What is BLYTHE POST ACUTE LLC's CMS rating?

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

Does BLYTHE POST ACUTE LLC have any serious inspection findings?

Yes, BLYTHE POST ACUTE LLC has 1 Immediate Jeopardy citation on record, which represent the most serious type of deficiency. The facility has 69 total deficiencies from recent inspections.

What are the staffing levels at BLYTHE POST ACUTE LLC?

BLYTHE POST ACUTE LLC has a two-star staffing rating from CMS with 0.41 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 BLYTHE POST ACUTE LLC located?

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

How many beds does BLYTHE POST ACUTE LLC have?

BLYTHE POST ACUTE LLC has 48 certified beds.

Who owns BLYTHE POST ACUTE LLC?

BLYTHE POST ACUTE LLC is a for profit - limited liability company facility and is part of the DAVID & FRANK JOHNSON chain.

Is BLYTHE POST ACUTE LLC safe?

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

Was BLYTHE POST ACUTE LLC ever fined?

No, BLYTHE POST ACUTE LLC has no federal fines on record, indicating a clean compliance history with Medicare and Medicaid requirements.

Is BLYTHE POST ACUTE LLC on any federal watch list?

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

What have inspectors found at BLYTHE POST ACUTE LLC?

Medicare inspectors have found 69 deficiencies at BLYTHE POST ACUTE LLC: 1 critical, 1 serious, 67 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting BLYTHE POST ACUTE LLC?

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

How does BLYTHE POST ACUTE LLC compare to other nursing homes?

BLYTHE POST ACUTE LLC has a 2-star overall rating, which is below average compared to other nursing homes in CA. Families should carefully review inspection findings and consider alternatives.

BLYTHE POST ACUTE LLC | 33/100 (Grade F)

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a comprehensive care plan was developed for one of one resid...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a comprehensive care plan was developed for one of one resident reviewed for tobacco use (Resident 1) following her re-admission to the facility, despite a documented history of marijuana use. This failure had the potential to place the resident at risk for adverse health effects related to medical diagnoses, unsafe use or storage of marijuana, and smoke-related safety hazards. Findings:On June 10, 2025, Resident 1's admission record was reviewed. Resident 1 was initially admitted on [DATE] and re-admitted on [DATE], with diagnoses which included heart failure (when the heart doesn't pump blood effectively), chronic obstructive pulmonary disease (lung disease) and nicotine dependence (smoker). Resident 1 had a history of marijuana use while in the facility.A review of Resident 1's History and Physical, dated June 22, 2025, indicated Resident 1 had the capacity to understand and make decisions.A review of Resident 1's Minimum Data Set (MDS - an assessment tool), dated June 24, 2025, indicated Resident 1 had Brief Interview of Mental Status (BIMS - a tool to assess cognitive function of an individual) score of 15 (intact cognitive response).A review of Resident 1's previous Short Term Goals care plans, dated October 31, 2024, indicated resident had a positive test for THC (Tetrahydrocannabinol ingredient in marijuana).A further review of Resident 1's care plan indicated no interventions addressing marijuana use being identified in the admission history. On July 10, 2025, at 11:06 a.m., a concurrent observation and interview was conducted with Resident 1. Resident 1 was sitting in her wheelchair in her room and was receiving 2L (liters) of oxygen via nasal canula (tubing that delivers oxygen into nostril). Resident 1 stated she was a smoker and did not need supervision. Resident 1 stated she needed oxygen sometimes because she had difficulty breathing. On July 10, 2025, at 2:12 p.m., a concurrent interview and record review of Resident 1's care plans were conducted with the Registered Nurse (RN). The RN stated Resident 1 was re-admitted to the facility on [DATE] and should have new set of care plans developed for her specific needs and should be available in her records. The RN stated Resident 1 was a smoker and had previous history of testing positive for THC. The RN verified and stated there was no smoking care plan available in Resident 1's current records. The RN stated Resident 1 should have a care plan to ensure she remained safe and was not continuing to smoke marijuana to prevent any health risks due to her health history.On July 10, 2025, at 3:35 p.m., a concurrent interview and record review of Resident 1's care plans were conducted with the Director of Nursing (DON). The DON stated she was responsible for conducting assessments and developing care plans for residents. The DON stated for newly or re-admitted residents, a set of new care plans should be implemented to address their conditions and specific needs. The DON stated Resident 1 was sent out to the hospital and returned back to facility on June 17, 2025. The DON verified and stated Resident 1 did not have a smoking care plan in her current records. The DON stated Resident 1 was a smoker and had previously tested positive for THC. The DON stated, Resident 1 should have a smoking care plan to avoid safety related risks and ensure the resident was following facility rules of not continuing to smoke marijuana and further compromise her health.A review of the facility's policy and procedure titled, Care Plans, Comprehensive, dated 2016, indicated .a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet resident's physical, psychosocial and functional needs is developed and implemented for each resident.the comprehensive, person-centered care plan is developed within seven (7) days of the completion of required comprehensive assessment (MDS).assessment of residents are ongoing and care plans are revised as information about the residents and residents' conditions change.the Interdisciplinary Team must review and update the care plan.when the resident has been readmitted to the facility from a hospital stay.

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

Deficiency F0728 (Tag F0728)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four Certified Nursing Assistants reviewed (CNA 1) ma...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four Certified Nursing Assistants reviewed (CNA 1) maintained an active State-approved CNA certification and current CPR certification (cardiopulmonary resuscitation - an emergency lifesaving procedure performed when the heart stops beating) before providing direct care to residents. This failure had the potential to result in unsafe and inadequate care to residents. Findings:A review of CNA 1's Employee file indicated, CNA 1's license was issued on [DATE], and expired on [DATE].A further review of CNA 1's employee file indicated no documentation of a current CPR certificate. A review of facility's Staffing Assignment dated [DATE] and [DATE], indicated CNA 1 was scheduled to work on both dates.On [DATE], at 3:50 p.m., a concurrent interview and record review of staffing schedule and employee personnel file was conducted with the Director of Staff Development (DSD). The DSD stated she assists with the facility's hiring process and is responsible for verifying staff employment requirements, including current and active licenses and CPR certificates. The DSD stated, CNA 1 worked the morning shift on [DATE], and the night shift on [DATE], and stated she should not have been scheduled. The DSD further stated, CNA 1 should not have been placed on the schedule without an active license and CPR certification, as this created the potential for not being able to provide adequate care to residents. On [DATE], at 4:31 p.m., a concurrent interview and record review of staffing schedule and CNA 1's employee personnel file was conducted with the DON. The DON stated CNAs are required to have an active license and CPR certification to provide direct care to residents. The DON stated, CNA 1 was on the schedule on [DATE], and [DATE], despite her expired CNA license and lacking a CPR certificate. The DON stated her expectations was for all staff to keep their licenses up to date and for the DSD to follow up. The DON stated it was an oversight and CNA 1 should not have been allowed to work without a current license due to a potential in not being able to deliver safe and adequate care to residents.A review of facility's policy and procedure titled Hiring, dated [DATE], indicated, .This facility provides an equal employment opportunity to all person qualified to perform the essential functions of the position that is to be filled.the following criteria will be considered in determining whether an applicant is qualified for a particular job positions.skill, knowledge, training, efficiency, etc.; and certification and licenses.A review of the facility's job description, titled Position Description: Certified Nursing Assistant, dated [DATE], indicated, .minimum qualification requirements.education.current, active, California Nursing Assistant Certification.A review of the facility's job description, titled Position Description: Director of Staff Development, dated [DATE], indicated, .detailed duties and responsibilities, essential functions.assist and tracks CNA staff in renewal of required State certification.

Jul 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

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure a safe water system was in place for 44 residents when: 1. The high temperature alarm (a mechanism to alert the staff when water tem...

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Based on interview and record review, the facility failed to ensure a safe water system was in place for 44 residents when: 1. The high temperature alarm (a mechanism to alert the staff when water temperatures exceed 120 degrees Fahrenheit [°F]) was not working. This failure had the potential to place the residents at risk of scalding from high temperature water. 2. The facility did not monitor hot water temperature for three out of 12 days for the month of June 2025. This failure had the potential to contribute to unsafe conditions without timely staff awareness. Findings: 1. On July 3, 2025, at 10:30 a.m., during an interview with the Maintenance Supervisor (MS). The MS stated, the facility's procedure was to monitor hot water temperatures daily. The MS stated, the high temperature alarm was used to ensure that water used by residents did not exceed 120°F. The MS further stated, the high temperature alarm at the nurses station was currently not working. On July 3, 2025, at 1:30 p.m., during an interview with the Administrator (ADM), the ADM stated to ensure resident safety, the MS was responsible for daily hot water monitoring and the high temperature alarm should be functioning. 2. A review of facility document titled, Daily Hot Water Temperature Record, Month of June 2025, indicated blank entries on the following dates: - June 1, 2025; - June 6, 2025; and - June 7, 2025. On July 3, 2025, at 10:30 a.m., during a concurrent interview and record review with the Maintenance Supervisor (MS), the MS stated no hot water temperature checks were performed on June 1, June 6, and June 7, 2025. The MS stated, it should have been checked, since it's a risk not knowing if the water may be too hot, which may place residents at risk of burning themselves. A review of facility's policy and procedure titled, Water Supply, revised November 2009, indicated, .Tap water in the facility shall be kept within a temperature range to prevent scalding of residents .Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no less than 105°F and no more than 120°F . Maintenance staff shall conduct periodic tap water temperature checks and record the water temperatures in a safety log .

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess and document residents' vital signs (an assessment of reside...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess and document residents' vital signs (an assessment of resident's physiological stability, including a blood pressure, pulse, temperature and oxygen saturations) prior to non-emergent transport to a general acute care hospital (GACH) for two of three sampled residents (Residents 1 and 2). This failure had the potential to result in unrecognized changes in condition and adverse outcomes during transport. Findings: On May 8, 2025, at 10:25 a.m., an unannounced visit was made to the facility for a quality-of-care issue. 1. A review of Resident 1's, Personal Information, dated May 8, 2025, indicated, resident was admitted to the facility on [DATE], with a diagnosis of chronic obstructive pulmonary disease (a lung disease that cause airflow obstruction). Further review indicated Resident 1 had a Brief Interview for Mental Status (short structured tool to assess cognitive function) score of 15 (intact cognition). On May 8, 2025, at 1:40 p.m., an interview was conducted with Resident 1, who verified, she was recently transferred out of the facility for further evaluation at GACH (from April 23 - 27, 2025). A review of Resident 1's, Progress Notes, dated, April 23, 2025, at 7:30 a.m., indicated, . (Resident 1) (complained of) increased difficulty breathing and . edema (swelling caused by excess fluid buildup in tissue) to (both lower legs). Requesting to go to GACH for evaluation. Taken via wheelchair . (new orders) received for transfer . Further review indicated no documented vital signs were taken prior to the transfer to GACH on April 15, 2025. A review of Resident 1's, Notice of Transfer/Discharge, dated, April 23, 2025, untimed, indicated, resident was transferred to GACH on the same day on April 23, 2025. A review of Resident 1's vital signs, indicated, the last assessment of vital signs before transferring to GACH on April 23, 2025, were documented on April 22, 2025, between the hours of 2 p.m. and 10 p.m. and were as follows: - Blood pressure: 109/64 - Pulse: 78 - Temperature: 96.8 - Respirations: 20 - O2 (oxygen) Saturation: 93%. On May 8, 2025, at 3:07 p.m., an interview was conducted with the Director of Nursing (DON), who stated, a resident's vital signs provide a baseline of their over health status and are used to evaluate a resident's (physiological) stability, prior to transport. The DON stated, it is her expectations that nursing staff obtain and document a set of resident's vital signs prior to any transfer to GACH. The DON stated, if a residents' vital signs were not stable, they would be transported for evaluation via ambulance, not the facility van. On June 16, 2025, at 2:47 p.m., an interview was conducted with the DON, who stated, vital signs should be taken at least one hour prior to hospital transfer and documented in the medical record. 2. A review of Resident 2's medical records, titled, Resident Information, dated, May 8, 2025, at 10:53 a.m., indicated, resident was admitted to the facility on [DATE], with a diagnosis of heart failure, and muscle weakness. A review of Resident 2's BIMS indicated a score of 10 (Moderate impairment). On May 8, 2025, at 1:46 p.m., an interview was conducted with Resident 2, who verified, she had recently been transferred to a general acute hospital for further evaluation from April 30 to May 4, 2025. A review of Resident 2's, Nurses Progress Notes, dated, April 30, 2025, at 0800, indicated, . (Resident 2) (complained of) shortness of breath, increased weakness, not answering questions appropriately and lethargic . (New Orders) received for transfer to (General Acute Care Hospital {GACH}). Taken via (wheelchair) Van to (GACH) . Further review of Resident 2's record indicated no set of vital signs was documented prior to Resident 2's transfer to GACH on April 30, 2025. A review of Resident 2's, Notice of Transfer . , dated, April 30, 2025, untimed, indicated resident was transferred to GACH on April 30, 2025. A review of Resident 2's, vital signs documentation, indicated, the last recorded set of vital signs before transfer to GACH was from April 29, 2025, between the hours of 2 p.m., and 10 p.m.: - Blood Pressure: 134/75 - Temperature: 97.7 - Pulse: 62 - Respirations: 16 - O2 Saturation: 94%. On May 8, 2025, at 3:07 p.m., an interview was conducted with the Director of Nursing (DON), who stated, a resident's vital signs provide a baseline of their over health status and are taken to evaluate a resident's (physiological) stability, prior to transport. The DON stated, it is her expectations for nursing staff to take and document vital signs in the resident's medical record prior to transfer to GACH. The DON stated, if the residents' vital signs were not stable, the resident should be transported via an ambulance, not the facility VAN. On June 16, 2025, at 2:47 p.m., an interview was conducted with the DON, who stated, the nursing staff are expected to obtain and document a set of vital signs at least one hour prior to transport to the hospital for further evaluation. A facility Policy & Procedure, titled, Change in a Resident's Condition or Status, revised, May 2017, indicated, . 1. The nurse will notify the resident's Attending Physician or Physician on call when there has been a (an): . g. need to transfer the resident to a hospital/treatment center . 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider . 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status .

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed for one of three sampled residents (Resident 1) to conduct a thorough ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed for one of three sampled residents (Resident 1) to conduct a thorough investigation into Resident 1's allegation of abuse involving Certified Nursing Assistant (CNA 1) before allowing the alleged perpetrator to return to work. This failure had the potential to expose Resident 1 to further abuse and compromised the integrity of the abuse investigation process. Findings: On March 28, 2025, at 10:50 a.m., an unannounced visit was made to the facility to investigate an allegation of abuse. On March 28, 2025, at 11:10 a.m., an interview was conducted with Resident 1, who stated, CNA 1 was rough while changing her brief, pushing her against the bed railing and causing pain and a bump on her left wrist on March 15, 2025. Resident 1 stated It upset me at the time. A Review of Resident 1's medical record, title, Resident Information, dated, March 18, 2025, at 11:50 a.m., indicated, resident was admitted to the facility on [DATE], with a diagnosis of hemiplegia and hemiparesis (One-sided {Left} paralysis or weakness) following a stroke. A review of Resident 1's, Brief Interview for Mental Status (a cognitive assessment), indicated a score of 15 (cognitively intact). A review of Resident 1's, Change of Condition, (A deviation from baseline condition) note, dated, March 15, 2025, at 8:00 p.m., by Licensed Vocational Nurse (LVN) 1, indicated, . (Resident 1 . accusing {CNA 1} being rough while changing (resident), (Resident 1) complained of a bump (on) left wrist . (LVN 1 assessed Resident 1's left wrist) bone, no noted (injuries) skin intact, no discolorations . (CNA 1) stated she was not rough with (resident) and had . (CNA 2) with her, while changing Resident 1 . (LVN 1) . notified . Director of Nursing (DON) and Administrator ({Admin}-Abuse Coordinator) . DON informed all staff to take a second person at all times caring for (Resident 1) . Police officer arrived and spoke to (LVN 1) . (Resident 1) and (Admin). (Admin) called (the facility) and tried to speak to (Resident 1) twice and (resident) said No I'm not talking to (Admin) . On March 28, 2025, at 1:18 p.m., an interview was conducted with CNA 1, who stated, she worked double shift on March 15, 2025, and cared for Resident 1 in the morning without incident. CNA 1 stated she was informed on March 15, 2025, at 9:23 p.m. (one hour after the allegation was reported), that she could return to work the next morning, March 16, 2025 at 6:30 a.m. On March 28, 2025, at 1:37 p.m., an interview was conducted with the DON, who stated, she was informed of the allegation and spoke with Resident 1 by phone, then reported the incident to the Administrator. The DON stated, she did not participate further in the investigation, as she was off duty. On March 28, 2025, at 2:23 p.m., an interview was conducted with the Administrator (Abuse Coordinator), who stated, he was responsible for abuse investigations. The Administrator stated, he received the report from LVN 1, spoke with the police, and attempted to interview Resident 1, who declined. The Administrator stated, he interviewed staff who assisted with Resident 1's care but did not interview Resident 1 or any other residents assigned to CNA 1 prior to allowing the CNA to return to work. The Administrator stated, he believed he had enough information and permitted CNA 1 to return to her shift on March 16, 2025, even though the investigation was not complete. On April 1, 2025, at 10:29 a.m., an interview was conducted with LVN 1, who stated, Resident 1 reported the incident around 7:50 p.m. on March 15, 2025. LVN 1 stated she assessed the resident, notified the DON and Administrator. LVN 1 stated, the police arrived shortly afterward to interview Resident 1. LVN 1 stated CNA 1 was sent home around 8:45 p.m. that evening. On April 1, 2025, at 4:45 p.m., an interview was conducted with the Administrator, who stated, on March 17, 2025 (a day after the reported allegation of abuse), he presented to the facility to interview other residents who had received care from CNA 1 and conducted a follow-up with Resident 1, who decline to discuss the incident further. The Administrator stated, he allowed CNA 1 to return to work on March 16, 2025. A review of the facility Policy and Procedure, titled, Abuse Investigation and Reporting, revised, July 2017, indicated, . Policy Statement: All reports of resident abuse . shall be promptly . and thoroughly investigated by facility management. Policy Interpretation and Implementation: Role of the Administrator . 4. The administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 5. The administrator will ensure that any further potential abuse, neglect exploitation or mistreatment is prevented . Role of the investigator: 1. The individual conducting the investigation will, as a minimum: c. Interview the person(s) reporting the incident; g. Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; i. Interview other residents to whom the accused employee provides care or services; and j. Review all events leading up to the alleged incident . 2. The following guidelines will be used when conducting interviews: a. Each interview will be conducted separately and in a private location . d. Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it .

Feb 2025 9 deficiencies

CONCERN (D)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure, for three residents (Resident 3, 18, and 32), the consultan...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure, for three residents (Resident 3, 18, and 32), the consultant pharmacist identified, and made recommendations on, non-standardized and inconsistent procedures by nursing staff for holding blood pressure medications that were ordered by the physician without holding parameters to residents. This failure had the potential for ineffective management of the residents' hypertension (high blood pressure (BP). Findings: On February 27, 2025, during a record review for Resident 3, 18, and 32, the following was noted: 1. Resident 3 was admitted on [DATE], with diagnoses which included, hypertensive heart disease with heart failure; A review of the physician order on January 30, 2025, for lisinopril (BP) medication 40 mg (milligram, unit of measurement) with the direction to give one tablet by mouth one time a day for hypertension with no hold parameters; A review of the physician order on January 30, 2025, for carvedilol (BP) medication 3.125 mg with the direction to give one tablet by mouth two times a day for hypertension with no hold parameters; A review of the medication administration record (MAR) for Resident 3 indicated lisinopril and carvedilol morning doses were administered when: a. On February 4, 2025, based on BP measurement of 100/57, b. On February 7, 2025, based on BP measurement of 97/69, c. On February 8, 2025, based on BP measurement of 100/60, and d. On February 19, 2025, based on BP measurement of 102/80. A review of the care plan for cardiopulmonary related to diagnosis of hypertension, hyperlipidemia (high blood fat level), and stroke indicated, The resident will have systolic pressure between 160 and 90, and diastolic pressure between 100 and 40 . 2. A review of the medical record indicated Resident 18 was admitted on [DATE], with diagnoses which included, hypertension (high blood pressure); A review of the the physician order on March 7, 2024, for Lotensin (blood pressure medication) 10 mg with the direction to give one tablet by mouth one time a day for hypertension; A review of the MAR for Resident 18 indicated Lotensin morning doses were held when: a. On October 8, 2024, was held, based on BP measurement of 109/57, b. On October 22, 2024, based on BP measurement of 117/56, and c. On October 24, 2024, based on BP measurement of 113/48. 3. A review of the medical record indiated Resident 32 was admitted on [DATE], with diagnoses which included, hypertension; A review of the physician order on February 15, 2025, for lisinopril 20 mg with the direction to give one tablet by mouth one time a day for hypertension with no hold parameters; A review of the physician order on February 14, 2025, for carvedilol 3.125 mg with the direction to give one tablet by mouth two times a day for hypertension with no hold parameters; A review of the MAR for Resident 32 indicated lisinopril and carvedilol morning doses were held when: a. On February 16, 2025 based on BP measurement of 102/57, b. On February 17, 2025 based on BP measurement of 103/61; However, the doses were given to Resident 32 on February 27, 2025, based on BP measurement of 104/61. A review of the care plan for cardiopulmonary related to diagnosis of hypertension, hyperlipidemia (high blood fat level), and stroke indicated, The resident will have systolic pressure between 160 and 90, and diastolic pressure between 100 and 40 . On February 26, 2025, at 11:30 a.m., an interview was conducted with Licesned Vocational Nurse (LVN 1), when asked the reason for holding the BP medication with no hold parameters for Resident 34 based on BP measurement of 104/61, LVN 1 stated she would use nursing clinical judgment to decide when to hold and not administer blood pressure (BP) medications. LVN 1 stated she would hold the blood pressure medication dose if the BP measurement was below 120/70 (millimeter of Mercury, mmHg, unit of pressure) and hold beta blockers (one class of BP medication) if the heart rate measurement is below 60. On February 27, 2025, at 11 a.m., an interview was conducted with LVN 2, she stated the BP medications were given to residents based on nurse's clinical judgment. LVN 2 stated she would like to have hold parameters for BP medications. LVN 2 stated the facility had always used the nursing judgment to give or not to give BP medications based on the BP measurement. On February 27, 2025, at 4:35 p.m., an interview was conducted withthe Director of Nursing (DON ), stated the expectation was for nursing staff to use nursing clinical judgment to determine whether blood pressure medications should be held and not be given the to residents. The DON stated physicians should be contacted only if the BP medications were held for three days or more. The DON was not able to provide policies and procedures on holding BP medications based on vital signs. On February 28, 2025, at 9:30 a.m., an interview was conducted with the Consultant Pharmacist (CP), stated the he did not identify and made recommendations on the inconsistencies on nursing staff making independent decisions to hold BP medications with no holding parameters ordered by a physician. According to California Code of Regulation (CCR) Title 16, Section 2518.5, Scope of Vocational Nursing Practice: .The licensed vocational nurse performs services requiring technical and manual skills which include the following: (a) Uses and practices basic assessment (data collection), participates in planning, executes interventions in accordance with the care plan or treatment plan, and contributes to evaluation of individualized interventions related to the care plan or treatment plan. (b) Provides direct patient/client care by which the licensee: (1) Performs basic nursing services as defined in subdivision (a); (2) Administers medications; (3) Applies communication skills for the purpose of patient/client care and education; and (4) Contributes to the development and implementation of a teaching plan related to self-care for the patient/client . The facility's policy and procedure titled, Medication Regimen Reviews, last revised, May 2019, was reviewed, and it indicated: .The Consultant Pharmacist performs a medication regimen review (MRR) for every resident in the facility receiving medications .The MRR involves a thorough review of the resident's medical record to prevent, identify, report and resolve medication related problems, medication errors and other irregularities .

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure antipsychotic medications (medication to treat thought disor...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure antipsychotic medications (medication to treat thought disorder that changes sense of reality) were used after non-pharmacological interventions were tried and the residents were assessed to be distressed and a danger to self or others. This failure resulted in one resident (Resident 18) with dementia receiving an unnecessary antipsychotic medication with a boxed warning issued by the Food and Drug Administration (FDA, a federal agency that regulates drugs and other products). A boxed warning is the strongest warning the FDA requires and signifies the drug carries a significant risk of serious events. Findings: A review of Resident 18's medical record was conducted: Resident 18 was admitted on [DATE], with diagnoses which included, unspecified dementia with psychotic disturbance; A review of the physician order on March 6, 2024, for Seroquel 50 mg (milligram, unit of measurement) with the direction to give one tablet by mouth two times a day for psychosis manifested by hallucinations; A review of the hospital record prior to admission to the facility indicated Resident 18 did not have a history of psychosis and Resident 18's past medication history did not include an antipsychotic medication; A reveiw of the hospital record indicated, while a patient at the hospital, Resident 18 received one dose of Seroquel 50 mg, a one-time order, on March 5, 2024, at 10:26 p.m. for agitation and one dose Seroquel 50 mg, a one-time order on March 6, 2024, at 12:25 a.m.; A review of Resident 18's care plan indicated there was a medical diagnosis of psychosis as evidenced by auditory/visual hallucinations dated, March 6, 2024; A review of Resident 18's Minimum Data Set (MDS, a federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) dated, March 13, 2024, indicated Resident 18 did not have hallucinations (perceptual experiences in the absence of real external sensory stimuli) or delusions (misconceptions or beliefs that are firmly held, contrary to reality), and Resident 18's Brief Interview for Mental Status (BIMS, a screening tool that can help identify cognitive impairment in older adult) score was 9 (moderately impaired); and The facility's medical record did not contain evidence non-pharmacological interventions were tried and Resident 18's thoughts, moods, and mental status placed the resident in significant distress and a danger to self or others. On February 27, 2025, at 12:05 p.m., during an interview, the Director of Nursing (DON), stated because Resident 18 received one-time doses of Seroquel 50 mg at the hospital the facility did not attempt non-pharmacological intervention and assess the resident for danger to self or others. The DON also stated there was no psychiatric consult done for the resident. A review of the facility's policy and procedure titled, Psychotropic Drug Treatment, last revised, December 2020, indicated, .The resident has the right to be free from unnecessary drugs/medications and protection from medication errors. When their use is indicated, the facility should use the least restrictive alternative for the least amount of time and document on-going evaluation of the need for psychotropic drug treatment .Psychotropic drugs shall be used only after alternative methods have been tried unsuccessfully and only upon the written order of a physician and after informed consent has been obtained by the physician from the resident or his/her representative . A review of the boxed warning for Seroquel by the FDA: Warning: Increased mortality in elderly patients with dementia-related psychosis .Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death .Seroquel is not approved for the treatment of patients with dementia-related psychosis .

CONCERN (D)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility had a medication error rate of 11.11% when three medication erro...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility had a medication error rate of 11.11% when three medication errors occurred out of 27 opportunities during the medication administration for two out of seven residents (Resident 99 and 39). The deficient practice resulted in medications not given in accordance with the prescriber's orders and had the potential for residents not receiving the full therapeutic effects of medications with the potential for worsening of residents' medical conditions. Findings: 1. On February 26, 2024, at 8:35 a.m., during a medication pass observation, Licensed Vocational Nurse (LVN 1) was observed preparing five medications to Resident 99. LVN 1 was observed handing the fluticasone/salmeterol (generic for Advair 250/50, used for chronic obstructive pulmonary disease [COPD], a lung disease causing breathing problems) inhaler to Resident 99 with an instruction, in English, to spit out the water in the cup on the bedside tray. Resident 99 did not positively acknowledge understanding of the instruction LVN 1 gave Resident 99. Resident 99, then, was observed taking one puff by mouth from the Advair inhaler and swallowing the water after rinsing the mouth. LVN 1 was observed to step away and not witnessing Resident 99 spitting out the rinsed water. On February 26, 2025, at 11:30 a.m., an interview was conducted with LVN , 1 stated it was out my hand because Resident 99 swallowed the water even after instructing Resident 99 to spit out the water after rinsing the mouth. LVN 1 stated Resident 99's English was not the problem, but Resident 99's hearing was not good. LVN 1 stated it would have been better if LVN 1 used a designated facility interpreter or Spanish speaking staff at the facility. On February 28, 2025, at 8:35 a.m., during an interview with a Spanish-speaking Certified Nursing Assistant (CNA 1), CNA 1 stated Resident 99 preferred Spanish. It was noted Resident 99 was not able to understand when he was spoken to in English regarding the use of the inhaler and spitting out water after rinsing the mouth. CNA 1 also stated Resident 99 did not have issues with hearing and was observed to communicate effortlessly in Spanish with CNA 1. On February 28, 2025, at 9:30 a.m., during an interview, the Consultant Pharmacist (CP) stated Resident 99 should have spit out the water after rinsing the mouth after Advair use to prevent oral fungal infection. A review of the prescribing information for fluticasone/salmeterol DISKUS inhaler from Dailymed Website (a national database for prescribing information submitted to the Food and Drug Administration, FDA): .Fluticasone Propionate/Salmeterol DISKUS should be administered as 1 inhalation twice daily by the orally inhaled route only. After inhalation, the patient should rinse his/her mouth with water without swallowing to help reduce the risk of oropharyngeal candidiasis (fungal infection of the mouth) . 2. On February 26, 2025, at 8:35 a.m., during a medication pass observation, LVN 1 prepared morning medications doses which included Atrovent (medication for shortness of breathing) inhaler for Resident 99. The expiration date on the manufacturer label on the canister of the Atrovent inhaler indicated, 12/2024, It was observed LVN 1 did not check the expiration date of Atrovent inhaler during the morning medication preparation for Resident 99. In a concurrent interview, LVN 1 confirmed the expiration date. LVN 1 stated the medication was brought in with Resident 99 to the facility and a new Atrovent inhaler needed to be ordered from the pharmacy. On February 26, 2025, a review of Resident 99's medical record was conducted. Resident 99 was admitted to the facility on [DATE]; A review of the physician order on February 10, 2025, for ipratropium (generic name for Atrovent) HFA (a type of inhaler propellant) aerosol solution 17 microgram per actuation (mcg/act) to be given to Resident 99 two puffs orally four times a day for COPD (chronic obstructive pulmonary disease, a lung disease resulting in breathing difficulties); and A review of the medication administration record (MAR) for Resident 99 indicated Atrovent inhaler was administered to Resident 99 four times a day since February 11, 2025. 3. On February 26, 2025, at 8:25 a.m., during a medication pass observation, LVN 1 prepared and administered two tablets of acetaminophen (generic for Tylenol, pain medication) 325 mg (milligram, unit of measurement) to Resident 39. On February 26, 2025, Resident's 39's medical record indicated there was a physician order on September 3, 2024, for Tylenol 325 mg, with the direction to give one tablet by mouth every 6 hours as needed for pain. Resident 39's medication administration record (MAR) indicated LVN 1 had documented the administration of one tablet of Tylenol 325 mg. On February 26, 2025, at 11:30 a.m.,an interview was conducted with LVN 1, stated the dose should have been one tablet of Tylenol 325 mg, but LVN 1 gave two tablets instead to Resident 39. A review of the facility's policy and procedure titled, Administering Medications, last revised, April 2019, indicated, .Medications are administered in a safe and timely manner, and as prescribed .The expiration/beyond use date on the medication label is checked prior to administering . A review of the facility's policy and procedure titled, Administering Medications, last revised, April 2019, indicated, .Medications are administered in a safe and timely manner, and as prescribed .The expiration/beyond use date on the medication label is checked prior to administering .

CONCERN (D)

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

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to honor Resident 35's dietary preference by serving fis...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to honor Resident 35's dietary preference by serving fish during a meal. This failure had the potential to negatively impact Resident 35, affecting the resident's nutritional status and overall well-being Findings: A review of Resident 35's admission Record indicated Resident 35 was admitted to the facility on [DATE], with diagnoses which included muscle weakness and failure to thrive (physical decline in older adults). A review of Resident 35's MDS (Minimum Data Set an assessment tool) dated November 28, 2024, indicated a BIMS (Brief Interview for Mental Status) score of 14 (cognitively intact). A review of Resident 35' s meal ticket indicated .Lunch .NO: FISH .Dinner .NO: FISH . On February 27, 2025, at 11:42 a.m., during tray line observation, Resident 35 's tray ticket was reviewed and indicated the NO FISH preference for both lunch and dinner. On February 27, 2025, at 12:15 p.m., the [NAME] placed a slice of fish on Resident 35's tray. On February 27, 2025, at 12: 34 p.m., during an interview with the [NAME] and the Dietary Manager (DM), the [NAME] stated she missed that; and the DM stated serving food against Resident 35's preferences could upset the resident and potentially lead to reduced food intake. A review of the facility policy and procedure titled Resident Food Preferences, dated July 2017, indicated .Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team .the staff will .the resident is satisfied with .

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure that the required Personal Protective Equipment (PPE) usage was clearly indicated before entering rooms of residents o...

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Based on observation, interview, and record review, the facility failed to ensure that the required Personal Protective Equipment (PPE) usage was clearly indicated before entering rooms of residents on Enhanced Barrier Precautions [EBP - a set of infection control measures using gowns and gloves to reduce the spread of multidrug-resistant organisms (MDRO)]. This failure had the potential to result in staff and visitors being unaware of necessary PPE requirements prior to entering rooms requiring isolation precautions. Findings: A review of the facility document titled, RESIDENTS WITH ENHANCED BARRIER PRECAUTIONS, undated, indicated, Residents 4, 6, 7, 8, 18, 21, and 37 were on Enhanced Barrier Precautions. On February 27, 2025, at 2:51 p.m., Residents 4, 6, 7, 8, 18, 21, and 37 rooms did not have EBP signage posted by the door. There was no indication of which bed was on EBP. On February 26, 2025, at 9:24 a.m., during concurrent interview and observation with Resident 7 and Certified Nurse Assistant (CNA) 1, CNA) 1 stated Resident 7 had a wound on the right foot and was on EBP. CNA 1 further stated there were no signage indicating the required PPE or the specific precautions for the resident. CNA 1 stated without prior communication with the Director of Nursing, she might have been unaware of the necessary precautions. CNA 1 stated EBP signage should be posted by the door. On February 26, 2025, at 9:30 a.m., during an interview with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 7 was on EBP for a right foot wound and that appropriate EBP signage should have been posted by the door. On February 27, 2025, at 3:19 p.m., during an interview with the Infection Preventionist (IP), the IP stated the facility's practice was to place residents with conditions such as wounds, indwelling devices, or those undergoing dialysis on EBP. The IP stated, the signage was to inform staff and visitors of the necessary isolation precautions and the protective equipment required to prevent the spread of infection. The IP stated, EBP signage should have been posted for Residents 4, 6, 7, 8, 18, 21 and 37's room. A review of the facility policy and procedure titled, infection Control-Enhanced Barrier Precautions, dated October 2022, indicated .Enhanced Barrier Precaution are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes .

CONCERN (E)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure expired medications were not available for use...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure expired medications were not available for use for one resident (Resident 99) and in an E-Kit (a kit containing urgently needed medications to quickly treat the residents without delay) This failure resulted in Resident 99 receiving an expired medication. This failure also had the potential for facility residents to receive sub-therapeutic medication therapy from expired medications. Findings: 1. On February 26, 2025, at 8:35 a.m., during a medication pass observation, LVN 1 prepared morning medications doses which included Atrovent (medication for shortness of breath) inhaler for Resident 99. The expiration date on the manufacturer's label on the canister of the Atrovent inhaler indicated, 12/2024, It was observed LVN 1 did not check the expiration date of Atrovent inhaler during the morning medication preparation for Resident 99. In a concurrent interview, LVN 1 confirmed the expiration date. LVN 1 stated the medication was brought in with Resident 99 to the facility and a new Atrovent inhaler needed to be ordered from the pharmacy. On February 26, 2025, Resident 99's record was reviewed: The resident was admitted to the facility on [DATE]; A review of the physician order on February 10, 2025, for ipratropium (generic name for Atrovent) HFA (a type of inhaler propellant) aerosol solution 17 microgram per actuation (mcg/act) to be given to Resident 99 two puffs orally four times a day for COPD (chronic obstructive pulmonary disease, a lung disease resulting in breathing difficulties); and A review of the medication administration record (MAR) for Resident 99 indicated Atrovent inhaler was administered to Resident 99 four times a day since February 11, 2025. 2. On February 25, 2025, at 11:25 a.m., during an inspection of Medication Cart #2 with LVN 2, there was a CIII-CV (referring to Schedule III to V controlled substances) E-Kit with an expiration date, 12/2024. Inside the same CIII-CV E-Kit, there were four tablets of carisoprodol (generic name for Soma, a muscle relaxant) 350 mg (milligram, unit of measurement) with an expiration date, 12/30/24. In a concurrent interview, LVN 2 confirmed carisoprodol tablets were expired. A review of the facility's policy and procedure titled, Expired Medications, last revised, April 2019, indicated, .Expired medications are identified and removed from current medication supply in a timely manner for disposition . A review of the The facility's policy and procedure titled, Emergency Medications, last revised, April 2007, indicated, .The Consultant Pharmacist shall inspect the emergency medications kits monthly and record the findings on the record maintained with each kit . A review of the facility's policy and procedure titled, Administering Medications, last revised, April 2019, indicated, .Medications are administered in a safe and timely manner, and as prescribed .The expiration/beyond use date on the medication label is checked prior to administering .

CONCERN (E)

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

Deficiency F0912 (Tag F0912)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to ensure multi-resident bedrooms provided the required minimum of 80 square feet per resident in seven out of 17 rooms (Rooms 5...

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Based on observation, interview, and record review, the facility failed to ensure multi-resident bedrooms provided the required minimum of 80 square feet per resident in seven out of 17 rooms (Rooms 5, 6, 8, 9, 10, 11, and 12). This failure had the potential to negatively affect the residents' quality of life. Findings: A review of the facility's, Census, dated, February 25, 2025, indicated, all resident bedroom assignments, and the number of resident's sharing each room. During initial tour of the facility on February 25, 2025, Rooms 5, 6, 8, 9, 10, 11, and 12 were observed to contain three beds each, with three residents per room. On February 25, 2025, at 10:52 a.m , an interview was conducted with the Administrator (AM). The AM stated, the facility had to provide residents with bedrooms measuring at least 80 square feet per resident in a multi-resident rooms. The AM further stated that Rooms 5 through 12 each measured 239 square feet, accommodating three residents per room, resulting in approximately 79.6 square feet per resident. The AM stated, these rooms did not meet the required 80 square feet per resident. The AM further stated, there have been no complaints from residents or staff regarding insufficient living space or not providing care due to room size. The AM stated, Rooms 5, 6, 8, 9, 10, 11, and 12 did not contain bariatric equipment or excessive personal items that could impact the available space. On February 25, 2025, at 10:52 a.m. the AM requested a continued room waiver for rooms 5, 6, 8, 9, 10, 11, and 12 to accommodate all residing residents. During the survey days from February 25, 2025, to February 28, 2025, no negative impacts on the health, safety, and comfort of the residents were observed. Residents residing in Rooms 5, 6, 8, 9, 10, 11, and 12 who were interviewed stated they were comfortable in their rooms. A review of the facility Policy & Procedure, titled, Bedrooms, revised, May 2017, indicated, . Policy Statement All residents are provided with clean, comfortable and safe bedrooms that meet federal and state requirements . Policy Interpretation and Implementation 1. Bedrooms measure at least 80 square feet of space per resident in double rooms, and at least 100 square feet of space in single rooms .

CONCERN (F)

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

Deficiency F0802 (Tag F0802)

Could have caused harm · This affected most or all residents

Based on interview and record review, the facility failed to ensure a dietary staff was able to accurately verbalize the proper cool down process (proper method of cooling cooked foods to safe tempera...

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Based on interview and record review, the facility failed to ensure a dietary staff was able to accurately verbalize the proper cool down process (proper method of cooling cooked foods to safe temperatures). This failure had the potential to expose a population of 44 residents to foodborne illnesses (illnesses resulting from eating contaminated food). Findings: On February 27, 2025, at 2:40 p.m., an interview was conducted with the [NAME] regarding the cool down process. The [NAME] stated the cooling process from hot food temperature of 135 degrees Fahrenheit (°F- unit of measurement) to ambient temperature of 70°F would take one hour and from 70°F to a cold temperature of 40°F, it would take less than an hour. The [NAME] further stated when she had questions about the cool-down process, she would refer to the cool down log. A review of the facility policy and procedure titled, Food Preparation and Service, dated April 2019, indicated .Potentially hazardous foods are cooled rapidly. This is defined as cooling from 135 degrees F to 70 degrees F within 2 hours and then to a temperature of 41 F or below within the next 4 hours. The total cooling time between 135 degrees F and 41 degrees F is not to exceed 6 hours .

CONCERN (F)

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices when: 1. Turkey and bologna were not maintained at safe temp...

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Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices when: 1. Turkey and bologna were not maintained at safe temperatures within the refrigerator; 2. One dietary staff was observed preparing milk for residents without wearing a beard net; 3. The airconditioning unit air inlet /outlet grill was dirty; 4. An unlabeled juice container, intended for cleaning the grill, was stored alongside food items; and 5. A quaternary (quat) sanitizer test kit readily available in the kitchen was expired. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) among a vulnerable population of 44 out of 45 residents who received food prepared in the facility's kitchen. Findings: 1. On February 25, 2025, at 10:10 a.m., during the initial tour of the kitchen, with Dietary Manager (DM), turkey and bologna in the reach-in refrigerator were warm to the touch. Temperature measurements indicated: -Turkey deli slices (20 slices): 46.7°F -Bologna slices (8 slices): 46.9°F The DM stated, safe storage temperatures for these meats should be below 41°F to prevent bacterial growth. The DM stated storing deli meats above 41°F had the potential risk for foodborne illnesses among residents. On February 28, 2025, at 1 p.m., during an interview with the Registered Dietician (RD), she stated when the turkey and bologna were not in the safe temperature range the kitchen staff were instructed to discard the meat as there was a potential for the resident who consume it could get ill. A review of the facility policy and procedure titled, Food Receiving and Storage, dated October 2017, .Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee and documented .Refrigerated foods must be stored below 41 degrees F . A review of the facility policy and procedure titled, Food Preparation and Services, dated April 2019, . The danger zone, for food temperature is between 41degrees F and 135 degrees F . 2. On February 25, 2025, at 3:29 p.m., during an observation of Dietary Aide (DA) 1 and concurrent interview with the DM, DA 1 was observed preparing resident's milk. DA 1 was observed preparing residents' milk without wearing a beard net. The DM stated the beard net should be worn to prevent cross contamination. A review of the facility policy and procedure titled, Food Preparation and Service, dated April 2019, indicated .Food and Nutrition services staff wears hair restraints -hair net, hat, beard restraint . 3. On February 25, 2025, at 9:58 a.m., during a concurrent observation and interview with the DM inside the kitchen, the air conditioning unit's air outlet grill, located above the food preparation table, was found to have a black substance when wiped with the white paper towel. The DM stated, it is the cook's responsibility to clean the air conditioning unit daily. The DM stated the grill was dirty. A review of the facility policy and procedure titled, Sanitization, dated October 2008, indicated, .Kitchen .surfaces not in contact with food shall be cleaned on regular and frequently enough to prevent accumulation of grime . 4. On February 25, 2025, at 10 a.m., during an observation and interview with the DM inside the kitchen, a lemon juice container intended for cleaning the grill, was found near bundles of bananas and a bag of bread. The DM stated, cleaning agents should be labeled accordingly and stored separately from food items to prevent potential contamination. 5. On February 27, 2025, at 2:50 p.m., during an observation and interview with DA 2, DA 2 used a quaternary sanitizer test kit that had expired in September 2024 to test the sanitizing solution's concentration. DA 2 stated, using an expired test kit could result in inaccurate readings, leading to ineffective sanitization, potential foodborne illness and compromised cleanliness of kitchen surfaces and utensils.

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to conduct and complete neurological assessment (neuro checks - assessment of neurological function and [LOC]-level of conscious...

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Based on observation, interview, and record review, the facility failed to conduct and complete neurological assessment (neuro checks - assessment of neurological function and [LOC]-level of consciousness) for the first hour after an unwitnessed fall for one out of three sampled residents (Resident 1). This failure had the potential to result in serious consequences, including loss of consciousness, seizures (uncontrolled movements), and coma (unable to wake up) which could go undetected. Findings: On January 16, 2025, at 9:25 a.m., an unannounced visit was made to the facility for a quality-of-care issue. On January 16, 2025, at 9:35 a.m., a concurrent observation & interview with Resident 1 was conducted. Resident 1 was observed in her room, lying face down on the floor next to her bed. Resident 1 was turned over onto her back, then helped to sit on her bed, by Licensed Vocational Nurse (LVN 1) and a Certified Nursing Assistant (CNA). Observation of Resident 1, indicated, a small pinkish, discolored area of resident's right forehead. Resident 1 stated she had fallen, hit her head, and had complaints of right shoulder discomfort, and nausea. On January 16, 2025, at 9:42 a.m., LVN 1 was interviewed. LVN 1 stated, Resident 1 hit her head and stated she would initiate neurochecks every 15 minutes for the first hour, every 30 minutes for the second hour and then every 4 hours for 24 hours. LVN 1 further stated neurochecks are important to assess residents for any changes in their level of consciousness. A review of Resident 1's Resident Information, dated January 17, 2025, at, 8:31 a.m., indicated, resident was admitted to the facility on , August 30, 2024, with a diagnosis of muscle weakness and history of falling. A review of Resident 1's Brief Interview for Mental Status (a cognitive assessment), dated December 9, 2024, indicated a score of 12 (moderate cognitive impairment). A review of Resident 1's SBAR (Situation, Background, Assessment, Recommendation)/COC (Change of Condition) ASSESSMENT FORM, dated January 16, 2025, indicated, .unwitnessed fall . A review of Resident 1's progress notes dated January 16, 2025, indicated, .Resident was found on the floor by CNA(Certified Nursing Assistant) .Neuro checks implemented .Patient (Resident 1) complained of headache. Will continue to monitor per doctors ordered . A review of Resident 1's document titled NEUROLOGICAL ASSESSMENT, dated January 16, 2025, indicated, the licensed nurses did not complete Resident 1's neurological assessment during the start of neuro-checks by not assessing the resident's pupil response. In addition, the licensed nurses did not conduct a neurological assessment (pupil response, eye response, level of consciousness, speech, and motor response) after 9:55 a.m., despite the requirement for assessments every 15 minutes for the first hour following the fall. On January 16, 2025, at 10:25 a.m., a concurrent interview and observation of CNA 1 were conducted. CNA1 was observed entering Resident 1's room. CNA 1 stated, she was returning to assess Resident 1's vital signs (pulse, respirations, blood pressure, and temperature) every 15 minutes, per neuro-check policy. CNA 1 stated, other components of the neuro checks would be completed by the licensed nurse. CNA 1 stated, the licensed nurse should have returned after 15 minutes to reassess Resident 1. On January 16, 2025, at 10:36 a.m., an observation of LVN 1 was conducted. LVN 1 was seen by down the hall from Resident 1's room, working at the medication cart and passing medications to residents. LVN 1 was not observed returning to Resident 1's room to conduct a neuro check assessment between 9:55 a.m. and 10:36 a.m. On January 16, 2025, at 10:47 a.m., an interview with LVN 1 was conducted. LVN 1 stated, she notified Resident 1's physician of the resident's fall and received an order to monitor Resident 1 and conduct neuro checks. LVN 1 stated her last assessment of Resident 1 was at 9:55 a.m. and has not returned to re-assess Resident 1. LVN 1 further stated she reported Resident 1's unwitnessed fall to RN 1 at approximately 10:30 a.m. and RN 1 was to take over the monitoring and neurological assessment of Resident 1. On January 16, 2025, at 10:59 a.m., an interview with RN 1 was conducted. RN 1 stated, at approximately 10:40 a.m., she received a report from LVN 1 indicating Resident 1 had an unwitnessed fall. RN 1 stated she informed LVN 1 that she would monitor Resident 1 and conduct neuro checks per facility protocol. RN 1 stated Resident 1 should be assessed, initiate neuro-checks every 15 mins the first hour, every 30 minutes for the second hour, hourly for four hours, and then every four hours for 24 hours.RN 1 stated, she had not yet assessed Resident 1 for neuro checks. On January 16, 2025, at 11:10 a.m., an interview was conducted with the Director of Nursing (DON), who stated, the licensed nurse should monitor a resident who experienced an unwitnessed fall by conducting neuro checks assessment, at the time of the fall, every 15 minutes the first hour, every 30 minutes the second hour, hourly for 4 hours, then every 4 hours for 24 hours. The DON stated neuro-check assessments are important to complete, to ensure residents who hit their head during a fall do not experience an altered level of consciousness. The DON stated physical assessments are part of the neuro-check process and are important to complete to ensure a resident did not sustain additional physical injuries during a fall. The DON verified, RN 1 and LVN 1 had not monitored & assessed Resident 1's neuro-checks for the first hour, per facility policy. The DON stated, it is her expectations licensed nurses follow facility protocol of neuro-check monitoring & assessments. The DON further stated, the facility does not have a written policy and procedure specifically for Neuro-checks. The DON stated, the procedures and time frames written on the neuro-check document, are followed. The DON further stated, Resident 1 is on a blood thinning medication (Blood thinners place a resident at increased risk for internal bleeding after a fall), and she had received orders to transfer Resident 1 to acute hospital for further evaluation.

Nov 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 F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a care plan (Identified healthcare conditions, including in...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a care plan (Identified healthcare conditions, including individualized goals and interventions) addressing the use of an illegal drug (marijuana- mind-altering [psychoactive] drug) while at the facility, for two of three sampled residents (Residents 1 and 2). This failure has the potential to result in mismanagement of resident's medical health issues for Resident 1 and 2. Findings: On October 30, 2024, at 11:40 a.m., an unannounced visit was made to the facility for a quality-of-care issue. On October 30, 2024, at 1:45 p.m., an interview was conducted with the Maintenance Supervisor (MS), who stated, on October 25, 2024, at approximately 4:00 p.m., she witnessed Resident 1 outside, who stated, I feel weird, like I'm having a stroke. The MS stated, she assisted Resident 1 into the facility and notified the nursing staff. A review of Resident 1's admission records undated, indicated the resident was admitted to the facility on [DATE], with diagnoses which included embolism (a vascular clot) and thrombosis (blood clot). A review of Resident 1's Minimum Data Set (an assessment tool) indicated Resident 1 had a Brief Interview for Mental Status (BIMS- a cognitive assessment) score of 15 (no cognitive impairment). On October 30, 2024, at 3:26 p.m., during an interview, Registered Nurse (RN) 1 stated on October 25, 2024, she overheard Resident 1 stating she used marijuana and felt like she was having a stroke. RN 1 stated she did not initiate a care plan to address use of marijuana and the resident's feeling of having a stroke. A review of Resident 1's care plans did not indicate a care plan was developed to address alleged use of an illegal drug. On October 31, 2024, at 1:40 p.m., a concurrent interview with the Director of Nursing (DON), and review of Resident 1's care plans was conducted. The DON stated, it is the responsibility of the charge nurse to initiate a care plan when a change of condition occurred. The DON verified on October 25, 2024, the charge nurse did not initiate a care plan for Resident 1's marijuana use, to include interventions of monitoring for the resident's safety. 2. A review of Resident 2's admission record, undated, indicated, the resident was admitted to the facility on [DATE], with diagnoses which included asthma (a lung disease that affects normal breathing). Further review of Resident 2's Minimum Data Set (an assessment tool) indicated Resident 2 had a BIMS score of 15. A review of Resident 2's progress notes, dated October 26, 2024, at 4:15 p.m., indicated, . (Resident 2) sitting in wheelchair with head slumped down unresponsive to verbal stimuli, unresponsive to sternal rub (hard knuckle rub on chest to illicit a response) .911 called . (Resident 2) awaken . (Licensed Vocational Nurse [LVN] 1) asked (Resident 2) if she was smoking (Marijuana) outside . (Resident 2) did not answer . (Medical Transport) arrived and (LVN 1) . gave report to . (Medical Transport Personnel [MTP]) . (MTP reported to LVN 1, Resident 2) admitted to (MTP) she did smoke (marijuana). (Resident 2 transferred) to (general acute care hospital [GACH] for evaluation) . On October 30, 2024, at 4:15 p.m., an interview was conducted with LVN 1, who stated it is the duty of the charge nurse to assess and monitor residents for safety, and initiate care plans. LVN 1 stated on October 26, 2024, she was the charge nurse, and at approximately 4:20 p.m., she was notified by nursing staff that Resident 2 was outside in her wheelchair, unresponsive, and 911 was called to send resident to GACH for further evaluation. A review of Resident 2's GACH laboratory results dated [DATE], at 5:30 p.m., indicated, a positive drug screen for marijuana use. Further review of Resident 2's care plans indicated; a care plan had not been initiated to address the use of marijuana. On October 31, 2024, at 1:40 p.m., a concurrent interview and review of Resident 2's care plans were conducted with the DON. The DON stated, a care plan should be updated or initiated, by nursing staff, or herself, when a new condition is discovered. The DON reviewed Resident 2's care plans and verified there was no care plan for positive marijuana use, after being confirmed via drug screen at the GACH. The DON stated care plan should have been initiated to ensure monitoring for adverse effects. The DON stated a care plan should have been initiated for the use of marijuana. A review of the facility policy and procedures, titled, Care Plans, Comprehensive, dated, December 2016, 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 . 6. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Incorporated identified problem areas; c. Incorporate risk factors associated with identified problems; d. Reflect treatment goal, timetables and objectives in measurable outcomes; e. Identify the professional services that are responsible for each element of care; 7. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). 8. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess and monitor the change in condition for one of two residents...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess and monitor the change in condition for one of two residents (Resident 1). This failure had the potential to delay necessary treatment for Resident 1. Findings: On October 30, 2024, at 1:45 p.m., an interview was conducted with the Maintenance Supervisor (MS), who stated, on October 25, 2024, at approximately 4:00 p.m., she heard Resident 1 saying she felt weird and felt like she was having a stroke. The MS stated, she assisted Resident 1 into the facility and notified nursing staff. A review of Resident 1's admission record, undated, indicated, resident was admitted to the facility on [DATE], with diagnoses which included embolism (a vascular clot) and thrombosis (blood clot). A review of Resident 1's Minimum Data Set (an assessment tool) dated July 20, 2024, indicated Resident 1 had a Brief Interview for Mental Status (a cognitive assessment) score of 15 (cognitively intact). On October 30, 2024, at 3:26 p.m., an interview was conducted with Registered Nurse (RN) 1, who stated, when a resident had a change of condition; she would assess, notify the physician, monitor the resident, and update or initiate the care plan. RN 1 stated on October 25, 2024, the MS assisted Resident 1 into the lobby. RN 1 stated Resident 1 told RN 2 she felt weird, as if she was having a stroke and she had smoked marijuana outside. RN 1 stated Resident 1 had a change of condition and should have been monitored. RN 1 further stated, she did not follow-up or monitor Resident 1. A review of Resident 1's progress notes, dated October 25, 2024, indicated no documentation reflecting Resident 1 was monitored and followed-up regarding the use of marijuana. A review of Resident 1's medical records, dated, October 25, 2024, indicated no documentation, such as a progress note, or COC, indicating the resident used marijuana, and experiencing feelings of having a stroke. A review of Resident 1's Care Plans indicated that no care plans were initiated for marijuana use or the reported symptoms of having a stroke. On October 31, 2024, at 9:40 a.m., an interview was conducted with RN 1, who verified, she was the only RN/Charge Nurse, scheduled to work the day of October 25, 2024. RN 1 stated RN 2 had come to draw blood (laboratories) on the residents and deliver the lab work to the outside laboratory. RN 1 verified, she did not follow-up with RN 2, regarding Resident 1's change of condition on October 25, 2024, to ensure monitoring interventions, documentation, and physician's instructions were completed. On October 31, 2024, at 1:40 p.m., a concurrent interview and review of Resident 1's progress notes were conducted with the Director of Nursing (DON). The DON stated, she was not aware of the incident on October 25, 2024, involving Resident 1's use of marijuana and change of condition, as it had not been reported to her. The DON further stated, the charge nurse should be assessing the resident, notifying the physician for orders and instructions, initiating COC documentation, including 72 hours of monitoring, and updating the resident's care plan. The DON further stated, the charge nurse should have initiated the change of condition process for Resident 1 right away, as it would have been safer for the resident. The DON further stated, when a resident complained of having a stroke the protocol was to transfer the resident to acute hospital for further evaluation. A facility Policy & Procedure, titled, Change of Condition, revised, May 2017, indicated, . Our 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 . 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): a. accident or incident involving a resident; d. significant change in the resident's physical/emotional/mental condition; e. need to alter the resident's medical treatment significantly; g. need to transfer the resident to a hospital/treatment center; i. specific instruction to notify the physician of changes in the resident's condition. 2. A significant change of condition is a major decline or improvement in the resident's status . a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions . b. Impacts more than one area of the resident's health status; 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provide, including (for example) information prompted by the SBAR (COC) Form . 8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status .

Sept 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 F0925 (Tag F0925)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an effective pest control program to address ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an effective pest control program to address the presence of flies in the building. This failure resulted in flies in the facilities common areas and resident bedrooms potentially leading to infections, increase in health issues such as gastrointestinal infections or skin irritations to vulnerable population in the facility. Findings: On September 24, 2024, at 9:25 a.m., an unannounced visit was made to the facility for a quality-of-care issue. 1. On September 24, 2024, at 9:50 a.m., a concurrent interview with Resident 1 and an observation of the resident's bedroom were conducted. Resident 1 stated, he had noticed an increase in flies in the facility and in his bedroom. Resident 1 stated, Sometimes they bother me. Resident 1 was observed swatting at a fly in the air as he spoke. Resident 1 further stated, staff had given him a fly swatter to help with the flies. A review of Resident 1 ' s medical records, titled, Face Sheet, indicated, resident was admitted to the facility on [DATE], with a diagnosis of cerebral infarction ({Stroke}-a decreased supply of oxygen to the brain causing tissue damage). A review of Resident 1's Minimum Data Set (MDS - an assessment tool), indicated, Resident 1 had a Brief Interview for Mental Status ({BIMS}-cognitive/memory assessment) score of 15 (cognitively intact). 2. On September 24, 2024, at 10:15 a.m., a concurrent interview with Resident 2 and an observation of the resident ' s bedroom were conducted. Multiple flies were observed in the resident ' s bedroom. Resident 2 stated, there were flies in his bedroom, (The flies) are getting bed, they ' re everywhere. A review of Resident 2 ' s Face Sheet, indicated, resident was admitted to the facility on [DATE], with a diagnosis of muscle weakness and difficulty walking, and a BIMS score of 15 (cognitively intact). On September 24, 2024, at 10:34 p.m., a concurrent interview with the Maintenance Supervisor (MS), and observation of fly traps within the facility were conducted. The MS stated, approximately three weeks prior (exact date unknown), the pest control company removed the fly traps within the facility. The MS stated, two fly traps were removed from the South Hall, one trap by the exit door, one trap by the Lobby door, and one fly trap from the North Hall. The MS further stated, since the fly traps were removed, The flies (within the facility) have gotten worse. 3. On September 24, 2024, at 10:49 a.m., an observation of Resident 3 was conducted, showing the resident resting in bed with her eyes closed. Resident 3 was observed to have a large black necrotic (tissue death) area surrounding the tip of her nose and upper lip. Further observation indicated that Resident 3 was swatting at flies hovering around her nasa and upper lip area. A review of Resident 3 ' s Face Sheet, indicated, resident was admitted to the facility on , November 13, 2023, with a diagnosis of, Pituitary Gland (pea sized gland at base of the brain), cancer. Further review indicated a BIMS score of 10 (Moderate cognitive impairment). On September 24, 2024, at 11:05 a.m., an interview was conducted with the Director of Staff Development (DSD), who stated, (Approximately) one month ago, the pest control company removed the fly traps from the interior walls of the facility. DSD was unsure why this happened. On September 24, 2025, at 3:43 p.m., an interview was conducted with the Administrator (Admin), who stated, a couple of weeks ago, the pest control company removed all the fly traps, due to corporate (home office) confusion and non-payment. The Admin further stated, he would verify dates of non-service with corporate office. On September 25, 2024, at 12:12 p.m., an interview was conducted with Admin, who stated, the facility has not been contracted with a pest control company since their last treatment in April 2024. The Admin further stated, the facility ' s corporate office, has sent a maintenance crew to the facility monthly, starting on June 27, 2024, to treat for insects such as ants and roaches. The Admin verified, corporate had not, and is not, providing treatments for interior flies, and the facility does not currently have a pest control program for flies. A facility Policy, titled, Pest Control, revised, May 2008, indicated, .Policy Statement: Our facility shall maintain an effective pest control program . Policy Interpretation and Implementation: 1. This facility maintains an on-going pest control program to ensure that the building is free of insects and rodents .

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' admission orders included all current medications...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' admission orders included all current medications, and the correct dosages for two out of three sampled residents (Residents 4 & 5) when: 1. Resident 4 ' s admission order for Sertraline (an anti-depressant medication) had an incorrect dosage; and 2. Resident 5 ' s admission orders did not include her asthma (a lung disease that causes difficulty breathing) inhalers, Symbicort (medication to help manage and prevent symptoms in residents with asthma) and albuterol (medication used to treat asthma). This failure resulted in: 1. Resident 4 receiving an incorrect dosage of Sertraline on September 6, 2024, which could result in worsening of depression. 2. Resident 5 not receiving physician orders for her asthma medications, which could result in breathing difficulties and worsening asthma symptoms. Findings: On September 24, 2024, at 9:25 a.m., an unannounced visit was made to the facility for a quality-of-care issue. 1. A review of Resident 4 ' s, General Acute Care Hospital (GACH) Active Medications list, dated, September 2, 2024, indicated, resident was receiving, Sertraline 100 mg, two times per day. A review of Resident 4 ' s facility medical records, titled, Face Sheet, indicated, resident was admitted on [DATE], with a diagnosis which included, major depressive disorder (a condition characterized by a persistent and intense feeling of sadness, hopelessness, and a lack of interest or pleasure in most activities). A review of Resident 4's Minimum Data Set (MDS - an assessment tool) dated September 8, 2024, indicated, Resident 4 had a Brief Interview for Mental Status ({BIMS}-a cognitive/memory assessment) score of 15 (no cognitive impairment). A review of Resident 4 ' s physician orders dated, September 4, 2024 (untimed), indicated, Sertraline 100 mg (milligram) once per day. On September 25, 2024, at 3:31 p.m., a concurrent interview and record review of Resident 4 ' s GACH Active Medications List and physician orders were conducted with the Director of Nursing (DON). The DON stated, when a resident is admitted to the facility from GACH, the admission nurse reviews the GACH Discharge or active medication lists, verifies the information with the resident and/or representative, then receives physician orders for the medications. The DON stated, Resident 4 had been receiving Sertraline 100mg twice per day at GACH and once per day at the facility. The DON stated, Resident 4 received the incorrect dose of Sertraline on September 6, 2024. 2. A review of Resident 5 ' s, GACH Discharge Medications list, dated, September 12, 2024, at 1:56 p.m., indicated, a Symbicort inhaler and an albuterol inhaler. A review of Resident 5 ' s Face Sheet, indicated, resident was admitted to the facility on , September 12, 2024, with a diagnosis of asthma. A review of Resident 5's MDS dated [DATE], indicated, Resident 5 had a BIMS score of 15 (cognitively intact). A review of Resident 5 ' s physician orders, indicated, no orders for Symbicort and/or albuterol inhalers. On September 25, 2024, at 3:31 p.m., a concurrent interview and review of Resident 5 ' s GACH Discharge Medications list, and physician orders were conducted with the DON. The DON stated, when a resident is admitted to the facility from GACH, the admission nurse will review the GACH discharge medication list, verifies the information with the resident and/or representative, then receives physician orders for the medications. The DON stated, Resident 5 ' s GACH medications included Symbicort and albuterol. The DON further stated, Resident 5 did not receive physician orders for Symbicort and albuterol upon admission on [DATE]. The DON stated, Resident 5 should have received orders for Symbicort and albuterol upon admission to the facility. A review of the facility policy and procedure titled, Medication Therapy, revised, April 2007, indicated, .Policy heading . 2. Medication use shall be consistent with an individual ' s condition, prognosis . Policy Interpretation and Implementation: 1. The resident ' s clinical record must contain a written order for all prescription and over-the-counter medications taken by the resident. 2. On admission or readmission, the admitting nurse will verify with the resident ' s physician medication or treatment orders carried out from discharging hospital, community, or other healthcare settings. 3. Upon or shortly after admission, and periodically thereafter, the staff and practitioner . will review an individual ' s current medication regimen, to identify whether: a. there is a clear indication for treating that individual with the medication; b. the dosage is appropriate; c. the frequency of administration and duration of use are appropriate .

Sept 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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an alleged abuse involving three of three residents reviewed...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an alleged abuse involving three of three residents reviewed (Residents 1, 2, and 3) were reported to the California Department of Public Health (CDPH) immediately or within 24 hours. This failure resulted in a delayed investigation of the alleged abuse causing a delay in implementation of corrective actions which placed the residents at risk for further abuse. Findings: On September 5, 2024, at 9:25 a.m., an unannounced visit was made to the facility to investigate an abuse allegation. A review of Resident 1 ' s Face Sheet, indicated the resident was admitted to the facility on [DATE], with diagnoses which included urinary tract infection (an illness in any part of the urinary tract, the system of organs that makes urine.) A review of Resident 1 ' s Change of Condition (COC) Assessment form, dated August 30, 2024, indicated, .allegedly (sic) verbally abused by CNA (Certified Nursing Assistant) . A review of Resident 1 ' s progress notes, dated August 30, 2024, indicated, CNA reported to Administrator that another CNA had shaken the resident ' s bed, antagonized her, stuck her finger in her face & (and) told her to Shut your mouth at around 2130 (9:30 a.m.) on Sunday August 25th . A review of Resident 2 ' s, Face Sheet, indicated the resident was initially admitted to the facility on [DATE], with diagnoses which included dementia (A progressive brain disorder that effects cognitive ability such as memory, thinking and reasoning). A review of Resident 2 ' s COC assessment form dated August 30, 2024, indicated, allegedly given sleeping medicine by CNA . A review of Resident 2 ' s progress notes dated August 30, 2024, indicated, CNA alleging that fellow CNA potentially gave resident ' sleeping medicine ' . A review of Resident 3 ' s Face Sheet, indicated, the resident was initially admitted to the facility on [DATE], with diagnoses which included dementia. A review of Resident 3 ' s COC assessment form dated August 30, 2024, indicated, Allegedly given ' sleeping medicine ' by CNA . A review of Resident 3 ' s progress notes dated August 30, 2024, indicated, CNA accused fellow CNA of giving ' sleeping medicine '. On September 5, 2024, at 1:05 p.m., during an interview, CNA 3 stated she was placed on suspension while an allegation was being investigated, but was cleared to come back to work. CNA 3 stated she received training on abuse, and they were supposed to report abuse as soon as possible to the Administrator. On September 5, 2024, at 1:35 p.m. to 1:50 p.m., during an interview, the Administrator stated, on August 28, 2024, at 8:00 p.m., she received a call from a CNA, alleging CNA 2 giving medication to Resident 3. The Admin stated the CNA reported witnessing CNA 2 getting a medication (unknown) from the staff ' s locker, crushing it, and mixing it with Resident 3 ' s coffee. The Administrator stated he did not report the CNA's allegation against CNA 2, as he was waiting on the cna ' s written statement of the allegation. The Administrator verified receiving a written statement from CNA 1 on August 30, 2024. The Administrator stated the written statement indicated CNA 1 ' s abuse allegation involved three residents (Residents 1, 2, and 3) and CNA ' s 2 and 3. The Administrator stated he did not report the abuse allegations, within 24 hours, as he thought he needed more proof to report to CDPH, to the Ombudsman, and to the local police. The Admin further stated, he reported to CDPH on September 4, 2024, and to the Ombudsman. The Admin verified, he should have reported the abuse allegations within 24 hours, in accordance with the facility policy. A review of the facility ' s Policy & Procedure, titled, Abuse Allegation Reporting, updated, February 10, 2019, indicated, . 1. All allegations involving abuse of any type will be reported immediately to the Administrator/Abuse Coordinator or designee . 2. as a mandated reporter, an employee who identifies suspected abuse committed against an individual who is a resident must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source . are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious body or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator/Abuse Coordinator or designee and to other official (including to the State Survey Agency, local law enforcement entity, local Ombudsman, and adult protective service where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures . 4. The Administrator/Abuse Coordinator or designee will report all allegations of abuse according to the Abuse Allegation Investigation time frames .

Jul 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 F0557 (Tag F0557)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review, the facility failed to treat Resident 1's possessions with respect for one of four sampled residents (Resident 1), when facility did not store reside...

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Based on observation, interview and record review, the facility failed to treat Resident 1's possessions with respect for one of four sampled residents (Resident 1), when facility did not store resident's electric wheelchair in a manner which would keep it clean and damage free. The failure had the potential to damage Resident 1's electric wheelchair, while in storage. Findings: On July 01, 2024, at 8:20 a.m., an unannounced visit was made to the facility for a Quality-of-Care issue. On July 01, 2024, at 10:57 a.m., an interview was conducted with Resident 1, who stated, her electric chair was being stored at the facility, while not in use. On July 16, 2024, at 10:42 a.m., a concurrent interview with the Maintenance Supervisor (MS), and observation of Resident 1's electric wheelchair in the storage room were conducted. The MS stated, Resident 1's electric wheelchair was being stored in the maintenance/supply office. The MS stated, Resident 1's wheelchair was not protected with any type of cover, and a large roll of silver window insulation was sitting on top of the wheelchair. The MS stated, the roll of silver window insulation belonged to the facility, not Resident 1. The MS further stated, she was not instructed by the facility to cover the chair for protection. On July 16, 2024, at 4:25 p.m., a concurrent interview with the Director of Nursing (DON) and observation of Resident 1's electric wheelchair in storage were conducted. The DON stated, she would expect a resident's wheelchair to be protected with a cover, and no equipment (no belonging to resident) stored on top of it. The DON stated, Resident 1's electric wheelchair was not protected with a cover, and facility belongings (roll of silver window insulation) were stored on top of it. The DON stated, it was a bit disrespectful. A review of the facility's Policy & Procedure, titled, revised on, stated, . A facility Policy & Procedure (P&P), titled, Resident Rights, revised, December 2016, was reviewed, which indicated, . Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. (Be) treated with respect, kindness, and dignity; h. be supported by the facility in exercising his or her rights; p. participate in, his or her care planning and treatment .

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 F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide for one of five sampled residents (Resident 2), services with...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide for one of five sampled residents (Resident 2), services within reasonable accommodation of the resident's needs and preferences: 1. The facility did not have a working electric Hoyer lift, preferred by Resident 2 for transfer assists; and 2. The facility has one large Geri-chair which was unavailable for use by the resident because it was shared among multiple residents. These failures had the potential to exclude Resident 2 from being transferred out of bed, and sitting comfortably in a chair, while out of bed. Findings: On July 16, 2024, at 8:45 a.m., an unannounced visit was made to the facility to investigate a quality-of-care issue. On July 16, 2024, at 10:20 a.m., a concurrent observation of Resident 2 and interview was conducted. Resident 2 was observed lying in bed, watching t.v. with a disheveled appearance, as his hair appeared uncombed. Resident 2 stated, he relies on staff to transfer him via a Hoyer lift (A lift device used by caregivers to safely transfer residents). Resident 2 stated, he prefers staff to use the electric versus the manual Hoyer lift, during transfers, as he feels safer and more comfortable in it. Resident 2 stated, the electric Hoyer lifts were broken, and unavailable for transfers, leaving only the manual lift for use. Resident 2 further stated, when he is transferred out of bed, he prefers to sit in the large Geri-chair (a large, padded chair, that reclines, designed to help residents with limited mobility), instead of a wheelchair, as it's more comfortable. Resident 2 stated, the facility only has one large Geri-chair, shared by multiple residents. A review of Resident 2's medical records, titled, Face Sheet, indicated, resident was admitted to the facility on [DATE], with a diagnosis of left sided muscle weakness following a cerebral infarction ({Stroke} - decreased blood flow to the brain, which can cause loss of muscle control). Further review of Resident 2's Minimum Data Set (an assessment tool) dated April 22, 2024, indicated, Resident 2 had a Brief Interview of Mental Status ({BIMS} - an assessment of cognitive intactness) score of 15 (cognitively intact). On July 16, 2024, at 11:05, an interview was conducted with the Maintenance Supervisor (MS), who stated, the facility has one large Geri-chair, shared by multiple residents, and 2 electric Hoyer lifts, but both lifts are currently unavailable, because the batteries are dead. The MS further stated, the Administrator (Admin) ordered a new large Geri-chair, and new batteries for the electric Hoyer lifts, but neither had arrived. The MS stated he was not sure when they would be delivered. On July 16, 2024, at 12:45 p.m., an interview was conducted with Certified Nurses Assistant (CNA) 1, who stated, Resident 2 prefers the electric Hoyer lift for transfers. CNA 1 stated the facility did not have an electric Hoyer lift because it was broken. CNA 1 stated, resident had refused showers in the past because the electric Hoyer lift was not available for the transfer. CNA 1 also stated, Resident 2 prefers to sit in a large Geri-chair, when he is out of bed. CNA 1 stated, the facility has one large Geri-chair, which is shared by multiple residents, and Resident 2 does not have a dedicated Geri-chair for daily use. On July 16, 2024, at 4:25 p.m., an interview was conducted with the Director of Nursing (DON), who stated, Resident 2 prefers to sit in a large Geri-chair, because the Geri-chair was more comfortable to sit in than a regular wheelchair. The DON stated, the facility has one large Geri-chair, shared by multiple residents, and if Resident 2 wanted to get out of bed, and sit in the Geri-chair, while it was being used by another resident, the facility would not be able to accommodate Resident 2's preference until it was available. The DON further stated, the facility did not currently have a working electric Hoyer lift available to transfer residents. The DON stated, she was not sure of the status of the electric Hoyer lifts. On July 16, 2024, at 5:15 p.m., an interview was conducted with the Admin, who stated, the facility is currently waiting for a new one. The Admin. further stated, the electric Hoyer lifts are not available for use, due to dead, batteries, and an order for new batteries had been placed on July 15, 2024. A facility Policy & Procedure (P&P), titled, Resident Rights, revised, December 2016, was reviewed, which indicated, . Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. (Be) treated with respect, kindness, and dignity; h. be supported by the facility in exercising his or her rights; p. participate in, his or her care planning and treatment .

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to coordinate cardiology specialty (specialty doctor that treats conditions related to the heart) care for one of three sampled residents (Res...

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Based on interview and record review, the facility failed to coordinate cardiology specialty (specialty doctor that treats conditions related to the heart) care for one of three sampled residents (Resident 3), after a new diagnosis of atrial fibrillation (an irregular and often very rapid heart rhythm) on May 4, 2024. This failure had the potential to result in worsening cardiac (heart) function, stroke (occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts), and/or other serious medical complications. Findings: During an interview on July 1, 2024, at 12:05 p.m., with Resident 3, Resident 3 stated she was diagnosed with atrial fibrillation during a recent admission to the hospital several weeks ago. Resident 3 stated it was a new diagnosis that she never had before. Resident 3 stated about a week after she returned to the facility, she asked the DON (Director of Nursing) to notify the physician about the need to follow up with cardiology. Resident 3 stated she reminded the DON again last week of the need for an appointment with cardiology but has not been informed of any appointments with cardiology as of July 1, 2024. On July 1, 2024, Resident 3's record was reviewed. A review of Resident 3's Licensed Nurses Progress Notes, indicated the following: - Dated April 29, 2024, . Resident is noted to be confused & (and) altered from baseline .for transfer to (name of the hospital) . - Dated May 4, 2024, .returned to (name of skilled nursing facility) . A review of Resident 3's Discharge Documentation/Instructions, from acute hospital, dated May 4, 2024, indicated Resident 3 had a diagnosis of atrial fibrillation with RVR [rapid ventricular (lower chambers of the heart, to beat too fast) response]. Further review of Resident 3's Progress Notes, from May 4, 2024 to July 1, 2024, indicated, there was no documentation Resident 3 was seen by cardiology. During an interview and record review with the DON on July 1, 2024, at 1:55 p.m., the DON stated, the facility physician (FP) saw Resident 3 two days after the hospital discharge. The DON stated on May 4, 2024, the FP ordered Eliquis (apixaban - used to prevent serious blood clots from forming due to a certain irregular heartbeat, such as atrial fibrillation) 5 milligram orally twice daily. The DON stated the only follow up care listed on discharge instructions was with primary care physician. During an interview and record review on July 1, 2024, at 4:05 p.m. with the FP, the FP stated, he could not recall if he ordered an appointment with cardiology for Resident 3, or if an order was written for follow up. The FP stated he did write an order for Eliquis on 5/4/2024. The FP stated the licensed nurses should have followed up with him. The FP stated if Resident 3 was having symptoms, Resident 3 should have been seen sooner to address what was going on with her. The FP stated he was not aware Resident 3 had not seen a cardiology. The FP stated with a new diagnosis of atrial fibrillation, Resident 3 should have been seen by cardiology within 1 month of discharge from acute hospital. During a review of the policy and procedure titled, Physician Visits , revised April 2013, states that .the attending physician will visit residents in a timely fashion .depending on the individual's medical stability, recent and previous medical history, and the presence of medical conditions or problems .The attending physician must perform relevant tasks at the time of each visit, including a review of the resident's total program of care and appropriate documentation. During a review of the policy titled Change in a Resident's Condition or Status , revised May 2017, states .Facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status .the nurse will notify the resident's attending physician on call when there has been a .significant change in the resident's physical/emotional/mental condition; need to alter the resident's medical treatment significantly .specific instruction to notify the physician of changes in the resident's condition . If a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition will be conducted as required by current OBRA regulations .

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 F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure for two of four sampled residents (Residents 1 and 3), were ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure for two of four sampled residents (Residents 1 and 3), were free of significant medication error when the prescribed Augmentin (amoxycillin and potassium clavulanate - drug used to treat bacterial infections in many different parts of the body (ear, lungs, sinus, skin, urinary tract) was not administered on three occasions for Resident 1 and on two occasions for Resident 3. This failure had the potential to worsen both residents' infections, leading to prolonged illness and discomfort. Findings: On June 8, 2024, at 11:50 a.m., an unannounced visit to the facility was conducted to investigate a quality of care and treatment issue. 1. During an interview on June 8, 2024, at 1:26 p.m., with Resident 1, she stated it takes three days for her to receive Augmentin. Resident 1 stated last night (June 7, 2024), she did not receive her antibiotics because the facility ran out. Resident 1 further stated the antibiotics would not be effective in killing germs if the body is a log gap between doses. Resident 1 stated the antibiotices should be given on time, as scheduled. During a review of Resident 1's admission record, indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD- a respiratory problem). A review of Resident 1's Physician's order dated June 6, 2024, indicated, .Augmentin Oral Tablet 500- 125 MG (milligram- unit of measurement) (Amoxycillin & Pot clavulanate) Give 1 tablet by mouth every 8 hours for cough and congestion for 7 days . A review of Resident 1's Nurses Medication Notes, for the month of June 2024, indicated Resident 1 was not administered with Augmentin for the following dates and times: a. On June 6, 2024, at 10 p.m., .Augmentin .unavailable awaiting from pharmacy . b. On June 7, 2024, at 6 a.m., .Augmentin .awaiting delivery from pharmacy . c. On June 7, 2024, at 10 p.m., .Augmentin .no med (medication) available . During a concurrent interview and review of Resident 1's Medication Administration Record for the month of June 2024, was conducted with Licensed Vocational Nurse (LVN) 1, on June 24, 2024, at 2:16 p.m. LVN 1 stated when the initials of the LVN were circled on the MAR, it meant that the medication was not given. LVN 1 stated Resident 1 was not administered Augmentin on the night of June 6, 2024, and twice on June 7, 2024. 2. A review of Resident 3's admission record indicated, Resident 3 was admitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar) and urinary tract infection (UTI-kidney or bladder infection). A review of Resident 3' s Physician's Order, dated June 4, 2024, at 18:54 (6:54 p.m.) indicated, .Augmentin Oral Tablet 500- 125 MG (Amoxycillin & Pot clavulanate) Give 1 tablet by mouth three times a day for UTI for 10 days . A review of Resident 3's Nurses Medication Notes, for the month of June 2024, indicated, the following: a. June 6, 2024, at 12 p.m., Amoxicillin-Clavulanate .out of med (medication) . b. June 6, 2024, at 10 p.m., Amoxicillin-Pot (potassium) Clavulanate .unavailable awaiting from pharmacy . During a concurrent interview and review of Resident 3's Medication Administration Record for the month of June 2024, with LVN 1, on June 24, 2024, at 2:16 p.m., LVN 1 stated when the initials of the licensed nurse were circled on the MAR, it indicated Augmentin was not administered. LVN 1 stated the medication Augmentin was not available and awaiting delivery by the pharmacy. LVN 1 stated, it should have been given within two hours. During an interview on June 24, 2024, at 3:55 p.m., with the Pharmacist, she stated the drugs were taken by the driver at 1: 45 p.m., on June 7, 2024, and delivered to the facility at 11:16 p.m. The Pharmacist further stated the staff should have pulled the antibiotic from the e-kit (emergency kit) while waiting for the delivery. During an interview on June 24, 2024, at 4:03 p.m., with the Registered Nurse (RN), she stated the Augmentin should have been administered within 2 hours from the time it was ordered. The staff should have retrieved the drug from the E-kit. During an interview on July 1, 2024, at 10:50 a.m., with the Director of Nursing (DON), the DON stated if the E-kit does not contain the needed medication, the licensed nurse should notify the physician and/or obtain a new order or an order to wait for the required medication. The DON stated E-kits are supposed to be replenished within 48 hours. The DON further stated if the E-kits are not replenished, they should notify the pharmacy. The DON further stated the licensed nurse who opens the E-kit or is responsible for passing the medication when it is unavailable is the one who should contact the pharmacy for a replacement. During a review of facility policy and procedure, titled Administering Medications, dated April 2019, indicated .Medications are administered in accordance with prescriber order, including any required time frame .Medication are administered within one hour of their prescribed time .If a drug is withheld, .refused or given at a time other than the scheduled time .the individual administering the medication shall initial and circle in the MAR space . During a review of facility policy and procedure, titled Emergency Medications, dated April 2007, indicated .The emergency medication kit will include medications .that are essential in providing emergency treatment .Medication and supplies used from the emergency medication kit must be replaced upon the next routine drug 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

Deficiency F0808 (Tag F0808)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the diet order was followed according to the p...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the diet order was followed according to the physician's order, for two of three sampled residents (Residents 2 and 3), when Residents 2 and 3 did not receive lemon pound cake on lunch meal tray on 7/1/2024 according to the diet ordered by the physician. These failures had the potential to result in compromising Resident 2 and 3's nutritional and medical condition. Findings: 1. On July 1, 2024, at 12:30 p.m., a concurrent meal tray observation and review of Resident 2's Meal Tray Card, on July 1, 2024, were conducted. Resident 2 was observed being served cheesecake with cherry topping. A review of Resident 2's admission RECORD, printed July 1, 2024, indicated, Resident 2 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes mellitus (a disease in which the pancreas does not produce enough insulin [a hormone that regulates the movement of sugar into the cells] and cells respond poorly to insulin and take in less sugar). A review of the Resident 2's Physician's order, dated May 1, 2024, indicated, NAS (no added salt), LCS (Low Concentrated Sweets), Puree (cooked food that has been ground, pressed, blended to the consistency of a creamy paste or liquid). A review of the Resident 2's Resident Diet Order History, dated May 1, 2024, indicated, NAS (no added salt), LCS (Low Concentrated Sweets - avoiding foods with a lot of sugar). A review of Resident 2's Lunch Meal Tray Card (menu based on the resident's diet physician order), indicated, No concentrated sweets, no added salt, puree. A review of the facility Spreadsheet, indicated, .Consistent carbohydrate (terminology use for no concentrated sweets) .Lemon Pound Cake . On July 1, 2024, at 4:10 p.m., a concurrent interview and review of Resident 2's diet order, dietary spreadsheet, and physicians order were conducted with the Dietary Supervisor (DM). The DM stated the physician had ordered a low concentrated sweets, puree, and no added salt diet for Resident 2. After reviewing the food items served to Resident 2 on July 1, 2024, the DM stated Resident 2 did not receive the correct dessert on the lunch meal tray. The DM stated the dietary staff should follow the diet spreadsheet and physicians order providing what was specified for a carbohydrate-restricted diet. The DM stated the dessert given on July 1, 2024, for Resident 2 was incorrect and Resident 2 should have received the lemon pound cake. On July 1, 2024, at 4:30 p.m., a concurrent interview and review of Resident 2's physician diet order were conducted with the Director of Nursing (DON). The DON stated Resident 2 had a diet order for low concentrated sweets, no added salt, and a pureed diet. The DON stated the dietary department should have followed the orders as written by the physician. During a review of the facility policy and procedure (P&P) titled Nursing Care of the Resident with Diabetes Mellitus , revised April 2011, the P&P indicated, .the purpose of this guideline is .To help the resident control his/her diabetes with diet, exercise, and insulin . During a review of the policy titled Therapeutic Diet , 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 and in accordance with his or her goals and preferences A ' therapeutic diet is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: .Diabetic/calorie controlled diet . 2. On July 1, 2024, at 12:30 p.m., a concurrent meal observation, interview, and review of Resident 2's Meal Tray Card, were conducted with Resident 3 in Resident 3's room. Resident 3 was observed being served cheesecake with cherry topping. Resident 3 stated she this is what I normally receive on my meal tray. Resident 3 stated they give me regular desserts all the time and I have told them. A review of Resident 3's admission RECORD, printed July 1, 2024, indicated, Resident 3 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes mellitus. During a review of the facility document titled, Resident Diet Order History, dated July 1, 2024, indicated, Resident 3 is on a NAS, mechanical soft, LCS diet. A review of Resident 3's Lunch Meal Tray Card indicated, Mechanical soft, No concentrated sweets . No indication of NAS observed on meal tray card. On July 1, 2024, at 4:10 p.m., a concurrent interview and review of the physician diet order were conducted with the DM. She stated the physician had ordered LCS, NAS, Mechanical soft diet on June 10, 2022. After reviewing the lunch meal tray food items served on July 1, 2024, the DM admitted Resident 3 should not have received cheesecake with cherry topping and should have received lemon pound cake as indicated on the dietary spreadsheet for July 1, 2024. The DM stated the dietary staff should have followed the diet spreadsheet and physicians order, providing what was specified for a carbohydrate-restricted diet. The DM stated the dessert given for Resident 3 was incorrect. On July 1, 2024, at 4:30 p.m., a concurrent interview and review of Resident 3 meal tray image and Lunch Meal Tray Card were conducted with the DON. After reviewing the lunch meal tray being served to Resident 3 on July 1, 2024, and the meal tray card, the DON stated Resident 3 should have received lemon pound cake. The DON stated the dietary staff should have followed the physician order. The DON stated she was unaware that the residents were receiving the wrong items. During a review of the facility provided spreadsheet listed, Diet Extensions: Monday Week 2, Menu Press Cycle 1, 2024 by US Foods, dated December 7, 2023, indicated .Lunch .Consistent Carbohydrate/Regular .0.5 (2x3 square) Lemon Pound Cake . Listed under Regular/Regular menu on same spreadsheet, has 1 slice of cheesecake with cherry topping .

Jul 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 F0559 (Tag F0559)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written notice to resident of a pending room change for one...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written notice to resident of a pending room change for one of three sampled residents (Resident 3). This failure had the potential for Resident 3 to develop anxiety, confusion, and emotional distress. Findings: A review of Resident 3's medical records, titled, Face Sheet, dated July 1, 2024, indicated, Resident 3 was admitted to the facility on [DATE], with a diagnosis of bipolar disorder (a mental health condition that causes shifts in moods and concentration). A review of Resident 3's Minimum Data Set (an assessment tool), dated May 18, 2024, indicated, Resident 3 has a Brief Interview of Mental Status (mental cognition assessment) score of 15 (cognitively intact). On July 1, 2024, at 12:33 p.m., an interview was conducted with Resident 3, who stated her room was recently changed to a new room. Resident 3 stated, she liked her previous room more. A review of Resident 3's medical records, titled, Progress Notes, indicated the following: - Dated July 14, 2024, at 7:00 p.m., . Resident notified of room change tommorrow (sic) afternoon in order to open up additional female bed for scheduled admit. Resident stated she did not have to move rooms . - Dated July 18, 2024, at 6:30 p.m., .Spoke to resident at bedside regarding complaints and concerns regarding room (change) .Resident relayed that she does not 'react well' . Further review of Resident 3's Progress Notes, dated July 14, 2024 to July 18, 2024, indicated, no written notice of the room change was provided to Resident 3. On July 1, 2024, at 3:10 p.m., an interview was conducted with the DON, who stated, the room change procedure is to Give the resident as much notice of possible, and document (in resident's medical record). The DON stated, the facility verbally notifies residents of a pending change and does not give a written notice of room changes. A facility Policy & Procedure, titled, Room Change/Roommate Assignment, revised, May 2017, indicated, . Policy Statement: Changes in room or roommate assignment shall be made when the facility deems it necessary or when the resident requests the change . Policy Interpretation and Implementation: 2. Prior to changing a room or roommate assignment all parties involved in the change/assignment (e.g., residents and their representatives (sponsors) will be given advance notice of such change (sic) . 3. Advanced notice of a roommate change will include why the change is being made and any information that will assist the roommate in becoming acquainted with his or her new roommate. 4. Unless medically necessary or for the safety and well-being of the resident(s), a resident will be provided with an advance notice of the room change. Such notice will include the reason(s) why the move is recommended . 7. Documentation of a room change is recorded in the resident's medical record .

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 F0912 (Tag F0912)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the required 80 square feet (sq ft) per reside...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the required 80 square feet (sq ft) per resident (80 sq ft/resident) in a multi-resident bedroom, was met for 8 out of 18 rooms (Rooms 5, 6, 7, 8, 9, 10, 11, & 12). This failure had the potential to negatively affect the quality of life of the residents. Findings: On July 1, 2024, at 8:40 a.m., an unannounced visit was made to the facility for a Quality-of-Care issue. On July 1, 2024, at 930 a.m., a concurrent interview with Resident 1 and an observation of room [ROOM NUMBER] bed C were conducted. Resident 1 stated, her room size was Ok, but sometimes she had difficulties navigating her wheelchair through the room. room [ROOM NUMBER] was observed to have three residents sharing the room, with an unobstructed path from each bed to the bedroom door. One staff member was observed attending to roommates' needs without difficulty due to room size. A review of Resident 1's, Face Sheet, dated, July 1, 2024, indicated, resident was admitted to the facility on [DATE], with a diagnosis of Chronic Obstructive Pulmonary Disease (A lung disease that makes it difficult to breath). Further review of Resident 1's Minimum Data Set (MDS - an assessment tool), dated April 22, 2024, indicated Resident 1 has a Brief Interview for Mental Status ({BIMS} - Cognitive assessment) score of 15 (cognitively intact). On July 1, 2024, at 10:30 a.m., an interview was conducted with Certified Nursing Assistant (CNA) 1, who stated, he does not have difficulty tending to the needs of the residents due to room size. On July 1, 2024, at 10:57 a.m., a concurrent interview with Resident 2 and an observation of room [ROOM NUMBER] bed B were conducted. Resident 2 stated, My room is too small for my (belongings). Resident 2's room was observed with multiple personal belongings on her bedside table, and her closet had space for more belongings. Further observation indicated room [ROOM NUMBER] was shared by 3 residents; 2 staff members were in the room attending to roommates' needs, without difficulties due to room size. A review of Resident 2's, medical records, titled, Face Sheet, dated, July 1, 2024, indicated, resident was admitted to the facility on [DATE], with a diagnosis of paraplegia (paralysis of lower body). Further review of Resident 2's MDS, dated [DATE], indicated Resident 2 has a BIMS score of 15 (cognitively intact). On July 1, 2024, at 11:19 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated she was not aware of current residents' bedroom square footage and was not aware of the minimum square footage required in each bedroom for each resident (80 sq ft/resident). On July 1, 2024, at 12:33 p.m., a concurrent interview with Resident 3 and an observation of room [ROOM NUMBER], bed A were conducted. Resident 3 stated, she recently changed rooms, and her current room, is smaller, than her previous room. Resident 3 stated It's ok I guess, but I like my other room more. Staff member was observed entering the room to deliver a lunch tray to roommate, without difficulty due to size. A review of Resident 3's, Face Sheet, dated, July 1, 2024, indicated, resident was admitted to the facility on [DATE], with a diagnosis of muscle weakness. Further review of Resident 3's MDS, dated [DATE], indicated Resident 3 has a BIMS score of 15. A review of the facility's, Census, dated, July 1, 2024, indicated, all resident bedroom assignments, and the number of resident's sharing each room. A review of a facility document, titled, Blythe Post Acute - Plan of Correction Project (POCP), dated November 2017, provided by the facility Administrator (Admin), indicated, the square footage of all resident bedrooms. Further review indicated, 8 bedrooms (Rooms 5, 6, 7, 8, 9, 10, 11 & 12) out of 18 bedrooms, measured less than 80 sq ft/resident. On July 9, 2024, at 11:55 a.m., a concurrent interview with the Administrator and record review of July 1, 2024 census and POCP room measurements were conducted. The Admin stated, it is the facility's policy to provide residents with bedrooms measuring at least 80 sq ft/resident in multi-resident rooms. The Admin verified Rooms 5 through 12 each measured 239 sq ft, with an occupancy of 3 residents, per room, equaling 79.6 sq ft/resident. The Admin verified Rooms 5 through 12 provide less than the required 80 sq ft/resident. The Admin further stated, there have been no complaints from residents or staff stating that Rooms 5 through 12 did not provide enough living space, or care could not be provided for residents due to small room size. A facility Policy & Procedure, titled, Bedrooms, revised, May 2017, indicated, . Policy Statement All residents are provided with clean, comfortable and safe bedrooms that meet federal and state requirements . Policy Interpretation and Implementation 1. Bedrooms measure at least 80 square feet of space per resident in double rooms, and at least 100 square feet of space in single rooms .

Jun 2024 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain temperatures between 71 to 81 degrees Fahren...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain temperatures between 71 to 81 degrees Fahrenheit (F), with resident room temperatures in three of six sampled resident rooms, reaching 84.7 degrees F. This deficient practice resulted in discomfort for two of eleven sampled residents (Residents 1 and 2), and potential adverse health effects for residents, staff and visitors including dehydration (loss of body fluids), heat stress (a series of conditions where the body is under stress from overheating), and heat stroke (when the body can no longer control its temperature). Findings: An unannounced visit was conducted on June 25, 2024, at 12:32 p.m. to investigate a complaint related to the facility 's physical environment. On June 25, 2024, at 1:41 p.m., an observation and concurrent interview was conducted with Resident 1. Resident 1 was observed lying in bed near the window with the shades closed, perspiring with a small fan running on his bedside table. Resident 1 stated he was not comfortable in his room because of the heat. Resident 1 further stated the sun comes in the morning on his side of the building, making the room hot. Resident 1 ' s window was observed with a type of reflector material covering it. Resident 1 ' s facility medical record was reviewed. According to the facility's Facesheet, Resident 1 was admitted on [DATE], with diagnoses including cellulitis of right and left lower limbs (a deep infection of the skin caused by bacteria), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (stroke) affecting his left non-dominant side. A review of Resident 1 ' s MDS (Minimum Data Set - an assessment tool) dated April 22, 2024, indicated Resident 1 had a BIMS (brief interview for mental status) score of 15, which indicates Resident 1 was cognitively intact. A review of Resident 1 ' s History and Physical dated January 2, 2024, indicated Resident 1 had the capacity to understand and make decisions. During a concurrent observation and interview with Resident 2, on June 25, 2024, at 1:48 p.m., Resident 2 was observed sitting on the side of his bed near the hallway. He is perspiring, with a small fan running on his bedside table. Resident 2 stated he feels like it is too hot in the facility. Resident 2 further stated he is not sleeping well because it is too hot in the facility. Resident 2 ' s facility medical record was reviewed. According to the facility ' s Facesheet, Resident 2 was admitted to the facility on [DATE], with diagnosis that included ventricular tachycardia (a type of abnormal heart rhythm), chronic obstructive pulmonary disease (COPD - lung disease causing restricted airflow and breathing problems), and heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). A review of Resident 2 ' s MDS dated [DATE], indicated Resident 2 had a BIMS score of 15, which indicates Resident 2 was cognitively intact. A review of Resident 2 ' s History and Physical dated May 24, 2024, indicated Resident 1 had the capacity to understand and make decisions. During a concurrent observation and interview with the facility Maintenance Supervisor (MAS) on June 25, 2024, at 2:08 p.m., the MAS indicated the air conditioner was functioning properly in the facility. The MAS further stated sprinklers were installed on the roof to spray water on the compressor to help the compressor stay cool. The MAS also stated, we purchased two industrial fans that are at each end of the hallway. During a concurrent observation and interview with the MAS on June 25, 2024, at 2:08 p.m., the MAS checked six resident rooms and the main hallway with a handheld laser thermometer gun with the following results: room [ROOM NUMBER] - 84.7 degrees Fahrenheit room [ROOM NUMBER] - 76.6 degrees Fahrenheit room [ROOM NUMBER] - 81.3 degrees Fahrenheit room [ROOM NUMBER] - 79.3 degrees Fahrenheit room [ROOM NUMBER] - 79.0 degrees Fahrenheit room [ROOM NUMBER] - 84.0 degrees Fahrenheit Main hallway - 81.5 degrees Fahrenheit On June 25, 2024, at 3:12 p.m., an interview was conducted with the facility Administrator (ADM) who stated the temperature in the facility should be between 71 and 81 degrees. He agreed that the temperatures of three rooms and the main hallway were above 81 degrees Fahrenheit. On June 26, 2024, at 12:25 p.m., a telephone interview was conducted with the Registered Nurse Charge (RNC). The RNC stated the risk associated with high internal temperatures at the facility include residents experiencing dehydration, heat exhaustion and exacerbation (the worsening of a disease or an increase in its symptoms) of their current morbidities (being symptomatic or unhealthy for a disease or condition). On June 26, 2024, at 12:57 p.m., a telephone interview was conducted with the facility Administrator (ADM). The ADM stated the risks associated with higher temperatures the 71 to 81 degrees Fahrenheit range include residents becoming upset, and possibly experiencing medical issues such as dehydration. A review of the facility policies and procedures titled Policy and Procedure: Internal Temperature of the Facility, undated, indicated .the facility maintains the temperature from 71 degree to 81 degree .utilizing a log which records the daily temperatures of the facility . A review of the facility policy and procedure titled Quality of Life - Homelike Environment, revised May 2017 indicated .The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include . Comfortable and safe temperatures (71 °F - 81 °F)the potential to cause discomand hadfort and adverse health effects to residents, staff and visitors including dehydration (loss of body fluids), heat stress (a series of conditions where the body is under stress from overheating), and heat stroke (when the body can no longer control its temperature).

Feb 2024 13 deficiencies

CONCERN (D)

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

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to inform the resident's share of cost and amount of charges for the items and services covered by Medicare (federal health insurance for anyo...

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Based on interview and record review, the facility failed to inform the resident's share of cost and amount of charges for the items and services covered by Medicare (federal health insurance for anyone aged 65 and older)/Medicaid (federal and state program that gives health coverage to some people with limited income and resources), for one of four residents reviewed (Resident 43). This failure had the potential to result in confusion and frustration for Resident 43, affecting his psychosocial and mental wellbeing. Findings: During an interview on January 29, 2024, at 3:37 p.m., with Resident 43, he stated, They (the name of the facility) were taking all my money. Resident 43 stated, he was getting 35 dollars a month. Resident 43 further stated, he cannot live with 35 dollars, he had monthy bills to pay. During an interview on January 31, 2024, at 10:36 a.m., with the Business Office Manager (BOM) 2, she stated, she should have informed Resident 43 about the share of cost and charges to services covered by Medicaid. BOM 2 further stated, she should have informed Resident 43 upon receipt of the letter from Medicaid. During a review of the facility document titled, Medicare and Medicaid Benefits, dated April 2017, the document indicated, .When changes are made to items and services covered by Medicare or Medicaid State plans, residents will be informed of these changes as soon as possible .

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an accurate assessments were conducted for two...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an accurate assessments were conducted for two of three residents reviewed for resident assessment (Resident 33 and 42), 1. Resident 33's functional impairment of the upper extremities and lower extremities. This failure had the potential to affect management of care for Resident 33's current functional impairment which could cause further decline in mobility; and 2. Resident 42 had no natural teeth. This failure resulted for Resident 42 not receiving the appropriate level of care and treatment. Findings: 1. During a concurrent observation and interview on January 31, 2024, at 9:03 a.m., with Resident 33, in his room, Resident 33's left wrist was flexed inward, and could raise about two inches high from the bed. Resident 33 could not raise his left foot but could move his left big toe. Resident 33 stated that's the best he can do. During a review of Resident 33's HISTORY AND PHYSICAL EXAMINATION (H&P), dated January 2, 2024, the H&P indicated, Diagnosis .L (left) Hemiparesis (muscular weakness or partial paralysis restricted to one side of the body) .CVA (Cerebral Vascular Accident - stroke) . During a review of Resident 33's Minimum Data Set (MDS), dated October 22, 2023, the MDS (an assessment tool) indicated, .Functional Limitation in Range of Motion .Upper extremity (shoulder, elbow, wrist, hand)- 0 (No impairment) .Lower extremity (hip, knee, ankle, foot) - 0- (No impairment) . During a concurrent interview and record review on January 31, 2024, at 2:50 p.m., with the MDS Coordinator (MDSC), the MDSC stated, Resident 33 had no decline in functional range of motion. The MDSC stated, the MDS Functional Limitation in Range of Motion for Resident 33 was inaccurate. The MDSC stated, it was an error. 2. During a concurrent observation and interview on January 30, 2024, at 2:37 p.m., with Resident 42, she was observed without teeth. Resident 42 stated, she had been without teeth since admission. During a review of Resident 42's admission MDS, dated [DATE], the MDS indicated: - .Section L (Oral/Dental Status) .Dental .Check all that apply .No natural (edentulous)- blank (the box was unchecked) . During a concurrent interview and record review on January 31, 2024, at 2:45 p.m., with the MDSC, the MDSC stated, Resident 42 had no teeth. The MDSC stated, she coded Section L in error. During a review of facility's Policy titled, Certifying Accuracy of the Resident Assessment, dated November 2019, indicated, .A person who completes any portion of the MDS assessment .certifying the accuracy of .assessment .

CONCERN (D)

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

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled for eight consecutive hours in a 24-hour period for January 21, 2024, and January 28, 2024. Th...

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Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled for eight consecutive hours in a 24-hour period for January 21, 2024, and January 28, 2024. This failure had the potential to adversely affect oversight and direction regarding residents' quality of care and quality of life directly impacting overall health and well-being. Findings: During a review of the RN monthly schedule, dated January 2023, indicated there was no RN coverage for January 21, 2024, and January 28, 2024. During a review of January 2024 payroll records indicated there was no RN coverage for January 21, 2024, and January 28, 2024. On February 1, 2024, at 10:53 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated there was no RN scheduled to cover the facility on January 21, 2024, and January 28, 2024. The DON stated the policy is we staff RNs for 8 hours per day. On February 6, 2024 at 9:23 a.m., an interview was conducted with the facility Administrator (ADM), he stated we have to meet requirements for state and federal requirement for nursing staff. The ADM stated further when they have open shifts, they have staff to cover the shifts. The ADM stated furter if there is no staff to cover those shifts, our corporate office will send resource staff. The ADM stated there should be a registered nurse present for eight hours daily. A review of the facility's policy titled Staffing dated April 2019 indicated, licensed registered nursing will be onsite at least 8 consecutive hours a day, 7 days a week to provide and monitor the delivery of resident care services .

CONCERN (D)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure facility's policies and procedures were developed and implemented to track accurately the movement of controlled substances (CS) and...

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Based on interview and record review, the facility failed to ensure facility's policies and procedures were developed and implemented to track accurately the movement of controlled substances (CS) and to fully account for use of all CS to minimize the time and loss of diversion. Two out of three residents' medical record did not accurately account for removal and administration of CS. This had the potential for drug diversion by impaired staff caring for the residents. Findings: On January 30, 2024, at 11:45 a.m., during the medication cart inspection with Licensed Vocational Nurse (LVN) 1, blister cards containing controlled substances (CSs) stored in the locked drawer of the cart were audited to determine the accuracy of CS use documentation. The discrepancies in the documentation of CS use were as follows: 1. Resident 38's blister card indicated there were 23 doses of oxycodone (narcotic pain medication) 10 mg remaining. The label on the blister card had the direction to give one tablet by mouth every six hours as needed for severe pain; The resident's Controlled Substance Administration Record (CDAR) for documenting the removal of CS from the blister card indicated seven doses were removed in January 2024; The resident's medication administration record (MAR) indicated one dose was documented as administered, in January 2024, a discrepancy of six doses; and The resident's PRN Non-Pharmacological Intervention and Medication Flowsheet (PNIM) indicated two doses were documented as administered and assessed for effectiveness post administration, in January 2024, a discrepancy of five doses; 2. Resident 22's blister card indicated there were 18 doses of tramadol (narcotic pain medication) 50 mg remaining. The label on the blister card had the direction to give one tablet by mouth every eight hours as needed for pain; The resident's CDAR indicated ten doses were removed in January 2024; The resident's MAR indicated one dose was documented as administered, in January 2024, a discrepancy of nine doses; and The residents PNIM indicated three doses were documented as administered and assessed for effectiveness post administration, in January 20224, a discrepancy of eight doses. On January 30, 2024, at 11:15 a.m., in an interview, LVN 1 agreed the removal from the CDAR for these residents did not match the administration record on the residents' MAR. LVN 1 stated the documentation needed to be on the CDAR, MAR, and PNIM. On February 1, 2024, at 11:45 a.m., in an interview, the DON acknowledged the discrepancies in documentation on CDAR and MAR. The facility's policy and procedure titled, Administering Medications, last revised, October 2015, was reviewed, and it indicated: .The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones . The facility's policy and procedure titled, Controlled Substances, last revised, April 2019, was reviewed, and it indicated: .The nurse administering the medication is responsible for recording: (1) name of the resident receiving the medication; (2) name, strength, and dose of the medication; (3) date and time of administration; (4) quantity of the medication remaining; and (5) signature of nurse administering medication .

CONCERN (D)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the physician order when the medication Humalog Injection So...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow the physician order when the medication Humalog Injection Solution (Insulin Lispro) a rapid-acting insulin was administered to the resident at a lower dose, for one of one resident reviewed for insulin (Resident 26). This failure had the potential for the medication to inadequately control resident's blood sugar level leading to hyperglycemia (high blood sugar). Findings: A review of Resident 26's record, indicated, Resident 26 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar). A review of Resident 26's physician order dated January 23, 2024, indicated, .HumaLOG Injection Solution (Insulin [medication used to lower blood glucose] Lispro) inject as per sliding scale . If 60 - 200 = 0 units (unit of measurement); 201 - 250 = 2 units; 251 - 300 = 4 units; 301- 350= 6 units; 351 - 400 = 8 units; 401 - 500 = 8 units & (and) call MD (physician) . During a concurrent interview and review of Resident 26's FINGER STICK BLOOD GLUCOSE / INSULIN CHARTING RECORD, on February 2, 2024, at 3:05 p.m., with the Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 26 's blood sugar level was 357 and Resident 26 received two units of insulin on December 14, 2023, at 5 p.m. LVN 1 stated, Resident 26 should be getting eight units of insulin. LVN 1 stated, the dose ordered by the physician was not followed. LVN 1 further stated, this can lead to signs and symptoms of elevated blood sugar such as blurred vision. During an interview with the Director of Nursing (DON) on February 2, 2024, at 3:35 p.m., the DON stated, the resident who was given two units instead of eight units had increased chance to have signs and symptoms of hyperglycemia. During a review of the facility document titled, Nursing Care of the Resident with Diabetes Mellitus, dated April 2011, indicated, .It is the policy of the facility to help the resident control his /her diabetes .insulin (as ordered) .

CONCERN (D)

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

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide dental appointment for dentures to a resident...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide dental appointment for dentures to a resident without dentition for one of one resident reviewed for dental (Resident 42). This failure had the potential to result in inadequate chewing, oral health issues such as gum disease. Findings: During a concurrent observation and interview on January 30, 2024, at 2:37 p.m., with Resident 42, she had no teeth. She stated, she had been without teeth since admission. She stated, she missed eating an apple. Resident 42 stated, she was not asked if she needed a denture. A review of Resident 42's record indicated, Resident 42 was admitted to the facility on [DATE], with diagnoses which included spondylolisthesis (a displacement of a bone in which the bone slides out of its proper position). A review of Resident 42's record titled, Order Summary Report, for the month of October 2023, indicated, .DENTAL CONSULT FOR EVALUATION AND TREATMENT AS NEEDED . A review of the facility document titled, PSYCHO-SOCIAL ASSESSMENT FORM,dated October 6, 2023, indicated Resident 42 was not assessed for dentition. A review of Resident 42's History & Physical Examination, dated November 3, 2023, indicated, .Resident 42 has the capacity to understand and make decisions . During a concurrent interview and record review on January 31, 2024, at 12:12 p.m., with the Social Service Director (SSD), the SSD stated residents were referred to the dentist only when the resident made a request to see a dentist or the nurse informed her. The SSD stated, she did not ask Resident 42 if she needed dentures, not until now. During a review of the facility policy titled, Dental Services, dated December 2016, indicated, Social Services .will assist residents with appointments .dental services .Routine or 24-hour emergency dental services are provided to our residents . During a review of the facility policy titled, Social Assessment, dated July 2014, indicated, .Social assessment will be done to help identify resident's personal .needs .to help staff develop a personalized plan of care .

CONCERN (E)

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

Grievances (Tag F0585)

Could have caused harm · This affected multiple residents

Based on interview and record review, the facility failed to ensure the residents were provided information on how to file a grievance. This failure had the potential for residents to not be able to ...

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Based on interview and record review, the facility failed to ensure the residents were provided information on how to file a grievance. This failure had the potential for residents to not be able to address their issues and voice their concerns which could worsen the existing problems. Findings: During an interview on January 30, 2024, at 9:33 a.m., with the resident council, multiple residents (Residents 12, 26, 30, 31, 33, and 39) stated they were not given information on how to file a grievance. During an interview on February 2, 2024, at 12:01 p.m., with the Director of Staff Development (DSD), the DSD stated, Social Service Director was responsible for the resident's grievances. During an interview on February 2, 2024, at 12:12 p.m., with the Social Service Director (SSD), the SSD stated, If the resident will ask about the grievance process, they will be taught how to file a grievance, but the facility does not inform all residents on admission. During a review document titled, The Facilty admission Agreement, Facility Rules and Grievance Procedure, dated, May, 2011, indicated, .when you are admitted , we will give you a copy of the Facility Grievance Procedure .

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On February 01, 2024, at 11:45 a.m., CNA 2 was interviewed regarding process when Residents have skin changes. She stated, an...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On February 01, 2024, at 11:45 a.m., CNA 2 was interviewed regarding process when Residents have skin changes. She stated, any skin changes noted on a resident such as open skin, discoloration, redness, or anything unusual, should be reported to the charge nurse immediately. CNA 2 stated, examination of skin were completed daily by the CNA's. CNA 2 stated, the charge nurse assessed the skin concern. CNA 2 stated she filled out Head to Toe Skin and Pressure Point Examination form, which would indicate where the skin changes were located with a description of the skin. CNA 2 stated, the licensed nurse and the CNA signed the form. CNA 2 stated, she was familiar with Resident 24. She stated, Resident 24 was at high risk for pressure sores. On February1, 2024, at 2:40 p.m., an interview was conducted with the DSD. The DSD stated, skin assessment was done on admission and daily by the CNAs. The DSD stated, the CNA should report any skin changes to the charge nurse. The DSD stated, if a resident had any skin treatment, the treatment nurse should be responsible for daily skin assessments and treatments. The DSD further stated, weekly skin assessment was done by the treatment nurse. On February 1, 2024, at 3 p.m., a concurrent interview and review of Resident 24's record were conducted with the DON. The DON stated, the Head to Toe Skin and Pressure Point Examination document was completed by the CNA for 12/19, 12/20, 12/22, 12/24, 12/25, 12/26, 12/27/23, 1/1 and 1/ 9/24. The DON stated skin examinations were likely not done from 1/2 to 1/8/24. The DON stated, all residents should have daily skin examinations and the form Head to Toe Skin and Pressure Point Examination should be completed and signed. The DON stated, Resident 24 should have daily skin examinations done on 12/21, 12/23, 12/28, 12/29, 12/30, 12/31/23 and from 1/11 to 1/29/24. The DON stated, the outcome of not completing these daily examinations could lead to progression of undetected and untreated skin problem. Based on observation, interview and record review, the facility failed to ensure three of four residnets sampled (Residents 14, 24 and 33's) skin was monitored and assessed in accordance with the facility's policy and procedures. This failure had the potential for Residents 14, 24, and 33 to develop skin breakdown and or pressure injury (PI's- localized damage to the skin and underlying soft tissue over a bony prominence or from a medical device) affecting the residents overall health and wellbeing. Findings: 1. On February 1, 2024, at 10:40 a.m., during a concurrent observation and interview with the Director of Nursing (DON) inside Resident 14's room. The coccyx (tailbone) area was observed to have an open skin and had no dressing in place. The DON stated, the coccyx had an open wound with a red base and has a small serosanguinous drainage (blood and clear yellow liquid.) The DON further stated, the wound measured four centimeters (cm - unit of measurement) in length, 4 cm in width and 0.25 cm in depth. The DON stated, Resident 14 was incontinent of stool and urine, immobile and required maximum assistance with his Activities of Daily Living (activities related to personal care). On February 1, 2024, Resident 14's records were reviewed. Resident 14 was admitted to the facility on [DATE], with diagnoses which included muscle weakness and reduced mobility. A review of Resident 14's History and Physical, dated December 6, 2023, indicated, Resident 14 does not have the capacity to understand and make decisions. A review of Resident 14's Minimum Data Set (an assessment tool), dated December 11, 2023, indicated, Resident 14 was dependent to staff with toileting and required maximum assistance with repositioning. Resident 14 was at risk for developing PIs. On February 1, 2024, at 12:02 p.m., during a concurrent interview and record review of facility document titled Head to Toe Skin and Pressure Point Examination, from December 2023 through January 2024, with the Director of Staffing Development (DSD), the DSD stated, Resident 14's skin was not assessed every day. The DSD further stated the skin assessment should have been done daily to closely monitor Resident 14's skin and to make sure any new wounds are addressed timely. On February 1, 2024, at 3 p.m., during a concurrent interview and review of the facility document titled Head to Toe Skin and Pressure Point Examination, dated December 2023, through January 2024, with the DON, she stated, Resident 14's skin was not assessed daily. The DON stated, there was no documentation Resident 14 was assessed on 12/1 to 12/26/23, 12/29 to 12/30/23, 1/3 to 1/4/24, 1/6 to 1/7/24, 1/9 to 1/11/24, and 1/13 to 1/29/24. The DON further stated Resident 14's skin assessment was just not done. The DON further stated the CNA's should do a body examination daily for all residents, filled out the head to toe skin and pressure point examination form. The DON stated, Resident 14's skin assessment should have been done daily to monitor the resident's skin and to address any new wounds timely. 3. During a concurrent observation and interview on January 31, 2024, at 9:10 a.m., with Resident 33, in his room, the left wrist was contracted, and can only raise about two inches from the bed. Resident 33 stated, his left foot could only move the big toe. A review of Resident 33's record, indicated Resident 33 was admitted on [DATE], with diagnoses which included hemiplagia (paralysis of one side of the body) and hemiparesis (muscular weakness or partial paralysis restricted to one side of the body) following CVA (Cerebral Vascular Accident - stroke). A review of Resident 33's HISTORY AND PHYSICAL EXAMINATION, dated January 2, 2024, indicated .This resident .has the capacity to understand and make decisions . Resident 33's position was observed on the following dates: 1. On January 29, 2024, at 2:52 p.m., Resident 33 was in his room lying in bed, on his back; 2. On January 30, 2024, at 10:18 a.m., Resident 33 was in his room lying in bed, on his back; and 3. On January 31, 2024, at 8:35 a.m. Resident 33 was in his room lying in bed, on his back. A review of facility's document titled, Head to Toe Skin and Pressure Point Examination, dated November 22, 2023, thru January 13, 2024, indicated, skin examinations were not done daily by the CNAs. Resdient 33 was not examined by the CNAs on 11/24, 11/25, 11/26, 11/29, 12/9, 12/11, 12/14, 12/15, 12/19, 12/21 to 12/30/23, 1/4, 1/5, 1/7, 1/9 to 1/29/24. During a review of facility document titled, LICENSED NURSE RECORD WEEKLY SUMMARY, dated September 13, 2023, thru January 27, 2024, indicated, there was no documented evidence the licensed nurse completed the weekly summary report on week of January 8, 2034 to January 13, 2024. On February 1, 2024, at 11:52 a.m., CNA 2 was interviewed. CNA 2 stated, when there was a break in the skin, she let the charge nurse looked at the resident's skin. CNA 2 stated she filled out the form (Head to Toe Skin and Pressure [NAME] Examination). CNA 2 stated, she saw Resident 33 on January 30, 2024. CNA 2 stated Resident 33's buttocks was red and bleeding. CNA 2 stated, she was not sure for how long Resident 33 had the skin problem. On February 1, 2024, at 3 p.m., the DON was interviewed. The DON stated, Resident 33 should have been assessed from January 11 to January 29, 2024. A review of the facility's policy and procedure titled, Pressure Ulcer Risk/Skin Assessment and Management, dated August 1, 2023, indicated, .Based on outcomes generated from the pressure sore risk .Preventative measures shall be implemented as part of the skin care program .Skin care program shall include .Assess skin daily .

CONCERN (E)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document and record review, the facility failed to ensure medication irregularities were identified durin...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document and record review, the facility failed to ensure medication irregularities were identified during monthly medication regimen review (MRR) by the Consultant Pharmacist (CP) and recommendations were made to ensure appropriate use of medications when the CP did not make recommendations on the use of medications that were on the Beers Criteria for potentially inappropriate medications for elderly over the age of 65 for three of the five residents reviewed (Residents 5, 9 and 43). In addition, the facility failed to employ CP services for monthly review of all facility residents' medication regimen in October 2023. This had the potential to expose residents to severe adverse events from inappropriate medication use. According to, American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults by the 2023 American Geriatrics Society Beers Criteria Update Expert Panel, in the May 7, 2023's issue of Journal of the American Geriatrics Society, .The American Geriatrics Society (AGS) Beers Criteria (TM) (AGS Beers Criteria) for Potentially Inappropriate Medication (PIM) Use in Older Adults is widely used by clinicians, educators, researchers, healthcare administrators, and regulators. Since 2011, the AGS has been the steward of the criteria and has produced updates on a regular cycle. The AGS Beers Criteria is an explicit list of PIMs that are typically best avoided by older adults in most circumstances or under specific situations, such as in certain diseases or conditions . The primary target audience for the 2023 AGS Beers Criteria is practicing clinicians. The criteria are intended to support shared decision-making about pharmacologic therapy with adults [AGE] years old and older in all ambulatory, acute, and institutionalized settings of care, except hospice and end-of-life care settings. The intention of the AGS Beers Criteria is to reduce older adults' exposure to PIMs by improving medication selection; educate clinicians and patients; reduce adverse drug events; and serve as a tool for evaluating the quality of care, cost, and patterns of drugs use in older adults. Others who utilize the criteria include healthcare consumers, researchers, pharmacy benefits managers, regulators, and policymakers . Diphenhydramine (oral) .Highly anticholinergic .risk of confusion, dry mouth, constipation, and other anticholinergic effects or toxicity. Cumulative exposure to anticholinergic drugs is associated with an increased risk of falls, delirium, and dementia .Avoid . Metoclopramide .Can cause extrapyramidal effects (involuntary movements), including tardive dyskinesia (irreversible involuntary movement disorder) .Avoid . Rivaroxaban for long-term treatment of nonvalvular atrial fibrillation or venous thromboembolism (VTE) .appears to have a higher risk of major bleeding and GI bleeding in older adults than other DOACs (direct oral anticoagulants - blood thinner), particularly apixaban .Avoid for long-term treatment of atrial fibrillation or VTE in favor of safer anticoagulant alternatives . Findings: On January 31, 2024, Resident 9's medical record was reviewed, and the following was noted: The resident, [AGE] years old, was originally admitted on [DATE], with diagnoses that included, dementia, anemia, and insomnia; There was a physician order on November 13, 2023, for Benadryl (diphenhydramine - medication used for allergic reactions) 25 mg (milligram - unit of measurement) with the direction to give the resident, one tablet by mouth at bedtime for allergies; and The medication administration record (MAR) for December 2023 and January 2023, had documentation the resident was given a dose of Benadryl 25 mg at bedtime consistently. On January 31, 2024, Resident 43's medical record was reviewed, and the following was noted: The resident, [AGE] years old, was admitted on [DATE], with diagnoses that included, Parkinson's disease (disease that causes imprecise movement, tremor, and muscle rigidity), history of falling, difficulty walking, atrial fibrillation (AFIB - irregular heart rhythm) and GERD (heartburn). There was a physician order on November 14, 2023, for diphenhydramine 50 mg, with the direction to give the resident, one tablet by mouth every six hours as needed for itching; There was a physician order on November 14, 2023, for metoclopramide (medication used for nausea/vomiting, bowel obstruction, or gastroparesis (slowing of the food in stomach to empty) 10 mg with the direction to give the resident, one tablet by mouth before meals and at bedtime for GERD; There was a physician order on November 14. 2023, for rivaroxaban (a blood thinner) 15 mg, with the direction to give the resident, one tablet by mouth one time a day for AFIB; and The MAR for January 2024 had documentation the resident was given a dose of metoclopramide 50 mg four times a day, and a dose of rivaroxaban 15 mg once a day consistently. On January 31, 2024, Resident 5's medical record was reviewed, and the following was noted: The resident, [AGE] years old, was admitted on [DATE], with diagnoses that included, schizoaffective disorder (mental disorder that includes altered sense of reality and mood symptoms), type 2 diabetes mellitus (disease that causes too much sugar in the blood), morbid obesity and high blood pressure: There was a physician order on March 27, 2023, for Benadryl 25 mg with the direction to give the resident, two tablets by mouth at bedtime for allergies; and The MAR for December 2023 had documentation the resident was given a dose of Benadryl 50 mg at bedtime consistently. The review of the monthly Consultant Pharmacist (CP) medication regimen review (MRR) for the facility residents for 2023 indicated the CP did not identify as potentially inappropriate use of and make recommendations on the use of diphenhydramine, metoclopramide, and rivaroxaban. In addition, the MRR for the month of October 2023 was not present. On February 1, 2024, at 12 p.m., in an interview, the CP stated he started in November 2023 and was catching up on MRR reviews of the facility's residents by focusing the review on the lab results and psychotropic medication use. The CP stated he would normally review residents' medications that were on the Beers list for possible unnecessary medications but did not make any recommendations for medications on the Beers list for the above residents. On February 1, 202402, at 12:20 p.m., in an interview, the Director of Nursing (DON) stated no MRR was done for the month of October 2023 due to the facility transitioning to a new CP. The facility's policy and procedure titled, Drug Regimen Review, dated, October 2012, was reviewed, and it indicated: .It shall be this facility's policy to formulate measures that will comply with requirements of Drug Regimen Review, whereby drug regimen of each resident will be reviewed at least once a month by a licensed pharmacist . During the drug regimen review, pharmacy consultant shall submit report of drug irregularities to the Director of Nurses and residents' physician . The facility's policy and procedure titled, Pharmacy Services - Role of the Consultant Pharmacist, last revised, April 2019, was reviewed, and it indicated: .The consultant pharmacist may also collaborate on other aspects of pharmacy services, including .issue and/or adverse effects, including what information to gather before contacting the prescriber . The Consultant Pharmacist will provide specific activities related to medication regimen review including .A documented review of the medication regimen of each resident at least monthly, or more frequently under certain conditions, based on applicable federal and state guidelines . The manufacturer's prescribing information for metoclopramide included a boxed warning, a highest warning issued by the US FDA (Food and Drug Administration), and it indicated: .Metoclopramide can cause tardive dyskinesia (TD), a serious movement disorder that is often irreversible. There is no known treatment for TD. The risk of developing TD increases with duration of treatment and total cumulative dosage .Avoid treatment with metoclopramide for longer than 12 weeks because of the increased risk of developing TD with longer-term use . Review of the Resident 43's physician order on November 14, 2023, for metoclopramide, did not indicate the duration of therapy.

CONCERN (E)

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

Deficiency F0802 (Tag F0802)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews the facility failed to ensure dietary staff were able to carry out the functions of food...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews the facility failed to ensure dietary staff were able to carry out the functions of food and nutrition services safely and effectively when the Dietary Supervisor (DSS) and [NAME] (CK) 1 was unable to accurately verbalize the cool down process for hot food and ambient food temperatures. This failure had the potential to place residents at risk for food borne diseases (illness that result from ingestion of contaminated food) that can cause sickness and or death. Findings: On January 30, 2024, at 10:15 a.m., during an interview with CK 1 of the cool down process for hot food and ambient food temperatures inside the kitchen. CK 1 stated the hot food cooldown temperature starts at 165 degrees, then check every 30 minutes for one and a half hours with a goal temperature of 145 degrees. CK 1 further stated as long as the food reaches 145 degrees, she does not check the temperature of the food again. CK 1 stated the cool down process for ambient food temperature is after food was made, food will be placed in the refrigerator and check every 30 minutes for one and a half hours with a goal temperature of 36 degrees. CK 1 further stated if the food did not reach goal temperature after one and a half hours, the food will be thrown away. On January 30, 2024, at 10:22 a.m., during an interview with DSS of the cool down process for hot food and ambient food temperatures. The DSS stated for ambient food temperature cooldown process, like tuna salad, the food is placed in the refrigerator after it was made, and the dietary staff will check the food temperature at 8:30 p.m. before the end of their shift. The DSS further stated, the staff do not check the food temperature in between and the next food temperature check will be right before serving the tuna salad to the residents the next day. The DSS stated the cool down process for hot food temperature will start at 165 degrees and will cool down to 145 degrees and the food will be kept at that temperature. On January 30, 2024, at 2:51 p.m., during an interview with the Registered Dietitian (RD). The RD stated the cool down process for ambient food temperature is the food needs to be at 41 degrees within 4 hours and if that temperature is not achieved the food will be thrown away. The RD stated hot food cooling process, temperature starts at 135-140 degrees then 70 degrees with two (2) hours and then 41 degrees within four (4) hours with a total of six (6) hours cool time. The RD further stated if hot food does not reach 41 degrees within 6 hours, the food will be discarded. RD stated her expectation was for the dietary staff to follow the Policy and Procedure for the rapid cooling of hazardous foods to provide safe food to the facility's residents. The RD further stated there has been no previous inservice provided to staff regarding the cool down process of hot food and ambient food temperatures. A review of the facility's policy and procedure titled, Rapid Cooling, dated April 2019, indicated, .Potential Hazardous food are cooled rapidly .from 135°F to 70°F within two hours and then to a temperature of 41°F or below within the next 4 hours .The total cooling time from 135°F and 41°F is not to exceed 6 hours . A review of the facility's document titled, Cooling Log,, indicated, .Cool foods made from room temperature or cold ingredients must be 41°F within 4 hours . A review of the facility's document titled, Job Description Cook, dated December 1993, indicated, .Detailed Duties and Responsibilities: Prepared /[NAME]/cooks all food items in accordance with .facility procedures . A review of the facility's document titled, Personnel Management, dated 1999, indicated, .Dietary Supervisor Responsibilities: Directs the food service operation following the facility dietary policy and procedure .Completes inservice education requirements .

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to ensure sanitary environment, prepare, and served food in accordance with professional standards for food service safety when:...

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Based on observation, interview, and record review, the facility failed to ensure sanitary environment, prepare, and served food in accordance with professional standards for food service safety when: 1. There were multiple areas in the kitchen and kitchen equipment that were not clean; 2. Multiple wet and moist pans and pots were stored and stacked on top of each other; 3. Multiple chopping boards had brown-yellowish discoloration and multiple deep cuts and indentations; 4. There was a 1/3 open container of salsa found on the kitchen preparation counter left at room temperature; 5. The inside of the ice machine had a black goo-like grime; and 6. The resident refrigerator had no thermometer gauge and no temperature monitoring. These failures had the potential to place residents at risk for food borne diseases (illness that result from ingestion of contaminated food) that can cause sickness and or death. Findings: 1. On January 29, 2024, at 10:10 a.m., during a walk-through observation inside the kitchen with the Director of Staffing Development (DSD), the following were observed: a. The condiment shelves, the preparation area under the condiment shelves, and the spice shelves were observed to have a whitish-gray colored debris. b. The hood above the stove, the hood ventilation, the two (2) chains holding the hood into the ceiling, and the sprinkler and pipes above the hood were observed to have black hair like debris. c. The inside of the small and large ovens were observed with black goo-like grime. On January 29, 2024, at 11:40 a.m., during an interview with the DSD, she stated, the whitish-gray colored debris on the condiment shelves, the preparation area under the condiment shelves and the spice shelves is dust. The DSD further stated, dust should not be there and can fall into resident food and can cause cross-contamination and foodborne illness. On January 29, 2024, at 12:10 p.m., during a concurrent observation and interview with the DSD and Dietary Aide (DA) 1, both stated, the black hair like debris covering the hood above the stove, the hood ventilation, the two (2) chains holding the hood into the ceiling, and the sprinkler and pipes above the hood were dust fibers. The DSD and DA 1 stated dust fibers should not be there, and it could fall into residents' food while cooking and could cause cross-contamination and foodborne illness. On January 29, 2024, at 12:15 p.m., during a concurrent observation and interview with [NAME] (CK) 1, she stated, the oven was old and the black grime inside the small and large oven was dried grease residue. CK 1 further stated, the oven should be cleaned, and should not have grease residue that could cross-contaminate food and caused food borne illness. 2. On January 29, 2024, at 11:45 a.m., during a concurrent observation and interview with the DSD and DA 1 in the kitchen, the following were observed: a. Wet, moist with water dripping and were stacked on top of each other: - Seven (7) silver steam pans (4 quarts - unit of measurement); - Two (2) silver steam pans (2 quarts); - Two (2) stock pots; and - Seven (7) roast pans b. Three (3) chopping boards were observed with brown-yellowish discoloration and with multiple deep cuts and indentations. The DSD and DA 1, both stated, the steam pans, stock pots and roast pans were moist, wet, and dripping and should not have been stacked on top of each other. The DSD and DA 1 further stated, it should be completely dry before storing, the moisture lead to bacterial growth and contaminate the food and caused foodborne illness. DA 1 stated, the brown-yellowish discoloration on the chopping boards was meat and food residue. DA 1 further stated the chopping boards were overused and old with multiple deep cuts and markings. DA 1 stated, the chopping boards should be cleaned with no food residue and the surface should be with minimal slice marks. DA 1 further stated, the deep cuts and markings harbor bacteria and cross-contaminate food and causing foodborne illness. 4. On January 29, 2024, at 12:00 p.m., during a concurrent observation and interview with the DSD and DA 1 in the kitchen, one (1) 10 oz (ounce-unit of measurement) open container of salsa was on the preparation table under the spice shelves at room temperature. DA 1 stated, she did not know how long the open container of salsa had been left on the counter at room temperature. DA 1 further stated, the salsa required to be refrigerated and not left on the counter and the residents can get sick if they eat that. The DSD stated, the salsa should have been refrigerated promptly after using to prevent bacterial growth and cause food poisoning if served to residents. The DSD further stated, the salsa manufacturer label, indicated, the salsa needs to be refrigerated promptly after opening. 5. On January 29, 2024, at 12:50 p.m., during a concurrent observation and interview of the ice machine with the Maintenance Director (MTD). The right-side area of ice machine below the motor and directly above the ice chute was observed to have a black goo-like grime. The MTD stated she does not know what the black goo-like grime is. The MTD stated, the black goo-like grime is not supposed to be there and can fall on the ice. The MTD further stated, if consumed by residents it can make the residents sick. 6. On January 29, 2024, at 3:40 p.m., during a concurrent observation and interview with Certified Nurse Assistant (CNA) 1 inside the utility-break room, the residents' refrigerator was observed to not have a thermometer gauge with the following items inside: - Six (6) Vanilla Mighty Shake 4oz.; - One (1) Strawberry Mighty Shake 4oz.; - One (1) Glucerna Original 4oz.; - Six (6) Yogurt 6oz.; and - One (1) Yogurt 4oz. CNA 1 stated nursing and dietary staff shared the responsibility in checking the refrigerator temperature daily and it should be at below 41 degrees to prevent foodborne illness. CNA 1 further stated the Resident refrigerator had no thermometer gauge. CNA 1 stated, she did not know what the refrigerator temperature was and she was not aware of a temperature monitoring log for the refrigirator. CNA 1 stated she could not say if the items inside the Resident refrigerator was at the right temperature and the beverages or food could be bad or spoiled. CNA 1 further stated, if the residents drinks or eat those, they can get sick and get food poisoning. On January 29, 2024, at 3:55 p.m., during a concurrent observation and interview with the Dietary Supervisor (DSS) of the resident refrigerator inside the utility-break room. The DSS stated, the resident refrigerator has no thermometer gauge, and she could not tell what temperature the refrigerator was at. The DSS stated, there was no temperature monitoring log for the refrigerator. The DSS stated the refrigerator should be at temperature below 41 degrees to prevent foodborne illness. The DSS further stated, she could not say if the beverages or food inside the refrigerator was good or safe and if given to residents they can get very sick. On January 30, 2024, at 2:51 p.m., during an interview with the Registered Dietician (RD), she stated the kitchen or any kitchen equipment should be clean, free of dust, debris and grime. The RD further stated the dust or debris, and grime can contaminate the food and lead to foodborne illness. The RD stated pans and pots should be completely dry, not moist, and not wet before storing to prevent bacterial growth which contaminate food and cause foodborne illness. The RD stated chopping boards should not have deep indentation and not have staining. The RD further stated the indentations harbor bacteria and lead to food borne illness. The RD stated the open container of salsa should not be left on the counter at room temperature and should have been refrigerated after use to prevent bacterial growth that cause food borne illness. The RD stated the refrigerators should have a thermometer gauge and it should be monitored for the appropriate and safe temperature levels to prevent food borne illness. A review of the facility's policy and procedure titled, Sanitization, dated October 2008, indicated, The food servie area shall be maintained in a clean and sanitary manner .All utensils, counters, shelves and equipment shall be kept clean .Food preparation equipment and utensils .will be allowed to air dry .Ice machines and ice storage containers will be .cleansed and sanitized .Kitchen .shall be cleaned .to prevent accumulation of grime . A review of the facility's policy and procedure titled, Refrigerator and Freezers, dated December 2014, indicated, .Acceptable temperatures ranges are 35°F to 40°F for refrigerators .Monthly tracking sheets for all refrigerators .will be posted to record temperatures .Food Service Supervisor or designated employee will check and record refrigerator .temperature daily . A review of FDA (Food and Drug Administration) Food Code 2022, Section 4-501.12 Cutting Surfaces, the FDA Food Code indicated, .Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize .As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces . A review of the FDA Food Code 2022 Annex 3 4-901.11 Equipment and Utensils, Air-Drying Required, the Food Code indicated, .Items must be allowed to drain and to air-dry before being stacked or stored .Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow .

CONCERN (E)

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

Room Equipment (Tag F0908)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure, one (1) microwave oven, two (2) bottom oven s...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure, one (1) microwave oven, two (2) bottom oven shelves, four (4) oven door hinges, and one (1) dry storage room shelf were maintained in a safe operating condition. These failures had the potential to place residents at risk for food borne diseases (illness that result from ingestion of contaminated food) that can cause sickness and or death. Findings: On January 29, 2024, at 12:15 p.m., during a concurrent observation and interview inside the kitchen of the small and large oven bottom shelves and the oven door hinges with the Director of Staff Development (DSD) and [NAME] (CK) 1. The two (2) bottom shelves inside the oven and the four (4) oven door hinges were observed to have a brown-copper discoloration. The DSD and CK 1, both stated, the brown-copper discoloration is rust. The DSD and CK 1 further stated, rust should not be there and the oven should be clean to prevent food cross-contamination and foodborne illness. On January 29, 2024, at 12:33 p.m., during a concurrent observation and interview inside the dry storage room with the DSD, there was one (1) metal rack shelf observed to have a brown-copper discoloration. The DSD stated, the metal rack shelf is rusted. The DSD further stated rust should have not been there and all shelves need to be free of rust for food safety and to prevent food cross contamination and foodborne illness. On January 29, 2024, at 12:43 p.m., during a concurrent observation and interview inside the Utility-Break Room of the microwave oven with the DSD. The inside front bottom and top areas of the microwave oven was observed to have a brown-copper discoloration with peeled paint. Further observed the inside top upper area and the back area of the microwave oven to have paint bubbles and brown [NAME] discoloration. The DSD stated, the microwave oven is used to warm residents' food during NOC (night) shift and as needed when resident request. The DSD further stated the microwave paint is bubbled and peeled, and the brown-copper discoloration is rust. The DSD stated rust and peeled paint is not supposed to be there and can fall on resident's food when heated up. The DSD further stated it's pretty nasty and it should not be used to heat up resident food, it can cause food contamination and foodborne illness. On January 29, 2024, at 3:40 p.m., during a concurrent observation and interview inside the utility-break room of the microwave oven with Certified Nurse Assistant (CNA) 1, she stated, the microwave oven is used to warm residents' food during NOC (night) shift and as needed when resident request. CNA 1 further stated the microwave oven is rusted and the paint is chipped and bubbled. CNA 1 stated rust and peeled paint is not supposed to be there and can fall on resident's food when heated up. CNA 1 further stated the microwave is not supposed to be like that, that can cause food contamination and foodborne disease. On January 29, 2024, at 3:55 p.m., during a concurrent observation and interview inside the utility-break room of the microwave oven with Dietary Supervisor (DSS), she stated the microwave oven is rusted and the paint is peeled. DSS further stated, it is not supposed to be like that, the rust and paint can fall on the resident food and can cross-contaminate and cause foodborne illness. On January 30, 2024, at 2:51 p.m., during an interview with the Registered Dietician (RD). The RD stated rust, peeled paint, or any decomposition on any kitchen equipment should have not been there and the equipment should not have been used. The RD further stated rust and peeled paint is a food safety hazard that can fall into food and can cross contaminate and cause foodborne illness. A review of the facility policy and procedure titled, Sanitization, dated October 2008, indicated, .All utensils, counters, shelves and equipment shall be .maintained in good repair and shall be free from .corrosions .cracks and chipped areas . A review of the Federal and Drug Administration (FDA) Food Code 2022, 4-101.11 Equipment Characteristics, indicated, .FOOD-CONTACT SURFACES of EQUIPMENT .shall be: (D) to have a smooth, easily cleanable surface and . (E) Resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition . A review of the Federal and Drug Administration (FDA) Food Code 2022, Annex 4-501.11 Equipment Good Repair and Proper Adjustment, indicated, .Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed .Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk .

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

Based on observation, interview, and record review, the facility failed to implement infection control practices when: 1. The laundry staff transported the clean laundry uncovered; 2. Facility did not...

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Based on observation, interview, and record review, the facility failed to implement infection control practices when: 1. The laundry staff transported the clean laundry uncovered; 2. Facility did not sanitize washer in between laundering. 3. The facility did not monitor for legionella (bacteria that can cause a severe from of pneumonia [lung condition]) in the water system annually. These failures potential to increased cross-contamination (the physical movement or transfer of harmful bacteria from one person, object or place to another) which could result to increse infections to facility residents. Findings: 1. On January 31, 2024, at 8:25 a.m. a staff member was observed exiting the laundry room with clean clothes and linens on an uncovered laundry cart. On January 31, 2024, at 8:48 a.m., during an interview was with Laundry Staff (LS) 1, she stated, she put clean, folded clothes of the resident in the the laundry cart uncovered. LS 1 further stated, she transported the uncovered laundry cart through the dirty area to deliver the clean laundry to the residents. LS 1 stated, the clean laundry should have been covered and secured to prevent cross contamination from the dirty area. On January 31, 2024, at 1:36 p.m., during an interview with the Infection Preventionist (IP) . The IP stated there was a potential for cross contamination when uncovered clean laundry crossed over the dirty area. The IP stated, the laundry staff should have covered clean laundry when distributing to prevent cross contamination. The IP further stated, the residents could get sick. During a review of the facilities policy and procedure titled, Laundry and Bedding, Soiled, revised dated October 2018, indicated, .Clean linens are protected from dust and soiling during transport and storage to ensure cleanliness .Laundry/bedding shall be handled, transported, and processed according to best practices for infection, prevention and control . 2. On January 31, 2024, at 9:15 a.m., during an interview with LS 1, she stated, she was laundering housekeeping mops and rags mid-day at 1:30 p.m. LS 1 further stated, after washing the mops and rags, she continued to wash residents linens and gowns. LS 1 stated, she did not sanitize the washing machine in between. LS 1 stated, she should have sanitized the washing machine in between laundering the mops and rags and the residents linens and gowns to prevent cross contamination. On January 31, 2024, at 1:43 p.m. during an interview with the IP, she stated soiled mops and housekeeping rags should be washed at the end of the day and the washer should be sanitize in between laundering residents' items. The IP further stated, if the washer was not sanitized it could cause cross contamination and could get the residents sick. 3. On January 31, 2024, at 9: 40 a.m., during an interview with Maintenance Director (MTD), she stated the facility had not conducted Legionella surveillance and she was not aware the facility needed to. On February 1, 2024, at 9:02 a.m., during an interview with the facility Administrator, he stated, there had been no Legionella surveilance conducted, since he started working at the facility. The Administrator further stated, Legionella should be monitored yearly and if not monitored there was potential for residents to get waterborne illness (illness caused by consuming or coming in contact with contaminated water). On February 1, 2024, at 3:36 p.m., during an interview with the IP, the IP further stated, the facility should have conducted Legionella surveilance annually, to prevent residents from getting waterborne illness. During a review of the facilities policy and procedure titled, Legionella Water Management Program, dated July 2022, indicated, .Our facility is committd to the prevention, detection and control of water-borne contaminatns, including Legionella .

Dec 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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assure a pain re-assessment was completed, after Resident 2 receive...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assure a pain re-assessment was completed, after Resident 2 received Tylenol 650mg for complaints of back pain, after an unwitnessed fall on October 24, 2023. This failure could have led to Resident 2 continuing to experience unrelieved back pain. Findings: On November 1, 2023, a review of Resident 2's admission records was conducted. Resident 2's facesheet indicated she was admitted to the facility on [DATE], with a diagnosis of Muscle weakness, reduced mobility and Parkinson's disease (A progress disease of the nervous system marked by tremors and muscle ridgidity). Further review indicated Resident 2's BIMS score was 15 (Cognitive intactness). A review of Resident 2's SBAR, dated, October 24, 2023, at 3:02 a.m., by LVN1, indicated, resident had experienced a fall, and her vital signs were taken and withing normal limits. A pain assessment was not completed by LVN1. A review of Resident 2's progress notes, dated October 24, 2023, at 3:02 a.m., indicated, Resident 2 experienced an unwitnessed fall, stating, . went to (Resident 2's room) . to see what the commontion was . saw (Resident2) sitting on her back side (Glutes) outside the bathroom door . complained of back pain . Tylenol 325 mg (milligrams unit of measure) (times) 2 given per Dr. Order . No pain re-assessment on Resident 2 was documented post administration of Tylenol for complaints of back pain. A review of Resident 2's Doctor's (Dr's) order, dated October 24, 2023, at 3:02 a.m., indicated orders for, .Acetaminophen (Tylenol) Oral Tablet 325 mg (Milligrams, a unit of measure) Give 2 tablets by mouth every 6 hours as needed for non-injury fall . A review of Resident 2's October 2023, Medication Administration Record (MAR), indicated, LVN1 administered Tylenol 650 mg to Resident 2, at 3:02 a.m., for pain rated 7 out of 10 on (1-10 pain scale, 10 being the worst pain felt). A pain re-assessment for effectiveness of pain medication, Tylenol, was not documented. On November 14, 2023, at 9:17 a.m., an interview was conducated with LVN1. LVN1 stated, . I got a Drs order for (Resident2's) back pain, tylenol 650 mg, gave to her, and she feel asleep for about 4 hours. I checked on her to re-assess (her) pain, but she was sleeping. LVN1 verified resident 2's back pain did not get re-assessed after receiving Tylenol 650 mg. On November 14, 2023, at 10:40 a.m., an interview was conducted with the Director of Nursing (DON), who stated, Per facility policy, the nurse should re-assess a resident 1 hour post administration of a pain medication, for effectiveness of treatment. The results should be documented on the resident's PRN (As needed) flow sheet . A review of the facility's Policy & Procedure, titled, Pain Monitoring and Management, dated, October 2014, indicated, . Procedures: 4. When documenting results of pain monitoring, licensed nurse should indicate: Pain rating before administration of medication; Pain rating after administration of medication .

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 F0921)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to provide a properly functioning call light system in Resident1's bathroom, which did not activate each time the call light cor...

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Based on observation, interview, and record review, the facility failed to provide a properly functioning call light system in Resident1's bathroom, which did not activate each time the call light cord was pulled. This failure had the potential to delay staff's assistance in Resident1's bathroom, when the improperly functioning call light cord was pulled. Findings: On November 1, 2023, an unannounced visit was made to the facility to investigate a Quality-of-Care issue. On November 1, 2023, at 9:45 a.m., an interview was conducted with Resident1, who indicated, his bathroom call light did not work, stating, They (staff members) keep jiggling it (Bathroom call light), it'll work for a minutue, then (Bathroom call light) doesn't work again. On November 1, 2023, at 3:40 p.m., an observation of Resident1's bathroom was conducted. The call light was pulled in the bathroom to engage the call light system, indicating the call light and alarm did not turn on or alarm. The call light did not function. On November 1, 2023, at 3:50 p.m., a concurrent interview with CNA1, and observation of Resident1's bathroom call light was conducted. CNA1 observed the call light cord had been pulled and call light system was not activated, CNA1 stated, It (Resident1's call light system) should be on. CNA1 then pulled the call light cord, and the call light system did not activate on the third pull, CNA1 further stated, Ya it (Resident 1's Call light system) should be on, and it was not. On November 1, 2023, a concurrent interview with the Director of Nursing (DON), and observation of Resident1's bathroom call light system was conducted. DON verified Resident1's bathroom call light system was pulled down, and the call light system was not activated. DON stated, Resident1's bathroom call light, Should be on, and it was not. DON further stated, I don't know what's going on with (Resident1's bathroom call light), I'll have maintenance take a look at it. A review of the facility's Policy & Procedure, titled, Answering Call Lights, Revised, April 2018, indicated, .Report all defective call lights to the nurse supervisor promptly .

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to: 1. Provide a safe environment to help prevent falls, as Resident 3'...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to: 1. Provide a safe environment to help prevent falls, as Resident 3's bedrails were not up, per doctor's (Dr's) orders, prior to his unwitnessed fall on October 12, 2023. 2.The facility failed to identify Dizziness, as a resident specific fall risk, prior to Resident 4's unwitness fall on October 9, 2023, and failed to incorporate Resident 3's history of Feeling Dizzy, into his resident-centered ' Falls care plan, per facility's Policy & Procedure (P&P), Falls and Fall Risk, Managing. These failures could have resulted in Resident 3 & Resident 4, experiencing additional falls, resulting in injuries. Findings: 1. On November 1, 2023, at 9:35 a.m., an unannounced visit was made to the facility for a Quality-of-care visit. On November 1, 2023, a review of Resident 3's admission records was conducted. Resident 3's facesheet (A document that gives a resident's medical information at a glance), indicated, Resident 3 was admitted to the facility on [DATE], with a diagnosis of Left (Hip) fracture and a history of falling. Further review indicated Resident 3's BIMS (Brief Interview for Mental Status) indicated a score of 6 (Severly impaired mental cognition). On November 1, 2023, a review of Resident 3's Situation, Backround, Assessment, & Situation (SBAR) (A communication form shared between staff members, explaining a situation or change of condition of a resident, i.e., an unwitness fall), dated, October 10, 2023, at 2:00 a.m., by RN1 was conducted. The SBAR indicated, Resident 3 experienced a .Fall (with) bruising to hip and pelvis . (Resident 3) verbalized pain . bruising to pelvis and (right) hip . A review of Resident 3's Licensed Nurses Progress Notes, dated October 12, 2023, at 1:45 a.m., indicated, Notified by (Certified Nursing Assistant) CNA that (Resident3) was on the floor . lying on his (Left) side . was on the fall mat, but mobility rails were not in place as they should be been . On November 13, 2023, at 2:11 p.m., an interview was conducted with RN1, who verified, The mobility (Bed) rails were not up, and should have been, when he found Resident 3 on the floor, after his unwitnessed fall on October 10, 2023. A review of Resident 3's Dr's orders, dated, 10/10/2023, indicated, 1/3 mobility rail for increased bed mobility and transfer assist . On November 13, 2023, at 10:40 a.m., an interview was conducted with the Director of Nursing (DON), who verified, Resident 3's mobility rails should have been up, while he was lying in bed, stating, (Mobility) rails should always be (Up) when a (Dr's) order specifies it. On November 14, 2023, a review of the facility policy, titled, Falls and Falls Risk Managing, indicated, . Based on previous evaluations and current data, the staff will 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 . 6. In conjunction with the attending physician, staff will identify and implement relevant interventions . to try to minimaize serious consequences of falling . 2. A review of Resident 4's admission records, indicated, resident was admitted to the facility on [DATE], with a diagnosis of Dementia (Cognitive decline, impaired ability to remember), Muscle weakness, reduced mobility, and difficulty walking. Further review indicated Resident 4's BIMS score was 08 (Moderate cognitive impairment). Review of Resident 4's SBAR, dated, October 23, 2023, at 9:20 a.m., indicated, resident experienced a non-injury fall; Doctor was notified, with new orders received for Change of Condition documentaton for 72 hours. Review of Resident 4's progress notes, dated, October 9, 2023, at 9:20 a.m., by LVN1, stated, . CNA notified me that (Resident4) fell on his bottom while attempting his wheelchair . he is oriented to self and surroundings . denies hitting his head . free of pain and stable vital signs . will continue to monitor per Doctor . On November 13, 2023, at 4:40 p.m., a concurrent interview with the DON, and review of Resident 4's At Risk for Fall, and Dizziness, care plans was conducted. DON stated, Resident4 Had dizziness long before he was (at the facility), and (The facility) wanted to send (Resident4) out (to Acute Care Hospital) for a dizziness assessment, but resident's POA (Power of Attorney for Healthcare decisions) did not want (Resident4) to get assessed. DON further verified, a resident, Feeling dizzy can contribute to falls, and Resident 4 should have had Assess for dizziness, included in resident's patient-centered interventions on his At Risk for Fall care plan, and it was not. On November 1, 2023, at 4:48 p.m., an interview was conducted with the DON, who stated, after a fall she will ensure the (SBAR) is completed, the care plans are updated, and an Interdisciplinary Team meeting (Team members from different disciplines, working collaborately to make decisions) will follow-up to discuss the situation surrounding the fall, including interventions that work (to decrease the risk of fall) and don't work. The DON further stated, The results (of the IDT post fall meeting), are documented on the Interdisciplinary Team Post Fall Review. Review of Resident 4's, Interdisciplinary Teams (IDT's) Post Fall Review, dated, 10/09/2023, untimed, indicated the following . Recommendations: Falling Star Program; Reminders to ask for assistance if needed (with) transfers . Futher review indicated, Resident 4 was assessed for . Signs and Symptoms with Event . including .Dizziness . Review of Resident 4's care plans, titled, At risk for fall/injury, dated, October 10, 2023, indicated, . Interventions for post 1st fall, date (October 9, 2023): Attempt to detemine reason for fall; Notify MD and family promtly; Post falling star to alert continued fall risk; Teach resident and family regarding falls and safety. Resident-centered interventions not present on care plan. Further review of Resident 4's care plans, titled, Short term goals: Dizziness, dated, August 11, 2023, with interventions, which include the medication, Meclizine 25 mg (Medication to help prevent feelings of dizziness) (as needed three times per day). Assessment for Dizziness was not included in Resident4's patient-centered fall interventions. Review of Resident 4's, October 2023, Medication Administration Record (MAR), indicated, Resident 4 received the medication Meclizine, on the dates of October 17 & 25, 2023, for complaints of dizziness. Review of facility's Policy & Procedure, titled, Fall and Fall Risk, Managing, revised March 2018, indicated, . Based on previous evaluations and current data, the staff will 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 . 1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls .

Nov 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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide monitoring on a resident who wandered to other resident's r...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide monitoring on a resident who wandered to other resident's room, for one of three sampled residents (Resident 1). This failure resulted in an allegation of physical abuse. Findings: On September 5, 2023, at 11:35 a.m., an unannounced visit was conducted to the facility to investigate an allegation of abuse. a. Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses of dementia (memory loss). A review of Resident 1's document titled History and Physical (H&P), dated March 15, 2023, the H&P indicated, .This resident .does NOT have the capacity to understand and make decisions . During a review of Resident 1's Minimum Data Set (MDS – an assessment tool), dated July 27, 2023, indicated, Resident 1 had severe cognitive impairment. During review of Resident 1's Progress Notes (PN), dated August 24, 2023, the PN indicated, .Notified .that resident (name of Resident 2) came into Resident's room .resident stated that she told him to get out .no one wants you in here. Resident then states (name of Resident 2) hit her on the chin .Stated He (Resident 2) hit her in chin . b. Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses which included metabolic encephalopathy (refers to any disturbance of the brain's functioning that leads to problems like confusion and memory loss). A review of Resident 2's Care Plan (CP), dated June 21, 2023, the CP indicated, .Will not have conflict with other resident's within the facility if wandering in to other rooms .Interventions .Redirect to activities of choice: Bingo, movies, T.V. (television) . Monitoring of resident location constantly, check every 30 minutes were not included in one of their interventions. A review of Resident 2's document titled History and Physical (H&P), dated July 1, 2023, the H&P indicated, .This resident .does NOT have the capacity to understand and make decisions . During a review of Resident 2's Minimum Data Set (MDS – an assessment tool), dated June 28, 2023, indicated, Resident 2 had cognitive impairment. During a review of Resident 2's Progress Notes (PN), dated August 24, 2023, the PN indicated, .Resident reportedly .went into room [ROOM NUMBER] (Resident 1's room) accidentally. She then heard a camotion (sic) in the room .when she went in she found resident (Resident 2) at bedside of 8A (Resident 1) .8A's allegation that he hit her . Further review of Resident 2's record indicated there was no documentation Resident 2 was monitored for his wandering episodes. On October 11, 2023, at 10:14 a.m., Certified Nursing Assistant (CNA) 1 was interviewed. She stated, she heard someone screaming. CNA 1 stated, she saw Resident 2 inside Resident 1's room. CNA 1 stated, she saw Resident 1 crying and holding her chin. CNA 1 stated Resident 1 reported Resident 2 hit her on the chin. CNA 1 stated Resident 2 wandered to other resident's room. CNA 1 stated she had other residents that were a handful, so it was difficult to watch Resident 2 and kept him from going to other resident's room. On October 11, 2023, at 10: 20 a.m., the Director of Nursing (DON) was interviewed. The DON stated the staff had to keep an eye on the resident. The DON stated, for wandering residents, the staff had to sit beside the resident. The DON stated, when the incident happened, the CNA who was watching him was not available. On October 23, 2023, at 3:19 p.m., the Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated the facility did not have enough manpower to keep the CNA beside a wandering resident. LVN 1 stated CNA 1 should have informed the charge nurse to keep an eye on Resident 2. LVN 1 stated Resident 2 wandered to other resident room because he was confused.

Nov 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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the licensed nurse conducted an assessment and...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the licensed nurse conducted an assessment and monitoring of the purplish black discoloration (bruise) observed on the right hand, for one of three sampled residents (Resident A). This failure had the potential to result in delayed provision of care and treatment for Resident A's skin condition. Findings: On October 9, 2023, at 10:50 a.m., an unannounced visit to the facility was conducted to investigate an allegation of quality of care/treatment. On October 9, 2023, at 1:05 p.m., in a concurrent interview and observation of Resident A in the room with Certified Nurse Assistant (CNA), he stated Resident A had a bruise measuring 6 centimeters (cm) by 8 cm on the right hand. The CNA stated, she observed the bruise on Monday (October 2, 2023). The CNA stated, Resident A's bruising should have been recorded. Resident A's record was reviewed. Resident A was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss) and anemia (a condition in which the body does not have enough healthy red blood cells [which provide oxygen to body tissues]). During further review of Resident A's Progress Notes, dated October 5, 2023, the PN indicated, Resident A did not have a purplish black discoloration on the right hand. There was no assessment and monitoring regarding Resident A's purplish black discoloration on the right hand. On October 9, 2023, at 1:05 p.m., the Director of Nursing was interviewed. She stated she was not aware Resident A had a bruise on the right hand. The DON stated, there was no documentation in the resident's record that an assessment was conducted for Resident A's skin discoloration. On October 9, 2023, at 1:47 p.m., the Licensed Vocational Nurse (LVN) was interviewed. The LVN stated, the CNA should have notified the licensed nurses for resident's skin problem, to address the issue right away. The LVN stated Resident A was transferred and came back from the hospital. The LVN stated the licensed nurse should have done a complete assessment of Resident A, document, and notified the physician. The LVN stated, there was no documentation of Resident A's purplish discoloration on her right hand. The LVN stated, Resident A's skin changes should have been assessed and monitored, the physician notified, and treatment should have been provided. A review of the facility policy and procedure titled, Pressure Ulcer Risk/Skin Assessment/Management, dated April 2008, indicated, .It shall be the facility policy to assess a resident on admission or readmission of his/her risk factors for developing .other types of skin breakdown and provide necessary care and services that will meet patient needs and promote skin integrity .

Oct 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 F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Certified Nursing Assistant (CNA) who observed a new ski...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Certified Nursing Assistant (CNA) who observed a new skin discoloration (bruise) on the resident's left thigh documented and notified the licensed nurse of a change of condition, for one of three residents reviewed (Resident 1). This failure had the potential for the resident to experience a delay in treatment and further compromise resident's physical and emotional wellbeing. Findings: On September 21, 2023, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnosis which included unspecified cirrhosis of liver (a type of liver damage where health cells are replaced by scar tissue). During a review of Resident 1's Care Plan (CP), dated August 22, 2023, indicated: - .Poor safety awareness .monitor and document any skin tears, abrasions, lacerations, bruising, or c/o pain . - .Be free of injury r/t falls prevention of injury is goal .monitor and document any skin tears, abrasions, lacerations, bruising, or c/o pain . There was no documented evidence in Resident 1's record that the CNA documented and reported the resident's bruising to the left hip. On September 21, 2023, at 1:37 p.m., an interview was conducted with the Registered Nurse (RN). The RN stated, she was informed by a CNA on September 11, 2023, that Resident 1 had bruising to his left hip. The RN stated if bruising was noted for any resident, it should be reported to the nurse on duty, documented a change of condition, notified the physician, family, and Director of Nursing (DON) . The RN stated, Resident 1's bruising should be documented in the resident's record according to facility policy. On September 25, 2023, at 1:49 p.m., an interview was conducted with the Certified Nursing Assistant (CNA) 3. CNA 3 stated, she observed Resident 1's bruising to the left thigh, after she was informed by the afternoon shift CNA on September 9, 2023. CNA 3 stated, Resident 1 had bruising to his left thigh and that a verbal report was provided to the Licensed Vocational Nurse (LVN) 1. On September 26, 2023, at 3:39 p.m., an interview was conducted with the DON. The DON stated, she was not informed of bruising for Resident 1 prior to September 11, 2023. The DON stated, CNAs and licensed nurses are expected to report and document skin changes which are considered a change of condition. The DON stated the staff should have documented and reported the bruising immediately according to the facility policy and procedure. On September 26, 2023, at 4:17 p.m., an interview was conducted with the Licensed Vocational Nurse (LVN) 1. LVN 1 stated she was not informed about Resident 1's bruising on September 9, 2023. LVN 1 stated if she was made aware the resident's bruising, she would have reported it immediately to the MD, the family, and the DON. LVN 1 stated Resident 1's bruising should be documented according to facility policy and procedure. A review of the facility policy and procedure dated July 2017 titled, Charting and documentation, indicated, .All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care .

Sept 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to complete a 5 day summary and an abuse investigation in a timely manner, after accusations of verbal abuse...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to complete a 5 day summary and an abuse investigation in a timely manner, after accusations of verbal abuse towards Resident 1 which were reported to the facility Administrator. This failure had the potential to subject Resident 1 to further incidents of verbal abuse. Findings: On July 26, 2023, at 10:30 a.m., an unannounced visit was made to the facility for an abuse issue. A Review of Resident 1 ' s medical records, face sheet, indicates, Resident 1 was admitted to the facility on [DATE], with a diagnosis of Diabetes mellitus (A disease which cause high blood sugars), Obesity (Weight higher than what ' s considered health), and high blood pressure. Further review indicated Resident 1 had a Brief Interview Mental score of 15 (intact mental cognition). On July 26, 2023, at 2:22 p.m., and interview was conducted with Resident 1. Resident 1 stated, The other day (CNA1) was arguing with me, because she wouldn ' t touch her own cell phone because, she said her hands were dirty, so I said, don ' t touch me then, if your hands are dirty, (CNA1) started arguing with me, then she went around the curtain, and left the room. Resident 1 stated, she felt safe at the facility, and had not been physically harmed by (CNA1), but she prefers not to have (CNA1) work with her anymore. On July 26, 2023, at 12:57 p.m., an interview was conducted with the facilities Administrator (Admin). Admin confirmed he ' s also the facilities Abuse coordinator, and stated, There has been one recent complaint regarding (CNA1 and Resdient1). (Resident1) made a comment, that (CNA1) is just being rude. When I (Admin) asked (Resident1) how (CNA1) was being rude, (Resident1) said I don ' t remember, and she couldn ' t give any examples. Admin confirmed the incident was reported to CDPH and proper authorities on July 20, 2023. Admin further stated, he has started his 5-day investigation The day it was reported (July 20, 2023), but has not completed it, further stating It usually doesn ' t take a week to complete the investigation, but the facilities A/C (Airconditioning) went out last week, and I ' ve been trying to deal with that, and I ' ve followed up several times with the resident, and on a couple occasions, and she couldn ' t remember what she said about CNA1. Also, (Resident1) stated she felt safe, and comfortable at the facility. Admin. gave a copy of his undated investigation he ' s In the middle of. On July 26, 2023, a Record Review of Admin ' s undated incomplete 5-Day investigation was conducted, and stated, . Informed (July 21, 2023) via ambassodor rounds (Rounds performed by department heads on Mondays & Thursdays, asking residents about their care, and if they have any concerns) that CNA1 is rude as per (Resident1). Followed up with Resident1 on (July 21, 2023) and asked what happened and . (Resident 1) was unable to give (sid) example or recall any activitiy, only said (CNA1) was rude . (July 25, 2023) Followed up with (Resident1) . has no complaints about weekend staff . and . asked about (CNA1) and (Resident1) stated (CNA1) is rude . (Resident1) did not recall any incidents of examples of rudeness . (July 26, 2023) Attempted to call (CNA1) . but unable to reach her. Will atempt to call later in PM. (Resident1) still sleeping today, unavailable to interview . No other information from investigation, available. On July 26, 2023, Record Review of Ambassodor Visit Form, from Ambassador rounds on July 20, 2023, by Maintenance Supervisor (MS), was conducted, and stated, . Additional Comments or concerns: (Resident1) said (CNA1) is rude (and) has a bad attitude} . On July 26, 2023, at 2:48 p.m., an interview was conducted with Maintenance Supervisor (MS). MS stated, During ambassodor rounds on July 20, 2023, at approximately 9:00 a.m., MS asked Resident 1, If everyone is treating her fine, Resident 1 stated, No, (CNA1) has a bad attitude. MS asked Resident 1, could be more specific, and resident was unable to give a specific situation. MS further stated, she reported the conversation, Right away, to Social Services Worker (SSW), and Admin. On July 27, 2023, at 3:58 p.m., an interview was conducted with CNA1. CNA1 stated, she has received training on resident abuse upon hire, annually, and during in-services; She was supposed to attend an in-service on abuse at the facility today, but she was sent home, Until the investigation into abuse of (Resident1) is done. CNA1 further stated, I don ' t remember having any problems with a resident, but if you ' re talking about (Resident 1), she ' s very bipolar, and gets upset a lot. A review of Nursing Assignments, indicated, CNA1 was scheduled to work the PM shift on the dates of July 20, 23 and 25, 2023, prior to the completion of Admins 5-day investigation, subjecting Resident 1 to further exposure to CNA1 on these dates. On July 26, 2023, an interview with Admin, and concurrent record review of the Nursing Assignments for July 20, 23, and 25, 2023 was conducted. Admin confirmed (CNA1) did work on the dates of July 23rd and 25th, 2023, and called in sick on July 20, 2023. Admin further confirmed (CNA1) had access to (Resident1) on these dates. Admin stated, he did not take (CNA1) off the nursing schedule, because (Resident1) had told him, she felt Safe, in the facility. Admin further stated, he did not feel it was Necessary, to take (CNA1) off the schedule, when (Resident1) could not give him a reason (CNA1) was Rude and had a bad attitude. was safe with (CNA1) in the building. Admin further stated, he expects staff members to treat Resident ' s Like a loved one, with kindness, and rude statements towards a resident by a staff member is not acceptable behavior. A Review of the facilities Policy Abuse Prevention Program, dated December 2016, was conducted, and indicated, . Our residents have the right to be free from abuse, neglect, misappropriation of resident property . Policy Interpretation and Implementation: As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to : facility staff .

Sept 2023 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

Quality of Care (Tag F0684)

A resident was harmed · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure treatment were consistently provided. In addition, the facility failed to reassess and to monitor weekly the status of...

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Based on observation, interview, and record review, the facility failed to ensure treatment were consistently provided. In addition, the facility failed to reassess and to monitor weekly the status of the open wound on the left side of the forehead for one of the three sampled resident (Resident 1). These failures resulted in the facility licensed nurses unaware on the changes in the resident's left forehead open wound causing a delay in the provision of an appropriate treatment. Resident 1's open wound on the left forehead was noticed with maggot infestation (parasitic skin infestation caused by the larvae [maggots]of certain fly species) on May 20, 2023; and the resident had to be transferred to the general acute care hospital (GACH) for evaluation. In addition, the resident was diagnosed with cellulitis (bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin) to the left forehead open wound (the area infested with maggot) while at the GACH on May 20, 2023. Findings: On May 23, 2023, at 10:20 a.m., an unannounced visit was made to the facility to investigate a quality care issue. A review of Resident 1 ' s facility admission notes, dated October 6, 2022, at 12 p.m., indicated Resident 1 was admitted to the facility with a head wound measuring four x (by) six. The admission notes further indicated the resident was admitted with melanoma (skin cancer typically appears as a brown or black raised lump with dark, irregular colors and borders). A review of Resident 1's care plan titled, Actual Alteration in Skin: Related to squamous cell carcinoma (type of skin cancer), dated October 6, 2022, indicated, Interventions . Inspect skin weekly and PRN (As needed); Report lack of progress toward healing after two weeks to MD (medical doctor) & change treatment as ordered . Educate resident regarding consequences of non-compliance behavior . A review of Resident 1's a care plan titled, Refusal of Care/Demanding of Staff, dated, November 2, 2022, indicated, . Goal: Will not have a negative impact on medical status (related to) refusals of care . Interventions . Keep head wound clean and covered at all times .Educate resident related to the results of refusing . A review of Resident 1's progress notes dated March 8, 2023, indicated, Physician notified of worsening large skin lesion to left (L) side forehead. Wound is malodorous, yellow/brown with uneven boarders. New orders (N.O.) received to transfer resident to (name of GACH) emergency room (ER) for evaluation . A review of Resident 1's physician order dated March 8, 2023, indicated the physician gave an order for Resident 1 to be transferred to the GACH for non-healing forehead lesion (any damage or abnormal change in the tissue of an organism). A review of Resident 1 ' s consultation physician assessment from the GACH dated March 8, 2023, at 1:49 p.m., indicated, .brought in from the nursing home for a chronic draining wound (skin wound not healing) on the forehead. The patient states that it ' s been present for about a year and that he does not have a diagnosis as to the etiology . Physical Examination .on the forehead there is approximate 7 x (by) 4 cm. (centimeters) .exudative (has drainage seeping out of the wound) and not purulent (pus) .He has multiple other small lesions on his head . A review of the physician order dated April 4, 2023, indicated Resident 1 would have a surgery on April 5, 2023, for debridement (removal of damaged tissue from a wound) of the open wound located on the left side of the forehead. A review of the dermatologist ' s (medical practitioner specializingin the diagnosis and treatment of skin disorders) notes from the GACH dated April 5, 2023, indicated Resident 1 had his forehead wound assessed by the dermatologist, and came back with treatment orders for, . Saline (mixture of sodium chloride and water used to clean wounds) moist to dry 4 x (by) 4 gauze dressing (Twice a day) .Bacitracin/Neosporin (topical medication used to treat minor skin injuries, including cuts, scrapes, and burns) and Dry 4 x 4 after washing head, every (day) . (Follow-up dermatologist visit) next month . A review of Resident 1's skilled nursing facility progress notes titled, Skin Wound Progress Report, related to the resident's open wound on the left forehead indicated the following: a. April 6, 2023, .size: 4 x 4; color of drainage: yellow; wound bed: red; no undermining (separation of the wound edges from the surrounding healthy tissue) and no tunnelling (wound extends deeper into the tissue) . b. April 12, 2023, size: 4 x 5; color of drainage: yellow; wound bed: red; no undermining and no tunnelling .; and c. April 19, 2023, . 4 x 4 (cm); color of drainage: none, wound bed: Pink; No undermining/tunneling . Further review of Resident 1's skin/wound progress notes for April 2023, indicated no other wound assessment was conducted after April 19, 2023. A review of Resident 1 ' s Treatment Administration Record (TAR), dated April 2023, indicated Resident 1 received treatment of normal saline to the open wound on the left side of the forehead from April 5 to April 18, 2023; except on April 10 and 18, 2023. Further review of the TAR dated April 2023, indicated Resident 1 did not receive treatment of normal saline for his open wound on the left side of the forehead after April 18, 2023. A review of Resident 1's Nurses Treatment Notes, dated April 2023, indicated Resident 1 had refused treatment to the open wound on the left forehead on April 10 and 18, 2023. A review of Resident 1's Nurses Treatment Notes, dated May 2023, indicated Resident 1 had refused treatment to the open wound on the left forehead on May 2, 2023. A review of Resident 1 ' s dermatologist ' s follow-up notes dated May 4, 2023, at 2:30 p.m., indicated, . Per RN (Registered nurse), refusing wound care, dressing changes . (Diagnosis) Squamous Cell (Cancer) . Recommend wound care if resident agrees; plastic surgery (surgical specialty involving restoration of a body or tissue defect) consult should resident become compliant; this will not heal without treatment . A review of Resident 1 ' s Licensed Nurse Record, dated May 7 and 14, 2023; indicated, .Skin: Please refer to the skin assessment and/or Weekly Wound progress report, for size/location, staging . Open lesion . A review of Resident 1 ' s Skin Assessment and/Weekly Wound Record, for the month of May 2023, indicated no assessments on Resident 1 ' s forehead open wound was documented on May 7, and 14, 2023. A review of Resident 1's skin/wound progress report on a cellulitis on the left forehead open wound dated May 20, 2023, indicated the wound was measured 6 x 5.5 x .5. A record review of Resident 1 ' s progress note, dated May 20, 2023, at 6:30 a.m., indicated, . had maggots crawling on his head wound (open wound on the left forehead) . multiple maggots were crawling in resident's head . Resident to be sent out to acute care hospital for evaluation . A record review of Resident 1 ' s GACH Admission/discharge note, dated May 20, 2023, at 2:50 p.m., indicated, . Disheveled in appearance with large lesion on scalp oozing pus and has maggots crawling everywhere from his head . multiple scrapes and has large lesion on forehead with lots of maggots eating his flesh . Discharge (Diagnosis): Cellulitis (Skin infection) of scalp, Maggot infestation . A review of Resident 1 ' s Physician ' s orders dated May 21, 2023, indicated, Cleanse cellulitis with maggot infestation left forehead, cleanse with normal saline (NS) and H2O2 (hydrogen peroxide-mild antiseptic used on the skin to prevent infection) important disinfectant and bleach and is currently manage (treatment) 50/50 mix (half normal saline and half hydrogen peroxide mixture). apply clean dry dressing Q evening x 14 days until 6/2/2023. On May 23, 2023, at 10:50 a.m., Resident 1 was observed lying in bed inside his room, with a bandage partially covering the left side of his forehead. Resident 1's head was observed to have a loose-fitting gauze, covering the wound on the left side of the forehead. In addition to the forehead open wound, Resident 1 was observed to have an uncovered open wound on top of his head. On May 23, 2023, at 11:12 a.m., a concurrent observation and interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 was observed removing Resident 1 ' s bandage on the the resident's forehead, revealing a forehead open wound which appeared pink and granulated (roughened surface) with clear discharge. LVN 1 stated the weather had been hot and the inevitable happened. She stated Resident 1's forehead open wound got infested with maggots. LVN 1 further stated, Resident 1 went to the GACH on May 20, 2023, for wound debridement (removal of damaged tissue or foreign objects from a wound), after maggot infestation occurred on Resident 1's open wound on the left side of the forehead. On May 23, 2023, at 1:17 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident 1 was not receiving wound care treatments to the open wound on the forehead between the dates of April 19, 2023, and May 20, 2023, due to the resident's refusals of wound treatments. On May 24, 2023, at 1:45 p.m., during an interview with Certified Nursing Assistant (CNA)1, CNA 1 stated on May 20, 2023, at approximately 5:30 a.m., CNA 1 saw maggots on Resident 1's forehead. CNA 1 further stated she reported the situation to the LVN (LVN 3), and the licensed nurse (LVN 3) called 911 for transport to the GACH emergency room. On July 21, 2023, at 4:46 p.m., an interview was conducted with the DON. The DON stated LVN 2 discussed the dermatologist's recommendation on May 4, 2023, to Resident 1 and the family member. The DON stated the resident and the family member refused treatments and she stated at that point the wound treatment for the resident's head was just not being done until the maggot infestation was discovered on May 20, 2023. On August 25, 2023, at 4:03 p.m., during an interview, the DON was asked on how often the treatment nurse conducted wound assessment. She stated the wound would be assessed daily during wound treatment; and the Treatment (Tx) Nurse would measure the extent of the wounds weekly. The DON stated the Tx Nurse would document the measurement of the wound and would conduct an assessment if further treatment is needed during the weekly wound assessment. However, there was no consistent weekly wound assessment completed for April and May 2023, since the resident would sometimes refuse wound treatment. A review of the facility policy and procedure titled, Wound Care, revised December 2010, indicated, .6. Record in the resident's medical record the type of wound care given and the date and time the wound care was given. 7. Notify the supervisor if the resident refuses the wound care. 8. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure ulcer (an injury that breaks down the skin and underlying tissue) to the supervisor.

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 F0925 (Tag F0925)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to maintain an effective pest control program, to prevent the presence of flies within the building.This fai...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to maintain an effective pest control program, to prevent the presence of flies within the building.This failure had the potential to result in flies infestation inside the facility, which could negatively impact the health and safety of the residents. Findings: On May 23, 2023, at 10:20 a.m., an unannounced visit was made to the facility to investigate a quality-of-care issue. During concurrent observation, flies were observed in the facility lobby, hallway, and were observed crawling on a resident. On May 23, 2023, at 11:36 a.m., two staff members were observed walking the facility hallways, and into the resident rooms with fly swatters. A record review of Resident 1 ' s medical record, indicated Resident 1 was admitted to the facility on [DATE], with a BIMS (Brief Interview for Mental Status) score of 09, and diagnoses which included squamous cell carcinoma (cancer of the skin) of the (Forehead of the top of head), muscle weakness and reduced mobility. On May 23, 2023, at 10:50 a.m., an observation of Resident 1 was conducted. Resident 1 was observed lying in bed with a bandage partially covering the left side of his forehead. The gauze cover was loose fitting and lifting on the corners of the wound. An additional wound was noted on top of Resident 1 ' s head, uncovered. On May 23, 2023, at 11:12 a.m., a concurrent observation and interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 removed Resident 1 ' s bandage on his forehead, the wound appeared pink and granulated with clear discharge and no maggots, or flies observed. LVN 1 stated, We live in a hot climate, and the inevitable happened, (Resident 1 ' s) wound got infested with maggots. LVN 1, further stated, Resident 1 went to the Acute Care Hospital (ACH) for debridement (Removal of damaged tissue or foreign objects from a wound), after the maggots were discovered. On May 23, 2023, at 11:26 a.m., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated she would see flies over the front door,. She stated the staff would try to keep the windows shut in the resident's rooms even if the windows have screens, since sometimes the screens were not completely closed. On May 23, 2023, at 11:38 a.m., an interview was conducted with Resident 2. The resident stated flies are normal around the facility, and would sometimes land on the food that it had to be swat away. On May 23, 2023, at 11:55 a.m., an interview was conducted with the facility Maintenance Supervisor (MS). The MS stated there were tons of flies in the facility and the (MS) heard one of the resident had maggots in his forehead wound. She stated there are fans on at the front door, and the back door. On May 24, 2023, at 3:45 p.m., an interview was conducted with CNA 2. CNA 2 stated there were missing screens on some of the windows, mostly in the resident's bathroom windows. On May 25, 2023, at 12:50 p.m., during an observation of the facility property, three resident bathroom windows were observed bare of screen coverings. On May 25, 2023, at 12:57 p.m., an interview was conducted with the facility Administrator (Admin), who stated, after walking the facility property, he had noticed several screens were not fitting properly, and the screen covering the bathroom windows had tears and had to be replaced. A review of the facility ' s policy and procedure titled, Pest Control, dated, May 2008, indicated, . This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents . 3. Windows are screened at all times .

Sept 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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain the required air temperature ranging from 71 ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain the required air temperature ranging from 71 to 81 degrees Fahrenheit inside the resident's rooms on multiple occasions. This failure increased the risk for dehydration and could negatively affect the residents' already compromised health condition. Findings: On July 18, 2023, at 9:55 a.m., an unannounced visit to the facility was conducted to investigate a physical environment issue. On July 18, 2023, at 10:00 a.m., during a concurrent observation and interview with the Maintenance Director (MD), the MD stated the facility air conditioning contractor instructed her not set the thermostat below 75 degrees F. The MD acknowledged the facility thermostat near the nursing station was set at 79 degrees F and reading 79 degrees. She stated the Director of Nursing (DON) increased the temperature to 79 degrees. She stated she was not in the facility at the time. On July 18, 2023, at 10:10 a.m., during an observation with the MD, the following temperatures were observed: room [ROOM NUMBER]- 88 degrees F room [ROOM NUMBER]- 83 degrees F room [ROOM NUMBER]- 82 degrees F On July 18, 2023, at 10:15 a.m., during an observation of the facility lobby, cooling units were noted in the facility lobby and at the adjacent nursing station. On July 18, 2023, at 10:18 a.m., during an observation of the facility storage shed, three portable cooling units were noted stored in the shed. On July 18, 2023, at 11:20 a.m., during an interview with the Director of Nursing (DON), she stated the facility had implemented interventions of portable cooling units, fans, and foil on the windows. She stated the facility ordered more cooling units. She stated she increased the thermostat from 75 to 79 degrees based on her history with the facility and the air conditioning units. She stated she was not instructed by the air conditioning contractor, the Administrator, nor the MD not to raise the thermostat. On July 18, 2023, at 12:00 p.m., during an interview with the DON, she stated the temperatures, per regulation, are to be 71 to 81 degrees F. She stated the room temperatures above 81 degrees were not within regulation. She stated the resident in room [ROOM NUMBER] was being relocated to another room. A review of the facility's temperature log dated July 17, 2023, completed by the maintenance assistant (MA) indicated the following: room [ROOM NUMBER]- 83.5 Fahrenheit (F) room [ROOM NUMBER]- 82 F room [ROOM NUMBER]- 82 F room [ROOM NUMBER]- 82 F room [ROOM NUMBER]- 82.6 F room [ROOM NUMBER]- 83.7 F room [ROOM NUMBER]- 81.5 F room [ROOM NUMBER]- 86.5 F room [ROOM NUMBER]- 83 F room [ROOM NUMBER]- 83.5 F On July 18, 2023, at 1:10 p.m., during an interview with the Maintenance Director (MD), stated the facility process for when temperatures are outside of regulation was to verify the temps were actually out of range and adjust the facility thermostat. She stated if that did not resolve the issue, she would notify the ADM for guidance for further interventions. She stated she expected the staff to know the regulated temperatures, and expected the staff to inform leadership if the temperatures are outside of range. She reviewed the temperature log dated July 17, 2023. She could not state if the maintenance assistant notified leadership of the temperatures. She stated she found the log on her desk when she returned to work. On July 18, 2023, at 12: 50 p.m., during an interview with the DON, she stated the facility's process for temperatures outside of regulated range was to consult with the maintenance director. The MD would attempt to determine the cause of the issue. Afterwards, she will notify the administrator for further guidance. She stated she expects her maintenance staff to know the regulated temperatures. She expected the MD, the ADM, or herself to be notified if the temps were outside of range. The DON reviewed the documentation dated July 17, 2023, and stated she was not informed about the temperatures. She knew it was warm but did not know the specifics temperatures recorded. On July 21, 2023, at 2:40 p.m., during an interview with the Maintenance Assistant (MA), he stated he checked the facility's temperatures over the weekend of July 15 & 16, 2023. He stated he put the temperature logs in the logbook. He stated he did not know what the temperature ranges the room temperatures are to be per regulation. He stated if he measured a temperature, and he felt the temperature was too extreme he would report to his supervisor the maintenance director, the head nurse, or the administrator. On July 21, 2023, at 3:42 p.m., during an interview with the Administrator (ADM), he stated he expected his maintenance staff to know what the regulation temperature range was for the facility. The ADM was informed that his maintenance assistant did not know the regulated temperatures. He stated he needed to provide an in-service to his maintenance staff. On July 18, 2023, at 3:20 p.m., during an observation with the MD, the following temperatures were observed: room [ROOM NUMBER]-83 degrees F room [ROOM NUMBER]-83 degrees F room [ROOM NUMBER]- 84 degrees F room [ROOM NUMBER]- 82 degrees F room [ROOM NUMBER]- 83 degrees F room [ROOM NUMBER]- 82 degrees F room [ROOM NUMBER]- 82 degrees F A review of the facility's temperature log dated July 18, 2023, at 4:15 p.m. indicated: room [ROOM NUMBER]- 81.5 degrees F room [ROOM NUMBER]- 85.3 degrees F room [ROOM NUMBER]- 81.9 degrees F room [ROOM NUMBER]- 81.4 degrees F room [ROOM NUMBER]- 82.6 degrees F room [ROOM NUMBER]- 85.5 degrees F room [ROOM NUMBER]- 81.5 degrees F room [ROOM NUMBER]- 83 degrees F room [ROOM NUMBER]- 82 degrees F room [ROOM NUMBER]- 82.8 degrees F room [ROOM NUMBER]- 82.9 degrees F On July 18, 2023, at 3:30 p.m., during an interview with the DON, she stated she attempted to follow up with the coolers ordered by the company. She stated she was unable to track the order because it was tied to a telephone number, and they were not sure whose number was affiliated with the order. A review of the facility's temperature log dated July 19, 2023, at 8:00 a.m. indicated: room [ROOM NUMBER]- 82.3 degrees F room [ROOM NUMBER]- 84 degrees F room [ROOM NUMBER]- 82.8 degrees F A review of the facility's temperature log dated July 19, 2023, at 9:00 a.m. indicated: room [ROOM NUMBER]- 82.5 degrees F room [ROOM NUMBER]- 82 degrees F room [ROOM NUMBER]- 82.9 degrees F A review of the facility's temperature log dated July 19, 2023, at 10 a.m. indicated: room [ROOM NUMBER]- 82 degrees F (empty) room [ROOM NUMBER]- 82.4 degrees F room [ROOM NUMBER]- 84.4 degrees F room [ROOM NUMBER]- 84.2 degrees F A review of the facility's temperature log dated July 19, 2023, at 11:00 a.m. indicated: room [ROOM NUMBER]- 82.6 degrees F room [ROOM NUMBER]- 83.5 degrees F room [ROOM NUMBER]- 84.7 degrees F On July 21, 2023, at 4:10 p.m., during a concurrent observation and interview with the resident in room [ROOM NUMBER], the resident noted to be lying in bed watching television. The resident appeared clean appearance. No foul smells noted. When asked about the resident's comfort with the portable cooler. The resident stated, It's warm. A review of the facility's policy and procedure titled Internal Temperature of the Facility , undated indicated, .the facility maintains the temperature from 71 degree to 81 degree.

Aug 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

Room Equipment (Tag F0908)

Could have caused harm · This affected multiple residents

Based on interview and record review the facility failed to regularly maintain and inspect the oven within the facility. This failure had the potential to affect the overall safety of the vulnerable r...

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Based on interview and record review the facility failed to regularly maintain and inspect the oven within the facility. This failure had the potential to affect the overall safety of the vulnerable residents of the facility. Findings: On June 7, 2023, at 11:05 a.m., an unannounced visit to the facility was conducted to investigate an issue on physical environment. On June 7, 2023, at 11:45 a.m. the Director of Staff Development (DSD) was interviewed. The DSD stated yesterday (June 6, 2023), at 8:30 a.m., there had been a gas odor throughout the building. The DSD stated, the staff promptly guided the residents outside of the building. On June 7, 2023, at 12:05 p.m. the Maintenance Director (MD) was interviewed. The MD stated the gas leak from the oven was caused by a broken gas connector tubing. A review of the (Name of Gas Company) document titled Job Order, dated June 6, 2023, indicated .Check House line no leaks. Found connector leaking on Range. Replaced connector . On June 7, 2023, at 1: 15 p.m., the MD was again interviewed. The MD stated, the oven did not receive regular maintenance services. The MD stated the manufacturer's instructions for maintenance could not be found. On June 7, 2023, at 1: 15 p. m., the Dietary Manager (DM) was interviewed. The DM stated, she had overseen the kitchen since 2015. The DM stated, no regular maintenance services have been done to the oven. On August 31, 2023, at 8:44 a.m., the MD was interviewed. The MD stated, if the manufacturer's instructions were not available, it would be the MD's duty to create a schedule and regularly maintain the equipment to ensure that it remains safe and functional. The MD stated, he did not schedule a regular maintenance for the oven. A review of the facility Policy and Procedure titled, Maintenance Service, dated December 2009, indicated .Maintenance Service shall be provided to .equipment in safe and operable manner at all times .The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure .equipment is maintained in a safe and operable manner .Maintenance personnel shall follow the manufacturer's recommended maintenance schedule .

Aug 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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure, for one of the six sampled residents (Residen...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure, for one of the six sampled residents (Resident 2), the call light button within his reach and easily accessible. This failure has the potential to result in Resident 2 not getting the help he needed. Findings: On June 29, 2023, an unannounced visit was conducted at the facility to investigate a complaint allegation. On June 29, 2023, at 11:00 a.m. an observation with a concurrent interview was conducted with Resident 2. Resident 2 was in bed, alert, and conversant. Resident 2' s call light button was observed to be wrapped around the call light box that was attached to the wall on the right side of the bed. Resident 2's call light button was not within his reach. Resident 2 stated he did not know where his call light button was. On June 29, 2023, Resident 2's record was reviewed. Resident 2 was admitted to the facility on [DATE], with diagnoses that include Muscle Weakness, Other Reduced Mobility, Osteoarthritis (a joint disease, in which the tissues in the joint breakdown overtime) and Polyneuropathy (a condition in which a person's peripheral nerves are damaged). The Minimum Data Assessment (MDS - an assessment tool) dated April 23, 2023, indicated Resident 2's cognition was moderately impaired. The MDS further indicated Resident 2 required extensive assist with one person for bed mobility and locomotion. The care plan dated October 22, 2022, indicated Resident 2 was at risk for a fall or injury related to diagnoses of osteoarthritis and history of falls. The care plan further indicated to educate resident on how to call for assistance and to keep the call light button within his reach. On June 29, 2023, at 11:09 a.m. an observation with a concurrent interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated Resident 2' s call light button was wrapped around call light box. CNA 1 stated Resident 2 will not get the help he needed if resident was not able to reach and use the call light button and neglect can occur. On June 29, 2023, at 2:00 p.m. an interview was conducted with the Director of Nursing (DON). The DON stated that Resident 2's call light button wrapped around the call box and not within the resident's reach was unacceptable. The facility's policy and procedure titled, Answering Call Light, dated April 2028 was reviewed. The policy indicated, . When the resident is in bed or confined to a chair be sure the call light is within easy each of the resident .

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment on one of three sampled residents' ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment on one of three sampled residents' (Resident 1) lower right arm skin tear in accordance with the physician's orders. This failure has the potential to result in delayed wound healing, while increasing the risk for infection. Findings: On April 14, 2023, at 10:45 a.m., an unannounced visit to the facility was conducted to investigate a nursing service issue. On April 14, 2023, at 12:24 PM, a concurrent observation and interview was conducted with Resident 1. Resident 1's lower right arm was observed to have multiple steri-strips (Wound closure tape) hanging from an unadhered piece of skin, stacked on top of each other in a criss-crossed pattern. The steri-strips appeared to be stuck together with dried blood. Resident 1 stated she hit her right lower arm approximately one week ago, and she stated, A large piece of skin peeled back, and staff put this (Pointing at the steri-strips) on it. A review of Resident 1's medical records indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included difficulty walking and muscle weakness. A review of the Licensed Progress Notes by Licensed Vocational Nurse (LVN) 1 dated April 10, 2023, indicated, . (name of Resident 1) had contracted a skin tear to her R (Right) lower arm as a result of being in her wheelchair. The Physician ordered 6 steri-strips to R (Right) lower arm . A review of the Physician's order, dated April 10, 2023, indicated, . Triple Antibiotic External Ointment (Neomycin-Bacitracin-Polymyxin) Apply to Right lower arm topically one time only for Skin Tear for 1 Day apply steri-strips (6) (Six steri-strips) . On April 14, 2023, at 1:15 PM, during observation of Resident 1 with LVN 2, LVN 2 stated the steri- strips (pointing on Resident 1's right lower arm skin tear) have attached themselves to the piece of skin that was torn. LVN 2 counted 15, steri-strips on Resident 1's lower right arm skin tear. LVN 2 stated the number of steri-strips placed on Resident 1's lower right arm skin tear, Is a problem because, it doesn't give the site the opportunity to breath. LVN 2 stated it looked like the steri- strips were stuck to Resident 1's skin tear by the dried blood. On April 14, 2023, at 1:53 p.m., an interview with the Infection Prevention Nurse (IPN) was conducted and the IPN stated, The number of steri-strips on Resident 1's (Lower right arm) skin tear is a lot. The IPN stated we usually only use a couple of steri-strips to approximate the wound. The IPN further stated, The dried blood on the resident's steri-strips is also concerning because dried blood can increase the chance of infection. A review facility Policy and Procedure titled, Wound Care, revised December 2010, indicated, .The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .3. Provide wound care treatment as ordered .

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 F0727 (Tag F0727)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure a registered nurse (RN) was scheduled for eight consecutive hours in a 24-hour period. This failure had the potential ...

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Based on observation, interview, and record review, the facility failed to ensure a registered nurse (RN) was scheduled for eight consecutive hours in a 24-hour period. This failure had the potential to negatively impact the needs of the facility residents. Findings: On April 14, 2023, at 10:45 a.m.; an unannounced visit to the facility was conducted to investigate nursing services concern. During a concurrent interview with the Director of Staff Development (DSD), the DSD stated the Director of Nursing (DON) was not scheduled to work for the day. A review of the facility nursing assignments, indicated there was no RN scheduled on April 14, 2023. On April 14, 2023, at 11:30 a.m., an interview was conducted with the DON. The DON stated there was no RN scheduled to cover the facility for today. The DON also stated RN 2 was scheduled today (April 14, 2023), but she called-in sick, and she (DON) would not be available to cover RN 2's shift. On April 14, 2023, at 12:10 p.m., during observation the DON was no longer present in the facility. On April 14, 2023, at 2:49 PM, a telephone interview was conducted with the facility Administrator (ADM). The ADM stated his plan for RN coverage was to have RN 2 cover (April 14, 2023) and thought RN 2 was already at the facility. The ADM stated, he was not aware that RN 2 called-off sick, that the DON was no longer at the facility, and there was no RN scheduled for April 14, 2023. The Adm stated he would get an RN to cover the facility for April 14, 2023. On April 14, 2023, at 3:20 p.m., the ADM called and stated an RN Supervisor (RNS) would be at the facility, at approximately between 5-6 p.m. On April 14, 2023, at 6:15 p.m., the RNS stated he would be covering the RN shift for the remainder of April 14, 2023. ( less than 7 hrs. for the 24 hrs. period)

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to report an allegation of abuse to the California Department of Publ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) immediately, but not later than 2 hrs. after an allegation was made, for one of six residents (Resident 1) reviewed. This failure had the potential to result in a delay to protect Resident 1 from further abuse. Findings: On March 13, 2023, at 1:28 p.m., an unannounced visit to the facility was conducted to investigate an allegation of abuse. A review of Resident 1's medical record indicated she was admitted on [DATE], with diagnoses of heart failure (lifelong condition in which the heart muscle can't pump enough blood to meet the body's needs for blood and oxygen), chronic kidney disease (the gradual loss of kidney's ability to filter wastes and excess fluids from the blood), and dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). The document titled History and Physical dated February 6, 2022, indicated she had the capacity to understand and make decisions. On March 13, 2023, at 3:54 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated she received a phone call from Resident 1's family member (FM) on February 23, 2023, at approximately 4:30 p.m., The DON stated the FM reported that in the afternoon of February 22, 2023, a CNA stated to Resident 1 that she did not have a home anymore, and that her family hates the resident, and shut the F--- up (an expletive word). The DON stated on February 23, 2023, she interviewed all parties involved, and it was not reported to California Department of Public Health (CDPH). On March 13, 2023, at 4:19 p.m., an interview was conducted with the Licensed Vocational Nurse (LVN) 2. LVN 2 stated she was on duty on the night of February 22, 2023. LVN 2 stated that she observed Resident 1 in a wheelchair in the hallway with the CNA. LVN 2 stated that Resident 1 was trying to leave. LVN 2 stated that she observed the CNA walking away from Resident 1. LVN 2 denied hearing any verbal abuse towards Resident 1. A record review of Resident 1's Licensed Nurses Progress Notes, dated February 22, 2023, at 6:30 p.m., indicated Resident up in wheelchair packing personal belongings into bags. (sic) noted throwing all personal belongings away into a trash can .Resident aggressive toward staff, swinging arms and hitting, stating leave me alone: and I'm leaving Resident attempted to go outside multiple times .Resident instructed that she lives here now. She does not have her previous house any longer . A record review of Resident 1's Licensed Nurses Progress Notes dated February 23, 2023, at 4:30 p.m., indicated Resident relayed to (name of family member) that her CNA last night (name of CNA)said cruel things to her causing her to pack up belongings and attempt to leave such as, your family doesn't love you , Shut the F--- up (expletive word), + you don't have a home anymore. Interviewed Licensed Staff + C.N.A.'s that worked last night + myself that was present until 8:30 p.m. No verbal comments as relayed to family by resident was completely disoriented, aggressive, + uncontrollable last night as happens intermittently . A record review of the facility's policy and procedure titled Abuse Allegation Reporting revised February 10, 2019, indicated .as a mandated reporter, an employee who identifies suspected abuse committed against an individual who is a resident must ensure that all alleged violations involving abuse .are reported immediately, but no later than 2 hours after the allegation is made .to the Administrator/Abuse Coordinator or designee and to other officials (including to the State Survey Agency, local Ombudsman .)The conclusion of all abuse allegations will be reported to the State Survey Agency and Ombudsman within five working days of the incident .

Mar 2022 13 deficiencies 1 IJ (1 affecting multiple)

CRITICAL (K)

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0692 (Tag F0692)

Someone could have died · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure for five of seven residents reviewed for nutri...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure for five of seven residents reviewed for nutrition (Residents 6, 26, 34, 41, and 43), additional interventions such as fortified diet [adding nutrients to the food], feeding program, and other protein supplements were provided for resident's weight loss and the Registered Dietitian (RD) participated in the weight variance review meetings. These failures had the potential to result in the deterioration in overall residents' condition causing harm, impairment, and death. Findings: 1. On March 21, 2022, at 12:43 p.m., during observation in the dining room, Resident 26 was observed not drinking the milk and eating the lunch meal served. On March 22, 2022, at 9:42 a.m., Resident 26 was interviewed. She stated she had been losing a lot of weight. Resident 26 stated she could not take her food and felt like throwing up. Resident 26 stated she was trying to take the food but she felt nauseated. Resident 26's record was reviewed. Resident 26 was readmitted to the facility on [DATE], with diagnoses which included dementia (memory loss) and intra-abdominal pelvic (near or in the fallopian tubes [a pair of tubes along which eggs travel]), ovaries [egg producing organs], uterus [hollow pear shaped organ], and connecting tissue [tissue that protects, supports and gives structures to other organs of the body]) swelling, mass, and lump. A review of the document titled NUTRITIONAL SCREENING ASSESSMENT, dated January 6, 2021, indicated, .Registered Dietitian Assessment .Res (Resident 26) has poor appetite, wt (weight) loss .on comfort measures only. current wt 90 lb. last year ranges fr (from) 97 lb -135 lb. Rec (recommend) to offer food of Resident's choice as tolerated . A review of the physician order dated April 29, 2021, indicated, NAS (no added salt), LCS (low concentrated sweets) diet Mechanical Soft (foods that are soft and easy to chew) texture. Mighty shake TID (three times a day) with meals. A review of the document titled DIETARY PROGRESS NOTES, dated October 29, 2021, indicated, .Resident (Resident 26) Quarterly Review .Continue diet Mechanical Soft, LCS, NAS, plus Mighty Shakes eats 10-20% of most meals. Current Weight 79.2 .continue Monthly Weight . During review of Resident 26's record, there were no additional interventions provided for the resident when there was a progressive decline in Resident 26's weights. There were no other recommendations provided by the RD to improve the caloric intake of Resident 26. A review of the quarterly Minimum Data Set (an assessment tool) assessment dated [DATE], indicated Resident 26 was independent with eating and did not require staff oversight at any time. A review of the document titled MONTHLY RECORD OF V/S AND WTS (Vital signs and weights), indicated Resident 26 had an admission weight of 140 pounds (lbs) on June 25, 2018, and on: - January 3, 2021, 90 lbs; - February 7, 2021, 84.2 lbs.; - March 7, 2021, 80.4 lbs.; - April 4, 2021, 75.6 lbs.; - May 2, 2021, 81 lbs.; - June 6, 2021, 79.6 lbs.; - July 4, 2021, 76.4 lbs.; - August 1, 2021, 77.4 lbs.; - September 6, 2021, 76.2 lbs.; - October 3, 2021, 79.2 lbs.; - November 7, 2021, 83.8 lbs.; - December 5, 2021, 79.6 lbs.; - January 2, 2022, 71.2 lbs.; - February 2022, 74.6 lbs.; - March, 2022, 73.6 lbs. A review of the document titled, The Weight Variance Review, dated January 3, 2022, indicated, Resident 26 had 8 lbs. (11 percent) weight loss for one month, with recommendations to .Assist/Supervise at meals .Allow extra time to eat .Nurishments (sic) .cont. (continue) wkly (weekly) wt. until stable . During review of Resident 26's record, there was no participation of the RD during the weight variance review meeting and there was no notification of the RD or the MD for the continued decline in Resident 26's weight. On March 28, 2022, at 4:41 p.m., the RD was inerviewed. She stated for Resident 26, she was aware resident's weight was 79 lbs. last December 2021, but not the present weight of 73.6 lbs. She stated the staff should have informed her of the resident's weight. The RD stated even if there was no significant weight change, she should have been informed of resident's weight of 73.6 lbs. She stated she could have modified the diet to a fortified diet to provide more calories to the resident. On March 28, 2022, at 5:20 p.m., the Medical Director (MD) was interviewed. He stated he was not aware of Resident 26's weight loss. He stated he should have been notified by the staff and he should have evaluated the resident regarding the resident's weight loss. On March 29, 2022, at 10:02 a.m., an interview and record review was conducted with the DON and she stated they did not provide other interventions for Resident 26's weight loss when the other interventions were ineffective. 2. Resident 34's record was reviewed. Resident 34 was admitted to the facility on [DATE], with diagnoses which included malignant neoplasm of the colon (cancer of the large intestine) and dementia (memory loss). A review of the document Nutritional Screening Assessment, dated August 16, 2021, indicated, .Ideal Body Weight Range: 122 -149 .Usual wt: 135 per res/family/chart .Weight: 101 .Body Mass Index (BMI) 16 (<20 underweight) Registered Dietitian Assessment .Vitamin D 50,000 po (per oral) every Wednesdays to promote bone health. Will cont (continue) to monitor po intake + wt. chg. (weight change) . During review of Resident 34's [NAME], there was no additional recommendation and other interventions from the RD to increase caloric intake of Resident 34. A review of the document titled, Weight Variance Review, dated February 7, 2022, indicated, Resident 34 had a weight of 96.6 lbs, 11 lbs. (10%) weight loss in one month, with recommendations to .Weight change is unintended .Assist/Supervise at meals .Allow extra time to eat .Nurishments (sic) .Other approaches .weekly wts . A review of the document titled, Follow-up weight Reviews, indicated: - Dated February 14, 2022, Weight: 91.7 .Change: - 5 lbs . -5% change in 1 (one) week . - Dated February 28, 2022, Weight: 86.4 Change: - 6lbs . -6% in 1 week .` During review of Resident 34's record, there was no documentation the physician was notified of the weight changes on February 14 and 28, 2022. There were no additional interventions in Resident 34's plan of care when Resident 34 had progressive decline in weight loss. There was no participation of the RD during the weight variance review. A review of Resident 34's care plan titled, Alteration in Nutrition, indicated: - Dated February 9, 2021, .Interventions .weekly wt. until stable .encourage Food & Fluid intake .Mighty Shake TID (three times a day) . - Dated Februray 10, 2022, .Interventions .wkly wts .Encourage Food & Fluid intake .Assist c (with) meals . A review of Resident 34's Minimum Data Set (an assessment tool) dated February 17, 2022, indicated, Resident 34 was independent with eating and did not require staff oversight at any time. A review of the document titled MOTHLY (sic) RECORD OF V/S AND WTS (Vital signs and weights), indicated Resident 34 had an admission weight of 122 pounds (lbs.) on August 18, 2020 and on: - January 3, 2021, 124 lbs.; - February 7, 2021, 116 lbs.; - March 7, 2021, 113.4 lbs.; - April 4, 2021, 111.8 lbs.; - May 2, 2021, 112.8 lbs.; - June 6, 2021, 114.2 lbs.; - July 4, 2021, 110.6 lbs.; - August 1, 2021, 113 lbs.; - September 6, 2021, 110.2 lbs.; - October 3, 2021, 105.6 lbs.; - November 7, 2021, 101.8 lbs.; - December 5, 2021, 98.8 lbs.; - January 2, 2022, 107.6 lbs.; - February 2022, 96.6 lbs.; - March, 2022, 93.6 lbs. On March 28, 2022, at 4:41 p.m., the RD was interviewed. The RD stated Resident 34 had gradually declining weight loss. She stated she was not aware Resident 34's weight was 93.6 lbs. The RD stated if Resident 34 had progressive weight loss, even if there were no significant changes in the weight, she should have been notified. She would assess Resident 34, evaluate the feeding ability of Resident 34, modify the diet to fortified diet. The RD stated the care plan should have been updated to provide new interventions for Resident 34's progressive weight loss. On March 28, 2022, at 5:20 p.m., the Medical Director (MD) was interviewed. He stated the licensed nurses would let him know if resident had significant weight changes. He was not aware Resident 34 had weight loss. The MD stated he should have been notifed and he should have evaluated the resident. 3. Resident 41's record was reviewed. Resident 41 was admitted to the facility on [DATE], with diagnoses which included protein calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function). A review of Resident 41's physician order dated August 23, 2021, indicated, Regular diet Pureed texture, No dairy, Might Shake QAM (every morning). A review of Resident 41's Minimum Data Set (an assessment tool) dated January 29, 2022, indicated, Resident 41 was independent with eating and did not require staff oversight at any time. A review of the document MOTHLY (sic) RECORD OF V/S AND WTS, indicated, - January 3, 2021, 81.6 pounds (lbs); - February 7, 2021, 75.4 lbs.; - March 7, 2021, 82.6 lbs.; - April 4, 2021, 78.4 lbs.; - May 2, 2021, 77.4 lbs.; - June 6, 2021, 73.6 lbs.; - July 4, 2021, 73 lbs.; - August 1, 2021, 73.4 lbs.; - September 6, 2021, 74.2 lbs.; - October 3, 2021, 69.6 lbs.; - November 7, 2021, 69.4 lbs.; - December 5, 2021, 68.8 lbs.; - January 2, 2022, 70.8 lbs.; - February 6, 2022, 71 lbs.; - March 6, 2022, 69.8 lbs. A review of Resident 41's care plan titled, Alteration in Nurtition, indicated: - February 27, 2021, Promote comfort & (and) healthy wt (weight) .weekly wt until stable .Encourage & assist c (with) milk intake & fluids. - June 7, 2021, .wt. loss .continue Mighty Shake q AM .encourage meal intake .wkly (weekly wt (weight) until stable. - February 10, 2022, wt. loss .Promote healthy wt .Encourage food/fluid intake .wkly wt until stable. During review of Resident 41's record, there were no additional interventions provided to prevent progressive decline in Resident 41's weight loss. There was no documentation the Registered Dietitian was informed of the present weight of the resident. On March 29, 2022, at 3:11 p.m., a concurrent interview and record review was conducted with the DON, she stated Resident 41 was not provided with additional interventions to improve resident's nutritional status. The DON stated she did not ask the RD for other interventions and she did not inform the RD of Resident 41's present weight. On March 30, 2022, at 2:50 p.m., the MD was interviewed. He stated when a licensed nurse referred a resident with weight loss, the licensed nurse would tell him the pounds lost by the resident and not the actual weight of the resident. 4. In a review of Resident 6's record, indicated Resident 6 was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis, (one sided weakness, paralysis) following cerebral infarction (stroke). A review of Resident 6's document titled, MONTHLY WEIGHT VARIANCE TRACKING MATRIX, indicated the following: September 2021= 130.8 lbs. (pounds) October 2021= 129.6 lbs. November 2021= 118.4 lbs. December 2021= 118.4 lbs. January 2022= 117.6 lbs. February 2022= 116.6 lbs. March 2022= 117.6 lbs. A review of Resident 6's Minimum Data Set (an assessment tool), dated December 16, 2021 .Section G .Functional Status .Eating .Self -Performance .4 (total dependence) .Section K .Swallowing/Nutritional Status, indicated, .Coughing or choking during meals or when swallowing medications . A review of Resident 6's Minimum Data Set, dated [DATE], .Section G .Functional Status .Eating .Self -Performance .4 (total dependence) .Section K .Swallowing/Nutritional Status, indicated, .Coughing or choking during meals or when swallowing medications . A review of facility document titled, Weight Variance Review, with a review date of November 7, 2021, indicated, Change .11 lbs .8.6 % change in 1 month .Unintended weight loss .Diet .Puree thickened liquid .Nourishment .mighty shake .Poor Meal Tolerance .Recommendations .Assist/Supervise at meals .Allow extra time to eat .Monitoring .Weekly weights .Other approaches .Encourage assist with meal intake . During review of Resident 6's record, there were no additional interventions provided to prevent progressive decline in Resident 6's weight loss and there was no documented evidence physician was notified. On March 28, 2022, at 1:47 p.m., in an interview with Licensed Vocational Nurse (LVN) 5, she stated when a resident had a significant weight loss the physician and the RD should be notified. In a concurrent review of Resident 6's record with LVN 5, LVN 5 stated was no documentation the physician and the registered dietician (RD) were notified. LVN 5 stated there should have been documentations of the COC (Change of Condition), notification of physician and RD in Resident 6's record. She stated swallow evaluation was not done because they do not have Speech Therapist in the facility. On March 28, 2022, at 4:50 p.m., in an interview with the RD, she stated she comes to the facility twice weekly mostly during the weekends. The RD stated for Resident 6 current weight falls below the BMI, and must be between 21- 25, to reach this goal the interventions needed to be revised, by fortifying her foods, like adding fortified peanut butter and protein fortified milk. 5. In a review of Resident 43 record, indicated Resident 43 was admitted to the facility on [DATE], with diagnoses which included dehydration (the absence of a sufficient amount of water in your body), dementia (memory loss). A review of Resident 43's History and Physical (H & P) dated June 10, 2021, indicated, Resident 43 does not have the capacity to understand and make decisions. A review of Resident 43's document titled, MONTHLY WEIGHT VARIANCE TRACKING MATRIX, indicated the following: September 2021= 120 lbs. October 2021= 116.4 lbs. November 2021= 116 lbs. December 2021= 91 lbs. January 2022= 83.2 lbs. February 2022= 90.2 lbs. March 2022= 90.4 lbs. A review of facility document titled, Weigh Variance Review, with a review date of December 6, 2021, indicated, .Change .25 lbs. 22% change in 1 month .Unintended weight loss .Diet .Regular NAS .Nourishment .MS (mighty shake) .TID (three times daily) with meals .Poor Meal Tolerance .Recommendations .Assist/Supervise at meals .Allow extra time to eat .Between meal snacks .Nourishment .Monitoring .Weekly weights .Other approaches .Encourage assist with meal intake .Add M.S. TID .promote healthy weight . During review of Resident 43's record, there were no other interventions added to meet the caloric needs of Resident 43 when the resident had a weight loss from September 2021 to December 2021. There were no additional interventions to increase caloric content of foods when the resident continue to loose another 7.8 lbs. from December 2021 to January 2022 On March 28, 2022, at 02:04 p.m., in an interview with the Director of Nursing (DON), the DON stated the facility conducted weight variance review meetings every month. She stated when there is significant weight loss (> 5% in a month; > 7.5 % in 3 months; or > 10% in 6 months) there will be a weight variance meeting review, the Dietary Service Supervisor (DSS), and herself will be in that meeting. The DON stated the RD will not be a part of the weight variance meeting, but will be consulted, when needed. She stated the physician was also not involved in the weight variance review meetings. The DON stated the interventions provided for the residents were monitoring of weight weekly until stable; nourishments like mighty shake 3x a day. The DON stated there were no additional interventions to ensure caloric intakes were able to meet the nutritional need of the resident. On March 28, 2022, at 4:41 p.m., the RD was interviewed. She stated she talked to the DSS regarding resident's weight loss. The RD stated if the interventions provided were not effective, the facility should have provided new interventions. She stated there are other interventions such as doing a calorie count, modifying the diet to a fortified diet, and provide other protein supplements. The RD stated for progressive weight loss, the resident should be assessed and provided new interventions to boost the caloric intake of the resident. On March 29, 2022, at 9:20 a.m., in an interview and record review with the DSS, she stated when a resident had significant weight loss, she would notify the RD. The DSS stated the RD was in the facility during the weekends and the DSS was not around. The DSS stated the RD was not present during the weight variance review meetings. She stated no other interventions were added to meet the caloric needs of the residents who had weight loss, like fortified foods. A review of the facility document titled, Weight Assessment and intervention, with date revised September 2008, indicated, The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents .Weight Assessment .The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter .If no weight concerns are noted, weight will be measured monthly thereafter .Any weight change of 5% or more since last weight measure .nursing will notify the dietician .the dietician will respond within 24 hours of receipt of written notice .The threshold for significant unplanned and undesired weight loss .a. 1.month- 5% weight loss is significant; greater than 5% is severe; b. 3 months- 7.5% weight loss is significant; greater than 7.5 % is severe; 6 months- 10 % weight loss is significant; greater than 10 % is severe .Analysis .Assessment Information shall be analyzed by the multidisciplinary team .and conclusion shall be made regarding: Resident target weight range (including rationale if different from ideal body weight), Approximate calorie, protein and other nutrient needs compared with resident's current intake .the Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing risk of weight loss for example .Cognitive or functional decline .Chewing or swallowing abnormalities . A review of the facility policy and procedure titled, Care Plans, Comprehensive Person-Centered, dated December 2016, indicated, .Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process .Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change .The Interdisciplinary Team must review and update the care plan .when there has been a significant change in the resident's condition . In a review of facility document titled, Job Description, dated 2003, indicated, .Dietician .The primary purpose of your job position is to plan, organize, develop and direct overall operation of the Food Services Department .to assure that quality nutritional services are being provided on a daily basis .Meet with the food service personnel, on a regular basis and solicit advice from staff concerning the operation of the Food Service Department. Assist in identifying and correcting problem areas and/or the improvement of services .

CONCERN (D)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident was treated with dignity and respec...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident was treated with dignity and respect for one of nine residents during dining observation (Resident 6), when a staff member was observed standing over a resident while assisting the resident to eat. This failure had the potential to affect the resident's self-esteem and self-worth. Findings: On March 21, 2022, at 12:29 p.m., the Occupational Therapist (OT) was observed feeding Resident 6. The OT was standing over the resident while feeding the resident. Resident 6 was observed extending her neck and tilting her head backward. The OT was observed leaving Resident 6 in between feeding, to attend to other residents' needs. On March 23, 2022, at 8:57 a.m., Certified Nursing Assistant (CNA) 1 was interviewed. CNA 1 stated she should be sitting down when feeding a resident. On March 23, 2022, at 9:08 a.m., the OT was interviewed. She stated she was standing up while feeding residents in the dining room. The OT stated it would be quicker for her to attend to the needs of the other residents. On March 23, 2022, at 3:59 p.m., the Director of Staff Development (DSD) was interviewed. The DSD stated the staff who was feeding the resident should be sitting down with the resident, always. On March 30, 2022, at 1:36 p.m., the Director of Staff Development (DSD) was interviewed again. She stated she trained the staff on how to properly feed the residents. She stated she never trained the OT on how to properly feed a resident. The DSD stated she instructed the CNAs to sit with the resident when feeding them. Resident 6's record was reviewed. Resident 6 was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). The document titled, HISTORY AND PHYSICAL, dated March 21, 2021, indicated, Resident 6 does not have the capacity to understand and make decisions. A review of the facility policy and procedure titled, Quality of Life - Dignity, dated February 2020, indicated, .Each resident shall be cared for in manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem .Residents are treated with dignity and respect at all times .Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents .

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the physician was notified when the resident c...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the physician was notified when the resident complained of nausea, left the dining room with food and milk untouched, for one of 12 residents reviewed for quality of care (Resident 26). This failure had the potential for the physician to be unaware of the present medical condition of the resident resulting in decrease oral intake and weight loss. Findings: On March 21, 2022, at 12:48 p.m., during the dining observation, Resident 26 was observed with her milk and meal untouched. She told the staff she felt nauseous. On March 22, 2022, at 9:42 a.m., Resident 26 was interviewed. She stated she had been losing a lot of weight. Resident 26 stated she could not take her food and felt like throwing up. Resident 26's record was reviewed. Resident 26 was readmitted to the facility on [DATE], with diagnoses which included dementia (memory loss) and gastroesophageal reflux (a chronic disease that occurs when stomach acid flows into the food pipe and irritates the lining). There was no documentation the physician was notified on March 21, 2022, after Resident 26 complained of nausea to the staff. On March 29, 2022, at 9:35 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. She stated Resident 26 had periods of nausea and vomiting. LVN 1 stated the resident would have nausea and vomiting once every three weeks. She stated if the nausea and vomiting persisted, she would notify the physician. On March 29, 2022, at 10:02 a.m., the Director of Nursing (DON) was interviewed. She stated Resident 26 had a change of condition and the physician should have been notified and evaluated. In a concurrent review of Resident 26's record, the DON stated there was no documentation the resident was reevaluated and the physician was notified. A review of the facility policy and procedure titled, Change in a Resident's Condition or Status, dated May 2017, indicated, .Our facility shall promptly notify the resident, his or her Attending Physician, and representative .of changes in the resident's medical/mental condition and/or status .The nurse will notify the resident's Attending Physician or physician on call when there has been a(an) .significant change in the resident's physical/emotional/mental condition . A review of the facility policy and procedure titled, Resident Status, Notification of Changes, undated, indicated, .The resident's attending physician and other responsible persons are notified in the event of the following .a significant change of condition .

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the care plan for fall was implemented for one...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the care plan for fall was implemented for one of one resident reviewed for fall (Resident 34), when the floor mats were not observed in place while resident was in bed. This failure had the potential to result in injury and further falls. Findings: On March 22, 2022, at 11:43 a.m., Resident 34 was observed in bed. There were no floor mats in place. On March 22, 2022, at 11:54 a.m., Resident 34's representative was interviewed. She stated Resident 34 had multiple falls and she did not know what the facility was doing for the resident to prevent her falls. Resident 34's record was reviewed. Resident 34 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss) and seizure disorder (episodes of uncontrolled electrical activity in the brain). Resident 34's care plan dated August 18, 2020, indicated, .At risk for fall/injury . related to .Seizure disorder .Dementia .Interventions .Fall mats on both sides of bed to prevent injury r/t (related to) chronic Falls . The document titled, FALL RISK EVALUATION, dated February 17, 2022, indicated, Resident 34 was a high risk for fall. On March 24, 2022, at 3:46 p.m., Certified Nursing Assistant (CNA) 2 was interviewed. CNA 2 stated Resident 34 was not a fall risk anymore. He stated the resident did not need fall mats while in bed. CNA 2 stated he was taking care of the resident and he did not see floor mats at the bedside. On March 24, 2022, at 3:53 p.m., the Director of Nursing (DON) was interviewed. She stated Resident 34 was high risk for fall. The DON stated Resident 34 required floor mats while in bed as part of the fall care plan. The DON stated the care plan intervention should be implemented.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic drugs for ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic drugs for one of eight residents reviewed for unnecessary medications (Resident 43) when there was no adequate indication for the use of Seroquel (medication to treat mental disease). This failure had the potential for Resident 43 to receive medication with out an indicated diagnosis. Findings: In a review of Resident 43's record, Resident 43 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss). Resident History and Physical (H & P) dated June 10, 2021, indicated Resident 43 does not have the capacity to understand and make decisions. Resident 43's document titled, Order Summary Report, dated December 10, 2021, indicated, Seroquel Tablet 25 MG (milligram) (Quetiapine Fumarate) Give 1 tablet by mouth at bedtime for Psychosis (when people lose some contact with reality) m/b (manifested by) Paranoid ideations (feelings of suspiciousness). Further review of Resident 43's record, indicated there was no diagnosis of Psychosis. On March 24, 2022, at 1:53 p.m., in a concurrent interview and record review with the Director of Nursing (DON), she stated Resident 43 was taking Seroquel. She stated she did not identify documentation from the physician the diagnosis of psychosis. On March 28, 2022, at 3:47 p.m., in an interview with the Director of Nursing (DON), she stated the physician is the one assessing the use of unnecessary medication such as the psychotropic. The physician assesses the indication and the behavior, for the use of psychotrophics. A review of the facility policy and procedure titled, Antipsychotic Medication Use, revised date December 2016, indicated, .Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective .The attending Physician and other staff will gather and document information to clarify resident's behavior, mood, function, medical condition, specific symptoms, risks to the resident and others .The Attending Physician will identify, evaluate and document, with input from other disciplines and consultants as needed .

CONCERN (D)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5% when: 1. For Resident 3, the supplement Magnesium oxide (mineral) and Thiam...

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Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than 5% when: 1. For Resident 3, the supplement Magnesium oxide (mineral) and Thiamine (vitamin) were not administered as ordered. 2. For Resident 32, the medications Eliquis (blood thinner) and Tamsulosin (relaxes the muscles in the prostate [male gland] and bladder neck, making it easier to urinate) were not administered as ordered. This failure resulted in a medication error rate of 13.3% which had the potential to cause complications to an already compromised residents. Findings: 1. On March 23, 2022, at 9:07 a.m., during the medication administration observation, Licensed Vocational Nurse (LVN 4 ) administered the following medications orally to Resident 3: Vitamin C- 500 mg 2 tablets; -Iron (is part of hemoglobin, a protein which carries oxygen from our lungs throughout our bodies) 325 mg 1 tablet; - Metformin (is used to treat high blood sugar levels) 500 mg 1 tablet; - Multivitamin 1tablet; - Protonix (medication used to decrease the amount of acid produced in the stomach) 40 mg 1 tablet; - Spirinolactone (water pill) 50 mg 1 tablet; - Lasix (water pill) 40 mg 1 tablet; - Folic Acid (medication that helps make healthy red blood cells) 1 mg 1 tablet; - Neomycin (antibacterial that works by stopping the growth of bacteria in the intestines) 500 mg 1tablet; and - Lactulose (medicine can help you empty your bowels if you have constipation (difficulty pooing) 10 gm/15 ml 40 ml. The medications administered were reconciled with the Order Summary Report, for the month of March 2022, indicated the following medications were not observed to be administered to Resident 3: MagOx 400 tablet (Magnesium Oxide) Give 1 tablet by mouth 2x a day (9 a.m; 5 p.m.). Thiamine HCl (hydrochloride) Tablet 50 MG Give 1 tablet by mouth one time a day ( 9 a.m.). 2. On March 23, 2022, at 9:17 a.m., during the medication administration observation, Licensed Vocational Nurse (LVN 4) administered the following medications orally to Resident 32: - Tamsulosin 0.4 mg 1 tablet; - Protonix (pantoprazole) 40 mg 1 tablet; - Metoprolol (medication used to treat high blood pressure); 100 mg 1 tablet; - Lisinopril (medication used to treat high blood pressure) 20 mg, 1 tablet; - Nifedipine ER (medication used to treat high blood pressure) 30 mg 1 tablet; - Rosuvastatin (medication used to help lower bad cholesterol and fats) 20 mg 1 tablet; - Clopidogrel (blood thinner) 75 mg 1 tablet; and - Vitamin C- 500 mg 2 tablets. The medications administered were reconciled with the Order Summary Report, for the month of March 2022: Eliquis not administered due to not being available was missed due to medication not available. Tamsulosin was ordered to administer at bedtime and was given at 9:17 a.m., On March 23, 2022, at 12:15 p.m., in an interview with LVN 5, she stated, the licensed nurse should make a request for refill three days in advance. Licensed nurse should call or fax the refill request form to the pharmacy. On March 23, 2022, at 10:37 a.m., in an interview with LVN 4, she stated she missed administering Magnesium oxide and Thiamine to Resident 3 and Tamsulosin was administered this morning, it should be at bedtime for Resident 32. A review of undated facility policy and procedure titled Ordering and Receiving Medications from Provider Pharmacy indicated, .Medications . are received from provider pharmacy on a timely basis .medications are written on a medication order form and transmitted to the pharmacy .Reorder medication (three to four) days in advance of need to assure adequate supply is on hand .the refill order is called in, faxed or otherwise transmitted to the pharmacy .

CONCERN (D)

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

Deficiency F0825 (Tag F0825)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed for one of five residents reviewed for weight loss (Resident 6) to ensu...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed for one of five residents reviewed for weight loss (Resident 6) to ensure an evaluation for speech was provided when Resident 6 had episode of coughing or choking during meal. This failure had the potential to result in Resident 6 having another episode of choking which could lead to complications and could lead to death. Findings: In a review of Resident 6's record, indicated Resident 6 was admitted to the facility on [DATE], with diagnoses which included hemiplegia and hemiparesis, (one sided weakness, paralysis) following cerebral infarction (stroke). Resident 6's History and Physical (H & P) dated March 21, 2021, indicated, Resident 6 does not have the capacity to understand and make decisions. Resident 6's Minimum Data Set (an assessment tool), dated December 16, 2021 .Section G .Functional Status .Eating .Self -Performance .4 (total dependence) .Section K .Swallowing/Nutritional Status, indicated, .Coughing or choking during meals or when swallowing medications . Resident 6's Minimum Data Set, dated [DATE], .Section G .Functional Status .Eating .Self -Performance .4 (total dependence) .Section K .Swallowing/Nutritional Status, indicated, .Coughing or choking during meals or when swallowing medications . There was no documentation Resident 6 was evaluated by speech therapist for the choking or coughing episode during meal. On March 28, 2022, at 1:47 p.m., in an interview with Licensed Vocational Nurse (LVN5), she stated swallow evaluation was not done because they do not have speech therapist in the facility. LVN 4 stated there was no documentation that Resident 6 was referred to a speech therapist. On March 28, 2022, at 4: 50 p.m., in an interview with the Registered Dietician (RD), she stated swallow eval should have been done. On March 30, 2022, at 2:50 p.m., in an interview with the Medical Director (MD), he stated he is not aware of the episode of choking or coughing episode during meal. The MD stated resident 6 should be referred to a speech therapist for a swallow evaluation.

CONCERN (E)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident's room temperature was maintained at ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident's room temperature was maintained at a comfortable level when residents in room [ROOM NUMBER] were complaining that the room was cold. This failure had the potential for the resident to not be able to feel comfortable due to cold temperature which could place the residents at risk for hypothermia (dangerous drop in body temperature). Findings: On March 22, 2022, at 10:57 a.m., Resident 36 was interviewed. She stated the room (room [ROOM NUMBER]A) was cold and the staff could not adjust the room temperature. Resident 36 stated the staff would put covers on her and she could not move her legs due to many covers on top of her. On March 22, 2022, at 11:14 a.m., Resident 26 was interviewed. She stated the room (room [ROOM NUMBER]D) was cold ever since she was admitted to the facility. On March 22, 2022, at 11:18 a.m., Resident 41 was interviewed. She stated the room (room [ROOM NUMBER]B) had been cold for four weeks. Resident 41 stated everyone knew about it. In a concurrent observation with Resident 41, Resident 41 was bundled up tightly to her neck. On March 23, 2022, at 8:03 a.m., Residents 26, 36, 41, and 42 were observed bundled up with three to four blankets. Outside room [ROOM NUMBER], the thermostat indicated 69°F. On March 23, 2022, at 8:08 a.m., Certified Nursing Assistant (CNA) 1 was interviewed. She stated she was aware room [ROOM NUMBER] was cold. CNA 1 stated she did not have the key to the thermostat control panel. She stated she did not know if the room temperature could be adjusted. On March 23, 2022, at 8:25 a.m., CNA 1 was again interviewed. She stated she informed the charge nurse and the Maintenance Supervisor (MS) yesterday when Resident 36 in room [ROOM NUMBER] complained that the room was cold. On March 23, 2022, at 8:35 a.m., the MS was interviewed. She stated she checked residents' room temperature every day. The MS stated she was not aware residents in room [ROOM NUMBER] were complaining that the room was cold. The MS stated the licensed nurse could adjust the thermostat. In a concurrent observation, the MS checked the room temperature in room [ROOM NUMBER] and stated the room temperature was at 69.8°F. She stated the room temperature should be between 71 to 81 degrees. On March 29, 2022, at 7:11 a.m., Licensed Vocational Nurse (LVN) 2 was interviewed. She stated when resident complained about the room being cold at night, she would give them blankets. LVN 2 stated she could not adjust the temperature since the facility had centralized air conditioning. LVN 2 stated if there was a complaint about the room temperature she would call the MS. A review of the facility policy and procedure titled, INTERNAL TEMPERATURE OF THE FACILITY, undated, indicated, It is the policy of the facility to maintain the temperature of environment at the level that residents feels comfortable at all time .Adjust the thermometer, should the temperature is either below 71 degree or above 81 degree .

CONCERN (E)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure for four of 12 residents reviewed for quality ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure for four of 12 residents reviewed for quality of care (Resident 20, 22, 24, and 32), residents received the appropriate services and treatment when: 1. For Resident 20, an assessment and monitoring was completed for the resident's skin discoloration on left forearm. 2. For Resident 24, an assessment and monitoring was completed for the resident's rashes on the neck. 3a. For Resident 32, the sutures were removed a month after the resident's admission. 3b. For Resident 32, monitoring and treatment was provided for resident's incision on the left lower leg. 4. For Resident 32, an assessment was conducted and the physician was notified when resident's blood sugar level was high. 5. For Resident 22, an assessment was conducted and the physician was notified when resident's blood sugar level was high. 6. For Resident 32, the medication Eliquis was administered as per physician order. These failures had the potential for the delay in treatment resulting to a decline in resident's medical condition. Findings: 1. On March 21, 2022, at 4:44 p.m., during a concurrent observation and interview with Resident 20, Resident 20 was observed with purplish discoloration approximately five by five centimeters on his left forearm. Resident 20 stated he did not know where and when he got it. He stated he had no idea if he bumped his arm somewhere. On March 24, 2022, at 10:02 a.m., Certified Nursing Assistant (CNA) 1 was interviewed. She stated if a resident had a change in skin condition, she would notify the charge nurse and the charge nurse would assess the resident. On March 24, 2022, at 11:06 a.m., Licensed Vocational Nurse (LVN) 1 was interviewed. She stated Resident 20 had a red and purple discoloration on his left forearm. LVN 1 stated she was not aware of the resident's skin discoloration. She stated the CNA should inform her if resident had a change in skin condition. She stated for a change of condition, she would assess the resident, update the care plan, and notify the physician. Resident 20's record was reviewed. Resident 20 was admitted to the facility on [DATE], with diagnoses which included pressure ulcer (bedsores) and chronic renal failure (condition involving a decrease in the kidney's ability to filter waste and fluid from the blood). The document titled, LICENSED NURSE RECORD, from March 19 to March 23, 2022, indicated, Resident 20 had no skin discoloration on his left forearm. There was no documentation an assessment and monitoring were completed for Resident 20's skin discoloration. 2. On March 21, 2022, at 11:51 a.m., in a concurrent observation and interview with Resident 24, he stated he had rashes on his neck which was present since his admission. Resident 24 stated the staff had not looked at his rashes. Resident 24's record was reviewed. Resident 24 was admitted to the facility on [DATE], with diagnoses which included coronary artery disease (a condition when the major blood vessels that supply your heart become damaged or diseased). There was no documentation Resident 24's rashes were assessed and monitored. On March 29, 2022, at 1:10 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed. She stated Resident 24 had rashes on the neck area. She stated Resident 24's rashes on the neck area was treated three months ago. LVN 1 stated she was not aware resident's rashes recurred. She would be aware of the resident's skin change if it was brought to her attention by the CNAs. On March 29, 2022, at 1:19 p.m., Certified Nursing Assistant (CNA) 2 was interviewed. She stated the practice was to check the resident's skin all the time when doing care. CNA 2 stated for a change in skin condition, the charge nurse should be informed. CNA 2 stated there was a change in condition form to fill out for a change in resident's condition. On March 29, 2022, at 1:29 p.m., CNA 3 was interviewed. She stated she would check the skin when doing resident care. CNA 3 stated she did not observe Resident 24 with rashes. On March 29, 2022, at 1:51 p.m., the Director of Nursing (DON) was interviewed. The DON stated the practice of the facility was for licensed nurses and CNAs to perform skin assessment daily and if there was a change in skin condition, notify the physician and update the care plan. 3. Resident 32's record was reviewed. Resident 32 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal blood sugar) and diabetic neuropathy (nerve damage caused by diabetes that leads to numbness and sometimes pain and weakness in the hands, arms, feet, and legs). Resident 32's NURSE'S admission RECORD, dated February 8, 2022, indicated Resident 32 had incision with sutures to left lower leg. There was no documentation Resident 32's incision was monitored for signs and symptoms of infection since admission. There was no physician order regarding Resident 32's wound care and suture removal since admission. Further review of Resident 32's physician order indicated: - February 28, 2022, Cleanse incision site c (with) sutures to LLE (left lower extremity) daily . - March 2, 2022, Remove sutures to LLE incision . - March 3, 2022, .Monitor incision site x (for) 3 days for wound dehiscence or S/S (signs and symptoms) of infection . On March 24, 2022, at 4:25 p.m., in an interview and record review with the Director of Nursing (DON), the DON stated the practice was to monitor incision for signs and symptoms of infection on admission. The DON stated if there was no treatment initiated at the start of admission, the staff should have initiated the treatment, call the physician for the order. The DON stated there should be a plan of care. She stated there was no monitoring for signs and symptoms of infection for Resident 32's incision The DON stated there was no treatment provided for the resident since admission. She stated the sutures were removed on March 3, 2022 (23 days after admission). On March 24, 2022, at 4:58 p.m., Licensed Vocational Nurse (LVN) 3 was interviewed. She stated there should be a physician order for wound treatment and removal of sutures. LVN 3 stated she would call the physician for treatment order when a resident came in on admission without an order. On March 30, 2022, at 2:50 p.m., the Medical Director (MD) was interviewed. The MD stated sutures were left in for a week to ten days. The MD stated the longer the sutures are left in, the harder for the suture to get out due to the healing around them. 4. Resident 32's record was reviewed. Resident 32 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (abnormal blood sugar) and diabetic neuropathy (nerve damage caused by diabetes that leads to numbness and sometimes pain and weakness in the hands, arms, feet, and legs). The document titled, FINGERSTICK BLOODSUGAR/INSULIN CHARTING RECORD, indicated: - February 12, 2022, at 9 p.m., .Blood Sugar result .Hi .MD notified .N (No) . - February 15, 2022, at 6 a.m., .Blood Sugar result .Hi .MD notified .N . There was no documentation the blood sugar level of Resident 32 was rechecked when the glucometer (blood glucose meter - machine to measure how much sugar in the blood) reading indicated Hi (blood glucose reading higher than 600 milligram per deciliter). The physician was not notified of the high blood sugar level. On March 28, 2022,at 3:44 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed. She stated the physician should be notified immediately and administer the insulin as ordered when the glucometer reading indicated hi. On March 28, 2022, at 3:50 p.m., the Director of Nursing (DON) was interviewed. The DON stated if the blood sugar level of the resident was high, the physician should be notified. In a concurrent record review and interview, the DON stated the physician was not notified by the licensed nurses. The DON stated the physician should have been notified. On March 28, 2022, at 5:20 p.m., the Medical Director (MD) was interviewed. The MD stated the licensed nurse was expected to notify him if the glucometer reading indicated hi. 5. In a review of Resident 22's record, indicated, Resident 22 was admitted to the facility on [DATE], with diagnoses which included diabetes (high blood sugar level). Resident 22's document titled, Order Summary Report, dated January 21, 2022, indicated Lantus Solution (Insulin Glargine-long acting insulin) Inject 50 unit subcutaneous (SQ-under the skin) two times a day for DM (diabetes mellitus) . Humalog Solution (Insulin Lispro-short acting insulin) Inject as per sliding scale: if 81-150= 3 units; 151-200= 3 units (u) ; 201-250= 6 units; 251-300= 9 units; 301-350= 12 units; 351-400= 15 units & call MD (physician). Resident 22's FINGERSTICK BLOODSUGAR /INSULIN CHARTING RECORD, for March 2022, indicated the following: March 1 at 6 a.m. BS (blood sugar) - 578 .MD Notified (No). March 1 at 9 p.m. BS- 555 .MD Notified (No). March 2 at 6 a.m. BS- 445 .MD Notified (No). March 2 at 11:30 a.m. BS (left balnk) .MD Notified (No). March 2 at 2 p.m. BS- 589 .MD Notified (No). March 2 at 9 p.m. BS- 583 .MD Notified (No). March 3 at 9 p.m. BS- 555 .MD Notified (No). March 5 at 5 p.m. BS- 549 .MD Notified (No). March 5 at 9 p.m. BS- 498 .MD Notified (No). March 7 at 11 a.m. BS- 465 .MD Notified (No). March 8 at 6 a.m. BS- 486 .MD Notified (No). March 8 at 11 a.m. BS- 497 .MD Notified (No). March 9 at 6 a.m. BS- 480 .MD Notified (No). March 9 at 5 p.m. BS- Hi .MD Notified (No). March 9 at 9 p.m. BS- Hi .MD Notified (No). March 10 at 6 a.m. BS- Hi .MD Notified (No). March 10 at 11:30 a.m. BS- 505 .MD Notified (No). March 11 at 5 p.m. BS- 478 .MD Notified (No). March 13 at 5 p.m. BS- 409 .MD Notified (No). March 16 at 6 a.m. BS- 397 .MD Notified (No). March 16 at 5 p.m. BS- Hi .MD Notified (No). March 16 at 9 p.m. BS- Hi .MD Notified (No). March 17 at 2 p.m. BS- Hi .MD Notified (No). March 17 at 9 p.m. BS- Hi .MD Notified (No). March 18 at 5 p.m. BS- 500 .MD Notified (No). March 19 at 5 p.m. BS- 477 .MD Notified (No). March 20 at 6 a.m. BS- 505 .MD Notified (No). March 22 at 9 p.m. BS- Hi .MD Notified (No). March 21 at 6 a.m. BS- 524 .MD Notified (No). March 21 at 11 a.m. BS- 387 .MD Notified (No). March 22 at (blank) BS- 560 .MD Notified (No). March 24 at 9 p.m. BS- 434 .MD Notified (No). March 24 at 11:30 a.m. BS- 415 .MD Notified (No). On March 29, 2022,at 10:23 a.m., in a concurrent interview and record review with the Director of Nursing (DON), she stated the physician was not notified when the BS was more than 351. The DON stated they should have notified the physician. The DON stated the resident had the potential to develop complications from diabetes. On March 30, 2022, at 2:50 p.m., in an interview with the Medical Director (MD), he stated that when the BS exceeded the parameter set by the physician, the license nurse should call the physician. The MD stated he was not notified when the BS were exceeding the parameter. 6. On March 23, 2022, at 9:17 a.m., during medication pass observation, Licensed Vocational Nurse (LVN) 4 was observed not to administer Eliquis. In a review of Resident 32's record, indicated, Resident 32 was admitted to the facility on [DATE], with diagnoses which included, coronary artery disease (CAD- disease develops when the major blood vessels that supply your heart become damaged or diseased) with stent (a small, metal mesh tube that expands inside a coronary artery). Resident 32's PYSICIAN'S ORDER, dated March 3, 2022, indicated, Eliquis (blood thinner) 5 mg PO (oral) BID (twice daily- 9 a.m. and 9 p.m.) for Cardiac Stent. Resident 32's Pharmacy receipt for Eliquis, indicated, .Date Filled: 3/01/2022 .QTY (quantity) .60 .DAYS SUPPLY .30 . Resident 32's Medication Administration Record, March 2022, indicated, Eliquis was administered twice daily from March 3, 2022 to March 19, 2022. On March 20, 2022, Eliquis was administered at 9 a.m. From March 20, 2022, at 9 p.m. to March 23, 2022 Eliquis was not administered. On March 23, 2022, at 12:15 p.m., in an interview with LVN 5, she stated, the licensed nurse should make a request for refill three days in advance. Licensed nurse should call or fax the refill request form to the pharmacy. On March 23, 2022, at 12:17 p.m., in an interview with Pharmacist from the contracted pharmacy, he stated he did not received the request for refill of Eliquis. On March 30, 2022, at 2:50 p.m., in an interview with the Medical Director (MD), the MD stated that he was not notified when the medication Eliquis was not given for 3 days. He stated potential outcomes from not taking blood thinner for heart disease is cardiac thrombosis (the formation of a blood clot inside a blood vessel of the heart) or even heart attack (happens when a part of the heart muscle doesn't get enough blood). A review of the contract with the pharmacy indicated, .Delivery Schedule: The Pharmacy agrees to deliver to the Facility any prescriptions and supplies daily, seven (7) days a week . A review of undated facility document titled Ordering and Receiving Medications from Provider Pharmacy .Policy .Reorder medication (three to four) days in advance of need to assure adequate supply is on hand .the refill order is called in, faxed or otherwise transmitted to the pharmacy .

CONCERN (E)

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

Garbage Disposal (Tag F0814)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to ensure the dumpster was completely covered, and not overflowing with garbage. This failure had the potential to result in att...

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Based on observation, interview, and record review, the facility failed to ensure the dumpster was completely covered, and not overflowing with garbage. This failure had the potential to result in attracting pests which could harbor organisms that can cause foodborne illnesses. Findings: On March 21, 2022, at 11:10 a.m., two dumpsters outside the facility were observed with the Housekeeping. The dumpsters were overflowing with garbage. The dumpster's lid did not completely cover the dumpsters. In a concurrent interview with Housekeeping, she stated the dumpster was overflowing with garbage. She stated the garbage truck should have collected the trash early this morning. The Housekeeping stated when the dumpster was overflowing, she would call the Maintenance Supervisor (MS) and the MS would call the garbage pick-up company. On March 28, 2022, at 4:27 p.m., the MS was interviewed. She stated the staff should make sure the dumpster was not overflowing. The MS stated the dumpster's lid should be tightly closed. A review of the facility policy and procedure titled, Food-Related Garbage and Refuse Disposal, dated October 2017, indicated, Food-related garbage and refuse are disposed of in accordance with current state laws .All garbage and refuse containers are provided with tight-fitting lid or covers and must be kept covered when stored or not in continuous use .Outside dumpsters provided by garbage pick up services will be kept closed and free of surrounding litter.

CONCERN (E)

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

Administration (Tag F0835)

Could have caused harm · This affected multiple residents

Based on interview and record review, the facility failed to ensure the Administrator was involved in the oversight of the facility issues encountered daily. This failure had the potential to not meet...

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Based on interview and record review, the facility failed to ensure the Administrator was involved in the oversight of the facility issues encountered daily. This failure had the potential to not meet the needs of the residents. Findings: On March 28, 2022, at 1:59 p.m., the Director of Nursing was interviewed, she stated there has not been an Administrator in the facility since last year. On March 30, 2022, at 4:11 p.m., in an interview with the Assistant Administrator (AA) and the DON , The AA stated he was not present in the facility everyday. He stated he delegated the responsibility to the Department heads, and facility issues were discussed in the monthly quality audit which he attended virtually. The DON stated issues were resolved by the IDT(Interdisciplinary team : Department heads). A review of the facility undated document titled, Performance Improvement /Risk Management Plan for . (name of facility) indicated, The goals of this Performance improvement/Risk management Plans are: .the facility Administrator (Performance Improvement Coordinator) .will be responsible .actively participate in monitoring and evaluation activities .

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

2. On March 23, 2022, at 11:10 a.m., [NAME] 1 was observed wearing gloves while preparing dessert for the residents. [NAME] 1 wiped the table with the gloved hands and continued to prepare dessert for...

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2. On March 23, 2022, at 11:10 a.m., [NAME] 1 was observed wearing gloves while preparing dessert for the residents. [NAME] 1 wiped the table with the gloved hands and continued to prepare dessert for the resident, touching the dessert with the dirty gloves. [NAME] 1 was not observed removing the gloves and performing hand hygiene. On March 23, 2022, at 2:38 p.m., [NAME] 1 was interviewed. She stated the practice was to perform hand hgyiene in between changing of gloves. [NAME] 1 stated when the gloves were soiled, the gloves should be replaced. On March 23, 2022, at 4:09 p.m., the Infection Preventionist (IP) was interviewed. She stated the staff should be performing hand hygiene in between donning and doffing of gloves. The IP stated if the gloves get soiled, the staff should remove the gloves and donn new gloves. A review of the facility policy and procedure titled, Handwashing/Hand Hygiene, dated August 2019, indicated, .All facility personnel 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 .for the following situations .Before donning sterile gloves .after removing gloves . Based on observation, interview and record review the facility failed to ensure, the practice of infection control was within the standard of practice when: 1. Multiple staff were wearing long artificial nails. 2. One staff did not perform hand hygiene. These failures had the potential to spread infection to vulnerable residents. Findings: On March 22, 2022, at 11:28 a.m., Certified Nurse Assistant (CNA 6) was observed with long artificial fingernails extending over her finger tips. On March 22, 2022, at 2:09 p.m., Licensed Vocational Nurse (LVN 1), medication and treatment nurse, was observed with long artificial fingernails with rhinestones in the nurse station. On March 22, 2022, at 2:13 p.m., the Infection Preventionist (IP) had nails longer than her fingertips. On March 23, 2022, at 2:16 p.m., the IP was interviewed, she stated, it is strongly discouraged to wear artificial finger nails in the facility. On March 28, 2022, at 1:30 p.m., CNA 6 was observed wearing long artificial nails. In a concurrent interview with the CNA 6, she stated that health care staffs should not be wearing long artificial nails for they carry a lot of germs, and they can rip the gloves and can poke residents when rendering care to the residents. A review of the facility policy, titled, Handwashing/Hand Hygiene, date revised August 2019, indicated, .Wearing artificial fingernails is strongly discouraged among staff members with direct resident-care responsibilities .they present infection control risk .

CONCERN (F)

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review, the facility failed to ensure food were stored in accordance with professional standards for food service safety, when: 1a. Dead gnats were observed...

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Based on observation, interview, and record review, the facility failed to ensure food were stored in accordance with professional standards for food service safety, when: 1a. Dead gnats were observed inside the facility refrigerator; 1b. Employee food were observed inside the facility refrigerator and freezer; 2. Rotten oranges were stored in the dry storage room; and 3. Refrigerator temperature was not maintained below 41°F. These failures had the potential to result in foodborne illnesses. Findings: 1. On March 21, 2022, at 10:45 a.m., the following were observed during dry room storage inspection: a. Dead gnats inside the refrigerator. b. Employee food in the facility refrigerator and freezer. On March 21, 2022, at 1:14 p.m., in a concurrent observation and interview with the Dietary Service Supervisor (DSS), the DSS stated she and the dietary staff were cleaning the refrigerator daily. The DSS stated there were dead gnats inside. The DSS stated the refrigerator should not have dead gnats. She further stated for the employee food, it was allowed to be stored in the facility refrigerator but should be date labeled. She stated the employee food was not date labeled and should be discarded. 2. On March 21, 2:56 p.m., during a follow-up inspection of the dry room storage, in a box, was observed two rotten oranges with many fruit flies flying out of the box. In a concurrent interview with the Dietary Aide (DA) 1, he stated the rotten oranges should be discarded and should not be stored. 3. On March 28, 2022, at 2:45 p.m., in a concurrent observation and interview with the Dietary Service Supervisor (DSS), she stated the internal temperature of the refrigerator was 45°F. The DSS stated the refrigerator temperature should be 41°F and below. She stated the food delivery truck came in and the refrigerator door was left open for a while. A review of the refrigerator temperature log indicated: - March 1 to March 26, 2022, 41°F - March 27, 2022, 43°F - March 28, 2022, 42°F On March 28, 2022, at 4:10 p.m., during a follow-up observation and interview with the DSS, she stated the refrigerator temperature was at 44°F. The DSS stated the cook was preparing meals and got food items from the refrigerator. The DSS stated she did not know the temperature of the refrigerator could be adjusted. Further interview with the DSS was conducted and stated she was not informed the refrigerator temperature for the past two days were above 41°F. The DSS stated it could be, the staff were getting food items from the refrigerator and the refrigerator door was open for a time. On March 28, 2022, at 4:11 p.m., [NAME] 1 was interviewed. She stated she was monitoring the refrigerator temperature every morning. [NAME] 1 stated the temperature increased above 41°F. cook 1 stated the refrigerator door was open most of the time and the temperature was not stable. She stated she did not inform the DS when the refrigerator temperature was higher than 41°F and above. On March 29, 2022, at 9:13 a.m., the DSS was interviewed. She stated the refrigerator temperature should be below 41 degrees. The DSS stated the resident might get sick if the food in the refrigerator was warm. A review of the facility policy and procedure titled, Food Receiving and Storage, dated October 2017, indicated, .Foods shall be received and stored in a manner that complies with safe food handling practices .Refrigerated foods must be stored below 41°F unless otherwise specified by law .Food Services, or other designated staff, will maintain clean food storage areas at all times .Non-refrigerated foods .will be stored in a designated dry storage unit which is temperature and humidity controlled, free of insects .and kept clean .

BLYTHE POST ACUTE LLC

The Good

The Bad

The Ugly 69 deficiencies on record

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Our Honest Assessment

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BLYTHE POST ACUTE LLC

Strengths

Concerns