/2025 at 4:15 p.m. with the Director of Rehabilitation (DOR), the DOR stated it was best practice to have a second staff member assist in changing or repositioning a resident that was identified as maximal assist or dependent for repositioning or toileting hygiene. The DOR stated that CNA 4 could have probably done better. The DOR stated Resident 23 was hurt because of the fall. During an interview on 3/12/2025 at 8:06 a.m. with Restorative Nurse Aide (RNA) 1, RNA 1 stated she was familiar with Resident 23's bed mobility before the resident's fall (on 12/31/2024). RNA 1 stated it was necessary to have a nurse on each side of Resident 23's bed for repositioning or cleaning to ensure the resident's safety and to prevent a fall. During a concurrent interview and record review on 3/12/2025 at 1:38 p.m. with Occupational Therapist (OT) 1, Resident 23's CNA Task Flowsheet, dated 12/2024, was reviewed. OT 1 stated the CNA Task Flowsheet indicated Resident 23 was dependent for the task of rolling to the left and right in bed. OT 1 stated the CNA Task Flowsheet indicated dependent meant two or more nurses were needed for repositioning. During an interview on 3/13/2025 at 9:29 a.m. with CNA 8, CNA 8 stated Resident 23 used an air mattress which caused residents to be unstable in bed because of the slippery texture of the mattress. CNA 8 stated Resident 23 required the assistance of two CNAs during care and repositioning to ensure safety. During a concurrent interview and record review on 3/13/2025 at 10:13 a.m. with CNA 5, Resident 23's CNA Task Flowsheet, dated 12/2024, was reviewed. CNA 5 stated the CNA Task Flowsheet indicated Resident 23 was dependent for bed mobility and toileting hygiene [which meant Resident 23 required two-person assistance for safely repositioning Resident 23]. CNA 5 stated Resident 23's trunk and core strength was unstable before the fall on 12/31/2024. CNA 5 stated she was always very cautious with Resident 23, especially because the resident utilized an air mattress that contributed to Resident 23's bed instability. CNA 5 stated the texture of all air mattresses were very slippery which was why she (CNA 5) always made sure she had another nurse to assist her whenever she repositioned or provided peri care to Resident 23. CNA 5 stated she always exercised caution with Resident 23 even if Resident 23 was able to grab the grab bars on her bed. CNA 5 stated the use of two nurses to reposition and provide peri care for Resident 23 was best practice to ensure Resident 23's safety, and to prevent bodily injury from a fall. During a concurrent interview and record review on 3/13/2025 at 10:26 a.m. with the (DOR), Resident 23's Physical Therapy Discharge summary, dated [DATE], was reviewed. The DOR stated he was not made aware of any improvements or decline in mobility for Resident 23 after she had been discharged from physical therapy in 2022. The DOR stated Resident 23 was assessed as total dependence with attempts to initiate for bed mobility. The DOR stated Resident 23's fall was preventable if a second nurse had assisted Resident 23 reposition in bed. During a concurrent interview and record review on 3/13/2025 on 11:31 a.m. with Licensed Vocational Nurse (LVN) 3, Resident 23's Weekly Nursing Progress Notes, dated 12/23/2024 and 12/30/2024, were reviewed. The Weekly Nursing Progress Notes indicated Resident 23 was dependent on staff for bed mobility and toileting hygiene. LVN 3 stated she authored the Weekly Nursing Progress Notes for Resident 23 and was familiar with Resident 23's physical capabilities and necessary level of care. LVN 3 stated Resident 23 required the assistance of two staff for safe handling. LVN 3 stated Resident 23 had poor strength and relied on staff when she was repositioned and cleaned. During a concurrent interview and record review on 3/13/2025 at 2:20 p.m., with MDSN 1, Resident 23's Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) Care Plan, initiated 1/4/2023 and revised 1/21/2025, was reviewed. The care plan indicated Resident 23 was totally dependent on staff for toilet use and required two staff participation to use the toilet. The care plan did not indicate how many staff members were needed for Resident 23's bed mobility and repositioning. MDSN 1 stated it was important to ensure the number of staff needed to the complete the task was included in the ADL Care Plan to ensure that care was rendered properly.

CONCERN (D)

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

Deficiency F0557 (Tag F0557)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to label the personal belongings of one of one sampled resident (Resident 120). This failure placed Resident 120 at risk of not maintaining possession of her belongings due to staff being unaware of who the item belonged to. Findings: During a review of Resident 120's admission Record, the admission Record indicated Resident 120 was admitted on [DATE]. Resident 120's admitting diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought) and dementia (a progressive state of decline in mental abilities). During a review of Resident 120's Minimum Data Set (MDS, a resident assessment tool), dated 11/21/2024, The MDS indicated Resident 120 had had severe cognitive impairment (a significant decline in cognitive abilities that interferes with daily functioning and independence). The MDS indicated Resident 120 required partial to moderate assistance from staff for mobility while in and out of bed. The MDS indicated it was somewhat important to Resident 120 to take care of her personal belongings or things. During an interview on 3/10/2025 at 4:22 PM, with Resident 120's Family Member (FM) 2, FM 2 stated she brought a blanket to the facility for Resident 120 because Resident 120 would get cold, and the blankets in the facility were not sufficient to keep her warm. FM 2 stated the blanket was laundered by the facility but was not returned to Resident 120. During a review of Resident 120's inventory list, dated 11/17/2024, the inventory list indicated Resident 120 had a blanket brought in upon admission. During a review of Resident 120's inventory list, dated 11/18/2024, indicated Resident 120's belongings were inventoried at discharge. The inventory list did not indicate Resident 120 was discharged with the blanket. During a concurrent interview and record review, on 3/12/2025 at 3:44 PM, with the Social Services Director (SSD), Resident 120's inventory lists dated 11/17/2024 and 11/18/2024 were reviewed. The SSD stated the inventory lists indicated Resident 120 was admitted with a blanket but was not discharged with the blanket. The SSD stated that the facility was responsible for ensuring that residents' belongings were maintained and kept safe. The SSD stated that all belongings on the inventory list were supposed to be labelled to ensure that they can be returned to the correct resident if list or misplaced. The SSD stated that based on the description of the blanket, she knew where the blanket was and stated it was in outdoor storage at the facility. The SSD stated the facility had washed the blanket, but it was not returned to Resident 120. During an interview on 3/12/2025 at 3:53 PM, with the SSD, the SSD retrieved Resident 120's blanket from the outdoor storage. The SSD stated the blanket was not labeled and should be labeled with Resident 120's name or other identifiers. The SSD stated that because it was not labeled, it could cause laundry staff to be unsure of who the blanket belonged to and therefore placed in storage and not returned to Resident 120. During a review of the facility's policy and procedure (P&P) titled Homelike Environment, undated, the P&P indicated it was the facility's policy to ensure residents were provided with a comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The P&P indicated staff were to provide person-centered care that emphasized the residents comfort and personal needs and preferences.

CONCERN (D)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure needs and preferences were accommodated for two of 26 sampled residents (Resident 65 and Resident 40) when: 1. Staff failed to ensure the call light was within reach for Resident 40. 2. Staff failed to ensure the call light was within functional reach of Resident 65, and ensure staff assisted Resident 65 to put on her bifocal glasses. These deficient practices created the potential for a delay or an inability for Resident 40 and Resident 65 to obtain necessary care and services as needed. These deficient practices also created the potential to negatively impact Resident 65's quality of life due to her inability to see clearly without her glasses. Findings: 1. During a review of Resident 40's admission Record (a document that contains a summary of basic information about the resident), the admission Record indicated Resident 40 was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including cerebral infarction (stroke, caused by a blockage or loss of blood flow to a part of the brain), hemiplegia (total paralysis [loss of the ability to move and feel in all or part of the body] of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one or both sides of the body) affecting right dominant side, paraplegia (loss of movement and/or sensation, to some degree, of the legs) and quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury). During a review of Resident 40's History and Physical (H&P), dated 12/22/2024, the H&P indicated Resident 40 could make needs known but could not make medical decisions. During a review of Resident 40's Minimum Data Set (MDS, a resident assessment tool), dated 2/18/2025, the MDS indicated Resident 40's cognition (ability to think, remember, and reason) was intact. The MDS indicated Resident 40 was dependent (helper does all the effort) for oral hygiene, toileting, bathing, and personal hygiene. During a review of Resident 40's care plan titled The resident has a communication problem, initiated on 9/21/2023 and revised on 12/31/2024, the care plan indicated Resident 40's communication problem was related to expressive aphasia (a disorder that makes it difficult to speak), respiratory impairment (conditions that affect the lungs and airway making it difficult to breath), stroke, and weak or absent voice. The care plan interventions indicated to anticipate and meet the needs of the resident and provide a safe environment by ensuring the call light was within reach. During a concurrent observation and interview on 3/10/2025 at 12:12 PM, with Resident 40, observed Resident 40 lying in bed with his right hand folded across his chest. Resident 40's call light device was observed resting on the right side of his bed below his waist area. Resident 40 stated he did not call the nurses for assistance because he could not reach the call light placed on his right side. Resident 40 stated he could not use his right hand, but he would have been able to use his call light if the nurses had placed it closer to his left hand. During an interview on 3/12/2025 at 4:32 PM, with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 40 could not reach his call light on his right side because he uses his left hand. LVN 2 stated it was important to have Resident 40's call light within reach to be able to attend to his needs or if he is in distress and needed help immediately. During an interview on 3/13/2025 at 12:12 PM, with the Director of Nursing (DON), the DON stated the call light should always be accessible and within the resident's reach. The DON stated Resident 40 could have an accident like a fall or respiratory distress and would not be able to call out for assistance. 2. During a review of Resident 65's admission Record, the admission Record indicated Resident 65 was admitted on [DATE]. Resident 65's admitting diagnoses included major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 65's H&P, dated 9/25/2024, the H&P indicated Resident 65 had the capacity to understand and make decisions. During a review of Resident 65's MDS, dated [DATE], the MDS indicated Resident 65 had severely impaired cognition (a significant decline in cognitive abilities that interferes with daily functioning and independence). The MDS indicated Resident 65 required partial to moderate assistance from staff to eat and required substantial to maximal assistance from staff for all other activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). a. During a concurrent observation and interview on 3/11/2025 at 11:06 AM, at Resident 65's bedside, Resident 65 was observed with a pad call light clipped to her chest. When asked to demonstrate pressing the call light, Resident 65 was unable to reach the call light and press it. Resident 65 was unable to move her fingers and her hands were stiff. Resident 65 stated her hands were weak and stated she usually asked her roommate to call for help for her. During interview on 3/11/2025 at 11:11 AM, with Certified Nursing Assistant (CNA) 9, CNA 9 stated placement of the pad call light was resident-specific and stated the call light should be placed in a position that allows the resident to call for help. CNA 9 stated the call lights should be accessible because if a resident could not call for help, they might not receive the assistance the need. During an observation on 3/11/2025 at 11:14 AM, with CNA 9, CNA 9 asked Resident 65 to press the call light while it was clipped to her chest. Resident 65 could not press the call light. CNA 9 moved the pad call light to a lower position, on Resident 65's abdomen, and Resident 65 able to press the call light with her elbow. During an interview on 3/11/2025 at 11:17 AM, with CNA 9, CNA 9 stated Resident 65 originally had the call light clipped to her chest. CNA 9 stated this location was not functional to ensure Resident 65 could use the call light. CNA 9 stated staff should assess appropriateness of call light placement and ensure it was resident-specific to meet the resident's needs. CNA 9 stated Resident 65 was verbal, and usually yelled for assistance. CNA 9 stated that yelling was not an appropriate method to call for help and stated Resident 65 should be able to use her call light. b. During a review of Resident 65's optometry progress note, dated 11/5/2024, the progress note indicated Resident 65 required bifocal glasses (glasses that provide two different lens powers, correcting vision at both long and short distances) for improvement of vision and quality of life. The progress note indicated a new prescription was ordered for Resident 65's bifocal glasses. During a review of Resident 65's progress note, dated 2/3/2025, the progress note indicated Resident 65's new glasses were provided to her by the Social Services Director. During an interview on 3/11/2025 at 10:44 AM, with Resident 65, Resident 65 stated an eye doctor prescribed glasses because she had glaucoma (a group of eye diseases that damage the optic nerve, potentially leading to vision loss and blindness). Resident 65 stated the glasses were brought to her, but she did not wear them because she could not put them on. Resident 65 stated she could not move her hands, so she asked nursing staff to help her out them on, but the nursing staff said they were busy and did not come back. Resident 65 stated she had the glasses in the bedside dresser. During an interview on 3/11/2024 at 3:24 PM, with Certified Nursing Assistant (CNA) 7, CNA 7 stated she did not know Resident 65 required glasses. CNA 7 stated it was important for residents requiring glasses to have access to them so they can participate in ADLs and leisure activities like watching television. CNA 7 stated should assist residents to put on and take off their glasses if the resident could not do it on their own. During a concurrent observation and interview on 3/11/2025 at 3:27 PM, with CNA 7, at Resident 65's bedside, CNA 7 stated Resident 65 had a rose-gold colored pair of glasses in her bedside dresser. The glasses were wrapped in a protective foam cover inside of their case, and did not appear to have been used. CNA 7 stated she provided care to Resident 65 for the last month and never observed Resident 65 wearing the glasses. CNA 7 put the glasses on for Resident 65, and Resident 65 stated she could see better and wanted to wear the glasses all the time. During an interview on 3/11/2025 at 3:35 PM, with the Director of Nursing (DON), the DON stated staff should assist the resident to put on their glasses if the resident does not have the mobility to put them on themselves. The DON stated any nursing staff could assist the resident. The DON stated it was important for the residents to have access to visual aids to prevent accidents, and to allow the resident to participate in daily activities of living. During a concurrent observation and interview on 3/12/2025 at 8:31 AM, at Resident 65's bedside, Resident 65 was observed lying in bed with the television on. Resident 65 was not wearing any glasses, and a pad call light was clipped to her chest. Resident 65 stated she could not see well without her glasses and stated she wanted to wear them but could not put them on. When asked if she had asked staff to assist her in putting her glasses on, Resident 65 stated she was unable to push the call light because it was placed in a position where she was too weak to reach it and press hard enough to activate it. During a concurrent observation and interview on 3/12/2025 at 8:39 AM, at Resident 65's bedside, with CNA 1, CNA 1 asked Resident 65 to press her call light. Resident 65 was unable to activate the call light while clipped to her chest. CNA 1 stated the current placement of the call light was not effective if the resident could not press it. CNA 1 stated that the call light needed to be repositioned to allow the resident to reach it and press it with enough strength to activate it. CNA 1 clipped the call light lower on Resident 65's abdomen and Resident 65 was able to press the call light. During a review of the facility's policy and procedure (P&P) titled Accommodation of Needs, revised 3/2021, the P&P indicated facility environment and staff behaviors were to be directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. The P&P indicated staff were to accommodate the resident's individual needs, including maintaining glasses and other adaptive devices for residents and promoting their communication and dignity. During a review of the facility's P&P titled Answering the Call Light, revised 9/2022, the P&P indicated staff were to ensure the call light was accessible to the resident when in bed, from the toilet, from the shower or bathing facility, and from the floor.

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) assessments for four of 26 sampled residents (Residents 65, 84, 23, and 109) were completed and documented accurately. This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) regarding Residents 65, 84, 23, and 109's health status. This deficient practice also created the potential for Residents 65, 84, 23, and 109 to not receive the care and interventions needed to reach their highest practicable physical and psychosocial well-being. Findings: 1. During a review of Resident 65's admission Record, the admission Record indicated Resident 65 was admitted on [DATE]. Resident 65's admitting diagnoses included major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 65's History and Physical (H&P), dated 9/25/2024, the H&P indicated Resident 65 had the capacity to understand and make decisions. During a review of Resident 65's MDS, dated [DATE], the MDS indicated Resident 65 had severely impaired cognition. The MDS indicated Resident 65 required partial to moderate assistance from staff to eat and required substantial to maximal assistance from staff for all other activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). The MDS did not indicate Resident 65 required glasses, and indicated Resident 65's vision was adequate. During a review of Resident 65's optometry (pertaining to the eyes) progress note, dated 11/5/2024, the progress note indicated Resident 65 required bifocal glasses (glasses that provide two different lens powers, correcting vision at both long and short distances) for improvement of vision and quality of life. The progress note indicated a new prescription was ordered for Resident 65's bifocal glasses. During a review of Resident 65's progress note, dated 2/3/2025, the progress note indicated Resident 65's new glasses were provided to her by the Social Services Director (SSD). During an interview on 3/11/2025 at 10:44 AM, with Resident 65, Resident 65 stated she was seen by an eye doctor and the eye doctor prescribed glasses because she had glaucoma (a group of eye diseases that damage the optic nerve, potentially leading to vision loss and blindness). During a concurrent interview and record review on 3/11/2025 at 3:25 PM, with the Director of Nursing (DON), Resident 65's MDS dated [DATE] was reviewed. The DON stated the MDS did not indicate Resident 65 required glasses. During an interview on 3/11/2024 at 3:44 PM, with Minimum Data Set Nurse (MDSN) 1, MDSN 1 stated she assessed Resident 65's vision for the MDS dated [DATE]. When asked how the assessment was completed, MDSN 1 stated Resident 65 waved to her (MDSN 1) while MDSN 1 was walking in the hallway outside of Resident 65's room. MDSN 1 stated this meant Resident 65 could see adequately. MDSN 1 stated she did not assess Resident 65's ability to see things at a close distance, including her ability to read written material. MDSN 1 stated Resident 65 was not wearing glasses at the time of her assessment dated [DATE]. During a concurrent interview and record review, on 3/13/2024 at 11:44 AM, with MDSN 1, Resident 65's optometry progress note dated 11/5/2024, and MDS dated [DATE], were reviewed. MDSN 1 stated the optometry progress note indicated Resident 65 required bifocal glasses, and stated the MDS did not indicate Resident 65 required glasses. MDSN 1 stated the Resident Assessment Instrument (RAI) manual (a manual that helps nursing staff gather definitive information on a resident's strengths and needs) indicated Resident 65's vision adequacy should have been assessed by asking Resident 65 to read printed material. MDSN 1 stated she did not do this when assessing Resident 65's vision. MDSN 1 stated Resident 65's MDS was not completed accurately. MDSN 1 stated this places Resident 65 at risk of not receiving the care and assistance needed to ensure her physical and psychosocial well-being. During an interview on 3/13/2025 at 2:07 PM, with the Assistant Director of Nursing (ADON), the ADON stated MDS assessments should be conducted using the instructions provided in the RAI manual and stated MDSN 1 had access to the RAI Manual in the electronic medical record (EMR). The ADON stated it was not appropriate to assume Resident 65's vision was adequate based on her ability to wave to someone in the hallway. The ADON stated it was important to perform accurate assessments to identify changes in vision, including changes due to complications from other diagnoses. The ADON stated accurate assessments also ensured nursing staff could identify and care plan resident-specific interventions to address the resident's needs. The ADON stated absence of interventions to address Resident 65's impaired vision could negatively impact Resident 65's quality of life and could place Resident 65 at risk for injury. During an interview on 3/13/2025 at 2:45 PM, with the MDS Nurse Consultant (MDSC), the MDSC stated her role was to train and re-educate MDS staff (including MDSN 1), to ensure MDS assessments were completed accurately and in accordance with the RAI manual. The MDSC stated the RAI manual indicated use of corrective lenses should be assessed through record review and interviews with the resident and direct care staff. The MDSC stated this would ensure the identification of need for visual aids, if indicated, and ensure the assessment for vision adequacy could be conducted accurately. The MDSC stated the RAI manual indicated vision adequacy was assessed by bringing printed reading material to the resident, providing the resident with any required visual aids (including glasses), and asking the resident to read. The MDSC stated it was not appropriate to rely on the resident's ability to see or wave at people in the hallway. 2. During a review of Resident 84's admission Record, the admission Record indicated Resident 84 was originally admitted on [DATE] and was most recently readmitted on [DATE]. Resident 84's admitting diagnoses included lack of coordination, abnormal posture, generalized muscle weakness, and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). During a review of Resident 84's MDS, dated [DATE], the MDS indicated Resident 84 had severely impaired cognition. The MDS indicated Resident 84 required substantial to maximal assistance from staff for mobility while in bed, and was dependent on staff for toileting hygiene, bathing, and dressing her lower body. The MDS indicated Resident 84 did not have any impairments to her upper extremities (shoulders, elbows, wrists, and hands) or lower extremities (hips, knees, ankles, and feet) that interfered with her daily function or placed her at risk for injury. During a review of Resident 84's active physician orders, dated 12/20/2024, the orders indicated staff provided passive range of motion exercises (PROM, exercises that use external force like gravity, leverage, or hands to move a joint where the resident does not assist) to Resident 84 four times a week, as tolerated. During an interview on 3/12/2025 at 1:25 PM, with the Director of Rehabilitation (DOR), the DOR stated Resident 84 was discharged from physical therapy services on 12/19/2024 and could not perform any active range of motion (AROM, exercises that involve moving joints through their normal range of motion using the patient's own muscle strength) in her upper or lower extremities. The DOR stated these limitations in mobility affected Resident 84's ability to perform ADLs and placed Resident 84 at risk for injury. During a concurrent interview and record review, on 3/12/2025 at 1:40 PM, with the DOR, Resident 84's MDS dated [DATE] was reviewed. The DOR stated the MDS was not accurate and should have indicated Resident 84 had impairments to her upper and lower extremities on both sides of her body. During and interview on 3/12/2025 at 1:46 PM, with MDSN 1, MDSN 1 stated she did not assess for impairments to Resident 84's upper and lower extremities in accordance with the RAI manual. MDSN 1 stated the MDS assessment for extremity impairments should be assessed and documented accurately to ensure staff knew how to safely care for the resident. During a concurrent interview and record review, on 3/12/2025 at 1:56 PM, with MDSN 1, Resident 84's MDS dated [DATE] was reviewed. MDSN stated the MDS indicated Resident 84 did not have any impairments to her upper and lower extremities. MDSN 1 stated Resident 84 could not move any of her extremities on her own and could not carry out any daily functions. MDSN 1 stated she did not conduct or document her assessment of Resident 84 accurately. During an observation on 3/13/2025 at 2:58 PM, with the MDSC, at Resident 84's bedside, observed MDSC assess for impairments to Resident 84's upper and lower extremities. Resident 84 was unable to follow any of the MDSC's commands and was not observed moving any of her extremities. During an interview on 3/13/2025 at 3:01 PM, with the MDSC, the MDSC stated her assessment indicated Resident 84 had impairments to all extremities due to her inability to follow commands and complete tasks. The MDSC stated Resident 84 had functional limitations that interfered with her daily functioning, and stated her MDS should indicate impairments to all upper and lower extremities.4. During a review of Resident 23's admission Record, the admission Record indicated Resident 23 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 23's diagnoses included fracture (broken bone) of the left and right femur (thigh bone), morbid obesity (a severe form of obesity characterized by an excessive amount of body fat that significantly impacts health and well-being), contracture of muscle multiple sites (a permanent or prolonged shortening of muscles, tendons, or other soft tissues that results in limited range of motion and stiffness), functional quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), neuromuscular dysfunction of bladder (poor bladder control), dementia (a progressive state of decline in mental abilities), and anxiety (a feeling of uneasiness). During a review of Resident 23's MDS, dated [DATE], the MDS indicated Resident 23's cognitive skills (ability to think and reason) for daily decision making was moderately impaired. The MDS indicated Resident 23 had an impairment on both sides of her lower extremities. The MDS indicated Resident 23 required substantial or maximal assistance (helper does more than half the effort, helper lifts or holds trunk or limbs and provides more than half the effort) for rolling to the left and right side of the bed. During a review of Resident 23's Physical Therapy Discharge summary, dated [DATE], the discharge summary indicated Resident 23 was assessed as total dependence with attempts to initiate for bed mobility. During a review of Resident 23's Certified Nursing Assistant (CNA) Task Flowsheet, dated 12/2024, the flowsheet indicated Resident 23 was assessed as dependent for the task of rolling to the left and the right side of the bed on the 7 a.m. to 3 p.m. shift on 21 days out of the 31 days in the month of December. The flowsheet indicated Resident 23 was assessed as dependent for the task of toileting hygiene on the 7 a.m. to 3 p.m. shift on 24 days out of the 31 days in the month of December. During a concurrent interview and record review, on 3/11/2025 at 4:00 PM, with Minimum Data Set Nurse MDSN 1, Resident 23's MDS Section GG (an assessment that evaluates the need for assistance with self-care and mobility activities, functional limitations in range of motion, and current and prior device use), dated 12/29/2024, was reviewed. MDSN 1 stated Resident 23's MDS Section GG indicated Resident 23 required substantial maximal assistance (helper does more than half of the effort) when rolling left and right in bed. MDSN 1 stated the normal process to code Section GG accurately was to gather data by conducting interviews from CNA staff, reviewing the CNA documentation, and the Rehabilitation Department documentation. MDS 1 stated she did not physically observe and assess Resident 23 reposition herself in bed to the left and the right side. During a concurrent interview and record review on 3/12/2025 at 1:46 PM, with MDSN 1, Resident 23's Physical Therapy Discharge summary, dated [DATE], and Resident 23's CNA Task Flowsheet, dated 12/2024, were reviewed. MDSN 1 stated most of the CNA documentation indicated Resident 23 was dependent on staff for rolling left and right in bed and for toileting hygiene. MDSN 1 stated Resident 23's Physical Therapy Discharge summary, dated [DATE], indicated Resident 23 was assessed as total dependence with attempts to initiate for bed mobility. MDS 1 stated there was a lack of documentation of the interviews she conducted with the CNAs to obtain the usual performance of Resident 23. MDSN 1 stated Resident 23's Section GG MDS assessment for rolling left and right in bed, dated 12/29/2024, did not accurately reflect the data and the documentation authored by the CNAs and the Rehabilitation Department. MDSN 1 stated it was important to ensure the MDS accurately reflected the true abilities and assessments of the residents so that care could be rendered appropriately. During an interview on 3/13/2025 at 12:36 PM with the ADON, the ADON stated the best practice for the MDSN was to observe the resident [performing] the action when coding the MDS assessment. The ADON stated the best source of information to accurately code MDS was from the Rehabilitation Department and CNA documentation. The ADON stated the MDS nurse could overrule the charting by conducting interviews with CNAs and the Rehabilitation Department and by documenting the interviews conducted. During a review of the facility's policy and procedure (P&P) titled Comprehensive Assessments, dated 10/2023, the P&P indicated comprehensive MDS assessments were conducted to assist in developing person-centered care plans. The P&P indicated the comprehensive assessment process included direct observation and communication with residents, as well as communication with licensed and non-licensed direct care staff members on all shifts. The P&P indicated staff were to conduct accurate assessments of each resident's functional capacity using the RAI manual. During a review of the facility's P&P titled MDS Assessment Coordinator, undated, the P&P indicated each individual who completes the MDS assessment must certify the accuracy of the assessment. 3. During a review of Resident 109's admission Record, the admission Record indicated Resident 109 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), hypertension (HTN, high blood pressure), and muscle weakness (loss of muscle strength). During a review of Resident 109's MDS, dated [DATE], the MDS indicated Resident 109's cognitive (the ability to think and process information) skills for daily decision making was intact. The MDS indicated Resident 109 was dependent (helper does all the effort) from staff for ADLs. During a concurrent observation and interview, on 3/11/2025 at 9:18 AM, with Resident 109, in Resident 109's room, Resident 109 was observed sitting up in bed, eating his breakfast. Resident 109 stated it was hard to chew his food because he did not have his natural teeth. Resident 109 stated his dentures were broken. During a concurrent observation and interview, on 3/12/2025 at 10:18 AM, in Resident 109's room, with MDSN 2, Resident 109 was observed lying in bed. MDSN 2 stated Resident 109 did not have his upper and bottom teeth. MDSN 2 stated Resident 109 did not have his natural teeth and the MDS assessment should be coded correctly to reflect Resident 109's dental status. During a concurrent interview and record review on 3/12/2025 at 2:04 PM, with MDSN 2, Resident 109's MDS, dated [DATE] was reviewed. MDSN 2 stated Resident 109's MDS oral/dental status assessment was coded incorrectly as it did not reflect the resident's actual oral and/or dental status. MDSN 2 stated because Resident 109 did not have his natural teeth, the MDS should have been coded. MDSN 2 stated accuracy of the MDS assessment was important for, quality measures tools that help quality and measure healthcare process, outcome, and resident perceptions, and care plan for the resident. MDSN 2 stated inaccuracy of the MDS assessment had the potential to result in not meeting the resident's care needs and services.

CONCERN (D)

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

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR- a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) Level II Evaluation was completed for one of six sampled resident (Resident 86). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Residents 86. Findings: During a review of Resident 86's admission Record, dated 3/13/2025, the admission record indicated Resident 86 was admitted to the facility on [DATE] and readmitted on [DATE]. The admission record indicated Resident 86's diagnoses included schizophrenia (a mental illness that is characterized by disturbances in thought), delusional disorder (a mental illness characterized by having false or unrealistic beliefs), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in life). During a review of Resident 86's History and Physical (H&P), dated 11/8/2024, the H&P indicated Resident 86 had the capacity to understand and make decisions. During a review of Resident 86's Minimum Data Set (MDS - a resident assessment tool), dated 2/5/2025, the MDS indicated Resident 86's cognitive skills (ability to think and reason) for daily decision making was intact. The MDS indicated Resident 86 required supervision (helper provides verbal cues and or touching assistance) for eating and substantial assistance (helper does more than half the effort) for toileting and bathing. During a review of Resident 86's Level I PASRR Screening, dated 5/4/2025, the Level I PSARR Screening indicated Resident 86 required a Level II PASRR evaluation due to suspected mental illness. The Level 1 PASRR Screening indicated a Level II mental health evaluation would be conducted to determine if the resident could benefit from specialized mental health services. The Level 1 PASRR Screening indicated the facility would be provided recommendations for specialized services once the mental health evaluation was complete. During an interview on 3/12/2025 at 11:50 a.m., with the Social Services Director (SSD), the SSD stated she was not responsible for completing the PASRR and did not know the process of following up on a Level II PASRR. The SSD stated the MDS Nurses (MDSNs) would have more information regarding Level II PASRRs. During an interview on 3/12/2025 at 11:53 a.m., with MDSN 1, MDSN 1 stated she did not know the PASRR process or what took place once a resident was recommended a Level II PASRR. MDSN 1 stated she would have to inquire who in the facility was responsible for following up on residents that required a Level II PASRR evaluation. During an interview on 3/12/2025 at 2:34 p.m. with MDSN 1, MDSN 1 indicated the facility did not have a process for following up on Level II PASRR evaluations. MDSN 1 stated the facility would implement a process moving forward. MDSN 1 stated because Resident 86's PASRR was not followed up, the resident did not benefit from any mental health services. During an interview on 3/12/2025 at 3:34 p.m., with the Director of Nursing (DON), the DON stated the SSD should have followed up on Resident 86's PASRRs to ensure Level I and Level II PASRRs were indicated for the resident. The DON stated the facility did not have a policy and procedure (P&P) pertaining to PASRRs. The DON stated not following up on Resident 86's PASRR could delay treatment and qualifications regarding mental health. The DON stated because the facility did not have a PASRR P&P, the SSD did not know it was her responsibility to follow up with the PASRRs.

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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure care plans were developed and/or implemented for 7 of 26 sampled residents (Residents 66, 21, 65, 62, 72, 109, and 12) when: 1. Resident 66's call light was not within reach on 3/11/2025 and fall mats (cushioned floor pads designed to help prevent injury should a person fall) were not placed at the bedside on 3/11/2025, 3/12/2025, and 3/13/2025. 2. Resident 21 and Resident 66 did not have care plans for their use of insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication). 3. Resident 65 did not have a care plan developed for her use of corrective lenses (glasses). 4. Resident 62 did not have care plans for his use of Levetiracetam (a drug used to help control seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness]) and Valproic Acid (a drug used to treat seizures). 5. Resident 72 did not have a care plan for his use of Eliquis (a blood thinner drug used to treat blood clots [clumps of blood that changed from a liquid to a gel]). 6. Resident 109 did not have a care plan addressing his missing teeth. 7. Resident 12 did not have an active plan of care for his self-releasing, nonrestraint seat belt that was used to ensure he did not fall from his wheelchair. These deficient practices placed Residents 66, 21, 65, 62, 72, 109, and 12 at risk for physical and psychosocial harm due to lack of provision of the required resident-specific interventions to meet the residents' needs. Findings: 1. During a review of Resident 66's admission Record, the admission record indicated Resident 66 was originally admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 66's admitting diagnoses included generalized muscle weakness, reduced mobility, and age-related osteoporosis (weak and brittle bones due to lack of calcium and Vitamin D). During a review of Resident 66's Minimum Data Set (MDS, a resident assessment tool), dated 2/20/2025, the MDS indicated Resident 66 had moderately impaired cognition (a condition where a person experiences noticeable declines in cognitive functions, such as memory, attention, and problem-solving, but these impairments are not severe enough to interfere significantly with daily life). The MDS indicated Resident 66 required substantial to maximal assistance from staff to roll left and right in bed and was fully dependent on staff to transition from sitting to lying, and lying to sitting positions, and chair/bed-to-chair transfers. During a review of Resident 66's care plan titled The resident is at risk for unavoidable falls, created 7/6/2024, the care plan indicated goals of care were Resident 66 being free from falls and associated injury. Care plan interventions indicated staff were to ensure Resident 66's call light was within reach. During a review of Resident 66's care plan titled [Resident 66] has had an actual fall .with serious injury, created 7/6/2024, the care plan indicated goals of care were Resident 66 not having any additional fall incidents. Care plan interventions indicated staff were to ensure Resident 66 had fall mats on both sides of her bed. During a review of Resident 66's Post-Fall Review assessment, dated 1/7/2025, the assessment indicated Resident 66 had an unwitnessed fall on 1/7/2025. The assessment indicated Resident 66's care plan was reviewed after the fall, and Resident 66 was to have floor mats to both sides of her bed and be encouraged to request for assistance. During a review of Resident 66's Quarterly Risk Data Collection Tool assessment, dated 1/17/2025, the assessment indicated Resident 66 was at risk for falls and had fallen one to two times in the last six months. During an observation on 3/11/2025 at 11:48 AM, at Resident 66's bedside, Resident 66 was observed lying in a left-facing position, with a blanket and sheet draped over her right arm. Resident 66's call light was placed on her bedside table, on her right side. When asked to demonstrate reaching the call light, Resident 66 was unable to reach it. During a concurrent observation and interview on 3/11/2025 at 1:13 PM, at Resident 66's bedside, with Resident 66, the resident stated she fell while in the facility. No fall mats were observed at Resident 66's bedside. During an observation on 3/12/2025 at 8:29 AM, at Resident 66's bedside, no fall mats were observed. During a concurrent observation and interview on 3/12/2025 at 11:53 AM, at Resident 66's bedside, with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 66 did not have fall mats to either side of her bed. CNA 1 stated the purpose of the fall mats was to lessen or prevent injury from a fall. CNA 1 stated the fall mats were softer than the floor, and stated that without the mat, there was increased potential for injury. During a concurrent observation and interview, on 3/12/2025 at 11:56 AM, at Resident 66's bedside, with CNA 2, CNA 2 stated she had provided care to Resident 66 for the last month. CNA 2 stated that in the last month, she did not observe fall mats at Resident 66's bedside. During a concurrent interview and record review, on 3/12/2025 at 12:07 PM, with Licensed Vocational Nurse (LVN) 1, Resident 66's care plan titled [Resident 66] has had an actual fall .with serious injury, dated 7/6/2024, was reviewed. LVN 1 stated the care plan indicated Resident 66 required fall mats to both [NAME] of her bed. LVN 1 stated Resident 66 was high risk for falls and the fall mats would minimize potential for injury if Resident 66 fell. During an observation on 3/13/2025 at 9:31 AM, at Resident 66's bedside, no fall mats were observed. During an interview on 3/13/2025 at 9:38 AM, with LVN 1, LVN 1 stated it was important for a resident's call light to be within reach. LVN 1 stated that if the call light was not within reach, the resident's needs might not be met, or they might attempt to get up unassisted and could fall and sustain injuries. 2. During a review of Resident 66's admission Record, the admission record indicated Resident 66 had an admitting diagnosis of type 2 diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 66's active physician order, dated 2/3/2025, the order indicated insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) twice a day for DM. During a review of Resident 21's admission Record, the record indicated Resident 21 was admitted to the facility on [DATE] and was most recently readmitted on [DATE]. Resident 21's admitting diagnoses included DM with diabetic retinopathy (a complication of diabetes that damages the blood vessels in the retina, the light-sensitive tissue at the back of the eye) to the left eye. During a review of Resident 21's MDS, dated [DATE], the MDS indicated Resident 21 had severely impaired cognition (a significant decline in cognitive abilities that interferes with daily functioning and independence) and was dependent on staff for mobility while in bed. During a review of Resident 21's active physician orders, dated 12/20/2024 and 3/5/2025, the orders indicated Resident 21 was to receive two types of insulin, twice a day, for DM. During an interview on 3/12/2025 at 3:09 PM, with Registered Nurse (RN) 3, RN 3 stated use of insulin required a care plan to ensure staff were aware of the interventions required for insulin administration. RN 3 stated interventions included monitoring the resident's blood sugar, oral intake of food, if applicable, monitoring hemoglobin A1c (a blood test that measures the average blood sugar level over the past 2-3 months) levels, and rotating insulin injection sites. RN 3 stated care plan goals would ensure staff monitored for effectiveness of the insulin, as well as adverse effects of the insulin, including excessively high or low blood sugar levels. During an interview on 3/13/2025 at 11:56 AM, with RN 1, RN 1 stated Resident 21 did not have a care plan for his use of insulin. During an interview on 3/13/2025 at 12:00 PM, with RN 1, RN 1 stated Resident 66 did not have a care plan for her use of insulin. 3. During a review of Resident 65's admission Record, the admission Record indicated Resident 65 was admitted on [DATE]. Resident 65's admitting diagnoses included major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 65's History and Physical (H&P), dated 9/25/2024, the H&P indicated Resident 65 had the capacity to understand and make decisions. During a review of Resident 65's MDS, dated [DATE], the MDS indicated Resident 65 had severely impaired cognition. The MDS indicated Resident 65 required partial to moderate assistance from staff to eat and required substantial to maximal assistance from staff for all other activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 65's optometry progress note, dated 11/5/2024, the progress note indicated Resident 65 required bifocal glasses (glasses that provide two different lens powers, correcting vision at both long and short distances) for improvement of vision and quality of life. The progress note indicated a new prescription was ordered for Resident 65's bifocal glasses. During a review of Resident 65's progress note, dated 2/3/2025, the progress note indicated Resident 65's new glasses were provided by the Social Services Director and indicated Resident 65 was happy. During an interview on 3/11/2025 at 10:44 AM, with Resident 65, Resident 65 stated she was seen by an eye doctor and the eye doctor prescribed glasses because she had glaucoma (a group of eye diseases that damage the optic nerve, potentially leading to vision loss and blindness). Resident 65 stated she had the glasses but could not put them on due to pain and limited mobility in her hands. Resident 65 stated the glasses were in her bedside dresser, but staff did not assist her to put them on. During an interview on 3/11/2024 at 3:24 PM, with CNA 7, CNA 7 stated she did not know Resident 65 required glasses. CNA 7 stated it was important for residents requiring glasses to have access to them so they can participate in ADLs and leisure activities like watching television. During a concurrent observation and interview on 3/11/2025 at 3:27 PM, with CNA 7, at Resident 65's bedside, CNA 7 stated Resident 65 had a rose-gold colored pair of glasses in her bedside dresser. The glasses were wrapped in a protective foam cover inside of their case, and did not appear to have been used. CNA 7 stated she provided care to Resident 65 for the last month and never observed Resident 65 wearing the glasses. During an interview on 3/11/2025 at 3:25 PM, with the Director of Nursing (DON), the DON stated use of corrective lenses/glasses should be care planned to ensure staff know why the resident required glasses, and to ensure staff knew if the resident required assistance with putting them on and taking them off. The DON stated Resident 65 did not have a care plan for her use of glasses. The DON stated that without a care plan, staff would not know Resident 65 required glasses, which placed Resident 65 at risk for accidents, and could also interfere with her ability to participate in and enjoy activities. 7. During a review of Resident 12's admission Record, the admission Record indicated Resident 12 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 12's diagnoses included muscle wasting and atrophy, muscle weakness, and dementia. During a review of Resident 12's MDS, dated [DATE], the MDS indicated Resident 12's cognitive skills (ability to think and reason) for daily decision making were intact. The MDS indicated Resident 12 required partial or moderate assistance (helper does less than half the effort) when eating and performing oral hygiene. The MDS indicated Resident 12 required substantial or maximal assistance (helper does more than half of the effort) when performing toileting hygiene, and showering. The MDS indicated Resident 12 required substantial or maximal assistance when sitting to standing. During an observation on 3/10/2025 at 10:42 AM, in Resident 12's room, Resident 12 observed seated on a wheelchair with the wheelchair seat belt fastened. During a concurrent observation and interview on 3/11/2025 at 10:26 AM, with CNA 4, observed Resident 12's wheelchair seat belt fastened. CNA 4 stated Resident 12 used the seat belt for safety. During a review of all of Resident 12's Care Plans, dated 2024 to 2025, there was no active care plan in place for Resident 12's wheelchair seat belt. During an interview on 3/12/2025 at 3:38 PM with RN 3, RN 3 stated that a care plan was needed for Resident 12's seat belt, especially if the staff were utilizing the seat belt for safety. RN 3 stated there was the potential for an accident to occur if the seat belt was not regularly monitored. RN 3 stated a restraint (devices or methods used to limit a patient's movement, primarily to prevent harm to themselves or others) assessment should be regularly performed to ensure Resident 12 was able to unfasten the seat belt. During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated a comprehensive, person-centered care plan, was to include includes measurable objectives and timeframes and describe the services that staff were to furnish to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 4. During a review of Resident 62's admission Record, the admission Record indicated Resident 62 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included convulsions (muscles contract uncontrollably during seizure), dementia (a progressive state of decline in mental abilities), major depression, dysphagia (difficulty swallowing), and muscle weakness (loss of muscle strength). During a review of Resident 62's MDS, dated [DATE], the MDS indicated Resident 62's cognitive (the ability to think and process information) skills for daily decision making severely impaired. The MDS indicated Resident 62 required moderate (helper does less than half the effort) assistance from staff for ADLs. During a review of Resident 62's Order Summary Report, dated 1/24/2025, the order summary report indicated Resident 62's physician prescribed Levetiracetam 750 milligram ([mg]- metric unit of measurement, used for medication dosage and/or amount), oral tablet, Resident 62 would receive one (1) tablet every 12 hours for seizures. The Order Summary Report indicated Resident 62's physician prescribed Valproic Acid 250 mg/milliliter ([ml]- metric unit of measurement, used for medication dosage and/or amount), oral solution, Resident 62 would receive 15 ml every 12 hours for seizures. During a concurrent interview and record review, on 3/12/2025 at 9:00 AM, with Registered Nurse (RN) 1, Resident 62's Medication Administration Record (MAR), dated 1/24/2025 to 3/12/2025 was reviewed. RN 1 stated Resident 62's MAR indicated the resident received Levetiracetam 750 mg, 1 tablet every 12 hours for seizures, and Valproic Acid 15 ml every 12 hours for seizures from 1/24/2025 through 3/12/2025. RN 1 stated Resident 62's seizure medication should have a care plan to guide the nurses to monitor for seizure any side effects of the seizure medications. During a concurrent interview and record review on 3/12/2025 at 9:20 AM, with RN 1, Resident 62's active care plans, dated 1/24/2025 through 3/12/2025 were reviewed. RN 1 stated the care plans did not indicate Resident 62's use of Levetiracetam and Valproic Acid was addressed and care planned. RN 1 stated Resident 62 was receiving scheduled seizure medications which should have been care planned to ensure Resident 62 was monitored for seizures and the nursing staff could communicate to Resident 62's physician the efficacy of the Levetiracetam and Valproic Acid. RN 1 stated the care plan would guide the nurses to monitor for side effects and be aware of the black box warning (a label on a drug that alerts the healthcare providers to a serious risk of injury or death by administering the drug). RN 1 stated without the appropriate care plans in place, Resident 62 was at risk of not receiving the necessary care and services. 5. During a review of Resident 72's admission Record, the admission Record indicated Resident 72 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included major depression disorder, anxiety (a feeling of fear), and quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury). During a review of Resident 72's MDS, dated [DATE], the MDS indicated Resident 72's cognitive skills for daily decision making was intact. The MDS indicated Resident 72 was dependent (helper does all the effort) from staff for ADLs. During a concurrent interview and record review on 3/12/2025 at 9:30 AM, with RN 1, Resident 72's Order Summary Report, dated 2/27/2025, was reviewed. RN 1 stated order summary report indicated Resident 72 received Eliquis 2.5 mg, 1 tablet every 12 hours for blood clots prophylaxis (preventative treatment). RN 1 stated Eliquis was a blood thinner medication that can cause bleeding, abnormal bruising and should have a care plan to ensure Resident 72 was being monitored for any side effects. During a concurrent interview and record review on 3/12/2025 at 9:40 AM, with RN 1, Resident 72's active care plans were reviewed. RN 1 stated care plans did not indicate Resident 72's use of Eliquis was care planned. RN 1 stated a care plan was important to ensure staff were aware of the interventions required for the use of Eliquis and Resident 72 being monitored for effectiveness of the Eliquis. 6. During a review of Resident 109's admission Record, the admission Record indicated Resident 109 was admitted to the facility on [DATE] with diagnoses which included DM, congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), hypertension (HTN, high blood pressure), and muscle weakness. During a review of Resident 109's MDS, dated [DATE], the MDS indicated Resident 109's cognitive skills for daily decision making was intact. The MDS indicated Resident 109 was dependent from staff for ADLs. The MDS indicated Resident 109 was assessed as not having any oral and/or dental issues. During a concurrent observation and interview on 3/12/2025 at 1:18 PM, in Resident 109's room, with MDSN 2, Resident 109 was observed lying in bed. MDSN 2 stated Resident 109 did not have his upper and bottom teeth. MDSN 2 stated Resident 109 did not have his natural teeth and should have care planning to reflect Resident 109's oral and dental status. During a concurrent interview and record review on 3/12/2025 at 2:04 PM, with Minimum Data Set Nurse (MDSN) 2, Resident 109's electronic medical record (EMR) was reviewed. MDSN 2 stated she was not able to locate a care plan for Resident 109's dental status. MDSN 2 stated there should have been a care plan initiated upon Resident 109's admission to the facility to ensure staff were aware of the interventions required for oral care and monitoring for an increased risk of oral health problem. MDSN 2 stated if there was no care plan, the facility staff would not be able to provide quality of care to residents.

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain good grooming and personal hygiene for two of six sampled residents (Residents 49 and 62) by failing to keep Resident 49's fingernails, and Resident 62's toenails clean and neat. This failure had the potential to result in a negative impact on Residents 49 and 62's quality of life and self-esteem and had the potential for the development of infection. Findings: 1. During a concurrent observation and interview on 3/10/2025 at 11:18 AM, with Resident 49, in Resident 49's room, observed Resident 49's fingernails were long with a brown substance underneath the nails. Resident 49 stated, No one cuts or cleans my nails. Resident 49 stated his fingernails looked long and that he would like to have his fingernails cut and cleaned. During a review of Resident 49's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 49 was admitted to the facility on [DATE] with diagnoses which included dementia (a progressive state of decline in mental abilities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and hypertension (HTN- high blood pressure). During a review of Resident 49's Minimum Data Set ([MDS] - a resident assessment tool), dated 1/28/2025, the MDS indicated Resident 49' cognitive (the ability to think and process information) skills for daily living was severely impaired. The MDS indicated Resident 49 required moderate (helper does less than half the effort) assistance from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 49's care plan with a focus of Resident has an ADLs self-care deficit related to confusion, date initiated 10/24/2024, the care plan interventions indicated the facility would clean Resident 49's fingernails daily and trim as necessary. During a concurrent observation and interview on 3/10/2025 at 11:27 AM, with Certified Nursing Assistant (CNA 3), in Resident 49's room, Resident 49 was observed with long fingernails and a brown substance underneath the nails. CNA 3 stated Resident 49's fingernails were long and dirty. CNA 3 stated CNAs were responsible for cleaning the residents' fingernails daily and trimming as needed. CNA 3 stated it was important to keep Resident 49's fingernails clean and trimmed to prevent the growth of bacteria (infection). CNA 3 stated long, dirty fingernails had the potential for the resident to scratch his skin and if Resident 49 scratched himself hard enough, it could create an open wound and increased risk for infection. CNA 3 stated having dirty fingernails was not sanitary because the resident will use his hands to hold utensils when eating and any bacteria could transfer into the body. 2. During an observation on 3/10/2025 at 1:19 PM, in Resident 62's room, observed Resident 62 with long toenails and a black substance underneath and around his toenails. During a review of Resident 62's Face Sheet, the Face Sheet indicated Resident 62 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia, major depression, dysphagia (difficulty swallowing), and muscle weakness (loss of muscle strength). During a review of Resident 62's MDS, dated [DATE], the MDS indicated Resident 62's cognitive skills for daily living was severely impaired. The MDS indicated Resident 62 required moderate assistance from staff for ADLs. During a review of Resident 62's care plan with a focus of Resident has an ADLs self-care deficit related to dementia, date initiated 9/5/2024, the care plan interventions indicated the facility would clean Resident 62's nails daily and trim as necessary. During a concurrent observation and interview on 3/11/2025 at 1:20 PM, with CNA 3, in Resident 62's room, observed Resident 62 with long toenails and a black substance underneath and around the toenails. CNA 3 stated Resident 62's toenails were dirty and required cleaning and trimming. CNA 3 stated nail care was one of the CNAs duties, where they looked over the residents' nails and if the nails were long or dirty, the CNAs would clip, trim, and clean the nails. CNA 3 stated residents' toenails should be cleaned daily and trimmed as needed. CNA 3 stated it was important to keep residents' toenails clean and trim to prevent infection, cuts, and skin injury. During an interview on 3/13/2025 at 11:25 AM, with the Director of Staff Development (DSD), the DSD stated nail care should be performed daily and if the resident required assistance with cleaning or trimming their nails, the CNAs should assist. The DSD stated nails care was important because the residents' nails were a source of infection and having dirty nails could affect how residents' see themselves. The DSD stated the residents' hygiene was very important and residents' nails should have been addressed. The DSD stated dirty nails increased the risk for infection. The DSD stated residents should be provided with care and services necessary to maintain good personal hygiene. During a review of the facility's policy and procedure (P&P) titled Fingernails/Toenails, Care of, revised 2/2018, the P&P indicated the facility will clean the nails, and keep nails trimmed to prevent infections. The P&P indicated nail care included daily cleaning and regular trimming. During a review of the facility's P&P titled Activities of Daily Livings (ADL), Supporting, revised 3/2018, the P&P indicated residents who are unable to carry out ADLs independently would receive the services necessary to maintain good grooming and personal hygiene.

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the low air loss mattress (LALM - a mattress designed to distribute the individual's body weight over a broad surface area and help prevent skin breakdown) was set according to the resident's weight for one of six sampled residents (Resident 282). This deficient practice had the potential to cause the development, worsening or reinjury of pressure sores (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) to Resident 282. Findings: During an observation on 3/10/2025 at 11:42 a.m., in Resident 282's room, observed Resident 282 lying on a low air loss mattress (LALM - a mattress designed to distribute the individual's body weight over a broad surface area and help prevent skin breakdown). Resident 282's LALM was set to [PHONE NUMBER] pounds (lbs., measure of weight). A weight of 293 lbs. and a date of 1/21/2025 was posted on the LALM control panel. During a review of Resident 282's admission Record, dated 2/27/2024, the admission record indicated Resident 282 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission record indicated the following diagnoses which included acute respiratory failure with hypoxia (when the lungs suddenly fail to adequately provide oxygen to the body, resulting in a dangerously low level of oxygen in the blood), congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), anemia (a condition where the body does not have enough healthy red blood cells), cirrhosis of the liver (scarring of the liver caused by long-term damage), and morbid (severe) obesity (excessive body fat). During a review of Resident 282's History and Physical (H&P), dated 3/4/2025, the H&P indicated Resident 282 did not have the capacity to understand and make decisions. During a review of Resident 282's Minimum Data Set (MDS - a resident assessment tool), dated 2/17/2025, the MDS indicated Resident 282's cognition (ability to think, remember, and reason) for daily decision making was severely impaired. The MDS indicated Resident 282 was dependent (helper does all the effort) for oral hygiene, toileting, bathing, and personal hygiene. During a review of Resident 282's Braden Scale (measures the risk for development of a pressure sore) dated 3/4/2025, the Braden Scale indicated Resident 282 was bedbound (confined to bed), had very limited mobility (ability to move) and was at a high risk of developing pressure sores. During a concurrent observation and interview on 3/11/2025 at 4:26 p.m., with Licensed Vocational Nurse (LVN 2), Resident 282's LALM settings were observed. LVN 2 stated Resident 282's LALM should be adjusted according to his weight. LVN 2 stated the LALM was set to [PHONE NUMBER] lbs. which was too high for Resident 282. LVN 2 stated the higher the setting, the harder the bed would be. LVN 2 stated the hard bed would not be good for Resident 282's skin and would cause further skin breakdown. During a concurrent observation and interview on 3/13/2025 at 12:18 p.m., with Treatment Nurse (TN 1), Resident 282's LALM settings were observed. TN 1 stated he observed Resident 282's bed was set too high when he started the morning shift on 3/12/2025. TN 1 stated he set the LALM mattress to the correct setting according Resident 282's weight of 293 lbs. TN 1 stated because Resident 282's LALM was set too high, it was not protecting the resident's skin or promoting healing. TN 1 stated Resident 282 was lying on a hard surface due to the high settings which increased the pressure and could have caused redness and dead tissue to his skin. TN 1 stated all licensed nurses were responsible for checking the LALM setting every day and every shift. During a review of the facility's policy and procedure (P&P) titled Support Surface Guideline, revised February 2024, the P&P indicated residents at risk for developing pressure ulcers should be placed on a redistribution support surface such as alternating air or air-loss device when lying in bed and follow any air support surface mattress manufacture guidelines. During a review of the facility's document titled, Drive Med Air Plus 10 Alternating Pressure and Low Air Loss Mattress, undated, the document indicated to adjust the pressure based on the patient's weight and comfort level.

CONCERN (D)

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Director of Rehabilitation (DOR), or the assigned Licensed Vocational Nurse (LVN) were made aware of the development of a resident's right-hand contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion) for one out of two sampled residents (Resident 95). This failure had the potential to result in the worsening of Resident 95's right hand contracture. Findings: During a review of Resident 95's admission Record, the admission Record indicated Resident 95 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 95's diagnoses included cerebral infarction (a condition where blood flow to the brain is interrupted, causing brain cells to die), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), aphasia (a disorder that makes it difficult to speak), muscle weakness, gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), anxiety (a feeling of uneasiness) and delirium (a serious disturbance in a person's mental abilities that results in a decreased awareness of one's environment and confused thinking). During a review of Resident 95's Minimum Data Set ([MDS], a resident assessment tool), dated 12/15/2024, the MDS indicated Resident 95's cognitive skills (ability to think and reason) for daily decision making was severely impaired. The MDS indicated Resident 95 had an impairment on one side of his upper and lower extremities. The MDS indicated Resident 9 was dependent on staff (helper does all the effort) activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and bed mobility. During a review of Resident 95's Occupational Discharge summary, dated [DATE], indicated Resident 95's right upper extremities were within functional limits (a person's ability to perform tasks is sufficient for daily living, even if it's not within the normal range). During a review of all the Certified Nursing Assistant (CNA) Stop and Watch Forms (forms completed by the CNA or the RNA [restorative nurse aide] to document the notification to the LVN or the RN of a resident change of condition), dated 2/1/2025 to 3/11/2025, there was no Stop and Watch Form completed addressing Resident 95's contracture. During a review of Resident 95's Occupational Therapy Evaluation, dated 3/12/2025, the evaluation indicated Resident 95 had a contracture to the right hand. The evaluation indicated the right upper extremity (arm) range of motion of the wrist, hand, index finger, middle finger, ring finger, and little finger were impaired. During an interview on 3/11/2025 at 4:24 p.m. with the Director of Rehabilitation (DOR), the DOR stated he was not made aware of Resident 96's decline in range of motion or change of condition. The DOR stated changes of condition or decline in mobility were discussed in the daily meetings with the Rehabilitation Department and the restorative nurse aides (RNA). During a concurrent interview and record review on 3/12/2025 at 7:43 a.m. with Occupational Therapist (OT) 1, Resident 95's Joint Mobility Assessment (a medical evaluation that determines the range of motion (ROM) and flexibility of joints was conducted). OT 1 stated Resident 95 developed a right-hand contracture. OT 1 stated the normal practice was that a change of condition was reported to the LVN or the DOR. OT 1 stated if the Rehabilitation Department was made aware of the development of Resident 95's right hand contracture, then she would have expected an order for hand splinting to be inputted right away. During an interview on 3/12/2025 at 8:06 a.m. with RNA 1, RNA 1 stated she was familiar with Resident 95 and usually provided Resident 95 with passive range of motion exercises (joint movement achieved when an external force, like a therapist or device, moves a body part, without the person actively engaging their muscles to perform the movement). RNA 1 stated the normal process to report a change of condition or a decline in mobility was to document the change on a Stop and Watch form and notify the LVN or DOR. RNA 1 stated she noticed the development of Resident 95's contracture approximately two weeks ago. RNA 1 stated she did not complete the Stop and Watch form and because she recalled making the Rehabilitation Department aware. RNA 1 stated she should have completed a Stop and Watch form to document that she made the LVN aware. RNA 1 stated if the LVN or DOR was not made aware of the change, then there was a potential for continued decline in Resident 95's range of motion because orders for hand splinting would not be obtained. During a review of the facility's Policy and Procedure (P&P) titled, Acute Condition Changes, revised 3/2018, the P&P indicated the direct care staff, including nursing assistants would be trained in recognizing subtle but significant changes in the resident and how to communicate these changes to the Nurse. During a review of the facility's RNA Job Description (undated), the Job Description indicated the RNA was to report any changes in residents' condition immediately to the supervisor.

CONCERN (D)

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

Deficiency F0694 (Tag F0694)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assess the midline (a long thin, flexible tube inserted into a large vein used to administer medication) insertion site at least every shift and change the dressing every seven (7) days for two of six sampled residents (Residents 330 and 72). This deficient practice had the potential for Residents 330 and 72's Midline insertion site to develop an infection. Findings: 1. During an observation on 3/10/2025 at 11:11 AM, in Resident 330's room, observed a midline to Resident 330's left upper arm. The midline dressing was dated 2/27/2025. During a review of Resident 330's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 330 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included sepsis (a life-threatening infection), peritonitis (infection of an abdominal organ), and hypertension ([HTN]- high blood pressure). During a review of Resident 330's Minimum Data Set ([MDS] - a resident assessment tool), dated 2/18/2025, the MDS indicated Resident 330's cognitive (ability to think and reason) skills for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated Resident 330 was dependent (helper does all the effort) from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 330's Order Summary Report dated 3/6/2025, the Order Summary Report indicated Resident 330's physician prescribed Meropenem (drug used to treat infection) one (1) gram ([gm] - metric unit of measurement, used for medication dosage and/or amount) intravenously ([IV] - into or within the vein) two times a day for seven days for peritonitis. During a concurrent interview and record review on 3/11/2025 at 3:30 PM, with Registered Nurse (RN 1), Resident 330's Medication Administration Record ([MAR] - a daily documentation record used by licensed nurse to document medications/treatment given to a resident) from 3/6/2025 to 3/11/2025 was reviewed. RN 1 stated Resident 330's midline site was not assessed every shift and the dressing was not changed every 7 days per the facility policy. RN 1 stated it was important to monitor the midline site for redness, swelling, pain as signs of infection, document in the MAR, and change the dressing. 2. During a review of Resident 72's Face Sheet, the Face Sheet indicated Resident 72 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included sepsis, major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and HTN. During a review of Resident 72's MDS, dated [DATE], the MDS indicated Resident 72's cognitive skills for daily decision making was intact. The MDS indicated Resident 72 was totally dependent from staff for ADLs. During a review of Resident 72's MAR, dated 2/28/2025, the MAR indicated Resident 72 was to receive Ertapenem (drug used to treat infection) 1 gm, IV, one time a day for sepsis for 7 days. During a concurrent observation and interview on 3/11/2025 at 4:00 pm, with RN 1, in Resident 72's room, observed a midline to Resident 72's right upper arm. RN 1 stated Resident 72' midline dressing was soiled, dislocated, and dated 2/24/2025. RN 1 stated RNs were responsible for assessing the residents' midline site daily, changing the dressing every 7 days, and as needed for soiled or dislocated dressing to prevent infection. During a review of the facility's policy and procedure (P&P) titled Central Venous Catheter Care and Dressing Changes, revised 3/2022, the P&P indicated the facility will perform site care and dressing change every 7 days, if it becomes damp, loosed or visibly soiled. The P&P indicated to record assessments, dressing changes, and any observed complications in the resident's medical record.

CONCERN (D)

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

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure interventions were provided for one of three sampled residents (Resident 65) when: 1. Resident 65's call light was not placed within reach to allow Resident 65 to call for assistance. 2. Staff failed to reposition Resident 65 at least every two hours. These failures placed Resident 65 at risk for avoidable undue pain due to staying in the same position for a prolonged period. These failures also created the potential for a delay or an inability for Resident 65 to request help from staff for repositioning, also interfering with Resident 65's ability to report her pain to staff, and request interventions to address the cause of her pain and treat it. Findings: During a review of Resident 65's admission Record, the admission Record indicated Resident 65 was admitted on [DATE]. Resident 65's admitting diagnoses included generalized muscle weakness, abnormalities of gait (walking pattern) and mobility, right shoulder pain, dorsalgia (physical discomfort occurring anywhere on the spine or back, ranging from mild to disabling), major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 65's History and Physical (H&P), dated 9/25/2024, the H&P indicated Resident 65 had the capacity to understand and make decisions. During a review of Resident 65's Minimum Data Set (MDS, a resident assessment tool), dated 2/25/2025, the MDS indicated Resident 65 had severely impaired cognition (a significant decline in cognitive abilities that interferes with daily functioning and independence). The MDS indicated Resident 65 required substantial to maximal assistance from staff to roll to a left or right facing position from her back, and to transition from a sitting to lying position or lying to sitting position, while in bed. During a review of Resident 65's care plan titled Resident is risk for pain . initiated 5/18/2021 and revised 2/28/2025, the care plan indicated a goal that Resident 65 would verbalize adequate relief of pain or ability to cope with incompletely relieved pain. The interventions indicated staff were to monitor for probable causes of pain and remove/limit the cause where possible and respond immediately to any complaints of pain. During a review of Resident 65's care plan titled Impaired physical mobility related to muscle weakness (generalized), abnormalities of gait and mobility, pain in right shoulder, created 7/18/2024, the care plan indicated Resident 65 was totally dependent on staff for repositioning and turning in bed. During a concurrent observation and interview on 3/11/2025 at 10:10 AM, at Resident 65's bedside, Resident 65 was observed lying in bed in a left-facing position, with a pad call light clipped to her chest. Resident 65 stated the physical therapist told her she needed to be turned every two hours to prevent pain. Resident 65 stated she was sometimes kept in the same position for four to five hours, and she kept track of how long she was in the same position because she could see the clock on the wall. An analog clock was observed on the wall facing Resident 65's bed and the time on the clock was correct. Resident 65 stated that when she is kept in the same position for longer than two hours, the pain in her back was unbearable, and stated being kept in the same position made her feel sad because she could not move on her own and she was dependent on staff for help. During a concurrent observation and interview on 3/11/2025 at 11:06 AM, at Resident 65's bedside, Resident 65 was observed with a pad call light clipped to her chest. When asked to demonstrate pressing the call light, Resident 65 was unable to reach the call light and press it. Resident 65 was unable to move her fingers and her hands were stiff. Resident 65 stated her hands were weak and stated she usually asked her roommate to call for help for her. Resident 65's roommate was not in the room at the time of the interview. During interview on 03/11/2025 at 11:11 AM, with Certified Nursing Assistant (CNA) 9, CNA 9 stated placement of the pad call light was resident-specific and stated the call light should be placed in a position that allows the resident to call for help. CNA 9 stated the call lights should be accessible because if a resident could not call for help, they might not receive the assistance the need. During an observation on 3/11/2025 at 11:14 AM, with CNA 9, observed CNA 9 ask Resident 65 to press the call light while it was clipped to her chest. Resident 65 could not press the call light. CNA 9 moved the pad call light to a lower position, on Resident 65's abdomen, and Resident 65 able to press the call light with her elbow. During an interview on 3/11/2025 at 11:17 AM, with CNA 9, CNA 9 stated Resident 65 originally had the call light clipped to her chest. CNA 9 stated this location was not functional to ensure Resident 65 could use the call light. CNA 9 stated staff should assess appropriateness of call light placement and ensure it was resident-specific to meet the resident's needs. CNA 9 stated Resident 65 was verbal, and usually yelled for assistance. CNA 9 stated that yelling was not an appropriate method to call for help and stated Resident 65 should be able to use her call light. During an observation on 3/11/2025 at 12:13 PM, at Resident 65's bedside, Resident 65 was observed in the same left-facing position. During a concurrent observation and interview on 3/11/25 at 1:33 PM, at Resident 65's bedside, Resident 65 was observed in the same left-facing position. Resident 65 stated she had pain from being in the same position for too long. During a concurrent observation and interview on 3/12/2025 at 8:31 AM, at Resident 65's bedside, Resident 65 was observed lying on her back with her pad call light clipped to her chest. Resident 65 stated she was last turned at 5:00 AM, and she was unable to press the call light to request to be repositioned. Resident 65 stated she felt a pain score of seven (0= no pain, 10 being the worst pain) in her back, and she was grimacing during the interview. Resident 65 stated she felt pain from being in the same position for too long. During a concurrent observation and interview, on 3/12/2025 at 8:39 AM, at Resident 65's bedside, with CNA 1, CNA 1 asked Resident 65 to press her call light. Resident 65 was unable to activate the call light while clipped to her chest. CNA 1 stated the current placement of the call light was not effective if Resident 65 could not press it. CNA 1 stated the call light needed to be repositioned to allow the resident to reach it and press it with enough strength to activate it. CNA 1 clipped the call light lower on Resident 65's abdomen and Resident 65 was able to press the call light. During an interview on 3/13/2025 at 9:35 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident could not reposition herself and was fully dependent on staff for repositioning. LVN 1 stated that keeping Resident 65 in the same position for a prolonged period could cause her to experience pain. LVN 1 stated staff should reposition the resident at least every two hours, or more frequently, to prevent pain. LVN 1 stated residents should have their call light within reach to be able to report pain and/or request to be repositioned. During a review of the facility's policy and procedure (P&P) titled Pain Assessment and Management, undated, the P&P indicated pain management was a multidisciplinary process and included assessing the potential for pain, addressing the underlying causes of pain, and implementing approaches to pain management. The P&P indicated non-pharmacological interventions for main management included repositioning. During a review of the facility's policy and procedure (P&P) titled Accommodation of Needs, revised 3/2021, the P&P indicated facility environment and staff behaviors were to be directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. During a review of the facility's P&P titled Answering the Call Light, revised 9/2022, the P&P indicated staff were to ensure the call light was accessible to the resident when in bed.

CONCERN (D)

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

Deficiency F0740 (Tag F0740)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the following for one of one sampled residents (Resident 15): 1. Adequate documentation indicating Resident 15's physician (MD) 1 was made aware of Resident 15's newly prescribed antipsychotic (a class of medications used to treat mental health conditions medication) after being readmitted from the general acute care hospital (GACH). 2. Carry out MD 1's order for a psychiatrist consult (focusing on the diagnosis, treatment, and prevention of mental, emotional, and behavioral disorders, including substance use disorders) when Resident 15 displayed physically aggressive behaviors on 3/8/2025. These failures had the potential to result in a delay of necessary behavioral health treatment and services to maintain the highest practicable physical, mental and psychosocial well-being for Resident 15. Findings: During a review of Resident 15's admission Record, the admission Record indicated Resident 15 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 15's diagnoses included dementia (a progressive state of decline in mental abilities), anxiety (a feeling of uneasiness), depressive disorder (a mental health condition characterized by persistent low mood, loss of interest, and other symptoms that can significantly impact daily life), and agitation (a state of restlessness, unease, and distress). During a review of Resident 15's Minimum Data Set ([MDS], a resident assessment tool), dated 2/8/2025, the MDS indicated Resident 15's cognitive skills (ability to think and reason) for daily decision making were severely impaired. The MDS indicated Resident 15 exhibited delusions, (misconception or beliefs that are firmly held, contrary to reality) and exhibited verbal behavioral symptoms directed towards others (threatening others, screaming at others, cursing at others). The MDS indicated Resident 15 was dependent on staff (helper does all the effort) for toileting hygiene, bathing, and lower body dressing. The MDS indicated Resident 15 required partial or moderate assistance (helper does less than half of the effort) when performing oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 15 required substantial or maximal (helper does more than half of the effort) assistance for bed mobility. During a review of Resident 15's situation, background, assessment, recommendation (SBAR - a communication tool used by healthcare workers when there is a change of condition among the residents), dated 9/19/2024, the SBAR indicated on 9/19/2024, Resident 15 was physically aggressive towards staff while staff tried to change her clothing. During a review of Resident 15's SBAR, dated 2/7/2025, the SBAR indicated on 2/7/2025, Resident 15 exhibited increased confusion and was physically aggressive. During a review of Resident 15's admission Summary Note, dated 2/11/2025, the note indicated Resident 15 was admitted from the general acute care hospital (GACH). The note indicated all medications were verified and approved by MD 1. There was no documentation to indicate which medications were started or discontinued from the GACH. During a review of Resident 15's SBAR, dated 3/8/2025, the SBAR indicated on 3/8/2025, Resident 15 exhibited poor safety awareness and scratched staff during activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) care. The SBAR indicated MD 1 ordered a psychiatric consult for Resident 15 on 3/8/2025. During an observation on 3/10/2025 at 11:00 a.m., in Resident 15's room, Resident 15 was observed lying in bed yelling, You're a demon!. Resident 15 hit Certified Nursing Assistant (CNA) 5 with her teddy bear and proceeded to yell, Get out, get out, you're one of them!. During a concurrent observation and interview on 3/12/2025 at 8:03 a.m. with CNA 10, CNA 10's arm was observed. A two-centimeter (cm- a unit of measurement) scar was on her right arm. CNA 10 stated Resident 15 scratched her and it caused the scar. CNA 10 stated Resident 15 always hits me. 1. During a concurrent interview and record review on 3/12/2024 at 10:28 a.m. with Registered Nurse (RN) 1, Resident 15's GACH Discharge Medication List, dated 2/11/2025, and admission Summary Note, dated 2/11/2025, was reviewed. The GACH Discharge Medication List indicated Resident 15 was to start taking Seroquel (an antipsychotic medication) 50 milligram (mg- a unit of measurement) oral tablet once a day at bedtime. RN 1 stated the normal process for admitting a resident was to verify new and old medications to continue at the facility with the physician and document. RN 1 stated if there were newly prescribed medications, the physician had to be made aware and would decide whether the medications would be continued at the facility. RN 1 stated a rational for the discontinuation of any newly prescribed medications should be documented. RN 1 stated the admission Summary Note did not indicate MD 1 was made aware of Resident 15's new prescription of Seroquel 50 mg oral tablet once a day at bedtime. During an interview on 3/12/2025 at 1:30 p.m. with MD 1, MD 1 stated if she was made aware Resident 15 had a newly prescribed psychotropic medication from the GACH, then she would have automatically resorted to inputting a psychiatric consult. MD 1 stated it was her practice to ensure all psychotropic medications were appropriately evaluated and prescribed for a proper psychiatric diagnosis. MD 1 stated she exercised great caution with the prescribing of psychotropic medications. MD 1 stated there was a potential for Resident 15 to not improve if there was no psychiatric consult in place. MD 1 stated she reviewed Resident 15's Physician Orders and did not see an order after Resident 15's readmission to the facility. During a concurrent interview and record review on 3/12/2025 at 3:17 p.m. with RN 3, Resident 15's GACH Discharge Medication List, dated 2/11/2025, and admission Summary Note, dated 2/11/2025, were reviewed. RN 3 stated she authored the admission Summary Note and stated the normal process when admitting the resident was to verify the medications with the physician and fax the medication list to the physician. RN 3 stated it was not in her practice to explicitly list each newly prescribed medication that was started or discontinued. RN 3 stated that it was important for the physician to know of any new medications that were prescribed to a resident in the hospital. 2. During a concurrent interview and record review on 3/12/2025 at 3:38 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 15's SBAR, dated 3/8/2025, and Resident 15's Physician Order's, dated 2/2025 to 3/2025, were reviewed. Resident 15's Physician Orders indicated there was no order for a psychiatric consult placed on 3/8/2025. LVN 1 stated the normal process for obtaining a psychiatric consult was to place the order in the electronic medical record (EMR), call or text the psychiatrist, and notify the social services director. LVN 1 stated she authored the SBAR and received the order on 3/8/2025, but did not place an order for a psychiatric consult in the EMR. LVN 1 stated she did not start the process of obtaining a psychiatric consult because she believed the order was already placed in the past. LVN 1 stated if the order was not placed for a psychiatric consult, then there was potential for Resident 15 to continue exhibiting behaviors, which could lead to Resident 15 being sent out the GACH for a psychiatric evaluation. During a review of the facility's Policy and Procedure (P&P) titled, Reconciliation of Medications on Admission, revised 7/2017, the P&P indicated medication reconciliation helped to ensure that medications, routes and dosages had been accurately communicated to the Attending Physician and care team. The P&P indicated that the licensed nurse was to use an approved medication reconciliation form or other record, list all medications from the medication history, the discharge summary, the previous MAR (if applicable), and the admitting orders (sources). The P&P indicated the licensed nurse was to review the list carefully to determine if there are discrepancies/conflicts. For example: a. The dosage on the discharge summary does not match the dosage from the resident's previous MAR; b. There is a potential medication interaction between a medication from the admitting orders and a supplement from the resident's medication history; or c. There is a medication listed on the discharge summary for which there is no diagnosis or condition to support the use of the medication. The P&P indicated to document findings and actions. During a review of the facility's P&P titled, Telephone Orders (undated), the P&P indicated verbal telephone orders must be reduced to writing, by the person receiving the order, and recorded in the resident's medical record. During a review of the facility's P&P titled, Behavioral Health Services (undated), the P&P indicated residents who exhibit signs of emotional/psychosocial distress receive services and support that address their individual needs and goals for care.

CONCERN (D)

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

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure a resident window screen was the correct size and without gaping, and the toilet seat was not broken for one of six sampled residents (Resident 133). These deficient practices had the potential to place Resident 133 at risk for injury, entry of insects into the room, and negatively impact Resident 133's well-being. Findings: During a concurrent observation and interview on 3/10/2025 at 1:19 PM, with Resident 133, in Resident 133's room, observed two gaps around the window screen. Resident 133 stated flies and mosquitos were entering his room through the gaps of the screen. Resident 133's bathroom seat was not anchored in place and was broken. Resident 133 stated he felt scared while using the bathroom because the seat was moving around and he could fall. During a review of Resident 133 Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 133 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension ([HTN]- high blood pressure), and muscle weakness (loss of muscle strength). During a review of Resident 133's Minimum Data Set ([MDS] - a resident assessment tool), dated 2/27/2025, the MDS indicated Resident 133's cognitive (the ability to think and process information) skills for daily living was intact. The MDS indicated Resident 133 required supervision or touching (helper seat and clean up; resident completes activity) assistance from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a concurrent observation and interview on 3/10/2025 at 1:36 PM, with Maintenance Manager (MM 1), in Resident 133's room, the window was observed with a gap to the left and right side of the screen. MM 1 stated the window screen was not the correct size. MM 1 stated there was a seven inch gap to the left and right side of the window screen. MM 1 stated the ill-fitting window screen was dangerous and had the potential for a pest infestation. MM 1 stated he was not aware of this issue. MM 1 stated the window screen needed to be changed. During a concurrent observation and interview on 3/10/2025 at 1:45 PM, with MM 1, in Resident 133's bathroom, the toilet seat was observed. MM 1 stated the toilet seat was not locked into place and was broken. MM 1 stated the broken seat was a safety issue and had the potential to place Resident 133 at risk for fall and injury. MM 1 stated it was his responsibility to keep the resident's rooms and equipment in a safe manner. During a review of the facility's policy and procedure (P&P) titled Maintenance Services, revised 12/2009, the P&P indicated the facility would always maintain the buildings and equipment in a safe and operable manner. The P&P indicated maintenance department would maintain the building in good repair and free from hazards. During a review of the facility P&P titled Maintenance Manager Job Description, undated, the P&P indicated maintenance manager would perform regular inspections of resident rooms for safety.

CONCERN (F)

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure Minimum Data Set Nurse (MDSN) 1 demonstrated the competencies required of her job position and failed to evaluate MDSN 1's ability to accurately perform MDS assessments on an annual basis. This failure placed all facility residents at risk of receiving inaccurate Minimum Data Set (MDS, a resident assessment tool) assessments, which could negatively impact the care the residents received because their care plans were based on data contained in the MDS. Cross-reference F-tag F641. Findings: During an interview on 3/13/2025 at 2:07 PM, with the Assistant Director of Nursing (ADON), the ADON stated the purpose of the MDS was to accurately identify and document the resident's condition. The ADON stated MDS assessments allowed staff to identify changes in a resident's condition and care areas that needed follow up and/or intervention. The ADON stated the MDS also guided the plan of care, including interventions that staff provided to the resident. The ADON stated that to conduct the MDS assessment accurately, the MDSN should be utilizing the Resident Assessment Instruction (RAI) manual. The ADON stated MDSN 1 had access to an electronic copy of the RAI manual in all residents' electronic medical records, and there were no circumstances where the RAI manual should not be followed. During an interview on 3/13/2025 at 2:45 PM, the MDS Nurse Consultant (MDSC), the MDSC stated her role was to train and re-educate MDS staff (including MDSN 1), to ensure MDS assessments were completed accurately and in accordance with the RAI manual. The MDSC stated MDSNs were required to follow the instructions provided in the RAI manual when conducting and documenting MDS assessments. The MDSC stated she trained MDSN 1 a few years ago, but there were no routine performance evaluations of MDSN 1 since that time. MDSC stated she picked random resident MDS assessments to audit monthly, but it was not an observation of MDSN 1 performing the assessments directly. The MDSC stated the importance of an accurate MDS was to provide an accurate assessment of the resident and ensure they received resident-centered care that addressed their needs. During an interview on 3/13/2025 at 3:49 PM, with the Administrator (ADM), the ADM stated there was no current annual evaluation in place to evaluate MDSN 1's ability to accurately conduct or document MDS assessments. During a review of MDSN 1's employee record titled MDS Nurse, dated 7/1/2022, the record indicated the essential duties and responsibilities of MDSN 1. The record indicated MDSN 1 was responsible for restoring and/or maintaining the resident's health and well-being by conducting resident assessments. The record indicated MDSN 1 was responsible for ensuring residents' present/potential health and wellness problems were identified, and indicated the charting was to be documented accurately. During a review of the facility's policy and procedure (P&P) titled Performance Evaluations, revised 9/2020, the P&P indicated the job performance of each employee was to be reviewed and evaluated at least annually.

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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility to failed ensure infection control measures were implemented for five of 26 sampled residents (Residents 84, 6, 40, 101, and 104) when: 1. Signage for enhanced barrier precautions (EBP, precautions utilized to prevent the spread of multi-drug-resistant organisms [MDROs, microorganisms, primarily bacteria, that have developed resistance to multiple classes of antibiotics] to residents) was not posted outside of Resident 84's room or Resident 6's room. 2. Resident 101's oxygen tubing (flexible clear tubing used to connect to an oxygen source), nebulizer (a medical device that turns liquid medicine into a mist that can be easily inhaled) and respiratory (related to breathing) setup bag (a plastic bag with drawstring closure used to store and transport respiratory equipment) were not changed according to the facility's policy and procedure (P&P). 3. Resident 104's oxygen humidifier (a medical device used to add moisture to supplemental oxygen) was not changed according to doctor's orders. 4. Resident 40's suction tubing (a flexible, clear tubing that connects to a suction device used to remove fluid from the airway) and suction filter (protects from fluid back up in the suction tubing) were on the floor. These deficient practices placed all facility residents and staff at risk for infection from the potential spread of MDROs. These deficient practices placed Residents 101, 104, and 40 at risk for respiratory infections from contaminated respiratory equipment. Findings: 1a. During a review of Resident 84's admission Record, the admission Record indicated Resident 84 was originally admitted on [DATE] and was most recently readmitted on [DATE]. Resident 84's admitting diagnoses included gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems). During a review of Resident 84's Minimum Data Set (MDS, a resident assessment tool), dated 2/17/2025, the MDS indicated Resident 84 had severely impaired cognition (ability to think and reason). The MDS indicated Resident 84 required substantial to maximal assistance from staff for mobility while in bed. The MDS indicated Resident 84 had a gastrostomy and received more than 51 percent (%) of her calories from feeding administered through the feeding tube. During a review of Resident 84's active physician order, dated 7/10/2024, the order indicated Resident 84 required enhanced barrier precautions (EBP, precautions utilized to prevent the spread of multi-drug-resistant organisms [MDROs] to residents) due to dependency of [gastrostomy] tube. During a review of Resident 84's care plan titled Enhanced Barrier Precautions due to dependency of [gastrostomy] tube, dated 7/10/2024, the care plan indicated the goal of care was to prevent spread of infection and other MDROs. Staff interventions indicated a blue dot was to be placed next to the resident's name outside of the room to indicate the requirement for exercising EBP. During an observation on 3/10/2025 at 9:36 AM, at Resident 84's bedside, observed Resident 84 lying in bed receiving feeding through her gastrostomy. During an observation on 3/10/2025 at 9:41 AM, outside of Resident 84's room, no EBP signage, or indicators of the need for staff to exercise EBP, were observed. There was no personal protective equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) observed outside of Resident 84's room. b. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was originally admitted on [DATE] and was most recently readmitted on [DATE]. Resident 6's admitting diagnoses included transient ischemic attack (TIA, a temporary interruption of blood flow to the brain that causes sudden neurological symptoms that typically resolve within 24 hours) and cerebral infarction (stroke, loss of blood flow to a part of the brain). During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 was cognitively intact. The MDS indicated Resident 6 required substantial to maximal assistance from staff for toileting hygiene. During a review of Resident 6's active physician order, dated 3/10/2025, the order indicated Resident 6 required EBP due to the use of an indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine). During an observation on 3/10/2025 at 2:53 PM, at Resident 6's bedside, observed Resident 6 lying in bed, with an indwelling urinary catheter drainage bag hanging from the side of the bed. During an observation on 3/10/2025 at 3:03 PM, outside of Resident 6's room, observed no EBP signage, or indicators of the need for staff to exercise EBP. There was no PPE observed. During an interview on 3/12/2025 at 10:48 AM, with the Infection Preventionist Nurse (IPN), the IPN stated the purpose of EBP was to prevent spread of MDROs and infection. The IPN stated that absence of signage or indicators alerting staff of the need to exercise EBP created the potential for the spread of infection because staff would not know they needed to don (wear) PPE during high-risk patient care activities. During a concurrent interview and record review on 3/12/2025 at 10:52 AM, with the Infection Preventionist Nurse (IPN), the facility's policy and procedure (P&P) titled Enhanced Barrier Precautions, dated 4/2024, was reviewed. The IPN stated the P&P indicated EBP were indicated for residents with indwelling medical devices, including gastrostomy tubes and urinary catheters. The IPN stated the P&P indicated signs were supposed to be posted in the door or on the wall outside of the resident rooms indicating EBP and use of PPE was required. 2. During a review of Resident 101's admission Record, dated 3/14/2025, the admission record indicated Resident 101 was admitted on [DATE]. The admission record indicated the following diagnoses which included, chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing) and asthma (a condition in which the airways narrow and swell and may produce extra mucus). During a review of Resident 101's Progress Note, dated 2/14/2025, the progress note indicated Resident 101 was alert and oriented to person, place and time and forgetful of the date. During a review of Resident 101's MDS, dated [DATE], the MDS indicated Resident 101's cognition (ability to think, remember, and reason) was moderately impaired. The MDS indicated Resident 101 required supervision (helper provides verbal cues and/or touching/steadying to complete activity) with eating, oral hygiene and toileting and moderate assistance (helper does less than half the effort) for bathing. During an observation on 3/10/2025 at 10:25 AM, in Resident 101's room, observed Resident 101's oxygen tubing, nebulizer and respiratory set up bag was dated 2/14/2024. 3. During a review of Resident 104's admission Record, dated 3/17/2025, the admission Record indicated Resident 40 was admitted on [DATE]. The admission record indicated the following diagnoses which included tracheostomy (a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck), respiratory failure with hypoxia (lack of sufficient oxygen in the blood, tissues and cells). During a review of Resident 104's Progress Note, dated 2/14/2025, the progress note indicated Resident 104 was alert and oriented to person, place, time and event and could make needs known. During a review of Resident 104's MDS, dated [DATE], the MDS indicated Resident 104's cognition was intact. The MDS indicated Resident 104 required supervision for eating and was dependent (helper does all the effort) for toileting and bathing. During a review of Resident 104's Order Summary Report dated 3/17/2025, the order summary report indicated Resident 104 had an active order on 5/4/2024 to change the humidifier every Monday on night shift and as needed. During an observation on 3/10/2025 at 11:15 AM, in Resident 104's room, observed Resident 104's oxygen humidifier dated 2/28/2024. 4. During a review of Resident 40's admission Record, dated 3/14/2025, the admission record indicated Resident 40 was initially admitted on [DATE] and readmitted on [DATE]. The admission record indicated the following diagnoses which included tracheostomy status, acute respiratory failure (a serious condition that makes it difficult to breathe on your own), dependence on respirator (ventilator, a machine that helps you breathe), and cerebral infarction. During a review of Resident 40's History and Physical (H&P), dated 12/22/2024, the H&P indicated Resident 40 could make needs known but could not make medical decisions. During a review of Resident 40's MDS, dated [DATE], the MDS indicated Resident 40's was intact. The MDS indicated Resident 40 was dependent on staff for oral hygiene, toileting, bathing, and personal hygiene. During a review of Resident 40's Order Summary Report dated 3/13/2025, the order summary report indicated Resident 40 had an active order on 2/26/2025 to change the resident's suction filters as needed. During an observation on 3/10/2025 at 12:12 PM, in Resident 40's room, observed Resident 40's suction tubing and suction filter lying on the floor. During an interview on 3/12/2025 at 4:27 PM, with Licensed Vocational Nurse (LVN) 2, LVN 2 stated the respiratory therapy department, and the nursing staff were responsible for changing out respiratory equipment and making sure the equipment was up to date. LVN 2 stated Resident 40's suction tubing and filter should not be on the floor. LVN 2 stated respiratory equipment should be changed if found on the floor because the floor is dirty and can cause contamination and infection in the mouth and lungs. During an interview on 3/13/2025 at 12:25 PM, with the Treatment Nurse (TN) 1, TN 1 stated the humidifier should have been changed for Resident 104. TN 1 stated if the water in the humidifier was not fresh, it could grow bacteria and lead to infection. During a concurrent observation and interview on 3/13/2025 at 2:49 PM, with Respiratory Therapist (RT) 1, Resident 104's nebulizer, oxygen tubing and setup bag were observed with a date of 2/14/2025. RT 1 stated Resident 104's equipment should be changed every week. RT 1 stated 2/14/2025 was too long to keep respiratory equipment. RT 1 stated the respiratory equipment should have been changed to prevent Resident 104 from an infection. During an interview on 3/13/2025 at 3:01 PM, with RT 1, RT 1 stated Resident 104's humidifier should have been changed once a week. RT 1 stated Resident 104's humidifier needed to be changed to prevent the water from becoming contaminated which could have led to a lung infection. During an interview on 3/13/2025 at 3:38 PM, with the Director of Nursing (DON), the DON stated respiratory equipment should be changed every week and as needed due to infection control. The DON stated it was important to make sure the respiratory equipment was changed weekly because the residents are prone to infection. During a review of the facility's policy and procedure (P&P) titled Administering Medications through a Small Volume (Handheld Nebulizer), revised 10/2010, the P&P indicated the purpose of the policy was to safely and aseptically administer aerosolized particles of mediation into the resident's airway. The P&P indicated staff were to change the equipment and tubing every seven days. During a review of the facility's P&P titled Departmental (Respiratory Therapy) - Prevention of Infection, revised 11/2011, the P&P indicated the purpose of the policy was to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. The P&P indicated staff were to change the oxygen cannula and oxygen tubing every seven days or as needed.

Mar 2025 1 deficiency 1 IJ

CRITICAL (J) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Accident Prevention (Tag F0689)

Someone could have died · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the safety of one of eight sampled residents (Resident 1) at risk for wandering by failing to: 1. Ensure the front and back exit doors were monitored, after the front lobby exit door alarm was activated by Resident 1 on 2/24/2025 at 7:43 p.m. 2. Closely monitor Resident 1's whereabouts in the facility after he attempted to leave from the front exit door on 2/24/2025 at 7:43 p.m. 3. Educate Resident 1 on the risk of leaving the facility after his first elopement (the act of leaving a facility unsupervised and without prior authorization) attempt on 2/24/2025 at 7:43 p.m. 4. Ensure the facility's back exit door alarm was activated on 2/24/2025. As a result, Resident 1 eloped from the facility's back exit door on 2/24/2025 at 7:47 p.m., four minutes after activating the front exit door alarm. On 2/28/2025 at 2:15 p.m., an Immediate Jeopardy ([IJ], a situation in which the facility's noncompliance with one or more requirements of participation had cause, or was likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the Administrator (ADM) due to the facility's failure to provide supervision to Resident 1 on 2/24/2025 at 7:43 p.m. and failure to prevent Resident 1's elopement from the facility on 2/24/2025 at 7:47 p.m. On 3/1/2025 at 1:46 p.m., the facility submitted an acceptable IJ Removal Plan (IJRP). After onsite verification of the IJRP implementation through observation, interview, and record review, the IJ was removed while onsite at 3/1/2025 at 3:25 p.m., in the presence of the ADM. The IJRP included the following immediate actions: 1. On 2/24/2025 at 9:30 p.m., staff immediately initiated a search of the inside and outside of the facility including streets, and nearby areas in partnership with the local Police Department. (i) Facility-wide search for Resident 1 initiated by Registered Nurse (RN) 1 and staff on 2/24/2025 at 9:30 p.m. (ii) Headcount completed by RN 1 on 2/24/2025 after Resident 1 was found missing. (iii) The ADM, the Director of Nursing (DON), and the Maintenance Supervisor (MS) were notified by RN 1 of Resident 1's elopement on 2/24/2025. 2. Immediate in-service trainings were conducted from 2/24/2025 - 3/1/2025: a. All staff were trained on elopement policies, procedures, and risks by the Director of Staff and Development (DSD) and the DON. b. Certified Nursing Assistant (CNA) 1 and CNA 2 were counseled and retrained on reporting alarms and elopement supervision by the DON and DSD on 2/28/2025 and 2/24/2025. c. Weekly in-services would be initiated by the DSD for eight weeks for all shifts. 3. Identification of other at-risk residents: a. All residents were reassessed for elopement risk by the DON on 2/25/2025. b. On 2/27/2025, one newly admitted resident identified as high-risk for elopement. c. Care plans updated accordingly. 4. Measures to prevent recurrence: a. admission & Care Planning Process: (i) All new/readmitted residents assessed for elopement risk by the Inter-Disciplinary Team (IDT, a group of different disciplines working together towards a common goal for a resident) members and/or the DON. (ii) Comprehensive assessments of residents conducted at least quarterly or upon status change by the Minimum Data Set (MDS) Coordinator. (iii) Residents' care plans updated to reflect elopement risk by the MDS Coordinator and/or the DON. b. Facility security measures: (i) Exit door Monitoring: 1. Backdoor exit to be constantly supervised, maintained and validated by the MS daily from Monday to Friday and manager of the day for Saturday and Sunday. The MS to maintain a log and to be audited by the ADM. 2. Before the receptionist leaves the building at 7 p.m., the receptionist would communicate to the RN supervisor and/or the charge nurse that they are leaving. The RN and/or the charge nurse would activate the alarm system to ensure continuous monitoring of the back door exit.?RN supervisor would update the monitoring log which is to be kept at the nursing station. 3. Ensure all exit doors were equipped with functioning alarms. 4. The MS to maintain a log to ensure its functioning, to be audited by the ADM weekly. 5. Installed additional alarms where necessary. 6. Maintain documentation of alarm functionality. c. Staff education & training: (i) Mandatory in-services by the DSD for all staff on 2/27/2025: 1. Elopement procedures and monitoring exit doors after alarms. 2. Proper resident supervision strategies. 3. Assessment and care planning updates for elopement risks. 4. Educating residents on elopement dangers. 6. Policy and procedures for managing wandering risk. 5. Monitoring & Compliance: a. Routine Checks: (i) Weekly elopement risk audits to be conducted by the Medical Records Supervisor (MRS). (ii) IDT meetings to review findings and ensure follow-ups. (iii) Implementation of an Elopement Performance Improvement Plan (PIP) under Quality Assessment and Assurance (QAA). b. Reporting & Drills: (i) Regular elopement drills conducted by the DSD. (ii) Reporting process established for elopement incidents. c. Quality assurance & follow-up: (i) Findings presented at QAA meeting on 3/20/2025. (ii) Ongoing audits would be reported monthly for six months, then quarterly by the DON and the ADM and/or designee. (iii) The facility would sustain compliance through continuous monitoring and training. Findings: During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE]. Resident 1's diagnoses included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN- high blood pressure), difficulty in walking, and schizophrenia (a mental illness that was characterized by disturbances in thought). During a review of Resident 1's MDS (a resident assessment tool), dated 2/14/2025, the MDS indicated Resident 1's cognition (process of thinking) was moderately impaired. The MDS indicated Resident 1 required set up assistance with eating, and supervision with oral hygiene, personal hygiene, and walking. The MDS indicated Resident 1 had wandering behaviors (the act of roaming around and becoming lost or confused about his location). During a review of Resident 1's History and Physical (H&P) dated 11/7/2024, the H&P indicated Resident 1 could make his needs known but could not make medical decisions. a. During a telephone interview on 2/27/2025 at 12:42 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated on 2/24/2025 at 7:30 p.m., he saw Resident 1 exit his room. CNA 1 stated on 2/24/2025 at 7:43 p.m., while changing Resident 3 (Resident 1's roommate) he heard the front exit door alarm. CNA 1 stated he walked out of the room to check the alarm and saw Resident 1 by the door. CNA 1 stated he redirected Resident 1 back to the hallway, and Resident 1 walked down the hallway toward the nursing station. CNA 1 stated he did not report the incident to the charge nurse for further interventions like closer monitoring of the exit doors. During a telephone interview on 2/27/2025 at 1:59 p.m. with Registered Nurse (RN) 1, RN 1 stated on 2/24/2025 at 7:43 p.m., no one reported to him that Resident 1 activated the front exit door alarm. RN 1 stated CNA 1 should have informed the RN supervisor and charge nurses for immediate interventions. During a telephone interview on 2/27/2025 at 2:18 p.m., with CNA 2, CNA 2 stated on 2/24/2025 around 7:43 p.m., she went to use the restroom located near the facility's front exit door. CNA 2 stated she heard the front exit door alarm and saw Resident 1 standing at the door. CNA 2 stated she called Resident 1 by his name but the resident did not respond and continued to walk down the hallway. CNA 2 stated she thought the alarm was activated because Resident 1 got too close to the door. CNA 2 stated she did not think Resident 1 was trying to elope. CNA 2 stated she did not report the incident to anyone. CNA 2 stated the exit doors should have been closely monitored after the front exit door was activated by Resident 1. During an interview on 2/27/2025 at 2:58 p.m. with the Director of Staff Development (DSD), the DSD stated on 2/24/2025 at 7:43 p.m., CNAs 1 and 2 were aware that Resident 1 activated the front exit door alarm. The DSD stated CNAs 1 and 2 should have notified the charge nurse so the charge nurse could follow up and ensure Resident 1's safety and ensure the exit doors were monitored. During a concurrent interview and video review on 2/28/2025 at 8:58 a.m. with the Administrator (ADM), the facility's security surveillance video footage, dated 2/24/2025 from 7:43 p.m. to 7:48 p.m., was reviewed. The ADM stated at 7:47 p.m., the surveillance footage revealed Resident 1 pushed open the back exit door and walked out of the facility through the parking lot and onto the street. The ADM stated, there was no staff present at the back exit door. The ADM stated the back door should have been supervised. During an interview on 2/28/2025 at 4:04 p.m. with RN 2, RN 2 stated on 2/24/2025 at 7:43 p.m., staff should have made sure the facility's front and back doors were secured at all times after the front exit door alarm was activated. b. During a telephone interview on 2/27/2025 at 12:42 p.m. with CNA 1, CNA 1 stated 2/24/2025 at 7:43 p.m. was his last time seeing Resident 1 after the resident activated the front exit door alarm. CNA 1 stated he did not check on Resident 1 after that because he was busy changing other residents. CNA 1 stated he should have checked on Resident 1 after the resident activated the alarm. CNA 1 stated on 2/24/2025 at 9:30 p.m., he could not find Resident 1, and did not know what time Resident 1 left the facility. During a telephone interview on 2/27/2025 at 1:59 p.m. with RN 1, RN 1 stated on 2/24/2025 around 7:43 p.m., he heard the front exit door alarm but did not see anyone. RN 1 stated he continued to work on his admission and did not inquire on who or what activated the alarm. RN 1 stated after the alarm was activated staff should have checked to see if a resident left the facility, and the resident should have been placed on close monitoring, similar to one-on-one (1:1, a dedicated nurse assigned to continuously observe and attend to a single resident at all times, providing close supervision and immediate interventions when needed) supervision. RN 1 stated he would have assigned 1:1 supervision for Resident 1 or placed Resident 1 at the nursing station so he (RN 1) could monitor Resident 1. RN 1 stated on 2/24/2025 at 9:30 p.m., Licensed Vocational Nurse (LVN) 1 and LVN 2 informed him that Resident 1 was missing. During a telephone interview on 2/27/2025 at 2:26 p.m. with LVN 2, LVN 2 stated on 2/24/2025 around 7:40 p.m., she was told by staff (unable to recall name) that Resident 1 activated the front exit door alarm. LVN 2 stated staff were to make rounds every 15 minutes to check on wandering residents and make sure the residents' wander guards (a safety system used to prevent residents from wandering into unsafe areas or elopement) were on. LVN 2 stated the charge nurse should have checked Resident 1's wander guard placement after Resident 1 activated the alarm on 2/24/2025 at 7:43 p.m. LVN 2 stated Resident 1 was not her assigned resident and that was why she did not do so. LVN 2 stated on 2/24/2025 at 9 p.m., LVN 1 notified her (LVN 2) that Resident 1 was missing. During an interview on 2/27/2025 at 2:58 p.m. with the DSD, the DSD stated all CNAs should monitor all wandering residents by keeping an eye on them. The DSD stated if residents were observed wandering, trying to go to the patio, or had their belongings with them, staff were supposed to recognize those signs as elopement risk. The DSD stated RNs were supposed to immediately perform rounds to ensure all residents were in the facility. The DSD stated if the RNs did not see anything, they were supposed to find out who activated the alarm and what happened. The DSD stated the LVNs were supposed to monitor residents who activated the alarm and perform more frequent rounds. During a telephone interview on 2/27/2025 at 3:42 p.m. with LVN 1, LVN 1 stated on 2/24/2025 around 7:40 p.m., she was in another room and did not hear the alarm. LVN 1 stated on 2/24/2025 around 7:45 p.m., she observed Resident 1 in bed. LVN 1 stated Resident 1 was on hourly monitoring for his wandering behaviors and had a wander guard. LVN 1 stated on 2/24/2025 at 9 p.m., CNA 1 reported to her that Resident 1 activated the alarm around 7:40 p.m. and was now missing. LVN 1 stated she would have notified RN 1 at 7:45 p.m. if she was aware that Resident 1 activated the front exit door alarm and ensure Resident 1 was closely monitored. LVN 1 stated all staff was responsible for ensuring residents' safety. During an interview on 2/27/2025 at 4:16 p.m. with the DON, the DON stated Resident 1 activating the alarm was an exit-door-seeking behavior. The DON stated staff should assess the needs of residents with exit-door-seeking behavior and implement interventions. The DON stated when staff observed Resident 1's exit-door-seeking behavior, the licensed nurses should have documented the exit-door-seeking behavior in the resident's medical record and implemented closer monitoring. The DON stated on 2/24/2025 at 7:43 p.m., RN 1 and LVN 1 should have inquired to find out who activated the alarm and/or whether it was a false alarm so staff could do closer monitoring to ensure Resident 1's safety. c. During a review of Resident 1's care plan titled At risk for elopement/wandering, initiated 11/8/2024, the care plan indicated Resident 1 would have no incident of elopement and wandering outside of the facility property daily. The care plan interventions indicated will remind Resident 1 regularly and as needed (PRN) and explain risks and benefits of elopement/wandering. During a telephone interview on 2/27/2025 at 12:42 p.m. with CNA 1, CNA 1 stated on 2/24/2025 at 7:43 p.m., he did not educate Resident 1 on the risks of leaving the facility without supervision after Resident 1 activated the front exit door alarm. During a telephone interview on 2/27/2025 at 2:18 p.m., with CNA 2, CNA 2 stated on 2/24/2025 around 7:43 p.m., she called Resident 1 by his name after Resident 1 activated the front exit door alarm, but did not educate Resident 1 on the risks of leaving the facility unsupervised. d. During a concurrent observation and interview on 2/26/2025 at 3:40 p.m. with the Maintenance Supervisor (MS), the back exit door alarm was flashing with a high pitched sound when activated. The MS stated the alarm lit up when activated. During a concurrent interview and video review on 2/28/2025 at 8:58 a.m. with the ADM, the facility's security surveillance video footage, dated 2/24/2025 from 7:43 p.m. to 7:48 p.m., was reviewed. The ADM stated at 7:47 p.m., the surveillance footage revealed Resident 1 pushed open the back exit door, and the alarm did not light up. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, revised in 7/2017, the P&P indicated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities . a facility-wide commitment to safety at all levels of the organization .The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly. The P&P indicated Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs. The P&P indicated implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions c. Ensuring that interventions are implemented d. Ensuring that interventions are implemented correctly and consistently. During a review of the facility's P&P titled, Wandering and elopements, undated, the P&P indicated If an employee observes a resident leaving the premises, he/she should: a. attempt to prevent the resident from leaving in a courteous manner; b. get help from other staff members in the immediate vicinity, if necessary; and c. instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises.

Feb 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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview and record review, the facility failed to implement infection control practices designed to provide residents a safe, sanitary, and comfortable environment, by failing to follow the posted Novel (a newly identified respiratory pathogen that cause respiratory infections) Respiratory Precautions (NRP, a precaution to minimize spread of respiratory infection in caring for infected resident in a health care settings), indicating to wear a gown (a piece of protective clothing worn to prevent the spread of disease and contamination) on room entry, wear N-95 (a respiratory protective device designed to achieve a very close facial fit to form a seal around the nose and mouth to efficiently filter airborne particles)and face shield or goggles (protective covering for the eyes to reduce the spread of a transmissible disease) prior to entry of three COVID-19 [a highly contagious respiratory infection caused by a virus that can easily spread from person to person) isolation rooms, (Rooms A, B and C). This failure placed all the residents, staff, and the community at risk for cross contamination and increased spread of COVID-19 infection in the facility and the community. Findings: During an observation on 2/6/2025 at 9:35 a.m., outside Rooms A, B and C, an isolation sign was observed for NRP precautions, which indicated to wear a gown, N-95 and face shield or googles prior to room entry. During a concurrent observation and interview on 2/6/2025 at 9:54 a.m., with the Licensed Vocational Nurse (LVN) 1 LVN 1 was observed entered the COVID-19 isolation Room A without wearing an isolation gown. LVN 1 stated I did not wear the isolation gown when I entered Room A because it was only a COVID-19 exposed room and not COVID-19 positive. LVN 1 stated, regardless, the posted NRP sign recommendations should have been followed. During an observation on 2/6/2025 at 10:15 a.m., Restorative Nurse Assistant (RNA) 1 was observed entered COVID-19 isolation Room B, without wearing a face shield. RNA 1 stated I forgot to use the face shield before entering the isolation room. During an observation on 2/6/2025 at 11:38 a.m., LVN 2 was observed entered the COVID-19 isolation Room C without wearing a face shield. During an interview on 2/6/2025 at 11:13 a.m. with the RNA 1, the RNA 1 stated I went to Room C because a Certified Nurse Assistant (CNA) in Room C called for assistance to transfer the resident to the wheelchair. RNA 1 stated I put my gown on and forgot to put on the face shield. RNA 1 stated we need to use all the Personal Protective Equipment ([PPE] protective clothing, garments or equipment designed to protect the wearer or the resident from infections) to protect ourselves and the resident from being infected of COVID-19. During an interview on 2/6/2025 at 11:38 a.m. with LVN 2, LVN 2 stated all residents exposed to COVID-19 had signage posted by the door for all the staff to follow. LVN 2 stated the signs posted outside the door indicated we must use isolation gowns, mask, face shield, gloves prior to caring for exposed residents. LVN 2 stated that means I should have used all the PPE. During an interview on 2/6/2025 at 12:15 p.m. with LVN 1, LVN 1 stated staff should follow what is posted outside of rooms with NRP. LVN 2 stated all staff should wear an isolation gown, gloves, mask, and face shield before entering a resident room that is on isolation to protect themselves, for proper infection control and to stop the transmission of COVID-19 to the other residents and staffs. During an interview on 2/6/2025 at 1:10 p.m. with the Infection Preventionist (IP) nurse, the IP stated when nurses see a room with an isolation precautions sign, the nurses must wear mask, gloves, gown and face shield before entering the room. The IP stated the PPE is used to protect themselves and the residents from the transmission and infection of the COVID -19 virus. During an interview on 2/6/2025 at 4:26 p.m. with the Director of Nursing (DON), the DON stated nurses must follow the PPE sign posted outside of resident ' s room. The DON stated staff must use the recommended isolation gown, gloves, mask and face shield when taking care of residents regardless of, if COVID-19 positive or exposed to COVID-19. During a review of the facility ' s undated policy and procedure (P&P) titled, Coronavirus disease (COVID-19) – Using Personal Protective Equipment, the P&P indicated when caring for a resident with suspected or confirmed SARS-CoV-2 infection, the personnel who would enter the resident ' s room with suspected or confirmed SARS-CoV-2 infection, must adhere to standard precautions and use a National Institute for Occupational Safety and Health (NIOSH)- approved N-95 or equivalent or higher-level respirator, gown, gloves and eye protection.

Dec 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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its Policy and Procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation- Reporting and Investigating which indicated injuries of unknown source would be reported to the State Licensing/Certification Agency within two hours for one of four sampled residents (Resident 1) when Resident 1 developed new, multiple skin discolorations and bruising (collection of blood underneath the skin that is caused by an injury)to the left cheek and chin. This failure delayed the investigation by the State Agency and placed Resident 1 at risk for continuous abuse. Findings: During a record review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including respiratory failure with hypoxia (a condition where there is not enough oxygen in the blood), hepatic encephalopathy (brain dysfunction due to liver dysfunction that can cause issues with thinking and mobility) and coagulation defect (a condition that affects the ability to control bleeding). During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 10/20/2024, the MDS indicated Resident 1 did not speak and was rarely/never able to make their needs known and rarely/never able to understand verbal content. The MDS indicated Resident 1 was totally dependent on staff for Activities of Daily Living (ADLs) such as oral hygiene, toileting hygiene, personal hygiene, dressing and bed mobility (ability to roll from lying on back to left and right side and return to lying on back on the bed). During a record review of Resident 1's History and Physical (H&P), dated 12/21/2024, the H&P indicated Resident 1 did not have the ability to understand and make decisions. During a record review of Resident 1's SBAR Communication Form ([Situation, Background, Assessment, Recommendation- a communication tool used by healthcare workers when there is a change in condition among the residents), dated 12/4/2024, the SBAR indicated, Resident 1 was observed with light brown skin discoloration to the left cheek. During a record review of Resident 1's SBAR, dated 12/9/2024, the SBAR indicated, Resident 1 was noted with multiple discolorations to the left shoulder, right shoulder, left thigh and right elbow. During a record review of Resident 1's Progress Note, dated 12/12/2024, the Progress Note indicated Resident 1 had bruising on the resident's left lower chin. During a concurrent interview and record review on 12/30/2024 at 2:50 p.m. with Registered Nurse 1 (RN 1), Resident 1's SBAR Communication Form, Progress Notes and H&P were reviewed. RN 1 stated Resident 1's cheek discoloration was a bruise, measured 3 cm x 3 cm and grew twice as large later (size unknown). RN 1 stated neuro check was ordered by the physician for Resident 1 out of concern for mentation changes since facial bruising could have been caused by trauma to the resident's head. RN 1 stated the cause of Resident 1's facial skin discoloration and bruising were considered injuries of unknown source and should have been reported to the State Agency immediately. During an interview on 12/30/2024 at 3:45 p.m. with the Administrator (Admin), Admin stated, Resident 1's skin discolorations and bruises were not reported to the State Agency because they were attributed to the resident's condition. Admin stated, staff did not know how the bruise occurred or developed and should have been reported to the State Agency and investigated instead of just attributing the bruise to medical conditions. During a review of the facility's P&P titled, Investigating Injuries dated 12/2016, the P&P indicated an injury of unknown source was an injury that was not observed by any person, the source of injury could not be explained by the resident, and the injury was suspicious due to the injury's extent, location, quantity, or incidents over time. During a review of the facility's P&P titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 4/2021, the P&P indicated the facility will identify all possible incidents of abuse or mistreatment. The P&P indicated the facility will report any allegations within timeframes required by federal requirements. During a review of the facility's P&P titled, Abuse, Neglect, Exploitation and Misappropriation- Reporting and Investigating, dated 7/2022, the P&P indicated the facility will report resident abuse (including injuries of unknown origin) to local, state, and federal agencies (as required by current regulations). The P&P indicated if injury of unknown source is suspected, the suspicion must be reported immediately (within two hours of an allegation involving abuse or within 24 hours of an allegation that does not involve abuse) to the Administrator and to other officials according to state law.

CONCERN (D) 📢 Someone Reported This

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

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to investigate injuries of unknown source for one of four residents (Resident 1) when Resident 1 developed new, multiple skin discolorations and bruising (collection of blood underneath the skin that is caused by an injury) to the left cheek and chin. This failure had the potential to result in unidentified abuse and placed Resident 1 at risk for continuous abuse. Findings: During a record review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including respiratory failure with hypoxia (a condition where there is not enough oxygen in the blood), hepatic encephalopathy (brain dysfunction due to liver dysfunction that can cause issues with thinking and mobility) and coagulation defect (a condition that affects the ability to control bleeding). During a record review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool), dated 10/20/2024, the MDS indicated Resident 1 did not speak and was rarely/never able to make their needs known and rarely/never able to understand verbal content. The MDS indicated Resident 1 was totally dependent on staff for Activities of Daily Living (ADLs) such as oral hygiene, toileting hygiene, personal hygiene, dressing and bed mobility (ability to roll from lying on back to left and right side and return to lying on back on the bed). During a record review of Resident 1 ' s History and Physical (H&P), dated 12/21/2024, the H&P indicated Resident 1 did not have the ability to understand and make decisions. During a record review of Resident 1 ' s SBAR Communication Form ([Situation, Background, Assessment, Recommendation- a communication tool used by healthcare workers when there is a change in condition among the residents), dated 12/4/2024, the SBAR indicated, Resident 1 was observed with light brown skin discoloration to the left cheek. During a record review of Resident 1 ' s SBAR, dated 12/9/2024, the SBAR indicated, Resident 1 was noted with multiple discolorations to the left shoulder, right shoulder, left thigh and right elbow. During a record review of Resident 1 ' s Progress Note, dated 12/12/2024, the Progress Note indicated Resident 1 had bruising on the resident ' s left lower chin. During a concurrent interview and record review on 12/30/2024 at 2:50 p.m. with Registered Nurse 1 (RN 1), Resident 1 ' s SBAR Communication Form, Progress Notes and H&P were reviewed. RN 1 stated Resident 1 ' s cheek discoloration was a bruise, measured 3 cm x 3 cm and grew twice as large later (size unknown). RN 1 stated neuro check was ordered by the physician for Resident 1 out of concern for mentation changes since facial bruising could have been caused by trauma to the resident ' s head. RN 1 stated the cause of Resident 1 ' s facial skin discoloration and bruising were considered injuries of unknown source and should have been investigated. RN 1 stated residents were at risk of abuse because no investigation was conducted, and abuse was not ruled out for Resident 1. During an interview on 12/30/2024 at 3:45 p.m. with the Administrator (Admin), Admin stated, Resident 1 ' s skin discolorations and bruises were not thoroughly investigated because they were attributed to the resident ' s medical history. Admin stated, Resident 1 ' s injuries of unknown source (skin discoloration and bruising) should have been thoroughly investigated instead of just attributing them to the resident ' s medical conditions. During a review of the facility ' s Policy and Procedure (P&P) titled, Investigating Injuries dated 12/2016, the P&P indicated the Administrator will ensure that all injuries are investigated and will follow the protocols set forth in the facility ' s established abuse investigation guidelines. The P&P indicated an injury of unknown source was an injury that was not observed by any person, the source of injury could not be explained by the resident, and the injury was suspicious due to the injury ' s extent, location, quantity, or incidents over time. During a review of the facility ' s P&P titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 4/2021, the P&P indicated the facility will identify and investigate all possible incidents of abuse or mistreatment. The P&P indicated the facility will investigate any allegations within timeframes required by federal requirements.

Dec 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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), received treatment and care in accordance with the comprehensive person-centered care plan. This failure resulted in Resident 1 sustaining Moisture-Associated Skin Damage ([MASD] damage in the skin in response to prolonged skin exposure to moisture) to the sacrococcyx area and bilateral groin. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated, Resident 1 was originally admitted to the facility on [DATE] with diagnoses including acute (sudden) respiratory failure (a serious condition that makes it difficult to breathe on your own) unspecified whether with hypoxia (inadequate supply of oxygen to the tissues) or hypercapnia (too much carbon dioxide [CO2] in the blood due to the lungs being unable to remove CO2 or when the body produces too much). During a review of Resident 1 ' s care plan titled The resident has total bladder incontinence, dated 1/25/2024, the goal indicated the resident will remain free from skin breakdown. One of the interventions indicated to check the resident as required for incontinence, wash, rinse, and dry perineum and change clothing as needed after incontinent episodes. During a review of Resident 1 ' s Minimum Data Set ([MDS], a resident assessment tool), dated 7/25/2024, the MDS indicated Resident 1 had moderate (not extreme or excessive) cognitive (the ability to think and reason) impairment. The MDS indicated Resident 1 was dependent (helper does all the effort) withActivities of Daily Living (ADL) such as showering/bathing oneself, personal and toileting hygiene. The MDS indicated Resident 1 was always incontinent of urine. During a review of Resident 1 ' s care plan dated 10/17/2024, the care plan indicated Resident 1 had sacrococcyx MASD. The interventions indicated to keep affected area clean and dry, monitor for signs and symptoms of infection, pan and/ or discomforts, notify the physician for any changes and apply zinc oxide (topical ointment). During a review of Resident 1 ' s Change of Condition ([COC] a document used to assess and communicate any new issues or problems that occur with each resident after admission) documentation dated 12/10/2024, the COC indicated Resident 1 had bilateral (both side) groin (the area where the thigh meets the abdomen) MASD, moist and scattered with small open skin. During an interview on 12/11/2024 at 1:21 p.m., Certified Nursing Assistant (CNA) 1 stated it was not good for Resident 1 or other residents to be left wet or soiled because it could cause skin breakdown or infection. The CNA 1 stated incontinent residents should be checked by staffs at least every two hours to see if the resident is soaked with urine or bowel or needs to be changed to prevent further skin breakdown. During a concurrent interview and record review on 12/12/2024 at 12:23 p.m. with LVN 2, Resident 1 ' s COC, dated 10/17/2024 and Resident 1 ' s care plan titled, The resident has total bladder incontinence, dated 1/25/2024, were reviewed. LVN 2 stated Resident 1 had sacrococcyx MASD on 10/17/2024 and sustained the bilateral groin MASD on 12/10/2024. LVN 2 stated the cause of MASD was the incontinence (of bladder). LVN 2 stated Resident 1 ' s sacrococcyx MASD was preventable (something that could have been stopped or avoided from happening) and the facility did not ensure Resident 1 did not develop further MASD in the bilateral groin area by not implementing Resident 1 ' s plan of care. LVN 2 stated the facility did not ensure Resident 1 ' s diaper was not too tight or wet or was checked more frequently after Resident 1 had the MASD at the sacrococcyx area. During a concurrent interview and record review on 12/16/2024 at 9:42 a.m. with Director of Nursing (DON), Resident 1 ' s COC dated 12/10/2024 was reviewed. The DON stated, to address MASD, interventions should include keeping the patient dry and changing them on time, as indicated in Resident 1 ' s care plan. The DON stated, with MASD, we have to make sure it is resolved to prevent MASD from going to other areas. The DON stated, Resident 1 ' s MASD had declined because a new area (bilateral groin) had developed.

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe administration of gastric tube feeding (the administration of milk/nutrition via gastric tube [a surgical opening in the abdomen into the stomach] to one of three residents (Resident 1), by failing to ensure: 1. The gastric tube feeding was paused (on hold), while the staff was lowering the head of bed (HOB) prior to performing nursing care. 2. Licensed personnel paused Resident 1's tube feeding pump. These failures had the potential to cause Resident 1 to aspirate (inhale a substance into the lungs) and placed Resident 1 at risk for complications such as pneumonia (lung infection) and hospitalization. Findings: During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was originally admitted to the facility on [DATE] with diagnoses that included acute (sudden) respiratory failure (a serious condition that makes it difficult to breathe on your own) unspecified whether with hypoxia (a condition in which there is an inadequate supply of oxygen to the tissues) or hypercapnia (a condition in which there is too much carbon dioxide [CO2] in the blood due to the lungs being unable to remove CO2 or when the body produces too much). During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 7/25/2024, the MDS indicated Resident 1 had moderate (not extreme or excessive) cognitive (the ability to think and reason) impairment. The MDS indicated Resident 1 was dependent (helper does all the effort) withActivities of Daily Living (ADL) such as showering/bathing oneself, personal and toileting hygiene. During a review of Resident 1's order summary report dated 5/31/2024, Resident 1's physician's order indicated the following: 1. Nothing by mouth (NPO) 2. Elevate head of bed to 30 to 45 degrees during feeding. During a concurrent observation and interview on 12/11/2024 at 1:37 p.m. at Resident 1's bedside, Resident 1's tube feeding pump (machine used to administer milk/nutrition via gastric tube) was on going. Certified Nursing Assistant (CNA) 2 was observed lowering Resident 1's head of bed (HOB) prior to performing incontinence care while Resident 1's tube feeding pump was administering tube feeding. CNA 2 stated that Resident 1's feeding pump was on. CNA 2 was observed pressed to pause Resident 1's tube feeding pump. During a concurrent observation and interview on 12/11/2024 at 1:40 p.m. at Resident 1's bedside, Licensed Vocational Nurse (LVN) 1 arrived and observed Resident 1's feeding pump was paused. LVN 1 stated that CNAs were not allowed to touch or operate the feeding pump because they are not licensed to do so. LVN 1 stated, residents could aspirate if the tube feeding pump is running and the resident's HOB is flat. During an interview on 12/11/2024 at 1:58 p.m., CNA 2 stated prior to changing a resident, tube feeding pump should be paused by a licensed nurse. CNA 2 stated, after the nursing care is finished, the licensed nurse will turn the tube feeding back on. During an interview on 12/16/2024 at 9:42 a.m., the Director of Nursing (DON) stated CNAs are not allowed to touch the tube feeding pump because it is not within their scope of practice. CNAs should call and notify the charge nurse whenever the feeding pump needs to be paused and turned back on. During a review of the facility's policy and procedure (P&P) titled, Enteral Tube Feeding via Continuous Pump, dated 11/2018, P&P indicated resident's head of the bed should be positioned at 30-45 degrees for feeding, unless medically contraindicated.

Nov 2024 2 deficiencies 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

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care and services to prevent a fall for one of four sampled residents (Resident 1) by failing to: 1. Ensure Certified Nursing Assistant (CNA 1) provided a two-person physical assist (help from two persons) when using a Hoyer Lift (mechanical lift- a device used to transfer residents from a bed to a chair or other similar places) to transfer Resident 1 from the bed to a Geri-chair (padded chair to provide comfort and support for people with limited mobility). This deficient practice caused Resident 1 to fall and sustain an acute (immediate) fracture (broken bone) of the fifth cervical (relating to the neck) (C5) vertebra (bone in the spine). Resident 1 was transferred to a general acute care hospital (GACH) for evaluation and treatment. Findings: During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), hypertension ([HTN]- high blood pressure), anxiety (feeling of fear, or worry), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's History and Physical (H&P), dated 10/4/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] - a federally mandated resident assessment tool), dated 10/9/2024, the MDS indicated Resident 1 had the ability to express ideas and wants, and had clear comprehension (capability of understanding something). The MDS indicated Resident 1 was totally dependent (full staff performance) on staff with a two-person physical assist for transfer (how the resident moves between surfaces) and activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's care plan titled ADL Self Care Performance Deficit , dated 10/14/2024, the care plan indicated Resident 1 had a self-care deficit related to limited mobility, and quadriplegia. The care plan interventions indicated facility staff will provide total assistance for transfers with the use of a Hoyer lift. During a review of Resident 1's situation, background, assessment, recommendation ([SBAR]- a communication tool used by healthcare workers when there is a change of condition among the residents) report, dated 11/3/2024 at 11:00 a.m., the SBAR indicated Resident 1 fell on his back and hit his head during transfer from the bed to a Geri-chair. The SBAR indicated Resident 1 was assisted back to the bed and complained of back and neck pain rated at 7 out of 10, on a pain scale (0=no pain, 1-3=mild pain, 4-6=moderate pain, 7-10= severe pain). During a review of Resident 1's progress note dated 11/3/2024 at 1:24 p.m., the progress note indicated Resident 1 was transferred to the GACH emergency room (ER) for evaluation due to a fall and pain. During a review of Resident 1's GACH ER admission record, dated 11/3/2024 at 12:19 p.m., the GACH ER admission record indicated Resident 1 was seated on a Hoyer lift when it tipped over causing the resident to fall to the ground and hit his head. The GACH ER admission record indicated Resident 1 complained of left head pain rated at 7 out of 10 post fall. During a review of Resident 1's GACH ER Computed Tomography ([CT] a procedure that uses a computer linked to a machine to make a series of detailed picture of areas inside the body) Report, dated 11/3/2024 at 1:08 p.m., the CT report indicated acute fracture through the C5 vertebral body (recent break in the bone of the central part of the fifth cervical vertebra, which is located in the neck). During a review of Resident 1's GACH ER note, dated 11/3/2024 at 1:28 p.m., the GACH ER note indicated Resident 1 was administered morphine (medication used to treat moderate to severe pain) four (4) milligrams (mg, unit of measurement) intramuscularly (IM, injection into the muscle) for pain. During a review of Resident 1's GACH ER note, dated 11/3/2024 at 2:44 p.m., the GACH ER note indicated Resident 1 required a cervical collar (a medical device that supports neck and spine) and a follow-up with neurosurgery (surgery to the brain or spinal cord) within 6 to 8 weeks. During a review of Resident 1's progress note (from the facility), dated 11/3/2024 at 6:15 p.m., the progress note indicated Resident 1 returned to the facility on [DATE] at 6:15 p.m. During a review of Resident 1's progress note, dated 11/3/2024 at 11:30 p.m., the progress note indicated Resident 1 reported an excessive tingling sensation and discomfort to all extremities (arms and legs). The progress note indicated Resident 1 reported having 10 out of 10 pain all over his body. During a review of Resident 1's progress note, dated 11/4/2024 at 1:00 a.m., the progress note indicated Resident 1 was transferred back to the GACH for evaluation and treatment. During a review of Resident 1's GACH record, dated 11/4/2024 at 1:39 a.m., the GACH record indicated Resident 1 presented to the ER for pain to the bilateral upper and lower extremities. During a review of Resident 1's GACH medication record, dated 11/6/2024 at 2:46 p.m., the GACH medication record indicated Resident 1 was administered baclofen (medication to treat muscle spasms and pain) 10 mg for pain. During a review of Resident 1's GACH medication record, dated 11/8/2024 at 9:37 a.m., the GACH medication record indicated Resident 1 was administered fentanyl (medication used to treat severe pain) 50 microgram (mcg, unit of measurement) intravenously (IV, into the vein) for pain. During a review of Resident 1's GACH medication record, dated 11/9/2024 at 10:30 p.m., the GACH medication record indicated Resident 1 was administered morphine 4 mg IV for pain. During a review of Resident 1's GACH record, dated 11/10/2024, the GACH record indicated Resident 1 was discharged back to the facility. During a telephone interview on 11/5/2024 at 10:14 a.m., with CNA 1, CNA 1 stated, Resident 1 could not get up alone and required a two-person assist for ADLs. CNA 1 stated Resident 1 required a Hoyer lift for transfer from the bed to Geri-chair. CNA 1 stated on 11/3/2024 at 10:00 a.m., she was assisting Resident 1 with a Hoyer lift transfer from the bed to a Geri-chair. CNA 1 stated Resident 1 was seated on the Hoyer lift sling (device that holds a patient during a transfer). CNA 1 stated there were four straps, two in the front of Resident 1 and two on the back of Resident 1. CNA 1 stated she attached the four sling straps to the Hoyer lift and stood behind the Hoyer lift while lifting Resident 1 from the bed. CNA 1 stated Resident 1 was approximately four (4) feet (a unit of measurement for length) from the ground. CNA 1 stated Resident 1 fell to the ground and the Hoyer lift tipped over onto Resident 1. CNA 1 stated it could have been a safer transfer had another staff assisted in transferring Resident 1, as she (CNA 1) was alone. CNA 1 stated she was busy rushing to complete the care of her other assigned residents and did not ask for assistance. CNA 1 stated Resident 1's fall could had been avoided if she asked for assistance while transferring Resident 1 with the Hoyer lift. During a telephone interview on 11/5/2024 at 11:07 a.m., with Resident 1, Resident 1 stated he was admitted to the GACH on 11/4/2024 due to a neck bone fracture and pain. Resident 1 stated on 11/3/2024 around 10:00 a.m., CNA 1 transferred him (Resident 1) from the bed to a Geri-chair using a Hoyer Lift. Resident 1 stated the Hoyer lift tipped over, he fell to the ground and the Hoyer lift fell on top of him. Resident 1 stated he sustained a neck fracture. Resident 1 stated he was in pain. During an interview on 11/5/2024 at 11:22 p.m., with CNA 2, CNA 2 stated on the morning of 11/3/2024 around 10:30 a.m., she (CNA 2) heard help, help coming from Resident 1's room. CNA 2 stated she went to Resident 1's room and observed the resident on the floor with the Hoyer lift on the resident. CNA 2 stated she and four other staff assisted Resident 1 into bed. CNA 2 stated while Resident 1 was assisted into his bed, Resident 1 complained of neck pain. CNA 2 stated to prevent accidents and keep residents safe; staff should not operate the Hoyer lift using a one person assist. During a concurrent interview and record review on 11/5/2024 at 1:20 p.m., with Occupational Therapist (OT, a healthcare provider who helps you improve your ability to perform daily tasks) 1, Resident 1's Occupational Therapy Note , dated 10/8/2024 was reviewed. OT 1 stated Resident 1's upper extremities ([UE] arms) and lower extremities ([LE] legs) were impaired (loss of a physical ability). OT 1 stated Resident 1 required total assistance (two or more persons assist) with mobility and transfer. OT 1 stated due to Resident 1's UE and LE impairment it was safer for staff to use a Hoyer lift while transferring Resident 1. OT 1 stated the Hoyer lift should have been two persons assist to prevent falls, injury, and to keep Resident 1 safe. During an interview on 11/5/2024 at 2:25 p.m., with the Director of Nursing (DON), the DON stated Resident 1 was dependent with care and required two-person assist for transfer. The DON stated CNA 1 should have asked for assistance from another staff to transfer Resident 1 via the Hoyer lift. The DON stated there should have been a two-person physical assist when operating the Hoyer lift for the residents' safety, and to prevent falls, and injury. During a review of the facility's Policy and Procedure (P&P) titled, Safety and Supervision of Residents , revised 7/2017, the P&P indicated the facility will make the environment as free of accident hazards as possible. The P&P indicated the facility's priority was resident safety, supervision, and assistance to prevent accidents. During a review of the facility's P&P titled Safe Lifting and Movement of Residents , undated, the P&P indicated the facility will protect the safety and well-being of residents and staff. The P&P indicated the facility will promote quality care, use appropriate techniques and devices to lift and transfer residents. During a review of an undated Manufacturer's User Manual titled Invacare ([Invacare] manufacture of long-term care medical products), Manual/Electric Portable Patient Lift, the user manual indicated a recommendation to use two persons assist for lifting and transferring procedures. During a review of the facility's Certified Nursing Assistant (CNA) Job Description, dated 9/2020, the CNA Job Description indicated responsibilities and accountabilities include implementing care according to the care plan. The CNA Job Description indicated helping residents with their ADLs, and proper lifting and transitioning from bed to wheelchair, wheelchair to bed, etc.

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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident had the right to be free from neglect for one of four sampled residents (Resident 1) by failing to: 1. Ensure Certified Nursing Assistant (CNA 1) provided a two-person physical assist (help from two persons) when using a Hoyer Lift (mechanical lift- a device used to transfer residents from a bed to a chair or other similar places) to transfer Resident 1 from the bed to a Geri-chair (padded chair to provide comfort and support for people with limited mobility). This deficient practice caused Resident 1 to fall, sustain an acute (immediate) fracture (broken bone) through the fifth (C5) vertebral (neck bone), was admitted to a general acute care hospital (GACH), and had the potential to place other residents at risk for neglect. Findings: During a review of Resident 1's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury), hypertension ([HTN]- high blood pressure), anxiety (feeling of fear, or worry), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's History and Physical (H&P), dated 10/4/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] - a federally mandated resident assessment tool), dated 10/9/2024, the MDS indicated Resident 1 had the ability to express ideas and wants, and had clear comprehension (capability of understanding something). The MDS indicated Resident 1 was totally dependent (full staff performance) with a two-person physical assist for transfer (how the resident moves between surfaces) and activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's care plan titled ADL Self Care Performance Deficit , dated 10/14/2024, the care plan indicated Resident 1 had a self-care deficit related to limited mobility, and quadriplegia. The care plan interventions indicated facility staff would provide total assistance for transfers with the use of a Hoyer lift. During a review of Resident 1's situation, background, assessment, recommendation ([SBAR]- a communication tool used by healthcare workers when there is a change of condition among the residents) report, dated 11/3/2024 at 11:00 a.m., the SBAR indicated Resident 1 fell on his back and hit his head when being transferred from the bed to a Geri-chair. The SBAR indicated Resident 1 was assisted back to the bed and reported back and neck pain rated 7 out of 10 on a pain scale (0=no pain, 1-3=mild pain, 4-6=moderate pain, 7-10= severe pain). During a review of Resident 1's progress note dated 11/3/2024 at 1:24 p.m., the progress note indicated Resident 1 was transferred to a general acute care hospital (GACH) for evaluation due to a fall and pain. During a review of Resident 1's GACH emergency room (ER) admission record, dated 11/3/2024 at 12:19 p.m., the GACH ER admission record indicated Resident 1 was seated on a Hoyer lift when it tipped over and caused the resident to fall to the ground and hit his head. The GACH ER admission record indicated Resident 1 had complaints of left head pain rated 7 out of 10 post fall. During a review of Resident 1's GACH ER Computed Tomography ([CT] a procedure that uses a computer linked to a machine to make a series of detailed picture of areas inside the body) Report, dated 11/3/2024 at 1:08 p.m., the CT report indicated acute fracture through the C5 vertebral body (recent break in the bone of the central part of the fifth cervical vertebra, which is located in the neck). During a review of Resident 1's GACH ER note, dated 11/3/2024 at 1:28 p.m., the GACH ER note indicated Resident 1 was administered morphine (medication used to treat moderate to severe pain) four (4) milligrams (mg, unit of measurement) intramuscularly (IM, injection into the muscle) for pain. During a review of Resident 1's GACH ER note, dated 11/3/2024 at 2:44 p.m., the GACH ER note indicated Resident 1 required a cervical collar (a medical device that supports neck and spine) and a follow-up with neurosurgery within 6 to 8 weeks. During a review of Resident 1's progress note, dated 11/3/2024 at 6:15 p.m., the progress note indicated Resident 1 returned to the facility. During a review of Resident 1's progress note, dated 11/3/2024 at 11:30 p.m., the progress note indicated Resident 1 reported an excessive tingling sensation and discomfort to all extremities (arms and legs). The progress note indicated Resident 1 reported having 10 out of 10 pain all over his body. During a review of Resident 1's progress note, dated 11/4/2024 at 1:00 a.m., the progress note indicated Resident 1 was transferred back to the GACH for evaluation and treatment. During a telephone interview on 11/5/2024 at 11:07 a.m., with Resident 1, Resident 1 stated he was admitted to the GACH on 11/4/2024 due to a neck bone fracture and pain. Resident 1 stated on 11/3/2024 around 10:00 a.m., CNA 1 transferred him from the bed to a Geri-chair using a Hoyer Lift. Resident 1 stated the Hoyer lift tipped over and he fell to the ground and the Hoyer lift fell on top of him. Resident 1 stated he had a neck fracture. Resident 1 stated he was very upset, angry, and was in pain. Resident 1 stated he did not feel safe returningto the facility. During a telephone interview on 11/5/2024 at 10:14 a.m., with CNA 1, CNA 1 stated, Resident 1 could not get up alone and that the resident required a two person assist for ADLs. CNA 1 stated Resident 1 required a Hoyer lift for transfer from bed to Geri-chair. CNA 1 stated on 11/3/2024 at 10:00 a.m., she was assisting Resident 1 with a Hoyer lift transfer from the bed to a Geri-chair. CNA 1 stated Resident 1 was seated on the Hoyer lift sling (device that holds a patient during a transfer). CNA 1 stated she was standing behind the Hoyer lift while lifting Resident 1 from the bed. CNA 1 stated Resident 1 was approximately four (4) feet (a unit of measurement for length that equal 48 inches) from the ground. CNA 1 stated Resident 1 fell to the ground and the Hoyer lift tipped over onto the resident. CNA 1 stated it could have been a safer transfer had another staff assisted, as she (CNA 1) was alone. CNA 1 stated she was busy rushing to get the care done for her other assigned residents and did not ask for assistance. CNA 1 stated she was aware that Resident 1 was a two persons physical assist for transfer and she was aware the Hoyer lift must be operated with a two person assist. CNA 1 stated she made the decision to transfer Resident 1 with the Hoyer lift alone because other staff were busy and she (CNA 1) was rushing to get the tasks done. CNA 1 stated Resident 1's fall could had been avoided if she asked for assistance. During an interview on 11/5/2024 at 2:25 p.m., with the Director of Nursing (DON), the DON stated Resident 1 was dependent with care and required two persons assist for transfer. The DON stated CNA 1 should have asked for assistance from another staff to transfer Resident 1 via the Hoyer lift. The DON stated there should have been a two-person physical assist when operating the Hoyer lift for the residents' safety, and to prevent falls, and injury. The DON stated CNA 1's decision to continue Resident 1's care with the use of the Hoyer lift alone was unacceptable and considered resident neglect. During a review of the facility's policy and procedure (P&P) titled Resident Rights , revised 2/2021, the P&P indicated facility's employees would treat all residents with kindness, respect, and dignity. The P&P indicated residents at the facility have the right to be free from neglect. During a review of the facility's P&P titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program , revised 4/2021, the P&P indicated residents have the right to be free from neglect. The P&P indicated it was the facility's commitment to protect residents from neglect. During a review of the facility P&P titled Abuse and Neglect- Clinical Protocol , undated, the P&P indicated: a) Neglect as defined at §483.5 means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. During a review of the facility's Certified Nursing Assistant (CNA) Job Description, dated 9/2020, the CNA Job Description indicated responsibilities and accountabilities include implementing care according to the care plan. The CNA Job Description indicated helping residents with their ADLs, and proper lifting and transitioning from bed to wheelchair, wheelchair to bed, etc. The CNA Job Description indicated CNAs would commit to always do the right thing.

Aug 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

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review that facility staff failed to ensure one resident out of 3 sampled residents (Resident 1) was served the correct therapeutic diet, per doctors ' order. 1. The facility did not ensure Resident 1 received food that was prepared for a minced/moist diet (MM5, food that requires minimal chewing and food that is equal or less than 4 millimeters (mm) width and no longer than 15 mm in length). Resident 1 ' s food was not finely minced and a regular bread roll was served to resident. This deficient practice had the potential for Resident 1 to have problems chewing and swallowing. This deficient practice increased the risk for Resident 1 to choke while eating. Findings: During an observation on 8/20/2024 at 12:42 p.m., in the dining room, Resident 1 was eating lunch. Resident 1 ' s food tray contained slices of squash, full size spiral shaped pasta and a bread roll. During a review of Resident 1 ' s admission Record, indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of depression (a common and serious medical illness that negatively affects how a person feels, thinks, and acts. It causes feelings of sadness and/or a loss of interest in activities they once enjoyed) and dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of Resident 1 ' s History and Physical (H&P) dated 8/30/2023, the H&P indicated Resident 1 could make needs known but cannot make medical decisions. During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/27/2024, the MDS indicated that Resident 1 ' s cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was severely impaired. The MDS indicated Resident 1 needed moderate assistance (helper does less than half the effort) with eating, oral hygiene, and dressing. The MDS indicated Resident 1 was dependent on staff for toileting hygiene and showers/baths. During a review of Resident 1 ' s progress notes, dated 5/28/2024, the progress note indicated Resident 1 was noted to have trouble swallowing and Resident 1 was not chewing her food. During a review of Resident 1 ' s order summary report, dated 5/28/2024, the order summary report indicated Resident 1 was ordered to receive a minced and moist diet. During a review of Resident 1 ' s Dietary Profile/Preferences, dated 7/16/2024, the dietary profile indicated Rsidentv1 ' s diet order was minced and moist. During a review of Resident 1 ' s Nutrition Assessment, dated 8/15/2024, the assessment indicated Resident 1 ' s current diet was minced and moist. During a review of Resident 1 ' s food tray slip, dated 8/20/2024, the food tray slip indicated Resident 1 ' s diet was a minced and moist diet. During a review of facility ' s recipe titled Noodles, dated Week 4 Tuesday Noon Meal, the recipe indicated for a MM5 diet, the pasta had to be minced (4 mm, approximately 1/8th inches). The recipe indicated to use the slots between fork prongs to determine whether minced pieces were correct. During a review of facility ' s recipe titled Seas Zucchini, dated Week 4 Tuesday Noon Meal, the recipe indicated for a MM5 diet the zucchini had to be minced (4 mm, approximately 1/8th inches). The recipe indicated to use the slots between fork prongs to determine whether minced pieces were correct. During a review of facility ' s recipe titled Roll/Marg, dated Week 4 Tuesday Noon Meal, the recipe indicated for a MM5 diet to serve pureed bread slice or gelled bread. During an interview on 8/20/2024 at 1:17 p.m. with Certified Nursing Assistant (CNA 1), CNA 1 stated Resident 1 needs help to eat and staff feed her. CNA 1 stated Resident 1 ' s food must be chopped up into small pieces because she has difficulty chewing and swallowing. During an interview on 8/20/2024 at 1:48 p.m. with Dietary Aide (DA), the DA stated a minced diet was food that had been chopped up into tiny pieces. The DA stated a moist diet was food that had been dipped in something to keep it moist like a gravy. The DA stated a bread roll was not acceptable to serve to a resident on a MM5 diet, the resident should have received bread in a blended consistency. The DA stated residents that have problems with chewing or swallowing get ordered a MM5 diet. The DA stated it was important to serve the correct diet to residents for their therapeutic needs, nutritional value and for resident preference. The DA stated if a resident did not receive a MM5 diet they would have a risk of choking and possibly die. During a concurrent interview and record review on 8/20/2024 at 2:04 p.m. with Licensed Vocational Nurse (LVN 1), Resident 1 ' s progress notes were reviewed. LVN 1 stated Resident 1 ' s diet was minced and moist due to resident having difficulty chewing and swallowing. During an interview on 8/20/2024 at 3:28 p.m. with the Director of Nursing (DON), the DON stated it was important to provide the correct therapeutic diets to the residents to prevent any health complications. The DON stated if a resident did not receive their minced/moist diet they had the risk of their food getting stuck in their throats, get shortness of breath and would create complications with swallowing. The DON stated the kitchen staff, licensed nurses, and the CNAs were all responsible to make sure residents received the correct therapeutic diet. During a review of facility ' s Policy and Procedure (P&P) titled Therapeutic Diets, dated 10/2017, the P&P indicated therapeutic diets are prescribed by the attending physician to support the resident ' s treatment and plan of care and in accordance with residents ' goals and preferences. During a review of facility ' s Policy and Procedure (P&P) titled Food and Nutrition Services, dated 10/2017, the P&P indicated food and nutrition services staff will inspect food trays to ensure that the correct meal was provided to the residents. The P&P indicated if an incorrect meal was provided to a resident, nursing staff would report it and ask for a new food tray. During a review of facility ' s diet manual titled Minced and Moist Diet IDDSI Level 5 -MM5 the manual indicated food can be scooped and shaped into a ball shape and the size of the lump be no greater than 4mm x 15mm. The Manual indicated biting was not required with this diet and only minimal chewing was needed. The manual indicated gravy could be used to hold food together. The Manual indicated no regular or dry bread should be given to residents.

Aug 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain an informed consent (process of communication between resident/responsible party and health care provider that often leads to agreement or permission for care, treatment, or services) prior to the administration of psychotropic medication (medications that affect the mind, emotions, and behavior) for one out of one sampled resident (Residents 1). 1. The facility did not ensure an informed consent was obtained when lorazepam (medication that relieves symptoms of anxiety, causes paranoid or suicidal ideation and impairs memory, judgment, and coordination) medication dosage was increased from 0.5 milligrams (mg, unit of measurement) to 1 mg for Resident 1. This deficient practice violated Resident 1 ' s right to make an informed decision prior to the administration of lorazepam medication. Findings: During a review of Resident 1 ' s admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including anxiety disorder (an intense, excessive, and persistent worry and fear about everyday situations) and depression (a common and serious medical illness that negatively affects how a person feels, the way a person thinks and how they act. It causes feelings of sadness and/or a loss of interest in activities a person once enjoyed). During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/5/2024, the MDS indicated Resident 52 ' s cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 1 required supervision for eating, toileting hygiene, personal hygiene, and shower/bathing self. The MDS indicated Resident 1 required partial assistance (helper does less than half the effort) for dressing and putting shoes on. During a review of Resident 1 ' s History and Physical (H&P) dated 7/2/2024, H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Order Summary Report dated 7/13/2024, the Order Summary Report indicated Resident 1 was ordered to receive Lorazepam 1 milligram (mg) tablet every 12 hours as needed for anxiety. During a review of Resident 1 ' s medical chart, the medical chart did not have an informed consent for the administration of lorazepam 1 mg medication. During a concurrent interview and record review on 8/13/2024 at 2:49 p.m. with Licensed Vocational Nurse (LVN 1), Resident 1 ' s medical chart was reviewed. LVN 1 stated she did not find the informed consent for lorazepam 1 mg. LVN 1 stated a nurse must verify if there was an informed consent prior to the administration of an antipsychotic medication. LVN 1 stated every time there was a change in dosage for an antipsychotic medication, the licensed nurse must obtain an informed consent. LVN 1 stated Resident 1 received a medication that she did not consent to receive. LVN 1 stated it was important to get an informed consent to inform Resident 1 of new medication dosage and to get Resident 1 ' s consent to receive medication. LVN 1 stated the licensed nurses were liable of administering medication to Resident 1 without her being aware of the medication change and without her giving her consent. During an interview on 8/13/2024 at 3:43 p.m. with LVN 2, LVN 2 stated a nurse must check if there was an informed consent before the administration of the antipsychotic medication. LVN 2 stated the inform consent was the acknowledgement that a resident was informed about the medication and the resident gave their consent to receive the medication. LVN 2 stated a new informed consent was needed when the dosage of an antipsychotic medication was increased or decreased. LVN 2 stated Resident 1 needed an informed consent for Lorazepam because it was a chemical restraint. LVN 2 stated lorazepam should have not been administered to Resident 1 because there was no informed consent for that medication. During an interview on 8/13/2024 at 4:22 p.m. with Registered Nurse (RN 2), RN 2 stated when there was an increase on a medication a new informed consent was needed. RN 2 stated if a medication dosage was increased and there was no informed consent for the new dosage, the facility would not be in compliance and the medication should have not been administered to Resident 1. RN 2 stated it was important to have an informed consent for all staff to be on the same page with the care for Resident 1. During a review of the facility ' s Policy and Procedure (P&P) titled Resident Rights, dated 2/2021, the P&P indicated residents had the right to be informed of, and participate in, his or her care planning and treatment. During a review of the facility ' s P&P titled Antipsychotic Medication Use, dated 7/2022, the P&P indicated all residents will be informed of the recommendation, risk, benefits, purpose and potential adverse consequences of antipsychotic use and residents may refuse medications of any kind.

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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an interview and record review, the license nurses failed to review, update, and/or revise a care plan (written document developed for each individual by the support team using a person-centered approach that describes the supports, services, and resources provided or accessed to address the needs of the individual) to reflect the physician current order for lorazepam (medication that relieves symptoms of anxiety [feeling of unease, excessive worry]) for one out of one sampled resident (Resident 1). This deficient practice had the potential to result in Resident 1 not receiving an accurate dose of lorazepam and had the potential to negatively affect Resident 1 ' s physical and psychosocial well-being. Findings: During a review of Resident 1 ' s admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including anxiety disorder (an intense, excessive, and persistent worry and fear about everyday situations) and depression (a common and serious medical illness that negatively affects how a person feels, the way a person thinks and how they act. It causes feelings of sadness and/or a loss of interest in activities a person once enjoyed). During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/5/2024, the MDS indicated Resident 52 ' s cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 1 required supervision for eating, toileting hygiene, personal hygiene, and shower/bathing self. The MDS indicated Resident 1 required partial assistance (helper does less than half the effort) for dressing and putting shoes on. During a review of Resident 1 ' s History and Physical (H&P) dated 7/2/2024, H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Order Summary Report dated 7/13/2024, the Order Summary Report indicated Resident 1 was ordered to receive Lorazepam 1 milligram (mg, unit of measurement) tablet every 12 hours as needed for anxiety. During a review of Resident 1 ' s Care Plan for anti- anxiety medication related to anxiety disorder dated 5/6/2024, it indicated the goal was for Resident 1 to be free from discomfort or adverse reactions related to anti-anxiety therapy. The care plan indicated the interventions was to administer Lorazepam 0.5 mg tablet every 12 hours as needed for anxiety and to administer anti-anxiety medication as ordered by physician. During an interview on 8/13/2024 at 3:21 p.m. with Licensed Vocational Nurse (LVN 2), LVN 2 stated when a medication dosage was increased or decreased, the care plan must be revised. LVN 2 stated care plans served as a plan of care for nurses to follow. LVN 2 stated if the care plan was not revised, nurses would not know of the new medication order. During an interview on 8/13/2024 at 4:22 p.m. with Registered Nurse (RN 2), RN 2 stated a care plan must be revised when the doctor increased or decreased a medication. RN 2 stated it was important to revise care plans to provide a continuous care to the residents. RN 2 stated when Lorazepam was increased from 0.5 mg to 1 mg, the licensed nurse should have revised the care plan to reflect the new doctor order. The RN 2 stated care plans must be revised because it is the plan of care that licensed nurses must follow to safely care for residents. RN 1 stated if a care plan was not revised when there was a new medication order, the licensed nurses would not administer the correct medication to the resident. During a review of the facility ' s Policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents ' condition change.

Jul 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0675 (Tag F0675)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to answer call lights in a timely manner for three out of three sampled residents (Resident 1, 2, and 3). This deficient practice had the potential to cause a negative impact on Resident 1, 2, and 3's health and psychosocial well-being. Findings: 1. A review of Resident 1's admission Record, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including fracture (broken bone) of the pubis (bone that forms the lower and anterior part of each side of the hip bone) and fracture of the sacrum (large, triangle-shaped bone in the lower spine that forms part of the pelvis [area of the body below the abdomen that contains the hip bones, bladder, and rectum]). A review of Resident 1's History and Physical (H&P) dated 2/14/2024, indicated Resident 1 had the capacity to understand make medical decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/21/2024, indicated Resident 1's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 1 required supervision for eating, oral hygiene, upper body dressing, and personal hygiene. During an interview on 7/10/2024 at 11:55 a.m. with Resident 1, Resident 1 stated when she was admitted to the facility, she was bedridden and it took staff at least 15 minutes to see what she needed. Resident 1 stated when staff came to her room, she asked staff to change her diaper and staff told her she had to wait 15 minutes because they were going on a break. Resident 1 stated it was unacceptable for a resident to have to wait that long to get any assistance. Resident 1 stated it happened on a daily basis to all residents in the facility. 2. A review of Resident 2's admission Record, indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including respiratory failure (serious condition that makes it difficult to breathe on your own, lungs can't get enough oxygen into the blood) with hypoxia (a state in which oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis) and chronic pulmonary edema (condition where fluid accumulates in lung tissues, causing shortness of breath, wheezing and coughing up blood). A review of Resident 2's H&P dated 5/8/2024, indicated Resident 2 could make needs known but could not make medical decisions. A review of Resident 2's MDS, dated [DATE], indicated Resident 2's cognitive skills for daily decision making was intact. The MDS indicated Resident 2 required supervision for eating, oral hygiene, and upper body dressing and required moderate assistance (helper does less than half the effort) for toileting hygiene, personal hygiene, and lower body dressing. During an interview on 7/10/2024 at 10:59 a.m. with Resident 2, in Resident 2's room, Resident 2 stated staff did not like to answer call lights and when staff did answer call lights, they came into her room with an attitude. Resident 2 stated staff came into her room, asked why she needed help so much, and staff screamed at her. Resident 2 stated she felt staff did not like her. Resident 2 stated her vision was impaired and that was why she needed staff assistance to guide her to the restroom or around her room. Resident 2 stated she used her call light at night and no one came to her room to check on her. Resident 2 stated what was the point of having a call light if staff do not answer it. Resident 2 stated she knew if she had an emergency and she used the call light no one would come to help her. Resident 2 stated she felt sad because she felt the nurses did not care enough to help her. 3. A review of Resident 3's admission Record, indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia (a condition caused by a brain injury, that results in a varying degree of weakness, stiffness and lack of control in one side of the body) and respiratory failure (serious condition that makes it difficult to breathe on their own, lungs can't get enough oxygen into the blood). A review of Resident 3's H&P dated 10/23/2023, indicated Resident 3 did not have the capacity to understand and make decisions due to a cerebral vascular accident (a loss of blood flow to part of the brain, which damages brain tissue caused by blood clots and broken blood vessels in the brain). A review of Resident 3's MDS, dated [DATE], indicated that Resident 3's cognitive skills for daily decision making was intact. The MDS indicated Resident 3 required maximal assistance (helper does more than half the effort) with oral hygiene, dressing, and personal hygiene. The MDS indicated Resident 3 was dependent on staff for toileting hygiene and shower/baths. During an interview on 7/10/2024 at 10:37 a.m. with Resident 3, in Resident 3's room, Resident 3 stated staff took too long to change her diaper. Resident 3 stated most of the time her call light was not assessible. Resident 3 stated she used her call light but staff did not answer. Resident 3 stated sometimes staff answered her call light and told her they would return but they did not return to help her. Resident 3 stated she waited 2 hours to get her diaper changed. Resident 3 stated the night shift staff and day shift staff did not answer call lights in a timely manner. During an interview on 7/11/2024 at 1:49 p.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated all call lights must be answered quickly. LVN 1 stated residents should only wait a couple of minutes to get their call lights answered. LVN 1 stated if call lights were not answered quickly, it delayed care. LVN 1 stated it was important to answer call lights quickly to assist with resident needs, resident safety and prevent accidents. During an interview on 7/11/2024 at 2:04 p.m. with Certified Nursing Assistant (CNA 3), CNA 3 stated all staff were responsible for answering residents call lights. CNA 3 stated staff should not make residents wait to get assistance. CNA 3 stated when a CNA went on a break there were other CNAs available to assist residents with their needs. CNA 3 stated it was important to answer residents call light in a timely matter to assist residents with their needs and to prevent accidents. During an interview on 7/11/2024 at 2:26 p.m. with the Director of Staff Development (DSD), the DSD stated he expected all staff of the facility to answer resident call lights within five minutes. The DSD stated it was important to answer call lights in a timely manner to assist residents with their care needs and to provide the attention that residents need in case it was an emergency. The DSD stated if call lights were not answered in a timely manner, residents may get agitated and their care would get delayed. During an interview on 7/11/2024 at 3:45 p.m. with the Director of Nursing (DON), the DON stated she expected all staff of the facility to answer call lights in a timely manner. The DON stated all staff must answer the call light once they see it go on. The DON stated staff must ask the resident what assistance they need, and send designated staff to assist the resident. The DON stated it was important to answer call lights in a timely matter to prevent accidents and to meet resident needs. The DON stated if residents did not get their call light answered it could cause residents to be unhappy and their needs would not be met. The DON stated it was not acceptable to have residents siting on a wet diaper for a long time because it could cause skin issues and infections, and the resident would feel uncomfortable, and dirty sitting on a wet diaper. The DON stated all residents' needs should be met and all residents' diapers should be changed in a timely matter. A review of the facility's Policy and Procedure (P&P) titled Answering the Call Light dated 9/2022, indicated it was the facility purpose to ensure timely responses to the resident's requests and needs. The P&P indicated staff must ensure the call light is accessible to the resident while in bed. The P&P indicated staff must answer residents call light system immediately. The P&P indicated staff must complete what a resident asked for within five minutes.

CONCERN (D) 📢 Someone Reported This

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

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide safe oxygen administration practices for one of three sampled residents (Resident 2) when the facility failed to: 1. Ensure Resident 2 received oxygen at 2 liters per minute (LMP) per the physician's order. 2. Label Resident 2's nasal cannula (a plastic medical device to provide supplemental oxygen therapy to people who have lower oxygen levels, device goes directly into the nostrils). 3. Replace Resident 2's nasal cannula tubing after the nasal tubing prongs (portion of nasal tubing that goes into nostrils) touched the floor. These deficient practices had the potential to cause a negative respiratory outcome and increased the risk for Resident 2 to acquire a respiratory infection. Findings: During an observation on 7/10/2024 at 10:59 a.m., in Resident 2's room, Resident 2 was observed sitting up on the edge of the bed. Resident 2's nasal canula was observed on the floor. The oxygen was set at three liters ([unit of measurement] per minute [LPM]). The nasal cannula tubing was not labeled. The nasal cannula tubing had white particles in the tubing and was tangled under the oxygen compressor's (medical device that purifies air to deliver pure oxygen) wheels. Resident 2's wheelchair wheel was on top of nasal cannula tubing. A review of Resident 2's admission Record, indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including respiratory failure (serious condition that makes it difficult to breathe on your own, lungs can't get enough oxygen into the blood) with hypoxia (a state in which oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis) and chronic pulmonary edema (condition where fluid accumulates in lung tissues, causing shortness of breath, wheezing and coughing up blood). A review of Resident 2's History and Physical (H&P) dated 5/8/2024, indicated Resident 2 could make needs known but could not make medical decisions. A review of Resident 2's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 5/13/2024, indicated Resident 2's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making was intact. The MDS indicated Resident 2 required supervision for eating, oral hygiene, and upper body dressing and moderate assistance (helper does less than half the effort) for toileting hygiene, personal hygiene, and lower body dressing. A review of Resident 2's Order Summary Report, dated 5/6/2023, the report indicated Resident 2 had an order for oxygen at 2 LPM, via nasal cannula as needed for dyspnea (shortness of breath) on exertion. A review of Resident 2's Care Plan for oxygen therapy, related to dyspnea due to pulmonary edema indicated the goal was for Resident 2 not to have signs and symptoms of poor oxygen absorption (when oxygen intake occurs at a slow rate, results in higher levels of carbon dioxide in the blood and lower oxygen levels). The staff's interventions indicated to administer oxygen at 2 LPM via nasal cannula as needed for dyspnea on exertion. During an interview on 7/10/2024 at 11:08 a.m. with Resident 2, in Resident 2's room, Resident 2 stated she had taken off her nasal cannula because she was afraid to trip on it. Resident 2 stated the nasal cannula tubing was stuck on something and she did not have enough slack. Resident 2 stated her nasal cannula tubing always came in contact with the floor and the staff did not care because they did not pick it up. Resident 2 stated if a staff person picked up the nasal cannula tubing from the floor, they put it back on her. Resident 2 stated staff did not get new nasal cannula tubing. Resident 2 stated she could not pick up the nasal cannula tubing from the floor because she had a vision impairment and could not see it. During an interview on 7/10/2024 at 2:36 p.m. with Licensed Vocational Nurse (LVN 1), in Resident 2's room, LVN 1 stated she put Residents 2 nasal cannula back on after being on the floor. LVN 1 stated she did not replace the nasal cannula tubing before putting it on Resident 2. LVN 1 stated Resident 2's nasal cannula tubing was supposed to be dated but it was not. LVN 1 stated she did not know how often oxygen equipment was to be changed. LVN 1 stated she did not know the facility's policy for oxygen administration, nor did she did know Resident 2's oxygen order. During an interview on 7/11/2024 at 1:33 p.m. with LVN 1, LVN 1 stated oxygen equipment was labeled with the date it was opened. LVN 1 stated oxygen equipment was labeled to inform staff that the oxygen equipment was clean and for infection control purposes. LVN 1 stated if oxygen equipment was not labeled, staff would not know when the oxygen equipment was initially set up and would increase the risk for an infection. LVN 1 stated Resident 2 was supposed to receive 2 LPM, per the physician's order. LVN 1 stated if Resident 2 received over 2 LPM, Resident 2 might develop signs of fluid overload. LVN 1 stated nasal cannula tubing had to be replaced if it touched the floor. During an interview on 7/12/2024 at 3:45 p.m. with the Director of Nursing (DON), the DON stated all licensed nurses were responsible to know the oxygen's effect on residents and they must know how to administer oxygen to residents. The DON stated all nurses must check the physician's orders prior to the start of oxygen administration. The DON stated a nurse must check the physician's orders to find out how many liters of oxygen the resident was ordered to receive. The DON stated if a resident received more oxygen than ordered it could affect the resident's lungs. The DON stated the resident's breathing would be affected because the extra continuous oxygen would cause the resident not to fully exhale properly. The DON stated it was important to deliver the correct liters of oxygen to residents to provide efficient care and to follow the physician's orders. The DON stated the licensed nurse that set up the new nasal cannula tubing and must label the tubing with the date and name of the nurse because it was important to know how long resident has had that oxygen equipment. The DON stated if the nasal cannula tubing was not labeled with the open date, staff would not know when it was due to be changed. The DON stated the reason oxygen equipment was labeled with the date was to prevent residents from acquiring infections. A review of the facility's Policy and Procedure (P&P) titled Oxygen Administration , dated 10/2010, indicated its purpose was to provide guidelines for a safe oxygen administration. The P&P indicated staff must verify doctors order before oxygen administration. The P&P indicated staff must review the residents care plan before oxygen administration.

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 F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of six sampled residents (Resident 5) received food according to his preference. This deficient practice had the potential to result in decreased meal intake, weight loss and malnutrition (when the body does not get enough nutrients). Findings: A review of Resident 5's admission Record indicated Resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including orthopedic (relating to the branch of medicine dealing with correction of deformities of bones or muscles) after care, diabetes (abnormal blood sugar) and hypertension (high blood pressure). A review of Resident 5's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 11/6/2023, indicated Resident 5 had no cognitive (the ability to think and reason) impairment. The MDS indicated Resident 5 required supervision to substantial/maximal assistance (staff does more than half the effort) for Activities of Daily Living (ADLs) such as eating, upper and lower body dressing and toileting hygiene. A review of Resident 5's History and Physical (H&P), dated 4/16/2024, indicated Resident 5 had the capacity to understand and make decisions. During a concurrent observation, record review and interview on 7/11/2024 at 12:21 p.m. with Resident 5, Resident 5 was observed with lunch tray with bell peppers pushed off to the side of the plate. Resident 4 stated, he did not like bell peppers and the facility continued to serve bell peppers to him. A review of Resident 5's dietary slip (a paper that identified who the tray is to be served to along with prescribed diet and preferences) indicated Resident 5 disliked bell peppers. Resident 5 stated he had to order outside food on multiple occasions because he was unable to eat the food served by the facility. During a concurrent interview and record review on 7/12/2024 at 1:29 p.m. with Certified Nursing Assistant (CNA) 2, a picture of Resident 5's lunch tray and dietary slip dated 7/11/2024 were reviewed. CNA 2 stated Resident 5 disliked bell pepper and it was served on the resident's lunch tray. CNA 2 stated, CNAs should check resident's dietary trays prior to serving it to the residents. CNA 2 stated it was important to know the resident likes or dislikes and staff should have returned the tray to the kitchen to obtain a replacement tray for Resident 5. During a concurrent interview and record review on 7/12/2024 at 2:25 p.m. with Dietary Supervisor (DS), a picture of Resident 5's lunch tray and dietary slip dated 7/11/2024 were reviewed. DS stated, it was important for staff to check resident's trays prior to serving it to the residents to ensure the resident received food according to the resident's diet and food preferences. DS stated food was important and resident needs would not be met if the residents were served food they did not like. A review of facility's P&P titled, Food and Nutrition Services dated 10/2017, indicated each resident should be provided with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, and took into consideration the preferences of each resident. The P&P indicated Food and Nutrition Services staff were to inspect food trays to ensure the correct meal was provided to each resident. The P&P also indicated, nursing staff were to report to the service manager to make sure a new tray was issued to the resident, if an incorrect meal was provided to a resident, or a meal did not appear palatable.

Jun 2024 4 deficiencies 1 IJ (1 affecting multiple)

CRITICAL (K) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Safe Environment (Tag F0584)

Someone could have died · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Maintain residents' room temperatures in a range of 71 to 81 degrees (unit of measurement) Fahrenheit (F, a scale of temperature) for 9 out of 9 resident rooms (Rooms 106, 128, 129, 130, 132, 133, 134, 135, and 136). 2. Implement the facility's contingency plan (involves making various decisions as an organization before an emergency happens) when the air conditioning (A/C) unit became inoperable on 6/22/2024 affecting 9 out of 9 resident rooms (Rooms 106, 128, 129, 130, 132, 133, 134, 135, and 136). 3. Implement cooling measures to keep residents comfortable for 10 out of 10 residents (Resident 1, 2, 12, 13, 25, 26, 27, 28, 29, and 30) when the A/C unit became inoperable on 6/22/2024, a total of 3 days. These deficient practices put the residents in the affected rooms at risk for dehydration (excessive loss of body water) and/or heat stroke (internal body heat with complications involving the central nervous system that occur after exposure to high temperatures) and had the potential to negatively affect the identified 34 residents. On 6/25/2024 at 7:20 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was called. The facility ' s Director of Staff Development, Director of Maintenance, and Administrator were notified of the nine residents ' rooms and residents affected by the increased room temperatures above 81.0 degrees F which could potentially put the residents at risk for dehydration and heatstroke. On 6/26/2024, the facility provided an IJ Removal Plan ([IJRP] a plan on how the facility would correct the deficient practices for the benefit of the residents) that was not acceptable. On 6/27/2024 at 3:50 p.m., the facility provided an acceptable IJRP and the IJ was removed, after the team verified through observations interviews, and record review. The IJRP was implemented as follows: 1. Eight (8) portable air conditioning systems and 11 fans were placed in the affected rooms. 2. A hydration station (a table with cold ice water and cups) was set up in the affected area and two additional hydration stations were set up outside the front dining room and the back dining room, with staff distributing water to the residents. 3. In-service training provided to staff on all shifts regarding the Extreme Weather Advisory. 4. Temporary room changes for residents in rooms that did not receive a portable air conditioning unit (rooms [ROOM NUMBER]). 5. Received diagnostics and partial repair services from the air conditioning repair vendor, with full repair of the air conditioning unit pending due to parts not being readily available. 6. Staff monitoring residents for signs and symptoms of dehydration every two (2) hours. 7. Monitoring for heat exposure by taking room temperatures every hour, and resident vital signs taken every four (4) hours from until the air conditioning is repaired. 8. Water being offered throughout the day at least once every two (2) hours. Findings: 1. During an observation on 6/25/2024, at 12:02 p.m., Resident 1 was observed awake in bed, nonverbal. Resident 1 was observed with, dry, cracked lips. A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 6/8/2018. Resident 1's admitting diagnosis included dysphagia (difficulty swallowing) following a cerebral infarction (tissue death of the brain from a clot or other obstruction of blood flow), dementia (impaired ability to remember, think, and make decisions which interferes with everyday activities), and type two (2) diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 6/12/2024, indicated Resident 1 was severely cognitively impaired (ability to think and reason). The MDS indicated Resident 1 required total assistance (helper does all the effort) with oral hygiene, toileting hygiene, showering/bathing, dressing, and personal hygiene. During an interview on 6/25/2024, at 12:33 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1's lips looked a little dry. During an interview on 6/25/2024, at 2:02 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 1's room was hot. During an interview on 6/25/2024, at 3:15 p.m., with Resident 1's Family Member (FM) 1, FM 1 stated the past 7 days, between 3 p.m., to 6 p.m., she observed Resident 1's room was hot more than usual. FM 1 she complained to a nurse but did not know the nurse's name. During an interview on 6/25/2024, at 5:50 p.m., with FM 1, FM 1 stated she had not witnessed staff offering any of the residents in Resident 1's room water, popsicles, ice cream, or other cooling foods. 2. During a concurrent observation and interview on 6/25/2024, at 12:04 p.m., with Resident 2 (Resident 1's roommate), Resident 2 was observed awake, alert, and seated on a wheelchair. Resident 2 stated the air conditioning in their room had not been working since last week. Resident 2 stated it was so humid around 5 p.m. every day since the air conditioner stopped working last week that she could not breathe. A review of Resident 2's admission Record indicated the facility originally admitted Resident 2 on 3/20/2020, and most recently re-admitted Resident 2 on 11/03/2020. Resident 2's admitting diagnosis included anxiety disorder (a disorder involving persistent and excessive worry that interferes with daily activities), and gastro-esophageal reflux disease ([GERD] a condition in which the stomach contents move up into the esophagus). A review of Resident 2's MDS, dated [DATE], indicated Resident 2 was cognitively intact. The MDS indicated Resident 2 required moderate assistance (the helper does less than half the effort) with toileting hygiene, dressing the lower body, and putting on/taking off footwear. During an interview on 6/25/2024, at 3:55 p.m., with Resident 2, Resident 2 stated she was concerned about her roommate (Resident 1) because she could not ask for help. Resident 2 stated other than today (6/25/2024), in the activities room, no one offered her popsicles, ice cream, or any other cool foods to decrease the effects of the heat. 3. During a concurrent observation and interview on 6/25/2024, at 12:59 p.m., with Resident 12, Resident 12 was observed awake, alert, and in bed. Resident 12 stated it felt too hot and he had been uncomfortable. Resident 12 stated he reported the warmer temperature to unknown nursing staff a few days prior but they did not do anything about it. Resident 12 stated the room felt much hotter late in the afternoon. A review of Resident 12's admission Record indicated the facility originally admitted Resident 12 on 7/18/2021, and most recently re-admitted Resident 12 on 5/25/2022. Resident 12's admitting diagnosis included sepsis (infection of the blood) due to Escherichia coli ([E. Coli] a type of bacteria that causes disease in humans) and type 2 diabetes mellitus. A review of Resident 12's MDS, dated [DATE], indicated Resident 12 was moderately cognitively impaired. The MDS indicated Resident 12 required total assistance with showering/bathing. 4. During an observation and concurrent interview on 6/25/2024, at 1:41 p.m., with Resident 13, Resident 13 was observed awake, alert, and sitting on a wheelchair in the hallway, outside of his room. Resident 13 stated he was in the hallway because his room was too hot and had been so hot for a couple of days. Resident 13 stated he was going to buy a fan, to help keep him cool since no one was addressing the problem. A review of Resident 13's admission Record indicated the facility admitted Resident 13 on 4/28/2023. Resident 13's admitting diagnosis included type 2 diabetes mellitus and chronic kidney disease (when the kidneys do not function normally and have difficulty filtering waste from the blood). A review of Resident 13's MDS, dated [DATE], indicated Resident 13 was cognitively intact. The MDS indicated Resident 13 required maximum assistance for toileting hygiene, showering/bathing, dressing the lower body, and putting on/taking off footwear. 5. During a concurrent observation and interview on 6/25/2024, at 3:48 p.m., with Resident 25, Resident 25 was observed awake, alert, and in bed. Resident 25 stated it had been very hot in the facility for a couple of days and wished it was colder. Resident 25 stated none of the staff offered her popsicles, ice cream, or any cool foods since it had been hot. Resident 25 stated she felt staff do not care which made her feel sad. A review of Resident 25's admission Record indicated the facility admitted Resident 25 on 5/28/2024. Resident 25's admitting diagnosis included an unstageable (unable to determine the depth due to abnormal tissue covering healthy tissue) pressure ulcer (damage to an area of the skin or tissues because of constant pressure on the area for a long time) of the sacral region (lower back), and type 2 diabetes mellitus. A review of Resident 25's MDS, dated [DATE], indicated Resident 25 was moderately cognitively impaired. The MDS indicated Resident 25 required total assistance with showering/bathing, dressing the lower body, and putting on/taking off footwear. 6. During an interview on 6/26/2024, at 2:22 p.m., with Resident 26, Resident 26 stated his room was too hot on 6/25/2024, in the afternoon. Resident 26 stated staff did not offer him any foods like popsicles or ice cream the past week, to keep him cool. Resident 26 stated he asked the nurses (names unknown) to pat him down with a cold wet towel. A review of Resident 26's admission Record indicated the facility admitted Resident 26 on 1/21/2023. Resident 26's admitting diagnosis included type 2 diabetes mellitus, sepsis, and acute respiratory failure (the inability of the respiratory system to oxygenate the body) with hypoxia (low oxygen in the blood). A review of Resident 26's MDS, dated [DATE], indicated Resident 26 was cognitively intact. The MDS indicated Resident 26 had required total assistance with oral hygiene, toileting hygiene, showering/bathing, dressing the upper and lower body, and personal hygiene. 7. During an interview on 6/26/2024, at 3:18 p.m., with Resident 27, Resident 27 stated yesterday (6/25/2024), her room was too hot and had been very hot for one week. Resident 27 stated she told multiple nurses on multiple occasions. Resident 27 stated she did not recall the names of the nurses she told. Resident 27 stated when she told one nurse the heat was too much the nurse stated, it is a very hot day. Resident 27 stated staff did not offer him any cooling measures such as popsicles or ice cream. Resident 27 stated she drank cold water and fanned herself to keep cool. Resident 27 stated she was uncomfortable due to the heat. Resident 27 stated her roommate (Resident 28) was sweating a lot, and the nurses had to change her (Resident 28's) sheets because she was drenched in sweat. A review of Resident 27's admission Record indicated the facility originally admitted Resident 27 on 8/24/2016, and most recently re-admitted Resident 27 on 5/29/2023. Resident 27's admitting diagnosis included type 2 diabetes mellitus and acute respiratory distress syndrome ([ARDS] a condition in which fluid collects in the lungs' air sacs, depriving organs of oxygen). A review of Resident 27's MDS, dated [DATE], indicated Resident 27 was cognitively intact. The MDS indicated Resident 27 had required maximum assistance with toileting hygiene, showering/bathing, and dressing the lower body. 8. A review of Resident 28's admission Record indicated the facility originally admitted Resident 28 on 8/2/2022, and most recently re-admitted Resident 28 on 10/29/2023. Resident 28's admitting diagnosis included metabolic encephalopathy (a chemical imbalance in the blood effecting the brain) and type 2 diabetes mellitus. A review of Resident 28's MDS, dated [DATE], indicated Resident 28 was severely cognitively impaired. The MDS indicated Resident 28 required total assistance with toileting hygiene, and showering/bathing. 9. During an interview on 6/26/2024, at 3:45 p.m., with Resident 29, Resident 29 stated her room had been hot the past week and she had not been offered popsicles, ice cream, or other cold snacks. A review of Resident 29's admission Record indicated the facility admitted Resident 29 on 2/14/2024. Resident 29's admitting diagnosis included fracture (broken) to the left pubis (a part of the hip bone), fracture of the sacrum (lower back bone). A review of Resident 29's MDS dated [DATE], indicated Resident 29 was cognitively intact. The MDS indicated Resident 29 had required maximum assistance with toileting hygiene, showering/bathing, dressing the lower body, and putting on/taking off footwear. 10. During a concurrent observation and interview on 6/26/2024, at 4:08 p.m., with the Housekeeping Supervisor (HS), Resident 30 was observed in bed, asleep. A thermometer reading measured 81.9 degrees. Resident 30 ' s air conditioning vent was closed. The HS stated she was going to open the vent to help cool the room. A review of Resident 30's admission Record indicated the facility originally admitted Resident 30 on 8/8/2021, and most recently re-admitted Resident 30 on 1/16/2024. Resident 30's admitting diagnosis included dementia and chronic kidney disease. A review of Resident 30's MDS, dated [DATE], indicated Resident 30 was severely cognitively impaired. The MDS indicated Resident 30 had required total assistance with oral hygiene, toileting hygiene, showering/bathing, dressing both the upper and lower body, and personal hygiene. During an interview on 6/25/2024, at 9:12 a.m., with the DOM, the DOM stated the air conditioning unit affecting rooms 128 through 138 stopped working on 6/20/2024. The DOM stated the residents ' rooms and community areas must be between 71 to 81 degrees F. During an interview on 6/25/2024, at 1:58 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated it had been crazy hot for the past few days. CNA 1 stated when he gave residents showers, he was sweating. During an observation, on 6/25/2024, at 3:06 p.m., with the Director of Maintenance (DOM), the temperature in room [ROOM NUMBER] was 84 degrees Fahrenheit (F), room [ROOM NUMBER] was 81.5 degrees F, room [ROOM NUMBER] was 84 degrees F, room [ROOM NUMBER] was 84 degrees F, room [ROOM NUMBER] was 81.5 degrees F, and room [ROOM NUMBER] was 84 degrees F. During a concurrent observation and interview, on 6/25/2024, at 3:45 p.m., with the DOM, the DOM stated residents ' room temperatures were as follows: room [ROOM NUMBER] was 82 degrees F, room [ROOM NUMBER] was 82 degrees F, room [ROOM NUMBER] was 85 degrees F, room [ROOM NUMBER] was 84.5 degrees F, room [ROOM NUMBER] was 81.5 degrees F, room [ROOM NUMBER] was 86.5 degrees F, and room [ROOM NUMBER] was 84.5 degrees F. The DOM stated the room temperatures were above the regulated range which could cause discomfort to residents. During an interview on 6/25/2024, at 4:12 p.m., with the Director of Staff Development (DSD), the DSD stated the staff first started complaining of the heat on 6/19/2024. The DSD stated the facility was going to purchase fans for the residents' rooms without functioning air conditioning that day (6/25/2024). The DSD stated if residents get too hot, they could suffer from heat stroke. During an interview on 6/25/2024, at 4:21 p.m., with the DOM, the DOM stated the compressor on the air conditioner was replaced on 6/20/2024 by the Repair Vendor, but it stopped working again 6/21/2024. The DOM stated the facility took temperatures of the residents' rooms daily in the morning. The DOM stated on 6/25/2024, staff had not taken temperatures from 3:00 p.m. to 5:00 p.m., which unfortunately was the hottest part of the day. During a concurrent observation and interview, on 6/25/2024, at 4:32 p.m., with the DOM, the DOM stated the temperatures in room [ROOM NUMBER] was 81.5 degrees F, room [ROOM NUMBER] was 83 degrees F, room [ROOM NUMBER] was 84 degrees F, room [ROOM NUMBER] was 81.5 degrees F, room [ROOM NUMBER] was 86.5 degrees F, and room [ROOM NUMBER] was 85 degrees F. During an interview on 6/25/2024, at 6:35 p.m., with the DSD, the DSD stated the facility did not have a contingency plan in place to use if the air conditioner stopped working. The DSD stated the facility did not report the air conditioning ceasing to work to any the state or federal agencies. During an interview on 6/25/2024, at 6:36 p.m., with the DOM, the DOM stated the facility did not have a contingency plan for when the air conditioner turned off. and The DOM stated the facility did not have a Preventative Maintenance ([PM] log to keep track of preventative maintenance efforts to prevent the air conditioning system from not working) log. The DOM stated the only PM log the facility had was of the room temperatures. A review of the facility's resident room temperature log, dated 6/2024, indicated on 6/5/2024 through 6/10/2024, 6/15/2024, and on 6/22/2024 through 6/24/2024 the temperatures of residents' rooms were not documented. A review of the facility's A/C Repair Company ' s Invoice, dated 6/20/2024, indicated the old burnt compressor (part responsible for transferring heat from the refrigerant [the liquid that cools the air] to the condenser [device that takes heat away from the air]) was removed and a new one was installed to A/C Unit 16 (affecting rooms 128 through 138). A review of the facility's email dated, 6/25/2024, from the A/C Repair Company to the DOM, indicated AC Unit 16 needed further repair with a recommendation to replace the condenser coil (part of the cooling system that completes the heat exchange cycle). During an interview on 6/26/2025, at 1:35 p.m., with the Administrator (ADM), the ADM stated the facility's contingency plan was located in the facility's emergency binder and would provide it. During an interview on 6/26/2024 at 2:07 p.m., with the ADM, the ADM stated as part of their plan when the air conditioning stopped working, the facility would call the facility's A/C repair company right away to come assess and fix it. The ADM stated if the vendor was not able to fix the air conditioning immediately, the facility would provide fans in the residents ' rooms. The ADM stated the DSD and DOM were not aware of what a contingency plan for the air conditioning malfunction, and he and the director of nursing (DON) were not onsite 6/25/2025. During a concurrent interview and record review on 6/26/2024, at 2:07 p.m., with the ADM, the facility ' s undated Extreme Weather - Heat Emergency Operations Plan (EOP), was reviewed. The ADM stated the facility had not implemented the EOP until 6/26/2024. The EOP indicated the facility's initial actions during extreme heat included: a. Activate facility's EOP and appoint a Facility Incident Commander (IC) if warranted (facility failed to do). b. Assess residents for signs of distress and/or discomfort. c. Call 911 if any residents appear to be suffering from heat-related illness such as a heat cramps (painful muscle spasms that can happen during activity in hot environments), heat exhaustion (when the body overheats and cannot cool itself down), or heat stroke. d. Re-locating residents to a cooler part of the facility. e. If the outdoor temperature is cooler than the internal facility temperature, consider opening windows and using fans to bring cooler air into the building. If the outdoor temperature is not cooler, keep the windows closed and shades drawn. f. If the internal temperature of the facility remains high and potentially jeopardizes the safety and health of residents, consider evacuation to another facility and if the decision to evacuate was made to initiate the Rapid Response Evacuation EOP. g. Provide cool washcloths and cooling fans for air circulation. h. Encourage residents to drink fluids to maintain hydration. i. Notify the LA County DPH health Facilities Inspection Division (HFID) to report an unusual occurrence and activation of the facility ' s EOP. During an interview on 6/26/2024, at 2:15 p.m., with the DON, the DON stated not following their EOP could result in residents feeling too hot, dehydrated or suffer a heat stroke. A review of the facility's policy and procedure (P&P) titled Room Temperature, dated 11/2/2018, indicated all buildings were required to maintain an ambient temperature throughout resident areas in a temperature range of 71 to 81 degrees F. The P&P stated the variance in temperatures must not adversely affect resident health and safety. The P&P indicated: a. The time of day that the temperatures were taken should vary to ensure the desired temperature range is achieved under a variety of conditions. b. While meeting the requirement for indoor air temperature, consideration of the effective air temperature and the impact that humidity and air movement in the building may be having on comfort. A review of the facility's P&P titled Homelike Environment, undated, indicated the purpose of the policy was to provide residents with a safe, clean, and homelike environment. The P&P indicated included in a homelike environment is comfortable temperatures, and safe temperatures (71 degrees F to 81 degrees F). A review of the California Department of Public Health's All Facilities Letter ([AFL] a letter from the Center for Health Care Quality, Licensing and Certification Program to health facilities that are licensed or certified) 23-20 titled, dated, 6/28/2023, indicated facilities are to implement precautionary measures to keep individuals safe and comfortable during extremely hot weather, and must have contingency plans in place to deal with the loss of air conditioning. The AFL 23-20 indicated the facility measures include: a. Ensuring a comfortable climate for residents with climate control and adequate ventilation. b. Contingency planning includes using portable fans and other temporary cooling devices when indicated. c. Preparation to care for heat-related illnesses. d. Take precautions to maintain adequate hydration among residents. A review of an online article by the National Institute of Health (NIH) titled, Keep it Cool with Hot Weather Advice for the older People, dated 7/24/2006, indicated older people are at a high risk for developing heat-related illnesses because the ability to respond to summer heat can be less efficient with advancing years. The article indicated that the temperature did not have to hit 100 degrees F for the elderly to be at risk for hyperthermia (temperature being abnormally high) and other heat-related conditions due to many other factors relating to age, medications receiving and /or medical diagnoses. https://www.nih.gov/news-events/news-releases/keep-it-cool-hot-weather-advice-older-people.

CONCERN (D) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately document the activity attendance records for one out of three residents (Resident 1). This deficient practice had the potential to result in Resident 1 not receiving services needed such as getting out of bed to prevent a lack of mobility related injuries such as skin break down, and psychosocial injuries such as anxiety (excessive worry) and depression (lowering of a person ' s mood) related to isolation and a lack of stimulation. Findings: During an observation on 6/25/2024, at 12:02 p.m., Resident 1 was observed lying in bed, awake, and nonverbal. A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 6/8/2018. Resident 1 ' s admitting diagnosis included dysphagia (difficulty swallowing) following a cerebral infarction (tissue death of the brain from a clot or other obstruction of blood flow), dementia (an umbrella term for cognitive disorders of the brain with impaired ability to remember, think, and make decisions which interferes with everyday activities), and type two (2) diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). A review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 6/12/2024, indicated Resident 1 was severely cognitively impaired (ability to think and reason). The MDS indicated Resident 1 required total assistance (helper does all the effort) with oral hygiene, toileting hygiene, showering/bathing, dressing, and personal hygiene. A review of Resident 1 ' s Activity Attendance Record, dated 6/2024, indicated Resident 1 was out of bed on 6/5/2024, 6/9/2024, 6/13/2024, 6/16/2024, 6/17/2024, 6/21/2024, 6/22/2024, 6/25/2024, and 6/26/2024. The Activity Attendance Record indicated Resident 1 participated in group activities one time, on 6/2/2024. During a concurrent observation and interview on 6/25/2024, at 2:02 p.m., with Certified Nursing Assistant (CNA) 1, Resident 1 was observed lying in bed, awake. CNA 1 stated he did not get Resident 1 out of bed (6/25/2024). During a concurrent observation an interview on 6/25/2024, at 3:15 p.m., with Resident 1 ' s Family Member (FM) 1, in Resident 1 ' s room, Resident 1 was observed lying in bed, awake. FM 1 stated she asked the nurses to get Resident 1 out of bed every day on several occasions, but she did not believe nursing staff was getting Resident 1 up. During an observation on 6/25/2024, at 5:50 p.m., Resident 1 was observed lying in bed, awake. During an observation on 6/26/2024, at 3:12 p.m., Resident 1 was observed lying in bed, awake. During an interview, on 6/26/2024, at 3:55 p.m., with Resident 2, Resident 2 stated she had not seen Resident 1 in the activities room for over a month. A review of Resident 2 ' s admission Record indicated the facility originally admitted Resident 2 on 3/20/2020, and most recently re-admitted Resident 2 on 11/03/2020. Resident 2 ' s admitting diagnosis included a cerebral infarction. A review of Resident 2 ' s MDS, dated [DATE], indicated Resident 2 was cognitively intact. The MDS indicated Resident 2 required moderate assistance (the helper does less than half the effort) with toileting hygiene, dressing the lower body, and putting on/taking off footwear. During an observation on 6/27/2024, at 8:05 a.m. Resident 1 was observed lying in bed, asleep. During a concurrent interview and record review on 6/27/2024, at 10:55 a.m., with the Activities Aide (AA), Resident 1 ' s Activities Attendance Record, dated 6/2024, was reviewed. The AA stated even though her initials was on the document someone added Resident 1 being out of bed and into the Geri-chair (a chair used as a medical recliner for those who cannot sit up alone and need support). The AA stated she never witnessed or documented that Resident 1 was out of bed and in the Geri-chair on 6/5/2024, 6/9/2024, 6/13/2024, 6/16/2024, 6/17/2024, 6/21/2024, 6/22/2024, 6/25/2024, and 6/26/2024. During an interview on 6/27/2024, at 11:10 a.m., with the Activities Director (AD), the AD stated she documented in Resident 1 ' s Activities Attendance Record, dated 6/2024, indicating Resident 1 was out of bed, even though she did not witness it. The AD stated she asked LVN 2 earlier that morning if Resident 1 was out of bed and LVN 2 had told her yes. During an interview on 6/27/2024, at 11:36 a.m., with the AD, the AD stated she charted under the name of AA for Resident 1 being out of bed on 6/5/2024, 6/9/2024, 6/13/2024, 6/16/2024, 6/17/2024, 6/21/2024, 6/22/2024, 6/25/2024, and 6/26/2024 because FM 1 was very particular about Resident 1 ' s care and wanted Resident 1 to get out of the bed every day. During an interview on 6/27/2024, at 11:38 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she had not worked with Resident 1 yesterday (6/26/2024) and did not witness Resident 1 out of bed. LVN 2 stated she did not know if Resident 1 got out of bed. LVN 2 stated she never told the AD Resident 1 was out of bed, but the AD did ask her who the nurse was for Resident 1 on 6/26/2024. During an interview and record review on 6/27/2024, at 12:00 p.m., with the Director of Nursing (DON), the DON stated staff should not chart on another person ' s behalf and under their name. The DON stated the nurse who assessed the resident out of bed should have charted it, and it was not OK to chart under someone else ' s name because they could not sign for something they did not see or do. The DON stated she did not observe Resident 1 out of bed on 6/26/2024. The DON stated residents should be offered to get out of bed every day because it was important for socialization, good for their skin, lungs, and circulation. During an interview on 6/27/2024, at 8:15 a.m., with the AD, the AD stated the CNAs would get bedbound residents out of bed on their shower days. The AD stated she knows when residents got out of bed because she remembered the nurses bringing them to the dining room for activities. The AD stated the facility had at least 12 residents who were bedbound and would come into the dining room for activities. A review of the facility ' s policy and procedure (P&P) titled Charting and Documentation, undated, indicated objective observations should be documented in the medical chart, and not be opinionated or speculative. The P&P indicated the documentation must be complete and accurate. The P&P indicated the signature and title of the individual documenting should be included.

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

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to support four out of five residents (Resident 1, 3, 25, and 28) in their choice of activities for by failing to ensure: 1. Resident 1 was assisted out of bed every day. 2. Resident 3 was assisted to group activities and special events. 3. Resident 25 participated in activities in a group setting and was allowed to go outside to get fresh air when the weather was good. 4. Resident 28 participated in activities in a group setting. These deficient practices had the potential to cause depression, anxiety, and other psychosocial harm to Resident 1, 3, 25, and 28 due to a lack of socialization, stimulation, and self-esteem. Findings: 1. During an observation on 6/25/2024, at 12:02 p.m., Resident 1 was observed lying in bed, awake, and nonverbal. A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 6/8/2018. Resident 1 ' s admitting diagnoses included dysphagia (difficulty swallowing) following a cerebral infarction (tissue death of the brain from a clot or other obstruction of blood flow), dementia (an umbrella term for cognitive disorders of the brain with impaired ability to remember, think, and make decisions which interferes with everyday activities), and type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). A review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 6/12/2024, indicated Resident 1 was severely cognitively impaired (ability to think and reason). The MDS indicated Resident 1 required total assistance (helper does all the effort) with oral hygiene, toileting hygiene, showering/bathing, dressing, and personal hygiene. A review of Resident 1 ' s care plan titled Geri-chair, initiated on 10/25/2018, indicated the goal of the care plan was to stimulate Resident 1 by getting her out of bed 4 to 6 hours a day (on shower days), prevent restraint use, encourage socialization, participate in activities, stimulate, and to prevent complications related to being bedbound such as contractures (a condition where the joint shortens and become very stiff), skin breakdown, isolation, and withdrawal. The care plan had no resident-specific interventions. A review of Resident 1 ' s care plan titled, Activity Preferences, undated, indicated Resident 1 preferred to do activities with groups of people. The care plan had no resident-specific interventions. A review of Resident 1 ' s Activity Attendance Record, dated 6/2024, indicated Resident 1 was out of bed on 6/5/2024, 6/9/2024, 6/13/2024, 6/16/2024, 6/17/2024, 6/21/2024, 6/22/2024, 6/25/2024, and 6/26/2024. The Activity Attendance Record indicated Resident 1 participated in group activities one time, on 6/2/2024. During a concurrent observation and interview on 6/25/2024, at 2:02 p.m., with Certified Nursing Assistant (CNA) 1, Resident 1 was observed lying in bed, awake. CNA 1 stated he did not get Resident 1 or Resident 3 out of bed that day (6/25/2024). During a concurrent observation and interview on 6/25/2024, at 3:15 p.m., with Resident 1 ' s family member (FM) 1, in Resident 1 ' s room, Resident 1 was observed lying in bed, awake. FM 1 stated she asked the nurses to get Resident 1 out of bed every day on several occasions prior to the heat wave, but she did not believe nursing staff was getting Resident 1 up. During an observation on 6/25/2024, at 5:50 p.m., Resident 1 was observed lying in bed, awake. During an observation on 6/26/2024, at 3:12 p.m., Resident 1 was observed lying in bed, awake. During an observation on 6/27/2024, at 8:05 a.m. Resident 1 was observed lying in bed, asleep. During a concurrent interview and record review on 6/27/2024, at 10:45 a.m., with the Activity Director (AD), Resident 1 ' s Activities Attendance Record, dated 6/2024, was reviewed. The Activities Record indicated Resident 1 was out of bed in the Geri-chair 6/25/2024. The record was initialed by the Activities Aide (AA). The AD stated Resident 1 had gotten out of bed a total of 9 times for 6/2024. During a concurrent interview and record review on 6/27/2024, at 10:55 a.m., with the AA, Resident 1 ' s Activities Attendance Record, dated 6/2024, was reviewed. The AA stated even though her initials was on the document, she never documented that Resident 1 was out of bed and in the Geri-chair. The AA stated it must have been someone else who documented. During an interview on 6/27/2024, at 11:10 a.m., with the AD, the AD stated she documented on Resident 1 ' s Activities Attendance Record, dated 6/2024, indicating Resident 1 was out of bed, even though she did not witness it. The AD stated she asked Licensed Vocational Nurse (LVN) 2 earlier that morning if Resident 1 was out of bed and LVN 2 had told her yes. During an interview on 6/27/2024, at 11:36 a.m., with LVN 2, LVN 2 stated she was working on a different unit on 6/26/2024 and did not witness Resident 1 out of bed and did not know if Resident 1 got out of bed. LVN 2 stated she never told the AD Resident 1 was out of bed, but the AD asked her who the nurse was for Resident 1 that day. During an interview on 6/27/2024, at 11:36 a.m., with the AD, the AD stated she charted under the name of others for Resident 1 being out of bed on 6/5/2024, 6/9/2024, 6/13/2024, 6/16/2024, 6/17/2024, 6/21/2024, 6/22/2024, 6/25/2024, and 6/26/2024 because FM 1 was very particular about Resident 1 ' s care and wanted Resident 1 to get out of the bed every day. 2. During an observation on 6/25/2024, at 12:11 p.m., Resident 3 was observed lying in bed, asleep. A review of Resident 3 ' s admission Record indicated the facility originally admitted Resident 3 on 2/1/20217, and most recently re-admitted Resident 3 on 6/2/2020. Resident 3 ' s admitting diagnoses included Alzheimer ' s disease (a type of dementia that progressively destroys memory and other important mental functions), and dysphagia. A review of Resident 3 ' s MDS, dated [DATE], indicated Resident 3 was severely cognitively impaired. The MDS indicated Resident 3 required total assistance with toileting hygiene, and showering/bathing. A review of Resident 3 ' s care plan titled, Activities, undated, indicated Resident 3 was dependent on staff for activities, cognitive stimulation, and social interaction. The care plan indicated Resident 3 needed to be assisted to group activities and special events. The staff interventions indicated to invite Resident 3 to scheduled activities. A review of Resident 3 ' s Activity Attendance Record, dated 6/2024, indicated Resident 3 had not participated in group activities at all. The Activity attendance Record indicated Resident 3 never got out of bed 6/2024. During an observation on 6/25/2024, at 2:02 p.m., Resident 3 was observed lying in bed, awake, and muttering incomprehensible words. During an observation on 6/25/2024, at 5:51 p.m., Resident 3 was observed lying in bed, awake. During an observation on 6/26/2024, at 3:13p.m., Resident 3 was observed lying in bed, awake. During an observation on 6/27/2024, at 8:04 a.m. Resident 3 was observed lying in bed, asleep. During a concurrent interview and record review on 6/27/2024, at 10:45 a.m., with the AD, Resident 3 ' s Activities Attendance Record, dated 6/2024, was reviewed. The Activities Record indicated Resident 3 had not gotten out of bed for 6/2024. The AD stated Residents 3 had not gotten out of bed for 6/2024. 3. During an interview, on 6/26/2024, at 3:55 p.m., with Resident 2 (Resident 1 and 3 ' s roommate), Resident 2 stated she would participate in activities daily to keep busy and had not seen Resident 1 or Resident 3 attend activities for over a month. Resident 2 stated even on special events like the Candlelight dinner they just had on 6/26/2024 she did not see Resident 1 and 3 in the activities room participating with the group. A review of Resident 2 ' s admission Record indicated the facility originally admitted Resident 2 on 3/20/2020, and most recently re-admitted Resident 2 on 11/03/2020. Resident 2 ' s admitting diagnoses included cerebral infarction. A review of Resident 2 ' s MDS, dated [DATE], indicated Resident 2 was cognitively intact. The MDS indicated Resident 2 required moderate assistance (the helper does less than half the effort) with toileting hygiene, dressing the lower body, and putting on/taking off footwear. 4. During a concurrent observation and interview on 6/25/2024, at 3:48 p.m., with Resident 25, in Resident 25 ' s room, Resident 25 was observed awake, alert, and oriented. Resident 25 stated she never got out of bed because she could not walk, but she did not know it was an option to be put in a special chair and taken to the activities room. A review of Resident 25 ' s admission Record indicated the facility admitted Resident 25 on 5/28/2024. Resident 25 ' s admitting diagnoses included an unstageable (unable to determine the depth due to abnormal tissue covering healthy tissue) pressure ulcer (damage to an area of the skin or tissues because of constant pressure on the area for a long time) of the sacral region (lower back), and type 2 diabetes mellitus. A review of Resident 25 ' s MDS, dated [DATE], indicated Resident 25 was moderately cognitively impaired. The MDS indicated Resident 25 required total assistance with showering/bathing, dressing the lower body, and putting on/taking off footwear. A review of Resident 25 ' s care plan titled, Activity Preferences, undated, indicated Resident 25 preferred to do activities with groups of people, and preferred to go outside to get fresh air when the weather was good. The care plan had no resident-specific interventions. 5. During an observation on 6/26/2024, at 3:21 p.m., Resident 28 was observed lying in bed awake, alert, was emaciated (abnormally thin), messy hair, and was able to say hello but could not hold a conversation. A review of Resident 28 ' s admission Record indicated the facility originally admitted Resident 28 on 8/2/2022, and most recently re-admitted Resident 28 on 10/29/2023. Resident 28 ' s admitting diagnoses included metabolic encephalopathy (a chemical imbalance in the blood effecting the brain) and type 2 diabetes mellitus. A review of Resident 28 ' s MDS, dated [DATE], indicated Resident 28 was severely cognitively impaired. The MDS indicated Resident 28 had required total assistance with toileting hygiene, and showering/bathing. A review of Resident 28 ' s care plan titled, Activity Preferences, undated, indicated Resident 28 preferred to do activities with groups of people. The care plan had no resident-specific interventions. A review of Resident 28 ' s Activity Attendance Record, dated 6/2024, indicated Resident 28 had not participated in group activities at all. The Activity attendance Record indicated Resident 28 never got out of bed 6/2024. During an observation on 6/27/2024, at 9:30 a.m., Resident 28 was observed lying in bed, awake. During an interview on 6/27/2024, at 8:15 a.m., with the Activities Director (AD), the AD stated the CNAs would get bedbound residents out of bed on their shower days. The AD stated she knew when residents got out of bed because she remembered the nurses bringing them to the dining room for activities. The AD stated the facility had at least 12 residents who were bedbound and would come into the dining room for activities. During a concurrent interview and record review on 6/27/2024, at 10:45 a.m., with the AD, Resident 28 ' s Activities Attendance Record, dated 6/2024, was reviewed. The Activities Record indicated Resident had not gotten out of bed for 6/2024. The AD stated Resident 28 had not gotten out of bed 6/2024. During a concurrent interview and record review on 6/27/2024, at 12:00 p.m., with the Director of Nursing (DON), Resident 1, 3, and 28 ' s Activities Attendance Record, dated 6/2024, was reviewed. The DON stated per the Activities Record Resident 3 and Resident 28 had not been out of bed or in the activities room at all for 6/2024. The DON stated staff should not chart on another person ' s behalf and under their name. The DON stated the nurse who assessed the resident out of bed should have charted it, and it was not OK to chart under someone else ' s name because they could not sign for something they did not see or do. The DON stated she did not observe Resident 1 out of bed on 6/26/2024. The DON stated residents should be offered to get out of bed every day because it was important for socialization, good for their skin, lungs, and circulation. During a concurrent observation and interview on 6/27/2024, at 3:10 p.m., with the Housekeeping Supervisor (HS), a total of seven (7) Geri-chairs was observed. The HS stated the facility had a total of 7 Geri-chairs. A review of the facility ' s policy and procedure (P&P) titled Activities Programs, dated 9/2006, indicated the purpose of the P&P was to meet the needs of each resident daily, and are geared to the individual resident ' s needs. The P&P indicated activities reflect choices and rights of the residents.

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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Serving Drinking Water, for six out of 14 sampled residents (Resident 1, 2, 3, 20, 25, 27), after the air conditioner stopped working by not: 1. Offering water and providing adequate fluids to Resident 1 and Resident 3, who were completely dependent on staff for activities for daily living. 2. Ensuring fresh water was available at the bedside for Residents 2, 3, 20, 25, and 27. These deficient practices had the potential for Resident 1, 2, 3, 20, 25, 27 to become dehydrated and/or suffer from heat stroke (internal body heat with complications involving the central nervous system that occur after exposure to high temperatures). Findings: a. During an observation on 6/25/2024, at 12:02 p.m., Resident 1 was observed awake in bed covered with a blanket, nonverbal and unable to understand or respond to words. Resident 1 had dry, cracked lips. Resident 1 had an undated pitcher of water that was room temperature and 90 percent (%) full, and half a cup of water on her bedside dresser. A review of Resident 1 ' s admission Record indicated the facility admitted Resident 1 on 6/8/2018. Resident 1 ' s admitting diagnoses included dysphagia (difficulty swallowing) following a cerebral infarction (tissue death of the brain from a clot or other obstruction of blood flow), dementia (an umbrella term for cognitive disorders of the brain with impaired ability to remember, think, and make decisions which interferes with everyday activities), and type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). A review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 6/12/2024, indicated Resident 1 was severely cognitively impaired (ability to think and reason). The MDS indicated Resident 1 required total assistance (helper does all the effort) with oral hygiene, toileting hygiene, showering/bathing, dressing, and personal hygiene. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) with eating. During an interview on 6/25/2024, at 12:27 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated he gave Resident 1 one cup of water during his shift and changed Resident 1 ' s water pitcher that morning (6/25/2024). CNA 2 stated he checked the residents ' water pitcher to see if it was empty and needed to be refilled before he finished his shift around 2:30 p.m. CNA 2 stated Resident 1 ' s water pitcher looked full and had no date. CNA 2 stated he did not know when the water was last changed. CNA 2 stated he offered his residents ' water every 2 hours. During an interview on 6/25/2024, at 12:33 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 ' s lips looked a little dry. During a concurrent observation and interview on 6/25/2024, at 3:15 p.m., with Resident 1 ' s family member (FM) 1, observed Resident 1 ' s water pitcher was warm to touch and 90% full. Resident 1 had half a cup of water of warm water on the bedside dresser. FM 1 stated Resident 1 ' s room had been hot during her visits the past 7 days, from 3 p.m. to 6 p.m. FM 1 stated Resident 1 felt warm to the touch because it was so hot. FM 1 stated she never witnessed nursing staff offer Resident 1 and Resident 3 (Resident 1 ' s roommate) water. FM 1 stated Resident 1 ' s pitcher was full and warm and FM 1 did not know when Resident 1 last received fresh water. FM 1 stated one of the medication nurses tried to give Resident 1 medication with one bite of apple sauce, and she had to ask the nurse (identify unknown) to give Resident 1 some water since taking medications without water was bad for Resident 1 ' s kidneys. During an interview on 6/25/2024, at 5:50 p.m., with FM 1, FM 1 stated she had not witnessed staff offering any of the residents residing in Resident 1 ' s (Resident 1, 2, and 3) room water, popsicles, ice cream, or other cooling foods since she arrived to the facility around 3:00 p.m. on 6/25/2024. b. During a concurrent observation and interview on 6/25/2024, at 12:04 p.m., with Resident 2 (Resident 1 ' s roommate), Resident 2 was observed awake, alert, dressed, and seated on a wheelchair. Resident 2 stated the air conditioner had not been working since last week. Resident 2 stated nursing staff brought her fresh water every evening around 11:00 p.m. during the night shift, and the day shift only gave her water if she asked for it. Resident 2 stated she could ask for water herself, but her roommates Resident 1 and Resident 2 could not. Resident 2 stated she had not seen any nurses give Resident 1 water that day (6/25/2024). A review of Resident 2 ' s admission Record indicated the facility originally admitted Resident 2 on 3/20/2020, and most recently re-admitted Resident 2 on 11/03/2020. Resident 2 ' s admitting diagnoses included cerebral infarction. A review of Resident 2 ' s MDS, dated [DATE], indicated Resident 2 was cognitively intact. The MDS indicated Resident 2 required moderate assistance (the helper does less than half the effort) with toileting hygiene, dressing the lower body, and putting on/taking off footwear. During an interview on 6/25/2024, at 3:55 p.m., with Resident 2, Resident 2 stated she was concerned about her roommates Resident 1 and Resident 3 because they could not ask for help. Resident 2 stated other than today (6/25/2024), in the activities room, no one offered her popsicles, ice cream, or other cool foods since it had been hot. c. During an observation on 6/25/2024, at 12:11 p.m., Resident 3 was observed asleep in bed, emaciated (abnormally thin), and covered with a blanket. Resident 3 did not have any water at her bedside. A review of Resident 3 ' s admission Record indicated the facility originally admitted Resident 3 on 2/1/20217, and most recently re-admitted Resident 3 on 6/2/2020. Resident 3 ' s admitting diagnoses included Alzheimer ' s disease (a type of dementia that progressively destroys memory and other important mental functions), and dysphagia. A review of Resident 3 ' s MDS, dated [DATE], indicated Resident 3 was severely cognitively impaired. The MDS indicated Resident 3 required total assistance with toileting hygiene, and showering/bathing. The MDS indicated Resident 3 required moderate assistance with eating. d. During an observation on 6/25/2024, at 12:21 p.m., Resident 20 was observed awake, alert, dressed, lying in bed with no water at the bedside. A review of Resident 20 ' s admission Record indicated the facility admitted Resident 20 on 9/12/2020. Resident 20 ' s admitting diagnoses included dementia. A review of Resident 20 ' s MDS, dated [DATE], indicated Resident 20 was severely cognitively impaired. The MDS indicated Resident 20 required maximum assistance with showering/bathing. e. During a concurrent observation and interview on 6/25/2024, at 3:48 p.m., with Resident 25, Resident 25 was observed awake, alert, in bed. Resident 25 stated she wished it was colder since it was very hot and had been so for the past few days. Resident 25 stated none of the staff offered her popsicles, ice cream, or other cool foods since it had been hot. Resident 25 stated she sometimes asked for water, but the nurses would forget about her request and would not bring her water. Resident 25 stated her water at the bedside currently was very hot and she wished it was colder. Resident 25 stated the water pitcher at her bedside was from the previous night (6/24/2024). Resident 25 stated sometimes when the nurses bring her fresh water, they mixed the new water with her old water. Resident 25 ' s water pitcher was warm to touch and undated. A review of Resident 25 ' s admission Record indicated the facility admitted Resident 25 on 5/28/2024. Resident 25 ' s admitting diagnoses included an unstageable (unable to determine the depth due to abnormal tissue covering healthy tissue) pressure ulcer (damage to an area of the skin or tissues because of constant pressure on the area for a long time) of the sacral region (lower back), and type 2 diabetes mellitus. A review of Resident 25 ' s MDS, dated [DATE], indicated Resident 25 was moderately cognitively impaired. The MDS indicated Resident 25 required total assistance with showering/bathing, dressing the lower body, and putting on/taking off footwear. f. During an observation, on 6/26/2024, at 3:18 p.m., Resident 27 ' s water pitcher was undated. A review of Resident 27 ' s admission Record indicated the facility originally admitted Resident 27 on 8/24/2016, and most recently re-admitted Resident 27 on 5/29/2023. Resident 27 ' s admitting diagnoses included type 2 diabetes mellitus and acute respiratory distress syndrome ([ARDS] a condition in which fluid collects in the lungs ' air sacs, depriving organs of oxygen). A review of Resident 27 ' s MDS, dated [DATE], indicated Resident 27 was severely cognitively impaired. The MDS indicated Resident 27 required total assistance with toileting hygiene, and showering/bathing. During an interview on 6/25/2024, at 2:20 p.m., with CNA 3, CNA 3 stated she made sure her residents had water and their pitchers were full of ice. CNA 3 stated water pitchers should be checked in the morning and before the end of shift to make sure the water pitchers were full. CNA 3 stated water should be changed at least once a day. CNA 3 stated if the water pitchers were not dated there was no way to determine when it was last changed and could be old water. CNA 3 stated signs of dehydration were dry mouth with cracked lips. CNA 3 stated if she observed signs of dehydration in one of her residents, she would report it to the charge nurse. CNA 3 stated she offered her residents water in one to two hour intervals. During an interview on 6/25/2024, at 4:12 p.m., with the Director of Staff Development (DSD), the DSD stated the staff first started complaining of the heat on 6/19/2024. The DSD stated if residents get too hot, they could suffer from heat stroke. The DSD stated CNAs should offer residents water during their rounds and fresh water should be given to residents every shift. During an interview on 6/26/2024, at 1:37 p.m., with the Director of Nursing (DON), the DON stated due to the heat, residents should be given extra fluids more than the usual 2 to 3 hour intervals to prevent dehydration. The DON stated fresh water should be given every shift, and when the water pitcher was empty or warm/hot. The DON stated water pitchers should be dated because it was the only way staff could tell how old the water was. The DON stated if she wanted to determine if dependent residents who could not drink themselves had enough fluids she would check their water pitcher, and if the water pitcher was full all shift it would mean the water had not been offered to the dependent residents. The DON stated when residents receive medications, they should be given water to metabolize the medication. During an interview on 6/26/2024, at 1:40 p.m. with the DSD, the DSD stated no resident hydration or hot weather in-service trainings had been conducted to staff since the facility ' s air conditioner had been inoperable in some of the resident rooms and the temperatures reached beyond 81 degrees Fahrenheit (F). During an interview on 6/26/2024, at 2:07 p.m., with the Administrator (ADM), the ADM stated when the air conditioner stopped working, staff should offer residents fluids more frequently than usual. A review of the facility ' s document titled, Extreme Weather – Heat Emergency Operations Plan (EOP), undated, indicated the facility ' s initial actions during extreme heat included: a. Assess residents for signs of distress and/or discomfort. b. Encourage residents to drink fluids to maintain hydration. A review of the facility ' s policy and procedure (P&P) titled Resident Hydration and Prevention of Dehydration, dated 10/2/2017, indicated: a. Nurses will assess for signs and symptoms of dehydration during daily care. b. Aides will report intake of less than 1200 milliliters ([ml] a unit of liquid measurement) a day to nursing staff. c. If potential inadequate intake and/or signs and symptoms of dehydration are observed, intake and output monitoring will be initiated and incorporated into the care plan, and the physician will be notified. A review of the facility ' s policy and procedure (P&P) titled Serving Drinking Water, undated, indicated the purpose of the P&P was to provide the resident with a fresh supply of drinking water, and to provide adequate fluids for the resident and staff are empty the water pitcher and rinse the water pitcher and empty it before filling the water pitcher with fresh water, and to offer the resident a fresh cup of water. The P&P indicated the time the procedure was performed should be documented on a daily flow sheet or record, and if the resident refuses to drink water it should be documented and reported to the nursing supervisor. A review of an online article by the National Institute of Health (NIH) titled, Keep it Cool with Hot Weather Advice for the older People, dated 7/24/2006, indicated older people are at a high risk for developing heat-related illnesses because the ability to respond to summer heat can be less efficient with advancing years. The article indicated that the temperature did not have to hit 100 degrees F for the elderly to be at risk for hyperthermia (temperature being abnormally high) and other heat-related conditions due to many other factors relating to age, medications receiving and /or medical diagnoses. https://www.nih.gov/news-events/news-releases/keep-it-cool-hot-weather-advice-older-people

Mar 2024 17 deficiencies

CONCERN (D)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that call lights were within reach for two of 25 sampled residents (Resident 28 and Resident 14). These deficient practices had the potential to cause avoidable harm to Resident 28 and Resident 14 from an inability to call staff for assistance and the potential for falls and associated injuries. Cross Reference See F-tag F656 and F-tag F689. Findings: 1. During a review of Resident 28's admission Record, the admission record indicated Resident 28 was admitted on [DATE]. Resident 21's admitting diagnoses included Parkinson's disease (a movement disorder characterized by involuntary movements, tremors, stiffness in the limbs or the trunk of the body, or impaired balance), difficulty walking, lack of coordination, reduced mobility, generalized muscle weakness, and abnormal gait and mobility. During a review of Resident 28's History and Physical (H&P), dated 1/22/2024, the H&P indicated Resident 28 could make his needs known, but could not make medical decisions. During a review of Resident 28's Minimum Data Set (MDS, a standardized assessment and care screening/planning tool), dated 1/5/2024, the MDS indicated Resident 29 made poor decisions related to tasks of daily life and required cues and supervision. The MDS further indicated Resident 28 required staff supervision, including touching/steadying, for eating, toileting, hygiene after toileting, and getting dressed. Resident 28 also required the same level of assistance for repositioning in bed, transitioning from a sitting to standing position, or walking distances between ten (10) to fifty (50) feet. During a review of Resident 28's medical record titled Fall Risk Assessment, dated 2/18/2024, the record indicated Resident 28 had experienced falls in the last six months and was at risk for falls. During a review of Resident 28's care plans, the care plans indicated Resident 28 was at risk for falls due to gait and balance problems and generalized weakness. The care plans indicated Resident 28 had experienced falls on 12/11/2023 and 2/18/2024. Interventions to prevent further falls indicated be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Interventions also included maintaining a safe environment with .a working and reachable call light. During an observation on 3/4/2024 at 9:33 a.m., at Resident 28's bedside, Resident 28 was observed lying in bed. Call light was not observed in Resident 28's bed or placed near Resident 28. During a concurrent observation and interview, on 3/4/2024 at 9:42 a.m., at Resident 28's bedside, with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 28's call light was hanging under his bed. CNA 1 pulled the call light out from under the bed and placed it in the bed with Resident 28. CNA 1 stated the call light was supposed to be within Resident 28's reach. 2. During a review of Resident 14's admission Record, the record indicated the facility originally admitted Resident 14 on 6/17/2008, and most recently re-admitted Resident 14 on 11/13/2020. Resident 14's admitting diagnoses included reduced mobility, lack of coordination, abnormalities of gait and mobility, and generalized muscle weakness. During a review of Resident 14's H&P, dated 6/30/2023, the H&P indicated Resident 14 had the capacity to understand and make decisions. During a review of Resident 14's MDS, dated [DATE], the MDS indicated Resident 14 had intact cognition (sufficient judgment, planning, organization, and self-control). The MDS further indicated Resident 14 required a wheelchair and partial to moderate assistance from staff for eating, personal hygiene activities, rolling side to side in bed, and transferring from wheelchair to bed. The MDS further indicated Resident 14 required partial to moderate assistance to move his wheelchair. During a review of Resident 14's care plan, the care plan indicated Resident 14 was at high risk for falls and injury related to his decreased functional mobility and history of falls. The care plans indicated staff were supposed to be sure Resident 14's call light was within reach and encourage Resident 14 to use it for assistance as needed. Additional care plan interventions included maintaining a safe environment with .a working and reachable call light. During an observation on 3/4/2024 at 9:34 a.m., at Resident 14's bedside, observed Resident 14 sitting up in a wheelchair, to the right side of the bed, next to the right handrail. Observed Resident 14's call light wrapped in and hanging from the handrail on the left side of the bed. During a concurrent interview and observation on 3/4/2024 at 9:44 a.m., at Resident 14's bedside, with CNA 1, CNA 1 stated Resident 14's call light was wrapped in the left handrail of Resident 14's bed. CNA 1 stated the call light was not within Resident 14's reach. CNA 1 stated the call light was supposed to be within reach to allow Resident 14 to call for help if needed. During an interview on 3/7/2024 at 2:07 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated call lights are used by residents to notify the staff when assistance is needed and to communicate their needs. LVN 1 stated call lights are supposed to be kept within the residents' reach, and stated that if not in reach, the residents won't be able to call for help. LVN 1 stated there's the potential for falls and injury if call lights are not kept within reach. During an interview on 3/8/2024 at 11:36 a.m., with the Assistant Director of Nursing (ADON), the ADON stated that if a resident is unable to reach the call light, they (residents) will not be able to call for help. The ADON stated residents might attempt to get out of bed unassisted which created the risk for falls and subsequent injury. The ADON also stated that if it was the resident's preference to have the call light wrapped in the handrail to prevent it from falling to the floor, it should be wrapped in the handrail closest to the resident. The ADON stated that not answering a call light was a type of neglect. During a review of the facility's policy and procedure (P&P) titled Resident Rights, dated 2/2021, indicated employees shall treat all residents with kindness, respect, and dignity. The P&P further indicated federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: communication with and access to people and services, both inside and outside the facility. During a review of the facility's P&P titled Answering the Call light, dated 9/2022, indicated the purpose of the P&P was to ensure timely responses to the resident's needs and requests and indicated staff were supposed to ensure that the call light is accessible to the resident. During a review of the facility's P&P titled Safety and Supervision of Residents, dated 7/2017, indicated, resident safety and supervision and assistance to prevent accidents were facility-wide priorities. The P&P further indicated the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices and implementing interventions to reduce accident risks and hazards shall include . ensuring that interventions are implemented.

CONCERN (D)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide reasonable accommodations for resident needs for one of six residents (Resident 29) by failing to: 1. Ensure Resident 29's call light was within reach at the bedside. 2. Ensure Resident 29's call for assistance was answered timely. These deficient practices had the potential to cause avoidable harm to Resident 29 from an inability to call staff for assistance and the potential for falls and associated injuries and skin breakdown. Findings: During a review of Resident 29's admission Record, the admission Record indicated Resident 29 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including hemiplegia (muscle weakness) and hemiparesis (one-sided muscle weakness), diabetes ( high blood sugar), major depression ( loss of interest in activities), hypertension( high blood pressure), and heart failure ( a condition in which the heart doesn't pump enough blood to meet the body needs). During a review of Resident 29's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 2/12/2024, the MDS indicated Resident 29 was totally dependent from staff for toileting, hygiene, bathing. During a review of Resident 29's History and Physical (H&P), dated 12/14/2023, the H&P indicated Resident 29 was able to make needs known but cannot make medical decisions. During a review of Resident 29's undated risk for falls care plan, the care plan indicated Resident 29 was at risk for falls and injury related to confusion, incontinence (inability to control bowel and bladder functions), and impaired vision. The staff's interventions indicated Resident 29's call light should be within reach and be responded promptly to all requests for assistance. During a concurrent observation and interview on 3/5/2024 at 2:47 p.m., in Resident 29's room, Resident 29 was observed lying in bed. Resident 29's call light was observed on the floor, at the left side of Resident 29's bed. Resident 29 was calling for nurse assistance. Resident 29 stated he was not able to locate his call light, and he needed assistance from the nurse to change his diaper. Resident 29 stated he had been waiting for more than 30 minutes and felt upset, ignored, and anxious. During a concurrent observation and interview on 3/5/2024 at 2:50 p.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 was observed walking by Resident 29's room but did not stop to check if Resident 29 needed assistance. CNA 2 stated she was busy with another resident and was not able to check and assist Resident 29. CNA 2 stated she should have checked Resident 29 needs and asked the supervisor for help. CNA 2 stated not attending to Resident 29's needs timely placed Resident 29 at risk for falls, injury, skin breakdown, and the resident may feel ignored, or neglected. During an interview on 3/4/2024 at 4:12 p.m., LVN 5 stated residents' call lights should be within reach. LVN 5 stated everyone working on the unit were responsible to check on the residents' status and make sure call lights were within reach, next to the resident at the bedside. LVN 5 stated if the resident was unable to reach the call light and called for assistance, it could delay resident assessment and care. LVN 5 stated it placed Resident 29 at risk for fall and injuries. During an interview on 3/6/2024 at 10:30 a.m., with the Director of Nursing (DON), the DON stated call light should be placed within resident reach at the bedside. DON stated call light was important for the resident to be able to communicate with staff. The DON stated the facility's licensed staff were responsible to check the residents' call light, place and ensure the call light was within reach at the bedside. The DON stated residents' needs should be answered promptly. The DON stated Resident 29 being wet for extensive period placed Resident 29 at risk for skin breakout. The DON stated call lights not within reach and not answered promptly puts any resident at risk for falls and injury. The DON stated residents should be treated with respect and dignity. During a review of facility's policy and procedure (P&P) titled, Dignity, dated 2/2021, the P&P indicated residents should always be treated with dignity and respect. The P&P indicated staff should promote dignity and assist residents promptly, responding to resident's request for toileting assistance. During a review of facility's P&P titled Answering the Call light, dated 9/2022, the P&P indicated: 1. Respond to the resident's requests and needs timely. 2. Ensure call light is accessible to the resident when in bed. 3. If the resident needs assistance, indicate the approximate time it will take for you to respond. 4. If the resident's request is something you can fulfill, complete the task within five minutes. 5. If resident's request, you cannot fulfill ask the nurse supervisor for assistance.

CONCERN (D)

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the certified nursing assistants (CNA)failed to notify the licensed nurse, and the licensed nurse failed to notify the physician of loose bowel movements for one of one sampled resident (Resident 50). This deficient practice had the potential for Resident 50 to exhibit dehydration, the continued unnecessary use of a laxative medication, electrolyte imbalances (important minerals in the blood), and an undetected infection of Clostridium Difficile ([C. Diff]- a bacteria that causes life-threatening diarrhea). Findings: During a review of Resident 50's admission Record, the admission Record indicated Resident 50 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to cerebral infarction (an interruption of blood flow to the brain), hemiplegia (loss of strength on one side of the body) and hemiparesis (weakness to one side of the body) affecting the right dominant side. During a review of Resident 50's Minimum Data Set [MDS- an assessment tool], dated 12/20/2023, the MDS indicated Resident 50's cognition (ability to think and reason) was intact. The MDS indicated Resident 50 was dependent on nursing staff to perform oral hygiene, toileting, bathing, and dressing. During a review of Resident 50's Order Summary Report, dated 3/5/2024, the report indicated Resident 50 was ordered Lactulose (a medication used to increase bowel movements) solution 10 milligrams/ 15 milliliters (mg/ml- units of measurement) give 20 grams (G, unit of measurement) via gastrostomy tube ([G-tube] - a stomach tube) three times a day for bowel management 20 gram/ 30 ml. During a review of Resident 50's Change of Condition (COC) progress notes, dated 3/2024, the COC progress notes indicated there was no documented change of condition progress note for the month of March 2024. During a concurrent observation and interview, on 3/4/2024, at 3:40 p.m. with Licensed Vocational Nurse (LVN) 7, Resident 50 was observed soiled with loose bowel movement. LVN 7 stated that Resident 50 did not exhibit loose bowel movements prior to this episode, and Resident 50 had a loose bowel movement because the resident received Lactulose as ordered for constipation (a condition in which a resident may have fewer than three bowel movements a week). During an observation on 3/5/2024, at 7:42 a.m., in Resident 50's room, Resident 50's incontinence pad was soiled with a loose, brown bowel movement. During an interview on 3/6/2024, at 10:00 a.m., with the Infection Preventionist Nurse (IPN), the IPN stated that Resident 50 was on contact precautions because the resident was diagnosed with New Delhi [NAME] Beta Lactamase - 1 ([NDM]-a chemical produced by the body that makes bacteria resistant to a broad range of antibiotics [medications that fight bacteria]) and stated it was commonly detected in the gut. The IPN stated that she was not made aware that Resident 50 had loose bowel movements and that it was important to know because it could be a symptom of his diagnosis or may indicate a worsening of his condition. The IPN stated that it was important for the physician to know so that a stool sample could be ordered. The IPN stated that there was a possibility that Resident 50 could concurrently have NDM and Clostridium Difficile. During an interview, on 3/7/2024, at 11:27 a.m., with Registered Nurse (RN) 3, RN 3 stated that she was not made aware Resident 50 was having loose bowel movements. RN 3 stated that if Resident 50 exhibited loose stools, the physician would need to be notified, and the ordered Lactulose would need to be held and clarified, and an additional stool sample may be needed. RN 3 stated that after the loose bowel movement was noticed (on 3/4/2024) a change of condition note, and a care plan should have been developed. During an interview, on 3/7/2024, at 11:35 a.m., with LVN 7, LVN 7 stated that if she had known that Resident 50 had more loose bowel movements, then she would have called the physician. LVN 7 stated that it was important to call the physician right away after she had noticed the first loose bowel movement (on 3/4/2024) so that she could clarify the order or have the physician decide whether a stool sample would be collected. LVN 7 stated that it was also important to let the IPN know about Resident 50's loose bowel movement. During an interview, on 3/7/2024, at 11:37 a.m., with Certified Nursing Assistant (CNA) 4, CNA 4 stated Resident 50 had loose bowel movements (on 3/6/2024) and stated that she did not inform LVN 7 of Resident 50's loose bowel movements because she (CNA 4) was too busy. CNA 4 stated that it was important to let LVN 7 of loose bowel movements because it was not normal for Resident 50. During an interview, on 3/8/2024, at, 10:45 a.m., with LVN 1 stated that there was no change of condition monitoring documentation for Resident 50 and that he would have expected LVN 7 to perform change of condition monitoring, notify the physician and hold the administration of Lactulose once LVN 7 noticed the lose bowel movement. LVN 1 stated that this was important to monitor because the resident could be at risk for dehydration, electrolyte imbalances, and could possibly require additional treatment for a coexisting infection, like Clostridium Difficile. During an interview, on 3/8/2024, at 11:37 a.m., with the Director of Nursing (DON), the DON stated that for any change of condition, she expected the nurses to conduct an assessment of the resident, call the physician, and alert the family of the resident. During an interview on 3/8/2024, at 2:26 p.m., the Assistant Director of Nursing (ADON), the ADON stated, For anything that could possibly cause a decline in a resident, the nurses should open a change of condition note which would generate 72-hour monitoring every shift. The ADON stated that a care plan should be started to show how the facility addressed the issue. The ADON stated that if the resident had loose bowel movements (on 3/4/2024 and 3/5/2024), then the physician and the IPN should have been notified, and the order for Lactulose should have been clarified. The ADON stated that Resident 50 could have been at risk for dehydration, further decline, electrolyte imbalances, and prone to worsened skin conditions. During a review of the facility's Policy and Procedure (P&P), titled, Acute Condition Changes, revised 3/2018, the P&P indicated the nursing assistants would be trained to recognized subtle but significant changes in the resident and how to communicate these changes to the Nurse. During a review of the facility's Certified Nurse Assistant Job Description (undated), the job description indicated that CNAs were expected to timely report a change in the resident's condition to the Nurse Supervisor.

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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement interventions for six of 25 sampled residents (Residents 14, 28, 81, 15, 17, and 96) as indicated in the care plan when the following occurred: 1. Resident 28 and Resident 14 did not have theirs call lights in reach, as indicated in their fall risk care plans. 2. Resident 81 did not have a care plan in place for his tendency to wander into other facility residents' rooms. 3. Resident 15, Resident 17, and Resident 96 were not repositioned every two hours and/or provided with pressure relieving devices as indicated in their pressure ulcer (PU, injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time) prevention care plan. These deficient practices had the potential for staff to be unaware of the interventions needed to prevent complications in the residents' health conditions and had potential to cause injuries related to accidents. Cross Reference F-tag F689 and F-tag F686. Findings: 1. During a review of Resident 28's admission Record, the admission record indicated Resident 28 was admitted on [DATE] with diagnoses including parkinson's disease (a movement disorder characterized by involuntary movements, tremors, stiffness in the limbs or the trunk of the body, or impaired balance), difficulty walking, lack of coordination, reduced mobility, generalized muscle weakness, and abnormal gait and mobility. During a review of Resident 28's History and Physical (H&P), dated 1/22/2024, the H&P indicated Resident 28 could make his needs known, but could not make medical decisions. During a review of Resident 28's Minimum Data Set (MDS, a standardized assessment and care screening/planning tool), dated 1/5/2024, the MDS indicated Resident 29 made poor decisions related to tasks of daily life and required cues and supervision. The MDS indicated Resident 28 required staff supervision, including touching/steadying, for eating, toileting, hygiene after toileting, and getting dressed, repositioning in bed, transitioning from a sitting to standing position, or walking distances between ten (10) to fifty (50) feet. During a review of Resident 28's medical record titled Fall Risk Assessment, dated 2/18/2024, the record indicated Resident 28 had experienced falls in the last six months and was at risk for falls. During a review of Resident 28's care plans, the care plan indicated Resident 28 was at risk for falls due to gait and balance problems and generalized weakness. The care plans indicated Resident 28 had experienced falls on 12/11/2023 and 2/18/2024. One of the interventions to prevent further falls indicated be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Interventions also included maintaining a safe environment with .a working and reachable call light. During an observation on 3/4/2024 at 9:33 a.m., at Resident 28's bedside, Resident 28 was observed lying in bed. Call light was not observed in Resident 28's bed or placed near Resident 28. During a concurrent observation and interview, on 3/4/2024 at 9:42 a.m., at Resident 28's bedside, with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 28's call light was hanging under his bed. CNA 1 pulled the call light out from under the bed and placed it in the bed with Resident 28. CNA 1 stated the call light was supposed to be within Resident 28's reach. During a review of Resident 14's admission Record, the record indicated Resident 14 was originally admitted on [DATE], and readmitted on [DATE] with diagnoses including reduced mobility, lack of coordination, abnormalities of gait and mobility, and generalized muscle weakness. During a review of Resident 14's H&P, dated 6/30/2023, the H&P indicated Resident 14 had the capacity to understand and make decisions. During a review of Resident 14's MDS, dated [DATE], the MDS indicated Resident 14 had intact cognition (sufficient judgment, planning, organization, and self-control). The MDS further indicated Resident 14 required a wheelchair and partial to moderate assistance from staff for eating, personal hygiene activities, rolling side to side in bed, and transferring from wheelchair to bed. The MDS further indicated Resident 14 required partial to moderate assistance to move his wheelchair. During a review of Resident 14's care plan, the care plan indicated Resident 14 was at high risk for falls and injury related to his decreased functional mobility and history of falls. The care plans indicated staff were supposed to be sure Resident 14's call light was within reach and encourage Resident 14 to use it for assistance as needed. Additional care plan interventions included maintaining a safe environment with .a working and reachable call light. During and observation on 3/4/2024 at 9:34 a.m., at Resident 14's bedside, observed Resident 14 sitting up in a wheelchair, to the right side of the bed, next to the right handrail. Observed Resident 14's call light wrapped in and hanging from the handrail on the left side of the bed. During a concurrent interview and observation on 3/4/2024 at 9:44 a.m., at Resident 14's bedside, with CNA 1, CNA 1 stated Resident 14's call light was wrapped in the left handrail of Resident 14's bed. CNA 1 stated the call light was not within Resident 14's reach. CNA 1 stated the call light was supposed to be within reach to allow Resident 14 to call for help if needed. 2. During a review of Resident 81's admission Record, the admission record indicated Resident 81 was admitted on [DATE] with diagnosis including dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), psychosis (a mental disorder characterized by a disconnection from reality), restlessness and agitation, and lack of coordination. During a review of Resident 81's H&P, dated 10/27/2021, the H&P indicated Resident 81 did not have the capacity to understand and make decisions due to Resident 81 confused and with dementia. During a review of Resident 81's MDS, dated [DATE], indicated Resident 81 had impaired cognition (problems with a person's ability to think, learn, remember, use judgement, and make decisions) and issues with his long term memory (ability to recall information from the past) and short term memory (ability to recall information after five minutes). The MDS further indicated Resident 81 used a manual wheelchair and required partial to moderate assistance from staff while operating the wheelchair. During an observation on 3/4/2024 at 9:46 a.m., observed Resident 81 propelling himself in a wheelchair, through a facility corridor, unassisted and without any staff in the corridor. During an observation on 3/4/2024 at 9:50 a.m., from outside of Resident 43's room, observed Resident 81 enter Resident 43's room in his wheelchair, unsupervised and unassisted. Resident 43 and Resident 81 were not visible from outside the room. The call light outside of Resident 43's room turned on after Resident 81 entered the room. During an observation on 3/4/2024 at 9:51 a.m., outside of Resident 43's room, observed Resident 81 leaving Resident 43's room in his wheelchair. There were no staff in the hallway when Resident 81 exited the room. During an observation on 3/4/2024 at 9:54 a.m., outside of Resident 43's room, observed staff responding to Resident 43's call light. During a review of Resident 43's admission Record, the admission record indicated Resident 43 was admitted on [DATE] for acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body), muscular dystrophy (a group of genetic diseases that cause progressive weakness and loss of muscle mass), and generalized muscle weakness. During a review of Resident 43's H&P, dated 2/15/2024, indicated Resident 43 had the capacity to understand and make decisions and recognizes/recalls .people without prompts or repetition. The H&P further indicated Resident 43 required full breathing support from a mechanical ventilator. During a review of Resident 43's MDS, dated [DATE], the MDS indicated Resident 43 had impairments to the upper and lower extremities on one side of his body that interfered with daily function or placed him at risk for injury. The MDS also indicated Resident 43 was completely dependent on staff for repositioning in bed, transferring between surfaces (e.g., bed to wheelchair). During an interview on 3/4/2024 at 9:52 a.m., with Resident 43, Resident 43 stated he did not invite Resident 81 into his room and stated Resident 81 wandered into his room often. Resident 43 stated he used to be in a different room, and Resident 81 used to wander into that room also, and would make a mess and then leave. During an observation on 3/7/2024 at 2:44 p.m., observed Resident 81 propelling himself in a wheelchair, through a facility corridor, unassisted and without any staff in the corridor. During a concurrent observation and interview on 3/7/2024 at 2:55 p.m., with Resident 43, observed Resident 43 in bed connected to a mechanical ventilator and oxygen machine. Resident 43 stated Resident 81 tried to come into his room that day, and Resident 43 yelled at Resident 81 telling him to leave. Resident 43 stated Resident 81 tends to knock things over when he is in the room and stated in his previous room, Resident 81's wheelchair would get caught on or bump into things, knocking them down. Resident 43 stated staff had escorted Resident 81 from his room multiple times in the past and were aware that Resident 81 wanders into his room. Resident 43 stated that sometimes he calls the nursing station from his personal phone, in addition to the call light, because Resident 81 is in his room and staff are not responding to the call light. Resident 43 stated there was a time he pressed the call light because Resident 81's wheelchair was stuck between the foot of the bed and the wall, and Resident 81 could not move. Resident 43 stated it bothered him that he had to worry about Resident 81 coming into his room and possibly knocking things down. Resident 43 stated Resident 81 does not talk and seems disoriented when he is in the room. During a review of Resident 81's discontinued care plan, the care plan indicated Resident 81 was punched by another resident, and goals of care included Resident 81 will not be punch again by another resident. One of the interventions to achieve this goal included constant visual check due to resident's wandering behavior and redirect and reorient resident when wandering. This care plan was discontinued on 2/3/2022. During a review of Resident 81's discontinued care plan, the care plan indicated Resident 81 was at risk for elopement/wandering related to .impaired decision making and wanders into other resident's rooms. Goals of care included Resident will have minimize episodes of wandering into other resident's rooms through the next review date. One of the intervention to achieve this goal included frequent visual checks of the resident's whereabouts. This care plan was discontinued on 10/20/2022. During a review of Resident 81's discontinued care plan, the care plan indicated Resident 81 wanders aimlessly, sometimes finding himself in other residents' rooms. Goals of care included the resident's safety will be maintained through the review date. The care plan was initiated on 3/7/2024 and discontinued on 3/7/2024. During a review of Resident 81's active care plan, the care plan indicated Resident 81 had a tendency of wandering about the facility in his wheelchair related to cognitive loss. Goals of care included Resident 81 having no incident of wandering outside of facility property/elopement. The care plan did not address Resident 81 wandering into other residents' rooms. During an interview on 3/7/2024 at 3:03 p.m., with LVN 1, LVN 1 stated facility residents were not supposed to go into other residents' rooms without permission. LVN 1 stated Resident 43 required a mechanical ventilator to breathe, and stated Resident 81 did not have a sitter or direct supervision, and it was not safe for Resident 81 to wander into other residents' rooms. LVN 1 stated Resident 81 might hit something or disconnect critical medical equipment. LVN 1 stated Resident 81 could also get stuck, which was an accident hazard for Resident 81 and other facility residents. LVN 1 stated that wandering behaviors are also supposed to be care planned. During a concurrent interview and record review, on 3/8/2024 at 11:23 a.m., with the ADON, the ADON stated Resident 81's wandering was a pattern of behavior. The ADON stated that Resident 81's tendency to wander into other residents' rooms should be on the care plan and stated it was not currently care planned. The ADON stated Resident 81 required frequent supervision to stop him before he goes into another resident's room to protect the other residents' privacy and safety. The ADON stated that Resident 81 wandering into other residents' rooms unsupervised was a safety concern for Resident 81 and other facility residents. 3. During a review of Resident 15's admission Record, the record indicated the facility originally admitted Resident 15 on 5/17/2018, and most recently re-admitted Resident 15 on 9/23/2020. Resident 15's admitting diagnoses included multiple sclerosis (a disorder of the central nervous system marked by weakness, numbness, a loss of muscle coordination, and problems with vision, speech, and bladder control), quadriplegia (inability to move from the neck down), and a stage IV (4) pressure ulcer (a pressure ulcer that penetrates through to the bone) to the sacral region (area above the tailbone). During a review of Resident 15's MDS, dated [DATE], the MDS indicated Resident 15 was fully dependent on staff for repositioning while in bed. During a review of Resident 15's care plans, the care plans indicated Resident 15 had a stage IV PU and was at risk for skin breakdown or pressure ulcer development. Goals of care included the PU showing signs of healing, and interventions to achieve that goal included turn and reposition Resident 15 at least every 2 hours. During an observation on 3/5/2024 at 8:19 a.m., observed Resident 15 in bed on her back, with one flat pillow behind each shoulder. Resident 15's left arm was flexed at the elbow and right arm was extended at her side. Her head was facing the left, but the remainder of her body was flat against the bed. During an observation on 3/5/2024 at 10:49 a.m., observed Resident 15 in bed on her back, with one flat pillow behind each shoulder. Resident 15's left arm was flexed at the elbow and right arm was extended at her side. Her head was facing the left, but the remainder of her body was flat against the bed. During a review of Resident 17's admission Record, the record indicated the facility originally admitted Resident 17 on 3/5/2015, and most recently re-admitted Resident 17 on 10/11/2021. Resident 17's admitting diagnoses included hemiplegia and hemiparesis (muscle weakness or partial inability to move one side of the body that can affect the arms, legs, and facial muscles) following a stroke (when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts). During a review of Resident 17's MDS, dated [DATE], the MDS indicated Resident 17 had impairments to the upper and lower extremities on both sides of his body and was dependent on staff for repositioning while in bed. During a review of Resident 17's care plans, the care plans indicated Resident 17 had potential for pressure ulcer development or skin break down related to immobility and being fully dependent on staff for activities of daily living. Goals of care included intact skin and no further formation of [pressure ulcers]. Interventions to achieve these goals included turning and repositioning the resident every two hours and as needed. During an observation on 3/4/2024 at 10:03 a.m., Resident 17 was observed lying on his right side with pillows placed behind his back for support. Resident 17 was facing the doorway to the hallway. During an observation on 3/4/2024 at 11:50 a.m., Resident 17 was observed lying on his right side with pillows placed behind his back for support. Resident 17 was facing the doorway to the hallway. During an observation on 3/4/2024 at 12:48 p.m., Resident 17 was observed lying on his right side with pillows placed behind his back for support. Resident 17 was facing the doorway to the hallway. During an observation on 3/4/2024 at 4:46 p.m., Resident 17 was observed lying on his right side with pillows placed behind his back for support. Resident 17 was facing the doorway to the hallway. During an observation on 3/5/2024 at 8:16 a.m., Resident 17 was observed lying flat against the bed, with one pillow behind each shoulder. The pillows were not folded and were placed flat against the bed. Resident 17's head was facing the ceiling. During an observation on 3/5/2024 at 10:04 a.m., Resident 17 was observed lying flat against the bed, with one pillow behind each shoulder. The pillows were not folded and were placed flat against the bed. Resident 17's head was facing the ceiling. During an observation on 3/5/2024 at 4:33 p.m., Resident 17 was observed lying flat against the bed, with one pillow behind each shoulder. The pillows were not folded and were placed flat against the bed. Resident 17's head was facing the ceiling. During a review of Resident 96's admission Record, the record indicated the facility admitted Resident 96 on 12/9/2022 with admitting diagnoses that included hemiplegia and hemiparesis following a stroke and generalized muscle weakness. During a review of Resident 96's MDS, dated [DATE], the MDS indicated Resident 96 was dependent on staff for repositioning while in bed. During a review of Resident 96's care plans, the care plans indicated Resident 96 had potential for pressure ulcer and goals of care included Resident 96 having intact skin. Interventions to achieve this goal included resident needs to turn/reposition at least every 2 hours, more often as needed or requested. The care plans also indicated Resident 96 had potential for impairment to skin integrity and goals of care included Resident 96 being free from skin complication. Interventions included providing Resident 96 with pressure relieving/reducing mattress .to protect the skin while in bed. During an observation on 3/4/2024 at 10:19 a.m., Resident 96 was observed lying flat in bed on a SPAN brand PressureGuard Protocol mattress. The pump used to power the mattress was off. During an observation on 3/4/2024 at 11:54 a.m., Resident 96 was observed lying flat in bed on a SPAN brand PressureGuard Protocol mattress. The pump used to power the mattress was off. During an observation on 3/4/2024 at 2:54 p.m., Resident 96 was observed lying flat in bed on a SPAN brand PressureGuard Protocol mattress. The pump used to power the mattress was off. During an observation on 3/5/2024 at 8:18 a.m., Resident 96 was observed lying flat against the bed, with one flat pillow placed behind each shoulder. Resident 96 was lying on a SPAN brand PressureGuard Protocol mattress. The pump used to power the mattress was off. During an observation on 3/5/2024 at 10:05 a.m., Resident 96 was observed lying flat against the bed, with one flat pillow placed behind each shoulder. Resident 96 was lying on a SPAN brand PressureGuard Protocol mattress. The pump used to power the mattress was off. During an observation on 3/5/2024 at 10:49 a.m., Resident 96 was observed lying flat against the bed, with one flat pillow placed behind each shoulder. Resident 96 was lying on a SPAN brand PressureGuard Protocol mattress. The pump used to power the mattress was off. During an observation on 3/5/2024 at 4:34 p.m., Resident 96 was observed lying flat against the bed, with one flat pillow placed behind each shoulder. Resident 96 was lying on a SPAN brand PressureGuard Protocol mattress. The pump used to power the mattress was off. During an observation on 3/6/2024 at 8:50 a.m., Resident 96 was observed lying on a SPAN brand PressureGuard Protocol mattress. The pump used to power the mattress was off. During a concurrent observation and interview on 3/6/2024 at 10:10 a.m., at Resident 96's bedside, with Treatment Nurse (TN) 2, TN 2 stated Resident 96's SPAN brand PressureGuard Protocol mattress was off and was not plugged in. During an interview on 3/7/2024 at 3:09 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated a care plan is a plan of care, where they identify a problem, a goal, and the interventions to achieve that goal. During an interview on 3/8/2024 at 11:15 a.m., with the Assistant Director of Nursing (ADON), the ADON stated that care plans identified things that put the resident at risk for decline and was important in keeping the residents at their highest level of wellness. The ADON stated the care plan outlined interventions for staff to implement to achieve those goals and stated that not implementing the care plan could lead to a decline in the resident's condition. During a review of the facility policy and procedure (P&P) titled Care Plans, Comprehensive Person-Centered, dated 3/2022, 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. The P&P further indicated that the care plan 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 F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 35), who had difficulty with speech and spoke a language other than English, was provided a communication device in the language that the resident was able to understand. This deficient practice prevented Resident 35 from communicating with staff and had the potential to negatively affect Resident 35's physical, mental, and psychosocial needs and potentially causing missed or delayed care and/or treatments. Findings: During a review of Resident 35's admission Record, the admission record indicated Resident 35 was admitted to the facility on [DATE] with diagnoses including traumatic subarachnoid hemorrhage (bleeding between the spaces in the brain), hemiplegia (paralysis [loss of muscle function] on one side of the body) on the right dominant side, hemiparesis (inability to move one side of the body) on the right dominant side, hypertension (high blood pressure), encephalopathy (any brain disease that alters brain function or structure), dysphagia (difficulty swallowing), right hand contracture (a fixed tightening of tissues that causes deformity and prevents normal movement). During a review of Resident 35's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 12/23/2023, the MDS indicated Resident 35 had severe cognitive impairment (ability to understand and make decision) for daily decision making and required substantial assistance with toileting and bathing and moderate assistance with oral and personal hygiene. The MDS indicated that Resident 35 had limited ability to make concrete requests. The MDS also indicated that Resident 35's preferred language was Spanish and that an interpreter was needed to communicate with physicians and health care staff. During a review of Resident 35's History and Physical (H&P), dated 10/11/2023, the H&P indicated that Resident 35 did not have the capacity to understand and make decisions due to aphasia (unable to speak, write or understand speech due damage to the brain). During a review of Resident 35's undated care plan with focus on Communication Problem, the care plan indicated that Resident 35 had a communication problem due to subarachnoid hemorrhage, right side hemiplegia and encephalopathy. The care plan indicated that Resident 35 would maintain current level of communication function by making sounds, using appropriate gestures, responding to yes/no questions and using a communication board. The staff's interventions included encouraging resident to continue stating thoughts even if having difficulty and ensuring availability and functioning of adaptive communication equipment, monitoring, documenting, and reporting to medical doctor as needed any changes in Resident 35's ability to communicate, potential contributing factors for communications problems and potential for improvement. The interventions also included providing a program of activities that accommodated the resident's communication abilities and use communication techniques to enhance interaction such as communication book/board, writing pad, gestures, signs, and pictures. During a concurrent observation and interview on 3/4/2024 at 2:54 p.m., with Resident 35, while in Resident 35's room, observed Resident 35 sitting on a wheelchair. Resident 35 was asked about his experience in the facility. Resident 35 attempted to speak but his voice was very faint and muffled. Resident 35 also attempted to use his left hand to make gestures. Observed Resident 35 did not have use of his right arm or right hand. Resident 35 began touching his head and putting up three fingers with his left hand. Observed Resident 35 became visibly frustrated because he could not be understood. Asked Resident 35 if he had a communication board in his room. Resident 35 shook his head no and continued to attempt communication using his left hand. Resident 35 was also Spanish speaking. During a concurrent observation and interview on 3/4/2024 at 2:57 p.m., with Certified Nursing Assistant (CNA) 3, in Resident 35's room, observed CNA 3 speaking Spanish to Resident 35. CNA 3 attempted to understand Resident 35's hand gestures but stated that she could not comprehend what Resident 35 was trying to say. Resident 35 was observed sighing and shaking his head. Resident 35 seemed adamant about communicating to CNA 3, but CNA 3 could not understand him. CNA 3 was asked if Resident 35 had any type of communication device to assist him with communication. CNA 3 stated that Resident 35 had a white board, but he cannot use it because of the paralysis in his right dominant hand. CNA 3 stated that Resident 35 gets frustrated, but they show him pictures to help communicate as well. Asked CNA 3 to show where the pictures were kept for Resident 35. CNA 3 was unable to find the pictures in his room. CNA 3 stated that Resident 35 should have something to assist with his communication. CNA 3 stated that the picture cards or a folder with pictures in Spanish can be obtained from the Activities Department. During a concurrent observation and interview on 3/4/2024 at 3:00 p.m., with Activities Assistant (AA 1) and CNA 3, while in Resident 35's room, AA 1 was observed speaking to Resident 35 in Spanish. AA 1 attempted to understand what Resident 35 was saying, but AA 1 also had trouble understanding Resident 35. Observed both AA 1 and CNA 3 attempting to guess what Resident 35 was saying using his left hand to make gestures. Resident 35 shook his head, sighed, and smirked. AA 1 stated that they used a lot of Charades (a word guessing game where one player has to act out a word or action without speaking and other players have to guess what the action is) to communicate with Resident 35. AA 1 stated that sometimes the entire dining room joins in to try and guess what Resident 35 is saying. Asked AA 1 felt Resident 35 could use some form of communication device to assist him with communicating. AA 1 stated that she would speak with her director about getting him a book with pictures in Spanish to assist him with communicating. During an interview on 3/6/2024 at 9:52 a.m., with Licensed Vocational Nurse (LVN) 6, LVN 6 stated that picture communications would be best for Resident 35 since he has no use in his right dominant side and it's difficult for him to write. LVN 6 stated that Resident 35 will get sad and frustrated if he is unable to communicate his needs. During a concurrent observation and interview on 3/6/2024 at 10:02 a.m., while outside of Resident 35's room, observed Resident 35's communication chart that was provided by the Activities Department. The communication tool had basic pictures with words in Spanish under the pictures. Asked Resident 35 if this tool would help him communicate. Resident 35 smiled and shook his head yes. During an interview on 3/6/2024 at 3:49 a.m., with the Director of Nursing (DON), the DON stated that the Activities Department should provide communication in Resident 35's language with pictures printed out. The DON stated that this communication tool should be accessible to residents at all times. The DON also stated that Resident 35 using hand gestures could be misinterpreted. During a review of the facility's policy and procedure (P&P) titled, Accommodation of Needs, dated March 2021, the P&P indicated, in order to accommodate individual needs and preferences, staff attitudes and behaviors are directed towards assisting the resident in maintaining independence, dignity and well-being to the extent possible in accordance with the residents wishes by interacting with the residents in ways that accommodate the physical or sensory limitation of the residents, promote communication, and maintain dignity. During a review of the facility's P&P titled Dignity, dated February 2021, the P&P indicated, each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.

CONCERN (D)

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Restorative Nursing Aide (RNA) therapy orders were performed as ordered by the physician for four out of 10 sampled residents (Residents 83, 45, 82, and 79). This deficient practice had the potential to cause a decline in the mobility and range of motion for Residents 83, 45, 79, and 82. Cross reference to F-tag F725. Findings: a. During a review of Resident 83's admission Record, the admission Record indicated Resident 83 was admitted to the facility on [DATE] with diagnoses that included but not limited to hemiplegia (unable to move on one side of the body) and hemiparesis (muscle weakness on one side of the body) following a cerebral infarction (interruption of blood flow to the brain) affecting left non-dominant side and muscle weakness. During a review of Resident 83's Minimum Data Set (MDS- an assessment tool), dated 2/8/2024, the MDS indicated Resident 83's cognition (ability to think and reason) was intact. The MDS indicated Resident 83 was not able to sit-to-stand, required moderate assistance when lying to sitting on the side of the bed, and required maximal assistance when toileting and showering. During a review of Resident 83's Order Summary Report, dated 3/2024, the summary report indicated Resident 83 was ordered to have active range of motion exercises (exercises that allow for mobility in joints of the body) three (3) times a week using pulleys as tolerated (dated 2/13/2024), bicycle exercises three (3) times a week as tolerated (dated 2/13/2024), and sit to stand exercises using parallel bars three (3) times a week as tolerated (dated 11/22/2023). During a review of Resident 83's Activities of Daily Living (ADL) self-care performance deficit Care Plan, (undated) the care plan indicated the facility was to provide RNA therapy as ordered. During an interview on 3/4/2024, at 1:50 p.m., with Resident 83, Resident 83 stated that he did not get physical therapy consistently and that he only received services for bicycle exercises. Resident 83 stated that he felt like his mobility was getting worse. During a concurrent record review and interview, on 3/5/2024, at 9:43 a.m., with RNA 1, the RNA schedules, dated 2/2024 to 3/5/2024, were reviewed. The schedule indicated Resident 83 had the following three orders for RNA therapy: 1. Active range of motion exercises three times a week using pulleys, as tolerated (dated 2/13/2024). 2. Bicycle three times a week as tolerated (dated 2/13/2024). 3. Sit-to-Stand exercises using parallel bars three times a week as tolerated (dated 11/22/2023). The schedule also indicated the following: 1. Resident 83 received active range of motion exerciswes a total of five times on 2/13/2024, 2/18/2024, 2/23/2024, 2/27/2024, and 3/5/2024, instead of nine times from 2/2024 to 3/5/2024. 2. Resident 83 received bicycle therapy a total of two out of an opportunity of 9 times from February to 3/5/2024 (2/20/2024 and 3/1/2024). 3. Resident 83 received sit-to-stand exercises eight out of 12 times, from 2/2024 to 3/5/2024 (2/1/2024, 2/2/2024,2/4/2024, 2/6/2024, 2/9/2024, 2/11/2024, 2/16/2024 (refused), 2/25/2024, and 3/3/2024). There was was documentation (on 2/16/2024) of the resident's refusal or rational for the missing ordered RNA therapy. During the interview, RNA 1 stated that the form was used to document when the RNAs performed the ordered therapy for the residents. RNA 1 stated the X's on the boxes of the RNA schedule indicated that the resident was off that day and was not seen that day. RNA 1 stated that the blank boxes indicate when the resident should be seen for RNA therapy. RNA 1 stated that she was told by the Director of Rehabilitation (DOR) that it was acceptable to perform each order one time a week (on different days) to total three therapy sessions in the week. RNA 1 stated she knew that the practice did not align with the orders from the physician and that it was important that he received his RNA therapy (as ordered) for him to get better and have him gain motivation to get better. RNA 1 stated that this practice had the potential for Resident 83 to exhibit a decline in his mobility. During a concurrent record review and interview, on 3/5/2024, at 9:43 a.m., with the DOR, the RNA schedules, dated 2/2024 to 3/5/2024, were reviewed. The DOR stated that it was unacceptable for the RNAs to not follow the RNA orders as ordered and that the Director of Staff Development ( DSD) usually over saw the work of the RNAs. The DOR stated that if the RNAs were not performing RNA orders as ordered then there was a potential for Resident 83 to not maintain or increase his strength and mobility. During an observation of Resident 83's RNA sit-to-stand therapy session, on 3/5/2024, from 10:37 a.m. to 10:58 a.m., in the Rehabilitation Room, Resident 83 grunted loudly, clenched his teeth, furrowed his brows, and grabbed tightly on to both RNA 1's and RNA 4's arms, while they both supported his body weight to allow Resident 83 to stand on his feet after two to three minutes of being coached. During an interview, on 3/6/2024, at 8:03 a.m., with RNA 1, RNA 1 stated that Resident 83 required maximal assistance from the two RNAs during the sit-to-stand session (on 3/5/2024) and she noticed a decline in his physical strength compared to his sessions in early February 2024. RNA 1 stated that she believed that Resident 83 would benefit from more frequent RNA therapy or sessions with the Physical Therapy department. RNA 1 stated that she should have told the DOR of his decline. RNA 1 stated that she did not notify the DOR because she assumed Resident 83 would not have remained complaint with the additional therapy that would have been ordered and stated that she should have notified the DOR regardless. During an interview, on 3/7/2024, at 9:02 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated that if a resident with a history of a stroke (interruption of blood flow to the brain) does not get RNA therapy as ordered, then he or she has the potential for ADL decline, the development of contractures (rigid joints of the body) and the resident will not get better, and it did not align with the provision of high quality care for the resident. b. During a review of Resident 45's admission Record, the admission Record indicated Resident 45 was admitted to the facility on [DATE] with diagnoses that included but not limited to hemiparesis and hemiplegia following a cerebral infarction affecting the right dominant side. During a review of Resident 45's MDS, dated [DATE], the MDS indicated Resident 45's cognition (ability to think and reason) was severely impaired. The MDS indicated Resident 45 required substantial or maximal assistance when eating, performing oral hygiene, toileting, bathing, and dressing. During a review of Resident 45's RNA schedule, dated 2/2024, the schedule indicated Resident 45 had orders for RNA therapy that included active range of motion for both lower extremities five (5) days a week as tolerated and active range of motion for both upper extremities five (5) times a week as tolerated. The schedule also indicated Resident 83 received the therapy 4 out of the 5 times from 2/10/2024 to 2/16/2024, and four out of the 5 times from 2/17/2024 to 2/23/2024. No documentation of resident refusal or a rational for the missing ordered RNA therapy was provided. c. During a review of Resident 79's admission Record, the admission Record indicated Resident 79 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to quadriplegia (inability to move all four limbs). During a review of Resident 79's MDS, dated [DATE], the MDS indicated Resident 79's cognition (ability to think and reason) was severely impaired. The MDS indicated Resident 79 was dependent on staff when performing oral and personal hygiene, toileting, bathing, and dressing. During a review of Resident 79's RNA schedule, dated 2/2024, the schedule indicated Resident 79 had orders for RNA therapy that included active range of motion for both upper extremities seven (7) days a week as tolerated and passive range of motion for both lower extremities seven (7) days a week as tolerated. The schedule indicated Resident 79 received both therapies 25 out of the 28 opportunities from 2/2/2024 to 2/29/2024. No documentation of a refusal or a rational for the missing ordered RNA therapy was provided. d. During a review of Resident 82's admission Record, the admission Record indicated Resident 82 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included but not limited to motor-vehicle accident, muscle weakness, anterior spinal artery compression syndromes (interruption of blood flow to the spine), traumatic spondylopathy (cervical region) (dislocation of the neck region), and displaced fracture of the first cervical vertebra (broken bone of the neck). During a review of Resident 82's MDS, dated [DATE], the MDS indicated Resident 82's cognition was severely impaired. The MDS indicated Resident 82 was dependent on staff when performing oral and personal hygiene, toileting, bathing, and dressing. During a review of Resident 82's RNA schedule, dated 2/2024 and 3/2024, the schedules indicated Resident 82 had six orders for RNA therapy that included the following: 1. Resident may be up in the geriatric chair ([Geri-chair]-chair designed to help residents with limited mobility) for up to four (4) to six (6) hours maximum for three (3) times a week as tolerated, every day shift every Monday, Wednesday, and Saturday for Socialization, stimulation, and participation in activities. 2. RNA to apply bilateral elbow extension splint for one (1) to two (2) hours every day for seven (7) days as tolerated, every day shift. 3. RNA to apply bilateral knee splint for one (1) to two (2) hours as tolerated, every day shift 4. RNA to apply bilateral resting hand splints every day for seven (7) days a week, for one (1) to two (2) hours or as tolerated, every day shift. 5. RNA to perform passive range of motion exercises to bilateral upper extremities everyday for seven (7) days a week, as tolerated by patient, every day shift. 6. RNA to provide passive range of motion exercises to bilateral upper extremities everyday for seven (7) days a week, as tolerated by patient, every day shift. The schedules indicated the following: 1. Resident 82 was not up in a Geri-chair for up to 4 to 6 hours on 2/5/2024, 2/10/2024, and 2/17/2024. 2. Resident 82 did not receive bilateral resting hand splints or passive range of motion exericises on 3/2/2024. 3. Resident 82 did not receive all 6 of the above ordered therapies on 2/5/2024. There was no documentation of resident refusal or a rational for the missing ordered RNA therapy provided. During an interview on 3/8/2024 at 3:56 p.m., with the Director of Staff Development (DSD), the DSD stated that the DSD and RN supervisors oversaw the work of the RNAs. The DSD stated that it was an unacceptable practice to not follow the physician's orders for RNA therapy and that there was a potential for any resident to decline if he or she was not getting RNA services on a consistent basis and not as ordered. During an interview on 3/8/2024, at 12:11 p.m., with the Director of Nursing (DON), the DON stated that any resident had the potential to decline if the RNA orders were not being performed as ordered and if the services were not being offered. The DON stated that the RNA therapy orders for were inputted to improve the residents' abilities, maintain their physical abilities to remain stable and be more independent. During a review of the facility's Policy and Procedure (P&P), titled, Restorative Nursing Services, dated 7/2017, the P&P indicated the facility was to provide restorative nursing care as needed to help promote optimal safety and independence. During a review of the facility's P&P, titled Resident Mobility and Range of Motion, dated 7/2017, the P&P indicated the facility would ensure residents with limited range of motion will receive treatment and services to increase and/ or prevent a further decrease in range of motion and residents with limited mobility will receive appropriate services. The P&P indicated that interventions will be based on professional standards of practice and be consistent with state laws and practice acts.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a safe and hazard free environment was maintained for four of four sampled residents (Resident 28, Resident 14, Resident 81, and Resident 43) when the following occurred: 1. Resident 28 did not have his call light in reach. 2. Resident 14 did not have his call light in reach. 3. Resident 81 entered Resident 43's room unsupervised and without permission and Resident 81 did not have a care plan in place for his tendency to wander into other facility residents' rooms. This deficient practice had the potential to cause avoidable harm to Resident 28 and Resident 14 from an inability to call staff for assistance and the potential for falls and associated injuries. This deficient practice also had the potential to cause avoidable harm to Resident 43 related to Resident 81 accidentally interfering with or disrupting Resident 43's personal belongings and medical equipment, including Resident 43's mechanical ventilator (a machine that helps someone breathe or breathes for them when they can't breathe on their own). Cross reference to F-tag F656 and F-tag F550. Findings: 1. During a review of Resident 28's admission Record, the admission record indicated Resident 28 was admitted on [DATE] with diagnoses including Parkinson's disease (a movement disorder characterized by involuntary movements, tremors, stiffness in the limbs or the trunk of the body, or impaired balance), difficulty walking, lack of coordination, reduced mobility, generalized muscle weakness, and abnormal gait and mobility. During a review of Resident 28's History and Physical (H&P), dated 1/22/2024, the H&P indicated Resident 28 could make his needs known, but could not make medical decisions. During a review of Resident 28's Minimum Data Set (MDS, a standardized assessment and care screening/planning tool), dated 1/5/2024, the MDS indicated Resident 29 made poor decisions related to tasks of daily life and required cues and supervision. The MDS further indicated Resident 28 required staff supervision, including touching/steadying, for eating, toileting, hygiene after toileting, and getting dressed. Resident 28 also required the same level of assistance for repositioning in bed, transitioning from a sitting to standing position, or walking distances between ten (10) to fifty (50) feet. During a review of Resident 28's medical record titled Fall Risk Assessment, dated 2/18/2024, the record indicated Resident 28 had experienced falls in the last six months and was at risk for falls. During a review of Resident 28's risk for falls care plans, the care plans indicated Resident 28 was at risk for falls due to gait and balance problems and generalized weakness. The care plans indicated Resident 28 had experienced falls on 12/11/2023 and 2/18/2024. The interventions to prevent further falls indicated be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. The interventions also included maintaining a safe environment with .a working and reachable call light. During an observation on 3/4/2024 at 9:33 a.m., at Resident 28's bedside, Resident 28 was observed lying in bed. Call light was not observed in Resident 28's bed or placed near Resident 28. During a concurrent observation and interview, on 3/4/2024 at 9:42 a.m., at Resident 28's bedside, with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 28's call light was hanging under his bed. CNA 1 pulled the call light out from under the bed and placed it in the bed with Resident 28. CNA 1 stated the call light was supposed to be within Resident 28's reach. 2. During a review of Resident 14's admission Record, the admission record indicated the facility originally admitted Resident 14 on 6/17/2008, and was readmitted on [DATE] with diagnoses including reduced mobility, lack of coordination, abnormalities of gait and mobility, and generalized muscle weakness. During a review of Resident 14's H&P, dated 6/30/2023, the H&P indicated Resident 14 had the capacity to understand and make decisions. During a review of Resident 14's MDS, dated [DATE], the MDS indicated Resident 14 had intact cognition (sufficient judgment, planning, organization, and self-control), required a wheelchair and partial to moderate assistance from staff for eating, personal hygiene activities, rolling side to side in bed, and transferring from wheelchair to bed and required partial to moderate assistance to move his wheelchair. During a review of Resident 14's high risk for falls and injury care plan, the care plan indicated Resident 14 was at high risk for falls and injury related to his decreased functional mobility and history of falls. The care plan indicated staff were supposed to be sure [Resident 14's] call light [was] within reach and encourage [Resident 14] to use it for assistance as needed. Additional care plan interventions included maintaining a safe environment with .a working and reachable call light. During an observation on 3/4/2024 at 9:34 a.m., at Resident 14's bedside, observed Resident 14 sitting up in a wheelchair, to the right side of the bed, next to the right handrail. Observed Resident 14's call light wrapped in and hanging from the handrail on the left side of the bed. During a concurrent interview and observation on 3/4/2024 at 9:44 a.m., at Resident 14's bedside, with CNA 1, CNA 1 stated Resident 14's call light was wrapped in the left handrail of Resident 14's bed. CNA 1 stated the call light was not within Resident 14's reach. CNA 1 stated the call light was supposed to be within reach to allow Resident 14 to call for help if needed. During an interview on 3/7/2024 at 2:07 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated call lights were used by residents to notify the staff when assistance was needed and to communicate their needs. LVN 1 stated call lights were supposed to be kept within the residents' reach, and stated that if not in reach, the residents would not be able to call for help. LVN 1 stated there was the potential for falls and injury if call lights were not kept within reach. During an interview on 3/8/2024 at 11:36 a.m., with the Assistant Director of Nursing (ADON), the ADON stated that if a resident was unable to reach the call light, the resident would not be able to call for help. The ADON stated residents might attempt to get out of bed unassisted which created the risk for falls and subsequent injury. The ADON also stated that if it was the resident's preference to have the call light wrapped in the handrail to prevent it from falling to the floor, it should be wrapped in the handrail closest to the resident. During a review of the facility policy and procedure (P&P) titled Answering the Call light, dated 9/2022, the P&P indicated the purpose of the P&P was to ensure timely responses to the resident's needs and requests and indicated staff were supposed to ensure that the call light is accessible to the resident. 3. During a review of Resident 81's admission Record, the admission record indicated the facility admitted Resident 81 on 10/26/2021 with admitting diagnoses that included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), psychosis (A mental disorder characterized by a disconnection from reality), restlessness and agitation, and lack of coordination. During a review of Resident 81's H&P, dated 10/27/2021, the H&P indicated Resident 81 did not have the capacity to understand and make decisions due to [Resident 81] confused and with dementia. During a review of Resident 81's MDS, dated [DATE], indicated Resident 81 had impaired cognition (problems with a person's ability to think, learn, remember, use judgement, and make decisions) and issues with his long term memory (ability to recall information from the past) and short term memory (ability to recall information after five minutes). The MDS further indicated Resident 81 used a manual wheelchair and required partial to moderate assistance from staff while operating the wheelchair. During an observation on 3/4/2024 at 9:46 a.m., observed Resident 81 propelling himself in a wheelchair, through a facility corridor, unassisted and without any staff in the corridor. During an observation on 3/4/2024 at 9:50 a.m., from outside of Resident 43's room, observed Resident 81 enter Resident 43's room in his wheelchair, unsupervised and unassisted. Resident 43 and Resident 81 were not visible from outside the room. The call light outside of Resident 43's room turned on after Resident 81 entered the room. During an observation on 3/4/2024 at 9:51 a.m., outside of Resident 43's room, observed Resident 81 leaving Resident 43's room in his wheelchair. There were no staff in the hallway when Resident 81 exited the room. During an observation on 3/4/2024 at 9:54 a.m., outside of Resident 43's room, observed staff responding to Resident 43's call light. During a review of Resident 43's admission Record, the admission record indicated the facility admitted Resident 43 on 1/21/2023 for acute respiratory failure with hypoxia (a condition where you don't have enough oxygen in the tissues in your body), muscular dystrophy (a group of genetic diseases that cause progressive weakness and loss of muscle mass), and generalized muscle weakness. During a review of Resident 43's H&P, dated 2/15/2024, indicated Resident 43 had the capacity to understand and make decisions and recognizes/recalls .people without prompts or repetition. The H&P further indicated Resident 43 required full breathing support from a mechanical ventilator. During a review of Resident 43's MDS, dated [DATE], the MDS indicated Resident 43 had impairments to the upper and lower extremities on one side of his body that interfered with daily function or placed him at risk for injury. The MDS also indicated Resident 43 was completely dependent on staff for repositioning in bed, transferring between surfaces (e.g., bed to wheelchair). During an interview on 3/4/2024 at 9:52 a.m., with Resident 43, Resident 43 stated he did not invite Resident 81 into his room and stated Resident 81 wandered into his room often. Resident 43 stated he used to be in a different room, and Resident 81 used to wander into that room also, and would make a mess and then leave. During an observation on 3/7/2024 at 2:44 p.m., observed Resident 81 propelling himself in a wheelchair, through a facility corridor, unassisted and without any staff in the corridor. During a concurrent observation and interview on 3/7/2024 at 2:55 p.m., with Resident 43, observed Resident 43 in bed connected to a mechanical ventilator (machine that takes over the work of breathing when a person is not able to breathe on their own) and oxygen machine. Resident 43 stated Resident 81 tried to come into his room that day, and Resident 43 yelled at Resident 81 telling him to leave. Resident 43 stated Resident 81 tended to knock things over when he was in the room and stated in his previous room, Resident 81's wheelchair would get caught on or bump into things, knocking them down. Resident 43 stated staff escorted Resident 81 from his room multiple times in the past and were aware that Resident 81 wanders into his room. Resident 43 stated that sometimes he called the nursing station from his personal phone, in addition to the call light, because Resident 81 was in his room and staff were not responding to the call light. Resident 43 stated there was a time he pressed the call light because Resident 81's wheelchair was stuck between the foot of the bed and the wall, and Resident 81 could not move. Resident 43 stated it bothered him that he had to worry about Resident 81 coming into his room and possibly knocking things down. Resident 43 stated Resident 81 did not talk and seemed disoriented when he was in the room. During a review of Resident 81's discontinued care plan, the care plan indicated Resident 81 was punched by another resident. The goals of care included Resident 81 will not be punched again by another resident. Staff's interventions to achieve this goal included constant visual check due to resident's wandering behavior and redirect and reorient resident when wandering. This care plan was discontinued on 2/3/2022. During a review of Resident 81's discontinued care plan, the care plan indicated Resident 81 was at risk for elopement/wandering related to .impaired decision making and wanders into other resident's rooms. The goals of care included Resident will have minimize episodes of wandering into other resident's rooms through the next review date. One of the intervention to achieve this goal included frequent visual checks of the resident's whereabouts. This care plan was discontinued on 10/20/2022. During a review of Resident 81's discontinued care plan, the care plan indicated Resident 81 wanders aimlessly, sometimes finding himself in other residents' rooms. The goal of care included resident's safety will be maintained through the review date. The care plan was initiated on 3/7/2024 and discontinued on 3/7/2024. During a review of Resident 81's active care plan, the care plan indicated Resident 81 had a tendency of wandering about the facility in his wheelchair related to cognitive loss. Goals of care included Resident 81 having no incident of wandering outside of facility property/elopement. The care plan did not address Resident 81 wandering into other residents' rooms. During an interview on 3/7/2024 at 3:03 p.m., with LVN 1, LVN 1 stated facility residents were not supposed to go into other residents' rooms without permission. LVN 1 stated Resident 43 required a mechanical ventilator to breathe, and stated Resident 81 did not have a sitter or direct supervision, and it was not safe for Resident 81 to wander into other residents' rooms. LVN 1 stated Resident 81 might hit something or disconnect critical medical equipment. LVN 1 stated Resident 81 could also get stuck, which was an accident hazard for Resident 81 and other facility residents. LVN 1 stated that wandering behaviors are also supposed to be care planned. During an interview on 3/8/2024 at 11:23 a.m., with the ADON, the ADON stated Resident 81's wandering was a pattern of behavior. The ADON stated that Resident 81's tendency to wander into other residents' rooms should be on the care plan and stated it was not currently care planned. The ADON stated Resident 81 required frequent supervision to stop him before he goes into another resident's room to protect the other residents' privacy and safety. The ADON stated that Resident 81 wandering into other residents' rooms unsupervised was a safety concern for Resident 81 and other facility residents. During a review of the facility P&P titled Safety and Supervision of Residents, dated 7/2017, the P&P indicated, resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The P&P indicated the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices and implementing interventions to reduce accident risks and hazards shall include . ensuring that interventions are implemented. During a review of the facility P&P titled Wandering and Elopement, dated 3/2019, the P&P indicated the facility will identify resident who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. The P&P further indicated if identified as a risk for wandering, .or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 60's admission Record, the admission record indicated Resident 60 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including diabetes, hypertension, acute respiratory failure, heart failure ( heart is unable to pump blood around the body), muscle weakness ( lack of muscle strength), and dysphagia (difficulty swallowing). During a review of Resident 60's MDS dated [DATE], the MDS indicated Resident 60 could make self-understood and understand others, was cognitively intact and required moderate assistance from staff for toileting, and personal hygiene. During a review of Resident 60's Medication Administration Record (MAR), dated 12/6/2023, the MAR indicated to give oxygen at a rate of 3 LPM via nasal cannula continuously for hypoxia (not enough oxygen in the body) or hypercapnia (too much carbon dioxide (odorless gas a waste product made by the body). During an observation on 3/4/2024 at 10:41 a.m., in Resident 60's room, observed Resident 60 lying in bed receiving supplemental oxygen via nasal cannula at a rate of 4.5 LPM. During a concurrent observation and interview on 3/4/2024 at 11:26 a.m., with LVN 5 in Resident 60's room, LVN 5 confirmed Resident 60 was receiving supplemental oxygen via nasal cannula at a rate of 4.5 LPM. LVN 5 stated she was not sure what the physician's ordered for the oxygen rate. During a concurrent interview and record review on 3/4/2024 at 11:30 a.m., with LVN 5, Resident 60's Order Summary Report dated 12/06/2023 was reviewed. The order summary report indicated an active order to give oxygen at rate of 3 LPM via nasal cannula continuously for hypoxia (low oxygen in the blood) or hypercapnia (odorless gas a waste product made by the body) every shift. LVN 5 stated it was important to follow physician orders. LVN 5 stated too much oxygen can be harmful for Resident 60, and put Resident 60 at risk for trouble breathing, increase blood pressure, and lung (a pair of organs in the chest that supplies the body with oxygen) damage. During an interview on 3/6/2024 at 10:30 a.m., with DON, the DON stated nurses must assess residents on supplemental oxygen and follow physician orders. The DON stated if Resident 60 received too much oxygen, it placed Resident 60 at risk for oxygen poisoning, which could cause lung failure, and fluid in the lungs. During a review of the facility's Policy and Procedure (P&P) titled, Oxygen Administration, dated October 2010, the P&P indicated that the physician's order for oxygen administration must be reviewed and verified along with the facility's protocol for oxygen administration. The P&P also indicated to ensure that the oxygen device is comfortable, and the proper flow of oxygen is being administered. The P&P indicated to observe the resident upon set up and periodically thereafter to be sure oxygen is being tolerated. Based on observation, interview, and record review, the facility failed to provide oxygen as ordered by the physician and ensure the resident's nasal cannula (small, flexible tube that contains two open prongs intended to sit inside the nostrils for oxygen administration) was not on the floor for two of six sampled residents (Resident 274 and 60). These deficient practices had the potential to cause Resident 274 and 60 avoidable harm and respiratory distress. Findings: a. During a review of Resident 274's admission Record, dated 3/6/2024, the admission record indicated Resident 274 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (DM 2 - condition that results in too much sugar circulating in the blood), hypertension (high blood pressure), atherosclerosis (blockage of blood supply to the heart muscle due to buildup of plaque in the arteries), and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). During a review of Resident 274's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 2/23/2024, the MDS indicated Resident 274 had severe cognitive impairment (ability to understand and make decision). The MDS also indicated Resident 274 required some supervision with eating and substantial assistance with toileting and bathing. During a review of Resident 274's History and Physical (H&P), dated 2/20/2024, the H&P indicated that Resident 274 had fluctuating capacity to understand and make decision and reason due to dementia. During a review of Resident 274's Order Summary Report, dated 2/19/2024, the order summary report indicated an active order to give oxygen at two liters per minute (2L [unit of measurement] P [per] M [minute]) continuously via nasal cannula (small, flexible tube that contains two open prongs intended to sit inside the nostrils for oxygen administration) for the diagnosis of desaturation (low levels of oxygen in the blood). During a review of Resident 274's Order Summary Report, dated 2/19/2024, the order summary report indicated an active order to change the resident's oxygen nasal cannula every week on Friday and as needed. During a review of Resident 274's Order Summary Report, dated 2/19/2024, the order summary report indicated an active order to monitor oxygen saturation (level of oxygen in the blood) every shift and notify the medical doctor if the oxygen saturation was less than 92 percent (%). During a review of Resident 274's care plan titled Oxygen Therapy, [not dated], the care plan indicated that Resident 274 would have no signs and symptoms of poor oxygen absorption. The staff's interventions included to change the oxygen nasal cannula every Friday and as needed, monitor for signs and symptoms of respiratory distress (a serious lung condition that causes low blood oxygen) and report to the medical doctor, monitor oxygen saturation every shift and notify medical doctor if oxygen saturation is less than 92 %. During an observation on 3/4/2024 at 3:42 p.m., in Resident 274's room, observed Resident 274 sitting on the edge of her bed with continuous oxygen as ordered. Observed Resident 274's nasal cannula on the floor next to Resident 274's bed while oxygen was running at 2 LPM. During a concurrent observation and interview on 3/4/2024 at 3:48 p.m., with Restorative Nurse Aide (RNA) 3, while in Resident 274's room, RNA 3 stated RNA 3 observed Resident 274's nasal cannula lying on the floor while running at 2 LPM. RNA 3 stated that the oxygen should be on the resident and not on the floor. RNA 3 stated that Resident 274 could not receive oxygen if it was on the floor. During an interview on 3/6/2024 at 9:45 a.m., with Licensed Vocational Nurse (LVN 6), LVN 6 stated that Resident 274 was on continuous oxygen because the resident had a diagnosis of desaturation (low oxygen level in the blood). LVN 6 stated that Resident 274 could desaturate without her oxygen. LVN 6 stated that an oxygen sign was on the door to let staff know that the Resident 274 was on oxygen. LVN 6 stated that the Certified Nurse Assistants (CNAs) were responsible for letting the charge nurse or registered nurse (RN) know when the oxygen was not on the resident. LVN 6 stated that CNAs should check residents every two hours, during mealtime and when providing daily care to ensure residents are receiving oxygen as order by the physician. During an interview on 3/6/2024 at 10:20 a.m., with Respiratory Therapist (RT) 1, RT I stated that Resident 274's oxygen saturation could potentially drop if the resident was not receiving oxygen. During an interview on 3/6/2024 at 3:41 p.m., with the Director of Nursing (DON), the DON stated that the nasal cannula on the floor was defeating the purpose for the resident. The DON stated the resident could start to desaturate. The DON also stated that if a resident was found without oxygen, the resident must be assessed, and an oxygen saturation must be checked. The DON stated that if the oxygen saturation was less than 92 percent or if the resident was showing signs of distress, the physician and family must be notified, and a change of condition documented on the resident.

CONCERN (E)

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

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation and interview, the facility failed to remove medication labels that contain resident medical information from medication containers prior to disposing in the pharmaceutical (relating to medications, drugs) waste containers, in one of one inspected medication room. This deficient practice resulted in the privacy and confidentially of residents' medical records being jeopardized and not securely maintained. Findings: During an observation on 3/4/2024 at 2:16 PM, with Licensed Vocational Nurse (LVN) 5, in the medication room, there was a pharmaceutic white waste container with a blue lid that contained wasted medication tablets, capsules, medication measuring cups, 5 insulin (medication used to treat high blood sugar levels) pens (medication device), an inhaler (a medication used to help with breathing) and an orange colored medication pill bottle. 3 of the insulin pens and the orange-colored pill bottle had the pharmacy label (a label that includes the residents name, name of medication, dose of medication, instructions and use of medication) intact and attached to the pen and bottle. During a concurrent interview with LVN 5, LVN 5 stated a third-party (an outside contracted entity not part of the facility) vendor (an individual or company that sells goods or services to someone else) routinely picks up the pharmaceutical waste containers to dispose (discard) of the wasted medications. LVN 5 stated labels that include resident medical information should be removed from medications prior to placing them in the pharmaceutical waste containers to maintain resident confidentiality. During an interview on 3/4/2024 at 2:36 PM, with the Director of Nursing (DON), the DON stated that no medication should be disposed of in the pharmaceutical waste containers with pharmacy labels and resident identifiers affixed as this violates the Health Insurance Portability and Accountability Act ([HIPPA] - a law to protect medical records and other personal health information). The DON stated that pharmacy labels should be removed from medications prior to disposing in the waste containers to maintain confidentiality, and those labels should be disposed of in the shredder and confidentiality bin. During a review of the facility policy and procedure (P&P), titled Confidentiality of Information and Personal Privacy, dated October 2017, the P&P indicated Our facility will protect and safeguard resident confidentiality and personal privacy.The P&P indicated: 1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records. 2. The facility will strive to protect the resident's privacy regarding his or her: a. Medical treatment 3. Access to resident personal and medical records will be limited to authorized staff and business associates.

CONCERN (E)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure care and services were provided to prevent pressure ulcer (injury to the skin and/or underlying tissue) and/or pressure injury development for five of five sampled residents (Resident 106, Resident 96, Resident 15, Resident 17, and Resident 50). The facility failed to: 1. Ensure nursing staff turned and repositioned, and monitored Resident 106's skin integrity for skin breakdown to prevent a sacral (sacrum, tail bone) Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer from reopening. 2. Ensure the nursing staff monitored the settings of Resident 96's low air loss mattress (mattress designed to prevent and treat pressure wounds by redistributing airflow and positioning) for functionality. 3. Ensure the nursing staff turned and repositioned Resident 15 and Resident 17 every hours or sooner as needed. 4. Ensure Resident 50's heels were offloaded from the mattress. These deficient practices resulted in Resident 106's pressure ulcer reopening, and the potential for the development of new or worsening pressure ulcers and/or injuries for Resident's 96, 15, 17, and 50. Findings: e. During a review of Resident 50's, admission Record, the admission Record indicated Resident 50 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including cerebral infarction (an interruption of blood flow to the brain), hemiplegia and hemiparesis affecting the right dominant side. During a review of Resident 50's MDS, dated [DATE], the MDS indicated Resident 50's cognition was intact. The MDS indicated Resident 50 was dependent on nursing staff to perform oral hygiene, toileting, bathing, and dressing. During a review of Resident 50's Skin and Wound Evaluation, dated 10/10/2023, the evaluation indicated Resident 50 had a Stage III (full thickness skin loss, leaving the fat layer exposed) pressure ulcer to the right lateral malleolus (ankle joint). During a review of Resident 50's Weekly Wound Evaluation, dated 2/4/2024, the evaluation indicated Resident 50 had a history of a left heel suspected deep tissue injury (SDTI, purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure) and a right medial malleolus (inner ankle joint) pressure injury Stage III. During an observation, on 3/4/2024, at 9:58 a.m. to 10:23 a.m., in Resident 50's room, Resident 50's position was observed. Resident 50's feet and heels were pressed against the wood base board of the bed. During a concurrent observation and interview on 3/4/2024 at 10:23 a.m., with Registered Nurse (RN) 4, Resident 50's feet were observed. Resident 50's feet and heels were pressed against the wood base board of the bed. RN 4 stated she did not know how long Resident 50's feet were left against the wood base of the bed because she just had started her morning rounds. RN 4 stated Resident 50 may need a bed extension because of his height. RN 4 stated that Resident 50 had the potential to develop another pressure ulcer if his feet were not offloaded and that it was not acceptable to have his feet pushed against the wood portion of the bed for an extended amount of time. During an observation, on 3/5/2024, at 7:39 a.m. to 7:45 a.m., Resident 50's feet and heels were placed on top of a pillow. Resident 50's heels were not offloaded. During an observation, on 3/5/2024, at 2:43 p.m. to 2:49 p.m., Resident 50's right heel and ankle was resting on the mattress. Resident 50's right heel and ankle were not offloaded. During an observation, on 3/6/2024, at 7:59 a.m. to 8:03 a.m., Resident 50's right and left heel were resting on top of a pillow. Resident 50's heels were not offloaded. During an interview, on 3/6/2024, at 8:10 a.m., RN 1 stated that it was important to offload the heels so that Resident 50 did not get another pressure injury. During a concurrent review and interview, on 3/6/2024, at 8:25 a.m., with Licensed Vocational Nurse (LVN) 5, photos of Resident 50's heels that were taken on 3/5/2024 at 7:39 a.m. and 2:43 p.m. and on 3/6/2024 at 7:59 a.m. were reviewed. LVN 5 stated that Resident 50's feet were not effectively elevated and had the potential to develop another pressure ulcer. During a concurrent review and interview, on 3/8/2024, at 11:59 a.m., with the DON, photos of Resident 50's heels that were taken on 3/5/2024 at 7:39 a.m. and 2:43 p.m. and on 3/6/2024 at 7:59 a.m. were reviewed. The DON stated that the best way to prevent the development of a pressure ulcer on a resident's heels was to off load the heels. The DON stated Resident 50 was at high risk for the development of pressure ulcers and would have benefited from more pillows placed underneath Resident 50's legs so that the heels could be effectively elevated. During a review of the facility's P&P, titled, Repositioning, dated 5/2013, the P&P indicated the facility was to promote comfort for bed bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. a. During a review of Resident 106's admission Record, the admission record indicated Resident 106 was admitted on [DATE], with admitting diagnoses that included cerebral infarction (damage to the brain due to a loss of oxygen to the area), tracheostomy (a surgically created hole in the throat, where a tube is inserted to provide an alternative way to breathe), and sepsis (a life-threatening complication of an infection). During a review of Resident 106's MDS, dated [DATE], the MDS indicated Resident 106 had impairments to both arms and both legs, interfering with her daily functioning and placing her at risk for injury. The MDS indicated Resident 106 was fully dependent on staff for rolling from side to side in bed, and for maintaining hygiene to the area around the anus (opening where solid waste leaves the body) and genitals. The MDS indicated Resident 106 had an unhealed sacral Stage IV pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) and was at risk for developing pressure ulcers/injuries. During a review of Resident 106's assessment titled, Weekly Wound Evaluation, dated 1/26/2024, the assessment indicated Resident 106 was admitted to the facility with a sacral Stage IV pressure ulcer that was 6 centimeters (cm, a unit of measuring length) long, 6 cm wide, and 0.3 cm deep. During a review of Resident 106's assessment titled, Interdisciplinary Team [IDT, group of different disciplines working together towards a common goal of a resident] Wound Management Assessment, dated 1/30/2024, the assessment indicated Resident 106's sacral Stage IV pressure ulcer was 1.3 cm long, 0.8 cm wide, and 1 cm deep. During a review of Resident 106's record titled, IDT Wound Management Update, dated 2/13/2024, the record indicated Resident 106 was seen by Medical Doctor (MD) 1, a wound care physician, and Resident 106's sacral Stage IV pressure ulcer was resolved and treatments were discontinued. During a review of Resident 106's record titled, Change in Condition Evaluation, dated 3/5/2024, the record indicated Resident 106 noted with re-opened sacral area pressure injury Stage IV with a measurement of 3.0 cm (length) x 0.5 cm (width). During a review of Resident 106's care plan, the care plan indicated Resident 106 had a re-opened sacral Stage IV pressure ulcer and indicated staff interventions for care of the pressure ulcer included repositioning Resident 106 every two hours. During a review of Resident 106's record titled, Documentation Survey Report, dated 3/2024, the record indicated the dates and times that facility staff turned and repositioned Resident 106. The record indicated staff did not document any turning or repositioning of Resident 106 prior to 3/5/2024 at 11:56 a.m. During an observation on 3/5/2024 at 8:47 a.m., observed Resident 106 lying flat on her back against the mattress, with a pillow behind her right shoulder. The pillow was not folded and was lying flat against the mattress. During an observation on 3/5/2024 at 10:48 a.m., observed Resident 106 lying flat on her back against the mattress, with one pillow behind each shoulder. The two pillows were not folded and were lying flat against the mattress. During an observation on 3/6/2024 at 8:05 a.m., observed Resident 106 lying flat on her back against the mattress, with one pillow behind each shoulder. The two pillows were not folded and were lying flat against the mattress. During a concurrent observation and interview on 3/6/2024 at 9:42 a.m., at Resident 106's bedside, with Certified Nursing Assistant (CNA) 5, Resident 106 was observed lying flat on her back against the mattress, with one pillow behind each shoulder. Both pillows were not folded and were lying flat against the mattress. No space was observed between Resident 106's body and the mattress on her left or right side. CNA 5 stated Resident 106 was currently turned to her left side and stated residents were turned every two hours. During a concurrent observation and interview on 3/6/2024 at 9:49 a.m., at Resident 106's bedside, with Treatment Nurse (TN) 2, TN 2 observed Resident 106's position in the bed. Resident 106 was lying flat on her back against the mattress, with one pillow behind each shoulder. Both pillows were not folded and were lying flat against the mattress. No space was observed between Resident 106's body and the mattress on her left or right side. TN 2 stated pressure was not sufficiently offloaded to resident's sacrum and stated Resident was in a supine (flat) position. During a concurrent interview and record review on 3/7/2024 at 12:21 p.m., with CNA 4, Resident 106's Documentation Survey Report, dated 3/2024 was reviewed. CNA 4 stated all residents were turned and repositioned every two hours and stated that turning and repositioning was charted for all residents. CNA 4 stated the Documentation Survey Report was the flowsheet where staff documented the turning and repositioning of residents. CNA 4 stated staff were trained to place one folded pillow behind the shoulders, and one folded pillow behind the legs when turning and repositioning a resident. CNA 4 stated turning and repositioning should leave space where the wound is. During an interview on 3/7/2024 at 12:25 p.m., with TN 2, TN 2 stated residents were turned every two hours. TN 2 stated the pillow should be folded in half when used for turning and repositioning. TN 2 stated that if not folded in half, there should still be space between the wound and the surface of the mattress or pillow. TN 2 stated that a flat pillow was not enough to sufficiently support Resident 106's body and offload pressure to Resident 106's wound because she was a bariatric (extremely overweight) patient. During an interview on 3/8/2024 at 8:27 a.m. with Medical Doctor (MD) 1, MD 1 stated that a wound was considered resolved when it was fully healed. MD 1 stated that once a wound was resolved, it could re-open very quickly because the skin and tissue were at 80 percent (%) of their original strength. MD 1 stated that Resident 106's limited mobility, nutritional state, and body habitus (the physique or body build) contributed to the resident's risk for wounds to reopen. MD 1 stated that effective turning and repositioning of Resident 106 should leave the sacral area free from pressure. MD 1 stated the bones in the sacral area exert pressure outward onto the skin and tissue above, and any contact surfaces, such as pillows or mattresses, would exert pressure onto the skin and tissue in an opposite direction, contributing to wound formation or worsening. During an interview on 3/8/2024 at 11:32 a.m., with the Assistant Director of Nursing (ADON), the ADON stated that prior to 3/5/2024, staff were not documenting any turning and repositioning of Resident 106, and stated that without any documentation, there was no way to confirm that Resident 106 had been turned or repositioned. The ADON stated that when turning a resident from side to side, the pillow should be folded or rolled, and not kept flat. The ADON stated there should not be pressure on the wound and stated that all staff should be turning the residents. During a concurrent interview and record review on 3/8/2024 at 2:47 p.m., with the ADON, the facility's policy and procedure (P&P) titled, Repositioning, dated 5/2013 was reviewed. The ADON stated the P&P did not indicate a revision date and stated the P&P indicated residents who were in bed were supposed to be turned at least every two hours. The ADON further stated the P&P also indicated that any residents with a pressure ulcer were supposed to be turned more frequently than every two hours. The ADON stated the P&P needed to be discussed with management, but no additional P&P's were provided. The ADON stated potential complications related to pressure ulcers included wound infections, sepsis, a worsening in the resident's overall condition, and pain. During a review of the facility's P&P titled, Repositioning, dated 5/2013, the P&P indicated the following: a. Evaluate the resident for an existing pressure ulcer. If present, positioning the resident on the existing ulcer should be avoided b. Residents who are in bed should be on at least an every two hour (q2 hour) repositioning schedule c. For residents with a Stage I (superficial reddening of the skin) above pressure ulcer, an every two hour (q2 hour) repositioning schedule is inadequate. d. Prevent skin-to-skin contact with use of sheets, pillows or positioning devices. e. The following information should be recorded in the resident's medical record: The position in which the resident was placed. This may be on a flow sheet. b. During a review of Resident 96's admission Record, the admission record indicated Resident 96 was admitted on [DATE] with diagnoses that included hemiplegia (inability to move one side of the body) and hemiparesis (muscle weakness or partial inability to move one side of the body that can affect the arms, legs, and facial muscles) following a stroke (when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), and generalized muscle weakness. During a review of Resident 96's MDS, dated [DATE], the MDS indicated Resident 96 was dependent on staff for repositioning while in bed. The MDS also indicated Resident 96 was at risk of developing pressure ulcers/injuries. During a review of Resident 96's record titled, Braden Scale for Predicting Pressure Sore Risk, dated 12/24/2023, the record indicated Resident 96 was high risk for pressure ulcer development. During a review of Resident 96's care plans, the care plans indicated Resident 96 had potential for pressure ulcer and goals of care included Resident 96 having intact skin. Staff interventions indicated to achieve this goal resident needs to turn/reposition at least every 2 hours, more often as needed or requested. The care plans also indicated Resident 96 had potential for impairment to skin integrity and goals of care included Resident 96 being free from skin complication. Staff interventions included providing Resident 96 with pressure relieving/reducing mattress .to protect the skin while in bed. During a review of Resident 96's physician orders, dated 5/18/2023, the orders indicated low air loss mattress for wound management and every day shift monitor low air loss mattress for functioning. During an observation on 3/4/2024 at 10:19 a.m., Resident 96 was observed lying flat in bed on a SPAN brand PressureGuard Protocol mattress. The pump used to power the mattress was off. During an observation on 3/4/2024 at 11:54 a.m., Resident 96 was observed lying flat in bed on a SPAN brand PressureGuard Protocol mattress. The pump used to power the mattress was off. During an observation on 3/4/2024 at 2:54 p.m., Resident 96 was observed lying flat in bed on a SPAN brand PressureGuard Protocol mattress. The pump used to power the mattress was off. During an observation on 3/5/2024 at 8:18 a.m., Resident 96 was observed lying flat against the bed, with one flat pillow placed behind each shoulder. Resident 96 was lying on a SPAN brand PressureGuard Protocol mattress. The pump used to power the mattress was off. During an observation on 3/5/2024 at 10:05 a.m., Resident 96 was observed lying flat against the bed, with one flat pillow placed behind each shoulder. Resident 96 was lying on a SPAN brand PressureGuard Protocol mattress. The pump used to power the mattress was off. During an observation on 3/5/2024 at 10:49 a.m., Resident 96 was observed lying flat against the bed, with one flat pillow placed behind each shoulder. Resident 96 was lying on a SPAN brand PressureGuard Protocol mattress. The pump used to power the mattress was off. During an observation on 3/5/2024 at 4:34 p.m., Resident 96 was observed lying flat against the bed, with one flat pillow placed behind each shoulder. Resident 96 was lying on a SPAN brand PressureGuard Protocol mattress. The pump used to power the mattress was off. During an observation on 3/6/2024 at 8:50 a.m., Resident 96 was observed lying on a SPAN brand PressureGuard Protocol mattress. The pump used to power the mattress was off. During a concurrent observation and interview on 3/6/2024 at 10:10 a.m., at Resident 96's bedside, with TN 2, TN 2 stated Resident 96's SPAN brand PressureGuard Protocol mattress was off and was not plugged in. c. During a review of Resident 15's admission Record, the admission record indicated Resident 15 was originally admitted on [DATE], and readmitted on [DATE] with diagnoses including multiple sclerosis (MS, a disorder of the central nervous system marked by weakness, numbness, a loss of muscle coordination, and problems with vision, speech, and bladder control), quadriplegia (inability to move from the neck down), and a Stage IV pressure ulcer to the sacral region. During a review of Resident 15's Minimum Data Set (MDS), dated [DATE], the MDS indicated Resident 15 was fully dependent on staff for repositioning while in bed. The MDS indicated Resident 15 had an unhealed pressure ulcer and was at risk of developing pressure ulcers and/or injuries. During a review of Resident 15's record titled, Braden Scale for Predicting Pressure Sore Risk, dated 1/23/2024, the record indicated Resident 15 was very high risk for pressure ulcer development. During a review of Resident 15's undated care plan addressing Resident 15's pressure ulcer, the care plan indicated Resident 15 had a Stage IV pressure ulcer and was at risk for skin breakdown or pressure ulcer development. Goals of care included the pressure ulcer showing signs of healing. The staff's interventions indicated in order to achieve the indicated goal, staff were to turn and reposition Resident 15 at least every 2 hours. During an observation on 3/5/2024 at 8:19 a.m., observed Resident 15 lying in bed on her back, with one flat pillow behind each shoulder. Resident 15's left arm was flexed at the elbow and the right arm was extended at the resident's side. Resident 15's head was facing the left, but the remainder of her body was flat against the bed. During an observation on 3/5/2024 at 10:49 a.m., observed Resident 15 in bed on her back, with one flat pillow behind each shoulder. Resident 15's left arm was flexed at the elbow and right arm was extended at her side. Resident 15's head was facing the left, but the remainder of the resident's body was flat against the bed. d. During a review of Resident 17's admission Record, the record indicated Resident 17 was originally admitted on [DATE], and readmitted on [DATE] with diagnoses including hemiplegia and hemiparesis following a stroke. During a review of Resident 17's MDS, dated [DATE], the MDS indicated Resident 17 had impairments to the upper and lower extremities on both sides of his body and was dependent on staff for repositioning while in bed. The MDS further indicated Resident 17 was at risk of developing pressure ulcers and/or injuries. During a review of Resident 17's record titled, Braden Scale for Predicting Pressure Sore Risk, dated 2/5/2024, the record indicated Resident 17 was high risk for pressure ulcer development. During a review of Resident 17's care plans, the care plans indicated Resident 17 had potential for pressure ulcer development or skin break down related to immobility and being fully dependent on staff for activities of daily living. Goals of care included intact skin and no further formation of [pressure ulcers]. Staff interventions indicated to achieve these goals included turning and repositioning Resident 17 every two hours and as needed. During an observation on 3/4/2024 at 10:03 a.m., Resident 17 was observed lying on his right side with pillows placed behind his back for support. Resident 17 was facing the doorway to the hallway. During an observation on 3/4/2024 at 11:50 a.m., Resident 17 was observed lying on his right side with pillows placed behind his back for support. Resident 17 was facing the doorway to the hallway. During an observation on 3/4/2024 at 12:48 p.m., Resident 17 was observed lying on his right side with pillows placed behind his back for support. Resident 17 was facing the doorway to the hallway. During an observation on 3/4/2024 at 4:46 p.m., Resident 17 was observed lying on his right side with pillows placed behind his back for support. Resident 17 was facing the doorway to the hallway. During an observation on 3/5/2024 at 8:16 a.m., Resident 17 was observed lying flat against the bed, with one pillow behind each shoulder. The pillows were not folded and were placed flat against the bed. Resident 17's head was facing the ceiling. During an observation on 3/5/2024 at 10:04 a.m., Resident 17 was observed lying flat against the bed, with one pillow behind each shoulder. The pillows were not folded and were placed flat against the bed. Resident 17's head was facing the ceiling. During an observation on 3/5/2024 at 4:33 p.m., Resident 17 was observed lying flat against the bed, with one pillow behind each shoulder. The pillows were not folded and were placed flat against the bed. Resident 17's head was facing the ceiling.

CONCERN (E)

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on interview and record review, the facility failed to provide adequate and sufficient nursing staff to provide care for the 56 residents requiring Restorative Nursing Aide (RNA, nursing aide program that helps residents maintain their function and joint mobility) services. This deficient practice had the potential for 56 residents with physician's orders for RNA to experience a decline in range of motion (ROM, full movement potential of a joint) and mobility (ability to move). Cross Referenece to F-tag F688. Findings: During a review of the Order Listing Report of RNA orders for 2/2024, the order list indicated 56 residents of the skilled nursing side of the facility had physician's orders for RNA to provide either assistance with sit-to-stand transfers, ROM exercises to arms and legs, application of splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and / or increase range of motion), ambulation (walking), feeding, stair climbing, or exercises on the stationary bike (exercise machine with pedals that stays in one place). During a review of the facility's Nursing Staffing Assignment and Sign in Sheets for the month February 2024 indicated 2 RNAs were scheduled and signed in for their shift for 13 days out of the 29 days in the month. During an interview on 3/6/2024, at 8:03 a.m., with Restorative Nursing Aide 1 (RNA 1), RNA 1 stated that the RNAs were asked to perform CNA (Certified Nurse Assistant) duties often, especially when the CNAs call out [of work]. RNA 1 stated RNA services included providing exercises, ROM, ambulation, feeding assistance, stationary bike, and application of splints. RNA 1 stated the RNA workload was divided by station and was typically assigned 13 residents when there were three RNAs and depending on the number of RNA orders. RNA 1 stated that there was not enough RNAs for their workload and that RNA 1 usually did not have enough time to complete all the orders for all the residents because some residents require a lot more time than others. RNA 1 stated RNA 1 would sometimes document that RNA services were performed for a resident but did not actually have time to see the resident. RNA 1 stated the facility had been short staffed of RNAs for the month of February. RNA 1 stated that she had already made the Director of Staff Development (DSD) aware of the staffing issues. RNA 1 stated that there was potential for mobility decline for all residents that have orders for RNA therapy. During an interview on 3/7/2024, at 7:37 a.m., with RNA 2, RNA 2 stated that the RNAs have told the DSD that they needed more staff to perform and complete RNA duties. RNA 2 sated, We have to cover CNAs sometimes and do RNA and CNA work. It is especially harder on the weekends because of the call offs. We have to do this weekly. RNA 2 stated that three RNAs were usually scheduled each day, and stated that one more RNA would help to complete their RNA duties. RNA 2 stated that the workload with 13 residents per each RNA was hard because every resident had more than one order and some resident required more time. RNA 2 stated, We cannot do it [the RNA and CNA duties] all if we have CNA assignments or if it is only two of us. It is hard with three already. It is impossible. I have to try to give more time to the residents that I feel that actually need the therapy. RNA 2 stated the lack of sufficient staffing had negatively affected the quality of RNA services that were provided and if not all assigned residents were being seen, then it had the potential to lead to a decline in mobility for these residents (on RNA therapy). During a concurrent record review and interview, on 3/7/2024, at 10:04 a.m., with the Director of Rehabiliation (DOR), the Order Listing Report of RNA orders for 3/2024 was reviewed. The Order Listing report of RNA orders indicated 68 residents (on the Skilled Nursing Side of the facility) had orders for various types of RNA therapy. The DOR confirmed that if two RNAs had to split the work of three stations amongst themselves, then each RNA would be expected to assume care of about 19 to 20 residents. The DOR stated that it would be difficult for the RNAs to see all 20 residents, especially if they had to perform normal RNAs tasks and CNA duties. The DOR stated, Some patients need more time than others. It is about workload management. We cannot expect them [the RNAs] to do RNA work and CNA work, perform their charting, complete their duties, and remain compliant. We need to give them the tools to be effective and complaint at the same time. This affects all residents on RNA therapy. The DOR stated that the facility did not meet the needs of the residents if two (2) RNAs were scheduled or if the scheduled RNAs were also expected to perform CNA duties. During an interview, on 3/8/2023, at 8:31 a.m., with RNA 3, RNA 3 stated that the RNAs that were scheduled to work on the Skilled Nursing side of the facility had more orders and therapy to perform compared to the Subacute side of the facility. RNA 3 stated, If two RNAs were scheduled on shift on the Skilled Nursing side, then yes, it would make the assignment harder. RNA 3 stated that there was a greater chance that each resident would not be seen. RNA 3 stated there was a potential for the residents with RNA orders to decline in their mobility or ability to perform activities for daily living if they were not seen on a consistent basis. During a concurrent record review and interview, on 3/8/2024, at 9:28 a.m., with the DSD, the Order Listing Report of RNA orders for 3/2024 and the facility's Nursing Staffing Assignment and Sign in Sheets for the month of February was reviewed. The Order Listing report of RNA orders indicated 68 residents (on the Skilled Nursing Side of the facility) had orders for various types of RNA therapy. The Nursing Staffing Assignment and Sign in Sheets for the month of February indicated that there were 13 days in which two (2) RNAs were scheduled to work. The DSD stated that the facility required a minimum of three (3) RNAs to fulfill the RNA duties needed for the residents admitted to the Skilled Nursing side of the facility. The DSD stated that over time (any hours worked by an employee that exceed their normally scheduled working hours) was common amongst the RNA staff but was not mandatory. The DSD stated that the RNA staffing of the facility did not meet the needs of the residents that needed RNA therapy without the use of over-time and if there were only two RNAs for the Skilled Nursing side of the facility. The DSD stated the use of registry nurses was an option to staff more RNAs but was not used. The DSD stated that if the residents that needed RNA therapy were not getting their therapy consistently and as ordered, then there would be a potential for mobility decline in those residents. During an interview, on 3/8/2024, with the (Director of Nursing) DON, the DON stated that there should be at least three RNAs assigned to performed RNA duties on the Skilled Nursing side of the facility to ensure the provision of RNA services. The DON stated that if the RNAs are expected to do RNA and CNA work, then there would a be potential that all residents would be affected and that the residents with RNA orders would have the potential for decline. During a concurrent review and interview, on 3/8/2024, at 2:26 p.m., with the Assistant Director of Nursing (ADON), the Order Listing Report of RNA orders for 3/2024 and the facility's Nursing Staffing Assignment and Sign in Sheets for the month of February was reviewed. The ADON stated if there were less RNAs, then there would probably be an increased likelihood that the RNAs would not complete their RNA duties, especially if the RNAs were also expected to perform CNA duties. During a review of the facility's policy and procedure (P&P), titled Staffing, Sufficient, Competent Nursing, dated 8/2022, the P&P indicated the facility would ensure the provision of sufficient numbers of staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents to ensure resident needs are met. During a review of the facility's P&P, titled Resident Mobility and Range of Motion, revised 7/2017, the P&P indicated the facility would ensure residents with limited range of motion will receive treatment and services to increase and/ or prevent a further decrease in range of motion and residents with limited mobility will receive appropriate services. The P&P indicated that interventions will be based on professional standards of practice and ne consistent with state laws and practice acts.

CONCERN (E)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Account for one dose of controlled substance (CS) for Resident 420 in one of three inspected medication carts (Medication Cart 3). 2. Include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with Licensed Vocational Nurse (LVN) on the Antibiotic or Controlled Drug (also known as Controlled Medication or Controlled Substance [CM, CS]- medications which have a potential for abuse and may also lead to physical or psychological dependence) accountability logs for 29 of 29 sampled records. As a result, the control and accountability of CS awaiting final disposition (process of returning and/or destroying unused medications) were not followed as indicated in the facility policy and procedures. These deficient practices increased the opportunity for CS diversion (the transfer of a controlled substance or other medication from a lawful to an unlawful channel of distribution or use) and increased the risk that Resident 420 could have delayed medication treatment and continuity of care, due to the lack of availability of the CS, and accidental exposure to harmful medications, possibly leading to physical and psychosocial harm. Findings: During an observation and interview on 3/4/2024 at 1:04 p.m. , with Licensed Vocational Nurse (LVN) 4, of the Medication Cart Station 3, there was a discrepancy in the count between the Controlled Drug Record accountability log and the amount of medication remaining in the medication bottle for the following: One dose of pregabalin (a CS used for nerve pain) 150 milligram ([mg] - a unit of measure of mass) capsule was missing from the medication bottle compared to the count indicated in the Controlled Drug Record accountability log for Resident 420. The Controlled Drug Record accountability log for pregabalin indicated the medication bottle should have contained a total of 60 pregabalin 150 mg capsules, after the last administration of pregabalin 150 mg documented/signed-off on 3/3/2024 at 5:10 p.m The medication bottle contained 59 pregabalin 150 mg capsules and contained no other documentation of subsequent administrations. During the concurrent interview, LVN 4 stated LVN 4 administered pregabalin 150 mg capsule Resident 420 that morning at 9:00 a.m. and forgot to sign the Controlled Drug Record accountability log. LVN 4 stated LVN 4 failed to follow the facility's policy of signing each CS dose on the Controlled Drug Record accountability log after preparing the dose for Resident 420. LVN 4 stated LVN 4 understood the importance of signing each dose once administered to ensure accountability, prevention of CS diversion, and accidental exposures of harmful substances to residents. LVN 4 stated if documentation was not accurate then it can lead to medication error and overdosage (administering more than the prescribed dose) leading to stoppage of breathing and hospitalization for Resident 420. During a record review on 3/5/2024 at 10:24 a.m., with the DON, total of 29 Antibiotic or Controlled Drug Record, accountability logs for the CS's awaiting final disposition did not contain any verifying signatures. During the concurrent interview, the DON stated the DON was unable to locate the verifying signatures of LVNs and RN or DON on the 29 accountability logs, and that the DON failed to sign the logs upon receipt of the CS's. DON stated the DON counts the CS's with the LVNs upon receipt of the accountability logs, however, there was no consistent process to sign the logs. The DON stated the DON needed to immediately implement a process for including verifying signatures. The DON stated she understands the importance of CS accountability, to ensure each CS dose is accounted for until disposed. The DON stated it was also important to verify and sign the logs to prevent diversions and accidental exposure of harmful substances to residents. During an interview on 3/5/2024 at 1:00 p.m., the DON stated LVN 4 failed to follow policy in documenting the CS immediately on the Controlled Drug Record accountability log for Resident 420. The DON stated not having accurate records can lead to diversion, as well as underdose (administering less than the prescribed dose) or overdose of Resident 420 requiring communication with the family members and doctor, close monitoring of the resident vital signs and possibly respiratory (related to lungs) depression (stoppage.) During a review of Resident 420's admission Record dated 12/13/2023, the admission Record indicated Resident 420 was originally admitted to the facility on [DATE] with a diagnose of Neuromyelitis Optica (an inflammation in nerves of the eye and the spinal cord causing sharp, burning, shooting, or numbing pain in the arms or legs.) During a review of Resident 420's (Medication Administration Record ([MAR] - a record of medications administered to residents), for March 2024, the MAR indicated Resident 420 was prescribed pregabalin 300 mg every 12 hours for chronic pain at 9:00 a.m. and 5:00 p.m., starting 2/22/2024. During a review of the policy and procedures (P&P), titled Controlled Medications, dated August 2014, the P&P indicated Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. A. The Director of Nursing and the Consultant Pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications. C. When a controlled mediation is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the MAR: a. Date and time of administration b. Amount administered c. Signature of the nurse administering the dose on the accountability record at the time the medication is removed from the supply. During a review of the facility's P&P, titled Controlled Substances, dated November 2022, the P&P indicated that The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976. The P&P indicated, waste and/or disposal of controlled medication are done in the presence of the nurse and a witness who also signs the disposition sheet. During a review of the facility's P&P, titled Discarding and Destroying Medications, dated November 2022, the P&P indicated Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations. The P&P indicated: A. The DON and the CP maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications.

CONCERN (E)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Two medication errors out of 25 total opportunities contributed to an overall medication error rate of 8% affecting one of four residents observed for medication administration (Resident 63). The medication errors were as follows: Resident 63 did not receive a form of aspirin (a medication used to prevent stroke [condition where there is blockage of blood supply to the brain]) and was not instructed to rinse mouth after the administration of mometasone (a corticosteroid [an anti-inflammatory medication also known as steroid] medication used for wheezing [difficulty in breathing]) as ordered by Resident 63's physician. This deficient practice had the potential to result in Resident 63 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents 63's health and well-being to be negatively impacted. Findings: During an observation on 3/4/2024 at 9:45 a.m., in medication cart Station 1, Licensed Vocational Nurse (LVN) 3 was observed administering aspirin 81 milligram ([mg]-a unit of measure of mass) enteric coated ([EC] - a form of aspirin that is designed to slowly release medication) tablet orally and mometasone 2 puffs inhaled orally to Resident 63. Resident 63 was observed swallowing aspirin 81 mg EC tablet with a sip of water and orally inhaling 2 mometasone puffs. During an interview on 3/4/2024 at 12:00 p.m., LVN 3 stated during the morning medication administration on 3/4/2024 at 9:45 a.m., LVN 3 stated she did not instruct Resident 63 to rinse mouth after the 2 puffs oral inhalation of mometasone. LVN 3 stated that she failed to follow the physician orders to administer regular aspirin 81 mg and failed to instruct Resident 63 to rinse out mouth with water after administering mometasone inhalation. LVN 3 stated not rinsing the mouth after administering mometasone can cause medication to remain in the mouth harming Resident 63 by irritating the oral mucosa (membrane that lines the inside of the mouth.) During an interview on 3/5/2024 at 1:00 p.m., with Director of Nursing (DON), the DON stated that LVN 3 failed to administer the correct form of aspirin 81 mg to Resident 63 and failed to instruct Resident 63 to rinse mouth after administering 2 puffs of mometasone, as ordered by the physician. The DON stated it is important to rinse the mouth after inhalation of mometasone to remove any remaining medication in the mouth that can harm Resident 63 by causing an oral thrush (fungal [yeast or mold] infection). During a review of Resident 63's Face Sheet (a document containing demographic and diagnostic information) dated 3/4/2024, the face sheet indicated Resident 63 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including congestive heart failure (a condition in which the heart does not pump blood as well as it should) and chronic obstructive pulmonary disease (a condition that makes it difficult to breathe.) During a review of Resident 63's Order Summary Report, for March 2024, indicated Resident 63 was prescribed aspirin 81 mg capsule to be given by mouth once a day for cardiac (relating to the heart) and stroke prevention, and mometasone 2 puffs to be inhaled orally every 12 hours for wheezing and to rinse out mouth with water after dose, both starting 9/22/2023. The clinical record contained no documentation that the resident should be given the EC form of aspirin 81 mg or not to rinse out mouth after mometasone inhalation. During a review of Resident 63's Medication Administration Record ([MAR] - a record of mediations administered to residents), dated March 2024, the MAR indicated Resident 63 was prescribed aspirin 81 mg capsule to be given once a day, at 9:00 a.m., and mometasone 2 puffs to be given every 12 hours, at 9:00 a.m. and 9:00 p.m. During a review of the facility's undated policy and procedures (P&P), titled Administering Medications, the P&P indicated that Medications are administered in a safe and timely manner, and as prescribed. The P&P indicated . medications are administered in accordance with prescriber orders .The individual administering the medication checks the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. During a review of the facility's P&P, titled Administering Medications through a Metered Dose Inhaler, dated October 2010, the P&P indicated The purpose of this procedure is to provide guidelines for the safe administration of inhaled medications. The P&P indicated, the following equipment and supplies will be necessary when performing this procedure .Gargling solution. During a review of the facility's undated P&P, titled Spacing and Proper Sequence of Inhaled Medications, the P&P indicated, Corticosteroids: Rinse the mouth out following use (do not swallow the water) to help prevent oropharyngeal (relating to the roof of the mouth, side and back walls of the throat and back of tongue) fungal (yeast or mold) infection.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a review of Resident 51's admission Record (Face Sheet), the Face Sheet indicated, Resident 51 was admitted to the facility on [DATE] with diagnosis including, osteoarthritis (degenerative joint disease (tissue in the joint (part of the body where two or more bones meet) break down over time) ,diabetes (high blood sugar), dysphagia (difficulty swallowing), major depression (loss of interest in life), and hypertension (high blood pressure). During a review of Resident 51's Minimum Data set ([MDS] a standardized assessment and care screening tool), dated [DATE], the MDS indicated Resident 51 had an intact cognitive level and required maximum assistance from staff for activities of daily living (ADL). During a review of Resident 51's History and Physical (H&P), the H&P indicated Resident 51 had the capacity to understand and make decisions. During a review of Resident 51's admission Assessment Inquiry self-administration of medication evaluation dated [DATE], the self-administration of medication evaluation indicated Resident 51 would not self-administer medications. During a concurrent observation and interview on [DATE] at 9:52 a.m., with Resident 51 in the resident's room, a bottle of unlabeled refresh (eyedrop medication for dryness) eyedrops on Resident 51's bedside table was observed. Resident 51 stated the eyedrops were used when needed, and she self-administers the eyedrops. Resident 51 stated she wanted the nurse to administer the eyedrops because she was not sure if the eyedrops were administered correctly. During an interview on [DATE] at 10:14 a.m., with LVN 4, LVN 4 stated there should have been a physician order for Resident 51 medications at bedside. LVN 4 stated eye drops should have not been kept in the resident room as it was a safety risk. Resident 51 could administer excessive dose of medication, or the medication could be expired. During an interview on [DATE] at 10:30 a.m. with the DON, the DON stated staff did not leave medications at the bedside. The DON stated all medications must have a physician order, labeled, and kept safe in facility medications cart. The DON stated medications could not be left at the resident's bedside because it was a safety issue. The DON stated another resident could get a hold of the medication and take the medications. During a review of facility's policy and procedure (P&P) titled, Medication Labeling and Storage, dated 2/2023, the P&P indicated the facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and the medication label should include medication name (generic and /or brand), prescribed dose, strength, expiration date, resident's name, route of administration and appropriate instructions and precautions. Based on observation, interview, and record review, the facility failed to: 1. Store one insulin (medication used to regulate blood sugar levels) Humulin N (intermediate acting insulin) kwikpen (type of insulin injection device) for Resident 4, in accordance with manufacturer's requirements in one of three inspected medication carts (Medication Cart 3.) 2. Store one insulin Humulin R (short-acting insulin) vial for Resident 116 at room temperature, in accordance with manufacturer's requirements in one of three inspected medication carts (Medication Cart 3.) 3. Provide a safe storage and label of medication for one of one sampled resident (Resident 51). These deficient practices increased the risk that Residents 4 and 116 could have received ineffective or toxic medications due to improper storage or labeling, possibly leading to health complications resulting in hospitalization or death, and had the potential to place Resident 51 at risk for medication errors. These deficient practices had the potential for unsafe medication administration for other residents in the facility. Findings: During an observation on [DATE] at 1:04 p.m., of Medication Cart 3, in the presence of Licensed Vocational Nurse (LVN) 4, the following medications were found stored in a manner contrary to their respective manufacturer's requirements, not labeled with an open date as required by their respective manufacturer's specifications, or stored and labeled contrary to facility policies: 1. One unopened insulin Humulin N kwikpen for Resident 4 was found stored at room temperature without a date to indicate when storage or used at room temperature began, without a label to indicate date when to discard unused medication (after 14 days) and a pink label that indicated to refrigerate until used. According to the manufacturer's product labeling, unopened Humulin N Kwikpens should be stored refrigerated between 36 to 46 degrees Fahrenheit and used or discarded within 14 days of opening or once storage at room temperature began. 2. One open insulin Humulin R vial for Resident 116 was found stored at room temperature without a date indicating when storage or use at room temperature began. According to the manufacturer's product labeling, opened Humulin R vials should be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 31 days of opening or once storage at room temperature began. During the concurrent interview with LVN 4, LVN 4 stated that the Humulin N Kwikpen for Resident 4 found at room temperature was not opened and should have been stored in the refrigerator, and the Humulin R multi-dose vial for Resident 116 at room temperature, was not labeled with the date when used at room temperature began. LVN 4 stated LVN 4 opened the Humulin R vial for Resident 116 that morning and forgot to label the vial with the date opened. LVN 4 stated it is unknown when the Humulin N kwikpen was stored at room temperature, therefore, unknown when it would expire and need to be discarded. LVN 4 stated the Humulin N Kwikpen needs to be discarded and replaced with a new one from pharmacy to ensure expired insulin is not used in error for Resident 116. LVN 4 stated administering expired insulin will not be effective in keeping the blood sugar stable and can harm Resident 4 and 116 by causing high blood sugar levels, diabetic ketoacidosis (a condition that develops when the body doesn't have enough insulin resulting in the buildup of acid in the blood to levels that can be life threatening) and diabetic coma ( a life threatening complication that can result from very high blood sugar or very low blood sugar levels) leading to hospitalization and death. During an interview on [DATE] at 1:00 p.m., with the Director of Nursing (DON), the DON stated that the unopened insulin Humulin N Kwikpen for Resident 4 should have been stored in the refrigerator and labeled with a date when it came to storage at room temperate, and discarded 14 days later. The DON stated, the opened Humulin R vial for Resident 116 should have been labeled with a date when it came to use at room temperature to know when it expired. The DON stated LVN 4 failed to label Humulin R vial with a date open label, and several LVN's failed to refrigerate the unopened Humulin N Kwikpen or label with the date of room temperature storage. The DON stated without the proper date labeled, there was no way to know when the insulin could expire, which could potentially lead to the administration of expired insulin to residents leading to medication errors. The DON stated administering expired insulin to residents would not be effective in controlling the blood sugar levels and could lead to hospitalization.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, interview, and record review, the facility's dietary staff failed to ensure sanitary food preparation, food storage and food distribution practices, were followed by: 1. Failing to ensure the trash can lid opened correctly at the handwashing station. 2. The Dietary Supervisor (DS) touching the lid of the trash bin after performing hand hygiene. 3. Failing to properly package and label open food items in the dry storage area. 4. Failing to ensure poured milk and poured juices were labeled with the correct date in the refrigerator. 5. Failing to discard outdated poured milk and poured juices in the refrigerator. 6. Failing to ensure gloves were changed and hands were washed after touching face and mask during meal preparation. 7. Failing to ensure kitchen staff did not come in contact with the food and plates and cause food contamination during food preparation. 8. Failing to keep a thermometer inside the walk-in freezer. These deficient practices had the potential to cause cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illnesses for all 124 residents in the facility. Findings: During a concurrent observation and interview on 3/4/2024 at 8:55 a.m., with the Dietary Supervisory (DS), in the kitchen, the DS was observed washing her hands at the kitchen handwashing station. After the DS washed her hands and dried with paper towel, the DS opened the lid of the trash bin to throw away the paper towel with her clean, ungloved hands. The DS was asked if this was the proper technique in the kitchen when throwing a papertowel to the trash. The DS stated that she should not have used her hands to open the lid of the trash bin. The DS stated that the trash bin was supposed to be hands-free, but since it was broken, she must use her hands to open the lid. The DS stated that using her clean hands to open the dirty trash bin had the potential to cause cross contamination, when touching anything clean in the kitchen. The DS stated that she should have replaced the broken hands-free trash can at the hand-washing station to avoid others from opening the trash bin lid with their bare hands after handwashing. During a concurrent observation and interview on 3/4/2024 at 9:05 a.m., with the DS, in the kitchen, a tray with several glasses of milk, covered with plastic wrap, dated 3/1/2024 in the refrigerator and a tray with glasses of poured juice covered with plastic wrap dated 2/26/2024 were observed in the refrigerator. The DS stated the milk and juice were old because the date labeled should have been 3/4/2024. The DS stated that the poured milk and juice should been made daily, and the trays should indicate the date the milk and juice were poured. The DS stated that the poured milk and juice may be fresh, but there was no way to tell because the trays have the wrong date. The DS believes the milk and juice were poured that morning, but she stated that it must be discarded because they must follow the dates on the trays. The DS stated that either the milk and juice were old, or the trays were not labeled correctly. The DS stated that it was important to change the poured milk and juice every day and change the tray labels to the current date. She stated that outdated poured milk and poured juices must be discarded at the end of the day. The DS stated that labeling trays with the current date are important because to be able to know if the milk and juice are good to use. The DS also stated that serving poured milk and juices that are outdated, is not good because residents can potentially get sick with food poisoning. During a concurrent observation and interview on 3/4/2024 at 9:15 a.m., with the DS, while in the kitchen, observed that there was no internal thermometer in the walk-in freezer. The DS stated that the freezer should have an internal thermometer inside. The DS also stated that the thermometer on the inside of the freezer is important to ensure that the food is frozen and maintained at the correct temperature at all times. The DS also stated, if the food is at the wrong temperature, the food could go bad and that is not good for the residents. During a concurrent observation and interview on 3/4/2024 at 9:20 a.m., with the DS, in the dry storage area, observed an opened package of cookies and an opened package of fruit punch mix that was not dated and not placed in a seal-proof container after opening. The DS stated that the cookies and the fruit punch mix should have been dated after opening and placed in a zip-lock bag or other type of sealed container. The DS stated, it is important to label food after it is opened so that you can be sure to know when the food needs to be thrown away. The DS also stated, old food can make a resident sick. During a review of the facility's policy and procedure (P&P) titled, Refrigerators and Freezers, dated November 2022, the P&P indicated, that the facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation and will observe food expiration guidelines. The P&P also indicated that the supervisor is responsible for ensuring food is appropriately dated to ensure proper rotation by expiration dates and that use by dates are indicated once food is opened. During a review of the facility's P&P titled, Preventing Foodborne Illness - Food Handling, dated July 2014, the P&P indicated that food will be stored, prepared, handled and served so that the risk of food borne illness is minimized. During a review of the facility's P&P titled, Food Preparation and Service, dated November 2022, the P&P indicated that cross-contamination can occur when harmful substances are transferred to food by hands (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned. During a review of the facility's P&P titled, Sanitation, dated November 2022, the P&P indicated that garbage and refuse containers should be in good condition, without leaks.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During a review of Resident 102's admission Record, the admission record indicated Resident 102 was admitted to the facility on [DATE] with diagnoses including respiratory failure (a condition in which your body doesn't have enough oxygen), diabetes, muscle weakness( a lack of muscle strength),and renal disease( a condition in which kidneys stop working) dependent on renal dialysis ( a procedure to remove waste products and excess fluid from the blood when kidney stop working properly). During a review of Resident 102's MDS dated [DATE], the MDS indicated Resident 102 required substantial assistance from staff for bathing, and moderate assistance from staff for toileting, and personal hygiene. During a review of Resident 102's H&P dated 5/8/2023, the H&P indicated Resident 102 had the capacity to make needs known but cannot make medical decisions. During a review of Resident 102's Order Summary Report, dated 5/6/2023, the order summary report indicated active order Oxygen at 2 liter per minute (LPM) via nasal cannula as needed (PRN) for dyspnea on exertion (shortness of breath). During an observation on 3/4/2024 at 9:09 a.m., in Resident 102's room, observed Resident 102 lying in bed receiving supplemental oxygen via nasal cannula at a rate of 2 LPM. The nasal cannula was undated, and humidifier was dated 2/22/24. During a concurrent observation and interview on 3/4/2024 at 9:20 a.m., in Resident 102's room with LVN 5, LVN 5 was observed changing Resident 102's nasal cannula and humidifier. LVN 5 stated nasal cannula and humidifier must be changed weekly and should be dated. LVN 5 stated she doesn't know when nasal cannula was last time changed because nasal cannula was undated. LVN 5 also stated humidifier was dated 2/22/24, and it had been more than one week and should be changed right way. LVN 5 stated if nasal cannula was used for long time, this placed Resident 102 at risk for respiratory infection. 5. During a review of Resident 21's admission Record, the admission record indicated Resident 21 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including chronic obstructive pulmonary disease ([COPD] a group of diseases that cause airflow blockage and breathing-related problems), diabetes, muscle weakness, and hypertension. During a review of Resident 21's MDS dated [DATE], the MDS indicated Resident 21 was able to understand and understood others. The MDS also indicated Resident 21 was totally dependent from staff for toileting, bathing, and personal hygiene. During a review of Resident 21's Medication Administration Record (MAR) dated 1/15/2024, the MAR indicated oxygen at 2 liter per minute via nasal cannula as needed (PRN) for shortness of breath related to COPD. During an observation on 3/4/2024 at 4:10 p.m., in Resident 21's room, the supplemental oxygen humidifier, and nasal cannula at Resident 21's bedside were undated. During an interview on 3/6/2024 at 9:10 a.m., with IP, the IP stated residents on respiratory therapy, the licensed staff must assess nasal cannula, and humidifier daily. The IP stated nasal cannula, and humidifier should be changed weekly, every Sunday, and PRN, dated, and with resident room number. IP stated if nasal cannula are not changed weekly per facility P&P, it places residents at risk for infection. During an interview on 3/6/2024 at 10:30 a.m., with Director of Nursing (DON), the DON stated nasal cannula should be changed weekly, dated, and with resident room number. DON humidifier should be dated for staff to know when it was last changed. The DON stated following the facility's P&P on how to care for respiratory therapy equipment are important to protect residents from respiratory infection. During a review of the facility's P&P titled, Departmental (Respiratory Therapy) Prevention of Infection, dated November 2011, the P&P indicated that nasal cannula and tubing must be changed every seven days or as needed and nasal cannula must be kept in a plastic bag when not in use. 3. During a review of Resident 274's admission Record, dated 3/6/2024, the admission record indicated Resident 274 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus (DM2 - abnormal blood sugar levels), hyperlipidemia (an abnormally high concentration of fat particles in the blood), dementia (a loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), schizophrenia (a severe mental illness that causes disturbed or unusual thinking, loss of interest in life, and strong or inappropriate emotions), hypertension (high blood pressure), atherosclerosis (blockage of blood supply to the heart muscle due to buildup of plaque in the arteries), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). During a review of Resident 274's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 2/23/2024, the MDS indicated Resident 274 had severe cognitive impairment (ability to understand and make decision). The MDS also indicated Resident 274 required supervision with eating and substantial assistance with toileting and bathing. During a review of Resident 274's History and Physical (H&P), dated 2/20/2024, the H&P indicated Resident 274 had fluctuating capacity to understand and make decision and reason due to dementia. During a review of Resident 274's Order Summary Report, dated 2/19/2024, the order summary report indicated an active order to give oxygen at 2 liters per minute continuously via nasal cannula for the diagnosis of desaturation (low levels of oxygen in the blood). During a review of Resident 274's Order Summary Report, dated 2/19/2024, the order summary report indicated an active order to change oxygen nasal cannula every week on Friday and as needed. During a review of Resident 274's undated care plan titled Oxygen Therapy, the care plan indicated Resident 274 would have no signs and symptoms of poor oxygen absorption. One of the interventions included to change oxygen nasal cannula every Friday and as needed. During an observation on 3/4/2024 at 3:42 p.m., in Resident 274's room, observed Resident 274 sitting on the edge of the bed without oxygen. Resident 274's nasal cannula was observed on the floor next to her bed with oxygen running at 2 liters per minute. During a concurrent observation and interview with on 3/4/2024 at 3:48 p.m., with Restorative Nurse Aide (RNA) 3, while in Resident 274's room, RNA 3 stated that she also worked as a Certified Nursing Assistant (CNA) at the facility. RNA 3 observed Resident 274's nasal cannula lying on the floor. RNA 3 stated that the oxygen should be on the resident and not on the floor. RNA 3 stated, This is an infection control issue. She can get some type of infection from the oxygen tubing on the floor. RNA 3 stated that she would make sure the nasal cannula is changed and placed on Resident 274 right away. During an interview on 3/6/2024 at 9:45 a.m., with Licensed Vocational Nurse (LVN) 6, LVN 6 stated that Resident 274 is on continuous oxygen because she has a diagnosis of desaturation (low oxygen amount in the system). LVN 6 stated that the nasal cannula being on the dirty floor is an infection control issue and Resident 274 could catch (infect) whatever is on the floor if the nasal cannula is placed back on the resident. During an interview on 3/6/2024 at 10:14 a.m., with the IPN, the IPN stated that Resident 274's nasal cannula lying on the floor could have introduced germs and organisms to the resident and caused the resident to deteriorate which could lead to hospitalization. During an interview on 3/6/2024 at 10:20 a.m., with Respiratory Therapist (RT) 1, RT I stated that Resident 274's nasal cannula was dirty if it had fallen on the floor and must be replaced. During an interview on 3/6/2024 at 3:41 p.m., with the Director of Nursing (DON), the DON stated that if the nasal cannula was on the floor, it must be changed, because it could potentially cause an infection. Based on observation, interview, and record review, the facility failed to ensure infection prevention and control program, were maintained by failing to ensure: 1. Facility staff's personal and opened beverage containers were not stored on areas designated for clean resident clothing items; soiled linens and supplies were not stored in a handwashing sink in the laundry room and not placed on top of a storage cart containing personal protective equipment ([PPE] protective garments or equipment designed to protect the wearer's body from infection) in the laundry room. 2. Treatment Nurse (TN) 2 failed to follow facility policy and procedure for transmission-based precautions (TBP, precautions initiated when someone is at risk of spreading an infection to others) while providing care for Resident 15, who was on contact isolation precautions (intended to prevent the transmission of infectious agents from spreading from person to person). 3. Nursing staff stored Resident 274's nasal cannula (tube that provides oxygen through the nose) per facility policy and procedure. 4. Nursing staff changed Resident 102's, and 21's oxygen nasal cannula tubing , and humidifier (plastic bottle that infuses the normal flow of oxygen with water), and dated as indicated in the facility's policy and procedure (P&P). These deficient practices had the potential to cause the avoidable spread of harmful pathogens (bacteria, viruses, or other microorganisms that can cause disease) and infection to facility residents and staff. Findings: 1. During a concurrent observation and interview, on 3/7/2024 at 3:24 p.m., with the Housekeeping Supervisor (HS), in the soiled laundry room, the handwashing sink was observed full of plastic bags. The contents of the plastic bags were not readily identifiable. There were opened box of disposable gloves sitting on top of the plastic bags. The HS stated one plastic bag contained a dirty tablecloth that had been used in the dining room during lunch, and the other plastic bag contained unused incontinence briefs. The HS stated she did not know where the incontinence briefs were from and did not know if they had been in a resident's room. The HS removed the bag of unused diapers and the box of opened gloves from the sink, then placed them on top of the PPE cart. The HS stated there should not be dirty linens, or any other items, stored in the handwashing sink because staff would not be able to wash their hands. The HS stated it was an infection control risk. During a concurrent observation and interview, on 3/7/2024 at 3:34 p.m., with the HS, in the folding and sorting area of the laundry room, observed two opened water bottles on top of a storage container filled with clean linens and supplies intended for facility resident use. The HS stated the water bottled belonged to staff, and stated staff were not supposed to store their personal items in areas with supplies and linens intended for residents. The HS stated it could lead to cross contamination and potential spread of infection. During an interview on 3/7/2024 at 4:21 p.m., with the Infection Preventionist Nurse (IPN), the IPN stated staff were supposed to store their personal belongings in the employee lockers in the break room. The IPN stated staff's personal belongings should not be stored in the laundry area, the belongings might be contaminated and could be an infection control risk. The IPN also stated there should not be items, clean or dirty, stored in the handwashing sink. The IPN also stated that contaminated items should not be touching the PPE cart or its contents. The IPN stated it was also an infection control risk. During a review of the facility 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, and further indicated all used laundry is potentially contaminated and indicated. During a review of the facility P&P titled Employee Lockers, dated 1/2008, the P&P indicated our facility provides a locker for each employee, at no cost to the employee, for safekeeping his/her personal effects. 2. During a review of Resident 15's admission Record, the admission record indicated the facility admitted Resident 15 on 5/17/2018, and was re-admitted on [DATE]. Resident 15's admitting diagnoses included a Stage IV (4) pressure ulcer (a wound caused by prolonged pressure to the skin that penetrates through to the bone) to the sacral region (area above the tailbone) contact with and suspected exposure to other viral communicable diseases (diseases that spread from one person or animal to another, or from a surface to a person). During a review of Resident 15's physician orders, dated 12/6/2023, the physician orders indicated Resident 15 required contact isolation precautions (used for patients with diseases caused by bacteria and/or viruses that are spread through direct and indirect contact) due to New Delhi [NAME] beta lactamase-1 (a type of bacteria resistant to different medications used to treat infections). During an observation on 3/6/2024 at 8:48 a.m., outside of Resident 15's room, observed a sign posted indicating staff to follow contact isolation precautions. Observed TN 2 entered Resident 15's room without performing hand hygiene prior to entering, and without donning a disposable protective gown. TN 2 then exited the room and did not perform hand hygiene prior to or upon exiting Resident 15's room. TN 2 then pulled Resident 15's bedside table into the doorway of the room with bare hands. TN 2 did not perform hand hygiene after touching the bedside table. TN 2 then opened the treatment cart (cart with stored wound care supplies) and put on a pair of gloves, without performing hand hygiene. TN 2 then wiped the table with a disinfectant wipe, removed and discarded the gloves, then prepared Resident 15's wound care supplies. During an interview on 3/6/2024 at 8:53 a.m., with TN 2, outside of Resident 15's room, TN 2 stated Resident 15 was on contact isolation precautions and stated staff were required to perform hand hygiene, wear a disposable gown and apply gloves prior to entering the room and touching anything in the environment. TN 2 stated he did not perform proper contact isolation precautions when he entered and exited Resident 15's room. TN 2 stated that not implementing contact isolation precautions created the potential to spread infection to other facility residents and staff. During an interview on 3/6/2024 at 10:18 a.m., with the IPN, the IPN stated staff needed to perform hand hygiene, and then wear a gown and gloves prior to entering Resident 15's room for any reason. The IPN stated that before coming out of the room, the gown and gloves should be removed and disposed of in the room, and staff should perform hand hygiene. The IPN stated that if staff are not adhering to infection prevention policies, and contact isolation precaution requirements, there was the potential to spread the infection to other residents or staff. During a review of the P&P titled Isolation - Categories of Transmission Based Precautions, dated 9/2022, the P&P indicated contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. The P&P further indicated: a. Staff .wear gloves .when entering the room and gloves are removed and hand hygiene performed before leaving the room. b. Staff .wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces

CONCERN (E)

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

Room Equipment (Tag F0908)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Based on observation, interview and record review, the facility failed to ensure the walk-in freezer was maintained in good working condition. This deficient practice had the potential to cause foodborne illnesses and affect the quality of food for all 124 residents in the facility. Findings: During a concurrent observation and interview on 3/4/2024 at 9:15 a.m., with the Dietary Supervisor (DS), while in the kitchen, the walk-in freezer was observed. The walk-in freezer had large frozen clumps of ice that had accumulated on the floor as well as large clumps of ice surrounding the pipes inside the freezer. The walk-freezer also had drips came from the ceiling that were frozen. The DS stated that the clumps of ice located on the floor accumulated around the pipes were not normal. The DS stated that an outside company needed to be called to clean the freezer. During a concurrent observation and interview on 3/6/2024 at 1:20 p.m., with the Housekeeping Supervisor (HS), while in the kitchen, the HS observed the ice chunks accumulated on the floor and surrounding the pipes in the freezer. The HS stated that she was the Director of Maintenance (DM) in the facility for 25 years before she became the housekeeping supervisor. The HS stated that there may be a broken pipe or the fan in the freezer may be broken. The HS stated that it was important to make sure the freezer was working properly. The HS stated that the freezer could create bacteria which the residents coul eat and cause potential illness if the freezer was not working properly. During a concurrent observation and interview on 3/6/2024 at 1:32 p.m., with the Director of Maintenance (DM) and Housekeeping Supervisor (HS), while in the kitchen, observed the ice accumulation on the freezer floor and surrounding the pipes. The DM stated that the ice buildup is due to something not working correctly in the freezer. The DM stated he was not aware of the freezer ice. The DM stated that he performed routine maintenance checks on the freezer every month but did not see this during his last maintenance check. The DM also stated that he relied on the kitchen staff to inform him of any problems in the kitchen when they occur. The DM stated that the kitchen staff should have notified the maintenance department immediately when they noticed the ice building up in the freezer. During an interview on 3/6/2024 at 1:51 p.m., with the Administrator (ADM), the ADM stated that the kitchen's freezer not working properly could be a potential problem. The ADM stated that the freezer problem should have been reported to the maintenance department immediately so that it could have been repaired. During a review of the facility's Invoice Number INV029 from JPM, dated 3/6/2024, the invoice indicated a problem with the gaskets were found after inspection of the freezer room. During a review of the facility's policy and procedure (P&P) titled, Refrigerators and Freezers, dated 2001 and revised November 2022, the P&P indicated, that the facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation and will observe food expiration guidelines. The P&P also indicated that the supervisor will insect refrigerators and freezers monthly for gasket condition, fan condition, presence of rust, excess condensation, and any other damage or maintenance needs. The P&P indicated that necessary repairs are initiated immediately and maintenance schedules are followed per manufacturer guidelines.

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the policy and procedure titled, Certified Nurse Assistant (CNA) that indicated CNA will relay all pertinent information concerning a resident ' s condition to a charge nurse when required, was followed, when 1 of 3 sampled residents (Resident 1), had a fall. This failure resulted in a delayed body assessment to Resident 1. Findings: During a concurrent interview and record review on 1/26/2024 at 2:55 p.m., with the Assistant Director of Nursing (ADON), the ADON stated a Certified Nursing Assistant (CNA 1) put Resident 1 back in bed without informing the charge nurse that Resident 1 had a fall. The ADON stated CNA 1 should not have moved Resident 1, not until the charge nurse can do an assessment of his body and injuries. The ADON stated CNA 1 was suspended pending the facility ' s investigation. During a review of Resident 1 ' s admission record, dated 1/24/2024, indicated Resident 1 was admitted to the facility on [DATE], with diagnosis of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), major depressive disorder (is a mood disorder that causes a persistent feeling of sadness and loss of interest), and abnormalities of gait and mobility. During a review of Resident 1 ' s Minimum Data Set (MDS-an assessment and care planning tool) dated 1/4/2024, indicated Resident 1 had clear speech, the ability to express ideas and wants and understands. The MDS indicated Resident 1 required moderate assistance (helper does more than half the effort) with sit to lying (the ability to move from sitting on the side of the bed to lying flat on the bed) and sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed) and sit to stand (the ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed. During a record review of Resident 1 ' s Change of Condition (COC) Evaluation, dated 1/6/2024 at 23:55 p.m., the COC indicated Resident 1 stated he had a fall and pain in his right upper arm pain when touched. The charge nurse indicated nobody reported the fall and had no witnesses. During a record review of Resident 1 ' s Progress Notes, dated 1/7/2024 at 12:45 a.m., the progress notes indicated the charge nurse reported to the physician Resident 1 had right upper arm pain 10/10 (severe pain) after a fall around dinner time, and nobody reported the fall. The progress notes indicated Resident 1 has difficulty of movement of the right arm. During a record review of Resident 1 ' s x-ray (a form of electromagnetic radiation, similar to visible light) result of right shoulder 2 views, dated 1/8/2023, indicated Resident had osteoporosis (a condition in which there is a decrease in the amount and thickness of bone tissue) with nondisplaced fracture (broken bone) of the neck of the right humerus (upper arm bone). During a review of Resident 1 ' s physician order dated 1/8/2024, the physician order indicated to transfer Resident 1 to the general acute care hospital related to claim of fall and complaint of unable to move right shoulder. During a record review of CNA 1 ' s Counseling/Disciplinary Notice, dated 1/8/2024, indicated the reason for counseling/disciplinary action was necessary because of non-reporting of fall incident. During a review of Resident 1 ' s care plan with focus on being at risk for falls related to limited mobility, gait/balance problems, and unaware of safety needs, dated 1/3/2024, the care plan goal indicated Resident 1 will not sustain serious injury. The care plan nursing interventions included to anticipate and meet Resident 1 ' s needs, place bilateral floor mats for safety precautions, and ensure Resident 1 is wearing appropriate footwear when ambulating or mobilized in wheelchair. During a review of the facility ' s undated policy and procedure (P&P) titled Certified Nurse Assistant, the P&P indicated Certified Nurse Assistant will relay all pertinent information concerning a resident ' s condition to a charge nurse when required. During a review of the facility ' s undated P&P titled Falls-Clinical Protocol, the P&P indicated staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the event, etc. Falls should be identified as witnessed or unwitnessed events.

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to elevate head of bed at 30 to 45 degrees during tube feeding (nutrition administered via tube surgically inserted into the stomach) as indicated in the physician ' s order and care plan interventions for 1 of 3 sampled residents, Resident 2. This failure had the potential to result in aspiration (when food or liquid is breathed into the airways or lungs, instead of being swallowed), difficulty breathing and death. Findings: During a concurrent observation and interview on 1/24/2024 at 12 noon with Licensed Vocational Nurse (LVN 1), at Resident 2 ' s bedside, Resident 2 was observed lying in bed receiving the g-tube feeding infusing at a rate of 55 cc (cubic centimeter) an hour with the head of the bed elevated 10 degrees. LVN 1 stated the head of the bed is low and Resident 2 may aspirate (the drawing in of a foreign substance into the lungs). During a review of Resident 2 ' s admission record, dated 1/24/2024, the admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnosis of acute respiratory failure (often caused by a disease or injury that affects your breathing, such as pneumonia, opioid overdose, stroke, or a lung or spinal cord injury), sepsis (the body's extreme response to an infection), and paraplegic (the inability to voluntarily move the lower parts of the body). During a review of Resident 2 ' s Minimum Data Set (MDS-an assessment and care planning tool), dated 1/24/2024, the MDS indicated Resident 2 had unclear speech, sometimes understood, and responds adequately to simple, direct communication only and was dependent with sitting to lying and lying to sitting position. During a review of Resident 2 ' s Order Summary Report, dated 1/24/2024, the order summary report indicated enteral (nutrition delivered using the gut) feed order to administer Isosource (tube feeding formula) 1.5 kilocalorie (kcal) at a rate of 55/ cubic centimeter (cc) an hour, to elevate head of bed 30 to 45 degrees during feeding, check placement of feeding tube, and when pulled or clogged, call medical doctor. A review of Resident 2 ' s untitled and undated care plan, indicated a goal for Resident 2 to remain free of aspiration through next review date. The interventions included to elevate the head of the bed to 45 degrees during feeding and thirty minutes after tube feed, check residual (remaining after most of something has gone) prior to each feeding. During a review of the facility ' s undated policy and procedure (P&P) titled, Enteral Nutrition, the P&P indicated a risk of aspiration is assessed by the nurse and provider and address in the individual care plan. Risk of aspiration may be affected by diminished level of consciousness, moderate to severe swallowing difficulties, improper positioning of the resident during feeding, and failure to confirm placement of the feeding tube prior to initiating the feeding.

Jan 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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement its infection control policy and procedures (P&P) by failing to: a. Ensure staff properly wore Personal Protective Equipment ([PPE] specialized clothing or equipment such as a gown, respirator, surgical mask and faceshield worn to minimize exposure to serious illness) while in the facility. b. Ensure staff performed hand hygiene after exiting one of one resident ' s room (Resident 4) who was on Enhanced Standard Precautions ([ESP] an infection control measure designed to reduce the spread of multidrug resistant organisms ([MDRO] bacteria that are resistant to certain antibiotics). These failures had the potential to spread the Coronavirus ([Covid 19] a highly contagious respiratory infection caused by a virus that could easily spread from person to person) and infections to residents, staff, and the community. Findings: a.During a concurrent observation and interview on 1/8/2024 at 12:15 p.m. with Certified Nursing Assistant (CNA 1) in the hallway, CNA 1 was observed wearing a surgical mask below her nose. CNA 1 stated she was provided education to wear a surgical mask and failure to wear the surgical mask properly may lead to her contracting COVID-19 and becoming sick. During a concurrent observation and interview on 1/8/2024 at 12:20 p.m. with Licensed Vocational nurse (LVN 1) in the hallway, LVN 1 was observed wearing a surgical mask below her nose. LVN 1 stated not properly wearing her surgical mask may lead to her and others becoming sick. b.During a review of Resident 4 ' s admission Record (Facesheet), the Facesheet indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including respiratory failure with hypoxia (not having enough oxygen to the body), sepsis (life threatening complication of an infection), and pneumonia (an infection that inflames the air sacs in the lungs). During a review of Resident 4 ' s Minimum Data Set ([MDS] an assessment and care planning tool) dated, 11/23/2023, the MDS indicated Resident 4 had severely impaired cognitive (thought process) skills for daily decision making. The MDS also indicated Resident 4 was dependent on staff for dressing, showering/bath, and personal hygiene. During an observation on 1/8/2024 at 1:10 p.m. Resident 4 was on ESP. Licensed Vocational Nurse (LVN 2) was observed coming out of the bathroom in Resident 4 ' s room with a pitcher of water and placed it on the resident ' s bedside table. LVN 4 proceeded to walk out of Resident 4 ' s room without performing hand hygiene. During a review of Resident 4 ' s undated care plan focusing on the resident ' s Enhanced Standard Precautions due to ventilator dependent (trach), gastrostomy tube feeding (a tube inserted through the belly that brings nutrition directly to the stomach) dependence and a history of methicillin-resistant Staphylococcus aureus ([MRSA] infection caused by a type of staph bacteria that's become resistant to many of the antibiotics used). The care plan indicated nursing interventions included to clean hands before and when leaving the room and use enhanced standard precautions, proper use of personal protective equipment, and hand hygiene. During a review of the facility ' s P&P titled, COVID-19 Mitigation Plan Manual, dated 1/4/2023, the P&P indicated all staff will wear recommended PPE while in the building per CDPH PPE guidance. The P&P also indicated all staff will wear a facemask while in the facility for source control. During a review of the facility ' s undated P&P titled, Handwashing/Hand Hygiene, the P&P indicated the facility considers hand hygiene the primary means to prevent the spread of infections. All person shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol: or alternatively, soap and water for the following situations; after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident, after removing gloves and before and after entering isolation precaution settings

Nov 2023 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

Deficiency F0687 (Tag F0687)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two of three sampled residents (Resident 2 and Resident 4) who had long rough edges toenails received foot care and treatment according to the facility's policy and procedure (P&P). This deficient practice placed Residents 2 and 4 at risk for infection of the toenails, pain and injury. Findings: a. During a review of Resident 2's admission Record (Face Sheet), the admission Record indicated Resident 2 was admitted on [DATE], and re-admitted on [DATE] with a diagnoses including respiratory failure with hypoxia (respiratory system cannot adequately provide oxygen to the body), diabetes ([DM] high blood sugar), and muscle weakness (lack of exercise, aging, muscle injury) During a review of Resident 2's Care Plan for ADL self-Care performance Deficit dated 7/31/2023, the Care Plan indicated Resident 2 Interventions indicated to check nail length and trim and clean on bath day as necessary. The Care Plan also indicated to report any changes to the nurse. During a review of Resident 2's Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 9/18/2023, the MDS indicated Resident 2's cognitive skills (thought process) was severely impaired, and the resident rarely/never understood nor could be understood by others. The MDS indicated Resident 2 required total assistance from staff with activities of daily living (ADL) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). During a review of Resident 2's History and Physical (H&P) dated 10/17/2023, the H&P indicated Resident 2 did not have the capacity to understand and make medical decisions. During a review of Resident 2's physician orders dated 10/17/2023, the physician orders indicated Resident 2 had an order for Podiatry (medical specialist who help with care and treatment that affect the feet or lower legs) consult and treatment as needed. During a review of Resident 2' Convalescent Podiatry care sheet dated 10/17/2023, the convalescent podiatry care indicated Resident 2 was at the hospital at the time of doctors visit and did not receive podiatry care. During an observation on 11/9/2023 at 9:30 a.m., in Resident 2's room, Resident 2 was observed with long toenails with rough edges on both feet. During an interview on 11/9/2023 at 11:03 a.m. with Certified Nursing Assistance (CNA 1), CNA 1 stated she saw Resident 2's long toenails yesterday and had not notified anyone. b. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including respiratory failure with hypoxia, Myasthenia Gravis (a disorder in which antibodies destroy the communication between nerves and muscle, resulting in weakness of the skeletal muscles), and muscle weakness. During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4's cognitive skills was intact and was capable of understanding and be understood by others. The MDS indicated Resident 4 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with ADLs such as dressing, toilet use, personal hygiene, transfer, and bed mobility. During a review of Resident 4's H&P dated 10/18/2023, the H&P indicated Resident 4 had the capacity to understand and make medical decisions. During a review of Resident 4' Convalescent Podiatry care sheet dated 10/17/2023, the convalescent podiatry care indicated Resident 4 was not on the list for care. During a review of Resident 4's Care Plan for ADL Self-Care performance Deficit dated 10/18/2023, the Care Plan indicated Resident 4 Interventions indicated to check nail length, trim and clean on bath day as necessary. The Care Plan also indicated to report any changes to the nurse. During an observation on 11/9/2023 at 11:30 a.m., in Resident 4's room, Resident 4 was observed with long toenails with rough edges on both feet. During an interview on 11/9/2023 at 12:30p.m., with CNA 3 stated, the skin and nails needed to be assessed during resident's showers. CNA 3 stated, if toenails were long, the CNAs needed to report to the charge nurses, and the podiatrist would come and clip the toenails. CNA 3 also stated, Resident 4 had long toenails and had not notified anyone about it. During a concurrent interview and record review on 11/9/2023 at 2:50 p.m., with Social Services (SS), the SS Podiatry Care Binder was reviewed. SS stated the Podiatrist came to see the residents every two months and the last visit to the facility was on 10/2023. SS stated, Resident 2 and Resident 4 were last seen for toenail/podiatry services was on 8/8/2023. SS also stated, it was not acceptable for Resident 2 and Resident 4 to not have care and services to address their long toenails for three months. During an interview on 11/9/2023 at 3:10 p.m., with Registered Nurse (RN), RN stated, CNAs needed to assess residents for long toenails while residents received daily care and would report to the Treatment Nurse, Supervisor and Social Services for follow-up. RN stated, it was important to have toenails trimmed to prevent infection, keep resident comfortable and maintain the resident's personal hygiene. During an interview on 11/9/2023 at 3:30 p.m., with Director of Nursing (DON), DON stated, it was important to ensure toenail care was provided to prevent infection and bacteria growth inside the nails and cause fungal infection. During a review of the facility's undated P&P titled, Foot Care , the P&P indicated Residents were provided with foot care and treatment in accordance with professional standards of practice. The P&P indicated resident were assisted in making appointments and with transportation to and from specialist (podiatrist) as needed. The P&P also indicated trained staff may provide routine foot care (e.g., toenails clipping) within professional standards for residents without complicating disease process and residents with foot disorders

Oct 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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two of 4 sampled residents (Resident 2 and Resident 3) gastrostomy tube ([GT] tube placed directly into the stomach to give direct access for supplemental feeding, hydration, or medicine) feeding formula was labeled with the date and time according to the facility ' s policy and procedure (P&P). This deficient practice had the potential to result in Residents 2 and 3 receiving enteral tube feeding formula over the expiration or maximum formula hang time (how long a tube feeding formula should hang safely prior to discarding or changing) and could adversely affect the resident ' s health and wellbeing. Findings: During a review of Resident 2 ' s admission record (Facesheet), the admission record indicated Resident 2 was admitted on [DATE], and re-admitted on [DATE] with diagnoses including Dependence on Respirator ([ventilator] a machine that helps a resident breathe or breathes for the resident), Amyotrophic Lateral Sclerosis (neurological disorder that affects motor neurons, the nerve cells in the brain and spinal cord that control voluntary muscle movement and breathing), and encounter for attention to Gastrostomy (artificial opening to stomach). During a review of Resident 2 ' s History and Physical (H&P) dated 2/27/2023, the H&P indicated Resident 2 had the mental capacity to understand and make medical decisions. During a review of Resident 2 ' s Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 7/5/2023, the MDS indicated Resident 2 ' s cognitive skills (thought process) was intact and could understand and be understood by others. The MDS indicated Resident 2 was totally dependent on staff with activities of daily living (ADL) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). During a review of Resident 2 ' s physician orders dated 10/17/2023, the physician orders indicated Resident 2 had an order for enteral [GT] feeding of Diabetic source AC @65ml/hr. (milliliter/hour) x 20 hours to provide 1300 ml/ 1560 Kcal (kilocalories) or until dose was met. During a review of Resident 3 ' s admission record, the admission record indicated Resident 3 was admitted on [DATE] and re-admitted on [DATE] with diagnoses including Dependence on Respirator status, chronic respiratory failure with hypoxia (Low blood oxygen levels), and encounter for attention to Gastrostomy. During a review of Resident 3 ' s H&P dated 9/24/2023, the H&P indicated Resident 3 did not have the mental capacity to understand and make medical decisions. During a review of Resident 3 ' s MDS dated [DATE], the MDS indicated Resident 3 was totally dependent on staff for ADL ' s such as dressing, toilet use, personal hygiene, transfer and bed mobility. During a review of Resident 3 ' s physician orders dated 8/22/2023, the physician orders indicated Resident 3 had an order for enteral feeding of Diabetic source AC @65ml//hour x 20 hours to provide 1300 ml/ 1560 Kcal or until dose was met. During a concurrent observations and interviews on 10/16/2023 at 1:42 p.m. with LVN 1, Residents 2 and 3 were observed with GT feeding formula Diabetic source AC 1.2 @ 65ml/hr. labelled with dates of 10/15/2023 and no hanging time on the label. LVN 1 stated, she did not check for the date and time on the formula when she came in the morning. During a subsequent interview on 10/17/2023 at 12:20 p.m. with LVN 1, LVN 1 stated, nurses must label the feeding formula with the date, and time when the formula was hung. LVN 1 also stated, labeling the formula correctly was one of the P&P of taking care of residents with GT feeding. During an interview on 10/17/2023 at 12:32 p.m. with Registered Nurses (RN) 1, RN 1 stated it was important for the nurses to put the date and time when the GT feeding was hung, so the nurses would know when the feeding needed to be changed. RN 1 also stated, by not putting the date or time on the label, it placed Resident 2 and Resident 3 at risk of not receiving the renewed feeding formula and could lead to abdominal complications. During a review of the facility ' s undated P&P titled, Enteral Feedings – Safety precautions, the P&P indicated preventing errors in administration included checking the enteral nutrition label against the order before administration and to check the date and time the formula was prepared. The P&P also indicated, on the formula label document initials, date, and time the formula was hung, and initial that the label was checked against the order.

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

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure expired gastrostomy tube ([GT] tube placed directly into the stomach to give direct access for supplemental feeding, hydration, or medicine) feeding formula was discarded according to the facility policy and procedure (P&P) and not kept in the facility storage room. This deficient practice had the potential to result in the residents ingesting expired feeding formula which could lead to symptoms such as nausea, vomiting, stomach cramps, diarrhea, and hospitalization. Findings: During a concurrent observation and interview on [DATE] at 2:20 p.m., with Maintenance Supervisor (MS), MS stated, there were 4 bottles and one closed box with Jevity 1.2 Cal (high-protein, fiber-fortified formula that provided complete, balanced nutrition for long- or short-term tube feeding) GT feeding formula with expiration dates of [DATE]. MS stated, it was very dangerous to keep the expired feeding formula without an alert, because nurses could administer the expired formulas to the residents. During an interview on [DATE] at 12:32 p.m., with Registered Nurse (RN) 1, RN 1 stated, expired GT feeding formulas should be removed from the storage room, so nurses do not grab the formula and administer them to residents. RN 1 stated, if expired feeding formulas were administered to residents it could lead to the residents developing abdominal discomfort, diarrhea, vomiting, nausea and could become sicker. During an interview on [DATE] at 1:30 p.m., with the Director of Nursing (DON), DON stated, expired feeding formulas needed to be removed from the storage room. DON also stated, if by accident expired formulas were given to the residents, residents could require hospitalization for abdominal complications. During a review of the facility ' s undated policy and procedure (P&P) titled Enteral Feedings – Safety precautions, the P&P indicated general guidelines for preventing contamination included maintaining strict adherence to storage conditions and timeframes and maintaining inventory controls and to discard any formula past the expiration date.

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview and record review, the facility failed to follow the All Facilities Letter 23-08 ([AFL]-A letter to licensed facilities containing new updates, enforcements, or general information) in the reporting of 54 new COVID-19 (a contagious respiratory virus caused by SARS-CoV-2) positive cases of infected residents and 31 COVID-19 positive cases of infected staff to the respective district office (DO). This deficient practice had the potential to further spread COVID-19 to non-infected residents and staff and resulted in a delay in the investigation for infection control. Findings: During an interview on 7/20/2023 at 2:50 p.m. with the Infection Prevention (IP) nurse, the IP nurse stated the first COVID-19 positive case was on 7/12/2023 and the facility reported the positive case to the local public health officer but did not report the case to the DO. The IP nurse stated she was not aware of the AFL 23-08 and the new changes that required that COVID-19 outbreaks had to be reported to both the DO and the local public health officer. The IP nurse stated that as of today 7/20/2023, there was a total of 54 confirmed COVID-19 positive residents and 31 confirmed COVID-19 positive staff. During an interview on 7/20/2023 at 3:00 p.m. with the Director of Nursing (DON), the DON stated the COVID-19 outbreak was not reported to the DO because they were not aware of the new changes that were indicated on the AFL 23-08. The DON stated there were a lot of AFLs that were continuously being sent out to the facilities and it was a challenge to keep up with all the AFLs and the changes that were being implemented. During a review of the facility's undated COVID-19 Mitigation Plan ([MP]-policy developed by the facility to mitigate COVID-19 outbreaks in the facility), the MP indicated that facilities were required to report COVID-19 outbreaks to the local public health and the California Department of Public Health (CDPH) within 24 hours. During a review of the AFL 23-08, titled Requirement to Report Outbreaks and Unusual Infectious Disease Occurrences , dated 1/18/2023, the AFL 23-08 indicated health facilities licensed by the CDPH Licensing and Certification (L&C) are required to report outbreaks and unusual infectious disease occurrences to the local public health and their respective DO. The AFL 23-08 indicated that a facility outbreak of COVID-19 was an example of a reportable incident.

May 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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of the infectious diseases by: a) Failing to ensure Licensed vocational nurse 2 (LVN 2) disinfected the blood pressure (BP) machine (machine that measures the blood pressure [force it takes for heart to pump blood in the body]) after using it with Resident 3 and before using it with Resident 2. b) Failing to ensure Certified Nurse Assistant 1 (CNA 1) used hand hygiene prior to entering Resident 3's room. These deficient practices placed residents , staff, and the community at higher risk spread of infection. Findings: a. During a record review of Resident 3's admission Record (AR) dated 5/12/2023, the AR indicated Resident 3 was admitted to the facility on [DATE] with the diagnoses including acute and chronic respiratory failure (disease or injury that affects breathing) and the AR indicated the resident had a gastrostomy tube ([GT]tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications). During a review of Resident 3 ' s Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 4/28/2023, the MDS indicated Resident 3 ' s cognitive skills for daily decisions making was severely impaired. The MDS also indicated that Resident 3 was totally dependent on staff for all activities of daily living ([ADLs] activities related to personal care). During a record review of Resident 2's admission Record (AR) dated 5/12/2023, the AR indicated Resident 2 was initially admitted to the facility on [DATE] with the diagnoses including acute and chronic respiratory failure, quadriplegia (paralysis [inability to move] of all 4 limbs), and muscle weakness. During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 ' s cognitive skills for daily decisions making was severely impaired. The MDS also indicated that Resident 2 was totally dependent on staff for all ADLs. During an observation on 5/12/2023 at 8:25 a.m. LVN 2 was observed using the blood pressure machine on Resident 3 without disinfecting the BP machine before and after the procedure. During an observation on 5/12/2023 at 8:38 a.m. LVN 2 was observed using the BP machine without disinfecting the machine before using it on Resident 2. During an interview with LVN 2 on 5/12/2023 at 11:00 a.m., LVN 2 stated she did not disinfect the BP machine before and after use with Resident 2 and 3. LVN 2 stated that at the time of the procedure she ran out of disinfectant wipes. LVN 2 stated she should have used the wipes because that ' s facility process and it helps prevent the spread of infection. During a record review of the facility's policy and procedure (P&P) titled, Policies and Practices-Infection Control, (revised 10/2018), the P&P indicated the P&P was intended to facilitate maintaining a safe and sanitary environment to help prevent and manage transmission of diseases and infections. The P&P indicated there would be guidelines for the safe cleaning and reprocessing of reusable resident-care equipment. During a record review of the facility's P&P titled, Cleaning and Disinfection of Resident-Care Items and Equipment, (revised 10/2018), the P&P indicated resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current Centers for Disease Control and Prevention (CDC) recommendations for disinfection. Non-critical items are those that come in contact with intact skin but not mucous membranes including blood pressure cuffs. The P&P indicated most non-critical reusable items can be decontaminated where they are used (as opposed to being transported to a central processing location).Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident.

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure three of eleven sampled residents' (Resident 5,4, and 7) head of bed (HOB) was elevated at or greater than 30 degrees while on continuous tube feedings (uninterrupted administration of enteral formula [delivery of nutrients through a feeding tube directly into the stomach or intestines]) as indicated in the facility's policy and procedure (P&P). These deficient practices have the potential to result in aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident) which can cause serious health issues. Findings: a) During a record review of Resident 5's admission Record (AR) dated 5/12/2023, the AR indicated Resident 5 was admitted to the facility on [DATE] with the diagnoses including acute respiratory failure (disease or injury that affects breathing) and the AR indicated the resident had a gastrostomy tube ([GT]tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications). During a review of Resident 5's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 4/17/2023, the MDS indicated Resident 5's cognitive skills for daily decisions making was severely impaired. The MDS also indicated that Resident 5 was totally dependent on staff for all activities of daily living ([ADLs] activities related to personal care) During a record review of Resident 5's Physician Orders as of 5/12/2023, the orders indicated the following Enteral feed orders: 1. Starting on 11/9/2022, elevate head of bed 30 to 45 degrees during feeding 2. Starting on 5/6/2023, administer Nutrient 2.0 (tube feeding formula) via GT, for a total of 1,000 cubic centimeters (cc)/ kilocalories (Kcal) at a rate of 50 cc per hour for 20 hours or until dose is met. During a record review of Resident 5's care plan titled, Resident requires tube feeding related to dysphagia (swallowing problem) initiated 1/1/2022, the care plan goal indicated Resident 5 will be free from aspiration. The care plan intervention indicated to elevate head of bed 30 to 45 degrees during feeding. During a record review of Resident 4's AR dated 5/12/2023, the AR indicated Resident 4 was admitted to the facility on [DATE] with the diagnoses including acute respiratory failure. During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decisions making was severely impaired. The MDS also indicated that Resident 4 was totally dependent on staff for all ADLs. During a record review of Resident 4's Physician Orders as of 5/12/2023, the orders indicated the following Enteral feed orders: 1. Starting on 9/23/2020, elevated head of bed 30 to 45 degrees during feeding. 2. Starting on 3/15/2023, administer Diabetisource Advanced Control 1.2 (tube feeding formula) via GT, for a total of 1100 cc/ 1320 kcal at a rate of 55 cc per hour for 20 hours or until dose is met. During a record review of Resident 4's care plan titled, Resident requires tube feeding related to dysphagia initiated 5/17/2018, the care plan goal indicated Resident 4 will be free from aspiration. The care plan intervention indicated to elevate head of bed 30 to 45 degrees during feeding. During a record review of Resident 7's AR dated 5/12/2023, the AR indicated Resident 7 was admitted to the facility on [DATE] with the diagnoses including acute respiratory failure and the AR indicated the resident had a gastrostomy tube. During a review of Resident 7's MDS, dated [DATE], the MDS indicated Resident 7's cognitive skills for daily decisions making was severely impaired. The MDS also indicated that Resident 7 was totally dependent on staff for all ADLs. During a record review of Resident 7's Physician Orders as of 5/12/2023, the orders indicated the following Enteral feed orders: 1. Starting on 3/1/2021, elevated head of bed 30 to 45 degrees during feeding. 2. Starting on 3/15/2023, administer Diabetisource Advanced Control via GT, for a total 1500 cc/1800 kcal, at a rate of 75 cc per hour for 20 hours or until dose is met. During a record review of Resident 7's care plan titled, Resident requires tube feeding related to dysphagia, initiated 3/1/2021, the care plan goal indicated Resident 7 will be free from aspiration. The care plan intervention indicated to elevate head of bed 30 to 45 degrees during feeding. During a concurrent observation of Resident 4 and interview with Licensed Vocational Nurse 1(LVN 1) on 5/12/2023 at 12:52 p.m., Resident 4's tube feeding was observed to be infusing at 55 cc/ hour. Resident 4's HOB was noted at a 25 degrees angle. LVN 1 stated Resident 4's HOB should be at least 30 degrees and LVN 1 proceeded to increase the residents HOB with the bed control. During a concurrent observation of Resident 7 and interview with LVN 1 on 5/12/2023 at 12:59 p.m., Resident 7's tube feeding was observed to be infusing at 75 cc/ hour. Resident 7's HOB was noted at a 25 degrees angle. LVN 1 stated Resident 7's HOB should be at least 30 degrees and LVN 1 proceeded to increase the residents HOB with the bed control. During a concurrent observation of Resident 5 and interview with LVN 1 on 5/12/2023 at 1:05 p.m., Resident 5's tube feeding was observed to be infusing at 50 cc/ hour. Resident 5's HOB was noted at a 25 degrees angle. LVN 1 stated Resident 5's HOB should be at least 30 degrees and LVN 1 proceeded to increase the residents HOB with the bed control. LVN 1 stated the HOB needs to be greater than 30 degrees to prevent residents from aspirating. During a record review of the facility's Policy and Procedures (P&P) titled, Enteral Feedings- Safety Precautions, (revised 11/2018), the P&P indicated to prevent aspiration need to elevate the head of the bed (HOB) at least 30° during tube feeding and at least l hour after feeding.

Apr 2023 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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the results of two abuse investigations involving three out of four sampled residents (2, 3, and 4) within five working days of the incidents to the State survey agency ([DPH] Department of Public Health). These deficient practices resulted in the DPH being unaware of the facility's findings and had the potential to cause delay in remedies to ongoing abuse in the facility. Findings: During a review of the facility's Change in Condition (COC) dated for 2/10/2023, the COC indicated Resident 4 was hit by her roommate (Resident 2). During a review of the facility's COC, dated 2/13/2023, the COC indicated Resident 3 was hit by her roommate (Resident 2) with a call light. During a review of Resident 2's admission Records (Face Sheet), the Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of dementia (progress loss of memory) and anxiety (extreme worry). During a review of Resident 2's Minimum Data Set ([MDS]) a standardized assessment and care screening tool) dated 12/29/2022, the MDS indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was severely impaired. During a review of Resident 3's Face Sheet, the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, psychotic disorder with delusions (mental disorder that causes abnormal thinking and perceptions), atrophy (decrease in body mass), lack of coordination and abnormalities of gait and mobility. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making was severely impaired. The MDS indicated that Resident 3 required a two person assist for bed mobility and transfers. During a review of Resident 4's Face Sheet, the Face Sheet indicated Resident 4 was admitted to the facility on [DATE] with a diagnosis of generalized muscle weakness. During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decision making were moderately impaired. The MDS indicated that Resident 4 needed a one-two person physical assist for transfers and bed mobility. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 2/15/2023 at 3:43 p.m., LVN 1 stated she heard CNA 1 call for help from Resident 3's room. LVN 1 stated she ran to Resident 3's room and saw CNA 1 separating Resident 2 and Resident 3. LVN 1 stated CNA 1 reported when she heard Resident 3 calling for help she (CNA 1) ran to Resident 3's room and saw Resident 2 hitting Resident 3 with a call light. During a review of an email sent by the facility on 2/27/2023 (10-11 working days after the incidents occurred), the email indicated no evidence that the results of the two investigations were reported to the DPH within five working days. During a phone interview on 2/27/2023 at 1:39 p.m., with the Director of Nursing (DON), the DON stated an initial report should be sent to the Ombudsman and the DPH and the Administrator (ADM) turns in the final report. The DON stated she was aware a five day report should be submitted to the DPH and did not know why it was not. During a review of the facility's policy and procedure (P/P), titled Abuse, Neglect, Exploitation and Misappropriation-Reporting and Investigating revised 9/2022, the P/P indicated that within five business days of the incident, the administrator will provide a follow-up investigation report. Based on interview and record review, the facility failed to provide the results of two abuse investigations involving three out of four sampled residents (2, 3, and 4) within five working days of the incidents to the State survey agency ([DPH] Department of Public Health). These deficient practices resulted the DPH being unaware of the facility's findings and had the potential to cause delay in remedies to ongoing abuse in the facility. Findings: During a review of the facility's Change in Condition (COC) dated for 2/10/2023, the COC indicated Resident 4 was hit by her roommate (Resident 2). During a review of the facility's COC, dated 2/13/2023, the COC indicated Resident 3 was hit by her roommate (Resident 2) with a call light. During a review of Resident 2's admission Records (face sheet), the face sheet indicated Resident 2 was admitted to the facility on [DATE] with a diagnosis of dementia (progress loss of memory) and anxiety. During a review of Resident 2's Minimum Data Set (MDS) a standardized assessment and care screening tool, dated 12/29/2022, the MDS indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was severely impaired. During a review of Resident 3's face sheet, the face sheet indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, psychotic disorder with delusions (mental disorder that causes abnormal thinking and perceptions), atrophy (decrease in body mass), lack of coordination and abnormalities of gait and mobility. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making was severely impaired. The MDS indicated that Resident 3 required a two person assist for bed mobility and transfers. During a review of Resident 4's face sheet, the face sheet indicated Resident 4 was admitted to the facility on [DATE] with a diagnosis of generalized muscle weakness. During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognitive skills for daily decision making were moderately impaired. The MDS indicated that Resident 4 needed a 1–2-person assistance from staff for transfers and bed mobility. During an interview with Licensed Vocational Nurse 1 (LVN 1) on 2/15/2023 at 3:43 p.m., LVN 1 stated she heard CNA 1 call for help from Resident 3's room. LVN 1 stated she ran to Resident 3's room and saw CNA 1 separating Resident 2 and Resident 3. LVN 1 stated CNA 1 reported she heard Resident 3 calling for help she (CNA 1) ran to Resident 3's room and saw Resident 2 hitting Resident 3 with a call light. During a review of an email sent by the facility on 2/27/2023 (10-11 working days after the incidents occurred), the email indicated no evidence that the results of the two investigations were concluded and sent to the DPH within five working days. During a phone interview on 2/27/2023 at 1:39 p.m., with the Director of Nursing (DON), the DON stated an initial report should be sent to the Ombudsman and the DPH. The DON stated a five day follow up report should be given to DPH, and the administrator sends the report. The DON had no explanation why the 5-day investigation was completed and submitted to DPH. The DON stated she was aware a five day report should be turned in to the DPH but stated it was up to the Administrator (ADM) to turn in the final report. During a review of the facility's policy and procedure (P/P), titled Abuse, Neglect, Exploitation and Misappropriation-Reporting and Investigating revised 9/2022, the P/P indicated that within five business days of the incident, the administrator will provide a follow-up investigation report.

Apr 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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement its abuse prevention policy by failing to submit a conclusion report of their investigation within five (5) working days or in accordance with state or federal law for one of four residents (Resident 4). This deficient practice had the potential to place Resident 4 at risk for further abuse. Findings: During a review of Resident 4's admission Record (facesheet), the facesheet indicated Resident 4 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including acute and chronic respiratory failure (occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), dependence on ventilator status (device to regulate movement of air in and out of the lungs) , type 2 diabetes mellitus (characterized by high levels of sugar in the blood), hypertension (high blood pressure), and cognitive communication deficit (difficulty with thinking and how someone uses language), During a review of Resident 4's Minimum Data Set (MDS, a comprehensive standardized assessment and care-screening tool), dated 1/25/2023, the MDS indicated Resident 4 had severely impaired cognition (ability to think and reason). The MDS indicated Resident 4 required total dependence from staff with all activities of daily living (ADLs, self-care activities performed daily such as dressing, grooming, and personal hygiene). During a concurrent observation and interview with Resident 4 on 3/6/2023 at 1 p.m., Resident 4 was observed lying on her bed comfortably. Resident 4 stated she was hit by her family member (FM 1), however she still wanted to see FM 1 because he assisted her with all ADL needs. Resident 4 stated the facility did not want FM 1 to visit her. During an interview with Licensed Vocational Nurse (LVN) 1 on 3/6/2023 at 1:20 p.m. LVN 1 stated Resident 4 had a habit of telling stories. LVN 1 stated that FM 1 was always there almost every day to visit Resident 4. During an interview with the Administrator (ADMIN) on 3/6/2023 at 2:30 p.m., the ADMIN stated the Director of Social Services (DSS) reported to him on 2/17/2023 an abuse allegation. Resident 4 alleged FM 1 hit her on the left arm and left leg repeatedly during the week but Resident 4 did not report the incident until she told to the central supply staff. The ADMIN stated he contacted local law enforcement, the California Department of Public Health (CDPH) and Ombudsman immediately. The ADMIN stated FM 1 was informed that he was not allowed to visit per Resident 4's request and pending an investigation. During an interview with the ADMIN on 3/6/2023 at 4 p.m., the ADMIN stated and confirmed he did not provide the follow-up conclusionary report of the investigation within 5 working days, involving Resident 4 and FM 1. The ADMIN stated he concluded the investigation was unsubstantiated. During an interview with the Director of Nursing (DON) on 3/6/2023 at 4:20 p.m., the DON stated she was aware the conclusionary report of any investigations should be reported within 5 working days regardless of the outcome of the investigations. During a review Resident 4's Change in Condition (COC) evaluation initiated by LVN 2 dated 2/17/2023 at 1:40 p.m., the COC evaluation indicated Resident 4 verbally accused FM 1 of hitting her on the night of 2/16/23 around 6 p.m. on her left arm and left knee with a cellphone. No bruising or redness noted on the affected areas. Resident 4 denied any pain & no sign of discomfort noted. No sign of bruising or redness noted all over Resident 4's body upon assessment. Resident 4 denied the allegation. Resident 4 was calm & showed no sign of fear towards FM 1. During a review of the SSD's Progress Note dated 2/17/2023 at 3:57 p.m., the SSD note indicated staff informed the SSD that Resident 4 stated FM 1 hit her. The note indicated the SSD immediately went to the resident's room and gathered the information. The note indicated Resident 4 was informed the facility would have to make a report for her safety, contact law enforcement, the Ombudsman and CDPH. Resident 4 understood and stated she did not want FM 1 to come and visit her at that time. The note indicated the SSD informed the ADMIN and the Nursing Department of the situation and local law enforcement was contacted. The SSD and Assistant Director of Nursing (ADON) accompanied the officer when speaking with Resident 4 to obtain a report. However, Resident 4 refused to speak with the officer and stated she did not want to press charges against FM 1. Officer explained to the resident that if she did not make the report, he was unable to do anything. Resident 4 verbalized understanding and stated that was fine. The SSD and ADMIN then contacted FM 1 and informed him about the allegation and Resident 4 requested to not let FM 1 visit her. The note indicated FM 1 denied the allegation but verbalized understanding. During a review of Resident 4's care plan titled, Allegation of husband physically abused, initiated on 2/17/2023, the care plan indicated the goal was Resident 4 would not be harmed by FM 1. The staff's interventions indicated FM 1 would not be allowed to enter the facility per resident request, provide emotional support, report to the local law enforcement, and SOC 341 faxed to CDPH. During a review of the facility's policy and procedures (P&P), revised 9/2022, the P&P indicated all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The P&P indicated the following: Follow-up report: 1. 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. 3. The follow-up investigation report will provide as much information as possible at the time of submission of the report. 4. The resident and/or representative are notified of the outcome immediately upon conclusion of the investigation.

Apr 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

Deficiency F0551 (Tag F0551)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had severe impaired cognition for daily decision making (ability to think and reason), had a representative that acted on behalf of Resident 1 for his medical decision-making. This deficient practice placed Resident 1 at risk for not having a representative to decide on medications and treatments that would benefit the care for Resident 1. Findings: During a review Resident 1's admission Record (face sheet), the admission record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions) and anoxic brain damage (caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation). The admission record indicated Rresident 1 was his own financial representative. The admission record did not indicate a responsible party for Resident 1. During a review of Resident 1's Minimum Data Sheet (MDS, a standardized assessment and care planning tool) dated 2/9/2023, the MDS indicated Resident 1 was rarely/never understood, had a memory problem, and his cognitive skills for daily decision making were severely impaired. The MDS indicated Resident 1 was totally dependent on staff for activities of daily living (ADLs, self-care activities performed daily such as eating, dressing, toileting, and bathing). The MDS indicated that Resident 1 ' s locomotion on and off the unit did not occur. During a review of Resident 1 ' s admission assessment dated [DATE], the assessment indicated Resident 1 ' s level of consciousness was unresponsive/comatose/vegetative: No response to stimuli. During a review of Resident 1 ' s Cognitive Care Plan dated 2/15/2023, the care plan indicated Resident 1 had an impaired cognitive function or impaired thought process related to disease process, impaired decision making, anoxic brain damage, cerebral vasculature accident (a loss of blood flow to part of the brain, which damages brain tissue. It ' s caused by blood clots and broken blood vessels in the brain [CVA]) and schizophrenia. During a review of Resident 1 ' s Social Services admission Record, dated 2/7/2023, the admission record indicated information on the face sheet was verified with the resident and or representative. The admission record indicated social services staff did not have Resident 1 ' s history. During a review of Resident 1 ' s Referral for Probate cConservatorship (court proceeding where a judge appoints a responsible person to care for another adult who cannot care for him/herself), dated 3/6/2023, the referral indicated the facility would like a family member to be located. The referral indicated Resident 1 ' s mental ability was disoriented to person, place, and time. During an interview with Licensed Vocational Nurse (LVN) 1 on 3/23/2023 at 2:32 p.m., LVN 1 stated Resident 1 had a Brief Interview for Mental Status (evaluates cognitive impairments, [BIMS]) score of zero and the rsident did not have the capacity to make decisions for himself. LVN 1 stated Resident 1 did not have a responsible party and he did not know why. During an interview with the Social Services Director (SSD) on 3/24/2023 at 9:59 a.m., the SSD indicated Resident 1 did not have a responsible party to make medical decisions for him. The SSD stated on 3/6/2023, she submitted a referral for a probate conservatorship. The SSD for over one month the facility did not attempt to help Resident 1 get someone to help with the resident's medical decision making. The SSD stated it was important for residents to have someone to make decisions for them because they could not make decisions for themselves. During an interview with the MDS Nurse on 3/24/2023 at 10:32 a.m., the MDS Nurse stated Resident 1 did not have the mental capacity to make medical decisions. The MDS Nurse stated Resident 1 did not have a responsible party. During an interview with the Social Services Assistant (SSA) on 3/24/2023 at 11:10 a.m., the SSA stated Resident 1 did not have a responsible party. The SSA stated it was social services staff who were responsible for obtaining a representative for a resident that did not have one. The SSA stated she was responsible for the resident's admission assessments and not to find a responsible party for the residents. During an interview with LVN 2 on 3/24/2023 at 12:16 p.m., LVN 2 stated Resident 1 was semi- comatose, and not responsive to verbal interaction. LVN 2 stated Resident 1 was not able to make medical decisions. LVN 2 stated Resident 1 did not have a responsible party, and had no one to inform of any changes Resident 1 may have. During an interview with Registered Nurse (RN) 1 on 3/24/2023 at 12:45 p.m., RN 1 stated she was aware Resident 1 did not have the mental capacity to make medical decisions. RN 1 stated Resident 1 did not have a responsible party assigned to him. RN 1 stated she notified the Director of Nursing (DON) and SSD, and she waited for their recommendations on what to do with Resident 1. RN 1 stated she should have helped obtain a responsible party for Resident 1 because it was part of her responsibility. RN 1 stated nursing staff should make sure the residents have the mental capacity if they are assigned as self-responsible. RN 1 stated it was important for a resident to have a responsible party so they can make decisions regarding residents care, get notified of any change of conditions, and get informed of new doctor orders. During an interview with the DON on 3/24/2023 at 1:05 p.m., the DON stated Social Services was responsible for finding a public guardian for Resident 1. The DON stated social services had to find someone to make medical decisions for Resident 1. The DON stated for one month, Resident 1 did not have anyone making medical decisions for the resident. The DON stated she spoke to Social Services in January 2023 about making sure new admits have responsible parties. The DON stated the process was to verify if a resident had a responsible party, and if not, the facility must request a public guardian and have an Interdisciplinary Team (IDT, a group of different disciplines working together towards a common goal of a resident) meeting. During an interview with the DON on 3/24/2023 at 2:30 p.m., the DON stated she was not aware Resident 1 did not have a responsible party. The DON stated RN 1 did not inform her that Resident 1 did not have a responsible party. During a review of the facility ' s Policy and Procedure (P&P) titled, Resident Representative, dated February 2021, the P&P indicated the DON or designee is responsible for making reasonable efforts to obtain updates or changes that are made by the resident, including resident ' s revocation of delegated rights, to ensure that the resident ' s preferences are being upheld.

Mar 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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility's staff failed to notify the physician (MD) and responsible party (RP), for one of three sampled residents (Resident 1) who had complaints of severe pain to both knees. This deficient practice resulted in unresolved knee pain, requiring Resident 1 to be transferred to an acute care general hospital (GACH). Findings: During a review of Resident 1's admission Record (facesheet), the admission record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including right knee osteoarthritis (causes the cartilage in your knee joint to thin and the surfaces of the joint to become rougher, which means that the knee doesn't move as smoothly as it should, and it might feel painful and stiff), tubulointerstitial nephritis (inflammation that affects the tubules of the kidneys and the tissues that surround them, symptoms may include fever, painful urination, and pain in the lower back or side [flank]), type 2 diabetes mellitus (characterized by high levels of sugar in the blood), hypertension (high blood pressure), and reduced mobility. During a review of Resident 1's Minimum Data Set (MDS, a comprehensive standardized assessment and care-screening tool), dated 2/16/2023, the MDS indicated Resident 1's cognition (ability to think and reason) was intact. The MDS indicated Resident 1 required extensive assistance with bed mobility, transfer, toilet use, dressing and personal hygiene. According to the MDS, Resident 1's used a walker for mobility. During an interview with the Director of Nursing (DON) on 3/6/2023 at 11:47 a.m., the DON stated Resident 1 was transferred to a general acute care hospital (GACH) per family request. During an interview with Registered Nurse (RN) 1 on 3/6/2023 at 1:38 p.m., RN 1 stated that Resident 1 was transferred to a GACH on 2/16/2023 at 12:41 p.m. due to severe leg pain. RN 1 stated Resident 1 complained of severe pain starting on 2/15/2023 at approximately 3 a.m. RN 1 stated pain medication was administered, however Resident 1's physician and responsible party (RP) were not notified. RN 1 stated a change of condition report should have been initiated and the licensed nurse should have initiated 72-hour monitoring to properly manage Resident 1's pain. During an interview with Licensed Vocational Nurse (LVN) 1 on 3/6/2023 at 2:40 p.m., LVN 1 stated any change of condition from the base line of the resident should be reported immediately and documented correctly. LVN 1 stated Resident 1's complaint of pain should be reported to the physician immediately to receive orders for pain management. LVN 1 stated that any change of condition should also notify RP for them to know the current condition of the resident. During a telephone interview with Resident 1 on 3/6/2023 at 3 p.m. Resident 1 stated she was having a lot of pain to her left knee when she was in the facility and the nurses were not listening to her. Resident 1 stated the nurses were giving her pain medication, but the pain did not go away. During a telephone interview with Resident 1's RP on 3/6/2023 at 3:15 p.m., the RP stated the facility was not providing proper care to Resident 1. The RP stated Resident 1 was in severe pain and her pain medication was not working for her. The RP stated she confirmed and asked the facility to transfer Resident 1 back to the hospital for unrelieved severe knee pain. During a review of Resident 1's Physician's order dated 2/16/2023 at 11 a.m., the order indicated to transfer Resident 1 to a GACH. During a review of Resident 1's Nurse's Note dated 2/16/2023 at 12:41 p.m., the note indicated two emergency medical technician (EMT- medical personnel who provide care for patients at the scene of an incident and while taking patients by ambulance to a hospital) came to pick up Resident 1 for a transfer to the GACH. During a review of Resident 1's emergency room (ER) GACH notes dated 2/16/2023, the ER GACH notes indicated Resident 1 reported she had been experiencing severe pain to her left knee. Physical examination indicated Resident 1's right knee appeared normal without any obvious deformities or erythema (redness), however positive mild tenderness to palpation (touch) over the kneecap; and left knee appeared somewhat swollen, diffusely, and positive tenderness to palpation to patella (knee cap) as well as around the patella. Orthopedic consult to request knee injection for severe osteoarthritis related pain. During a review of Resident 1's GACH Radiologic examination (X-ray) dated 2/16/2023, the X-ray of Resident 1's bilateral (pertaining to both sides) knees indicated the right knee had replacement hardware, no acute fracture (partial or complete break of a bone) or dislocation, and left knee had severe osteophytes (bony growths that form in your joints or in the spine) with no joint space, bone-on-bone, no acute fracture or dislocation. During a review of Resident 1's Physician's Order dated 2/14/2023, the order indicated to monitor Resident 1's pain level (0-10, out of 10; 0-3 mild pain; 4-7 moderate pain; and 8-10 severe pain) every shift, however there was no adequate detail information regarding the pain levels. During a review of Resident 1's Physician's Order dated 2/14/2023, the order indicated Hydrocodone- (Norco, narcotic medication used to relieve moderate to severe pain) 10-325 milligram (mg, unit of measurement) to give 1 tablet by mouth every 6 hours as needed for severe pain for 5 days. There was no other pain medication order for mild and moderate pain levels. During a review of Resident 1's Medication Administration Record (MAR) dated 2/15/2023 at 3:34 a.m., the MAR indicated Resident 1 had a pain level of 8/10, and Norco 10-325 mg was given. However there was no adequate assessment of Resident 1's pain such as, location, intensity, characteristic, pattern and frequency. During a review of Resident 1's MAR dated 2/15/2023 at 12:15 p.m., the MAR indicated Resident 1 had a pain level of 5/10, and Norco 10-325 mg was given. However there was no adequate information regarding pain such as the location, intensity, characteristic, pattern and frequency. The MAR indicated Resident 1 received the incorrect dose and indication for her complaints of moderate pain level of 5/10. During a review of Resident 1's MAR on 2/15/2023 at 18:15 p.m. (6:15 p.m.), the MAR indicated Resident 1 had a pain level of 8/10, and was given Norco 10-325 mg. However there was no adequate information regarding Resident 1's pain such as, location, intensity, characteristic, pattern and frequency. During an interview with RN 2 on 3/23/2023 at 11:38 p.m., RN 2 stated she confirmed Resident 2 complained of severe pain on 2/15/2023 at 3:34 a.m. and was given pain medication. RN 2 stated there was no change of condition reported to Resident 1's physician nor to the RP until the RP requested Resident 1 to be transferred to the GACH. During a review of Resident 1's MAR dated 2/16/2023 at 7:28 a.m., the MAR indicated Resident 1 had a pain level of 5/10, and was given Norco 10-325 mg. However there was no adequate information regarding Resident 1's pain such as, location, intensity, characteristic, pattern and frequency. The MAR indicated Resident 1 received an incorrect dose and indication for her moderate pain level of 5/10. During a review of Resident 1's Nurse's Note dated 2/15/2023 at 3:34 a.m., the note indicated Resident 1 initially complained of severe pain 8/10 and was given pain medication, however there was no documentation the resident's physician or RP were notified. During a review of Resident 1's undated care plan titled, Risk for pain related to osteoarthritis of the right knee, the care plan indicated the following: Goals: 1. The resident will not have an interruption in normal activities due to pain through the review date. 2. The resident will not have discomfort related to side effects of analgesia (pain medication) through the review date. 3. The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Staff's Interventions: 1. Monitor pain level (0-10) every shift for pain. 2. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. 3. Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. 4. Monitor/record/report to Nurse any signs and symptoms of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). 5. Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. During a review of the facility's policy and procedures (P&P) titled, Change in a Resident's Condition or Status, revised 2/2021, the P&P indicated facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc,). The P&P indicated the following: 1. The Nurse will notify the resident's Attending Physician or Physician on call when there has been: a. An accident or incident involving the resident; b. A discovery of injuries of an unknown source; c. An adverse reaction to medication; d. A significant change in the resident's physical/emotional/mental condition; e. A need to alter the resident's medical treatment significantly; f. Refusal of treatment or medications (i.e., two (2) or more consecutive times); g. A need to transfer the resident to a hospital/treatment center; h. A discharge without proper medical authority; and/or i. Specific instructions to notify the Physician of changes in the resident's condition. 2. A significant change of condition is a decline or improvement in the resident's status that: a. Will not normally resolve itself without intervention by staff'or by implementing standard disease- related clinical interventions (is not self-limiting); b. Impacts more than one area of the resident's health status; c. Requires interdisciplinary review and/or revision to the care plan; and d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument and _42 CFR 483 .20(b )(ii). 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the SBAR (Interact Version 4.0) Communication Form. 4. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative (sponsor) when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source; b. There is a significant change. in the resident's physical, mental, or psychosocial status; c, There is a need to change the resident's room assignment; d. A decision has been made to discharge the resident from the facility; and/or e. It is necessary to transfer the resident to a hospital/treatment center. 5.Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. 6.Regardless of the resident's current mental or physical condition, the Nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to effectively manage a resident's pain for one of three sampled residents (Resident 1) by not: 1. Ensuring Resident 1's pain assessment was thoroughly and accurately completed. 2. Ensuring Resident 1 received the right dose of pain medication and was assessed timely after medication administration. 3. Ensuring the primary physician (MD) and responsible party (RP) was notified immediately when Resident 1 initially complained of severe pain. 4. Developing and implementing individualized resident-centered care plans with measurable objectives, timeframes, and interventions to meet Resident 1's complaints of severe pain. These deficient practices resulted in delayed treatment and services to Resident 1 who had severe pain to both knees requiring a transfer to the general acute care hospital (GACH). Findings: During a review of Resident 1's admission Record (facesheet), the admission record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including right knee osteoarthritis (causes the cartilage in your knee joint to thin and the surfaces of the joint to become rougher, which means that the knee doesn't move as smoothly as it should, and it might feel painful and stiff), tubulointerstitial nephritis (inflammation that affects the tubules of the kidneys and the tissues that surround them, symptoms may include fever, painful urination, and pain in the lower back or side [flank[), type 2 diabetes mellitus (characterized by high levels of sugar in the blood), hypertension (high blood pressure), and reduced mobility. During a review of Resident 1's Minimum Data Set (MDS, a comprehensive standardized assessment and care-screening tool), dated 2/16/2023, the MDS indicated Resident 1's cognition (ability to think and reason) was intact. The MDS indicated Resident 1 required extensive assistance with bed mobility, transfer, toilet use, dressing and personal hygiene. According to the MDS, Resident 1 used a walker for mobility. During an interview with the Director of Nursing (DON) on 3/6/2023 at 11:47 a.m., the DON stated Resident 1 was transferred to a GACH per family request. During an interview with Registered Nurse (RN) 1 on 3/6/2023 at 1:38 p.m., RN 1 stated Resident 1 was transferred to a GACH on 2/16/2023 at 12:41 p.m. due to severe leg pain. RN 1 stated Resident 1 complained of severe pain which started on 2/15/2023 at approximately 3 a.m. RN 1 stated pain medication was administered, however the resident's physician and RP was not notified. RN 1 stated a change of condition report should have been initiated and started 72-hour monitoring to properly manage Resident 1's pain. During an interview with Licensed Vocational Nurse (LVN) 1 on 3/6/2023 at 2:40 p.m. LVN 1 stated any change of condition from the base line of the resident should be reported immediately and documented correctly. LVN 1 stated Resident 1's complaints of pain should be reported to physician immediately to receive an order for pain management. LVN 1 stated any change of condition should also notify the RP for them to know the current condition of the resident. During a telephone interview with Resident 1 on 3/6/2023 at 3 p.m., Resident 1 stated she was having a lot of pain to her knees when she was in the facility and nurses were not listening to her. Resident 1 stated the nurses were giving her pain medication, but the pain did not go away. During a telephone interview with Resident 1's family member (RP) on 3/6/2023 at 3:15 p.m., the RP stated the facility was not providing proper care to Resident 1. The RP stated Resident 1 was in severe pain and her pain medications was not working for her. The RP stated she confirmed and asked the facility to transfer Resident 1 back to the hospital for unrelieved severe knee pain. During a review of Resident 1's Physician's Order dated 2/16/2023 at 11 a.m., the order indicated to transfer Resident 1 to a GACH. During a review of Resident 1's Nurse's Note dated 2/16/2023 at 12:41 p.m., the note indicated two emergency medical technician (EMT- medical personnel who provide care for patients at the scene of an incident and while taking patients by ambulance to a hospital) came to pick up Resident 1 for a transfer to the GACH. During a review of Resident 1's emergency room (ER) GACH notes dated 2/16/2023, the ER GACH notes indicated Resident 1 reported she had been experiencing severe pain to her left knee. Physical examination indicated Resident 1's right knee appeared normal without any obvious deformities or erythema (redness), however positive mild tenderness to palpation (touch) over the kneecap; and left knee appeared somewhat swollen, diffusely, and positive tenderness to palpation to patella (knee cap) as well as around the patella. Orthopedic consult to request knee injection for severe osteoarthritis related pain. During a review of Resident 1's GACH Radiologic examination (X-ray) dated 2/16/2023, the X-ray of Resident 1's bilateral (pertaining to both sides) knees indicated the right knee had replacement hardware, no acute fracture (partial or complete break of a bone) or dislocation, and left knee had severe osteophytes (bony growths that form in your joints or in the spine) with no joint space, bone-on-bone, no acute fracture or dislocation. During a review of Resident 1's Physician's Order dated 2/14/2023, the order indicated to monitor Resident 1's pain level (0-10, out of 10; 0-3 mild pain; 4-7 moderate pain; and 8-10 severe pain) every shift, however there was no adequate detail information regarding the pain levels. During a review of Resident 1's Physician's Order dated 2/14/2023, the order indicated Hydrocodone- (Norco, narcotic medication used to relieve moderate to severe pain) 10-325 milligram (mg, unit of measurement) to give 1 tablet by mouth every 6 hours as needed for severe pain for 5 days. There was no other pain medication order for mild and moderate pain levels. During a review of Resident 1's Medication Administration Record (MAR) dated 2/15/2023 at 3:34 a.m., the MAR indicated Resident 1 had a pain level of 8/10, and Norco 10-325 mg was given. However there was no adequate assessment of Resident 1's pain such as, location, intensity, characteristic, pattern and frequency. During a review of Resident 1's MAR dated 2/15/2023 at 12:15 p.m., the MAR indicated Resident 1 had a pain level of 5/10, and Norco 10-325 mg was given. However there was no adequate information regarding pain such as the location, intensity, characteristic, pattern and frequency. The MAR indicated Resident 1 received the incorrect dose and indication for her complaints of moderate pain level of 5/10. During a review of Resident 1's MAR on 2/15/2023 at 18:15 p.m. (6:15 p.m.), the MAR indicated Resident 1 had a pain level of 8/10, and was given Norco 10-325 mg. However there was no adequate information regarding Resident 1's pain such as, location, intensity, characteristic, pattern and frequency. During an interview with RN 2 on 3/23/2023 at 11:38 p.m., RN 2 stated she confirmed Resident 2 complained of severe pain on 2/15/2023 at 3:34 a.m. and was given pain medication. RN 2 stated there was no change of condition reported to Resident 1's physician nor to the RP until the RP requested Resident 1 to be transferred to the GACH. During a review of Resident 1's MAR dated 2/16/2023 at 7:28 a.m., the MAR indicated Resident 1 had a pain level of 5/10, and was given Norco 10-325 mg. However there was no adequate information regarding Resident 1's pain such as, location, intensity, characteristic, pattern and frequency. The MAR indicated Resident 1 received an incorrect dose and indication for her moderate pain level of 5/10. During a review of Resident 1's Nurse's Note dated 2/15/2023 at 3:34 a.m., the note indicated Resident 1 initially complained of severe pain 8/10 and was given pain medication, however there was no documentation the resident's physician or RP were notified. During a review of Resident 1's undated care plan titled, Risk for pain related to osteoarthritis of the right knee, the care plan indicated the following: Goals: 1. The resident will not have an interruption in normal activities due to pain through the review date. 2. The resident will not have discomfort related to side effects of analgesia through the review date. 3. The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. Staff's Interventions: 1. Monitor pain level (0-10) every shift for pain. 2. Monitor/document for probable cause of each pain episode. Remove/limit causes where possible. 3. Monitor/document for side effects of pain medication. Observe for constipation; new onset or increased agitation, restlessness, confusion, hallucinations, dysphoria; nausea; vomiting; dizziness and falls. Report occurrences to the physician. 4. Monitor/record/report to Nurse any signs and symptoms of non-verbal pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing) Body (tense, rigid, rocking, curled up, thrashing). 5. Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. 6. Notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. During a review of the facility's policy and procedure (P&P), revised 3/2020, titled, Pain Management and Assessment, the P&P indicated the purpose of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. The P&P indicated the following: 1. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. 2. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and establishes treatment goals. 3. Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain b. Recognizing the presence of pain c. Identifying the characteristics of pain d. Addressing the underlying causes of the pain e. Developing and implementing approaches to pain management f. Identifying and using specific strategies for different levels and sources of pain g. Monitoring for the effectiveness of interventions and h. Modifying approaches as necessary. 4. Cognitive, cultural, familial or gender-specific influences on the resident's ability or willingness to verbalize pain are considered when assessing and treating pain. 5. Acute pain (significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassessed as indicated until relief is obtained. Recognizing the pain: 1. Ask the resident if he/she is experiencing pain. Be aware that the resident may avoid the rem pain and use other description such as throbbing, aching, hurting, cramping, numbness or tingling. 2. Review the medication administration record to determine how often the individual requests and receives as needed pain medication, and to what extent the administrations relive the resident's pain. Assessing pain: 1. Characteristics of pain: a. Location of pain b. Intensity of pain ( as measured on a standardized pain scale) c. Characteristics of pain ( aching, burning, crushing, numbness) d. Pattern of pain (constant or intermittent e. Frequency , timing and duration of pain. 2. Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. 3. Discuss with the resident( or legal representative) his or her goals for pain management and satisfaction with the current level of pain control. Monitoring and modifying approaches: 1. Re-assess the resident's pain and consequences of pain at least each shift for acute pain or significant changes in levels of chronic pain. 2. Monitor the resident by performing a basic assessment with enough detail and as needed, with standardized assessment tools (approved pain scales) and relevant criteria for measuring pain management. 3. If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustment as indicated. Documentation: 1. Document the resident's reported level of pain with adequate detail (enough information to gauge the status of pain and the effectiveness of interventions for pain) as necessary and in accordance with the pain management program. Reporting: 1. Reporting the following information to the physician or practitioner: a. Significant changes in the level of the resident's pain b. Adverse effects from pain medications. c. Prolonged, unrelieved pain despite care plan interventions.

Feb 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and/or implement a comprehensive care plan for one of three sampled residents (Resident 1) that addressed the following: a. Resident 1's hemodialysis treatment (HD, a treatment to filter wastes and water from your blood, as your kidneys did when they were healthy) status. b. Resident 1's missed HD treatment on 12/12/2022. c. Interventions that included an alternative treatment plan for when Resident 1 missed HD treatment. These deficient practices had the potential to result in providing inadequate nursing care and services that can negatively affect Resident 1's health. Findings: During a record review of Resident 1's admission Record dated 12/23/2022, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease (a condition in which the kidneys [organ that removes waste and toxins , excess water from the bloodstream, which is carried out of the body in urine] are damaged). During a record review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/13/2022, the MDS indicated Resident 1's cognitive (the ability to understand or to be understood by others) skills for daily decision making was intact. The MDS indicated Resident 1 required supervision when eating and with personal hygiene; limited assistance from staff with bed mobility and transfer; and extensive assistance from staff with toilet use and dressing. During a record review of Resident 1 ' s Order Summary Report, active as of 12/21/2022, the order summary report indicated on 12/9/2022, Resident 1's scheduled HD treatment days were on Mondays, Wednesdays, and Fridays (MWF) at 12:15 p.m. (3.5 hours) at the dialysis center. The order summary report indicated transportation to pick up Resident 1 at 11:15 a.m. from the facility and at 4 p.m. from the dialysis center every MWF. During a record review of Resident 1's care plans, the records indicated there was no care plan developed and implemented addressing Resident 1's HD treatment. During a record review of Resident 1 ' s progress note dated 12/12/2022 at 2:21 p.m., the progress note indicated Resident 1 missed HD treatment on 12/12/2022 due to transportation arrangement issues. During a record review of Resident 1's medical records, the records indicated there was no care plan developed/implemented addressing Resident 1's missed HD treatment on 12/12/2022. During a record review of Resident 1 ' s Change of Condition (COC) Evaluation, dated 12/19/2023 at 12:43 p.m., the COC indicated Resident 1 missed HD treatment due to transportation not picking up the resident. During a record review of Resident 1's care plan titled, Resident Missed HD, initiated 12/19/2022, the care plan interventions did not indicate an alternative treatment plan when the resident missed HD treatment. During an interview with the Medical Records Assistant (MRA) on 12/23/2022 at 11:26 a.m., the MRA stated Resident 1 did not have any care plans for HD until after the resident missed HD treatment on 12/19/2022 due to transportation issues. During an interview with the Registered Nurse Supervisor (RN) 1 on 12/23/2022 at 12:28 p.m., RN 1 stated Resident 1 was dialyzed on 12/9/2022 (Friday) and missed his next scheduled HD day on 12/12/2022 (Monday). RN 1 stated Resident 1 then received HD treatment on 12/14/2022 (Wednesday) and the resident went 5 days without HD treatment. RN 1 stated Resident 1 missed scheduled HD day on 12/19/2022, but received HD treatment on 12/21/2022 (Wednesday) and went another 5 days without HD. During an interview with RN 1 on 12/23/2022 at 1:26 p.m., RN 1 stated when Resident 1 missed HD treatment on 12/12/2022, there was no documented evidence noted in the resident's records that the facility tried to make other arrangements for HD treatment. RN 1 stated there was no documented evidence a care plan was also created to address the missed HD treatment on 12/12/2022. During a telephone interview with Licensed Vocational Nurse (LVN) 1 on 12/27/2022 at 10:52 a.m., LVN 1 stated the staff should have tried to arrange for HD treatment as soon as possible by calling the HD center when Resident 1 missed HD on 12/12/2022. LVN 1 stated it should have been reflected in a care plan. LVN 1 stated Resident 1 did not have a care plan for his diagnosis of renal disease and HD. LVN 1 stated care plans guide the care rendered to residents and it was important. During a telephone interview with the Assistant Director of Nursing (ADON) on 2/3/2023 at 1:39 p.m., the ADON stated for missed HD treatment staff needed to: 1) Develop and implement a care plan for dialysis residents to guide care. 2) Develop and implement a care plan for missed HD treatment. 3) Ensure the care plan for missed HD treatment addressed the transportation issues and alternatives to HD treatment. During a record review of the facility's Policy and Procedure (P&P) titled, End-Stage renal Disease, Care of Resident with, (revised 9/2010), the P&P indicated residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. The P&P indicated agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including how the care plan will be developed and implemented. The P&P indicated the resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. During a record review of facility's P&P titled, Care Plans, Comprehensive Person-centered, (revised 3/2022), 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.

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) was assessed in a timely manner after she complained of left lower extremity (LLE) pain on 9/20/2022. The deficient practice resulted in a delay in treatment and potentially caused inadvertent pain and suffering. On 9/22/2022, two days after the initial complaint, Resident 3 presented with a slightly purplish discoloration and moderate swelling to the LLE. Resident 3 was later transferred to the emergency room after an x-ray diagnostic showed distal left tibia and fibula (shinbone/calf bone) fracture (broken bone). Findings: During a record review of Resident 3's admission Record, dated 12/23/2022, the admission Record indicated the facility initially admitted Resident 3 on 2/22/2018 and recently readmitted the resident on 9/26/2022 with diagnoses that included fracture of the shaft of left tibia and fibula, and left lower limb cellulitis (skin infection that causes redness, swelling, and pain in the infected area of the skin). During a record review of Resident 3's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 9/21/2022, the MDS indicated Resident 3's cognitive (the ability to understand or to be understood by others) skills for daily decision making was moderately impaired. The MDS indicated Resident 3 had the ability to express ideas/wants and understood verbal content. The MDS indicated Resident 3 required supervision when eating; limited assistance from staff with bed mobility; and extensive assistance from staff with toilet use dressing, transfer, and personal hygiene. During a record review of Resident 3 ' s Restorative Nursing flowsheet for the month of September 2022, the flowsheet indicated for the Restorative Nursing Assistant (RNA) to assist the resident with ambulation (walking) using a front wheel walker every day, five times a week. The flowsheet indicated RNA services were not completed on 9/20/2022. During a record review of Resident 3 ' s RNA Nurses note, dated 9/20/2022, the note indicated Resident 3 was unable to ambulate because the resident hurt her left foot. The note indicated the RNA notified the charge nurse of Resident 3's refusal and complaints of pain. During a record review of Resident 3 ' s Medication Administration Record (MAR) dated 9/20/2022 at 10:09 a.m., the MAR indicated Resident 3 was medicated with acetaminophen (medication for pain) 325 milligrams (mg, unit of measurement) orally. The MAR did not indicate the location of the pain or the type of Resident 3's pain. During a record review of Resident 3 ' s Nurse Progress Notes (NPN) for the month of September 2022, the NPN did not indicate any licensed nurse ' s observations or assessments of Resident 3 ' s left foot on 9/20/2022 . During a record review of Resident 3 ' s Change of Condition (COC) Evaluation dated 9/22/2022 at 7 a.m., the COC indicated Resident 3 ' s lower left extremity was moderately swollen with slight purple discoloration. The COC indicated Resident 3 ' s front left lower leg and left ankle and left tibia/fibula (shinbone/calf bone) had swelling. The COC indicated Resident 3 reported that a few days prior another resident accidentally ran into her with his wheelchair. The COC indicated the incident was unwitnessed and was not reported to staff. During a record review of Resident 3 ' s Pain assessment dated [DATE] at 7:04 a.m., the assessment indicated Resident 3 has had the pain on the left lower extremity in the last 5 days. This assessment was two days after Resident 3 first reported that ambulation caused left leg pain. During a record review of Resident 3's Physician Progress Note dated 9/30/2022 at 11:36 a.m., the progress note indicated repeat Xray confirmed left tibia/fibula fracture and left leg cellulitis on 9/22/2022. The progress note indicated Resident 3 underwent surgery on 9/24/2022 and was readmitted to the facility on [DATE]. During a telephone interview with the Minimum Data Set Coordinator (MDSC) and concurrent record review of Resident 3 ' s clinical records on 2/10/2022 at 11: 21 a.m., the MDSC stated the RNA reported to the charge nurse Resident 3 refused to ambulate because of left leg or foot pain on 9/20/2022. The MDSC stated the nurse gave pain medication without assessing or documenting at least the location or predisposing factors or what caused the pain. The MDSC stated two days later on 9/22/2022, Resident 3 complained of left leg pain and presented with swelling to the left leg. The MDSC stated the nurse on 9/20/2022 should have done a thorough assessment of Resident 3's LLE, and notified the physician of the complaints of pain. The MDSC stated Resident 3 ' s fracture could have been addressed sooner. During a record review of the facility's Policy and Procedures (P&P) titled, Change of Resident's Condition or Status, (revised 2/2021), the P&P indicated the facility needed to promptly notify the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The P&P indicated prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. The P&P indicated the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. During a record review of the facility's P&P titled, Pain assessment and management, (revised 3/2020), the P&P indicated the staff will address the underlying causes of residents' pain. The P&P indicated pain management was a multidisciplinary care process that included identifying the characteristics of pain-- location, intensity, characteristics, pattern, frequency, the symptoms that accompany pain and the underlying causes of the pain.

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide necessary hemodialysis (HD, treatment to filter wastes and water from your blood) services for three of three sampled dialysis residents (Resident 1, 2, and 3) by failing to: a) Implement the physician's order for Resident 1 to be transported to and receive HD treatment every Monday, Wednesday, and Friday. Resident 1 missed his scheduled HD treatment on 12/12/2022 and 12/19/2022 due to transportation issues. b) Ensure Resident 1 had a plan of care to address the resident ' s HD status and a care plan for Resident 1's missed HD treatment on 12/12/2022, and ensure the care plan for missed HD treatment for 12/19/2022 indicated interventions included an alternative treatment plan for when the resident missed HD treatment. c) Ensure Resident 1 was assessed after the resident returned to the facility from HD treatment on 12/9/2022, 1/4/2023, 1/18/2023, and 1/23/2023. d) Ensure Resident 2 and 3 were assessed before the residents left for HD treatment and/or when the residents returned from HD treatments from December 1 to December 21, 2022. Resident 2 had four missed opportunities where assessments were not completed. Resident 3 had five missed opportunities where the resident was not assessed. The deficient practice of missing HD treatment placed Resident 1 at risk for fluid overload. The deficient practice of not having a care plan for HD status had the potential to result in providing inadequate nursing care and services that can negatively affect the resident's health. The deficient practice of not assessing the residents pre or post HD treaatment placed the residents at risk for a delay in detecting complications of HD including bleeding and infections. Findings: a. During a record review of Resident 1's admission Record, dated 12/23/2022, the admission record indicated the facility initially admitted Resident 1 on 8/16/2022 and readmitted on [DATE] with diagnoses that included chronic kidney disease (a condition in which the kidneys [organ that removes waste and toxins , excess water from the bloodstream, which is carried out of the body in urine] are damaged). During a record review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/13/2022, the MDS indicated Resident 1's cognitive (the ability to understand or to be understood by others) skills for daily decision making was intact. The MDS indicated Resident 1 had the ability to express ideas and wants and understood verbal content. The MDS indicated Resident 1 required supervision when eating and with personal hygiene; limited assistance from staff with bed mobility and transfer; and extensive assistance from staff with toilet use and dressing. During a record review of Resident 1 ' s Order Summary Report, active as of 12/21/2022, the order summary report indicated on 12/9/2022, the resident's scheduled HD treatment days were Mondays, Wednesdays, Fridays (MWF) at 12:15 p.m. (3.5 hours) at the dialysis center. The order summary report indicated a transportation company was to pick up Resident 1 at 11:15 a.m. from the facility and at 4 p.m. from the HD center every MWF. During a record review of Resident 1's care plans, the records indicated there was no care plan addressing Resident 1's HD status was developed and implemented from the resident's readmission to the facility on [DATE]. During a record review of the resident's Dialysis Communication records, the records indicated an assessment prior to the resident's scheduled HD treatment session included the following: 1. Cognition, 2. Vital signs( body temperature, respiratory rate, heart rate, pain level, and blood pressure [amount of force it takes for blood to pump]), 3. Condition of HD site, 4. Breathing and lung sounds, 5. Presence of a cough, sore throat, fever, and shortness of breath. 6. Report of any change of conditions (COC) in the last 24 to 48 hours. During a record review of the resident's Dialysis Communication records, the records indicated an assessment after the resident's scheduled HD treatment session included the following: 1. Cognition, 2. Vital signs 3. Condition of HD site, 4. Breathing and lung sounds, 5. Presence of a cough, sore throat, fever, and shortness of breath. During a record review of Resident 1's Dialysis Communication records, the records indicated no documented evidence of an assessment after the resident returned from dialysis was completed on 12/9/2022, 1/4/2023, 1/18/2023, and 1/23/2023. During a record review of Resident 1 ' s progress notes, the notes indicated: 1) On 12/12/2022 at 2:21 p.m., the resident missed HD due to transportation arrangement issue. 2) On 12/12/2022, there was no documented evidence of nurses notifying dialysis center to arrange for extra chair time was noted. 3) On 12/12/2022 at 2:37 p.m., the social worker did not confirmation Resident 1's transportation for 12/19/2022. During a record review of Resident 1's medical records, the records indicated no care plan addressing resident's missed HD was developed and implemented on 12/12/2022. During a record review of Resident 1 ' s COC Evaluation, dated 12/19/2023 at 12:43 p.m., the COC indicated Resident 1 missed HD due to transport not picking up the resident. During a record review of Resident 1's care plan titled, Resident missed HD, initiated 12/19/2022, care plan interventions did not indicate what interventions will be done to ensure Resident 1 will have transportation going in and out of dialysis center or to ensure Resident 1 will not miss dialysis treatment again. The care plan did not indicate an alternative treatment plan when resident missed HD treatment. b. During a record review of Resident 2's admission Record dated 12/23/2022, the admission record indicated the facility initially admitted Resident 2 on 7/8/2022 with diagnoses that included end stage renal disease (ESRD, a condition in which the kidneys stop functioning leading to the need for a regular course of long term dialysis to maintain life). During a record review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making were intact. The MDS indicated the resident needed supervision when eating, personal hygiene, and bed mobility; and limited assistance from staff with transfer and toilet use. During a record review of Resident 2 ' s Order Summary Report, active as of 12/23/2022, the summary indicated starting on 7/8/2022 Resident 2 was scheduled for dialysis on MWF at 3:00 p.m. at the resident's dialysis center. During a record review of Resident 2's Dialysis Communication records and progress notes, the records indicated there was no documented evidence of an assessment on the following dates: 1. Before the resident went to HD treatment on 12/9/2022, 12/14/2022; and 2. After the resident returned from HD treatment on 12/5/2022, and 12/9/2022. c. During a record review of Resident 3's admission Record dated 12/23/2022, the admission record indicated the facility initially admitted Resident 3 on 9/26/2022 with diagnoses that included ESRD. During a record review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making was moderately impaired. The MDS indicated Resident 3 required supervision when eating; limited assistance from staff with personal hygiene; and extensive assistance from staff with bed mobility, transfer, dressing, and toilet use. During a record review of Resident 3 ' s Order Summary Report, active as of 12/23/2022, the summary indicated on 11/11/2022 the resident had scheduled HD treatment on MWF at 10 a.m. at the HD center. The order indicated as of 9/26/2022, the staff needed to complete Pre and Post dialysis assessments per policy each dialysis day. During a record review of Resident 3's Dialysis Communication records and progress notes, the records indicated there was no documented evidence of an assessment after the resident returned from HD treatment on 12/7/2022, 12/9/2022, 12/12/2022, and 12/19/2022. During an interview with the Medical Records Assistant (MRA) on 12/23/2022 at 11:26 a.m., the MRA stated Resident 1 did not have any care plans for HD except for when he missed HD treatment on 12/19/2022 due to transportation issues. During an interview with the Registered Nurse Supervisor 1 (RN 1) on 12/23/2022 at 12:28 p.m., after reviewing the Dialysis communication binder for the facility, RN 1 stated the following assessments were missing and therefore was not completed: 1. Resident 1 ' s pre and post dialysis assessments on 12/9/2022. 2. Resident 2's pre dialysis assessments on 12/9/2022and 12/14/2022. 3. Resident 2's post dialysis assessments on 12/5/2022 and 12/9/2022. 4. Resident 3's post dialysis assessments on 12/7/2022, 12/9/2022, 12/12/2022, and 12/19/2022. RN 1 stated Resident 1 had HD treatment on 12/9/2022, but missed HD treatment on 12/12/2022, and had dialysis on 12/14/2022 (5 days of no dialysis). RN 1 stated Resident 1 was last dialyzed on 12/16/2022, missed HD on 12/19/2022, and the next scheduled dialysis was on 12/21/2022 (5 days of no dialysis). During an interview with Social Services Assistant (SSA) on 12/23/2022 at 1:06 p.m., the SSA stated the last documented confirmation of transportation arrangement for Resident 1 was for transportation on 12/16/2022. The SSA stated there was no documented evidence of the transportation confirmation for 12/19/2022 noted for Resident 1. During an interview with RN 1 on 12/23/2022 at 1:26 p.m., RN 1 stated when Resident 1 missed HD treatment on 12/12/2022, there was no documented evidence noted in the resident's records the facility tried to make arrangements for HD treatment. RN 1 stated there was no documented evidence a care plan was created to address the missed HD treatment on 12/12/2022. During a telephone interview with Licensed Vocational Nurse (LVN ) 1 on 12/27/2022 at 10:52 a.m., LVN 1 stated If residents missed HD treatment, social services and nursing worked together to coordinate the residents received HD treatment as soon as possible. LVN 1 stated on 12/12/2022, the staff should have tried to arrange for HD treatment as soon as possible by calling the HD center. LVN 1 stated it should have been reflected in a care plan. LVN 1 stated Resident 1 did not have a care plan for renal disease and HD and he should have had it. LVN 1 stated care plans guide the care rendered to residents and it was important. During a telephone interview with the Dialysis Center Administrator (DA) on 12/27/2022 at 3:03 p.m., the DA stated if a resident missed HD treatment, the dialysis center expected the facility to notify the dialysis center so they could offer another day if available. During a telephone interview with the Assistant Director of Nursing (ADON) on 2/3/2023 at 1:39 p.m., the ADON stated for missed dialysis, staff needed to: 1) Call the doctor, responsible party, and dialysis center. 2) Arrange for another HD treatment to make up for the missed session. 3) Develop and implement a care plan for missed HD. 4) Ensure the care plan for missed HD addressed the transportation issue and alternatives to HD treatment. The ADON stated all HD residents needed a care plan for HD to guide care. The ADON stated staff needed to assess the HD residents before dialysis to have a good baseline assessment and to ensure the resident was alright to go to HD treatment. The ADON stated staff needed to monitor the HD residents post HD trreatment to make sure there were no complications. The ADON stated transportation needed to be arranged and confirmed by the facility so the resident did not miss HD treatment. During a telephone interview with the ADON on 2/10/2023 at 3:43 p.m., the ADON stated Resident 1 had no documented evidence of assessments after the resident returned from HD treatment on 1/4/2023, 1/18/2023, and 1/23/2023. The ADON stated the assessments were important to make sure the residents were stable and to catch complications. During a record review of the facility's Policy and Procedure (P&P) titled, End-Stage renal Disease, Care of Resident with, (revised 9/2010), the P&P indicated residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care. The P&P indicated agreements between this facility and the contracted ESRD facility included all aspects of how the resident's care will be managed, including how the care plan will be developed and implemented and how information will be exchanged between the facilities. The P&P indicated the resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care. During a record review of the facility's P&P titled, Hemodialysis Access Care, (revised 9/2010), the P&P indicated the general medical nurse should document in the resident's medical record every shift as follows: 1. Location of catheter. 2. Condition of dressing (interventions if needed). 3. If dialysis was done during shift. 4. Any part of report from dialysis nurse post-dialysis being given. 5. Observations post-dialysis.

Feb 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to respond in a timely manner to one of five sampled residents (Resident 1) when he requested for his soiled adult brief to be changed. This deficient practice resulted in Resident 1 waiting more than 30 minutes to be changed and caused him to feel uncomfortable and embarrassed to be sitting in a dirty, soiled adult brief. This deficient practice had the potential to lead to skin breakdown and may negatively impact Resident 1's psychosocial well-being. Findings: During a record review of Resident 1's admission Record (face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (a long-term condition that impairs the way the body regulates and uses sugar as a fuel), acquired absence of the left leg below the knee, difficulty walking, and lack of coordination. During a record review of Resident 1's History and Physical (H&P), dated 12/22/2022, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a record review of Resident 1's Minimum Data Set ([MDS], a standardized resident assessment and care screening tool), dated 12/27/2022, the MDS indicated Resident 1 had the capacity to understand, express ideas, and wants, and had the ability to understand others. The MDS indicated Resident 1 required extensive, one-person assistance for toilet use, dressing and transfers out of bed. The MDS indicated Resident 1 was frequently incontinent (inability to control) of bowel functions. During a review of Resident 1's care plan titled, The resident has episodes of bladder incontinence related to disease process, medication side effects, physical limitations, left below knee amputation, dated 1/4/2023, the care plan indicated the staff's interventions included to check Resident 1 as required for incontinence, wash, rinse, and dry perineum, and change clothing as needed after incontinence episodes. During a record review of the Resident Council Meeting Minutes, dated 10/19/2022 and 12/21/2022, the minutes indicated the certified nursing assistants (CNAs) took long to answer call lights during the dayshift and nightshift. The minutes indicated the registry was not answering call lights during the scheduled time. During an interview on 1/12/2023, at 11:44 a.m., with Resident 1, in his room, Resident 1 stated he activated his call light at 11:20 a.m. in order to be changed and the call light was answered at approximately 2 p.m. Resident 1 stated Housekeeper (HK) 1 brought him some water a couple times as he waited two to three hours for the nursing staff to bring him water. Resident 1 stated HK 1 looked for nursing staff to change his soiled brief as he had been waiting for two hours. Resident 1 stated last week, he waited over one hour to be changed. Resident 1 stated he was afraid of having skin breakdown because he waited a long time for his soiled brief to be changed. Resident 1 stated he was independent, working and riding his motorcycle and now he was waiting on someone to change him. Resident 1 stated he felt very uncomfortable and embarrassed to be left dirty, waiting on someone to change him. During an interview on 1/18/2023, at 11:45 a.m., with HK 1, HK 1 stated she brought Resident 1 water twice when he told her he had been waiting two to three hours for water. HK 1 stated the last time she brought Resident 1 water was the prior week but could not recall what day. HK 1 stated the prior week, at approximately 6 a.m., Resident 1 told her he had been waiting over an hour for his brief to be changed so she asked a nurse to change him. HK 1 stated she could not recall who she had asked to change Resident 1. During a telephone interview on 1/18/2023, at 12:53 p.m., with Certified Nurse Assistant (CNA) 4, CNA 4 stated Resident 1 waited twice for about 20 minutes to be changed because she was showering another resident. CNA 4 stated there was one incident when Resident 1 waited more than 30 minutes to have his brief changed. CNA 4 stated she had gone to lunch and when she returned, she responded to Resident 1's call light and the resident told her he had been waiting a long time to be changed. CNA 4 stated she was not told by staff that Resident 1 had been waiting to be changed. CNA 4 stated the staff was supposed cover each other when they go to lunch, so she did not know why no one changed the resident. CNA 4 stated Resident 1 should have been changed right away and it was not okay for residents to wait more than 30 minutes to be changed. CNA 4 stated she usually did not have residents waiting a long time to be changed, but if she got busy with another resident, they would wait a little longer. CNA 4 stated it was uncomfortable for the resident and he may get a rash if he was not changed in a timely manner. During an interview on 1/18/2023, at 2:42 p.m., with the Director of Staff Development (DSD), the DSD stated the call light should be answered immediately and residents should be informed if there was any delay. The DSD stated it was not acceptable for a resident to wait 20 minutes to be changed. The DSD stated CNAs and all staff were expected to answer the call light and assist a resident, even if it was not their resident. The DSD stated if a CNA was assisting a resident to the shower, she/he should communicate with the Registered Nurse (RN) Supervisor and/or the Charge Nurse to get help to change a resident if they were busy with other residents. The DSD stated the licensed nurses were equipped to assist if the CNAs were running behind and they needed assistance to ensure the residents were being taken care of. The DSD stated it was important to meet the residents' needs so the residents felt welcomed and taken care of. The DSD stated the risk for the resident was it could lead to skin breakdown, a rash, and may affect his self-esteem and dignity. During an interview on 1/18/2023, at 3:41 a.m., with the Director of Nursing, the DON stated the expectation was for the call light to be answered immediately. The DON stated a resident should not wait a long time to be changed because it may affect their skin integrity and make them prone to skin issues. The DON stated a person who was left in a soiled brief for an extended period was negatively affected physically, mentally, and psychologically in different ways. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, dated 9/2022, the P&P indicated, The purpose of this procedure is to ensure timely responses to the resident's requests and needs .Answer the resident call system immediately .If the resident's request is something you can fulfill, complete the task within five minutes if possible. If you are uncertain as to whether or not a request can be fulfilled, or if you cannot fulfill the resident's request, ask the nurse supervisor for assistance. During a review of the facility's P&P titled, Activities of Daily Living (ADL), Supporting, dated 3/2018, the P&P indicated, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care); b. mobility (transfer and ambulation, including walking); c. elimination (toileting) .

Feb 2023 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

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure three out of three sampled residents (Resident 1, 2, and 3) were provided their prescribed diet when going to dialyses (a treatment that does some of the things done by healthy kidneys) by: 1. Resident 1 who was on a puree diet (food that has a texture prepared lump-free, not firm, or sticky and holds its shape in a plate. This diet requires no biting or chewing) received a whole sandwich to eat during dialyses. 2. Resident 2 who was on a mechanical soft/chopped meat (food that has a texture prepared as minced and moist and the food is easily smashed with a fork. Biting is not required with this diet and only minimal chewing is need) diet received a whole sandwich to eat during dialyses. 3. Resident 3 who was on a mechanical soft/chopped meat diet was given a piece of chicken that was not chopped as the diet order. This deficient practice had the potential to result in choking (difficult breathing due to a constricted or obstructed throat) and aspiration (when a person swallows something that enters the lungs) for Resident 1, 2, and 3. Findings: A. During a review of Resident 1's admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of dysphagia (difficulty swallowing) and hemiplegia (total or partial paralysis of one side of the body). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 11/28/2022, the MDS indicated Resident 1's sometimes had the ability to understand and be understood by others. The MDS indicated Resident 1 needed one-person extensive assistance with bed mobility, locomotion, dressing, toilet, and personal hygiene. During a review of Resident 1's Speech Therapy (a trained person who treats language and swallowing problems) SLP Evaluation Notes dated from 5/15/2021 to 6/16/2021, the evaluation notes indicated Resident 1 had moderate-severe dysphagia and was at risk for aspiration. The evaluation notes recommended Resident 1 to continue with a puree consistency diet and close supervision during oral intake. During a review of Resident 1's Dietary Profile/Preferences Notes, dated 11/11/2022, the notes indicated Resident 1 was on a pureed diet. During a review of Resident 1's Order Summary Report dated 1/24/2023, indicated Resident 1 had a physician's order dated 12/29/2022 for a pureed diet and one to one feeder. B. During a review of Resident 2's admission Record, the admission record indicated that Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of dysphagia and end stage of renal disease ([ESRD]a medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognitive skills (mental action or process of acquiring knowledge and understanding) for daily decision making were intact. The MDS indicated Resident 2 needed one-person extensive assistance with, locomotion, dressing, and toilet use. During a review of Resident 2's Dietary Profile/Preferences Notes dated 11/17/2022, 12/6/2022, and 12/27/2022, the dietary notes indicated Resident 2 was on a mechanical soft/chopped diet. During a review of Resident 2's Speech Therapy SLP Evaluation Notes dated from 8/17/2022 to 9/15/2022, the evaluation notes indicated Resident 2 had dysphagia and the diet recommended was a mechanical soft/chopped texture. The evaluation notes indicated Resident 2 was at risk for aspiration. During a review of Resident 2's Order Summary Report dated 1/24/2022, indicated Resident 2 had a physician's order dated 12/19/2022 for mechanical soft/chopped meat diet. C. During a review of Resident 3's admission Record, the admission record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of dysphagia and ESRD. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decision making was intact. The MDS indicated Resident 3 needed one-person extensive assistance with bed mobility, transfer, dressing, and personal hygiene. During a review of Resident 3's Speech Therapy SLP Evaluation Notes dated from 3/15/2021 to 4/13/2021, the evaluation notes indicated Resident 3 had dysphagia and the recommended diet for Resident 3 was mechanical soft/chopped textures. The evaluation notes indicated Resident 3 was at risk for aspiration. During a review of Resident 3's Order Summary Report dated 1/24/2023, indicated Resident 3 had a physician's order dated 5/20/2021 for a mechanical soft/chopped meat diet. During a review of Resident 3's Dietary Profile/Preference Notes dated 12/7/2022, the dietary notes indicated Resident 3 was on a mechanical soft/chopped meat texture diet. During an interview with Certified Nurse Attendant (CNA) 1, on 1/17/2023, at 11:33 a.m., CNA 1 stated Resident 1 was on a puree diet and was totally dependent of assistant to eat. CNA 1 stated Resident 1 was provided with a bag with food when she went to dialysis. CNA 1 stated she did not check what foods where in Resident's 1 bag when Resident 1 went to dialysis. During an interview with Family 1 on 1/17/2023, at 12:30 p.m., Family 1 stated Resident 1 was sent to dialysis with a lunch bag which contained a sandwich and a bottle of water. Family 1 stated Resident 1 was on a pureed diet and could not eat a sandwich and drink water without being thickened. Family 1 stated the facility kept sending Resident 1 to dialyses with foods Resident 1 could not. During an interview with Licensed Vocational Nurse (LVN) 1, on 1/17/2023, at 1:30 p.m., LVN 1 stated Resident 1 was provided a sack lunch on her dialysis days. LVN 1 stated she was not sure what type of food was given to Resident 1 when she went to dialyses. LVN 1 stated she never checked what foods were in Resident 1's sack before she went to dialyses. During an interview with Dietary Services Supervisor (DSS) on 1/17/2023, at 1:45 a.m., DSS stated puréed food has a pudding consistency. DSS stated pureed diet and nectar thick fluids were ordered for residents who were coughing when eating. DSS stated Resident 1 always received pureed foods. DSS stated she was not sure what diet Resident 2 was ordered. DSS stated Resident 3 was on a regular diet. During an interview with Resident 2 on 1/17/2023, at 3:25 p.m., Resident 2 stated he received a sack lunch to take with him to dialysis. Resident 2 stated the sack usually contained two sandwiches and one juice. Resident 2 stated he could not chew the sandwiches because the sandwiches were too big for him to chew. Resident 2 also stated his food sack sometimes had graham crackers, but he could not eat the crackers because was too hard for him to chew and swallow. Resident 2 stated his foods must be chopped up to smaller pieces for him to be able to eat it. During an interview with CNA 2, on 1/17/2023, at 3:57 p.m., CNA 2 stated Resident 1 struggled to swallow foods. During an interview with Family 1, on 1/18/2023, on 11:13 a.m., Family 1 stated Resident 1 was provided a sacked lunch with scrambled eggs to go to dialyses on 1/18/2023. Family 1 stated the eggs were not pureed as ordered by the physician. During an observation and interview with Resident 3, on 1/18/2023, at 12:11 p.m., Resident 3 lunch tray was on bed side table. Resident 3's lunch tray had rice, broccoli, a bread roll, and chicken. Resident 3's bread roll and chicken were not cut to smaller pieces. Resident 3 stated when she went to dialysis, the facility packed her lunch with peanut butter and Jelly sandwich, apple juice, and graham crackers. Resident 3 stated her foods must be chopped up into small pieces to prevent her from chocking. Resident 3 stated the facility never chopped her food into small pieces. During an interview with [NAME] on 1/18/2023 at 12:30 p.m., the [NAME] stated the CNA's demanded a sack lunch with a sandwich, but the CNAs did not know what type of diet the resident was on. The [NAME] stated sandwich and graham crackers were not foods given to residents on a mechanical soft diet. The [NAME] stated was important to not feed these foods to residents on a mechanical soft diet as the residents could choke. During an interview with Director of Staff Development (DSD), on 1/18/2023, at 2:36 p.m., DSD stated the CNA's must verify with the charge nurse if the food in the resident's sack was corrected according to therapeutic diets. DSD stated that CNA's must tell kitchen staff, the name of resident and room number and kitchen staff must have food ready. During an interview with director of nursing (DON), on 1/18/2023, at 3:26 p.m., DON stated dialysis residents got a sack lunch when they leave to dialysis. DON stated that kitchen staff should show the food to the nurses to make sure the resident is receiving the prescribed diet. The DON stated a whole sandwich was not an appropriate food for a resident on a pureed diet and could lead to the resident chocking. DON stated a mechanical soft diet was softer than regular food and the food was chopped into small pieces. The DON stated the food served to Resident 3 on 1/18/2023 was not a mechanical soft/chopped meat diet. The DON stated Resident 3's chicken was not chopped into small pieces. During a review of the facility's policy titled Mechanical Soft Diet dated 7/2019, the policy indicated this type of diet was used in the management of dysphagia with the food texture prepared as minced and moist. The policy indicated the food size must be no greater than four millimeters ([mm] unit of measurement) by 4 mm. The policy indicated biting was not required with this diet and only minimal chewing was needed. The policy indicated foods were easily mashed with a fork. Policy stated a mechanical soft diet texture was achieved with best results after chopping food in small pieces. During a review of facility's policy titled Puree dated 7/2019, the policy indicated puree diet was used in management of dysphagia. The policy indicated puree food texture was prepared lump-free, not firm or sticky, and held its shape on a plate. The policy indicated the diet required no biting or chewing and the food could fall off a spoon intact. The policy indicated pureed food was more easily swallowed and prevented aspiration.

Jan 2023 1 deficiency

CONCERN (F) 📢 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

Room Equipment (Tag F0908)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to maintain patient care equipment in safe operating condition in their Subacute unit (provides a specialized level of care to medically fragile residents) by not: 1. Ensuring the use and continuous operation of remote ventilator alarms for 14 of 14 ventilator-dependent residents (a life support system designed to replace or support normal breathing lung function). 2. Ensuring the battery in the accessory ventilator alarms were changed every 60 days and as needed per policy. This deficient practice had a potential for 14 ventilator-dependent residents to not receive the required mechanical aid for breathing to achieve medical stability or maintain life. Findings: During a concurrent observation and interview with the Respiratory Therapist (RT) 1 on 12/14/2022 at 4:30 p.m., in the subacute unit, two (2) remote ventilator alarming devices were observed in the hallways. All of the resident room doors were slightly open. RT 1 stated and confirmed the remote ventilator alarming devices were not working and was reported immediately to the Maintenance Contractor (MC). RT 1 stated a ventilator machine alarms whenever there was a disconnection between from the resident's tracheostomy tube (an artificial airway that is surgically placed directly into the trachea through an opening in the throat) to the mechanical ventilator machine. RT 1 stated it should be reconnected immediately to prevent respiratory distress. During an interview with the Director of Nursing (DON) on 12/14/2022 at 4:48 p.m., the DON stated she was not aware the remote ventilator alarming devices were not working. The DON stated remote ventilator alarms were very important life supporting devices for residents on mechanical ventilators and should always be in good condition at all times. During an interview with Registered Nurse (RN) 1 on 12/14/2022 at 4:57 p.m., RN 1 stated the remote ventilator alarms served to alert all staff whenever a resident disconnected from mechanical ventilators. RN 1 stated each ventilator machine had audible alarms built-in, however the remote ventilator alarming devices were a necessity. RN 1 stated residents were at risk for hypoxia (decreased perfusion of oxygen to the tissues) when the oxygen supply was inadequate. During an interview with Licensed Vocational Nurse (LVN) 1 on 12/14/2022 at 5:10 p.m., LVN 1 stated he was not told the remote ventilator alarming devices were not working, however since the mechanical ventilator machine had a built-in audible alarm it could be heard outside the room since the door was open. During an interview with Certified Nurse Assistant (CNA) 1 on 12/14/2022 at 5:20 p.m., CNA 1 stated she did not know the remote ventilator alarms were not working. CNA 1 stated the remote ventilator alarms would voice prompt and visually show on the panel boards the resident's room numbers needed attention. CNA 1 stated she reported when beeping could be heard from inside the room to the charge nurse and/or RT. During an interview with the Maintenance Supervisor (MS) on 12/14/2022 at 5:35 p.m., the MS stated he checked the red receptacle outlet in each room every month wherein the mechanical ventilators were connected. The MS stated he did it by himself without the help of the RT nor the nurse, by just looking at the remote ventilator alarming devices outside the rooms. The MS stated it was the responsibilities of the nurses to check whether the mechanical ventilators were connected to the remote ventilator alarms. During a telephone interview with the Technical Support Maintenance (TS) 1 on 12/14/2022 at 5:38 p.m. TS 1 stated the remote ventilator alarm's receiver was down and he needed to be reformat the system. TS 1 stated the remote ventilator's alarm was unable to receive the information from the mechanical ventilator's alarm. During a telephone interview with the MC 1 on 12/16/2022 at 9:45 a.m., MC 1 stated mechanical ventilators' full preventive maintenance was done annually to check the operating hours of ventilators. MC 1 stated all other preventive maintenance were as needed only when the facility reported malfunction of the ventilator machine. MC 1 stated the remote ventilator alarms were only checked when reported they were malfunctioning. During an interview with RT 2 on 12/20/2022 at 9:30 a.m., in the subacute unit, RT 2 stated the battery change of accessory ventilator alarms were every 6 months, however, per the facility's policy it was every 60 days and as needed. RT 2 stated the battery should be checked more frequently to make sure it was in good operating condition. RT 2 confirmed the last battery change was in May 2022 for all the accessory ventilator alarms. During a review of the facility's policy and procedures (P&P) titled, Subacute program policy and procedure, reviewed on 6/26/2003, the P&P indicated it was the policy of the facility to utilize accessory ventilator alarms on skilled nursing facility (SNF)/Subacute unit if the ventilator alarms cannot be integrated within the resident call system. The P&P indicated it is also the policy of this facility to change the nine-volt battery in said alarms every 60 days and as needed when the low battery indicator light is visual. 1. Change the battery according to the manufacturer's directions in the operating manual thus, removing the old battery and inserting a new battery. 2. Re-set the alarm and test to insure correct operation. 3. Label the alarm box with the date and time of change and also, the initials of the staff member performing the change. 4. Document the battery change on the Resident Treatment Sheet or Ventilator flowsheet with the date, time, and initials.

Dec 2022 5 deficiencies

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

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess the residents for eligibility and failed to ensure residents were offered the pneumococcal vaccination (used to prevent pneumonia [infection of the lungs]) for five of five sampled residents (Residents 1, 2, 3, 4, and 5). This deficient practice placed Residents 1, 2, 3, 4, and 5 at a higher risk of acquiring and transmitting pneumonia to other vulnerable and immunocompromised residents in the facility. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), respiratory failure unspecified (cannot adequately provide oxygen to the body), and dysphagia (difficulty swallowing). During a review of Resident 1's MDS, dated [DATE], indicated, Resident 1 has no speech, rarely or unable to make self-understood or to understand others. Resident 1 needed total dependence from two staff on bed mobility, transfer, eating, toilet use, walking in the room, bathing and personal hygiene and locomotion on and off unit. During a record review of Resident 1's Immunization Record, there documentation indicated the pneumococcal vaccine was administered and/or offered for Resident 1. During a review of Resident 2's admission Record, the admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included dysphagia, COVID-19 (infectious disease caused by a coronavirus called SARs-Cov-2), hyperlipidemia (condition in which there are high levels of fat particles called lipids in the blood). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had clear speech, and was able to make self-understood and was able to understand others. The MDS indicated Resident 2 required extensive assistance from one to two staff on bed mobility, locomotion on and off the unit, dressing, toilet use, eating, toilet use and personal hygiene, and total dependence from staff with transfer and bathing. During a record review of Resident 2's Immunization Record, the record indicated Resident 2 received the pneumococcal vaccine on 6/10/2015. There was further documentation indicating the pneumococcal vaccine was administered and/or not offered for Resident 4 since 2015. During a record review of Resident 3's admission Record, the admission record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), hyperlipidemia, hypertension (high blood pressure). During a record review of the Resident 3's MDS dated [DATE], indicated the resident has a clear speech, able to make self-understood, and had the ability to understand others, and needed extensive assistance from one staff on bed mobility, toilet use, personal hygiene and total dependence on transfer and bathing. During a record review of Resident 3's Immunization Record, the immunization record indicated the pneumococcal vaccine was not administered and/or not offered for Resident 3. During a review of Resident 4's admission Record, the admission record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included COVID-19, dementia, and acute respiratory distress syndrome (condition in which fluid collects in the lungs air sacs, depriving organs of oxygen). During a review of Resident 4's MDS, dated [DATE], The MDS indicated Resident 4 had clear speech, and was usually able to make themselves understood, and usually had the ability to understand others. The MDS indicated Resident 4 required extensive assistance from one staff on bed mobility, transfer, dressing and personal hygiene and supervision for locomotion on and off the unit, limited assistance with eating, and total dependence with bathing. During a record review of Resident 4's Immunization Record, the record indicated the pneumococcal vaccine was not administered and/or not offered for Resident 4. During a review of Resident 5's admission Record, the admission record indicated Resident 5 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, COVID-19, hyperlipidemia and diabetes mellitus. During a review of the Resident 5's MDS dated [DATE], the MDS indicated Resident 5 had clear speech, and was sometimes able to make himself understood, and sometimes had the ability to understand others. The MDS indicated Resident 5 required extensive assistance from staff with bed mobility, transfer, dressing, and personal hygiene, limited assistance on locomotion on and off the unit. During a record review of Resident 5's Immunization Record, the record indicated there was no documentation indicating revaccination of the pneumococcal vaccine was administered or whether the vaccine was offered to Resident 5. During an interview with Infection Preventionist (IP) and concurrent record review of Resident's 1, 2, 3, 4, and 5 immunization records, on 12/20/2022 at 1:30 p.m., The IP stated she was responsible for the overseeing the administration of the flu and pneumococcal vaccines. The IP stated during the resident's admission, the admission nurse received consent from the resident and/or resident's responsible party to receive the pneumococcal vaccine, and the charge nurses would be the one to administer the vaccine. The IP stated new admissions usually arrived during the 3 p.m. to 11 p.m. (evening) shift, and she was responsible for checking whether the vaccines were administered, and if they were not administered, she offered the residents the vaccines to ensure compliance. The IP stated it was important to get vaccinated because it protected the resident from getting the flu or pneumonia. The IP stated if the residents happen to get the flu or pneumonia after being vaccinated, the symptoms would be lessened. The IP stated the elderly were most likely to get infected due to their immune system. The IP stated the pneumococcal vaccine should have been offered for Residents 1, 2, 3, 4, and 5, but she missed it. During an interview with the Director of Nursing (DON) on 12/20/2022 at 2:25 p.m., the DON stated it was the IP's responsibility to check and make sure the flu and pneumococcal vaccine were being offered to all residents. The DON stated after consent was provided by the resident or the resident's responsible party, it should be administered to the residents. The DON stated it was important to make sure those immunocompromised and elderly get vaccinated since they were at high risk of getting the disease. The DON stated she was aware a lot of the residents in the facility were not offered or provided the pneumoccal vaccine. During a record review of the facility's policy and procedure (P&P) titled, Pneumonia Vaccine, dated 3/2022, the P& P indicated all residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. The P&P indicated pneumococcal vaccines are administered to residents per our facility's physician- approved pneumococcal vaccination protocol.

CONCERN (F) 📢 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 most or all residents

Read full inspector narrative →

Based on observation, interview and record review, the facility failed to implement infection control measures by failing to ensure: Licensed Vocational Nurse (LVN) 1, LVN 2 and LVN3 washed or sanitize (make clean, hygienic or disinfect) hands before and after providing care for Resident 1, Resident 2 and Resident 3. This deficient practice had the potential to expose the residents, staff, visitors, and the community to COVID-19 (a highly contagious infection, caused by a virus that spreads from person to person) and other infections. Findings: During concurrent observation and interview on 12/21/2022 at 10:15 a.m., LVN 1 entered Resident 1's room wearing N95 mask (a protective device worn over the nose, mouth and chin which provides filtration of airborne particles to prevent the spread of COVID-19), gown, gloves, and face shield. LVN 1 did not wash nor sanitize her hands prior to performing wound dressing care for Resident 1, then exited Resident 1' s room without hand washing nor hand sanitizing. LVN1 stated she forgot to wash hands before and after performing wound care and should have washed hands to prevent spreading germs. During concurrent observation of medication administration and interview on 12/21/2022 at 10:42 a.m., with LVN 2, LVN 2 entered Resident 2' s room wearing N95 mask, and face shield. LVN 1 did not wash nor sanitize her hands then applied and wrapped a BP (blood pressure) cuff around Resident 2 ' s left upper arm and inflated the BP cuff to record Resident 2' s vital signs (BP, Pulse and Respirations). LVN 2 then exited Resident 2' s room and did not wash nor sanitize hands. LVN 2 did not sanitize the BP cuff after she used it on Resident 2. LVN2 stated she forgot to wash hands before and after taking blood pressure and should have washed hands or hand sanitize to prevent spreading germs. During concurrent observation and interview on 12/21/2022, at 11:30 a.m., in Resident 3' s room, LVN 3 entered Resident 3' s room wearing N95 mask, gown, gloves and face shield. LVN 3 did not wash nor sanitize her hands upon entering the room nor prior to providing wound dressing care to Resident 3. LVN 3 then exited Resident 3' s room and did not wash nor sanitize hands. LVN3 admitted she forgot to wash hands before and after performing wound care and should have washed hands to prevent spreading germs. During an interview on 12/21/2022, at 3:34 p.m., with Infection Preventionist Nurse (IPN), IPN stated that to prevent infection cross-contamination amongst residents, all must hand washed or sanitized hands before and after resident care. IPN also stated that all equipment should be sanitized before and after each resident use. During a review of facility ' s policy and procedures revised 7/2020 titled Coronavirus Disease (COVID-19)- Infection Prevention and Control Measures, indicated that the facility follows recommended standard and transmission-based precautions, environmental cleaning, and social distancing practices to prevent the transmission of COVID-19 within the facility. The policy indicated that while in the building, personnel are required to strictly adhere to established infection prevention and control policies, including hand hygiene and environmental cleaning with EPA-registered disinfectants approved for use against COVID 19. The policy also indicated that dedicated or disposable noncritical resident-care equipment (e.g., blood pressure cuffs, blood glucose monitoring equipment) are used, or if not available, then equipment is cleaned and disinfected according to manufacturers' instructions using an EPA-registered disinfectant for healthcare setting prior to use on another resident.

CONCERN (F) 📢 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 F0885 (Tag F0885)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident's representatives or responsible parties was informed by the next calendar day following the occurrence of a single confirmed infection of COVID-19 (highly contagious respiratory infection caused by a coronavirus) for one of one sampled resident (Resident 6). This deficient practice had the potential to violate Resident 6's and/or the resident's representative or responsible parties right to be informed of the resident's health status. Findings: During a review of Resident 6's admission Record (face sheet), the admission record indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus without complications (a group of diseases that result in too much sugar in the blood), benign prostatic hyperplasia without lower urinary tract symptoms (BPH, a benign condition in which an overgrowth of prostate tissue pushes against the urethra and the bladder, blocking the flow of urine), peripheral autonomic neuropathy (dysfunction of the nerves that regulate nonvoluntary body functions, such as heart rate, blood pressure, and sweating.). During a review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/15/2022, the MDS indicated Resident 6's cognition (ability to think, make decisions, understand, learn, and make needs known) was intact. The MDS indicated Resident 6 required limited assistance from staff with bed mobility and an extensive assistance with transfers, walking in the room and corridor, dressing, toilet use, and personal hygiene. The MDS indicated Resident 6 required supervision with eating, and total dependence with bathing. During a record review of Resident 6's COVID- Test History (CTH), the CTH indicated Resident 6's polymerase chain reaction (PCR, detects genetic material from a specific organism, virus) test detected COVID-19. During a record review of Resident 6's progress note, dated 12/6/2022 at 7:00 a.m., the progress note indicated Resident 6 had a change of condition and was being monitored for signs and symptoms (S/S) of COVID-19. During an interview with the Infection Preventionist (IP) Nurse on 12/20/2022 at 2:34 p.m., the IP stated informing the resident's families or responsible party was a divided responsibility between the Social Services Director (SSD), Charge Nurses (CN), Activity staff and the IP. The IP stated staff did not have a check list who they informed and what time they informed the resident's family members of any COVID-19 positive residents. The IP stated if there was a resident change of condition (COC) it was expected the charge nurses should inform the resident's family member or the resident. During a concurrent interview with the IP and record review of Resident's 6 medical chart on 12/21/2022 at 12:08p.m., the IP stated it was not documented Resident 6 or the resident's representative was informed of his current COVID-19 status. The IP stated it was important to inform resident's family member because it was the resident's rights. During a record review of the facility's Mitigation Plan (MP) dated 3/2020, the MP indicated it was the policy of the facility to protect their residents, staff and others who may be in our facility from harm during emergency events. The MP indicated to accomplish this, we have developed procedures and a communication plan during activation of this mitigation plan. Facility will assign staff member(s) to be communication lead(s) to families, residents, and staff about the facility's activities as it relates to its COVID-19 Mitigation Plan . supplemental to facility wide updates via email and/or website. The MP indicated communication to residents and families and staff will include the prevalence of cases in staff and residents in the facility. The facility provides emailed and/or website updates by 5pm the day after any significant development (defined as one or more new COVID-19 positive cases and/or three or more symptomatic cases reported within 72 hour) to update residents, families, and staff. In addition, phone and/or personal notification is made to appropriate individuals who do not have email and/or internet capacity/access. On a daily basis, management will meet in the morning to review, plan, and make any necessary assignments will ensure daily reporting to appropriate agencies, residents, families, and staff takes place.

CONCERN (F) 📢 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 F0886 (Tag F0886)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct and monitor COVID-19 (highly contagious respiratory infection caused by a coronavirus) testing. This deficient practice placed all 119 in-house residents, 164 staff members, and the community at risk for the transmission and spread of COVID-19. Findings: During an observation on 12/20/2022 at 10:24 a.m. staff were observed not wearing a facemask or N95 respirator mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) while entering the facility. During a review of Resident 6's admission Records (face sheet), the admission record indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus without complications (high blood sugar), benign prostatic hyperplasia without lower urinary tract symptoms (BPH, a benign condition in which an overgrowth of prostate tissue pushes against the urethra and the bladder, blocking the flow of urine), and peripheral autonomic neuropathy (dysfunction of the nerves that regulate nonvoluntary body functions, such as heart rate, blood pressure, and sweating). During a review of Resident 6's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/15/2022, the MDS indicated Resident 6's cognition (ability to think, make decisions, understand, learn, and make needs known) was intact. The MDS indicated Resident 6 required limited assistance from staff with bed mobility and an extensive assistance with transfers, walking in the room and corridor, dressing, toilet use, and personal hygiene. The MDS indicated Resident 6 required supervision with eating, and total dependence with bathing. During a record review of Resident 6's COVID- Test History (CTH), the CTH indicated Resident 6's polymerase chain reaction (PCR, detects genetic material from a specific organism, virus) test detected COVID-19. During a record review of Resident 6's progress note, dated 12/6/2022 at 7:00 a.m., the progress note indicated Resident 6 had a change of condition and was being monitored for signs and symptoms (S/S) of COVID-19. During an interview with the facility's COVID-19 Screener (Screener 1) on 12/20/2022 at 10:23 a.m., Screener 1 stated she screened everyone that entered the facility and provided a mask if individuals were not wearing one prior to entering. Screener 1 stated she was also responsible with performing rapid antigen COVID-19 tests (designed for rapid diagnoses of COVID-19) on staff/visitors. Screener 1 stated she was not PCR tested prior to entering the facility. During an interview with Registered Nurse (RN) 1 on 12/20/2022 at 10:39 a.m., RN 1 stated she asked the IP for a PCR test because the rapid testing was sometimes inaccurate. RN 1 stated there was an incident where staff or residents who had symptoms tested negative with the antigen test, but the PCR test indicated a positive result. RN 1 stated she performed the rapid testing for residents housed in the sub-acute unit (unit for residents who are medically fragile and require special services). RN 1 stated even if the residents had symptoms, she never performed a PCR test only an antigen test. During an interview with the Infection Preventionist (IP) Nurse on 12/20/2022 at 10:42 a.m., the IP stated an outbreak investigation was initiated when a single new case of COVID-19 occurred among residents or staff to determine if others have been exposed. The IP stated an outbreak investigation would not be triggered when a resident with known COVID-19 was admitted , but the resident would be placed on transmission-based precautions (TBP, infection control precautions used to help stop the spread of germs from one person to another). The IP stated when a resident was known to have close contact with someone with COVID-19 they were placed on TBP, and the TBP would be discontinued if the resident developed COVID-19. The IP stated an outbreak investigation, rapid identification and isolation of new cases was critical in stopping further viral transmission. The IP stated she conducted rapid point of care (POC) diagnostic testing to all the residents but not the staff. The IP stated she did not have any proof she tested all direct care staff that spent more than 15 minutes or were within 6 feet of a resident. The IP stated she did not start conducting response testing until 12/5/2022. The IP stated she was not aware or did not understand, a staff who tested at home and was positive on 11/27/2022 should have triggered the outbreak. During a record review of the facility's Response Testing Report initiated 12/5/2022, the report indicated the following: 1. On 12/05/2022, 118 of 118 residents were tested, and 35 of 164 staff were tested. No testing refusals and there were 129 staff not tested. Facility used antigen test kit. 2. On 12/7/2022, 19 of 19 residents were tested, 51 of 164 staff were tested. No testing refusals. Facility used antigen test kit. 3. On12/8/2022, 119 of 119 residents were tested, 25 of 164 staff were tested. No testing refusals. One staff tested positive. Facility used antigen test kit. 4. On 12/10/2022, 119 of 119 residents were tested, 32 of 164 staff were tested. No testing refusals. Two staff tested positive. Facility used antigen test kit. 5. On 12/11/2022, 49 of 119 residents were tested, 14 of 164 staff were tested. No testing refusals. One staff tested positive. Facility used antigen test kit. 6. On 12/13/2022, 118 of 118 residents were tested, 67 of 164 staff were tested. No testing refusals. One staff tested positive. Facility used antigen test kit. 7. On 12/8/2022, 22 residents of 118 residents were tested, 25 of 164 staff were tested. No testing refusals. One staff tested positive. Facility used antigen test kit. During an interview with the IP on 12/21/2022 at 9:30 a.m. the IP stated the facility did not conduct any confirmatory PCR tests for the residents or staff. The IP stated testing staff and residents was important to find out who else was infected with the virus. The IP stated during the time that the outbreak started she was also out sick and did not have a backup IP. During an interview with the Director of Nursing (DON) on 12/21/2022 at 1:40 p.m., the DON stated the facility tested twice a week, staff tested every Monday and Wednesday, and the residents were tested every Tuesday and Thursday. During an interview with the IP and concurrent record review of Resident 6's progress notes dated 12/13/2022 at 8:51 p.m., on 12/21/2022 at 10:04 a.m., the IP stated Resident 6 was taken off isolation on 12/14/2022. The IP stated if residents in the red zone developed symptoms during the isolation period, the isolation count should go back to zero from the day the symptoms developed. The IP stated she was not aware Resident 6 developed symptoms while residing in the red zone. The IP stated she thought both residents residing in the red zone were asymptomatic. The progress note was reviewed, and it indicated Resident 6 was coughing and was given medication for relief and breathing. The IP stated she was not able to follow the guidelines for isolating and testing the residents and staff. The IP stated she did not have any documentation indicating the lot number or expiration date of the antigen kit test used for testing the residents and staff. The IP stated there was no initials of the staff or person designated to read the results of the tests as well. During a record review of the facility's policy and procedure (P &P) titled, Coronavirus Disease (Covid-19)-Testing staff, dated 4/2022, the P&P indicated that viral testing of all staff (regardless of vaccination status) is conducted if there is an outbreak in the facility. An outbreak is defined as any single new onset of SARS-CoV-2 infection in a resident or a single case infection in any staff. The P&P indicated testing is conducted as soon as a new confirmed case is confirmed. Testing approaches may consist of contact tracing (focused testing) or broad based (facility- wide or group- level) testing. During a record review of the facility's P &P titled, Coronavirus Disease (COVID-19)-Testing Residents, dated 4/2022, the P&P indicated that viral testing may be provided by this facility (POC testing) or offsite through an approved laboratory that has rapid testing capabilities. During a review of the QSO-20-38-NH Revised 9/23/2022, Subject Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements, the QSO indicated to conduct testing based on parameters set forth by the Secretary, including but not limited to: (i) Testing frequency; (ii) The identification of any individual specified in this paragraph diagnosed with COVID19 in the facility; (iii) The identification of any individual specified in this paragraph with symptoms consistent with COVID-19 or with known or suspected exposure to COVID-19; (iv) The criteria for conducting testing of asymptomatic individuals specified in this paragraph, such as the positivity rate of COVID-19 in a county; (v) The response time for test results; and (vi) Other factors specified by the Secretary that help identify and prevent the transmission of COVID-19. (2) Conduct testing in a manner that is consistent with current standards of practice for conducting COVID-19 tests; (3) For each instance of testing: (i) Document that testing was completed and the results of each staff test; and (ii) Document in the resident records that testing was offered, completed (as appropriate to the resident's testing status), and the results of each test. (4) Upon the identification of an individual specified in this paragraph with symptoms consistent with COVID-19, or who tests positive for COVID-19, take actions to prevent the transmission of COVID-19.

CONCERN (F) 📢 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 F0888 (Tag F0888)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure the Rehabilitation Department staff, including the Physical Therapist (PT), Occupational Therapist (OT), and Speech Therapist (ST), who were contracted with the facility to provide services received the COVID-19 (severe respiratory illness caused by a coronavirus called SARS-CoV-2) vaccination. This deficient practice has the potential for the spread of COVID19. Findings: During an entrance conference on 12/20/2022 at 12:10 p.m. with the Administrator (ADMIN) and Infection Preventionist (IP), the ADMIN stated he did not have a list and/or roster of all the contracted direct care and indirect care staff. During a record review of the facility's Vaccination Matrix record dated 4/2022, the record indicated none of the staff for the rehabilitation department was listed. During an interview with the IP on 12/20/2022 at 3:35 p.m., the IP stated she did not have the list of the staff who worked under the Rehabilitation Department (Rehab Dept). The IP stated the Rehab Dept staff provided direct patient care and spent more than 15 minutes with the residents. The IP stated the Rehab Dept staff came within 6 feet of the residents while providing direct care and while re-training the residents to become independent with activities of daily living (ADLs, self-care activities performed daily such as grooming, personal hygiene). The IP stated she did not have a chance to get the contracted Rehab Dept staff's vaccination records and did not know who was vaccinated and who was unvaccinated. The IP stated it was important to know the contracted staff's vaccination status. The IP stated if a staff vaccination status was not verified, they were considered unvaccinated. During a concurrent interview with the IP and record review of the facility's Vaccination Matrix record on 12/21/2022 at 1:34 p.m., the IP stated she could not provide an updated vaccination matrix and confirmed the vaccination status of the Rehab Dept staff was not provided. During a record review of the facility's policy and procedure (P&P) titled, Coronavirus Disease (COVID-19) - Vaccination of Staff, dated 6/2022, the record indicated all staff are required to be fully vaccinated for COVID-19. The P&P indicated staff means individuals who provide any care, treatment, or other services for the facility and/ or its residents, regardless of clinical responsibility or resident contact, including individuals under contract or other arrangement, for example: hospice, dialysis, therapy personnel. The P&P indicated the IP maintains a tracking worksheet of staff members and their vaccination status. The tracking worksheet provides the most current vaccination status of all staff who provide any care, treatment, or other services for the facility and/ or residents. The worksheet includes staff name, initial start of employment or service, termination of employment or service, job title or role, assigned work area, a brief description of how they interact with residents, vaccination status, exemption status, delays.

Nov 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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the bathroom for one of three sampled residents (Resident 3) was clean, the toilet seat was properly maintained and without cracked, unpainted areas on the walls and stains around the sink. This deficient practice resulted in an unsightly, poorly maintained, unsanitary and unclean bathroom that placed Resident 3 at risk for cross-contamination, spread of disease-causing organisms and feelings of low self-worth. Findings: During a review of Resident 3's admission Records (face sheet), the face sheet indicated Resident 3 was admitted to the facility on [DATE] with diagnoses that included fracture of the shaft of the left tibia (a break of the larger lower leg bone below the knee joint) and reduced mobility. During a review of Resident 3's Minimum Data Set ([MDS] a standardized assessment and care-screening tool), dated 9/28/2022, the MDS indicated Resident 3's cognitive skills for daily-decision making were moderately impaired. The MDS indicated Resident 3 required limited one-person physical assist from staff with bed mobility and required extensive one-person physical assist with locomotion on/off the unit and with toilet use. The MDS indicated Resident 3 was not steady and only able to stabilize with staff assistance when moving from a seated to a standing position. The MDS indicated Resident 3 had a functional limitation in range of motion ([ROM] the distance and direction a joint can move to its full potential) to one of her lower extremities. During an interview on 10/25/2022 at 2:53 p.m., with Resident 3, Resident 3 stated the pull cord in her bathroom was relocated to the other side of the wall 1 ½ to 2 months ago after she fell and broke her knee in the bathroom and repair to the wall had not been completed. Resident 3 stated she felt uncomfortable using the bathroom because it was dirty and needed repairs. Resident 3 stated the facility was aware of the needed repairs, but the bathroom had not been fixed. During an observation on 10/25/2022 at 3:10 p.m., in Resident 3's bathroom, the toilet seat, and walls were observed to be in poor condition. The white wooden toilet seat had chipped paint and signs of worn areas on the seat. The right side of the bathroom wall had a 9-inch x 12-inch plastered area that was unpainted. Resident 3 stated that was the area where the pull cord used to be located. On the left side of the wall area adjacent to the sink, there was a light brown, elongated stain. Underneath the sink there was cracked, unpainted plaster with light brown stains around the water shut-off valve. To the right side of the sink in the corner of the wall there was a light brown stain going down the wall and black colored areas along the baseboard. During a concurrent observation and interview on 10/25/2022 at 3:46 p.m., with the Maintenance Supervisor (MS), the MS stated previously the pull cord was placed high on the wall and the resident was unable to reach it. The MS stated the pull cord was relocated to the other side of the bathroom near the toilet due to a previous resident fall but stated the repair of the wall had not been completed. The MS stated the toilet seat was more than on its last leg and it needed to be replaced. The MS stated the patched walls need to be painted and repairs on the walls near the bathroom sink need to be made. A review of the facility's policy and procedure, (P/P), revised 2/2021, titled, Homelike Environment, indicated, residents are provided with a safe, clean, comfortable, and homelike environment and the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a clean, sanitary, and orderly environment.

Dec 2021 23 deficiencies 4 IJ (1 facility-wide)

CRITICAL (J)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Abuse Prevention Policies (Tag F0607)

Someone could have died · This affected 1 resident

Read full inspector narrative →

Based on observations, interview, and record review, the facility failed to implement its written abuse prevention policy and procedure, including: 1. Investigating alleged incidents of abuse, when one (1) of two (2) residents (Resident 9) alleged that Certified Nurse Assistant 3 (CNA 3) had a fist fight with Resident 9 and Certified Nurse Assistant 2 (CNA 2) had wrung a towel soaked with hot water over Resident 9's genitals (a person's external organs for reproduction). 2. Ensuring CNA 3 and CNA 2 were suspended pending completion of an abuse investigation. 3. Reporting the results of the investigation of alleged abused perpetuated by CNA 3 and CNA 2 to the State Survey Agency (Department) within five (5) days. These deficient practices had the potential to result in an unidentified abuse of all residents who were assigned to CNA 3 and 2 and placed resident 9 at risk for the potential of ongoing abuse and resulted in Resident 9's feeling of intimidation, retaliation and neglect, and a decline in emotional wellbeing. On 12/21/2021, at 3:08 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident or residents) was identified and declared under F607. The facility's Administrator (ADM) was notified of the need for immediate action and seriousness of other residents' and staff members health and safety being threatened for failure to implement written policies for abuse to investigate an allegation of abuse (by Resident 9), prevent further potential abuse by failing to remove the alleged perpetuator (CNA 3 and CNA 2) while investigation was in progress, and follow policies for reporting the results of the investigation of the abuse to the Department. On 12/22/2021, at 11:32 a.m., the ADM and the facility's Nurse Consultant were informed that the IJ situation was removed after the implementation of the acceptable Plan of Action ([POA], interventions to correct the deficient practice) was verified while on onsite through observation, interview, and record review. Cross-reference F610. Findings: During a review of the Face Sheet (admission record), dated 12/17/2021, the Face Sheet indicated the facility admitted Resident 9 on 7/22/2021, with diagnoses including, pneumonia (infection of the lungs), hypertension (high blood pressure), anemia (a condition in which the blood doesn't have enough healthy red blood cells that carry oxygen to the body's organs), diabetes mellitus (disorder where the body does not produce enough or respond normally to insulin, which allows your body to use sugar for energy), acute respiratory failure (lung injury that allows fluid to leak into the lungs), tracheostomy (an opening surgically created through the neck into the windpipe to allow for a breathing tube), dysphagia (difficulty swallowing food or liquids), and a gastrostomy (a surgical opening in the abdominal wall into the stomach). During a review of the Minimum Data Set (MDS, a comprehensive assessment and care screening tool), dated 7/4/2021, the MDS indicated Resident 9 had intact cognitive (process of acquiring and understanding knowledge) response. The MDS indicated Resident 9 was totally dependent on staff for bed mobility, transfer, toileting, eating, and personal hygiene. During an interview, on 12/13/21, at 11:35 a.m., with Resident 9, Resident 9 stated she suffered pain after CNA 3 pulled the towel under her buttocks real hard during incontinence care on 11/28/2021 at 2:00 a.m. Resident 9 stated a fist fight happened between her and CNA 3 because CNA 3 forced Resident 9 to be cleaned, despite her objections. Resident 9 stated she did not report the fist fight between her and CNA 3 to staff but reported the incident (date and time unknown) to her family member (FM3). Resident 9 stated there was another incident (date and time unknown) of abuse where CNA 2 burned Resident 9 by wringing a towel soaked with hot water over her private parts. Resident 9 stated she reported the incident where CNA 2 burned her genitals to FM3. During an interview on 12/13/21, at 11:40 a.m., with FM3, FM3 stated ADM was notified (date and time unknown) of the allegations of abuse (from CNA 3 and CNA 2). FM3 stated that the ADM told FM3 that it [the alleged abuse of Resident 9 by CNA 3 and 2] will be taken care of. During an interview on 12/14/2021, at 12:44 p.m., with ADM, ADM stated he was not aware of the alleged abuse incidents where Resident 9 was allegedly abused by CNA 3 and 2. ADM acknowledged that he was now made aware of an abuse allegation where Resident 9 alleges that CNA 3 and CNA 2 were abusive towards Resident 9. Administrator stated he would try to look at it. During an observation on 12/16/2021 at 03:15 p.m., Resident 9 was observed talking to LVN 7. Resident 9 was observed informing LVN 7 that she had a fist fight with CNA 3 and that something must be done. Resident 9 stated, while emotional and crying, that the incident made her feel like she is less of a person. Resident 9 stated that she wanted to go home because she's scared for her life; that CNA 3 will continue the abuse. Resident 9 stated she did not tell anybody about the incident (the fist fight between Resident 9 and CNA 3 and CNA 2 burning Resident 9) because she felt like the staff would retaliate against her. Resident 9 stated she reported abuse by CNA 3 and CNA 2 to FM3 and FM3 made complaints to ADM. LVN 7 stated that if any resident complained about abuse, the abuse coordinator must investigate the allegation and the staff involve must be taken away from the assignment. LVN 7 stated he will take care and look about it [report to the abuse coordinator the alleged abuse]. During an interview on 12/21/2021, at 9:34 a.m. with Resident 9, Resident 9 stated CNA 3 was assigned to her last night (12/20/21 at 11:00 p.m. to 12/21/21 at 7:00 a.m.). Resident 9 stated she was really scared and wanted to go home. Resident 9 stated she felt intimidated and neglected by the abuse incidents perpetuated by CNA 3 and CNA 2. During a concurrent interview and record review, on 12/21/2021, at 10:30 a.m., with Assistant Staff Developer (ASD), the assignment sheet and clock-in record from 12/17/2021 to 12/20/2021 were reviewed. ASD stated CNA 3 was scheduled and signed-in to work on 12/17/2021 from 7:00 p.m. to 7:00 a.m. and was assigned to Resident 9. CNA 3 also clocked-in again on 12/17/2021 at 10:29 pm and clocked out on 12/18/2021 at 6:30 am (CNA 3 worked a double shift). CNA 3 was scheduled and signed-in to work on 12/20/2021 from 10:30 p.m. to 6:30 a.m. and was assigned to Resident 9. During a concurrent interview and record review on 12/21/2021, at 12:44 a.m., with ADM, the facility's policies titled Resident Safety and Prevention from Potential Abuse and Resident 9's medical records were reviewed. ADM stated that there is no documented evidence CNA 3 and CNA 2 allegedly abused Resident 9 or that an investigation began. ADM stated he could not explain why he did not start the investigation of Resident 9 abuse allegations. ADM stated social services and himself would initiate the investigation and conduct interviews with staff, resident, resident family and commence self-report within 2 hours for allegation of staff to resident abuse report the alleged incidents of abuse to the ombudsman, local law enforcement. ADM stated that the results of the investigation would be submitted to the Department within 5 days. ADM stated the facility did not follow the abuse policy by immediately investigating Resident 9's allegations of abuse perpetuated by CNA 3 and CNA 2 when ADM was made aware of the alleged abuse on 12/14/2021, immediately suspend CNA 3 and CNA 2, and report the results of the investigation to the Department within 5 days. ADM stated immediately investigating abuse allegations, suspending the alleged perpetrators, and reporting abuse allegations and the conclusion of the investigations are important because it can prevent ongoing abuse, psychosocial harm, and retaliation for the alleged perpetrators and other staff. During an interview on 12/22/2021, at 9:22 a.m., with the Social Services Assistant (SSA), SSA stated if any resident alleges abuse, the alleged abuse must be reported to the abuse coordinator, ADM. SSA stated all allegations of abuse must be investigated, so that we will know which staff is responsible. SSA stated that all staff are mandated to report any form of abuse. During an interview on 12/22/2021, at 9:35 a.m., with the Social Services Director (SSD), the SSD stated that allegations of abuse from residents must be reported to the abuse coordinator, ADM, immediately. The SSD stated that reporting the alleged abuse to the abuse coordinator ensures that the abuse will be investigated properly. During an interview on 12/22/2021 at 11:01 a.m., with the Director of Nursing (DON), the DON stated that every abuse allegation must be investigated timely because that is a reportable incident, and we need to know the truth about the abuse. During a review of the facility's P/P titled, Abuse Prevention Program dated revised December 2016, the P/P indicated: the residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion. verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. As part of the abuse prevention, the administrator: Protect our residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents. During a review of the facility's P/P titled, Abuse Investigation and Reporting dated revised July 2017, the P/P indicated: AII reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reponed. Role of the Administrator: If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the administrator will assign the investigation to an appropriate individual. The administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. The administrator will keep the resident and his/her representative (sponsor) informed of the progress of the investigation. The administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. The administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. The administrator will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident. Reporting: All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility administrator, or his/her designee, to the following persons or agencies: The State licensing/certification agency responsible for surveying/licensing the facility, the local/State Ombudsman, The Resident's Representative (Sponsor) of Record, Adult Protective Services (where state law provides jurisdiction in long-term care), Law enforcement officials, The resident's attending physician; and, The facility medical director. During a review of the facility's P/P titled, Abuse Investigation and Reporting dated revised July 2017, the P/P indicated: The administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within (5) working days of the occurrence of the incident.

CRITICAL (J)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Investigate Abuse (Tag F0610)

Someone could have died · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident was not subjected to a physical abuse from a Certified Nursing Assistant (CNA 2) and CNA 3, failed to investigate the alleged abuse, protect the resident from possible further abuse, and report the results of investigation to the officials in accordance with State Law for one of two sampled residents (Resident 9). The facility failed to: 1. Conduct the investigation of Resident 9's allegation of physical abuse. Resident 9 alleged that CNA 3 had a fist fight with Resident 9 and CNA 2 had wrung a towel soaked with hot water over Resident 9's genitals (a person's external organs for reproduction). 2. Suspend the alleged perpetrators, CNA 3 and CNA 2, per facilities policy titled Abuse Investigation Reporting. 3. Ensure CNA 3 and CNA 2 were not assigned to continue to care for Resident 9 after the allegation of abuse by both CNAs was made. 4. Report Resident 9's allegation of physical abuse to the State Survey Agency Licensing & Certification (L&C) Department immediately and report the results of all investigations within 5 working days to officials in accordance with State law, including to the State Survey Agency and L&C Department. These deficient practices placed Resident 9 at risk for the potential of ongoing abuse and resulted in Resident 9's feeling of intimidation, retaliation, neglect, and a decline in emotional wellbeing. On 12/21/2021, at 3:08 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident or residents) was identified and declared. The facility's Administrator (ADM) was notified of the immediacy and seriousness of other residents' and staff members health and safety being threatened for failure to investigate an allegation of abuse (by Resident 9), prevent further potential abuse by failing to remove the alleged perpetuator (CNA 3 and CNA 2) while investigation was in progress and report the results of the investigation of the abuse to the State Survey Agency L&C Department. On 12/22/2021, at 11:32 a.m., the ADM and the facility's Nurse Consultant were informed that the IJ situation was removed after the implementation of the acceptable Plan of Action ([POA], interventions to correct the deficient practice) was verified while on onsite through observation, interview, and record review. Findings: During a review of the Face Sheet (admission record), dated 12/17/2021, the Face Sheet indicated Resident 9 was admitted to the facility on [DATE], with diagnoses including pneumonia (infection of the lungs), hypertension (high blood pressure), anemia (a condition in which the blood doesn't have enough healthy red blood cells that carry oxygen to the body's organs), diabetes mellitus (disorder where the body does not produce enough or respond normally to insulin, which allows your body to use sugar for energy), acute respiratory failure (lung injury that allows fluid to leak into the lungs), tracheostomy (an opening surgically created through the neck into the windpipe to allow for a breathing tube), dysphagia (difficulty swallowing food or liquids), and a gastrostomy (a surgical opening in the abdominal wall into the stomach). During a review of Resident 9's Minimum Data Set (MDS, a comprehensive assessment and care-screening tool), dated 7/4/2021, the MDS indicated Resident 9 had intact cognitive (process of acquiring and understanding knowledge) skills for daily decision making. The MDS indicated Resident 9 was totally dependent on staff for bed mobility, transfer, toileting, eating, and personal hygiene. During an interview, on 12/13/21, at 11:35 a.m., Resident 9 stated she suffered pain after CNA 3 pulled the towel under her buttocks real hard during incontinence care on 11/28/2021 at 2:00 a.m. Resident 9 stated a fist fight happened between her and CNA 3 because CNA 3 forced Resident 9 to be cleaned, despite her objections. Resident 9 stated she did not report the fist fight between her and CNA 3 to staff but reported the incident (date and time unknown) to her family member (FM3). Resident 9 stated there was another incident (date and time unknown) of abuse where CNA 2 burned Resident 9 by wringing a towel soaked with hot water over her private parts (genitals). Resident 9 stated she reported the incident where CNA 2 allegedly burned her genitals to FM3. During an interview on 12/13/21, at 11:40 a.m., FM3 stated ADM was notified (date and time unknown) of the allegations of abuse (from CNA 3 and CNA 2). FM3 stated that the ADM told FM3 that it [the alleged abuse of Resident 9 by CNA 3 and 2] will be taken care of. During an interview on 12/14/2021, at 12:44 p.m., ADM stated he was not aware of the alleged abuse incidents where Resident 9 was allegedly abused by CNA 3 and CNA 2. ADM acknowledged that he was now made aware of an abuse allegation where Resident 9 alleges that CNA 3 and CNA 2 were abusive towards Resident 9. Administrator stated he would try to look at it. During an observation on 12/16/2021 at 3:15 p.m., Resident 9 was observed talking to LVN 7. Resident 9 was observed informing LVN 7 that she had a fist fight with CNA 3 and that something must be done. Resident 9 stated, while emotional and crying, that the incident made her feel like she is less of a person. Resident 9 stated that she wanted to go home because she was scared for her life and that CNA 3 will continue to abuse her. Resident 9 stated she did not tell anybody about the incident (the fist fight between Resident 9 and CNA 3 and CNA 2 burning Resident 9) because she felt like the staff would retaliate against her. Resident 9 stated she reported abuse by CNA 3 and CNA 2 to FM3 and FM3 informed ADM. LVN 7 stated that if any resident complained about abuse, the abuse coordinator must investigate the allegation and the staff involved must be taken away from the assignment. LVN 7 stated he will take care and look about it [report to the abuse coordinator the alleged abuse]. During an interview on 12/21/2021, at 9:34 a.m. Resident 9 stated CNA 3 was assigned to her last night (12/20/21 at 11:00 p.m. to 12/21/21 at 7:00 a.m.). Resident 9 stated she was really scared and wanted to go home. Resident 9 stated she felt intimidated and neglected by the abuse incidents perpetuated by CNA 3 and CNA 2. During a concurrent interview and record review, on 12/21/2021, at 10:30 a.m., with Assistant Staff Developer (ASD), the assignment sheet and clock-in record from 12/17/2021 to 12/20/2021 were reviewed. ASD stated CNA 3 was scheduled and signed-in to work on 12/17/2021 from 7:00 p.m. to 7:00 a.m. and was assigned to Resident 9. CNA 3 also clocked-in again on 12/17/2021 at 10:29 pm and clocked out on 12/18/2021 at 6:30 am (CNA 3 worked a double shift). CNA 3 was scheduled and signed-in to work on 12/20/2021 from 10:30 p.m. to 6:30 a.m. and was assigned to Resident 9. During a concurrent interview and record review on 12/21/21, at 12:44 a.m., with ADM, Resident 9's medical record was reviewed. ADM stated he did not investigate Resident 9's allegation of abuse from CNA 3 and CNA 2 when the allegations of abuse were reported to him on 12/14/21. ADM stated that there is no documented evidence CNA 3 and CNA 2 allegedly abused Resident 9 or that an investigation began. ADM stated it is important to begin an investigation once an allegation of abuse is made because it can keep the resident safe by preventing ongoing abuse and possible retaliation. ADM stated he should have suspended CNA 3 and CNA 2 while an investigation took place to prevent ongoing abuse, but he did not. ADM stated the results of the investigation of the alleged abuse perpetuated by CNA 3 and CNA 2 were not reported to State Survey Agency L&C Department within 5 working days of incident because an investigation into both incidents did not begin. ADM stated he did not have an excuse for not investigating and reporting to the Department Resident 9's allegation of abuse perpetuated by CNA 3 and CNA 2. A review of the facility's policy and procedure titled, Abuse Investigation and Reporting revised July 2017, indicated all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Role of the Administrator: If an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the administrator will assign the investigation to an appropriate individual. The administrator will provide any supporting documents relative to the alleged incident to the person in charge of the investigation. The administrator will keep the resident and his/her representative informed of the progress of the investigation. The administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. The administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented. The administrator will inform the resident and his/her representative of the status of the investigation and measures taken to protect the safety and privacy of the resident.

CRITICAL (K)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Infection Control (Tag F0880)

Someone could have died · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement acceptable infection control practices to prevent the spread and transmission of communicable diseases and for the prevention of coronavirus (COVID-19) and Clostridium Difficile ([C-diff] Inflammation of the colon caused by the bacteria Clostridium difficile. The facility failed to: 1. Ensure Resident 170's family member (FM) was educated and made aware of the facility's infection control practices for contact isolation due to clostridium difficile with active diarrhea. FM was observed to do the following: a. FM was observed not wearing gloves while feeding Resident 170. b. FM was observed bringing Resident 170's bedside table to the hallway outside of the room without disinfecting it and without performing hand hygiene (cleaning your hands can prevent the spread of germs [washing hands]). c. FM returned to the room with the previous gown and did not perform hand hygiene. d. Ensure Certified Nursing Assistant (CNA 4) wore gloves as indicated when returning the bedside table to the room of Resident 170, who was on contact isolation. 2. Ensure Certified Nursing Assistant (CNA 4) wore a Face shield while in the room of Resident 171, who was in the yellow zone (zone for residents who are mixed quarantine or symptomatic) to prevent transmission of COVID-19. 3. Ensure Certified Nursing Assistant (CNA 10) wore gloves and a gown while in a yellow zone room of Resident 319. 4. Ensure CNA 10 washed her hands between changing gloves and after completing peri care for Resident 321. 5. Ensure Housekeeper 1 (HK 1) followed the manufacturers recommended contact time to wait three minutes when using Disinfectant A wipes before wiping and drying up body fluids. HK 1 covered the body fluid and waited 10-30 seconds instead of three minutes before he wiped and dried the area. These failures placed all residents (122 total), staff, visitors, and the community at a high risk for cross contamination, and increased spread of C-Diff and COVID-19 (a potentially severe respiratory illness caused by a coronavirus and characterized by fever, coughing, and shortness of breath) infection. On 12/16/2021, at 1:06 p.m., the Immediate Jeopardy ([IJ] a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) related to the failure to implement acceptable infection control practices was called in the presence of the Administrator. On 12/21/21, at 1:58 p.m., the IJ situation was removed in the presence of the Administrator after implementation of the acceptable POA was verified onsite through observation, interview, and record review. Findings: 1. A review of Resident 170's Face Sheet (admission record) indicated Resident 170 was admitted to the facility on [DATE] with diagnoses including C-Diff, major depressive disorder (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts), acute respiratory failure with hypoxia (not enough oxygen in your blood, but your levels of carbon dioxide are close to normal) anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). A review of Resident 170's Minimum Data Set (MDS- a standardized assessment and care-screening tool) dated 12/22/21, indicated the resident had severely impaired cognitive skills for daily decision making and was totally dependent on staff for bed mobility, eating, locomotion off and on unit, transfers, dressing, toilet use, personal hygiene, and bathing. On 12/13/2021 at 12:29 p.m., Resident 170's FM was observed feeding Resident 170 in Resident 170's room without wearing gloves. FM proceeded to bring Resident 170's bedside table to the hallway outside of Resident 170's room without having table disinfected. At the same time, FM was observed not performing a hand hygiene. After FM was observed moving Resident 170's bedside table to the hallway, FM returned to Resident 170's room wearing the same gown and again did not perform a hand hygiene. Few minutes later, a Certified Nursing Assistant (CNA 4) was observed returning Resident 170's bedside table back to the resident's room without wearing gloves. Concurrently during an interview, Resident 170's FM stated that none of the facility's staff instructed her regarding proper use of required personal protective equipment (PPE) for Resident 170 contact isolation precaution due to C-diff. During an interview on 12/14/2021 at 9:06 a.m., the facility's infection preventionist ([IP] nurse in charge of infection prevention at the facility), stated when a family member wished to feed a resident, who is on isolation, the family member must be instructed and made aware that they must follow all isolation precautions and use of PPE. IP further stated when a resident is on contact isolation for C-Diff, staff and family members are required to wear a gown and gloves, and to wash their hands in between care. IP stated when any staff or family member, who has been in contact with the resident without the required PPE, does not wash their hands and goes outside the resident's room without removing their used gown, it is an infection control concern. It is very clear, when staff or family members do not follow necessary infection control practices there is a high risk for them to spread infection to other staff, residents and visitors in the facility. IP stated FM should have work gown and gloves and washed their hands between care of Resident 170. During an interview on 12/14/2021 at 9:28 a.m., the Registered Nurse supervisor (RN 1) stated that any staff or family member who provides care or visits with a resident on contact isolation for C-diff, must wear the required PPE before caring for a resident, remove the used gown and gloves, and wash their hands before leaving a resident's room, and put on clean PPE before going back to a resident's room. RN1 stated when staff or family members do not follow a required infection control practice, it becomes an infection control issue and has the potential for cross contamination and spread of infection to staff, resident, and their family members. RN 1 further stated when visitor's sign in, the receptionist must inform the charge nurse (CN) to educate the visitor regarding the required PPE for contact isolation precautions. On 12/14/2021 at 11:56 a.m., Resident 170's FM was observed at the resident's bedside interacting with the resident without wearing gloves. During an interview on 12/14/2021 at 1:10 p.m., the Licensed Vocational Nurse (LVN 3) stated that Resident 170's FM visits the facility daily and the FM must follow the required PPE requirements before going to see the resident due to contact isolation precautions related to C-diff. During an interview on 12/14/2021 at 1:18 p.m., the RN 1 supervisor stated that it is everybody's job to remind the resident's FM to follow the required isolation precautions when entering the isolation room. A review of the facility's revised policy and procedure dated October 2018 and titled, Clostridium Difficile indicated that measures are to be taken to prevent the occurrence of Clostridium difficile infections (CDI) among residents. Precautions are to be taken while caring for residents with C. difficile to prevent transmission to other residents. Frequent hand washing should be performed with soap and water by staff and residents. When caring for residents with C-diff, staff are to maintain vigilant hand hygiene. Residents with diarrhea associated with C. difficile (i.e., residents who are colonized and symptomatic) are placed on contact precautions. Hand washing with soap and water is superior to antimicrobial hand-rub (ABHR) for the mechanical removal of C. difficile spores from hand. A review of facility's policy and procedure titled Visitation-Infection Control During COVID 19, revised 11/2021, indicated the facility shall establish appropriate guidelines for visitors to try and prevent the transmission of communicable diseases. The top priority at this point with COVID 19 is to prevent the virus from entering the facility. All visitors shall be screened upon entry and shall be required to wear face coverings and adhere to the guidelines of the facility. Each visitor must wear a face covering upon entry and at all times within the facility and must wear other PPE as appropriate while in the patient's room. 2. A review of Resident 171's Face Sheet (admission record) indicated Resident 171 was admitted to the facility on [DATE], with diagnoses including pneumonia (Infection that inflames air sacs in one or both lungs, which may fill with fluid), hyperlipidemia (an abnormally high concentration of fats or lipids in the blood), atherosclerotic heart disease of native coronary artery without angina pectoris (a hardening and narrowing of your arteries caused by cholesterol plaques lining the artery over time). A review of the Minimum Data Set (MDS- a standardized assessment and care-screening tool) dated 12/20/21, indicated Resident 171 had an intact cognitive skill for daily decision making and required assistance with personal hygiene, toileting, and mobility. During an observation on 12/13/2021 at 3:21 p.m., CNA 4 was observed providing care to Resident 171 (a resident who was in the yellow zone who may be suspected of having COVID-19) while wearing a regular mask (not a N95 respiratory, as required for all staff providing care in the yellow zone) without out a face shield (eye protection is required for all staff who provide care to residents in the yellow zone. During an interview on 12/13/2021 at 3:23 p.m., CNA 4 stated that she should wear all required PPE when attending a resident while inside the isolation room, including a N95 and a face shield. CNA 4 stated that she does not have an excuse for not wearing all the required PPE. CNA 4 admitted that it was an infection control issue that can lead to cross contamination of staff and all the residents that she will encounter. During an interview on 12/14/2021 at 9:08 a.m., the IP stated that based on what is posted outside the resident room for isolation precautions, an N95, face shield, gown and gloves were required to provide care for Resident 171, who was on contact and respiratory droplets isolation. If one of the required PPE is not worn while providing care to the resident it becomes an infection control issue that can lead to cross contamination and places the resident at risk for getting infected. During an observation on 12/16/21 at 3:15 pm, a family member of Resident 171 was observed in the resident's room without a gown, face shield, and a N95 mask. At the same time there was a Respiratory Therapist 3 (RT 3) present and was providing respiratory care. RT 3 did not instruct the Family member about observing isolation precautions by wearing necessary PPE and of the potential risk for spread of infection if not followed the requirement for PPE. On 12/16/21 at 3:15 pm, during an interview, Resident 171's family member stated the facility staff did not instruct her to wash her hands, or to wear gloves and a face shield, but she was only told to bring a N95 mask or wear a gown when visiting. on 12/16/21 at 3:44 pm, during an interview, Respiratory Therapist 3 (RT) stated that he did not instruct the visitor about observing isolation precautions and of the potential for infection spread if isolation precautions were not practiced in the facility. 3. On 12/13/2021 at 11:04 a.m. inside the room for three residents, Resident 10, Resident 38, and Resident 55 there was a yellowish-brown semi-liquid substance observed on the floor. This room was on the green zone (zone for residents who do not have COVID-19). Concurrently, during an interview, CNA 1 stated that it could be apple sauce, but it could also be feces or body fluids. CNA 1 stated she would ask the housekeeper to clean it. During a concurrent observation and interview on 12/13/2021 at 11:11 a.m., LVN 5 stated the yellowish-brown substance on the floor in the room of Resident 10, Resident 38, and Resident 55 could be applesauce, feces, or could be body fluids and will have housekeeper to clean it. During a concurrent observation and interview on 12/13/2021 at 11:13 a.m., Housekeeper (HK1) stated the yellowish brownish substance in the room for Resident 10, Resident 38, and Resident 55, looks like feces. HK1 observed cleaning the yellowish-brown substance on the floor by using Disinfectant A wipes and immediately wiping it with a dry cloth towel. During an interview on 12/13/2021 at 11:25 a.m., HK1 stated he cleaned the potential body fluids by squeezing the disinfectant wipes so bleach will cover the potential body fluids then immediately wiped it using the same disinfectant wipes with contact time of 10 to 30 seconds and then he dried it with a dry rag. HK1 stated no additional steps were needed when cleaning potential body fluids. HK1 read the manufacturer recommended contact time on the bleach container and stated, according to the instruction on the bottle, contact time should be three (3) minutes. HK1 stated he normally disinfect with 10-30 seconds contact time because he has a lot of things to do. During an interview on 12/15/2021 at 12:15 p.m., Maintenance Supervisor (MS) stated the proper way to clean body fluids was first to remove the feces, clean the surface, then disinfect. MS stated when using Disinfectant A wipes the contact time should be three (3) minutes. During an interview on 12/15/2021 at 2:53 p.m., IP stated to clean potential body fluids or feces on the floor, the housekeeper needed to clean the feces first, then disinfect and follow manufacture recommended contact time. IP stated Disinfectant A's (disinfecting wipes) manufacturer recommended contact time was three minutes. IP stated not cleaning and disinfecting potential body fluids or contaminated surfaces can potentially infect residents, staff, and other visitors, and can cause illness, hospitalization, or death. A review of the facility's revised facility's policy and procedure dated January 2012 and titled, Cleaning Spills or Splashes of Blood or Body fluids, indicated spills or splashes of blood or other body fluids must be cleaned and the spill or splash area decontaminated as soon as practical. A review of the manufacturer label for Disinfectant A, indicated to clean and disinfect visibly soiled surfaces; pre-cleaning was required prior to disinfecting and contact time was 3 minutes. 4. On 12/13/21, at 12:22 p.m., a Certified Nursing Assistant (CNA 10) was observed in yellow zone room (area for newly admitted residents with incomplete or unknown COVID-19 [a highly contagious infection, caused by a corona virus that can easily spread from person to person] vaccination status), setting up Resident 319's lunch tray. CNA 10 was observed wearing a personal protective equipment ([PPE] equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses,), a N95 mask (PPE worn on the face, covers at least the nose and mouth, and is used to filter out at least 95% of airborne (infection virus-containing smaller particles that can remain suspended in the air over long distances) and a face shield, but was not wearing gloves or gown. CNA 10 was observed leaving Resident 319's room without performing hand-hygiene and walking across the hallway holding a plate cover and placing it on the food delivery cart. CNA 10 observed to performed hand-hygiene with ABHR near the food cart. During an interview on 12/13/21, at 12:30 p.m. CNA 10 stated it is required to wear a gown, a N95 mask, goggles or face shield, and gloves, and to sanitize hands before and after delivering the food tray in the yellow zone. CNA 10 stated she forgot to wear a gown and gloves when was in the yellow zone room. CNA 10 stated without wearing full PPE, there is a potential to spread an infection. CNA 10 confirmed that she must perform hand hygiene after delivering the meal trays for all residents but did not perform the hand hygiene after delivering Resident 319's meal tray. During an interview on 12/14/21, at 11:55 a.m. the IP stated Resident 319 was in room in the yellow zone for isolation because Resident 319 has not completed her full dose of the COVID-19 vaccine. IP stated Resident 319 received her second dose of the COVID-19 vaccine upon admission to the facility and has not completed her 14 days of quarantine in the yellow zone room. A review of Resident 319's admission record (Face sheet), indicated the resident was admitted to the facility on [DATE], with diagnoses including hyperlipidemia ([HLD] a condition that causes the levels of certain bad fats, or lipids, to be too high in the blood), major depressive disorder ([MDD] a common but serious mood disorder that can cause severe symptoms affecting how you feel, think, and handle daily activities, such as sleeping, eating, or working), hypertension ([HTN] a condition present when blood flows through the blood vessels with a force greater than normal), and urinary tract infection ([UTI] an infection of some part of the urinary tract). A review of the Minimum Data Set ([MDS], a standardized assessment and care-screening tool), dated 12/15/21, indicated Resident 319 moderately impaired cognitive skills for daily decision making and required extensive assistance from staff with bed mobility, dressing, and toileting and was totally dependent on staff with bathing. A review of Resident 319's COVID-19 vaccination record card, indicated the resident received her first dose of the Pfizer vaccine on 7/27/21, and the second dose on 12/10/21, while residing at the facility. During an interview on 12/15/21, at 3:33 p.m. the IP stated she provides education to her staff on PPE requirements and hand hygiene. IP stated staff going into the rooms on the yellow zone were required to perform hand hygiene prior to donning (putting on) PPE and were required to wear gloves, gown, N95 mask, and eye protection with googles or a face shield. When leaving the room, staff required to perform hand hygiene after removing PPE. IP stated if proper PPE and hand hygiene is not done, there is a risk to spread infection. A review of the facility's COVID-19 Mitigation Plan indicated the residents assigned in a yellow zone room will be treated with contact and droplets isolation precautions. When caring for patients with confirmed or suspected COVID-19, face shield or goggles, N95 mask or higher respirator, gloves, and isolation gown were to be used. A review of the facility's policy, Isolation - Categories of Transmission-Based Precautions, revised 10/2018, indicated staff caring for residents on contact precautions will wear gloves and gown upon entering the room. Staff caring for residents on droplet precautions will wear masks, gloves, a gown and googles should be worn if there is risk of spraying respiratory secretions. A review of the facility's policy, Handwashing/Hand Hygiene, revised 8/2019, indicated an alcohol-based hand rub containing at least 62% alcohol should be used or, alternatively soap (antimicrobial or non-antimicrobial) and water should be used before and after direct contact with residents; after contact with objects in the immediate vicinity of the resident; after removing gloves; before and after entering isolation precaution setting; before and after eating or handling food; before and after assisting a resident with meals. Hand hygiene is the final step after removing and disposing of personal protective equipment. 5. During a concurrent observation and interview, on 12/13/21, at 10:44 a.m., with CNA 10, CNA 10 was observed performing incontinence (the loss of bowel and/or bladder control) care to Resident 321. CNA 10 was observed wearing a N95 face mask and a face shield and putting gloves on after performing hand hygiene with ABHR. CNA 10 stated Resident 321 had a bowel movement. CNA 10 was observed wiping Resident 321's bottom with a pad, then cleaning the residents bottom with soap and water, and with a new towel patting dry the resident's bottom. CNA 10 then removed used gloves and put on a new pair of gloves to clean the resident's private parts with a clean towel without performing a hand hygiene between changing gloves. CNA 10 was observed to use a new towel to pat dry the resident's private area and then removing her gloves. CNA 10 was observed not performing hand hygiene with hand sanitizer or wash her hands with soap and water after removing gloves. Concurrently, during an interview, CNA 10 stated she forgot to get a new pad to place under the Resident 321. CAN 10 opened Resident 321's closet, went outside of the room to get a new incontinent pad from the clean linen cart in the hallway. Then CNA 10 returned to the room and washed her hands with soap and water, put on a new pair of gloves to complete the resident's care. She then removed her gloves and washed her hands with soap and water after finishing care. CNA 10 stated she usually changed gloves during care and would wash her hands after completing care. During an interview on 12/13/21, at 11:00 a.m., CNA 10 stated when performing patient care, one should gather equipment that will be used during care and wash hands prior to performing care. CNA 10 stated she was trained to change gloves if they become soiled during care, and to clean with hand sanitizer in between changing gloves, and to wash hands when done with care. During an interview on 12/15/21, at 2:52 p.m., the IP stated she provides education to her staff on proper handwashing. IP stated hand-hygiene was required before putting on or taking off PPE and before and after coming in contact with the resident. IP stated hand washing with soap and water was required if touching bowel movement because of possible contamination when going from dirty area to clean area. A review of Resident 321's Face sheet indicated the resident was admitted to the facility on [DATE], with diagnoses including UTI, weakness, heart failure (a condition in which the heart has trouble pumping blood thought the body), type 2 diabetes (abnormal blood sugar), Parkinson's disease (a brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), , hyperlipidemia (HLD), and atrial fibrillation (rapid, irregular beating of the heart). A review of Resident 321's MDS, dated [DATE], indicated the resident had severely impaired cognitive skills for daily decision making and required extensive assistance from staff with bed mobility, dressing, and toileting and required a total dependence from staff in bathing. A review of the facility's policy, titled Handwashing/Hand Hygiene, revised August 2019, indicated to use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water before and after direct contact with residents; after contact with objects in the immediate vicinity of the resident; after removing gloves; before moving from a contaminated body site to a clean body site during resident care. The use of gloves does not replace hand washing/hand hygiene. Integrating glove use along with routine hand hygiene as it is recognized as the best practice for preventing healthcare-associated infections.

CRITICAL (L)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Safe Environment (Tag F0921)

Someone could have died · This affected most or all residents

⚠️ Facility-wide issue

Read full inspector narrative →

Based on observation, interview and record review, facility failed to provide safe, functional, sanitary, and comfortable environment for 122 of 122 residents, staff, and visitors, by not maintaining the facility's roof, resulting in multiple water leakage from the ceiling in the dining room (also used for activities) and nurses' station. This deficient practice can potentially cause, structural damage including ceiling collapse, electrical outage, electrocution, and damage of medical records. During an annual recertification survey on 12/14/2021, at 6:05 p.m., an Immediate Jeopardy ([IJ] a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death of a resident or residents) was identified and declared. The facility's Administrator (ADM) was notified of the water leaking from the ceiling in the dining room and nurses ' station. During an interview on 12/15/2021, at 4:25 p.m., the ADM was informed that the IJ was lifted after implementation of the acceptable plan of action ([POA], interventions to correct the deficient practice) was verified while on onsite via observation, interview, and record review. Findings: Facility census: 122 a. During an observation on 12/14/2021, at 10:30 a.m., during the Resident Council Meeting, two black trash cans and one gray water basin were observed on the floor by the entrance door towards the back of the dining room (also used for activities) with water in the containers. The ceiling was observed to have a crack line approximately three (3) feet long with water dripping from ceiling during the Resident Council Meeting, which was attended by 13 residents. During an observation on 12/14/2021, at 12:30 p.m., during a dining observation, there were 20 residents eating in the dining room. Water was observed dripping from the ceiling into the two black trash cans and gray water basin by the entrance door towards the back of the dining room. There was no cautionary signage observed to indicate the possibility of a wet floor. During a concurrent observation and interview on 12/14/2021, at 12:35 p.m., with Licensed Vocational Nurse 5 (LVN 5), in the dining/activity room, water was observed dripping from the ceiling into the two black trash cans and the gray water basin by the entrance door towards the back of the dining room. LVN 5 stated it was raining hard today (12/14/21) and there was water dripping from the ceiling and the black trash cans and the gray water basin were used to catch the water from the ceiling. LVN 5 stated there were 20 residents inside the dining area despite water leaking from the ceiling and residents were positioned to avoid areas where the water was dripping from the ceiling. During an interview on 12/14/2021, at 2:21 p.m., with the Activities Assistant (AA1), AA1 stated it was raining hard today (12/14/21) and at 9:00 a.m. she observed water leaking from the ceiling inside the dining room, there was a water basin on the floor to catch water. AA1 stated the floor was wet and noticed there was more water leaking from the right side of the ceiling and asked Housekeeper 1 (HK1) to bring another bucket to catch the water. AA1 stated the residents did not start entering the back dining area until after 10:00 a.m. to prepare for the Resident Council Meeting. AA1 stated she ensured there were containers to catch the water dripping from the ceiling. AA1 stated she notified Maintenance Supervisor (MS) regarding the water leaking from the ceiling at the back dining area because she was concerned residents who were using the wheelchair could spread the water around and resident who were able to walk in the area might slip and fall. AA1 stated there was no signage placed around the area where water was leaking to indicate the floor was wet. AA1 stated that cautionary signage was important to alert people of a hazard that can cause slip and falls due to a wet floor. During a concurrent observation and interview, on 12/14/2021, at 2:30 p.m. with AA1, nine (9) residents were observed sitting towards the back of the dining room participating in activities. Two black trash cans and a gray water basin filled with water were observed and were initially observed during the Resident Council Meeting at 10:30 a.m. and during the dining observation at 12:30 p.m. AA1 stated the dining area was used at 10:00 a.m. by 13 residents for the Resident Council Meeting, used by 20 residents during lunch, and was currently being used for activities. AA1 stated the dining room was also scheduled for use for dinner later that evening (12/14/21). AA1 stated the staff and residents will continue to use the dining area despite the water leaking from the ceiling. During a concurrent observation and interview, on 12/14/2021, at 2:37 p.m. with MS, MS stated it was raining hard on 12/14/2021 and there was an abrupt water leakage from the ceiling in the dining/ activity room on 12/14/2021 at 6:00 a.m. MS stated there was a crack approximately three feet in length in the ceiling where the water was dripping. MS stated the cause of the crack was unknown. MS stated the facility placed buckets on the floor to prevent water from splashing everywhere but did not believe the water leaking from the ceiling was a potential hazard that could cause residents to slip and fall, get electrocuted, or injured from a ceiling collapse due to water accumulation. MS stated the facility continued to use the back dining room for activities and dining despite the continued water leakage from the ceiling. During an interview on 12/14/2021 at 3:00 p.m. with LVN 5, LVN 5 stated it was raining hard around 6:30 a.m. and when she passed by the dining room, she saw water leaking from ceiling. LVN 5 stated she was concerned that the ceiling might collapse and was scared for herself and the residents. LVN 5 stated the facility's staff continued to allow residents in the dining room for the Resident Council Meeting, dining for lunch, and activities despite water leaking from the ceiling. LVN 5 stated during dining on 12/14/2021, at around 12:00 p.m., she almost tripped on the gray water basin because there was no cautionary signage indicating the floor was wet nor that the gray water basin was on the floor. During an observation on 12/14/2021, at 4:50 p.m. water was observed dripping from the ceiling in the dining room. Water was observed dripping into the two black trash containers and gray water basin while there was one resident (Resident 112) and one staff in the dining area. During an interview on 12/14/21 at 03:23 p.m. with the Activities Director (AD), AD stated there was water dripping from the ceiling in the dining room this morning (could not specify the time) and buckets were placed on the floor to catch the water leaking from the ceiling. AD stated the facility was planning to use the room for dinner tonight (12/14/21) despite the water leaking from the ceiling. AD stated she did not know what could happen if there was accumulation of water in the ceiling. AD stated she did not think of the risks of occupying and using the dining and activities room despite the continued water leakage from the ceiling. AD stated the facility did not consider moving residents out of the dining and activities room to keep them safe from possible environmental hazard. During an interview on 12/14/2021, at 03:45 p.m. with MS, MS stated the roof, ceiling, and structure of the building, has not been assessed or inspected because he could not access the ceiling. MS stated he tried to contact Vendor 1, a third-party vendor, to assess and fix the leak in the roof but there was no response and was still waiting for a call back. During an interview on 12/14/21, at 03:51 p.m., with ADM, ADM stated the facility has not assessed the extent of the water damage caused by the rain because it was actively raining. ADM stated that the facility did not have a plan to address the leaking roof and ceiling. ADM stated the facility was not planning on evacuating or relocating the dining and activities service and will continue to use the dining and activities room despite the active water leak from the ceiling. The ADM could not verbalize whether the dining and activities room was safe to use despite the active water leak from the ceiling. b. During an observation on 12/14/2021, at 12:45 p.m., at the nurses' station (the only nurses' station in the facility), water was observed dripping from the ceiling. Six staff (LVN 5, LVN 8, Certified Nurse Assistant 9 [CNA 9], Registered Nurse 5 [RN 5], Director of Nursing [DON], and the Infection Preventionist [IP]) were present and all 122 resident medical records were observed at the nurses ' station. During an interview on 12/14/2021 at 12:35 p.m., with LVN 5, at the nurses' station, LVN 5 stated that Residents' charts were located at the nursing station and there was a continuous drip of water inside the nursing station. LVN 5 stated she was afraid that ceiling might fall. During an observation on 12/14/2021 at 3:00 p.m., at the nurses' station, water was observed continuously dripping from the ceiling. During a concurrent interview and record review, on 12/14/21, at 4:18 p.m., with ADM, the Emergency Preparedness Plan was reviewed. ADM stated the water leaking in the ceiling and pooled water in the ceiling was a safety hazard that could potentially cause anyone to fall, ceiling might collapse, and if water was leaking directly in the light fixture could cause electrical outage and short-circuit (allows a current to travel along an unintended path) and needed to be addressed right away. ADM stated the facility must close the dining room and secure the medical records until the ceiling was repaired of the water leak to ensure a safe environment where all residents, staff, and medical records are free from environmental hazards. During a review of the facility's Policy and Procedure (P/P) titled, Maintenance, dated revised 2009, the P/P indicated Maintenance service shall be provided to all areas of building, grounds, and equipment. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Function of maintenance personnel include but not limited to: Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. Maintaining the building in good repair and free from hazards. The maintenance Director is responsible for maintaining the following records/reports a. Inspection of the building, b. work order request, c. maintenance schedules d. authorize vendor listing, e. Warranties and guarantees. Records shall be maintained in the Maintenance Director's office. Maintenance personnel shall follow established safety regulations to ensure safety and well-being of all concerned.

CONCERN (D)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to protect the rights of the residents to be treated with dignity and respect and provide care in a manner that promotes the resident's quality of life for two of three sampled residents (Resident 9 and 66): a. by not thoroughly cleaning Resident 9 after a bowel movement. b. by not covering Resident 66's unclothed body to maintain privacy and dignity. These deficient practices had the potential to cause embarrassment, feelings of unworthiness and had a potential for more psychosocial harm to Resident's 9 and 66. Findings: a.A review of the admission record indicated Resident 9 was admitted on [DATE] with diagnoses of hypertension (high blood pressure), anemia (a condition where the body lacks the ability to carry adequate oxygen to the body tissues), acute respiratory failure, tracheostomy (surgically created hole that passes from the neck to the windpipe to allow direct access to breathing and airway) , dysphagia (difficulty swallowing food or liquids), and gastrostomy (a surgical opening in the abdominal wall of the stomach, used for liquid nutrition through plastic tubing). A review of the Minimum Data Set (MDS- a comprehensive assessment and care screening tool) dated 8/4/2021, indicated Resident 9 was cognitively (ability to learn, remember, understand, and make decisions) intact. The MDS indicated Resident 9 was totally dependent on staff for bed mobility, transfer, toileting, eating, and personal hygiene. During an interview on 12/13/2021 at 12:23 a.m., Resident 9 and a family member (FM1), Resident 9 stated that a lot of times when she pressed the call light for help, certified nursing assistant (CNA) 4 just turned the call light off and walked away, Resident 9 stated that when CNA 4 turned the call light off and walked away, without asking her what she needed, it really affected her dignity and made her feel like she was less of a person. FM 1 stated that many times, she had to come to the facility at 03:00 a.m., 03:30 a.m., and 04:00 a.m., to change Resident 9's adult briefs, because it was soaked with urine and feces. During an interview on 12/16/2021 at 3:15 p.m., Resident 9 stated that, there was a time at two O'clock in the morning when she called for help and nobody came to help her. Resident 9 stated she felt like she was wet, so she checked her adult briefs and pulled out a handful of feces. Resident 9 stated CNA 4 did not clean her nicely and she still had feces on her lower body. Resident 9 stated she had to call her daughter to come to the facility early in the morning to change her adult briefs and provide care for her. Resident 9 stated that it made her feel distressed, like she was nothing, it really affected her psychosocial being, her dignity and her whole being. b.A review of the admission record indicated Resident 66 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (when a lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off), dysphagia (difficulty swallowing), dependence on ventilator (dependent upon mechanical life support because of inability to breathe effectively), unspecified convulsion (a condition in which muscles contract and relax quickly and cause uncontrolled shaking of the body). A review of the MDS, dated [DATE], indicated Resident 66 had severe cognitive impairment. During an observation on 12/13/2021 from 11:39 a.m., until 11: 52 a.m., Resident 66 was laying on the bed, exposed and visible to passersby with only adult briefs on. During an interview on 12/14/2021 at 3:31 p.m., Resident 66's family member (FM) stated that the facility did not cover Resident 66's body and exposed her, to staff, vendors, and other residents' family members. FM stated that if she herself was left exposed for periods of time, that would really affect her whole being negatively, FM stated it really was a dignity issue. During an interview on 12/17/2021 at 12:03 p.m., CNA 12 acknowledged that leaving any resident exposed with no privacy is a dignity issue, that would make someone so uncomfortable. CNA 12 stated it was important to make sure Residents of the facility were treated with dignity. During an interview on 12/17/2021 at 12:06 p.m., CNA 13 stated that having someone seeing your private parts exposed not only to the staff but other residents and family members, was a bad feeling and very uncomfortable. That will really make you less of a human being. That's very clearly a dignity issue. During a review of the facility's P/P titled, Dignity dated revised February 2021, the P/P indicated: each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation: Residents are treated with dignity and respect at all times. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs. This begins with the initial admission and continues throughout the resident's facility stay. When assisting with care, residents are supported in exercising their rights. For example: residents are encouraged to dress in clothing that they prefer: Staff promote. maintain and protect resident privacy. including bodily privacy during assistance with personal care and during treatment procedures.

CONCERN (D)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the nursing staff failed to ensure bed control and call light devices were within reach for one of three sampled residents (Resident 74). This deficient practice had the potential for the facility not to address Resident 74's induvial hydration, medical, elimination and comfort needs. Findings: A review of Resident 74's Face Sheet (admission record) indicated Resident 74 was admitted to the facility on [DATE]. Resident 74's diagnoses included encephalopathy (term for any brain disease that alters brain function or structure), abnormalities of gait and mobility, epilepsy (a neurological disorder marked by sudden recurrent episodes of sensory disturbance, loss of consciousness, or convulsions, associated with abnormal electrical activity in the brain) and essential hypertension (high blood pressure). During a review of Resident 74's Minimum Data Set (MDS-a comprehensive assessment and care planning tool) dated 07/06/2021 indicated Resident 74 had impaired cognitive function (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) and required limited assistance for bed mobility and transfer and required extensive assistance for getting dressed, toilet use and personal hygiene. During a review of Resident 74's Care Plan (CP) dated, 06/08/2021, indicated, Resident 74 had ADL (activities of daily living) self-care performance deficit related to history of cardiovascular accident ([CVA] stroke) and seizure and resident required assistance by one staff to turn and reposition in bed and transfer and needed to use call bell for assistance. During an observation on 12/13/2021 at 10:11 a.m., Resident 74's bed control was on the floor and the call light was at the bottom of the head of bed. During an observation on 12/15/2021 at 09:32 a.m., Resident 74's bed control and call light were hanging on the floor. During an interview on 12/15/2021 at 09:35 a.m., certified nursing assistant (CNA 1) acknowledged that when a resident cannot reach the call light, there's a potential for falls and resident would be at high risk for injury. CNA 1 stated if the resident could not reach the call light and could not call for help, it did not accommodate the residents' needs and it would make the resident feel like less of a person, which could lead to depression, anxiety, restlessness because the resident did not have the control to ask for help. During an interview on 12/17/2021 at 12:01 p.m., licensed vocational nurse (LVN 2) confirmed that if a resident could not reach the call light, it was just too impossible to call for help and that could drive one crazy when one is not able to get help and when a resident really needed help and help did not come, it would affect ones psychosocial being and the resident might get up and fall if the resident cannot wait for the help needed. During a review of facility's policy and procedure (P/P) titled, Accommodation of Needs dated revised January 2020, indicated: Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being.

CONCERN (D)

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

Deficiency F0561 (Tag F0561)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to allowe bathing preference for five of five residents (Residents 13, 20, 59, 75, 92) This deficient practice had the potential to affect Resident's (Residents 13, 20, 59, 75, 92) quality of life. Findings: On 12/14/21, at 10:46 a.m., during Resident Council meeting Resident 59, and 88, two out of 13 alert and oriented residents who attended the meeting, stated rights of residents at this facility are not respected and encouraged. A review of Resident 59's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 09/22/2021, indicated the resident had intact cognitive skills (ability to think, understand and make daily decision) for daily decision making. A review of Resident 88 MDS dated [DATE] indicated the resident had intact cognitive skills for daily decision making. a. A review of Resident 13's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 8/8/2021, indicated the cognitive (the ability to understand or to be understood by others) skills for daily decisions making was intact, and total dependence with bathing with one-person physical assist (to help) and two persons assist for toilet use, locomotion and transfer. MDS indicated resident had an active diagnosis of diabetes mellitus ([DM] abnormal blood sugar), hypertension ([HTN] condition present when blood flows through the blood vessels with a force greater than normal), heart failure (a condition in which the heart has trouble pumping blood through the body), coronary artery disease ([CAD] a disease caused by cholesterol buildup in the wall of the major blood vessels that supply blood to the heart. During an interview on 12/20/21, at 9:54 a.m., Resident 13 stated shower was not provided on 12/13/21. Resident 13 stated Certified Nurse Assistant (CNA 10) was aware Resident 13 had to shower prior to treatment but CNA 10 told Resident 13 bed bath could only be provided because CNA 10 had too many residents to shower. Resident 13 stated Resident 13 felt disgusted and frustrated that Resident 13 cannot get a proper shower and had to settle with bed baths. During an interview on 12/17/21, at 2:22 p.m., CNA 14 stated sometimes they were so short staffed, CNAs were unable to take all residents to the shower room and were only able to provide bed baths. CNA 14 stated staffing issues were brought to the attention of Administrator (Admin) during a meeting when ASD was on vacation, but nothing was done. CNA 14 stated Resident 13 had verbalized showers were not being provided by CNA 10 on several occasions. During an interview on 12/21/at 10:00 a.m., ASD stated she usually made the CNA nursing assignment and there were plenty of days that staff called in sick and would ask staff to come in to work, but no one can work. ASD stated she did not try to reach out to registry (an agency that provides professional staff for temporary facility needs), because she was not aware if there was any registry and as far as she knows they do not use registry. ASD stated she notified the (DON) and Administrator (ADM) she did not have adequate staffing, but they were not able to provide additional staff and just have to work with the staff they have. During a concurrent interview and record review of Census and Nursing Hours per Patient Day ([NHPPD] form indicating projected daily nursing hours) for 12/13/2021 with Director of Nursing (DON) on 12/22/21 at 11:02 a.m., DON stated the NHPPD for 12/13/2021 was 3 and indicated they were not meeting the required 3.5 nursing hours on 12/13/2021 because they were short staffed: A review of All Facilities Letter (AFL) dated 1/23/18, indicated, effective July 1 ,2018, SB 97 (Chapter 52, Statutes 2017) requires SNFs, except those that are a distinct part of general acute care or a state- owned hospital or development center, to provide a minimum of 3.5 direct care service hours per patient day, with a minimum of 2.4 performed by certified nurse assistants. b. During an interview on 12/20/21, at 11:17 a.m., Resident 59 stated a shower schedule change request was made to ASD on several occasions so Resident 59 will be able to shower prior to attending dialysis visits on Mondays, Wednesdays, and Fridays, but request was denied by ASD due to staffing issues. Resident 59 stated additional showers were not granted because of staffing issues. Resident 59 stated this made Resident 59 feel dirty and embarrassed because dialysis staff have mentioned on several occasions to Resident 59 they prefer Resident 59 to come to visits showered and clean and they ask Resident 59 why Resident 59 wasn't showered on dialysis days. During an interview on 12/19/201 12:50 p.m. CNA 23 stated they are sometime short staff and when they were short staff, they ended up having 10 to 11 residents and that workload was heavy. They cannot provide shower as schedule and will only shower alert resident because they will complain and those who are not alert don't get shower even if they were scheduled to be shower. During an interview on 12/19/2021, at 1:00 p.m. CNA 22 stated facility was short staffed, and CNA sometimes have 11 residents each when they normally have 8 for day shift and were not able to shower resident as scheduled. They only shower alert resident because they will complain but unable to shower those who are not alert and can only give bed bath because showers takes too long and they cannot accommodate residents request to be showered when it was not their shower day. Giving shower takes about an hour specially when they have to use lift machine. Resident 20 and Resident 59 will request to be shower but we cannot grant their request because our workload was heavy when we are short staff and told the residents they cannot honor their request. CNA 22 stated they follow the shower days based on bed location and not on residents needs or preference because with short staff it was hard to accommodate residents' request. During an interview on 12/21/21 at 07:30 a.m., LVN 5 stated that starting October 2021 Staffing issues was bad and there were times CNAs have 12 each when they were only supposed to have 8 and they were not able to shower residents. Resident 59 shower schedule were Wednesday, Saturday and Sundays and she goes to dialysis Monday, Wednesday, and Friday. She was requesting to be showered when she goes to Dialysis, but some CNAs were not able to shower her because of short staffing. I agree that residents should be showered when they go to dialysis because dialysis residents were prone to infection, and we don't want the resident to get infection and our staffing should be improved so the CNAs can have enough time to perform their duties. A record review of Resident 59's Bathing record for December 2021 indicated Resident 59 did not received a bath/shower/ bed bath on her dialysis days on 12/1/2021, 12/3/2021, 12/5/2021, 12/8/2021, 12/13/2021, and 12/15/2021. During a review of the facility's policy and procedure titled, Resident Self Determination and Participation, dated February 2021, indicated each resident is allowed to choose activities, and schedule health care and healthcare providers, that are consistent with his or her interests, values, assessments and plans of care, including: daily routine and personal care needs, such as bathing schedules bathing methods, grooming and styles of dress. During a concurrent interview and record review of Facility Assessment form dated 10/27/2021, DON stated record indicated general staffing plan to ensure sufficient staff to meet the needs of the residents at any given time was direct care staff ratio was 1 CNA is to 8 residents' ratio for day shift, 1 is to 12 residents' ratio for evening shift and 1 CNA to 14 residents' ratio for night shift for Skilled Nursing Facility. c. A review of the admission Records indicated Resident 75 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses not limited to paraplegia (loss of the ability to move the legs and lower body), seborrheic dermatitis (a skin condition that causes dry, flaky patches and red skin, mainly on the scalp), major depressive disorder ([MDD] a common but serious mood disorder. It causes severe symptoms that affect how you feel, think, and handle daily activities, such as sleeping, eating or working), obesity (excess body fat). During a concurrent observation and interview on 12/13/21 at 10:58 a.m., at Resident 75's room, Resident 75 was observed moving his head side to side on pillow and complaining his head and back were very itchy. Resident 75 stated he was very uncomfortable and hated that his head, back and buttocks get itchy all the time. Observed CNA 9 turn Resident 75 to the right side to scratch Resident 75's head and back and noticed Resident 75 had red, dry patches of skin on entire back and buttocks. During an interview on 12/13/21 at 11:00 a.m. with CNA 9, CNA 9 stated Resident 75 has rashes all over his back and buttocks. CNA 9 stated that Resident 75 frequently asks to get his back scratched. CNA 9 stated treatment nurses put cream on Resident 75's back to help with the itchiness and rash but Resident 75 still complains of frequent itchiness. During an interview on 12/22/21 08:43 a.m., Resident 75 stated he wanted to be showered but they told him he cannot shower because he was too big. Resident 75 stated they do not shower him and only gets bed bath. Resident 75 stated he wanted to feel better and treat his rashes because he was itchy and felt uncomfortable without shower. During an interview on 1/22/2022, at 09:30 a.m., LVN 12 stated Resident 75 have rashes covering almost entirely his back and buttocks due to perspiration and his rashes gets worse during summertime because of heat. LVN 12 stated Resident 75 wanted to have shower and she was frustrated because she also wanted Resident 75 to have a shower, but the CNAs (did not specify name) response was how when he was overweight, too heavy as he weighs about 348 pounds (unit of measurement) and might fall. LVN 12 stated showering is very important to ensure to provide good skin care and assess skin condition, but facility was short staff and does not have enough CNA to be able to shower all residents. LVN 12 stated the DON was aware Resident 75 was not being showered and only getting bed bath. During an interview 12/22/2021 at 11:45 a.m., DON stated Resident 75 was being provided bed bath only because of his weight and unable to provide reason why resident cannot be showered and stated there was no contraindication for Resident 75 to be showered and CNAs should be able to shower resident and will ensure resident gets shower. A review of facility's policy and procedure (P/P) titled Bath, Shower/Tub Program, dated revised February 2018, indicated the purpose of this procedure are to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin. Document the date and time the shower/tub bath was performed. The name and title of the individual(s) who assisted the resident with the shower/tub. All assessment data (example any reddened areas, sores, etc., on the resident's skin) obtained during the shower/tub bath. If the resident refused the shower/tub bath, the reason. d. During an interview on 12/16/21, at 11:08 a.m., Resident 92 stated on one occasion Resident 92 wanted to shower prior to going out on pass for unspecified day and unnamed staff told her she does not have enough time to shower Resident 92 because the facility was short staffed. Resident 92 stated shower wasn't offered later in the day. Resident 92 stated lack of shower made Resident 92 feel embarrassed, disgusted, and dirty. During an interview on 12/17/21, at 9:52 a.m., Assistant Staff Developer (ASD), stated there was no written shower schedule policy. ASD stated residents should be able to change shower schedules and request for extra showers on nonscheduled days if staffing permits. ASD stated there were days they were short staffed, unable to find replacement and as a result staff were not able to make at least every two hours rounds because of heavy workload. A lot of residents were mad because we cannot attend to their needs timely. There was a Human Resource who came but nothing changed. ASD stated she agreed that facility was short staff and staffing needed to be improved, staff were tired and can get hurt when overworked and some may choose not to stay when overworked. During an interview on 12/17/21, at 2:22 p.m., with CNA 14, CNA 14 stated during the months of October and November, CNA morning shift was short staffed. CNA 14 stated on several occasions, he couldn't take several of the residents to the shower room and was only able to provide bed baths. During an interview 12/22/2021 at 11:45 a.m., DON stated all residents on Skilled Nursing Facility should be able to shower on their scheduled shower day and if anyone request for shower a preferred shower day, they should be allowed an opportunity to exercise his or her autonomy regarding those things that were important in his or her life including the residents' interests and preferences. DON stated showering was important to promote cleanliness, good hygiene and help improve skin condition. During a review of the facility's policy and procedure titled, Resident Rights, dated December 2016, indicated federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to self-determination, be supported by the facility in exercising his or her rights and participate in his or her care planning and treatment.

CONCERN (D)

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

Deficiency F0576 (Tag F0576)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on interview and record review, the facility failed to ensure resident's mail were delivered unopened and on Saturdays for two of 13 residents (Residents 59 and 88) as stated during the resident council. These deficient practices resulted in the feeling of lack of privacy and untimely delivery of mail for Residents 59 and 88. Findings: During the resident council meeting, on 12/14/21, at 10:46 a.m., Resident 59 stated sometimes her mail is opened and she does not always get mail right away. Resident 59 stated the staff wait for there to be more mail for individual residents before delivering. Resident 88 stated she had two pieces of mail opened before and gets mail on weekends sometimes. During an interview on 12/22/21, at 9:36 a.m., with Activities Director (AD), the AD stated mail is delivered to the business office daily. AD stated she distributed mail to alert residents and sent mail for non-alert residents to their family or conservators. AD stated there were days when mail delivery to residents got skipped because the mail arrived late in the day and the activities department were gone for the day. AD stated sometimes residents received more mail because they received two days' worth of mail. AD stated on the weekends she assigned an assistant to check and distribute the mail. AD stated mail should be delivered in good condition, closed, sealed, and not damaged. During an interview on 12/22/21, at 9:43 a.m. with Business Office Manager (BOM), the BOM stated her shift was from 8:30 a.m. to 5:00 p.m. on weekdays. BOM stated she sorted the mail and set residents' mail aside. BOM stated activities assistants usually collected the mail from her if they were working. BOM stated when she is not working, activities had access to her office to retrieve mail. BOM stated she saw mail left over from the weekend and realized activities did not distribute mail on the weekends. During a review of the facility's policy titled, Resident Rights, revised 12/2016, indicated federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to have access to a telephone, mail, and email.

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide 24 out of 27 sampled residents (323, 6, 3, 57, 173, 74, 11, 71, 4, 22, 42, 9, 66, 109, 419, 86, 96, 85, 420, 169, 23, 170, 102, and 171), and or their responsible parties, with written information on how to formulate an Advanced Directive (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor). This deficient practice had the potential for violating Resident 323, 6, 3, 57, 173, 74, 11, 71, 4, 22, 42, 9, 66, 109, 419, 86, 96, 85, 420, 169, 23, 170, 102, and 171 choices about their medical care. Findings: During a review of Resident's medical records, the following information was missing: -Resident 323 (admitted on [DATE]) did not have an advanced directive or a signature declining information on how to obtain an advanced directive. -Resident 6 (admitted on [DATE] and readmitted on [DATE]) did not have an advanced directive or a signature declining information on how to obtain an advanced directive. -Resident 3 (admitted on [DATE]) did not have an advanced directive or a signature declining information on how to obtain an advanced directive. -Resident 57 (admitted on [DATE] and readmitted on [DATE]) did not have an advanced directive or a signature declining information on how to obtain an advanced directive. -Resident 173 (admitted on [DATE]) did not have an advanced directive or a signature declining information on how to obtain an advanced directive. -Resident 74 (admitted on [DATE]) did not have an advanced directive or a signature declining information on how to obtain an advanced directive. -Resident 11 (admitted on [DATE] and readmitted on [DATE]) did not have an advanced directive or a signature declining information on how to obtain an advanced directive. -Resident 71 (admitted on [DATE] and readmitted on [DATE]) did not have an advanced directive or a signature declining information on how to obtain an advanced directive. -Resident 4 (admitted on [DATE]) did not have an advanced directive or a signature declining information on how to obtain an advanced directive. -Resident 22 (admitted on [DATE] and readmitted on [DATE]) did not have an advanced directive or a signature declining information on how to obtain an advanced directive. -Resident 42 (admitted on [DATE]) did not have an advanced directive or a signature declining information on how to obtain an advanced directive. -Resident 9 (admitted on [DATE]) did not have an advanced directive or a signature declining information on how to obtain an advanced directive. -Resident 66 (admitted on [DATE]) did not have an advanced directive or a signature declining information on how to obtain an advanced directive. -Resident 109 (admitted on [DATE] and readmitted on [DATE]) did not have an advanced directive or a signature declining information on how to obtain an advanced directive. -Resident 419 (admitted on [DATE]) did not have an advanced directive or a signature declining information on how to obtain an advanced directive. -Resident 86 (admitted on [DATE]) did not have an advanced directive or a signature declining information on how to obtain an advanced directive. -Resident 96 (admitted on [DATE] and readmitted on [DATE]) did not have an advanced directive or a signature declining information on how to obtain an advanced directive. -Resident 85 (admitted on [DATE] and readmitted on [DATE]) did not have an advanced directive or a signature declining information on how to obtain an advanced directive. -Resident 420 (admitted on [DATE]) did not have an advanced directive or a signature declining information on how to obtain an advanced directive. -Resident 169 (admitted on [DATE]) did not have an advanced directive or a signature declining information on how to obtain an advanced directive. -Resident 23 (admitted on [DATE]) did not have an advanced directive or a signature declining information on how to obtain an advanced directive. -Resident 170 (admitted on [DATE]) did not have an advanced directive or a signature declining information on how to obtain an advanced directive. -Resident 102 (admitted on [DATE]) did not have an advanced directive or a signature declining information on how to obtain an advanced directive. -Resident 171 (admitted on [DATE]) did not have an advanced directive or a signature declining information on how to obtain an advanced directive. During an interview on 12/14/2021 at 3:43 p.m., the Social Services Director (SSD) stated that advance directives must be in the resident's chart within 4 days upon admission, if the resident had an advance directive before admission, the facility would just obtain a copy, if the resident needs a witness then the facility can help accommodate witnessing for advance directives form. During an interview on 12/15/2021 at 4:12 p.m., the SSD assistant stated that advance directives must be in the chart upon admission. If the resident does not have an advance directive, it should be in the Social Services notes, if the resident does not want to execute one During an interview and concurrent record review (RR) on 12/22/2021 at 08:51 a.m., the SSD assistant stated that advance directive must be in the chart as soon as possible, there must be a form that it was offered, and it should be in the resident's chart, if not it must be documented in the Social Services notes. RR with SSD assistant indicated, there was no advance directives forms to all the mentioned residents' above and RR indicated, there was no documentation in the Social Services notes. During a review of the facility's policy titled, Advance Directives dated revised December 20, the P/P indicated: Advance directives will be respected in accordance with state law and facility policy. Upon admission, the resident will be 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. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. Nursing staff will document in the medical record the offer to assist and the president's decision to accept or decline assistance.

CONCERN (D)

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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview and record review, the facility failed to ensure residents know how to file their grievances (official statement of complaints) for four of 13 residents (Residents 10, 21, 24 and 49) who attended the resident council (a monthly gathering of residents independent of the facility to discuss concerns about quality of care, and quality of life) meeting. This deficient practice violated the resident's right to have their grievances addressed. Findings: During a group interview at the resident council meeting on 12/14/21, at 10:35 am, Resident 10, 21, 24 and 49 stated that they do not know how to file a grievance. During an interview on 12/22/2021, at 9:56 am with Social Services Director (SS), the SS stated residents are reminded and encouraged during admission and quarterly assessment on how to file grievances. SSD stated the process to file a grievance is to notify the social services department and fill out a grievances form. SS stated an investigation starts once an issue is made. SS stated that during the weekends, residents can bring up their issues to the nurses and grievances can be communicated to social services department on the following Monday. SS stated resolution time of the grievance varies. During a review of the facility's policy, Resident Rights, revised 12/2016, indicated resident has the right to voice grievances to the facility, or other agencies without discrimination or fear of reprisal.

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of three residents' (Resident 22) head of the bed was elevated to 30 to 45 degrees during administration of medications and enteral feeding (a form of nutrition that is delivered directly into the gastrointestinal system using a flexible tube inserted through the nose or abdominal wall) thru a gastrostomy tube (GT- is a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications This deficient practice placed Resident 22 at risk for aspiration (accidental breathing in of food or fluid into lungs which can cause serious lung problems). Findings: During a medication pass observation on 12/15/21, at 8:47 am, Licensed Vocational Nurse 3 (LVN 3 ) administered medication via gastrostomy tube while Resident 22 bed was on a flat position and receiving enteral feeding. During an interview on 12/16/21, at 10:53 am with Licensed Vocational Nurse 6 (LVN 6), LVN 6 stated that residents should be in a 45 degrees position when medicines are administered thru gastrostomy tube to prevent aspiration. During a record review of Resident 22's admission Record on 12/28/21, Resident 22 was admitted to the facility on [DATE], with diagnoses that included acute respiratory failure ((condition in where your lungs can not get enough oxygen into the blood), hemiplegia (paralysis of one side of the body), dysphagia (difficulty in swallowing caused by nerve or muscle problems), gastrostomy (an opening into the stomach from the abdominal wall, made surgically for the introduction of food), tracheostomy (an opening surgically created through the neck into the windpipe(trachea) to allow direct access to the breathing tube) and dependence on ventilator status (inability to breathe without the assistance of mechanical ventilator (a machine that takes over the work of breathing when a person is unable to breathe on his own). During a record review of physician's order dated 9/23/2018 , indicated an active physician's order to elevate head of the bed 30 degrees to 45 degrees during feeding. During a record review of policy and procedure titled, Enteral Feeding, revised in September 2018, indicated that residents receiving enteral feeding will be in a position where the head of the bed is at 30 degrees to 45 degrees for feeding. During a record review of an online article in a Nursing Journal title Nursing 2022, dated September 2011, indicated that the current recommendation is that all patients receiving enteral nutrition must have the backrest elevated to a minimum of 30 degrees and preferably to 45 degrees. During a record review of Lippincott procedures regarding Enteral tube feeding, (a method of delivering nutrients directly into the gastrointestinal tract), revised November 2021, indicated that patients receiving enteral nutrition will be positioned with the head of the bed at least 30 degrees or position the patient upright in a chair.

CONCERN (D)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent dehydration for one (1) out of eight (8) sampled resident (Resident 62) by failing to: 1. Monitor and address Resident 62's symptom of dehydration (elevated sodium) 2. Ensure Resident 62 received adequate hydration to maintain well being 3. Develop an individualized/person centered care plan with goals and interventions for dehydration. This deficient practice resulted in Resident 62's risk for dehydration, and hospitalization. Findings: During a review of Resident 62's admission Face Sheet, the Face Sheet indicated Resident 62 was originally admitted to the facility on [DATE] and recently re-admitted [DATE]. Resident 62's diagnoses included respiratory failure (inadequate gas exchange), pneumonitis due to inhalation of food and vomit (inflammation of lung tissue), dementia (disorder of mental processes caused by brain disease or injury and marked by memory disorder, personality changes, and impaired reasoning), Parkinson's disease (a progressive disease of the nervous system resulting in impaired movement), Alzheimer's disease (irreversible, progressive brain disorder that slowly destroys memory and thinking skills, and eventually the ability to carry out the simplest tasks), and diabetes mellitus (high blood sugar). During a review of Resident 62's Minimum Data Set (MDS), a comprehensive assessment and care screening tool, dated 9/19/2021, the MDS indicated Resident 62's cognitive (mental action or process of acquiring knowledge and understanding) function is severely impaired and always incontinent (inability to control) of bladder and bowel. The MDS indicated Resident 62 was totally dependent with a one to two-person physical assist for bed mobility, transfer, dressing, toilet use and personal hygiene. Resident 62 require extensive assistance with one-person physical assist for eating. During a review of Resident 114's admission Face Sheet, the Face Sheet indicated Resident 114 was originally admitted to the facility on [DATE] and recently admitted [DATE]. Resident 114's diagnoses included paraplegia (paralysis of the legs and lower body, typically caused by spinal injury or disease), neuromuscular dysfunction of bladder (lack of bladder control due to brain, spinal cord or nerve problems) and major depressive disorder (mood disorder that causes persistent feelings of sadness and loss of interest and can interfere with your daily functioning). During a review of Resident 114's Minimum Data Set (MDS), dated [DATE], the MDS indicated Resident 114's cognitive function was intact with the capacity to understand and make decisions. The MDS indicated Resident 114 required extensive assistance with one person assist for bed mobility and getting dressed. She required limited assistance with one person assist for toilet use and personal hygiene. Resident 62 required supervision with one-person physical assist for eating. 1.During a concurrent observation and interview on 12/13/21 at 12:19 p.m., Resident 62 was observed lying in bed sleeping. Resident 114 stated that Resident 62 was usually awake, but she has been sleeping more and more and eating less the past three (3) days. Resident 114 stated that Resident 62 need help with eating and drinking. She stated that she heard staff saying that Resident 62's diaper has been dry. During a concurrent observation and interview on 12/14/2021 at 7:22 a.m., Code blue (a medical emergency in which a team of medical personnel work to revive an individual when the heart stops) was called over head for Resident 62. Staff present included Registered Nurse (RN3), Licensed Vocational Nurse (LVN 8) and Respiratory Therapist (RT1). Director of Nursing (DON) stated that Resident 62 was desaturating (level of oxygen in the body is low) and residents' eyes are closed but with body movement. During observation on 12/14/2021 at 7:30 a.m., 911 arrived at the facility. During observation on 12/14/2021 at 7:38 a.m., 911 left facility with Resident 62 During an interview on 12/14/2021 at 7:45 a.m., Resident 114 stated that Resident 62 was sleeping all night and was awake in the morning but did not eat breakfast. Resident 114 stated that Resident 62 have not been eating for about two to three days. She stated that around 5:30 p.m. yesterday Resident 62 vomited during dinner after staff gave her ensure supplement to drink. She stated that Resident 62 would sometimes tell staff no pee pee. During an interview on 12/14/2021 at 7:47 p.m., LVN 8 stated that Resident 62 was found short of breath during rounds today and not responding. She stated vitals were taken and found resident's oxygen saturation ([O2 sat] measure of amount of oxygen traveling through the body with your red blood cells with normal level range between 95% - 100%) at 85% room air; 5 liters per minute (LPM) of oxygen via nasal canula (devise used to deliver supplemental oxygen or increased airflow) was placed on Resident 62 and O2 sat went up to 95%. During review of 'Progress Notes' dated 12/14/2021 timed at 7:20 a.m., indicated that paramedics arrived and assessed resident at bedside with O2 sat 95% at 5LPM via nasal canula, resident awake and alert to name, HOB (head of bed) maintained elevated, BP 124/819 ([BP - Blood pressure - force of blood pushing against the walls of your arteries with normal pressure below 120 mm Hg systolic and 80 mm Hg diastolic), pulse 119-120 (fluctuates) no c/o pain or discomfort, resident assisted by paramedics to gurney and transferred the resident to an acute care facility for eval and left at 7:40. During review of 'Progress Notes' dated 12/14/2021 at 6:00 p.m., indicated resident was readmitted from acute care x 1 nonverbal with O2 sat at 2LPM via N/C no facial grimacing or pain, transported via ambulance .with new order for Hospice (plan of comfort care with focus on quality of life with compassion and dignity for end-of-life care) Evaluation . During review of 'Progress Notes' dated 12/16/2021 time at 3:39 a.m., indicated upon rounds @ approx. 2300 (11:00 p.m.) writer ([License Vocational Nurse] - LVN10) noted resident lying on bed without distress noted, chest noted with rise and fall, respirations present, pulse palpable, resident warm to touch, @ approx. 0030 (12:30 a.m.) CNA came to writer to inform that resident seemed listless or non-responsive, writer noted resident with no respirations, pulse non-palpable, resident is DNR (no not resuscitate - medical written order by a physician that instructs health care providers not to do cardiopulmonary resuscitation), writer informed RN supervisor. During review of 'Progress Notes' dated 12/16/2021 time at 12:33 a.m., indicated resident found pulseless, no palpable B/P (blood pressure), resident DNR called Doc1's exchange. Spoke with exchange regarding resident passing. Called husband made aware, also called [NAME] Hills mortuary per husband wishes. Obtained T/O (telephone order) for D/C (discharge) body to [NAME] Hills Mortuary. During review of facility's 'Record of Death,' undated, indicated that Resident 62's date of death was 12/16/2021 and time of death was 12:33 a.m. During observation and interview on 12/16/2021 at 3:20 p.m., Resident 114 was observed crying in her room because she is very upset about Resident 62's passing. She stated Resident 62 was not eating or drinking for about 5 days and the staff don't try to feed or give her water. Resident 114 stated staff leave the tray at Resident 62's bedside and call her name, but if she doesn't respond they don't try to feed or give her fluids. She stated no water randomly offered to Resident 62 throughout the day, only with meals if staff is willing to sit and help her. Resident 114 stated there have been times that she helps Resident 62 because she can't do it herself. During review of 'Progress Notes' dated 12/9/2021 timed at 9:20 a.m., indicated that doctor (Doc1) ordered Atarax 10mg PO TID x5 for skin irritation to upper chest area. During review of 'Progress Notes' dated 12/9/2021 timed at 10:46 p.m., indicated resident is monitoring for itching. Resident noted with dry skin and minimal redness. During review of Resident 62's 'Lab Results Report' dated/collected 7/20/2021, indicated labs are as follows: Sodium ([Na+] electrolyte that helps regulate the amount of water that is in and around cells with normal range 136-145 meq/L (milliequivalents per liter - amount of a substance that will react with a certain number of hydrogen ions) Estimated Glomerular Filtration Rate (eGFR - measures kidney's ability to filter toxins or waste from your blood). Normal range 7-25mg/dl (milligram per deciliter - unit of measure that show the concentration of a substance in a specific amount of fluid) Blood Urine Nitrogen (BUN - medical test that measure amount of urea nitrogen found in blood with normal range 7-25mg/dl) Creatinine (measure of how well your kidneys are performing thier job of filtering waste from your blood with normal range 0.60 - 1.20 mg/dl) Sodium 152 Meq/L () eGFR 34 (normal range >/= 60) BUN 27 mg/dL (normal range 7-25mg/dl) Creatinine - 1.48 mg/dL (normal range 0.60 - 1.20 During review of Resident 62's 'Lab Results Report' dated/collected 7/25/2021, indicated labs are as follows: Sodium (Na+) 146 Meq/L (normal range 136-145meq/L) eGFR 43 (normal range >/= 60) BUN 28 mg/dL (normal range 7-25mg/dl Creatinine - 1.19 mg/dL (normal range 0.60 - 1.20 mg/dl) During review of Resident 62's 'Lab Results Report' dated/collected 9/8/2021, indicated labs are as follows: Sodium (Na+) 147 Meq/L (normal range 136-145meq/L) eGFR 44 (normal range >/= 60) BUN 28 mg/dL (normal range 7-25mg/dl Creatinine - 1.18 mg/dL (normal range 0.60 - 1.20 mg/dl) Notes indicated that Doc1 was made aware A review of Resident 62's acute hospital's Emergency Department documents dated 12/14/2021 at 4:39 p.m., indicated that assessment shows severe dehydration and malnutrition, renal failure, NSTEMI, Alzheimer, COPD, Parkinson and hypertension. During review of Resident 62's labs collected from acute hospital dated/collected 12/14/2021 at 8:07 a.m., indicated labs are as follows: Sodium (Na+) 176 Meq/L (normal range 136-145meq/L) eGFR 13 (normal range >/= 60) BUN 71 mg/dL (normal range 7-25mg/dl Creatinine - 3.4 mg/dL (normal range 0.60 - 1.20 mg/dl) During an interview and record review on 12/16/2021 at 3:55 p.m., Dietary Consultant (DC) stated that she looks at the resident's fluid intakes and labs such as sodium, BUN and creatinine to determine hydration. DC stated it looks like the last time Resident 62 had labs drawn were on 9/8/2021 which indicates that resident's sodium level of 147 and Bun of 28 are elevated from the normal range. She stated that she did not see those labs, but if she did, she would repeat and monitor Resident 62's labs, consult with a physician to consider intravenous fluids ([IVF] specifically formulated liquids that are injected into a vein to prevent or treat dehydration), continue to follow up and monitor repeated labs. DC stated that Resident 62's lab report from the hospital indicates that she is dehydrated and is very alarming. She stated that if labs were monitored more closely, the dehydration could possibly have been avoided. She stated that she is upset with herself that she missed reviewing the 9/8/2021 labs. During interview on 12/17/2021 at 8:28 a.m., RN3 stated Resident 62's oxygen saturation was in the 80s, residents head was elevated, placed 2-liter oxygen via nasal canula per standing order. She stated Resident 62's baseline is nonverbal but awake. She stated resident was sent to acute hospital on [DATE] but returned on the same day with hospice evaluation order. She stated sodium level of 176 is high and shows Resident 62 is dehydrated and it can cause death. During interview and record review on 12/21/2021 at 1:20 p.m., Licensed Vocational Nurse (LVN13) stated the Resident 62 is bed ridden, confused, need assistance with feeding, drinking, toileting, turning and ADLs (activities of daily living). She stated that when lab results are received, she would compare them from previous labs and notify the physician of any out-of-range labs. LVN13 stated that sodium 147 Meq/L is elevated and BUN 28 is reportable and if both elevated, intravenous fluids are usually ordered. She stated there is no charting in the progress notes that indicates the labs collected on 9/8/2021 were addressed but faxed to hematologist. During interview on 12/21.2021 at 2:38 p.m., Director of Nursing (DON) stated lab faxes the facility results and Registered Nurse supervisors or charge nurse will either call doctor or fax labs to specialist. He stated Resident 62 is high risk for dehydration and sign and symptoms he looks for includes dry skin, sunken face, drowsiness, urine output and labs. DON stated that Atarax was prescribed to Resident 62 for dry skin but is not sure if dry skin is due to dehydration because it could be anything. DON stated he does not know how Resident 62's sodium level was elevated to 176 meq/L at the hospital. He stated dehydration can happen quickly. 2. During review of Resident 62's December fluid intake are as follows: 12/1/2022 1:19 p.m. - 360 ml 1:19 p.m. - 360 ml 10:19 p.m. - 400 ml 12/2/2021 1:29 p.m. - 360 ml 1:29 p.m. - 360 ml 9:47 p.m. - 400 ml 12/3/21 4:40 p.m. - 240 ml 12/4/21 6:04 p.m. - 240 ml 12/5/21 7:30 a.m. - 240 ml 12:00 p.m. - 240 ml 4:45 p.m. - 240 ml 12/6/2021 9:48 a.m. - 240 ml 1:51 p.m. - 240 ml 9:02 p.m. - 240 ml 12/7/2021 1:53 p.m. - 360 ml 1:53 p.m. - 360 ml 9:22 p.m. - 400 ml 12/8/2021 5:00 p.m. - 240 ml 12/9/2021 2:14 p.m. - 360 ml 2:14 p.m. - 360 ml 4:36 p.m. - 240 ml 12/10/2021 9:32 p.m. - 240 ml 12/11/2021 1:28 p.m. - 360 ml 1:28 p.m. - 360 ml 10:22 p.m. - 120 ml 12/12/2021 9:11 p.m. - 240 ml 12/13/2021 2:11p.m. - 120 ml 2:12 p.m. - 240 ml 9:26 p.m. - 0 ml 12/14/2021 Resident not available 12/15/2021 10:25 p.m. - 400 ml During review of 'Bladder Continence Documentation Survey Report' in the month of December indicates the following output: 12/10/2021 2:52 a.m. x 1 4:43 p.m. x 1 12/11/2021 1:57 a.m. x 1 10:24 p.m. x 1 1:29 p.m. x 1 12/12/2021 2:09 a.m. x 1 4:49 p.m. x 1 12/13/2021 2:28 a.m. x 1 4:42 a.m. x 1 2:14 p.m. x 1 12/14/2021 5:40 a.m. x 1 12/15/2021 5:14 a.m. x 1 10:26 p.m. x 1 During review of facility's 'Nutritional Assessment' dated 1/21/2021, indicated that identification of risk indicators included current food and fluid intake of 51-75% with estimated fluid needs range of 1511 -1813 ml (25-30ml/kg). During an interview and record review on 12/16/2021 at 3:55 p.m., Dietary Consultant (DC) stated that according to the fluid intake recorded, Resident 62 was not getting enough water or fluids. She stated on 12/3/21, 12/4/21, 12/8/21, 12/10/21, 12/12/21 shows that Resident 62 only consumed 240 milliliters (ml - unit of volume in the metric system). DC stated in the month of December only 12/7/21, 12/9/21 and 12/11/21 indicates that Resident 62 received sufficient fluid. She stated that according to the amount of fluid intake charted correlates with the labs results found in the hospital. DC stated it's important to receive proper hydration because dehydration can cause death. During interview and record review on 12/21/2021 at 1:20 p.m., Licensed Vocational Nurse (LVN13) stated the Resident 62 is bed ridden, confused, need assistance with feeding, drinking, toileting, turning and ADLs (activities of daily living). Fluids are typically given during mealtimes and medication pass, but resident is not capable of asking for hydration. LVN 13 stated they make sure residents are voiding and look at the color of urine. She stated that if residents don't void for 8 hours, she would let the physician know. During interview and record review on 12/21.2021 at 2:38 p.m., Director of Nursing (DON) stated Resident 62 is alert, confused, slow feeder and needs help eating and drinking. He stated Resident 62 is high risk for dehydration and sign and symptoms he looks for includes dry skin, sunken face, drowsiness, urine output and labs. DON stated he does not know if Resident 62 was getting enough fluid daily. He stated he did not know how much fluid Resident 62 required before or after her hospitalization. DON could not verbalize when a physician should be alerted regarding hydration issues. 3. During an interview on 12/16/2021 at 3:55 p.m., Dietary Consultant (DC) stated that she ordered extra 8 ounces of water with meals back in September for the resident 62, but no care plan was initiated for dehydration. She stated that the extra fluid was placed in the weight loss care plan, but there should be one specific for dehydration. DC stated that care plan is important to keep everyone informed of residents' plan of care with goals and measurable outcomes. During an interview on 12/21/21 at 2:38 p.m., Director of Nursing (DON) stated there is no care plan for dehydration. DON could not verbalize whether a dehydration care plan is imperative in Resident 62's care. Facility could not provide a dehydration care plan for Resident 62. A review of facility's policy and procedure (P&P) titled 'Monitoring and Follow-Up' revised 9/2017, indicate 'the physician and staff will monitor for the subsequent development, progression, or resolution of fluid and electrolyte imbalance in at risk individuals. a. For example, replacement may be adequate if the resident is clinically stable, not having delirium, voiding at lease every 3-4 hours, and the urine specific gravity (where attainable) is less than 1.015. The physician will adjust treatments based on specific information (lab results, level of consciousness, etc.) relevant to that individual .b. Repeating the basic metabolic profile and/or serum osmolality can help track progress in correcting abnormalities. A review of facility's policy and procedure (P&P) titled 'Hydration' revised 9/2017, indicate that the physician and staff will help define the individual's current hydration status (fluid and electrolyte balance or imbalances). The physician will distinguish various types of fluid and electrolyte imbalance (for example hyponatremia, hypernatremia, pre-renal azotemia, etc) from true dehydration (clinically significant loss of total body water) .The staff, with physician's input, will identify and report to the physician individuals with signs and symptoms (for example, delirium, lethargy, increased thirst, etc) or lab test results (for example hypernatremia. Azotemia, etc) that might reflect existing fluid and electrolyte imbalance .The physician will manage significant fluid and electrolyte imbalance, and associated risk, appropriately and in a timely manner. Timeliness depends on the severity, nature, and causes of the fluid and electrolyte imbalance .The staff shall provide supportive measures such as supplemental fluids and adjusting environmental temperature, where indicated. A review of facility's policy and procedure (P&P) titled 'Change in a Resident's Condition or Status,' revised 12/2021, indicated the nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition; specific instruction to notify the physician of changes in the resident's condition. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); impacts more than on area of the resident's health status; requires interdisciplinary review and/or revision to the care plan . A review of the facility's policy and procedure titled, Care plans, Comprehensive person-centered, revised 12/2016, indicated that a comprehensive, person-centered care plan will that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being; .incorporate identified problem areas; incorporate risk factors associated with identified problems .The comprehensive, person centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). Assessments of residents are ongoing and care plans are revised a information about the residents and the residents' conditions change.

CONCERN (D)

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to complete an assessment post-hemodialysis ([HD] - process of removing waste, salt, and extra water to prevent build up in the body for residents who had impaired kidney function) for one (1) of eight (8) sampled residents (Resident 7). This deficient practice placed the resident at risk for a delay in detecting if the resident had a non-functioning arteriovenous shunt (AV- a connection or passageway between an artery and a vein used for hemodialysis) and a delay in detecting complications including infections, bleeding and/or nausea and vomiting. Findings: During a review of Resident 7's admission Record, the record indicated Resident 7 was admitted to the facility on [DATE]. Resident 7's diagnoses included End Stage Renal Disease ([ESRD] condition which a person's kidneys cease functioning on a permanent basis leading to the need for dialysis or kidney transplant to maintain life), diabetes mellitus (irregular blood sugar), hypertension (high blood pressure), hyperlipidemia (high level of fats in the blood), and atherosclerotic heart disease (build up of fats, cholesterol, and other substances in and on the artery walls). During a review of Resident 7's Minimum Data Set (MDS), a comprehensive assessment and care screening tool, dated 8/3/2021, the MDS indicated Resident 7's cognitive (mental action or process of acquiring knowledge and understanding) function was intact. The MDS indicated Resident 7 required extensive assistance with one to two persons assist with bed mobility, transfer, dressing, toilet use and personal hygiene. He requires limited assistance for eating. During observation, interview, and record review on 12/13/2021 at 12:56 p.m., Resident 7 stated he started HD five (5) months ago, but his dialysis this morning was rough. Resident 7 stated he started vomiting thirty (30) minutes after starting HD and had to be stopped for ten (10) minutes. Resident 7 stated he vomited again about an hour ago upon return to the facility. Resident 7 stated that staff was aware that he vomited and just does not feel right and feeling bad. He stated he felt dizzy, lightheaded and like he's getting sick. Resident 7 further stated that staff did not assess his AV shunt or take his vitals after he came back from HD. Resident 7 proceeded to show his 'Dialysis Communication Record' dated 12/12/2021, which indicated post dialysis assessment section was not filled out. During observation on 12/13/2021 at 1:24 p.m., Resident 7 grabbed a plastic bag and started vomiting. He then hit the call light to summon staff. During observation, interview, and record review on 12/13/2021 at 1:35 p.m., License Vocational Nurse (LVN 16) stated Resident 7 arrived at approximate 12:15 p.m. today, but she did not assess him as soon as he arrived because she was helping with meals. She stated she saw him at the entrance and Resident 7 informed her that he was not going out for an outing because he was not feeling well. LVN 16 confirmed she should have assessed him right there and then, especially because he was not feeling good. She stated that they're suppose to do an assessment and take vital signs before and after HD. It's important to assess AV shunt site for bleeding, vital signs and other sign and symptoms which may indicate infection or electrolyte imbalance. During review of care plan 'The resident needs hemodialysis r/t ESRD' initiated 7/28/2021, indicated that The resident will have immediate intervention should any s/sx of complications from dialysis occur . Facility could not provide a policy and procedure for Post Hemodialysis Resident Care. A review of facility's policy and procedure (P&P) titled 'Change in a Resident's Condition or Status,' revised 12/2021, indicated the nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition; specific instruction to notify the physician of changes in the resident's condition. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); impacts more than on area of the resident's health status; requires interdisciplinary review and/or revision to the care plan . A review of facility's policy and procedure (P&P) titled 'Hemodialysis Access Care,' revised 9/2010, indicated that documentation should include location of catheter, condition of dressing (interventions if needed), if dialysis was done during shift, any part of report from dialysis nurse post dialysis being given, and observations post dialysis.

CONCERN (D)

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

Staffing Information (Tag F0732)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview and record review, the facility failed to ensure staffing information was updated and posted in a visible and prominent place, accessible to staff, residents and visitors daily. This deficient practice resulted in inaccessibility of the accurate daily number of clinical staff taking care of residents, daily. Findings: During an observation on 12/20/21, at 12:50 p.m., the Census and Nursing Hours per Patient Day (NHPPD), form indicating projected daily nursing hours, dated 12/20/21 was posted outside of the nurse's station indicating the beginning patient census for the day was 99. During an interview and record review on 12/20/21, at 12:55 p.m., with Assistant Staff Developer (ASD), ASD stated she or the registered nurse (RN) supervisor can fill out the Census and NHPPD form. ASD stated the form is posted so anyone can view it and is important to be completed every day to predict staffing hours of the day for licensed nurses and certified nursing assistants (CNAs). ASD reviewed form for 12/20/21 and stated it was not completed, because sometimes staff calls off and she is not sure who is going to work, so she would not complete the form. During an interview on 12/17/21, at 10:40 a.m. with Director of Nursing (DON), the DON stated staffing hours for CNAs, licensed vocational nurses (LVNs), and RNs, are supposed to be posted daily for the public as part of the regulation. A review of the facility's policy, Posting Direct Care Daily Staffing Numbers, revised 7/2016, indicated within 2 hours of the beginning of each shift, the number of licensed nurse (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. Shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift. The information recorded on the form shall include the following: the resident census at the beginning of the shift for which the information is posted, 24-hour shift schedule operated by the facility, the shift for which the information is posted, type (RN, LPN, LVN, or CNA) and category (licensed and non-licensed) of nursing staff working during that shift; the actual time worked during that shift for each category and type of nursing staff, and the total number of licensed and non-licensed nursing staff working for the posted shift.

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview and record review, the facility failed to: a. Accurately account for the waste of two vials (a small glass container used for medication storage) of one controlled medication (medications with a high potential for abuse, in the Controlled Drug Record (a log signed by the nurse with the date and time of each instance a controlled medication is given to a resident) for Resident 11. b. Ensure controlled medications received from outside the facility were checked and discarded for Residents 68 and 111. These deficient practices increased the facility's risk for potential loss, diversion (transfer of a medication from a legal to an illegal use) or accidental exposure to controlled medications, and potential for harm to residents. Findings: a. During a concurrent observation and interview of the controlled medications awaiting disposition (destruction) and record review on 12/15/21, at 9:11 a.m., with Director of Nursing (DON), there were six vials of Ativan (medication used to treat anxiety) 2 milligrams (mg)/milliliter (ml) for Resident 11. A record review of Resident 11's Controlled Drug Record indicated the dosage of medication to be given is 0.5 milliliters ([ml] 1 mg). Controlled Drug Record indicated on: 10/6/21 at 10:40 a.m., 0.5 ml of Ativan 2 mg/ml was administered, no record for the rest of the contents in the vial, which should have been the amount wasted (irretrievably disposed of). 10/7/21 at 7:03 a.m., 0.5 ml of Ativan 2 mg/ml was administered, no record for the rest of the contents in the vial, which should have been the amount wasted. DON stated an Ativan vial is used once per dose and cannot be kept even if there is left over medication. DON confirmed the rest of the medication in the Ativan vial is supposed to be wasted in the presence of two nurses and documented on the Controlled Drug Record. A review of the facility's policy (P/P), Controlled Substances, revised 4/2019, indicated upon disposition, if a resident received partial tablets or single dose ampules (or it is not administered), the medication may not be returned to the container. Medications that are opened and subsequently not given (refused or partially administered) are destroyed. Waste and/or disposal of controlled medication are done in the presence of the nurse and a witness who also signs the disposition sheet. b. During a concurrent observation of Medication Cart Station #2 and interview on 12/15/21, at 10:53 a.m., Licensed Vocational Nurse (LVN 5), one hydrocodone-acetaminophen (medication used to treat pain) 5-325 mg medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication) was observed in the locked area of the cart. Medication card indicated it was from an outside pharmacy. Medication card label indicated a quantity of 10 tablets were dispensed. Medication card contained 7 tablets with holes punched out from #8, #9, #10 bubbles. 1. A record review of the Controlled Drug Record indicated that the medication card on hand started with 7 tablets. Controlled Drug Record indicated the resident name, medication name, medication strength, and prescription number, but did not indicate physician name, name of issuing pharmacy, quantity received, and date/time received. During an interview with LVN 5, the LVN stated the Controlled Drug Record indicated there are seven tablets in the medication card. LVN 5 stated LVN 14 gave her the medication card and Control Drug Record when Resident 11 was moved from station 1 to station 2. LVN 5 stated the Control Drug Record is not accurate and is a problem because she does not know where the three tablets from bubbles #8, #9, and #10 are. During an inspection of Medication Cart Station #1 on 12/15/21, at 11:28 a.m., with LVN 13, no other Control Log Record was found for the hydrocodone-acetaminophen 5-325 mg dispensed from outside pharmacy. During an interview on 12/15/21, at 11:22 a.m. with RN 5, the RN stated controlled medications come from the pharmacy with a Controlled Drug Record, and licensed nurse that receive medication would verify amount with another licensed nurse. RN 5 stated there is no record of the original Control Drug Record from pharmacy, and the issue is that it cannot be determined if medication was given at facility or not. RN 5 stated if there are discrepancies, licensed nurse should notify the RN supervisor or DON. During an interview on 12/16/21, at 4:00 p.m. with DON, the DON stated he was not able to verify if three hydrocodone-acetaminophen tablets dispensed from outside pharmacy were given at facility. DON stated he was trying to verify if tablets was given at Resident 11's previous facility but could not give an answer if they were or not. 2. During an inspection of Medication Cart Station #3 on 12/15/21, at 3:32 p.m. with LVN 15, one bottle of clonazepam (medication used to treat anxiety) 1 mg tablets, one bottle of quetiapine (medication used to treat certain mental/mood disorders) 50 mg tablets, and one bottle of quetiapine 400 mg tablets for Resident 111 was observed in the locked area of the cart. LVN 15 stated when resident comes back with controlled medications from the doctor, staff keep them in the medication cart, so it is not stored in the residents' room. LVN 15 stated if resident comes to the facility with controlled medications prescribed elsewhere, it should be reported to the registered nurse (RN) to ensure the medications are not being used by another resident. LVN 15 stated she will only give medications to residents dispensed from facility's pharmacy. During an interview on 12/15/21, at 3:29 p.m. with RN 5, the RN stated controlled medications from outside the facility are supposed to be turned into the DON, especially if it was from a different pharmacy. RN 5 stated staff can only give residents medication coming from the facility's pharmacy. RN 5 stated controlled medications that were found in the carts were not properly logged upon possession, so is uncertain if those medications were tampered with. RN 5 stated if controlled medications were found in the medication cart, they were not given to the DON right away. During an interview on 12/16/21, at 4:00 p.m. with DON, the DON stated the process for residents who come to the facility with controlled substances from the outside are to be stored with him for safekeeping. If resident is long-term, the controlled medication must be disposed, and facility's pharmacy will be able to reconcile and dispense. DON stated if controlled medications that are from outside pharmacy were found in the medication cart, they were not turned over and accounted for through documentation. During an interview on 12/21/21, at 10:15 a.m. with DON, the DON stated it is important to account for controlled medications received from outside of the facility. DON stated it is important for accountability, to know the exact number of medications residents come in with, so it is not being given out. DON stated it is important for controlled medications to be stored properly or disposed of because those medications will be reordered at the facility. A review of the facility's policy, Controlled Substances, indicated controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. At the end of each shift any discrepancies in the controlled substance count are documented and reported to the director of nursing services immediately. A review of the facility's policy, Medication Ordering and Receiving from Pharmacy, dated 8/2014, indicated medications brought into the facility by a resident or family member are used only upon written order by the resident's attending physician, after the contents are verified if required, and if the packaging meets the facility's guidelines. Unauthorized medications are not accepted by the facility. The medications received directly from another health care facility e.g., discharge medications arriving with the resident from an acute hospital, or those drugs dispensed or obtained after admission from a physician, or any licensed or governmental pharmacy are not subject to pharmacist verification. Medications not ordered by the resident's physician, or unacceptable for other reasons, are returned to the family or designated agent. If unclaimed within thirty days, the medications are disposed of in accordance with facility medication destruction/disposal procedures.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Label three multi-dose Tuberculosis ([TB] a potentially serious contagious, infectious disease that mainly affects the lungs) vaccine (medication that provides immunity [ability to resist infections]) vials (glass container for medication) with an opened date (the date it was first used, which would determine the expiration date). 2. Discard one over-the-counter medication after expiration. 3. Dispose Ipratropium Bromide (medication used to open the airways of the lungs) in a timely manner for one out of two sampled residents reviewed under the facility task of medication storage (Resident 23). 4. Re-order and replace items for one emergency kit ([e-kit] box containing a small quantity of medications that can be dispensed when pharmacy services are not available) after opening. 5. Properly log removed medication from the e-kit. These deficient practices had the risk that residents may receive medication that had become ineffective or toxic due to improper storage or labeling and may have not received medications due to emergent unavailability, possibly leading to health complications resulting in hospitalization or death. Findings: 1. On [DATE], at 8:26 a.m., during a concurrent inspection of the medication room and interview with Registered Nurse (RN 5), 3 multi-dose TB vaccine vials were found in the refrigerator with no open date. RN 5 stated opened TB vials must have a label with date and time it was opened to ensure medication is not expired for administration. During an interview on [DATE], at 10:15 a.m. with Director of Nursing (DON) the DON acknowledged TB vaccines had to be labeled with an open date because it is only good for a certain number of days. DON stated TB vaccines are supposed to be disposed of after 30 days. DON stated it is best practice to discard them if found with no open date, reorder and replace it. A review of the manufacturer's instructions indicated a vial of Tubersol (Brand Name for TB Vaccine) which has been opened and in use for 30 days should be discarded. Do not use after expiration date. 2. On [DATE], at 3:32 p.m., during an inspection of Medication Cart #3 with LVN 15, one bottle of B-Complex Plus Vitamin C with expiration date 11/21 was found. 3. On [DATE], at 10:02 a.m., during an inspection of Medication Cart on sub-acute unit and interview with LVN 7, one Ipratropium/Albuterol (medication used to open airway to help control symptoms of lung diseases) with open date [DATE] was found. LVN 7 confirmed after opening the medication, it has only 28 days to be used from the opened date and medication should have been discarded. During an interview on [DATE], at 4:00 p.m. with DON, the DON stated, for medications with expiration date 11/21, the medication was good until the end of that month. DON stated medications that expired were supposed to be discarded. A review of the facility's policy (P/P), Administering Medications, revised 4/2019, indicated the expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. A review of the facility's P/P, Discarding and Destroying Medications, revised 4/2029, indicated medications will be disposed of in accordance with federal, state, and local regulations governing management of non-hazardous pharmaceutical, hazardous waste and controlled substances. 4. On [DATE], at 11:16 a.m., during an inspection of the medication room and interview with LVN 5, one e-kit was found secured by a yellow tab. LVN 5 stated if there is a yellow tab securing the e-kit, it means that it was opened. During an interview on [DATE], at 12:28 p.m. with RN 5, the RN verified yellow tab securing the e-kit meant it was opened and if a red tab is securing e-kit it meant it was from the pharmacy. RN 5 stated once an e-kit had been opened, it should be replaced by the following day, but at most within 48 hours. RN 5 stated licensed nursing staff were supposed to be calling the pharmacy for the replacement. RN 5 stated that there is no evidence that a new e-kit was requested. During an interview on [DATE], at 10:15 a.m., with DON, the DON stated the last day the e-kit was ordered was on [DATE]. DON stated e-kit must be replaced as soon as possible from pharmacy to have complete emergency medications. DON stated it is important to have medications in case residents need it and are not available. During an interview on [DATE], at 9:42 a.m., with facility's pharmacy customer service representative, the representative stated the last e-kit the facility ordered was on the morning of [DATE] and was sent out that evening. Representative stated no e-kit was ordered or delivered after that day. 5. During a concurrent interview and record review on [DATE], at 12:28 p.m. with RN 5, the RN stated the process when opening an e-kit is to notify the pharmacy the need for removing the medication from the e-kit and to log the medications being dispensed on the Emergency Kit Pharmacy Log found inside the e-kit. RN 5 stated the Emergency Kit Pharmacy Log will consists of two copies, the white copy is placed in a binder, stored inside the facility's medication room, and the yellow copy is placed back into the e-kit for pharmacy to know what medication was removed. A review of the white copy of Emergency Kit Pharmacy Log record indicated one Bactrim (antibiotic medication) 800/160 milligrams (mg) DS tablet was removed on [DATE] at 8:00 p.m. A review of the yellow copy of Emergency Kit Pharmacy Log record indicated one Bactrim 800/160 mg DS tablet was removed on [DATE] at 8:00 p.m. and two Azithromycin (antibiotic medication) 250 mg tablets were removed on [DATE]. An inspection of the e-kit indicated there were 3 Bactrim/Septra DS 800/160 mg tablets and two Azithromycin 250 mg tablets remaining. A record review of the drug supply list inside the e-kit indicated there was a total of 4 Bactrim DS/Septra DS 800/160 mg tablets and 4 Azithromycin 250 mg tablets. A review of the facility's policy, Medication Ordering and Receiving from Pharmacy, dated 8/2014, indicated when an emergency or state dose of medication is needed, the nurse unlocks the container and removes the required medication. After removing the medication, complete the emergency e-kit slip and re-seal the emergency supply. An entry is made in the emergency log book containing all required information. As soon as possible, the nurse records the medication use on the medication order form and notifies the pharmacy for replacement of the emergency drug supply. A record of the name, dose of the drug administered, name of the patient, date, time of the administration, and the signature of the person administering the dose shall be recorded in the emergency log book. The used sealed kits are replaced with the new sealed kits within 72 hours of opening.

CONCERN (D)

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

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide food preferences for one of eight sampled residents (Resident 92). This deficient practice had the potential to result in decreased meal satisfaction and decreased overall caloric intake. Findings: During a review of Resident 92's admission Record (Face Sheet), the face sheet indicated Resident 92 was admitted to the facility on [DATE]. Resident 92's diagnosis included Hemiplegia (paralysis of one side of the body), weakness, abnormalities of gait and mobility. During a review of Resident 92's Minimum Data Set (MDS), a resident assessment and care planning tool, dated 10/19/2021, the MDS indicated Resident 92 was mildly cognitively (ability to think, understand and made daily decision) impaired and was able to understand and understood others. The MDS indicated Resident 92 required supervision and one-person physical assist for eating. During a concurrent observation and interview on 12/19/21 at 8:15 a.m. at Resident 92's room, Resident 92 stated she could not eat eggs because it upset her stomach. Resident 92 stated she had asked multiple times not to have eggs on her tray. Resident 92's breakfast tray was observed with two boiled eggs. The diet meal ticket indicating on Resident 92'meal tray indicated Resident 92 was not to have eggs. Resident 92 stated she had spoken to management on several occasions regarding her food preferences, but no changes had been made. During a review of Resident 92's physician orders summary report indicated an order dated 5/14/2021 for Regular-NAS (No Added Salt) diet, no eggs, no cheese, and no milk. During a current observation and interview on 12/19/2021 at 08:20 a.m., CNA 22 stated she delivered the breakfast tray to Resident 92's room and it had 2 boiled eggs on the tray. CNA 22 stated she only checked the resident's name on the breakfast tray to ensure the correct tray was given to the resident but she did not compare what diet was written on the meal ticket and what was on the breakfast tray. CNA 22 stated Resident 92 did not request for eggs and does not know why they gave her eggs when the meal ticket indicated no eggs and giving her food that she was not supposed to eat was not good because resident might have allergy or can get sick. During a concurrent observation and interview on 12/19/2021 at 08:24 a.m., LVN16 stated he was responsible for checking the meal trays and the dietary meal ticket, resident name, diet order and compare against what was on the meal tray. LVN 16 stated he did not catch that there were two boiled eggs on Resident 92's breakfast tray and had missed the instruction on the dietary meal ticket that indicated Resident 92 cannot have eggs. LVN16 stated it was important to check the meal ticket to ensure resident received the appropriate diet ordered, food preference and restrictions for resident safety and respect resident food preferences and wishes and encourage eating. During a concurrent interview and record review of Resident 92's dietary meal ticket for 12/19/2021 with Dietary Aide 1 on 12/19/21 at 10:20 a.m., [NAME] 2 stated Resident 92 did not request for hardboiled egg but sent Resident 92 a breakfast tray with two hardboiled egg because she remembered resident liked hardboiled egg with, harsh brown and bacon without checking the diet order or food preference prior to preparing Resident 92's breakfast meal. [NAME] 2 stated Resident 92's meal ticket indicated the resident should not have hardboiled egg and does not know why resident cannot have eggs, but she should follow the order because resident might have allergy that could make resident sick. [NAME] 2 confirmed it was important if a resident requested a food preference, the facility needed to follow it, to respect the resident's wish to eat what they wanted. During an interview on 12/19/2021 at 12:30 p.m., Director of Nursing (DON) stated they had an interdisciplinary team meeting (multi-disciplinary care conference) with Resident 92 and Resident 92's son and have discussed food preferences and have listed eggs, cheese and milk as something she did not like and did not mention why Resident 92 did not like eggs and have updated the Diet order not to have eggs, cheese and milk. DON acknowledged dietary and nursing staff should have checked the order and they should have not given Resident 92 eggs and followed the order and respect resident preference and respect the resident wish. During a record review of the Resident 92's multidisciplinary care conference notes dated 11/30/2021, indicated Resident 92 Dietary preferences/ restrictions included no added salt therapeutic diet (NAS), Resident verbalized she dislike eggs, cheese and milk and Resident 92 and Resident 92's son requested to have no eggs, cheese and milk in the diet order. During a record review of Resident 92's care plan for potential nutritional problems initiated on 8/1/2021 indicated interventions to provide, serve diet as ordered, Regular-NAS diet, regular texture, thin consistency, no eggs, no cheese, no milk. During a review of the facility's policy and procedure (P/P) titled, Resident Food Preferences, revised July 2017, the P/P indicated individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. Nursing staff will document the resident's food and eating preferences in the care plan. During a review of the P/P titled, Therapeutic Diets, revised October 2017, the P/P indicated therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care in accordance with his or her goal and preferences. Diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. During a review of the P/P titled, Tray Identification, revised April 2007, the P/P indicated to assist in setting up and serving the correct food trays/diets to residents, the Food Services Department will use appropriate identification e.g computer generated diet cards to identify the various diets. The Food Services Manager or supervisor will check trays for correct diets before the food carts are transported to their designated areas. Nursing staff shall check each food tray for the correct diet before serving the residents. If there is an error, The nurse supervisor will notify the Dietary Department immediately by phone so that the appropriate food tray can be served.

CONCERN (D)

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

Deficiency F0838 (Tag F0838)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview, and record review, the facility failed to assess, document, and implement the Facility Assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. The facility failed to: 1. follow its own policy to ensure the staff had the knowledge base, capability, and capacity to perform their duties by failing to demonstrate competency with infection control and abuse policies. 2. ensure facility has sufficient staff to assure residents' care and safety needs were met. 3. provide a safe, functional, sanitary, and comfortable environment for 122 residents, staff, and visitors, by not maintaining the facility's roof, resulting in multiple water leaks from the ceiling in the dining room (also used for activities) and nurses' station. These deficient practices had the potential for 122 of 122 residents who resided in the facility not being assisted timely or at all, not receive medically related care and services, which could cause serious injury, harm, impairment, or death., or had the potential to negatively affect the quality of life due to the leaking ceiling. Findings: 1a. During an observation and interview from 12/13/2021 to 12/22/2021, Facility failed to educate at least two Family members (FM1 and FM2) regarding what were the required infection control policies to follow when visiting resident (Resident 170) on clostridium difficile ([C-diff] a contagious infection, inflammation of the colon caused by the bacteria clostridium difficile, causing diarrhea) isolation with active diarrhea, and in yellow zone (area for newly admitted residents with incomplete or unknown COVID-19 vaccination status) room without a gown, face shield, N95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of infectious particles in the air) Both FM1 and FM 2 stated they were not instructed which personal protective equipment (PPE) was required and handwashing protocol, to stop the spread of infections, when visiting. During an observation from 12/13/2021 to 12/22/2021, at least four Staff (CNA4, CNA10, CNA9, LVN 13) did not wear the required PPE in the C-diff room, and in the yellow zone (rooms with residents that were symptomatic, or may have been exposed to Covid-19) rooms, did not wash their hands in between resident care for Resident 170, Resident 68, 93, 121, 171, 319 and 321. During an interview on 12/14/2021 at 9:06 a.m., the infection preventionist (IP) confirmed visitors should be educated and made aware they must follow the isolation precautions. IP stated contact isolation is used for C-Diff infections which is, wearing a gown, and gloves and washing hands in between resident care, when any staff or family member came in contact with a resident, without the required PPE and failed to perform, handwashing, the infection can spread, and to anybody in the facility. During an interview on 12/14/2021 at 9:08 a.m., IP verified an N95 respirator, face shield, gown and gloves were required PPE when entering yellow zone, and failing to wear this PPE was an infection control issues that put the residents at risk for getting infected for any virus or bacteria and could potentially cause transmission of communicable diseases and infections. During an interview on 12/15/21 at 2:52 p.m., IP stated she provided education to her staff that proper hand-hygiene was required before putting on or taking off PPE and before and after touching a resident. IP stated hand washing with soap and water was required if coming into contact with bowel movements because of possible contamination when going from dirty area to clean area. During a concurrent observation and interview on 12/13/2021 at 11:13 a.m., Housekeeper 1 (HK 1) was observed cleaning a yellowish brown substance (potentially body fluids) on the floor using bleach disinfectant wipes and immediately wiped it with a dry cloth towel and did not follow the manufacturer recommended contact time of 3 minutes and to pre clean prior to disinfecting. HK1 read the manufacturer recommended contact time on the Clorox Bleach container and stated according to the instruction on the bottle, contact time should have been 3 minutes. HK1 admitted he normally disinfected with 10-30 seconds contact time because he has a lot of things to do. During an interview on 12/22/21 at 10:21 a.m. with the Administrator (ADM), acknowledged the facility did not identify staff and visitors were not following infection prevention policies to prevent the spread of communicable disease. ADM stated the IP and DON and himself were trying their best to provide in-services but the full-time DSD was on maternity leave and the assistant DSD covering for the DSD was only working part time and did not to come to facility regularly which might have contributed to the lapse in infection control education of staff and visitors. A record review of Facility Assessment form dated 10/27/2021, indicated all personnel will be trained on infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities. 1b. facility failed to investigate a resident-to-staff altercation for 1 of 2 residents (Resident 9) after Health Facilities Evaluator Nurse (HFEN 1) had made the Administrator aware on 12/14/2021 at 12:44 p.m., Resident 9 reported an allegation of abuse and reported that on 11/28/2021 at 2:00 a.m. CNA 3 was involved in a fist fight with Resident 9. . During an interview and concurrent record review of investigation report for the allegation of abuse for Resident 9 on 12/21/21, at 12:44 a.m., ADM was unable to provide documentation and stated he had not initiated an investigation. ADM admitted he failed to report the abuse to Department and could not provide reason why the abuse was not reported and investigated but he should have initiated an investigation immediately when HFEN 1 informed him of the allegation of abuse. ADM stated if he had investigated as soon as he was made aware and dug deeper, he would have found out who the staff was and suspended her to keep the resident safe and prevent possible retaliation from staff. A record review of Facility Assessment form dated 10/27/2021, indicated that Staff training/education and competencies topic will include abuse, neglect and exploitation training that at a minimum educates staff on activities that constitutes abuse, neglect, exploitation and procedures for reporting incidents of abuse, neglect, exploitation or misappropriation of resident property and resident abuse prevention. 2. During a concurrent record review of nursing assignment sheets and census (number of residents in the facility) in the skilled-nursing facility (SNF) department for random dates with Assistant Staff Developer (ASD) on 12/21/at 10:00 a.m., ASD stated they were short staffed on the following days: a. 11/7/21, 4 CNAs, 2 LVNs, 1 RN assigned to 100 residents for 11:00 p.m. to 7:00 a.m. shift b. 11/13/21, 4 CNAs, 2 LVNs, 1 RN assigned to 105 residents for 11:00 p.m. to 7:00 a.m. shift c. 11/25/21, 4 CNAs, 2 LVNs, 1 RN assigned to 107 residents for 11:00 p.m. to 7:00 a.m. shift d. 12/16/21, 5 CNAs, 2 LVNs, 1 RN assigned to 104 residents, but 1 CNA called off for 11:00 p.m. to 7:00 a.m. shift e. 12/18/21, 4 CNAs, 3 LVNs, 1 RN assigned to 101 residents for 3:00 p.m. to 11:00 p.m. shift ASD stated she usually made the CNA nursing assignment and there were plenty of days that staff called in sick and would ask staff to come in to work, but no one can work. ASD stated she did not try to reach out to registry (an agency that provides professional staff for temporary facility needs), because she was not aware if there was any registry and as far as she knows they do not use registry. ASD stated she notified the DON and ADM that she did not have adequate staffing, but they were not able to provide additional staff. ASD verified, for a census of 103 they should have 6 CNA at night shift and assigned to maximum of 16 to 21 residents but sometimes they have 26 residents each CNA and that was a lot for 1 CNA. ASD stated they need to have adequate staff for safety of residents, CNAs were tired, and they can get hurt if they were tired and we are going to lose staff if we were always short staff. During an interview on 12/21/at 11:30 a.m., DON stated he was aware that there were days some staff called in sick but unable to find replacement. DON stated they tried to call other staff to come in to work but no one was available but did not try to reach out to sister company, call registry nor reached out to any agency. DON stated they do not have registry and only tried to work with the staff they have. During a concurrent interview and record review of Facility Assessment form dated 10/27/2021, DON confirmed records indicated the general staffing plan to ensure the facility meets the needs of the residents at any given time should be Direct care staff ratio was 1 CNA is to 8 residents' ratio for day shift, 1 is to 12 residents' ratio for evening shift and 1 CNA to 14 residents ratio for night shift for Skilled Nursing Facility. During a concurrent interview and record review of Census and Nursing Hours per Patient Day ([NHPPD] form indicating projected daily nursing hours) for random nursing hours with Director of Nursing (DON) on 12/22/21 at 11:02 a.m., DON stated the NHPPD indicated they were not meeting the required 3.5 nursing hours on the following days because they were short staffed: a. On 11/13/21 final NHPPD was 2.92 b. On 11/25/21 final NHPPD was 2.85 c. On 12/16/21 final NHPPD was 2.52 d. On 12/18/21 final NHPPD was 2.69 DON stated it was important to ensure they meet the required 3.5 NHPPD to follow to meet the overall needs of the residents, and to follow regulations. A record review of Facility Assessment form dated 10/27/2021 indicated NHPPD for SNF=3.5x hours per resident days indicating a) total number of license nurse staff hours per resident per day, b) RN hours per resident per day) LVN hours per resident per day, d) certified nursing assistant hours per day, e) physical therapy staff hours per resident per day. A review of All Facilities Letter (AFL) dated 1/23/18, indicated, effective July 1 ,2018, SB 97 (Chapter 52, Statutes 2017) requires SNFs, except those that are a distinct part of general acute care or a state- owned hospital or development center, to provide a minimum of 3.5 direct care service hours per patient day, with a minimum of 2.4 performed by certified nurse assistants. During an interview on 12/22/2021, at 10:50 a.m., ADM stated their process when short staffed was to ask staff to stay over, call off duty staff, and stated they have a contract with registry who can be reached 24 hours a day, 7 days a week. ADM stated he was not aware of the staffing shortage and if he was informed, he would have called registry, used Reddinet a tool that maybe used by the facility to communicate situational information to the county or to MHOAC [(Medical and Health Operational Area Coordinator) Local Emergency Medical Services agency] and report facility status. During a review of the facility's COVID-19 Mitigation Plan [(MP) a plan to reduce the spread of the COVID-19 virus), undated, the MP indicated it is the policy of the facility to maximize the staff availability and utilize these approved staffing registries if they were unable to cover staffing needs during an emergency. If this strategy does not meet the facility's needs, facility may request additional staff through Medical Health operational Area Coordinator program. 3. During an observation on 12/14/2021, at 10:30 a.m., two black trash cans and one gray water basin with water was observed on the floor by the entrance door towards the back of the dining room (also used for activities). The ceiling was observed to have a crack line approximately three (3) feet long with water dripping from ceiling during the Resident Council Meeting, which was attended by 13 residents. This deficient practice can potentially cause, structural damage including ceiling collapse, electrical outage, electrocution, and damage of medical records. A record review of Facility Assessment form dated 10/27/2021, indicated Maintenance service shall be provided to all areas of the building, grounds, and equipment. The maintenance department was responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personnel include but are not limited to maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. Maintaining the building in good repair and free from hazards. A record review of Facility Assessment form dated 10/27/2021, indicated nursing facility will conduct, document, and annually review a facility wide assessment, which includes both their resident population and the resources the facility needs to care for their residents. Facility resources needed to provide competent care for residents, including staff, staffing plan, staff training/education and competencies, education and training, physical environment and building needs, and other resources, including segments with third parties, health information technology resources and systems, a facility based and community-based risk assessment, and other information that you may choose.

CONCERN (D)

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

QAPI Program (Tag F0867)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on observation, interview, and record review the facility's Quality Assessment and Assurance ([QAA] develop and implement appropriate plans of action to correct identified quality deficiencies) and Quality Assurance Performance Improvement ([QAPI] takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed identify facility and resident care issues, develop and implement appropriate plans of action: 1. To ensure QAA/QAPI committee systematically implemented and evaluated measures to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections: These failures placed all the residents, staff, and the community at higher risk for cross contamination, and increased spread of clostridium difficile ([C-diff] Inflammation of the colon caused by the bacteria Clostridium difficile) and COVID-19 ([a highly contagious infection, caused by a corona virus that can easily spread from person to person]) infection in the facility and the community. 2. To ensure QAA/QAPI committee promptly implemented measures to correct problems with lack of sufficient competent staff to assure residents' care and safety needs were met. This deficient practice had the potential to affect all 122 residents who resided in the facility, and residents not receiving the treatments necessary to meet their highest potential and well-being. 3. To ensure QAA/QAPI committee provide safe, functional, sanitary, and comfortable environment for 122 residents, staff, and visitors by not maintaining the facility's roof, resulting in multiple water leaks from the ceiling in the dining room (also used for activities) and nurses' station. This deficient practice can potentially cause, structural damage including ceiling collapse, electrical outage, electrocution, and damage of medical records. 4. To ensure the QAA/QAPI committee implemented the facility's written abuse policy and procedure and ensured the alleged perpetrator CNA3 did not have continued access to one of 2 residents (Resident 9) by failing to report and investigate properly the alleged abuse. These deficient practices resulted in physical and psychological harm to Resident 9 when facility failed to follow-up on the abuse incidents to ensure Resident 9 felt safe and secure. Findings: Cross reference to F880 a. During an observation and interview from 12/13/2021 to 12/22/2021, at least two Family member (FM1 and FM2) were observed not following infection control practices for a resident (Resident 170) on clostridium difficile ([C-diff] inflammation of the colon caused by the bacteria clostridium difficile) isolation with active diarrhea, and in yellow zone (area for newly admitted residents with incomplete or unknown COVID-19 vaccination status) room without a gown, face shield, N95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of infectious particles in the air) . Both FM1 and FM 2 stated they were not instructed what were the required PPE and handwashing protocol when visiting. During an observation from 12/13/2021 to 12/22/2021, at least 4 Staff (CNA4, CNA10, CNA9, LVN 13) did not wear the required PPE in Cdiff room and in yellow zone room, did not wash their hands in between resident care for Resident 170, Resident 68, 93, 121, 171, 319 and 321. During an interview on 12/14/2021 at 09:06 a.m., the infection preventionist (IP) stated that visitors should be informed and made aware they must follow the isolation precaution. IP stated that for C-Diff contact isolation, it requires gown, gloves and mask and washing hands in between care, when any staff or family member will be in contact with the resident not wearing required PPE and not performing handwashing can spread, and cross contaminate with anybody in the facility. During an interview on 12/14/2021 at 09:08 a.m., IP stated N95, face shield, gown and gloves were required PPE when entering yellow zone and not wearing PPE was an infection control issues that will put the resident at risk from getting infected for any virus or bacteria and can potentially cause transmission of communicable diseases and infections. During an interview on 12/15/21 at 2:52 p.m., IP stated she provided education to her staff on proper handwashing and hand-hygiene was required before putting on or taking off PPE and before and after touching the resident. IP stated hand washing with soap and water was required if touching bowel movement because of possible contamination when going from dirty area to clean area. During a concurrent observation and interview on 12/13/2021 at 11:13 a.m., Housekeeper 1 (HK 1) was observed cleaning yellowish brown substance (potentially body fluids) on the floor using bleach disinfectant wipes and immediately wiped it with dry cloth towel and did not follow the manufacturer recommended contact time of 3 minutes and to pre clean prior to disinfecting. HK1 stated no additional steps was needed when cleaning potential body fluids. HK1 read the manufacturer recommended contact time on the bleach container and stated according to the instruction on the bottle, contact time should be 3 minutes. HK1 admitted he normally disinfect with 10-30 seconds contact time because he has a lot of things to do. During a review of the manufacturer label for Clorox Bleach wipe, indicated to clean and disinfect visibly soiled surfaces, pre cleaning is required prior to disinfecting and contact time is 3 minutes. During a concurrent interview and review of the QAPI minutes on 12/22/21 at 10:21 a.m. with the Administrator, the QAPI minutes indicated the facility addressed COVID-19 concerns monthly but despite monthly monitoring the facility did not identify staff and visitors were not following infection prevention policies to prevent the spread of communicable disease. According to the facility's P/P titled Quality Assurance and Performance Improvement (QAPI) QAPI Plan, undated, indicated the scope of the QAPI program encompasses all segments of facility, including House Keeping Services, will provide and ensure that all health, sanitation, and OSHA [(Occupational Safety and Health Administration) is a large regulatory agency of the United States Department of Labor that originally had federal visitorial powers to inspect and examine workplaces] requirements are met through regular cleaning, disinfection, and sanitation of all aspects of the building. Cross reference to F725 b. During a concurrent record review of nursing assignment sheets and census (number of residents in the facility) in the skilled-nursing facility (SNF) department for random dates with Assistant Staff Developer (ASD) on 12/21/at 10:00 a.m., ASD stated they were short staffed on the following days: a. 11/7/21, 4 CNAs, 2 LVNs, 1 RN assigned to 100 residents for 11:00 p.m. to 7:00 a.m. shift b. 11/13/21, 4 CNAs, 2 LVNs, 1 RN assigned to 105 residents for 11:00 p.m. to 7:00 a.m. shift c. 11/25/21, 4 CNAs, 2 LVNs, 1 RN assigned to 107 residents for 11:00 p.m. to 7:00 a.m. shift d. 12/16/21, 5 CNAs, 2 LVNs, 1 RN assigned to 104 residents, but 1 CNA called off for 11:00 p.m. to 7:00 a.m. shift e. 12/18/21, 4 CNAs, 3 LVNs, 1 RN assigned to 101 residents for 3:00 p.m. to 11:00 p.m. shift ASD stated she usually made the CNA nursing assignment and there were plenty of days that staff called in sick and would ask staff to come in to work, but no one can work. ASD stated she did not try to reach out to registry (an agency that provides professional staff for temporary facility needs), because she was not aware if there was any registry and as far as she knows they do not use registry. ASD stated she notified the (DON) and Administrator (ADM) that she did not have adequate staffing, but they were not able to provide additional staff and just have to work with the staff they have. ASD stated for census of 103 they should have 6 CNA at night shift and assigned to maximum of 16 to 21 residents but sometimes they have 26 residents each CNA and that was a lot for 1 CNA. ASD stated they need to have adequate staff for safety of residents, CNAs were tired, and they can get hurt if they were tired and we are going to lose staff if we were always short staff. During an interview on 12/21/at 11:30 a.m., DON stated he was aware that there were days some staff called in sick but unable to find replacement. DON stated they tried to call other staff to come in to work but no one was available but did not try to reach out to sister company, call registry nor reached out to any agency. DON stated they do not have registry and only tried to work with the staff they have. During a concurrent interview and record review of Census and Nursing Hours per Patient Day ([NHPPD] form indicating projected daily nursing hours) for random nursing hours with Director of Nursing (DON) on 12/22/21 at 11:02 a.m., DON stated the NHPPD indicated they were not meeting the required 3.5 nursing hours on the following day because they were short staffed: a. On 11/13/21 final NHPPD was 2.92 b. On 11/25/21 final NHPPD was 2.85 c. On 12/16/21 final NHPPD was 2.52 d. On 12/18/21 final NHPPD was 2.69 DON stated it was important to ensure they meet the required 3.5 NHPPD to follow the regulations and to meet the overall needs of the residents. During a concurrent interview and review of the QAPI minutes on 12/22/2021 at 10:50 a.m., with ADM, ADM stated they did not discussed concerns with staffing in their QAPI meeting and stated their process when short staffed was to ask staff to stay over, call off duty staff, and stated they have a contract with registry who can be reached 24 hours a day, 7 days a week. ADM stated he was not aware of the staffing shortage and if he was informed, he could have called registry, use Reddinet a tool that maybe used by the facility to communicate situational information to the county or to MHOAC [(Medical and Health Operational Area Coordinator) Local Emergency Medical Services agency] and report facility status. During a review of the facility's COVID-19 Mitigation Plan [(MP) a plan to reduce the spread of the COVID-19 virus), undated, the MP indicated it is the policy of the facility to maximize the staff availability and utilize these approved staffing registries if they were unable to cover staffing needs during an emergency. If this strategy does not meet the facility's needs, facility may request additional staff through Medical Health operational Area Coordinator program. A review of All Facilities Letter (AFL) dated 1/23/18, indicated, effective July 1 ,2018, SB 97 (Chapter 52, Statutes 2017) requires SNFs, except those that are a distinct part of general acute care or a state- owned hospital or development center, to provide a minimum of 3.5 direct care service hours per patient day, with a minimum of 2.4 performed by certified nurse assistants. Cross reference to F921 c. The QAA/QAPI committee failed to ensure to provide safe, functional, sanitary, and comfortable environment for 122 residents, staff, and visitors by not maintaining the facility's roof, resulting in multiple water leakage from the ceiling in the dining room and nurses' station. During a QAPI interview on 12/22/2021 at 10:50 a.m. with ADM, ADM stated they had not identified that roof needed repair and did not expect the heavy rain will cause leak in the ceiling and this can potentially cause, structural damage including ceiling collapse, electrical outage, electrocution, and damage of medical records. According to the facility's P/P titled Quality Assurance and Performance Improvement (QAPI) QAPI Plan, undated, indicated the scope of the QAPI program encompasses all segments of facility, including resident/family feedback, staff satisfaction, individualized resident care plans, information technology, facility maintenance plan and QAPI. Maintenance/ Engineering: Facility will provide comprehensive building safety, repairs, and inspections to ensure all aspects of safety are enforced, assuring the safety and well-being for each resident, visitor, and staff who enters the building. Cross Reference to F607/F610 d. The QAA /QAPI committee failed to monitor the provision of care to ensure the staff adhered to facility's abuse policy and procedure and ensured the alleged perpetrator CNA3 did not have continued access to one of 2 residents (Resident 9) by failing to report and investigate properly the alleged abused. During a QAPI interview on 12/22/2021 at 10:50 a.m. with ADM, ADM stated that all allegations of abuse should be reported and investigated. The Administrator acknowledged QAPI was a tool to identify and monitor issues and find a solution, but they had not identified some of the facility's concerns and were not discussed during QAPI meeting. According to the facility's P/P titled Quality Assurance and Performance Improvement (QAPI) Plan, undated, indicated the Quality Assurance (QA) committee will review data and input monthly to look for potential topics for PIP [(Performance Improvement Projects,)] will monitor and analyze data and review feedback and input from residents, staff, families, volunteers, and stakeholders. QA will look at issues, concerns, and areas that need improvement as well as areas that will improve quality of life and quality of care and services for the residents living and staying in our community. Factors we will consider: High risk, high volume, or problem prone areas that affect health outcomes, quality of care and services and areas that affect staff.

CONCERN (E)

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

Deficiency F0557 (Tag F0557)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 27 sampled residents (Resident 13) was treated with respect and dignity by not returning the resident's belongings when the resident requested for them after being re-admitted back into the facility. This deficient practice caused Resident 13 to have decreased feelings of self-worth and quality of life, resulting in Resident 13 not wanting to get out of bed. Findings: A review of the admission record (Facesheet) indicated Resident 13 was admitted to the facility on [DATE] and re-admitted to the facility on [DATE], with diagnoses not limited to heart failure (a condition in which the heart has trouble pumping blood thought the body), muscle weakness, type 2 diabetes (abnormal blood sugar), atrial fibrillation (rapid, irregular beating of the heart), and chronic kidney disease (kidneys are damaged and can get worse over time when not filtering blood the way they should). A review of the Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 11/8/21, indicated Resident 13's Brief Interview for Mental Status (BIMS) score was 15, indicating the resident had no cognitive impairment; required extensive assistance from staff with bed mobility, dressing, toileting, and total dependence from staff with bathing; and used a wheelchair as a mobility device. During an observation and interview on 12/16/21, at 9:22 a.m. with Resident 13, the resident's room was observed in the green zone (area for residents who are not exposed and have tested negative for COVID-19 [a highly contagious infection, caused by a virus that can easily spread from person to person]). The resident stated he was in the hospital from [DATE] to 12/8/21. Resident 13 stated he needed his shoes, glasses, and power chair. Resident 13 stated he feels uncomfortable without his belongings and that he needed his glasses to see because he has impaired vision. The resident stated he has the right to have his belongings and requested his belongings from Social Services Director (SS) but was told by SS that he would get his belongings back after he was out of quarantine. During a follow-up interview on 12/14/21, 4:05 p.m. with Resident 13, the resident stated, I don't get around. I sit in bed all day and night. I don't have my shoes, no house shoes. It makes me feel useless. I don't feel right. During an interview on 12/16/21, at 9:04 a.m. with Certified Nursing Assistant (CNA 17), the CNA stated Resident 13 has been staying in the bed and hasn't been getting up. CNA 17 stated the resident used to get up out of bed and use his powerchair. During a follow-up interview on 12/17/21, at 10:23 a.m. with CNA 17, the CNA stated she took care of Resident 13 last week and he told her he wanted his clothes back. CNA 17 stated she did not tell anyone. During an interview on 12/20/21, at 10:49 a.m. with CNA 10, the CNA stated Resident 13 had a doctor's appointment today at 10:30 a.m., and wanted to wear his personal clothing, not the facility's gown. CNA 10 stated he was frustrated and irritated and refused to go to the appointment. CNA 10 stated she told the social worker he needed his clothes, but he was already mad after he received them. CNA 10 stated the resident told her he wanted his clothes and dentures and did not want to go back to the other room. CNA 10 stated if he did not have his personal belongings it would affect his quality of life, resulting in resident not wanting to go out of his room. During an interview on 12/14/21, at 3:29 p.m. with SS, the SS stated when residents are admitted into the hospital, their belongings will be held in storage until the resident returns, and they are supposed to get their items back. During an observation and interview on 12/14/21, at 3:54 p.m. with SS, observed storage shed in parking lot. SS used key to unlock door and observed three bags of belonging and one power chair for Resident 13. SS stated Resident 13 was re-admitted to a different room and will get his items back once he returns to his old room. SS stated Resident 13 only requested for his cell phone and money and did not request for other items. SS stated Resident 13's old room is currently occupied and was not sure how long it would be occupied for. SS stated Resident 13 was on quarantine until returning to old room and had requested to go back to his room. During a follow-up interview on 12/17/21, at 10:18 a.m. with SS, the SS stated Resident 13's belongings are still in storage because his current room cannot accommodate his belongs because he has too much stuff. SS stated the other room is more spacious and will do a room change for the resident next week. SS stated Resident 13 did not request for anything else. During an interview on 12/17/21, at 10:40 a.m. with Director of Nursing (DON), the DON stated when a resident goes to the hospital, their belongings go to storage. DON stated Resident 13 had a lot of items but has the right to accommodate a few of those items in his current room, because he owns it. DON stated if resident expresses to CNA he wants his belongings, the expectation is for nursing or social services staff to address it. DON stated when Resident 13 was re-admitted to the facility he did not mention he wanted his belongings. DON stated his power chair could be accommodated in his current room. DON stated Resident 13 has used the power chair since he was admitted into the facility and it is his mode of transportation. A review of the facility's policy, Resident Rights, revised 12/2016, indicated federal and state laws guarantee certain basic rights to all residents of this facility including the right to retain and use personal possessions to the maximum extent that space and safety permit. A review of the facility's policy, Dignity, revised 2/2021, indicated residents' private space and property are respected at all times. Staff do not handle or move a resident's personal belongings without the resident's permission.

CONCERN (E)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: a.Provide supervision to one of five known residents who wander (Resident 83) from entering Resident 106's room. This deficient practice resulted in Resident 106 getting angry that Resident 106 violated his personal space and privacy. b. Provide safety to all facility's staff and residents by monitoring opened doors after paramedics left facility. This deficient practice had a potential for residents to leave the facility, with no one knowing their whereabouts, getting lost, getting hurt, and had the protentional for unauthorized persons entering the facility, placing the residents and staff of the facility at risk. Findings: a. During an observation on 12/13/21, at 12:28 p.m., surveyor overheard Resident 106 yelling loudly, Get the f&%k out of here. Surveyor observed Resident 83 who was in a wheelchair, wheel himself into Resident 106's room. Certified Nursing Assistant (CNA 19) took Resident 83 back to his room. A review of Resident 83's admission record, indicated the resident was admitted to the facility on [DATE], with diagnoses not limited to heart failure (a condition in which the heart has trouble pumping blood thought the body), dementia (memory loss) with behavior disturbance, end stage renal disease ([ESRD] the stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplantation to maintain life), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness) and major depressive disorder ([MDD] a common but serious mood disorder. It causes severe symptoms that affect how you feel, think, and handle daily activities, such as sleeping, eating, or working). A review of Resident 83's Minimum Data Set ([MDS] a standardized assessment and screening tool) dated 10/7/21, indicated the resident had severe cognitive impairments; required extensive assistance from staff for bed mobility, locomotion on/off unit, dressing, toileting; and total assistance from staff with bathing. During an interview on 12/14/21, at 8:21 a.m. with Resident 106, the resident stated yesterday resident 83 came into his room. Resident 106 stated Resident 83 has been in his room before and tried to take his belongings. During an observation on 12/13/21, at 3:48 p.m., Resident 83 was in his wheelchair and placed his hand on room [ROOM NUMBER]'s doorknob and attempted to open. Observed staff wheelchair the resident back to his room. During an observation and interview on 12/14/21, at 2:17 p.m., Resident 83 had wander guard (device that will transmit alarm when resident attempts to leave the facility) on his left wrist, sitting in the hallway with CNA 18, CNA 19, and Assistant Staff Developer (ASD). ASD stated Resident 83 is a wanderer. CNA 19 stated Resident 83 usually goes around the hallway in his wheelchair. During an interview on 2/14/21, at 2:24 p.m. with CNA 19, the CNA stated Resident 83 tends to get into the rooms a lot causing other residents to get mad and upset. The CNA stated Resident 83 wanders every day. CNA 19 stated staff assigned to him oversees monitoring him, but all staff knows his behavior and is watching him. CNA 19 stated yesterday when passing lunch trays, she saw Resident 83 go into Resident 106's room. CNA 19 stated Resident 106 was mad and was yelling. During an interview on 12/14/21, at 2:30 p.m., with Licensed Vocational Nurse (LVN 14), the LVN indicated Resident 83 goes around the facility in his wheelchair and sometimes goes to other residents' rooms. LVN 14 stated interventions to address his behavior are to use a wander guard, redirect him, provide constant reminders of where his room is, and having him participate in activities for distraction. LVN 14 stated CNAs know his behavior and will take him back to his room if he is wandering. During an interview on 12/14/21, at 2:37 p.m. with Registered Nurse Supervisor (RN 5), the RN stated residents are assessed for wandering upon admission and to update the care plan for behavior with interventions including the use of a wander guard, have residents participate in activities, have staff keep close on the resident and endorse shift to shift. RN 5 stated most of the CNAs know which residents have a habit of wandering. RN 5 stated it important to keep an eye on residents who wander to not lose them from entering other resident rooms, causing other residents to get upset. During an interview on 12/14/21, at 2:46 p.m. with Director of Nursing (DON), the DON stated wander assessment is part of admission assessment. If wandering is a triggered in the admission, it will be documented and to the doctor and family are notified, and wandering behavior is care planned for. DON stated interventions for resident who wander are to use wander guard, provide constant or adequate supervision by all staff through visual checks. A review of physician orders indicated Resident 83 had order wanderguard for elopement risk every shift starting 8/16/21. A review of Change of Condition form dated 8/16/21, indicated Resident 83 had wandering behavior, attempting to go out of the facility. A review of Resident 83's care plans did not indicate wandering behavior was care planned for. A review of the facility's policy, Wandering and Elopements, revised 3/2019, indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintain the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. b. During an observation on 12/17/21, at 5:58 a.m., observed two side doors facing the street wide opened, no gates surrounding the opened doors. Observed ambulance leaving facility. During an observation on 12/17/21, at 5:59 a.m., observed RN 6 glance at the side doors and used the restroom facing the doors. During an observation on 12/17/21, at 6:16 a.m., Admin arrived through the side doors and shut the doors. During an interview on 12/17/21, at 6:50 a.m. with RN 6, the RN stated when paramedics are leaving the facility, staff should usually escort them out and close the door. RN 6 stated it is important to close the doors immediately to prevent residents from going outside without being noticed, especially for residents that wander. RN 6 stated it is important to close the doors to prevent people from outside to enter the facility. RN 6 stated when she used the restroom in the morning, she did not notice the front doors were still open. During an interview on 12/17/21, at 6:16 a.m. with Admin, when asked what could happen if the doors were left open, Admin stated it would not be a problem for residents that wander because their bracelet will trigger the alarm when they pass the doors. Admin stated it could be a problem for those that are not a wanderer and will educate staff to close doors if left opened.

CONCERN (F)

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide sufficient staffing to accommodate the needs of 6 of 6 sampled residents (Residents 24, 49, 59,87, 88, 106) by failing to ensure: 1. Resident call lights were answered for activities of daily living ([ADLs] personal hygiene, getting dressed, and bathing) in a timely manner for Residents 24, 49, 59, 88, 106 2. Restorative Nursing Assistance (RNA) services ([RNA] care that emphasizes the evaluation of residents' underlying capabilities with regards to function and helping them to optimize and maintain functional abilities) was provided to Resident 87. These deficient practices caused feelings of discomfort, and frustration for 6 of 6 sampled residents and had the potential to affect 122 Residents that could lead to accidental falls, hypoglycemia (low blood sugar), unresolved pain, thirst, hunger, not meeting the residents' needs and negatively affecting the resident's quality of life. Findings: 1a. A review of the facility's resident council (an organized group of residents who meet regularly to discuss and address concerns about their rights, quality of care and quality of life) meeting minutes dated 6/30/2021, 7/29/2021, 8/31/2021, 9/2021, 10/29/21 and 11/29/2021 indicated the residents' concern included call lights not answered in a timely manner, on 7/29/2021 resident council had concerns about staff not checking on residents in their rooms. On 10/29/2021 resident council meeting had concerns about snacks not getting delivered timely during the 3 to 11 p.m. shift. On 12/14/21 at 10:34 a.m., during the resident council meeting (Residents 24, 49, 59, and 88) 4 of the 6 alert residents who attended the Resident Council Meeting stated call lights were not answered in a timely manner and residents did not get the help and care they needed without waiting a long time. The residents felt the facility was understaffed. The residents stated it takes about an hour to get someone to answer the call light. During a review of Resident 24's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 8/25/2021, indicated the resident was mildly impaired of cognitive (ability to think, understand and made daily decision) skills and was able to understand and understood others During a review of Resident 49 MDS dated [DATE], indicated the resident had no cognitive impairment. During a review of Resident 59 MDS dated [DATE] indicated the resident had no cognitive impairment During a review of Resident 88 MDS dated [DATE] indicated the resident had no cognitive impairment During resident council meeting on 12/14/21 at 10:34 a.m., Resident 88 stated during the night shift (11:00 p.m. - 7:00 a.m.), the facility was short staffed and only had one nurse to administer medications and 4 Certified Nurse Assistants (CNAs) and took about 22 minutes for call light to be answered and it felt like it takes a while to get assistance. During resident council meeting on 12/14/2021 at 11:15 a.m., Resident 49 stated staff did not offer care/assistance because she was self-sufficient and was not being asked if she needed help and felt ignored. Resident 49 stated on 12/14/2021 she called for assistance and it took 1 hour to get someone to help to assist going to Resident Council Meeting. 1b. During an interview on 12/13/21 at 11:28 a.m., Resident 106 stated there was not enough staff at night, especially during the last shift and response time to answer call light was slow. Resident 106 stated he pressed the call light on 12/13/2021 at 3:00 a.m., and it took the staff two hours to respond to answer call light. Resident 106 stated he needed assistance changing his colostomy bag (a plastic bag that collects fecal matter from the digestive tract through an opening in the abdominal wall called a stoma) because the seams of the colostomy bag were busted. Resident 106 stated when his colostomy was busted, and fecal matter was leaking all over, he felt helpless and frustrated. During a review of the Resident 106's admission record (Face sheet), indicated the resident was admitted to the facility on [DATE], with diagnoses not limited to end stage renal disease ([ESRD] the stage of renal impairment that appears irreversible and permanent, and requires a regular course of dialysis or kidney transplantation to maintain life), malignant neoplasm of the colon (cancer of large intestine), heart failure (a condition in which the heart has trouble pumping blood thought the body), type 2 diabetes (abnormal blood sugar levels), and hyperlipidemia ([HLD] a condition that causes the levels of certain bad fats, or lipids, to be too high in the blood). During a review of the Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 10/21/21, indicated Resident 106 had no cognitive impairment; required one-person assistance from staff with bed mobility, dressing, and toileting; and total dependence on staff with bathing. During a review of Resident 106's history and physical (H&P), dated 10/15/21, indicated Resident 106 had the capacity to understand and make decisions. During a review of Resident 106's physician orders, dated 12/16/21, indicated the resident had orders for colostomy site to be cleaned and colostomy bag to be changed as needed for leakage or dislodgement. During an observation on 12/14/21, at 8:50 a.m. at Resident 106 bedside, Licensed Vocational Nurse (LVN 12) was observed changing Resident 106's colostomy bag. Colostomy bag appeared inflated and Resident 106 told LVN 12 there was lots of air and leakage from the bag because it took so long for nursing staff to change it. An abdominal wound dressing on Resident 106, was slightly soiled with a brown substance that appeared to be from the contents if the colostomy bag. Resident 106 told LVN 12 he could not sleep when his colostomy bag was busted and was afraid his abdominal wound can get infected to the point of hospitalization. During an interview on 12/14/21 at 9:10 a.m., LVN 12 stated there was a little bit of leaking to colostomy bag that had soiled part of the abdominal dressing. LVN 12 verified, if the colostomy bag was not changed timely, the colostomy bag could leak into the abdominal dressing and could cause the abdominal wound to get infected. LVN 12 stated she informed nursing staff before that they need to change the colostomy bag immediately when it is leaking. During a review of the facility's policy and procedure (P/P) titled, Answering the Call Light revised March 2021, indicated the purpose of answering call light was to ensure timely responses to the resident's requests and needs. Some residents may not be able to use their call light and to be sure to check these residents frequently. If the request is something that can be fulfilled, complete the task within five minutes if possible and if the Resident request cannot be fulfilled ask the nurse supervisor for assistance. 2.During a concurrent record review of nursing assignment sheets and census (number of residents in the facility) in the skilled-nursing facility (SNF) department for random dates with, assistant staff developer (ASD) on 12/21/at 10:00 a.m., ASD stated they were short staffed on the following days: a. 11/7/21, 4 CNAs, 2 LVNs, 1 RN assigned to 100 residents for 11:00 p.m. to 7:00 a.m. shift b. 11/13/21, 4 CNAs, 2 LVNs, 1 RN assigned to 105 residents for 11:00 p.m. to 7:00 a.m. shift c. 11/25/21, 4 CNAs, 2 LVNs, 1 RN assigned to 107 residents for 11:00 p.m. to 7:00 a.m. shift d. 12/16/21, 5 CNAs, 2 LVNs, 1 RN assigned to 104 residents, but 1 CNA called off for 11:00 p.m. to 7:00 a.m. shift e. 12/18/21, 4 CNAs, 3 LVNs, 1 RN assigned to 101 residents for 3:00 p.m. to 11:00 p.m. shift ASD stated she usually made the CNA nursing assignment and there were plenty of days that staff called in sick and would ask staff to come in to work, but no one can work. ASD stated she did not try to reach out to registry (an agency that provides professional staff for temporary facility needs), because she was not aware if there was any registry and as far as she knows they do not use registry. ASD stated she notified the (DON) and Administrator (ADM) that she did not have adequate staffing, but they were not able to provide additional staff and just had to work with the staff they had. ASD stated for census of 103 they should have 6 CNA at night shift and assigned to maximum of 16 to 21 residents but sometimes they have 26 residents each CNA and that was a lot for 1 CNA. ASD stated they need to have adequate staff for safety of residents, CNAs were tired, and they could get hurt if they were tired and we are going to lose staff if we are always short staff. During an interview on 12/21/21 at 11:30 a.m., DON stated he was aware that there were days some staff called in sick but unable to find replacement. DON stated they tried to call other staff to come in to work but no one was available. DON acknowledged he did not try to reach out to their sister company, call a registry (agency that provides staffing as needed), nor reached out to any other agency. DON stated they do not have a registry they worked with and only tried to work with the staff they have on their roster. During a concurrent interview and record review of Census and Nursing Hours per Patient Day ([NHPPD] form indicating projected daily nursing hours) for random nursing hours with Director of Nursing (DON) on 12/22/21 at 11:02 a.m., DON stated the NHPPD indicated they were not meeting the required 3.5 nursing hours on the following day because they were short staffed: a. On 11/13/21 final NHPPD was 2.92 b. On 11/25/21 final NHPPD was 2.85 c. On 12/16/21 final NHPPD was 2.52 d. On 12/18/21 final NHPPD was 2.69 DON stated it was important to ensure they met the required 3.5 NHPPD in order to meet the overall needs of the residents, and to be compliant with regulations. During an interview on 12/22/2021 10:50 a.m., with ADM, ADM stated if they were short staffed, it was their process to ask staff to stay over, call off duty staff, and stated they have a contract with registry who can be reached 24 hours a day, 7 days a week. ADM stated he was not aware of the staffing shortage and if he was informed, he would have called a registry, use Reddinet a tool that maybe used by the facility to communicate situational information to the county or to MHOAC [(Medical and Health Operational Area Coordinator) Local Emergency Medical Services agency] and report facility status. During a review of the facility's COVID-19 Mitigation Plan [(MP) a plan to reduce the spread of the COVID-19 virus), undated, the MP indicated it is the policy of the facility to maximize the staff availability and utilize these approved staffing registries if they were unable to cover staffing needs during an emergency. If this strategy does not meet the facility's needs, facility may request additional staff through Medical Health operational Area Coordinator program. A review of All Facilities Letter (AFL) dated 1/23/18, indicated, effective July 1 ,2018, SB 97 (Chapter 52, Statutes 2017) requires SNFs, except those that are a distinct part of general acute care or a state- owned hospital or development center, to provide a minimum of 3.5 direct care service hours per patient day, with a minimum of 2.4 performed by certified nurse assistants. 3. During a review of Resident 87's Face Sheet, the face sheet indicated Resident 87 was admitted to the facility on [DATE]. The Face Sheet indicated Resident 87's diagnoses included unspecified osteoarthritis (joint disease that happens when the tissues in the joint break down over time), muscle weakness, abnormalities of gait and mobility, and major depressive disorder (it affects how one feels, thinks and behaves and can lead to a variety of emotional and physical problems.) During a review of Resident 87's MDS, dated [DATE], indicated Resident 87's cognitive skills for daily decisions making were mildly impaired, and required limited assistance of one-person physical assist for activities of daily living. A record review or Restorative Nursing Flowsheet for December 2021 indicated an order for Restorative Nurse Assistant (RNA) for PROM (Passive Range of Motion) to Bilateral Lower Extremity every day five times a week or as tolerated. During an interview on 12/20/21, at 3:23 p.m., (RNA 1), stated facility had a shortage with Certified Nurse Assistant, and RNA's were asked to work both as CNA and RNA at the same time, which was a heavy workload and as a result, they could not complete the RNA tasks as ordered. RNA 1 stated this has been brought up several times to Assistant Staff developer (ASD) who was in charge of staffing, but nothing has been done and RNA's continued to be scheduled as CNA's at the same time. RNA 1 acknowledged if the facility continued not to provide RNA services as ordered this would cause residents to be at risk for a decline in mobility and possibly in health as well. During a concurrent interview and record review of Restorative Nursing Flowsheet dated December 2021 with RNA 1 on 12/20/21 at 3:30 p.m., RNA1 stated Resident 87's Restorative Nursing Flowsheet indicated from 12/1/2021 to 12/14/2021 Resident 87 only received RNA services 8 out of 10 times. RNA 1 confirmed Resident 87's order indicated RNA services were to be done daily five times a week and admitted RNA services were not provided to Resident 87 two of the ten occurrences and stated the 2 days RNA services were not provided to Resident 87 were days when RNA 1 was required to work as both an RNA and CNA and were not able to perform RNA service to Resident 87. During a concurrent interview and record review of Restorative Nursing Flowsheet dated December 2021 with Physical Therapy Aide (PTA 1) on 12/20/21, at 4:18 p.m., PTA 1 stated Resident 87's Restorative Nursing Flowsheet, dated December 2021, was reviewed. The Restorative Nursing Flowsheet for Resident 87 indicated, from December 1st to December 14th, Resident 87 only received RNA services 8 out of 10 times. PTA 1 stated that documentation confirms that RNA services weren't provided on December 3rd, December 7th, December 10th, December 12th, and December 14th. PTA 1 stated orders indicated RNA services should be done daily 5x/wk. PTA 1 confirmed that Resident 87 missed RNA services twice on two different occasions between December 1st to December 14th. PTA 1 stated if RNA care was not completed per orders, residents are at risk for a physical and mobility decline leading to contractures and deep vein thrombosis (DVT). PTA 1 stated RNA's are supposed to report to Physical Therapists when there is a decline in resident's health or if services cannot be provided. PTA 1 stated that PTA 1 was unaware that Resident 87 has not received RNA therapy as ordered. During a review of the facility's P/P titled, Staffing, revised October 2017, the P/P indicated the facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents' care plans and the facility assessment. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. Staffing numbers and the skills requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. Other support services like activities/recreational, therapy is also staffed to ensure that residents needs are met.

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

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow proper sanitation and food handling practices by failing to: 1. Ensure that dietary staff knew how to calibrate (correlate the readings of an instrument with those of a standard to check the instrument's accuracy) of the food thermometer used per facility policies and procedures in order to identify the proper temperatures of the food being served. 2. To clean the thermometer in between food trays while checking food temperature. 3. To ensure personal protective equipment was properly worn during tray line. These deficient practices had the potential to result in foodborne illnesses (also called food poisoning caused by eating contaminated food or eating food not kept at appropriate temperatures) for all residents living in the facility. Findings: During a concurrent tray line observation and interview on 12/14/2021 at 11:45 a.m., [NAME] (Cook1) was not able to demonstrate how to calibrate the food thermometer to show accuracy. [NAME] 1 stated that he puts the thermometer in hot water to clean it and when it hits 20 degrees then he knows it's clean and ready. [NAME] 1 then went to grab another thermometer from a shelf and tried to put that thermometer in a bucket with ice. [NAME] 1 could not verbalize the process of how to check the thermometer for accuracy. Dietary Supervisor (DS) came to aid [NAME] 1 and stated that digital thermometers do not need to be calibrated, however DS could not verbalize how to check thermometer for accuracy. During tray line observation on 12/14/2021 at 12:10 p.m., [NAME] 1 did not wash his hands and change his gloves before proceeding to check food temperature after grabbing another thermometer from a shelf and breaking tray line. Cook1 also failed to clean the thermometer in between different food tray temperature checks. During tray line observation on 12/14/2021 at 12:10 p.m., Dietary Aide (DA1) was observed helping with tray line with her mask sitting right below her nostrils until the last tray was prepared. During an interview on 12/14/2021 at 1:05 p.m., Cook1 confirmed that he should have washed his hands and changed gloves because he broke tray line by leaving to grab things away from tray line. He also stated that he usually uses alcohol wipes to clean the thermometer in between food trays to prevent food contamination. Cook1 stated these infection control measures are important to keep resident safe from getting sick from the food. During an interview on 12/14/2021 at 1:10 p.m., DA1 stated that she did not notice her mask was sitting below her nostrils. DA1 then pulled up her mask and stated that she will make sure to always keep it over her nose. She stated that it's important to have her mask on properly to prevent germs or virus from getting in the food being prepared for the residents, because it can make them sick. During an interview on 12/14/2021 at 2:23 p.m., DS stated she did not know how to check for thermometer accuracy. She verified the thermometer should have been cleaned in between food trays. DS stated if dietary staff in the tray line leave the tray line to grab things then they must wash their hands and change gloves before they restart working on the tray line. DS stated that dietary staff masks should be worn properly to always cover the mouth and nose. All this is to prevent germs from getting in the residents' food and prevent sickness. During an interview on 12/16/2021 at 03:34 PM, Dietary Consultant (DC) stated that dietary staff should know how to use the thermometer and that even digital thermometers need to be calibrated. She stated dietary staff should know how to check for thermometer accuracy and DS should be the one doing the in-services (staff education) for that. DC stated that thermometers should be cleaned in between food tray temperature check to prevent food contamination. She stated there might be food that are not cooked that touches the cooked food or contaminate food that a resident may have an allergy to. DC stated the infection preventionist (IP) does the appropriate use of masks in-services, but she stated that dietary staff should always have their mask over their nose and mouth and not under the nostrils. Facility could not provide documentation of in-services for dietary staff regarding thermometer use. A review of facility's policy and procedure (P&P) titled 'Food Preparation and Service,' revised 10/2017, policy statement indicted food and nutrition services employees shall prepare and serve food in a manner that complies with safe food handling practices It further indicated Food preparation staff will adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness .Thermometers will be placed in hot and cold storage areas and checked for accuracy in accordance with accepted public health standards .The temperature of foods held in steam tables will be monitored by food and nutrition services staff .Food and nutrition services staff, including nursing services personnel, will wash their hands before serving food to residents. Employees also will wash their hands after collecting soiled plates and food waste prior to handling food trays .Gloves must be worn when handling food directly. However, gloves can also become contaminated and/or soiled and must be changed between tasks. Disposable gloves are single-use items and shall be discarded after each use. A review of facility's P&P titled 'Meal Temperatures,' undated, indicated that prior to dispensing of meals, the food will be tested for proper temperatures. A probe or digital thermometer will be used to record food temperatures for the current meal served. The thermometer shall be calibrated at least weekly by either ice point method (preferred) or boiling point method. *Ice Point Method: Fill a glass with ice; add water to the top of the glass. Place the thermometer in the glass. Wait 30 seconds. The temperature should register 32 F (0 C). Adjust the nut on the thermometer if needed. *Boiling Point Method: Bring clean tap water to a boikl I deep container. Place thermometer in the boiling water. Do not touch the sides or bottom of the pan. Wait 30 seconds. The temperature soul dread 212 (degrees) F (100 C) at sea level. Adjust the nut on the thermometer as needed. A review of facility's P&P titled 'Meal Temperatures,' undated, indicated that proper sanitizing procedures for use of the thermometer need to follow. Wipe the thermometer with a clean paper towel or disinfecting solution between food items. After temperatures are recorded: clean the thermometer by wiping it with a clean paper towel. Then immerse in 180 deg F hot water for 30 seconds. Allow to air dry OR clean thermometer with hot, soapy water. Wipe with alcohol swab or dip in disinfecting solution at least 50 PPM and allow to air dry. A review of facility's P/P titled 'Food Allergies and Intolerances', dated 8/2017, indicated steps are taken to prevent resident exposure to allergens(s) .meals for residents with severe food allergies are specially prepared so that cross-contamination with allergens does not occur. A review of facility's P/P titled 'Food [NAME] by Family/Visitors' dated 10/2017, indicated all personnel involved in preparing, handling, serving or assisting with meals or snacks will be trained in safe food handling practices.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

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

Our Honest Assessment

Strengths

• 27% annual turnover. Excellent stability, 21 points below California's 48% average. Staff who stay learn residents' needs.

Concerns

• Multiple safety concerns identified: 6 life-threatening violation(s), 2 harm violation(s), $102,711 in fines, Payment denial on record. Review inspection reports carefully.
• 106 deficiencies on record, including 6 critical (life-threatening) violations. These warrant careful review before choosing this facility.
• $102,711 in fines. Extremely high, among the most fined facilities in California. Major compliance failures.
• Grade F (0/100). Below average facility with significant concerns.

Bottom line: This facility has 6 Immediate Jeopardy findings. Serious concerns require careful evaluation.

Email me this report

About This Facility

What is Briarcrest Nursing Center's CMS Rating?

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

How is Briarcrest Nursing Center Staffed?

CMS rates BRIARCREST NURSING CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 27%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Briarcrest Nursing Center?

State health inspectors documented 106 deficiencies at BRIARCREST NURSING CENTER during 2021 to 2025. These included: 6 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, and 98 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Briarcrest Nursing Center?

BRIARCREST NURSING CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by CAMBRIDGE HEALTHCARE SERVICES, a chain that manages multiple nursing homes. With 135 certified beds and approximately 125 residents (about 93% occupancy), it is a mid-sized facility located in BELL GARDENS, California.

How Does Briarcrest Nursing Center Compare to Other California Nursing Homes?

Compared to the 100 nursing homes in California, BRIARCREST NURSING CENTER's overall rating (1 stars) is below the state average of 3.1, staff turnover (27%) is significantly lower than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Briarcrest Nursing Center?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.

Is Briarcrest Nursing Center Safe?

Based on CMS inspection data, BRIARCREST NURSING CENTER has documented safety concerns. Inspectors have issued 6 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in California. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Briarcrest Nursing Center Stick Around?

Staff at BRIARCREST NURSING CENTER tend to stick around. With a turnover rate of 27%, the facility is 19 percentage points below the California average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly.

Was Briarcrest Nursing Center Ever Fined?

BRIARCREST NURSING CENTER has been fined $102,711 across 2 penalty actions. This is 3.0x the California average of $34,106. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.

Is Briarcrest Nursing Center on Any Federal Watch List?

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

Facility Details

Beds: 135
Avg. Residents: 125
Occupancy: 93.2%
Ownership: For profit - Partnership
Chain: CAMBRIDGE HEALTHCARE SERVICES
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
Low Turnover: +3
6 Immediate Jeopardy citations: -72
2 Actual Harm citations: -10
106 Deficiencies: -10
Fines ($102,711): -15
Final Score: 0/100

Nearby Alternatives

MOUNT SAN ANTONIO GARDENS 5-star MONTECITO HEIGHTS HEALTHCARE &... 5-star MARYCREST MANOR 5-star

View all in BELL GARDENS →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 056220