How many inspection deficiencies does PIONEERS MEMORIAL SKILLED NURSING CENTER have?

PIONEERS MEMORIAL SKILLED NURSING CENTER has 62 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at PIONEERS MEMORIAL SKILLED NURSING CENTER?

PIONEERS MEMORIAL SKILLED NURSING CENTER has a one-star staffing rating from CMS with 0.15 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 PIONEERS MEMORIAL SKILLED NURSING CENTER located?

PIONEERS MEMORIAL SKILLED NURSING CENTER is located in BRAWLEY, CA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does PIONEERS MEMORIAL SKILLED NURSING CENTER have?

PIONEERS MEMORIAL SKILLED NURSING CENTER has 99 certified beds.

Who owns PIONEERS MEMORIAL SKILLED NURSING CENTER?

PIONEERS MEMORIAL SKILLED NURSING CENTER is a government - hospital district facility and operates independently (not part of a chain).

PIONEERS MEMORIAL SKILLED NURSING CENTER

Name: PIONEERS MEMORIAL SKILLED NURSING CENTER
Address: 320 CATTLE CALL DR., BRAWLEY, CA, 92227, US
Telephone: (760) 344-5431
Rating: 1.0

320 CATTLE CALL DR., BRAWLEY, CA 92227 · (760) 344-5431

Government - Hospital district 99 Beds Independent Data: November 2025

Trust Grade

20/100

#1087 of 1155 in CA

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Last Inspection: January 2025

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

Overview

Pioneers Memorial Skilled Nursing Center has received a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranking #1087 out of 1155 facilities in California places it in the bottom half statewide, and it is the last among the three nursing homes in Imperial County. While the facility is showing some improvement, reducing issues from 31 in 2024 to 15 in 2025, it still has serious deficiencies, including failure to properly manage diabetes care for a resident, resulting in hospitalization, and worsening a pressure ulcer due to inadequate care. Staffing is a mixed bag; despite a 37% turnover rate that is slightly better than average, the nursing home has concerning RN coverage, being below 99% of California facilities. Additionally, fines totaling $52,435 indicate compliance issues that are higher than 82% of other facilities in the state, raising further red flags for families considering this option.

Trust Score: F
In California: #1087/1155
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 37% turnover. Near California's 48% average. Typical for the industry.
Penalties: $52,435 in fines. Higher than 80% of California facilities, suggesting repeated compliance issues.
Skilled Nurses: Each resident gets only 8 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 62 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★☆☆☆☆

1.0

Staff Levels

★★★☆☆

3.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2024: 31 issues

2025: 15 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover below average (37%)
11 points below California average of 48%

Facility shows strength in fire safety.

The Bad

1-Star Overall Rating

Below California average (3.1)

Significant quality concerns identified by CMS

Staff Turnover: 37%

Near California avg (46%)

Typical for the industry

Federal Fines: $52,435

Above median ($33,413)

Moderate penalties - review what triggered them

The Ugly 62 deficiencies on record

2 actual harm

Apr 2025 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

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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 necessary care and services were provided according to the facility's fall policies and procedures for one resident (Resident 1) reviewed during a Facility Reported Incident (FRI) investigated after an unwitnessed fall. This deficient practice delayed Resident 1's necessary post-fall care and diagnosis (identifying injury from its signs and symptoms using tests) of multiple rib (chest bone) fractures that were sustained. Cross-Reference F-689 Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included a history of Parkinson ' s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), per the admission record. A record review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool) dated 4/9/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 10 points out of 15 possible points, which indicated Resident 1 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits. A record review of Resident 1 ' s comprehensive MDS dated [DATE] section GG indicated Resident 1 required maximum (helper lifts, holds, or supports limbs [arms and legs]and provides more than half the effort) assistance with toilet transfers, with most recent quarterly MDS, dated [DATE] indicating that Resident 1 had impairment to both lower extremities (legs). A review of Resident 1 ' s facility investigation note, titled UNWITNESSED FALL: [RESIDENT NAME] 4/10 ROOT CAUSE ANALYSIS was conducted. This record indicated: - On 4/10/25, .Resident fell on 4/10 with injuries to her right ribs . Put on neuros [neuro-checks; assessment that evaluates the brain, and spinal cord functioning, including vital signs, pain, muscle strength, balance, vision and cognitive alertness to think and reason] and monitoring for changes . - On 4/11/25, .Resident returned on 4/14 with Dx [diagnosis] of L2 compression and rib fractures, pain management .Findings: Resident appeared she may have hit the water faucets in the bathtub or the side of the bathtub. Left on the toilet without assist. Avoidable .Inservices [staff education]: Fall Management, do not leave resident unattended. A clinical chart review of Resident 1 ' s fall care plan was conducted. This record indicated: - Date initiated 1/3/25, .The resident is (High) risk for falls r/t [related to] Confusion, gait balance, poor communication/comprehension .Vision/hearing problems .Follow facility fall protocol . - Date initiated 4/11/25, The resident has had an actual fall with injury. 4/10/25 .4rth and 5th rib fractures right side acute (new/sudden) . On 4/28/25 at 12:47 P.M., an interview was conducted with Resident 1. Resident 1 stated that the fall incident happened in the bathroom. Resident 1 stated that the nursing staff put her on the toilet and that she lost balance and fell into the tub. Resident 1 stated she waited for about five minutes for staff to arrive and help her. Resident 1 stated she experienced rib pain after the fall (4/10/25). On 4/28/25 at 12:58 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that on the day of the unwitnessed fall (4/10/25), he was assigned to (care for) Resident 1. CNA 1 stated that the housekeeper heard Resident 1 yelling from the bathroom and said that Resident 1 fell. CNA 1 stated he was assisting another resident before he entered Resident 1 ' s room. CNA 1 stated that when he entered Resident 1 ' s room, he found Resident 1 in the bathtub in a sitting position with both feet hanging out the tub. CNA 1 stated that Resident 1 required minimal to maximal assistance with toileting and transfers. On 4/28/25 at 1:04 P.M., an interview and record review was conducted with licensed nurse (LN) 1. LN 1 stated that on 4/11/25 (one day after the fall) at 6:17 A.M., Resident 1 complained of pain on her right flank (rib area), and she discovered that Resident 1 had a new bruise on her right rib. LN 1 stated she notified Resident 1 ' s physician (MD) and responsible party (RP) on 4/11/25 at 2 P.M. (per the CHANGE OF CONDITION [COC] EVALUATION) about the unwitnessed fall, bruising on the rib area, and that the MD ordered to send the resident to the hospital for X-rays (images of the inside of the body). LN 1 stated they did not perform post-fall neuro-checks (neurological check; assessment that evaluates the brain, and spinal cord functioning to include vital signs, pain, muscle strength, balance, vision and cognitive alertness to think and reason) until the day (4/11/25) after the unwitnessed fall. On 4/28/25 at 1:18 P.M., an interview was conducted with LN 2. LN 2 stated that on the day of the unwitnessed fall (4/10/25), he assisted Resident 1 to her bathroom and onto the raised toilet seat. LN 2 stated he later saw Resident 1 in the tub with her feet dangling. LN 2 stated he thought that Resident 1 was her own RP (responsible party) and did not notify Resident 1 ' s RP. LN 2 stated he did not notify Resident 1 ' s MD or complete post-fall procedures for neuro-checks immediately after Resident 1 ' s unwitnessed fall, because the former Director of Nursing (DON) told him he did not have to do post fall procedures (i.e. notify MD/RP, neuro-checks, start COC evaluation and revise care plan). LN 2 stated he thought it was a fall, and further stated at any point if I place a patient on the toilet and she [Resident 1] was in another area from where I last placed her and sitting down or on the ground yelling out, in my book it ' s a fall and it should have been processed as an unwitnessed fall. LN 2 stated the fall incident with Resident 1 could have delayed necessary care, and that Resident 1 could have sustained worse complications. On 4/28/25 at 1:25 P.M., an interview with the (current) DON was conducted. The DON stated that the fall protocol and supervision should have been followed to prevent delayed care for Resident 1. The DON stated it was her expectation that the nursing staff followed the facility ' s fall policies and procedures and start neuro-checks immediately after a fall, to monitor for complications such as head injuries, bleeding, fractures that could result, along with death. A review of the facility's policy and procedure titled, FALL MANAGEMENT PROGRAM dated 3/13/21, indicated, .for an unwitnessed fall or witnessed fall with suspected or known head injury, the licensed nurse will complete neurological checks for 72 hours following the fall incident .The attending physician will be informed if there is a deviation from the Resident ' s baseline status for further instructions .15-20 minutes after a fall, the licensed nurse will initiate a Post-fall huddle as part of the Facility ' s internal quality assurance (QA) process .

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

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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 supervision and maintain a safe environment to prevent accidents for one resident (Resident 1) which resulted in an unwitnessed fall. As a result, this deficient practice resulted in harm for Resident 1, who sustained multiple rib (chest bone) fractures and pain. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included a history of Parkinson ' s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), per the admission Record. A record review of Resident 1's minimum data set (MDS - a federally mandated resident assessment tool) dated 4/9/25 indicated, a Brief Interview for Mental Status (BIMS- developed by reviewing the resident's status during the prior seven-day period) score of 10 points out of 15 possible points, which indicated Resident 1 had moderate cognitive (pertaining to memory, judgement and reasoning ability) deficits. A record review of Resident 1 ' s comprehensive MDS dated [DATE], section GG, indicated Resident 1 required maximum (helper lifts, holds, or supports limbs [arms and legs]and provides more than half the effort) assistance with toilet transfers with most recent quarterly MDS dated [DATE] indicating Resident 1 had lower extremity (leg) impairments to both legs. A review of Resident 1 ' s facility investigation entitled, UNWITNESSED FALL: [RESIDENT NAME] 4/10 ROOT CAUSE ANALYSIS was conducted, and indicated: - On 4/10/25, .Resident fell on 4/10 with injuries to her right ribs . It was reported Resident was assisted to the toilet and waved the Nurse away for privacy while on the toilet . - On 4/11/25, .Resident returned on 4/14 with Dx [diagnosis] of L2 compression and rib fractures, pain management .Findings: Resident appeared she may have hit the water faucets in the bathtub or the side of the bathtub. Left on the toilet without assist. Avoidable .Inservices [staff education]: Fall Management, do not leave resident unattended. A clinical chart review of Resident 1 ' s fall care plan was conducted and indicated: - Date initiated 1/3/25, .The resident is (High) risk for falls r/t [related to] Confusion, gait balance, poor communication/comprehension .Vision/hearing problems .Follow facility fall protocol . - Date initiated 4/11/25, The resident has had an actual fall with injury. 4/10/25 .4rth and 5th rib fractures right side acute (new/sudden) . On 4/28/25 at 12:47 P.M., an interview was conducted with Resident 1. Resident 1 stated that the fall incident happened in the bathroom. Resident 1 stated that the nursing staff put her on the toilet. Resident 1 stated that after staff left the bathrrom, she lost balance and fell into the tub. Resident 1 stated she waited for about five minutes for staff to arrive and help her. Resident 1 stated she experienced rib pain after the fall (4/10/25). On 4/28/25 at 12:58 P.M., an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that on the day of the unwitnessed fall (4/10/25), he was assigned to (care for) Resident 1. CNA 1 stated the housekeeper heard Resident 1 yelling from the bathroom and said Resident 1 fell. CNA 1 stated he was assisting another resident before he entered Resident 1 ' s room. CNA 1 stated that when he entered Resident 1 ' s room, he found Resident 1 in the bathtub in a sitting position with both feet hanging out the tub. CNA 1 stated Resident 1 required minimal to maximal assistance with toileting and transfers. On 4/28/25 at 1:18 P.M., an interview was conducted with LN 2. LN 2 stated that on the day of the unwitnessed fall (4/10/25), he assisted Resident 1 to her bathroom and onto the raised toilet seat. LN 2 stated that he later saw Resident 1 in the tub with her feet dangling. LN 2 stated he thought that Resident 1 was her own responsible party (RP). LN 2 stated, .at any point if I place a patient on the toilet and she [Resident 1] was in another area from where I last placed her and sitting down or on the ground yelling out, in my book it's a fall . On 4/28/25 at 1:25 P.M., an interview with the director of nursing (DON) was conducted. The DON stated it was necessary to provide a safe environment and supervision to prevent (residents from having) accidents/fall. A review of the facility's policy and procedure, titled FALL MANAGEMENT PROGRAM dated 3/13/21, indicated, .To provide residents a safe environment . The facility will implement . that supports providing an environment free from fall hazards .

Jan 2025 13 deficiencies

CONCERN (D)

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

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure confidential information was kept private for one of five sampled residents (Resident 28 ). As a result, Resident 28's right to privacy and confidentiality was violated. Findings: Resident 28 was re -admitted to the facility on [DATE] with diagnoses which included Acute Prostatitis (painful inflammation of the prostate gland), Local infection of the skin and subcutaneous tissue and Urinary Tract Infection per Facility's admission Record. On 1/7/25 at 7:05 P.M., an observation of nursing station One was conducted. The Vital signs record of Resident 28 was seen on the counter of nursing station one unattended. The vital signs record contains Resident 28's name, room number, blood pressure, pulse, temperature, respiratory rate, bowel movement consistency, and oxygen saturation. On 1/9/25 at 11:45 A.M., an interview with Infection Preventionist/Registered Nurse (IP/RN) was conducted. The IP/RN stated vital signs record are part of medical records. The IP/RN stated all medical records, including vital signs record should be kept secure and confidential. The IP/RN acknowledged by not keeping vital signs record secure and unattended, anybody can see a resident's information. The IP/RN stated vital signs record should had been secured in a manila folder for privacy but was not done. On 1/10/25 at 5:45 P.M., an interview with the Director of Nursing (DON) was conducted. The DON stated vital signs record of residents should had been kept secure and not left unattended exposed to public. The DON stated resident 28's right to privacy and confidentiality was violated. Per the facility's policy and procedure (P&P) titled, Disclosure of PHI, Medical records Manual - HIPAA revised December 1, 2012, the P&P indicated Procedure I . D. ii. Medical Records Use and Storage: a. Facility staff will keep medical records secure and confidential b. Care should be taken to keep a medical record shielded and inaccessible to other residents or to the general public .

CONCERN (D)

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

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide communication tool for 2 of 18 sampled residents (Resident 13 and Resident 36). As a result, there was a potential for Resident 13 and Resident 36 to not be able to communicate their needs to staff and effect their quality of life. Findings: 1. Resident 13 was admitted to the facility on [DATE] with diagnoses which included dementia (a decline in mental abilities that affects thinking, memory, and behavior), hemiplegia (paralysis of one side of the body), and urinary retention (unable to empty urine in bladder) per Resident 13's admission Record. Observations were conducted on 1/7/25 at 12:30 P.M., and on 1/8/24 at 10:30 A.M., with Resident 13. Resident 13 was observed having difficulty communicating, trying to say incomprehensible words, murmuring words, making sign language, nodding his head up and down or side to side. In addition, Resident 13 was also observed without a communication tool (a book or a board to convey a message). A review of Resident 13's Care Plan last revised on 11/17/23 indicated The resident has a communication problem r/t [related to] Dementia, CVA [Cerebrovascular Accident - sudden interruption of blood flow to brain] .Interventions/Tasks: .Use alternative communication tools as needed . A concurrent observation, interview and record review were conducted on 1/8/25 at 6:31 P.M., with Licensed Nurse (LN) 1. LN 1 stated Resident 13 did not have a communication tool to help him convey his message. LN 1 stated Resident 13's care plan indicated, The resident has a communication problem r/t [related to] Dementia, CVA [Cerebrovascular Accident - sudden interruption of blood flow to brain] .Interventions/Tasks: .Use alternative communication tools as needed . LN 1 acknowledged that Resident 13 did not have a communication tool to use that would help him convey his message to staff. An interview was conducted on 1/10/25 at 6 P.M., with the Director of Nursing (DON). The DON stated Resident 13 had difficulty expressing themselves and needed a communication tool. The DON acknowledged that Residents 13 should have had a communication tool but did not. The DON further stated the communication tool was important for Residents 13 to convey his message and needs to staff. A review of facility's policy and procedure titled, Care of Deaf or Hearing Impaired Resident dated 1/12/12 indicated, III Procedure for Communicating with the Resident: .D. If the resident is unable to hear, provide a pencil and paper to communicate in writing or a communication board if warranted . 2. Resident 36 was admitted to the facility on [DATE] with diagnosis which included aphasia (difficulty speaking) and hemiplegia (partial paralysis) per Resident 36's admission Record. Observations were conducted on 1/7/25 at 12:28 P.M. and on 1/8/24 at 10:45 A.M., with Resident 36. Resident 36 was observed having difficulty communicating and was making sign language, nodding his head up and down or side to side, and was making thumbs up. In addition, Resident 36 was also observed without a communication tool (a book or a board to convey a message). A review of Resident 36's Care Plan last revised on 7/3/23 indicated, The resident has a communication problem r/t [related to] Expressive Aphasia [difficulty expressing words and thought], Receptive Aphasia [difficulty to understand speech or symbol], Stroke [interruption of blood flow to brain causing damage to brain tissue] .Interventions/Tasks: .Use alternative communication tools as needed . A concurrent observation, interview and record review were conducted on 1/8/25 at 6:31 P.M., with Licensed Nurse (LN) 1. LN 1 stated Resident 36 did not have a communication tool to help him convey his message. LN 1 stated Resident 36's diagnoses included aphasia, and the care plan indicated The resident has a communication problem r/t [related to] expressive aphasia, receptive aphasia .Interventions/Tasks: .Use alternative communication tools as needed . LN 1 acknowledged that Resident 36 did not have a communication tool to help him convey his message to staff. An interview was conducted on 1/10/25 at 6 P.M., with the Director of Nursing (DON). The DON stated Resident 36 had difficulty expressing themselves and needed a communication tool. The DON acknowledged that Residents 36 should have had a communication tool but did not. The DON further stated the communication tool was important for Residents 36 to convey their message and needs to staff. A review of facility's policy and procedure titled, Care of Deaf or Hearing Impaired Resident dated 1/12/12 indicated, III Procedure for Communicating with the Resident: .D. If the resident is unable to hear, provide a pencil and paper to communicate in writing or a communication board if warranted .

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide the needed care for one of three residents (Resident 54) when Resident 54's skin discoloration was not assessed and documented for monitoring. This failure had the potential for nursing staff to not identify any deterioration on Resident 54's skin discoloration which could result in delay of treatment. Findings: A review of Resident 54's face sheet indicated, Resident 54 was admitted to the facility on [DATE] with diagnoses that included dementia (forgetfulness), atrial fibrillation (A-Fib -irregular heart rate). A review of Resident 54's physician order dated 1/1/25, indicated, Resident 54 was receiving Apixaban (generic name, anticoagulant - blood thinner) oral tablet. Give 2.5 milligrams (mg - unit of measurement) by mouth two times a day for A-Fib. An initial tour conducted on 1/7/25 at 10:45 A.M., Resident 54 was observed to have a purplish discoloration on his right side of his right elbow. A concurrent interview and record review was conducted with the Director of Staff Development (DSD) on 1/9/25. The DSD stated, Resident 54's nursing care plan dated 8/1/23 indicated, Resident 54's bruising should be monitored and documented on Resident 54's treatment activity record (TAR- documentation where skin is monitored). The DSD stated, there was no documentation on Resident 54's TAR the right elbow discoloration was recorded for monitoring. The DSD further stated, Resident 54's skin discoloration should have been monitored and documented timely to address the care needed. An interview was conducted with the Director of Nursing (DON) on 1/10/25 at 9:30 A.M. The DON stated it was her expectation that nursing staff monitor and properly documented any skin changes on the residents TAR. The DON further stated, Resident 54's skin discoloration should have been documented and monitored by nursing staff to address changes but was not. Review of the facility's policy titled, Skin and Wound Management dated 2022, indicated. III. Documentation .C. New non pressure ulcers, bruises and lacerations will be documented on the 24 Hour Log and an incident report will be completed by the Licensed Nurse to determine casual factors contributing to the development of the skin condition.

CONCERN (D)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a gastric tube (GT - tube surgically inserted inserted into the stomach to provide food and medication) was free from a possible complication for one of one resident (Resident 23) when Resident 23's GT had an air bubble (pocket of air trapped)in the line. This failure had the potential to compromise Resident 23's health condition. Finding: A review of Resident 23's face sheet indicated she was admitted to the facility on [DATE] with medical diagnoses of dysphagia (difficulty swallowing), cerebral infarction (blockage in the brain causing weakness), and hemiplegia (weakness in one part of the body). A review of Resident 23's Physician's History and Physical (PHP- physician assessment about a resident's health) dated 4/8/24 indicated, Resident 23 did not have the capacity to understand and make decisions on her own. A concurrent observation and interview were conducted with the Director of Staff Development (DSD) on 1/9/25 at 7:04 P.M. Resident 23's GT was observed to have air from the bottle down to the tubing near Resident 23's stomach. The DSD stated the licensed nurse who prepared the GT should have primed (run small amount of fluid) the tube. The DSD further stated Resident 23 and her GT should have been checked every two hours to monitor the GT feeding was free from air to prevent Resident 23 from experiencing possible abdominal discomfort. An interview was conducted with the Director of Nursing on 1/10/25 at 10:40 A.M. The DON stated, licensed nurses should have checked residents GT before, during and after infusion of GT feeding. The DON further stated Resident 21's GT should have been free from any air bubble that can cause complication. Review of the facility's policy titled, Enteral Feedings dated 9/7/23 indicated, .Prime pump tubing .

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to replace an oxygen cylinder for one of three residents (Resident 61) in a timely manner. This failure had the potential for Resident 61 to run out of oxygen and affect her wellbeing. Finding: A review of Resident 61's face sheet indicated, Resident 61 was admitted to the facility on [DATE] with diagnoses that included heart failure, respiratory failure with hypoxia (low level of oxygen). A review of Resident 61's physician order dated 7/9/24 indicated, Oxygen at 2 liters per minute via nasal cannula every shift for shortness of breath (SOB). An initial observation and interview was conducted with Resident 61 on 1/7/25 at 11:43 A.M. Resident 61 stated, there was no oxygen coming out of her cannula. Resident 61 further stated she needed continuous oxygen. Resident 61's oxygen tank was observed empty. An interview was conducted with certified nursing assistant (CNA) 6 on 1/7/25 at 11:50 A.M. CNA 6 stated, Resident 61's oxygen tank was empty and needed to be replaced with a filled-up oxygen tank. An interview was conducted with the Director of Staff Development (DSD) on 1/9/25 at 9:35 A.M. The DSD stated, Resident 61 was dependent on oxygen and her oxygen tank should have been checked by nursing staff every two hours for fullness and functionality. An interview was conducted with the Director of Nursing (DON) on 1/10/25 at 10:00 A.M. The DON stated she expects the nursing staff to provide adequate oxygenation to residents. The DON further stated, Resident 61's oxygen tank should have been replaced timely with a full oxygen tank to prevent Resident 61 from having SOB. Review of the facility's policy titled, Oxygen Therapy dated, 11/2017, indicated, Procedure. I. Administer oxygen per physician orders .

CONCERN (D)

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Licensed Nurse followed the physician order and had adequate competency in providing care to: 1. 4 of 18 (Resident 2, Resident 13, Resident 23, and Resident 52) sampled residents with low air loss mattress (mattress that uses air to relieve pressure). 2. 2 of 19 (Resident 2 and Resident 72) sampled residents with wound vacuum (wound vac - a device that uses negative pressure to help wounds heal). This failure had the potential risk to resident's care and well-being. Findings: 1a. Resident 2 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body), diabetes (high blood sugar) and pressure ulcer (wound) per Resident 2's undated admission Record. A review of Residents 2's physician orders indicated the low air loss mattress order: Low air loss mattress .settings are based on weight, may adjust for comfort . A concurrent observation, interview and record review was conducted on 1/9/25 at 5:30 P.M., with Licensed Nurse (LN) 4. Resident 2 was observed with a low air loss mattress and setting was at 120. LN 4 stated Resident 2's weight on 1/4/25 was 120.6 lbs. LN 4 stated she did not know about the low air loss mattress's manufacturer's guideline and how to set low air loss mattress according to weight per manufacturer's guideline. LN 4 further stated she did not receive a competency on the 3 different low air loss mattress and pump used in the facility. An interview was conducted on 1/10/25 at 6 P.M., with the Director of Nursing (DON). The DON stated she was not aware of the different kinds of low air loss mattress and pumps that were used in the facility. The DON stated she did not know about the low air loss mattress and pump manufacturer's guideline and the competency and training of the facility staff. The DON acknowledged that facility staff should be aware of the manufacturer's guideline of low air loss mattress and should have training and competency, but did not have. The DON further stated it was important to have the training and competency of the equipment low air loss mattress to ensure patient safety and maximum benefit as indicated by the physician order. A review of facility's policy and procedure titled, Mattress Resource (undated) indicated, .3. Air Mattress (Low Air Loss) .E. Follow manufacturer's guidelines to ensure appropriate settings . 1b. Resident 13 was admitted to the facility on [DATE] with diagnoses which included dementia (a decline in mental abilities that affects thinking, memory, and behavior), hemiplegia (paralysis of one side of the body), and urinary retention (unable to empty urine in bladder) per Resident 13's undated admission Record. A review of Residents 13's physician orders indicated the low air loss mattress order: Low air loss mattress .settings are based on weight, may adjust for comfort . A concurrent observation, interview and record review was conducted on 1/9/25 at 5:30 P.M., with Licensed Nurse (LN) 4. Resident 13 was observed with a low air loss mattress and setting was at 210. LN 4 stated Resident 13's weight on 1/1/25 was 129.6 lbs. LN 4 stated she did not know about the low air loss mattress's manufacturer's guideline and how to set low air loss mattress according to weight per manufacturer's guideline. LN 4 further stated she did not receive a competency on the 3 different low air loss mattress and pump used in the facility. An interview was conducted on 1/10/25 at 6 P.M., with the Director of Nursing (DON). The DON stated she was not aware of the different kinds of low air loss mattress and pumps that were used in the facility. The DON stated she did not know about the low air loss mattress and pump manufacturer's guideline and the competency and training of the facility staff. The DON acknowledged that facility staff should be aware of the manufacturer's guideline of low air loss mattress and should have training and competency,but did not have. The DON further stated it was important to have the training and competency of the equipment low air loss mattress to ensure patient safety and maximum benefit as indicated by the physician order. A review of facility's policy and procedure titled, Mattress Resource (undated) indicated, .3. Air Mattress (Low Air Loss) .E. Follow manufacturer's guidelines to ensure appropriate settings . 1c. Resident 23 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body), diabetes (high blood sugar) per Resident 23's undated admission Record. A review of Residents 23's physician orders indicated the low air loss mattress order: Low air loss mattress .settings are based on weight, may adjust for comfort . A concurrent observation, interview and record review was conducted on 1/9/25 at 5:30 P.M., with Licensed Nurse (LN) 4. Resident 23 was observed with a low air loss mattress and setting was at 150. LN 4 stated Resident 23's weight on 1/1/25 was 160 lbs. LN 4 stated she did not know about the low air loss mattress's manufacturer's guideline and how to set low air loss mattress according to weight per manufacturer's guideline. LN 4 further stated she did not receive a competency on the 3 different low air loss mattress and pump used in the facility. An interview was conducted on 1/10/25 at 6 P.M., with the Director of Nursing (DON). The DON stated she was not aware of the different kinds of low air loss mattress and pumps that were used in the facility. The DON stated she did not know about the low air loss mattress and pump manufacturer's guideline and the competency and training of the facility staff. The DON acknowledged that facility staff should be aware of the manufacturer's guideline of low air loss mattress and should have training and competency, but did not have. The DON further stated it was important to have the training and competency of the equipment low air loss mattress to ensure patient safety and maximum benefit as indicated by the physician order. A review of facility's policy and procedure titled, Mattress Resource (undated) indicated, .3. Air Mattress (Low Air Loss) .E. Follow manufacturer's guidelines to ensure appropriate settings . 1d. Resident 52 was admitted to the facility on [DATE] with diagnoses which included neoplasm of spinal cord (tumor around the spinal cord) and paraplegia (paralysis of the lower body) per Resident 52's undated admission Record. A review of Residents 52's physician orders indicated the low air loss mattress order: Low air loss mattress .settings are based on weight, may adjust for comfort . A concurrent observation, interview and record review was conducted on 1/9/25 at 5:30 P.M. with Licensed Nurse (LN) 4. Resident 52 was observed with a low air loss mattress and setting was at #3. LN 4 stated Resident 23's weight on 1/1/25 was 112.8 lbs. LN 4 stated she did not know about the low air loss mattress's manufacturer's guideline and how to set low air loss mattress according to weight per manufacturer's guideline. LN 4 further stated she did not receive a competency on the 3 different low air loss mattress and pump used in the facility. An interview was conducted on 1/10/25 at 6 P.M., with the Director of Nursing (DON). The DON stated she was not aware of the different kinds of low air loss mattress and pumps that were used in the facility. The DON stated she did not know about the low air loss mattress and pump manufacturer's guideline and the competency and training of the facility staff. The DON acknowledged that facility staff should be aware of the manufacturer's guideline of low air loss mattress and should have training and competency, but did not have. The DON further stated it was important to have the training and competency of the equipment low air loss mattress to ensure patient safety and maximum benefit as indicated by the physician order. A review of facility's policy and procedure titled, Mattress Resource (undated) indicated, .3. Air Mattress (Low Air Loss) .E. Follow manufacturer's guidelines to ensure appropriate settings . 2a. Resident 2 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body), diabetes (high blood sugar) and pressure ulcer (wound) per Resident 2's undated admission Record. A review of Resident 2's physician order dated 12/25/24 indicated, KCI Negative Wound Vac therapy device to be placed to Right Buttock stage 4 pressure injury and changed Wednesday and Saturdays. every day shift every Mon, Thu for stage 4 pressure injury for 21 days cleanse with Dakin's solution, pat dry, apply wound vac and change on specific days. A concurrent interview and record review was conducted on 1/9/25 at 6:15 P.M., with Licensed Nurse (LN) 4. LN 4 stated Resident 2 was on wound vac therapy was set with a negative pressure of 125 mm/Hg (Millimeters of mercury - a unit that measures the pressure). LN 4 stated Resident 2's physician order dated 12/25/24 was incomplete and should have been clarified with the physician. LN 4 stated, the nursing staff did not clarify the order and set the negative pressure setting of the wound vac to 125 mm/Hg. An interview was conducted on 1/10/24 at 6 P.M. with the Director of Nursing (DON). The DON stated the physician order on wound vac therapy was incomplete without the negative pressure settings and should have been clarified by the nursing staff. The DON further stated it was important to ensure physician orders were clear and complete to ensure physician orders were carried out as ordered for patient's safety. A review of facility's policy and procedure titled, Physician Orders last revised 11/16/22 indicated, .Policy: The licensed nurse will confirm that physician orders are clear, complete and accurate as needed . 2b. Resident 72 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus (high blood sugar) and chronic ulcer (wound) of right foot per Resident 72's undated admission Records. A review of Resident 72's physician order dated 12/18/24 indicated, KCI negative Wound Vacc [sic] therapy device to be placed to Right Dorsal foot x Surgical wound to be changed on Wednesday and Saturday. Every day shift every Wed, Sat for surgical wound for 21 Days. Cleanse with Dakin's Solution, pat dry, apply wound vacc [sic] on specific days. A concurrent interview and record review was conducted on 1/9/25 at 6:15 P.M., with Licensed Nurse (LN) 4. LN 4 stated Resident 72 was on wound vac therapy was set with a negative pressure of 125 mm/Hg (Millimeters of mercury - a unit that measures the pressure). LN 4 stated Resident 72's physician order dated 12/18/24 was incomplete and should have been clarified with the physician. LN 4 stated, the nursing staff did not clarify the order and set the negative pressure setting of the wound vac to 125 mm/Hg. An interview was conducted on 1/10/24 at 6 P.M. with the Director of Nursing (DON). The DON stated the physician order on wound vac therapy was incomplete without the negative pressure settings and should have been clarified by the nursing staff. The DON further stated it was important to ensure physician orders were clear and complete to ensure physician orders were carried out as ordered for patient's safety. A review of facility's policy and procedure titled, Physician Orders last revised 11/16/22 indicated, .Policy: The licensed nurse will confirm that physician orders are clear, complete and accurate as needed .

CONCERN (D)

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

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to provide a registered nurse (RN) for at least eight hours a day to 99 residents. This failure had the potential to affect residents care, health, and wellbeing. Findings: Review of the Centers for Medicare and Medicaid Services (CMS - federal agency responsible in implementing standards in the long-term care facilities) Payroll Based Journal (PBJ - system where staffing information are collected on a regular basis) for the quarter 4 2024 (July 1 - September 30) indicated, No RN hours four or more days. A concurrent interview and record review was conducted with the Director of Staff Development (DSD) on 1/9/25 at 12:45 P.M. The DSD reviewed the facility's daily assignment sheets dated, 7/13/24, 7/20/24, 8/10/24, 8/24/24 and 9/15/24. The DSD stated, there was no RN coverage for at least eight hours a day from July to September 2024. The DSD further stated, an RN should have been in the facility to provide RN care when needed. An interview was conducted with the Director of Nursing on 1/10/25 at 10:07 A.M. The DON stated, a RN should have been in the facility for at least eighth hours per day to provide residents with the necessary and appropriate RN care when needed. Review of the facility's policy titled, Nursing Department - Staffing, Scheduling and Postings revised 7/2018, indicated, .Procedure 1. Nurse Staffing .B. If the facility is licensed for 60 - 99 beds, it will have the following: i. At least one Registered Nurse or Licensed Vocational Nurse, in the facility at all times, day and night, in addition to the Director of Nursing Services (DONS).

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure administration of medication were implemented per physician orders to 2 of 18 sampled residents. This failure had the potential risk to the residents' well-being and care. Findings: 1. Resident 2 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body), diabetes (high blood sugar) and pressure ulcer (wound) per undated admission Record. A review of Resident 2's physician orders indicated the medication order Humalog Injection Solution 100 UNIT/ML (Insulin Lispro) inject as per sliding scale: if 0[noted possible typo 70}-150=0; 151-200=3; 201-250=5; 251-300=8; 301-350=12; 351-400=15, subcutaneous [under the skin] before meals and at bedtime for diabetes > 400 notify MD [medical doctor] if BS [blood sugar] below 70 and follow hypoglycemic protocol [management/treatment of low blood sugar] A review of facility's meal service times indicated, Breakfast: Rooms at 7:30 A.M. and Dining Room at 7:45 A.M.; Lunch: Dining Room at 11:15 A.M, and Rooms at 11:30 A.M.; Dinner: Dining Rooms at 5:15 P.M., and Rooms at 5:30 P.M. A review of Resident 2's Medication Administration Record (MAR) indicated blood sugar check and Humalog (Insulin Lispro) administration on 1/7/25 before lunch at 2:46 P.M., on 1/8/25 before breakfast at 11:46 A.M., and before dinner at 6:09 P.M. A concurrent interview and record review of Resident 2's Medication Administration Record (MAR) was conducted on 1/10/25 at 2:30 P.M. with Licensed Nurse (LN) 1. LN 1 stated Humalog administration were scheduled before breakfast at 7 A.M., before lunch at 12 P.M., and before dinner at 5 P.M. LN 1 stated Resident 2's MAR indicated that Blood sugar check and Humalog (Insulin Lispro) administration were not done before scheduled meals and within 1 hour of scheduled medication administration on 1/7 and 1/8/25. An interview was conducted on 10/10/25 at 5:44 P.M., with LN 1. LN 1 stated the physician order on Humalog (Insulin Lispro) was ordered and timed before meals. LN 1 stated Resident 2's physician order for Humalog was not followed and administered per Resident 2's MAR documentation. LN 1 stated the MAR indicated the Humalog physician order was completed after scheduled meals and were off the scheduled administration schedule. An interview was conducted on 1/10/25 at 6 P.M., with the Director of Nursing (DON). The DON acknowledged that Resident 2's Humalog (Insulin Lispro) administration time was not and should have been implemented before meals as ordered by physician. The DON stated it was important that Insulin medications should be administered timely to prevent adverse effect on the over-all health of the resident. A review of facility's policy and procedure titled, Medication-Administration last revised 1/1/12 indicated, .Policy: Medication will be administered directed by a Licensed Nurse and upon the order of a physician or licensed independent practitioner . 2. Resident 65 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis of one side of the body), diabetes (high blood sugar) per undated admission Record. A review of Resident 65's physician orders indicated the medication order Humalog Injection Solution 100 UNIT/ML (Insulin Lispro) inject as per sliding scale: if 70-150=0; 151-200=3; 201-250=5; 251-300=8; 301-350=12; 351-400=15, subcutaneous [under the skin] before meals and at bedtime for dm [diabetes mellitus]. A review of facility's meal service times indicated Breakfast: Rooms at 7:30 A.M. and Dining Room at 7:45 A.M.; Lunch: Dining Room at 11:15 A.M and Rooms at 11:30 A.M.; Dinner: Dining Rooms at 5:15 P.M. and Rooms at 5:30 P.M. A review of Resident 65's Medication Administration Record (MAR) indicated blood sugar check and Humalog (Insulin Lispro) administration on 1/6/25 before lunch at 12:02 P.M, 1/7/25 before lunch at 1:54 P.M., before dinner at 6:01 P.M., on 1/8/25 before breakfast at 9:25 A.M., and before dinner at 5:47 P.M. A concurrent interview and record review of Resident 65's MAR was conducted on 1/10/25 at 2:30 P.M., with Licensed Nurse (LN) 1. LN 1 stated Humalog administration were scheduled before breakfast at 7 A.M., before lunch at 11 A.M., and before dinner at 4 P.M. LN 1 stated Resident 65's MAR indicated that Blood sugar check and Humalog (Insulin Lispro) administration were not done before scheduled meals and within 1 hour of scheduled medication administration on 1/6, 1/7 and 1/8/25. An interview was conducted on 10/10/25 at 5:44 P.M., with LN 1. LN 1 stated the physician order on Humalog (Insulin Lispro) was ordered and timed before meals. LN 1 stated Resident 65's physician order for Humalog was not followed and administered per Resident 65's MAR documentation. LN 1 stated the MAR indicated the Humalog physician order was completed after scheduled meals and were off the scheduled administration schedule. An interview was conducted on 1/10/25 at 6 P.M., with the Director of Nursing (DON). The DON acknowledged that Resident 65's Humalog (Insulin Lispro) administration time was not and should have been implemented before meals as ordered by physician. The DON stated it was important that Insulin medications should be administered timely to prevent adverse effect on the over-all health of the resident. A review of facility's policy and procedure titled, Medication-Administration last revised 1/1/12 indicated, .Policy: Medication will be administered directed by a Licensed Nurse and upon the order of a physician or licensed independent practitioner .

CONCERN (D)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medication error rate for medication pass did not exceed 5 percent. There were 25 medication opportunities. Four medication errors were identified. The error rate was 16%. This failure had the potential to cause harm to the residents. Findings: 1. Resident 38 was admitted to the facility on [DATE] with diagnoses which included diabetes (high blood sugar), peripheral vascular disease (PVD - circulatory condition when blood vessels narrow, spasm, or become blocked) and foot ulcer (wound) per undated admission Record. A review of Resident 38's physician orders indicated the following medication orders: 1. Carvedilol oral tablet 3.125 MG (Carvedilol). Give 1 tablet by mouth every 12 hours for HTN. Hold SBP >90 or DBP <60; 2. Ticagrelor Oral Tablet 90 MG (Ticagrelor). Give 1 tablet by mouth two times a day for antiplatelet; 3. Hydrocodone-Acetaminophen Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen). Give 1 tablet by mouth every 6 hours as need for pain (Severe 7-10). A medication pass observation was conducted on 1/9/25 at 7:50 P.M., with Licensed Nurse (LN) 2. LN 2 prepared Resident 38's 3 medications that included Carvedilol 3.125 MG 1 tablet, Ticagrelor 90 MG 1 tablet and Hydrocodone-Acetaminophen 10-325 MG 1 tablet. LN 2 approached Resident 38 and administered the 3 medications. LN 2 did not identify the Resident 38 with 2 identifiers prior to medication administration. An interview was conducted on 1/9/25 at 8 P.M., with LN 2. LN 2 stated he did not check for resident identifier prior to the administration of the 3 medications. LN 2 stated he should have checked for the resident identifier before administering the medications even though he was familiar with the resident. LN 2 further stated it was important to ensure residents were properly identified during medication administration for the safety of the residents. An interview was conducted on 1/10/25 at 6 P.M., with the Director of Nursing (DON). The DON stated it was important to follow the identification process of residents during medication pass. The DON further stated identifying the right resident would prevent medication errors by not giving any medications to wrong residents. The DON acknowledged that during medication pass, residents should be identified per policy to ensure the safety of the residents. A review of facility's policy and procedure titled, Medication-Administration last revised 1/1/12 indicated, Purpose: To ensure the accurate administration of medications for residents in the Facility .Procedure: I. Administration of Medications: .D. Medications must be given to the resident by the Licensed Nurse preparing the medication. i. The licensed Nurse will verify the resident's identity before administering the medication . 2. Resident 13 was admitted to the facility on [DATE] with diagnoses which included dementia (a decline in mental abilities that affects thinking, memory, and behavior), hemiplegia (paralysis of one side of the body), and urinary retention (unable to empty urine in bladder) per Resident 13's admission Record. A review of Resident 13's physician order indicated the medication order: Artificial Tears Solution 1% (Carboxymethylcellulose Sodium). Instill 1 drop in both eyes three times a day for DM eyes. A medication pass was conducted on 1/10/25 at 3:11 P.M. with LN 3. LN 3 prepared Resident 13's medication that included Artificial Tear Solution 1%. LN 3 approached Resident 13 and administered the medication. LN 3 did not identify Resident 13 with 2 identifiers prior to medication administration. An interview was conducted on 1/10/25 at 3:15 P.M. with LN 3. LN 3 stated she did not identify the resident by asking for 2 identifiers. LN 3 stated she identified Resident 13 by calling for his name and was familiar with the resident. LN 3 stated she should have used the identifiers per policy to prevent medication administration error. An interview was conducted on 1/10/25 at 6 P.M., with the Director of Nursing (DON). The DON stated it was important to follow the identification process of residents during medication pass. The DON further stated identifying the right resident would prevent medication errors by not giving any medications to wrong residents. The DON acknowledged that during medication pass, residents should be identified per policy to ensure the safety of the residents. A review of facility's policy and procedure titled, Medication-Administration last revised 1/1/12 indicated, Purpose: To ensure the accurate administration of medications for residents in the Facility .Procedure: I. Administration of Medications: .D. Medications must be given to the resident by the Licensed Nurse preparing the medication. i. The licensed Nurse will verify the resident's identity before administering the medication .

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 13 was admitted to the facility on [DATE] with diagnoses which included dementia (a decline in mental abilities that affects thinking, memory, and behavior), hemiplegia (paralysis of one side of the body), and urinary retention (unable to empty urine in bladder) per Resident 13's admission Record. An observation was conducted on 1/9/25 at 9:18 A.M., with Resident 13. Resident 13 was observed on a wheelchair in the hallway. Resident 13 had a urinary catheter bag attached to a wheelchair and was touching the floor. A concurrent observation and interview were conducted on 1/9/25 at 9:21 A.M., with the Director of Nursing (DON). The DON stated Resident 13's urinary catheter bag was touching the floor. The DON further stated it was important that the urinary catheter bag does not touch the floor to prevent contamination and the spread of infection. A review of facility's policy and procedure titled, Care of Catheter last revised 6/10/21 indicated, Procedure: .IV Catheter Insertion: .D. The catheter and collecting bag or spigot will be anchored to not touch the floor . Based on observation, interview and record review, the facility failed to ensure infection control procedures were maintained in the facility when: 1) A water reservoir tank was observed to be leaking and with greenish black substance. 2) A suprapubic catheter (a tube inserted into the bladder through a cut in the tummy to drain urine from the bladder) bag and dignity bag (a bag used to cover and conceal contents inside), was lying on the floor for one of three residents reviewed for urinary catheter care (Resident 13). These failures had the potential for the spread of infection. Findings : 1) On 1/10/25 at 9:20 A.M., a tour of the facility with the Infection Preventionist (IP) was conducted. A 550-gallon water reservoir tank was observed just outside the kitchen. The water reservoir tank was observed to be with water leaking and with greenish black substance surrounding the opening of the faucet. The opening of the faucet was not covered. On 1/10/25 at 9:25 A.M., an interview with IP was conducted. IP stated the water reservoir tank should had been regularly inspected and checked for leaking but were not done. IP acknowledged the greenish black substance surrounding the opening of the faucet were molds. IP stated the water inside the water reservoir is not usable and it's an infection control issue. On 1/10/25 at 9:35 A.M., an interview with the Maintenance Supervisor (MS) was conducted. MS stated he should have checked the water reservoir tank for leaking and molds, but was not able to. MS stated leaking water can cause molds and its an infection control issue . On 1/10/25 at 5:30 PM , an interview with the Director of Nursing (DON) was conducted. DON stated the water reservoir tank should had been regularly inspected for water leaking and molds. DON acknowledged water leaks and molds are a potential cause of water borne pathogens and infections. Per the facility's policy and procedure (P&P) titled, Water management Program, Infection Control Manual revised June 2017, the P&P indicated, Policy . The facility will develop and maintain a water management program to reduce .and other waterborne pathogen growth and potential spread in the facility .

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview and record review, the facility failed to store foods under sanitary conditions when eight loaves of bread with use by labels (date when food should be consumed) were not discarded. This failure had the potential to cause food contamination and spread food-borne illness (illness resulting from contaminated food) in a population of 72 residents. Findings: During a tour of the kitchen with the Dietary Supervisor (DS) on 1/7/25 at 10:04 A.M., Eight loaves of bread were observed labeled with a use by date of 1/6/25. During an interview with the DS on 1/10/25 at 10:15 A.M., the DS stated the eight loaves of bread labeled with use by 1/6/25 should have been discarded either a day before the use by date or on the day of use by. The DS further stated, facility residents may get affected with food borne illness when they consume food pass the use by date. During an interview with the Registered Dietitian (RD) on 1/10/25 at 10:20 A.M. The RD stated bread with use by labels should be thrown away a day or on the day of the use by date. The RD further stated, the eight loaves of bread observed on 1/7/25 should have been discarded on either 1/5/25 or 1/6/25. Review of the Food and Drug Administration (FDA - a US government agency that ensures safety of food) 2022 indicated, 3-501.18 Ready to Eat, Disposition (A) A food shall be discarded if it . (3) Is inappropriately marked with a date or exceeds a temperature and time

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0911 (Tag F0911)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assure that resident rooms housed no more than four residents. Two rooms had the potential to accommodate five residents in each room (rooms [ROOM NUMBERS]). Seven rooms had the potential to accommodate six residents in each room (Rooms 2, 3, 4, 5, 13, 15, and 18). As a result, the potential existed to impact resident care and quality of life. Finding: On 1/7/25 through 1/10/25, observations were conducted during the course of the annual recertification survey at the facility. Additionally, interviews and records reviews were conducted. There were no observed quality of care or quality of life concerns related the number of residents in the rooms. A continuance of the waiver (variation) from the requirements of 42 CFR section 483.70(d)(1)(i) as granted pursuant to a letter from the Centers for Medicare and Medicaid Services (CMS), with CMS Certification Number: 555557, allowing more than four residents per room, is hereby recommended. This recommendation is also made with the expectation that the facility will obtain a timely renewal of the current waiver (variation) granted by CMS as reflected by CMS Certification Number: 555557 letter to the facility from CMS.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0912 (Tag F0912)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assure that resident rooms measured at least 80 square feet per resident in resident room [ROOM NUMBER]. As a result, the potential existed to impact resident care and quality of life. Findings: On 1/7/25 through 1/10/25, observations were conducted during the course of the annual recertification survey at the facility. The facility had one multiple resident room (room [ROOM NUMBER]) which did not meet the minimum 80 square feet per resident. room [ROOM NUMBER] measured 479 square feet and had the potential to house six residents. The allocated space for each resident would measure 79.83 square feet. The five residents occupying the room had no complaints. There were no observed quality of care or quality of life concerns that negatively impacted the residents residing in the identified room. A continuance of the waiver (variation) from the requirements of Code 42 of the Federal Regulations (CFR) section 483.70(d)(1)(ii) as granted pursuant to a letter from the Centers for Medicare and Medicaid Services (CMS), with CMS Certification Number: 555557, allowing less than 80 square feet per resident per room per room, is hereby recommended. This recommendation is also made with the expectation that the facility will obtain a timely renewal of the current waiver (variation) granted by CMS as reflected in the CMS Certification Number: 555557 letter to the facility from CMS.

Dec 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews, the facility failed to provide two-person physical assistance with transferring for one of one resident (Resident 1) when Resident 1 was transferred from bed to the Hoyer lift by a staff alone. This failure had the potential to result in harm or even death. Findings: The department received a facility reported incident on 12/16/2024. It was reported that, his (Resident 1) amputee was caught during a weight measuring procedure, skin tear occurred and bleeding. A record review of the facility's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that include acquired absence of left leg above the knee , and difficulty walking , not elsewhere classified. A joint observation and interview on 12/17/2024 at 11:40 A.M., with Resident 1 was conducted. Resident 1 had a bandage on his left leg s/p left above the knee amputation. Resident 1 stated the treatment nurse (TXN) last Sunday told him there was bleeding on his left leg. Resident 1 stated he told the TXN he had discomfort on the sling that was used when he was weighed by the staff. Resident 1 further stated he thought it was from that incident that caused the skin tear. An interview on 12/17/2024 at 4:13 P.M., with the RNA (restorative nursing assistant ) was conducted. The RNA stated she was alone when she did the transfer of resident 1 from his bed to the Hoyer lift when she weighed Resident 1. The RNA stated it was important to have two people with transfers of any resident in the facility to ensure safety and prevent accidents and falls. An interview on 12/18/2024 at 10:10 A.M., with TXN was conducted. The TXN stated she was called by Resident 1's CNA ( certified nursing assistant ) to his room and showed her the skin tear on Resident 1's left leg. The TXN asked Resident 1 what had happened, and Resident 1 stated he was not sure, but the sling caused him a bit of discomfort when he was weighed. The TXN stated with Hoyer lift transfers it was to her knowledge that the facility required two-person physical assistance to ensure safety and prevent accidents and falls. A record review of Resident 1's Minimum Data Set (MDS-a federally mandated assessment tool) dated 12/13/24, indicated a BIMS (brief interview for mental status) score of 14 which meant Resident 1's cognition was intact. A record review of Resident 1's MDS dated [DATE] section gg indicated Resident 1 was dependent for transfers and requires substantial maximum assistance with his trunk and limbs use. A record review of resident 1's physician orders dated 12/6/24 indicated Resident 1 was partial weight bearing. A record review of Resident 1's care plan indicated Resident 1 had limited physical mobility due to his left above the knee amputation and was dependent with two staff for transfers and ambulation. An interview on 12/18/2024 at 8:37 A.M, with the Director of Nursing (DON) was conducted. The DON stated it was important to have two person transfers with Hoyer lifts or any mechanical lift to prevent complications such as accidents and falls and ensure resident safety. A review of the facility's policy on total mechanical lift indicated, .111. at least two people are present while resident is being transferred with the mechanical lift .

Oct 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a care plan (a document providing a way of communication among facility staff) was revised for one of two residents (Resident 1) when Resident 1 ' s care plan did not reflect that he had an inappropriate behavior toward a female resident. This failure had the potential for Resident 1 ' s inappropriate behavior to continue. Findings: A review of Resident 1 ' s admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including dementia (a condition that causes memory loss and changes in behavior). An interview was conducted with Certified Nursing Assistant (CNA) 1 on 10/11/24 at 12:12 P.M. CNA 1 stated Resident 1 had been seen placing his hand on female residents ' arm or thigh. CNA 1 stated it seemed like a friendly touch, but others may think it was inappropriate. An interview was conducted with Licensed Nurse (LN) 2 on 10/11/24 at 2:40 P.M. LN 2 stated Resident 1 had a history of sitting next to female residents to help them eat or to touch their arm. LN 2 stated they would redirect Resident 1 or move Resident 1 away from the female resident, but he would become aggressive with the staff. A review of Resident 1 ' s progress notes was conducted on 10/11/24. A progress note dated 9/30/24 at 2:34 P.M., indicated Resident 1 had an interaction with two female residents and touched them on their legs. One of the female residents informed a staff member. A progress note dated 10/7/24 at 1:28 A.M., indicated Resident 1 tends to latch onto female residents and professes his love to them. A concurrent interview and record review was conducted with the Director of Nursing (DON) on 10/11/24 at 2:51 P.M. The DON stated there was no care plan about Resident 1 ' s inappropriate behavior of unwelcome touching of female residents. The DON stated it was important to have a care plan because it would alert the staff of the behavior that needed to be stopped and what interventions to implement. A review of the facility ' s policy titled Comprehensive Person-Centered Care Planning, revised on 8/24/23, indicated .the comprehensive care plan will also be reviewed and revised at the following times .to address change in behavior .

Feb 2024 29 deficiencies 2 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Quality of Care (Tag F0684)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the necessary care and treatment for one of five residents (Resident 51) reviewed for diabetes (a chronic [long lasting] health condition that affects how your body turns food into energy) care when: • Resident 51's physician was not notified of the resident's hypoglycemic (low blood sugar) episodes. • Resident 51's blood sugar was not monitored in accordance with the standard of practice (scope and authority related to a specific activity by defining who can do what activity, with what level of supervision and when) for residents with diabetes. • Resident 51 received multiple oral diabetic medications. As a result, Resident 51's became unresponsive and was sent to the hospital on 1/31/24. Resident 51 was diagnosed with sulfonylurea (medication use for the treatment of non-insulin dependent diabetes mellitus [DM - a condition in which the body has trouble controlling blood sugar] which can cause significant hypoglycemia [low blood sugar] after the ingestion of one or two pills), polypharmacy (simultaneous use of multiple drugs for the same ailment or condition) and urinary tract infection (an infection in the urinary system). Findings: A record review of Resident 51's undated admission Record indicated that Resident 51 was admitted to the facility on [DATE] with a diagnosis that included diabetes mellitus. A review of Resident 51's minimum data set (MDS- an assessment tool), dated 1/17/24 indicated a BIMS (brief interview for mental status - a tool to screen and identify the cognitive condition of residents) score of 1.0 which indicated severe cognitive impairment. A record review of Resident 51's physician orders, dated January 2024 indicated the following: • Glimepiride (a diabetic medication) 4 milligrams (mg), 1 tablet by mouth daily for DM ordered on 1/10/24 at 10:14 P.M. • Insulin glargine (a diabetic medication) inject 10 units subcutaneous (under the skin) at bedtime for DM ordered on 1/10/24 at 10:14 P.M. • Sitagliptin (a diabetic medication) 50 mg 1 tablet by mouth daily for DM ordered on 1/10/24 at 10:14 P.M. • Pioglitazone (a diabetic medication) 50 mg, 1 tablet by mouth daily for DM ordered on 1/10/24 at 10:14 P.M. An interview on 2/15/24 at 7:25 A.M., with licensed nurse (LN) LN 35 was conducted. LN 35 stated Resident 51's blood sugar needed to be monitored at least twice a day or more frequently due to the resident's history of low blood sugar. A record review of Resident 51's hospital history and physical, written by a physician, dated 2/8/24, indicated, I believe that polypharmacy is playing a significant role in the patient becoming hypoglycemic. Per the same history and physical, Resident 51 was diagnosed with sulfonylurea induced hypoglycemia (severe low blood sugar) and urinary tract infection. An interview with Resident 51's medical doctor (MD) 1 was conducted on 2/15/24 at 7:45 A.M. MD 1 stated the use of multiple diabetic medications without monitoring the resident's blood sugar could lead to hypoglycemia. MD 1 stated that residents diagnosed with DM should have their blood sugar monitored more than twice daily. MD 1 stated the nurses should have notified him of Resident 51's low blood sugar. On 2/15/24 at 7:52 AM., an interview with LN 31 was conducted. LN 31 stated Resident 51 was sent out to the hospital early this morning for a low blood sugar. LN 31 stated Resident 51 will be returning to the facility today (2/15/24), as reported by the hospital emergency room (ER) nurse. LN 31 stated according to the ER nurse, the ER physician recommended to stop all of Resident 51's diabetic oral medications until reviewed by Resident 51's physician. An interview with the Pharmacy Consultant (PC) was conducted on 2/15/24 at 8:06 A.M. The PC stated that Resident 51's blood sugar should have been checked twice daily or more since Resident 51 was on multiple diabetic medications. An interview and joint record review of Resident 51's January 2024 medication administration record (MAR)and progress notes was conducted with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 2/20/24 at 2:21 P.M. Resident 51's MAR indicated the following blood sugar results: • On 1/11/2024 at 9:00 P.M., blood sugar was 56. • On 1/20/2024 at 9:00 P.M., blood sugar was 60. • On 1/21/2024 at 9:00 P.M., blood sugar was 65. • On 1/22/2024 at 9:00 P.M., blood sugar was blank • On 1/24/2024 at 9:00 P.M., blood sugar was blank. • On 1/29/2024 at 9:00 P.M., blood sugar was 41. • On 1/30/2024 at 9:00 P. M.,blood sugar was 48. • On 1/31/2024 at 9:00 P.M., blood sugar was 43. Resident 51's nursing progress notes indicated the following: • On 1/11/24 at 9:51 P.M., Resident 51's blood sugar was 56. The nurse initiated the facility's hypoglycemia protocol (interventions to reverse low blood sugar). The DON stated there was no documented evidence that Resident 51's M.D., was notified regarding the resident's low blood sugar result. The DON stated there was no documented evidence that Resident 51's blood sugar was reassessed. • On 1/20/24 at 8:10 P.M., Resident 51's blood sugar was 60. The nurse initiated the facility's hypoglycemia protocol. The DON stated there was no documented evidence that Resident 51's M.D., was notified regarding the resident's low blood sugar result. The DON stated there was no documented evidence that Resident 51's blood sugar was reassessed. • On 1/21/24 at 8:45 P.M., Resident 51's blood sugar was 65. The nurse initiated the facility's hypoglycemia protocol. The DON stated there was no documented evidence that Resident 51's M.D., was notified regarding the resident's low blood sugar result. The DON stated there was no documented evidence that Resident 51's blood sugar was reassessed. • On 1/22/24 at 10 P.M., the DON stated Resident 51's blood sugar result was not documented on the MAR. According to the progress notes, Insulin glargine 10 units at bedtime held d/t (due to) BS (blood sugar) results outside of normal of BS parameter less than 60. The DON stated there was no documented evidence that Resident 51's M.D., was notified regarding the resident's low blood sugar result. The DON stated there was no documented evidence that Resident 51's blood sugar was reassessed. • On 1/24/24 at 9 P.M., the DON stated Resident 51's blood sugar was not documented on the MAR and progress notes. • On 1/29/24 at 9:48 P.M., Resident 51's blood sugar was 41. The DON stated there was no documented evidence that Resident 51's MD was notified regarding the resident's low blood sugar. The DON stated there was no documented evidence that Resident 51's blood sugar was reassessed. • On 1/30/24 at 9:44 P.M., Resident 51's blood sugar was 48. The DON stated there was no documented evidence that Resident 51's MD was notified regarding the resident's low blood sugar. The DON stated there was no documented evidence that Resident 51's blood sugar was reassessed. • On 1/31/24 at 5:29 P.M., Resident 51's son came to the facility and found Resident 51 unresponsive. Resident 51's blood sugar result was 43. The nurse called 911 and transferred Resident 51 to the hospital. An interview with LN 34 was conducted on 2/20/24 at 11:24 A.M., LN 34 stated that Resident 51's MD should have been notified of Resident 51's low blood sugars and documented in the progress notes. LN 34 stated if the care was not documented, then the care was not done. An interview and joint record review was conducted with the DON and ADON on 2/20/24 at 2:21 P.M. The DON stated when caring for a resident experiencing a hypoglycemia episode, the nurses should monitor the residents blood sugar, conduct a pre and post assessment of the residents condition, follow the facility's hypoglycemia protocol (give half (½) cup of orange juice , ½ cup of soft drinks, 1 cup of milk, ½ cup of apple juice, or other item with 15-30 grams of carbohydrates- calories and to continue offering the resident carbohydrates until blood sugar is above 70), notify MD and document the incident in the resident's medical record. The DON stated all the above were important to ensure that the resident care needs were addressed. The ADON stated she should have communicated Resident 51's multiple diabetic medications when the resident was first admitted to the facility. The ADON stated medication review should have been done due to Resident 51's multiple diabetic medications to avoid hypoglycemia episodes. A review of the facility's undated policy and procedure titled, Hypoglycemia was conducted. The policy indicated, Procedure . II- Treatment of hypoglycemia . B. Severe Hypoglycemia I. Notify the attending physician immediately . VI. Monitor resident closely, checking fingerstick and vitals every 15 minutes until stable or transferred. VII. document all interventions as ordered and implemented .

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 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 prevent a further decline of a pressure ulcer (skin damaged by lack of movement due to staying in a position for too long), for one of six residents (Resident 35) reviewed for pressure ulcer. As a result, Resident 35's sacral (tailbone) pressure ulcer worsened from a stage II (shallow wound like a blister or abrasion) to a stage III (full thickness tissue injury; open wound that goes deeper into the tissue beneath). Findings: A review of Resident 35's admission Record indicated Resident 35 was admitted to the facility on [DATE] with diagnoses which included a history of hemiplegia (total paralysis of one side of the body), hemiparesis (refers to partial paralysis, indicating weakness rather than complete loss of movement), cerebral infarction (stroke), and diabetes mellitus (high blood sugar). A record review of Resident 35's Minimum Data Set (MDS- assessment tool) dated 12/31/23, indicated Resident 35's Brief Interview for Mental Status (BIMS- zero to seven [0-7] suggested severe cognitive [thinking process] impairment) was zero. In addition, the MDS indicated that Resident 35 was at risk for developing pressure ulcers and was dependent on staff for bed mobility. A review of Resident 35's care plan was conducted. There was no care plan developed related to Resident 35's stage II pressure ulcer that was identified on 9/17/23. A record review of Resident 35's Change of Condition assessment dated [DATE] indicated Resident 35 developed a stage II pressure ulcer to the sacral that measured .0.4 (L-length) x0.5 (W-width) x0.1 (D-depth) [wounds measured in centimeters] to sacrum . A record review of Resident 35's Change of Condition assessment dated [DATE], indicated Resident 35 developed a stage III pressure ulcer to the sacrum that measured .3.5(L)x1.0(W) x0.3 (D) to sacrum . A record review of Resident 35's progress note, dated 11/7/23 was conducted. This note indicated, Chief Complaint .Wound Care Visit . an assessment was completed for a stage 3 [stage III] pressure ulcer to the sacrum and noted on 10/24/23-Pressure ulcer now st. 3 [stage III] .10/31/23-Pt [patient] wound not much improvement, continue with same tx [treatment] . A joint observation and interview were conducted on 2/15/24 at 8:20 AM, with CNA 23 in Resident 35's room. CNA 23 stated they did not have evidence of documentation that Resident 35 was turned and repositioned. CNA 23 stated Resident 35 should had been repositioned more frequently due to Resident 35's pressure ulcer. Observations of Resident 35 were conducted on the following dates and times: On 2/12/24 at 8 A.M., 9:10 A.M, 11:01 A.M., 2:21 P.M., and 5:24 P.M., Resident 35 was lying upright in bed, directly on her sacrum (referred to the tailbone), on an air pressure pad (APP- alternating pressure pad/mattress that alleviates pressure). A wedge pillow (triangle pillow used to redistribute body weight; helpful for positioning to prevent pressure sores/injuries) was on the bed, but not used. On 2/13/24 at 9 A.M., 11:30 A.M, 1:45 P.M., 3:30 P.M., and 5:45 P.M., Resident 35 was lying upright in bed, directly on her sacrum, on an APP. A wedge pillow was on the bed, but not used. On 2/14/24 at 7:10 A.M., Resident 35 was lying upright in bed. A wedge pillow was positioned on the right side of her upper back with Resident 35's sacrum directly on the APP. On 2/14/24 at 9:10 A.M., Resident 35 was lying upright in bed, directly on her sacrum, on an APP. A wedge pillow was on the bed, but not used. On 2/14/24 at 10:21 A.M., Resident 35 was lying upright in bed. A wedge pillow was positioned on the left side of her upper back with Resident 35's sacrum directly on the APP. On 2/14/24 at 12:21 P.M., Resident 35 was lying upright in bed. A wedge pillow was positioned on the right side of her upper back with Resident 35's sacrum directly on the APP. On 2/14/24 at 2:24 P.M., Resident 35 was lying upright in bed on an APP, directly on her sacrum. A wedge pillow was on the bed, but not used. On 2/15/24 at 7:30 A.M., Resident 35 was lying in a partially upright position on an APP with her sacrum directly on the bed. A wedge pillow was positioned on the right side of her upper back. On 2/20/24 at 7:55 A.M., 10 A.M., and 12:25 P.M., Resident 35 was lying in a partially upright position on an APP, with her sacrum directly on the bed. A wedge pillow was positioned on the right side of her upper back. On 2/20/24 3:24 P.M., Resident 35 was lying in an upright position on an APP, slightly turned, with her sacrum directly on the bed. A wedge pillow was positioned on the left side of her upper back. A joint observation and interview were conducted on 2/13/24 at 9:39 A.M., with licensed nurse (LN) 31 in Resident 35's room. A wedge pillow was on the bed, but not used. LN 31 stated Resident 35's stage III pressure ulcer was slightly bigger and measured 3.7 (L) x 1.6 (W) x 0.4 (D). LN 31 stated she could not find a care plan related to Resident's 35 stage II pressure ulcer that was identified on 9/17/23. LN 31 stated, there was no documentation to show that Resident 35 was repositioned to address the Resident's pressure ulcer. An interview and record review was conducted on 2/13/24 at 1:04 P.M., with LN 31. LN 31 stated Resident 35 was at high risk for developing pressure ulcers due to bowel and bladder (B/B) incontinence (loss of bladder control) and dependence on staff for repositioning. LN 31 also stated it was important for Resident 35 to be repositioned to avoid the development of new pressure ulcers as well as decline of existing pressure ulcers. An interview with the Director of Nursing (DON) was conducted on 2/20/24 at 8:52 A.M . The DON stated there was no evidence of documentation that Resident 35 was turned and repositioned frequently after a stage II pressure ulcer that was identified on 9/17/23. The DON acknowledged Resident 35's pressure ulcer deteriorated from stage II to stage III on 11/7/23, almost 2 months later. The DON stated staff should have been turning Resident 35 more frequently to prevent further decline of Resident 35's pressure ulcer. A review of the facility's policy titled, Pressure Injury Prevention revised August 12, 2016, was conducted. This policy indicated .The Nursing staff will implement interventions identified in the Care Plan on the individual risk factors . B. Repositioning and Turning . Other Risk Factors to consider A. Co-morbidities as Diabetes Mellitus, End Stage Renal Disease, Cancer, Vascular Disease, CVA [stroke], prior history of Pressure Injuries .C. Cognitive impairment that affects the communication and active participation of the resident in the plan of care . A review on the facility's undated lesson plan titled, Pressure Injury Management was conducted. The lesson plan indicated, Positioning Guidelines-Prevention . turn or reposition the resident's body at least every two hours . RULE OF 30 DEGREES Position the resident's body to avoid laying over existing ulcer or wound HOB [head of bed] <30 degrees. Note: The use of pressure relieving surfaces does not replace turning and repositioning .

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility was unaware of an Advanced Directive (a legal document which lists preferences for life-saving measures) related to a resident wishes for resuscitative efforts (life-saving measures) for one of three residents (Resident 36), reviewed for Advanced Directives. As a result, there was the potential Resident 36's wishes for resuscitative efforts would not be honored. Findings: Resident 36 was admitted to the facility on [DATE], with diagnoses of Parkinson's disease (a progressive neurological disease), per the facility's admission Record. On [DATE], Resident 36's clinical record was reviewed. According to the physician's order dated [DATE], CPR (cardio-pulmonary resuscitation, a life-saving measure) was listed, indicating if Resident 36 were to go into cardiac arrest (when the heart stops beating), the staff were to perform full resuscitation measures. There was no documented evidence a Physician's Order for Life Sustaining Treatment (POLST) was in the clinical record. According to Resident 36's electronic record, an Advanced Directive, signed and dated [DATE], had been scanned into the Documents section of the electronic record on [DATE]. The Advanced Directive indicated, Do not resuscitate, no life supporting measures. According to the facility's most recent Multidisciplinary Care Conference (a quarterly meeting when all department heads meet to discuss the resident's care and to identify potential issues), dated [DATE], .Section 9. Resident/Family. Care level reviewed: boxes labeled DNH (do not hospitalize), DNR (Do not resuscitate), Undecided, and Full resuscitation were blank and unmarked . On [DATE] at 1:16 P.M., and observation and interview was conducted of Resident 36 in the physical therapy department. Resident 36 was dressed, standing and doing independent arm exercises. Resident 36 was asked what her resuscitative wishes were. Resident 36 stated they asked her that in the hospital and she told them she did not want CPR (cardiopulmonary resuscitation) performed on her. Resident 36 stated, I just want them to make me comfortable and to let me go. Resident 36 stated no one at the facility had asked her what her wishes were. On [DATE] at 8:38 A.M., an interview and record review was conducted with the ADON. The ADON stated if there was no POLST in the paper chart, the staff would check the physician's order and do what was listed in the physician's order. The ADON stated if there was no POLST or physician's order, staff would automatically perform CPR. The ADON was unaware an Advanced Directive had been scanned into Resident 36's electronic chart, listing the Resident's wishes as, Do Not Resuscitate. The ADON stated by missing the resident's Advanced Directive, there was the potential for Resident 36's wishes to not be followed and it could also be a legal issue. The ADON stated this should have been captured and communicated and it was not. The ADON stated it was also missed during their quarterly Multidisciplinary Care Conference. On [DATE] at 8:34 A.M., an interview was conducted with the DON. The DON stated she expected all resident wishes for Advanced Directive and POLST to be recognized and honored. According to the facility's policy, titled Advanced Directive, dated [DATE], .The Facility will respect a resident's Advanced Directive and will comply with the resident's wishes expressed in an advanced directive. According to the facility's policy, titled Physician Orders for Life-Sustaining Treatment (POLST), dated [DATE], .VII. Whenever possible, ensure that the Advanced Directive and the POLST form are consistent .V .C. If the resident has an Advanced Healthcare Directive, copies of it may be attached to the current original POLST in the front of the medical record .

CONCERN (D)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to provide a safe, homelike environment when: 1. An exterior resident room door for one of 25 rooms (room A) had peeling paint, and 2. An exterior shower room door frame for one of two shower rooms (Station B), had holes and exposed drywall, along with two protruding nails. As a result, there was the potential for residents to experience diminished self-worth and the possibility of injury from the environment hazards (peeling paint and protruding nails). Findings: 1. On 4/9/24 at 8:24 A.M., an observation was conducted of room A's exterior door leading to the hallway. Room A housed four residents, two of whom were cognitively impaired (Residents 49 and 154) The exterior door had missing and peeling white paint, with an estimated size of 14 inches horizontally and nine inches vertically. On 4/9/24 at 8:56 A.M., an observation and interview was conducted with the Director of Maintenance (DM) of room A's exterior door. The DM stated he received work requests daily from staff, requesting repairs. The DM stated he repaired things as the requests were submitted by staff. The DM stated he did not keep a maintenance log of future repairs needed, stating he fixed things as they were identified and requested. The DM stated he did not have a work request for the exterior room door (Room A), and stated he was unaware the paint was peeling. The DM viewed room A's door and stated, It does not look good and needs repair. On 4/9/24 at 9:05 A.M. an observation and interview was conducted with the Administration (ADM) of room A's exterior door. The ADM stated the paint on the door was peeling and confused residents could grab and ingest the paint chips. The ADM stated the door looked bad and should be fixed. 2. On 4/9/24 at 8:27 A.M., an observation was conducted of the exterior shower room wall in Station B. Multiple holes and gaps were present on both sides of the wall next to the door frame. Two nails were observed protruding on the right side of the exterior door frame. One nail was approximately six feet above the floor and the second nail was approximately three feet above the floor. On 4/9/24 at 8:59 A.M., an observation and interview was conducted with the Director of Maintenance (DM) of Station B's exterior shower door frame. The DM stated new shower door frames had been installed by an outside company in approximately September 2023. The DM stated the outside company was supposed to return to the facility to repair the walls, but they had not. The DM stated he had not called the outside company to inquire when they would be back to fix the walls. The DM stated the walls around the new shower door frame looked bad, with the exposed holes and drywall. The DM removed the nail at the six-foot level with his pliers, and stated he would remove the second lower nail as well. The DM stated the protruding nails could have placed residents at risk of being injured . On 4/9/24 at 9:06 A.M., an observation and interview of Station B's exterior shower door frame was conducted with the ADM. The ADM stated the shower wall looked bad and did not present a homelike environment to the residents. The ADM stated residents and staff could have been injured if they came into contact with the protruding nails. The facility provided an undated policy, titled Resident Rooms and Environment, which indicated, .1. Facility staff aim to create a personalized, homelike atmosphere, paying close attention to the following: A. Cleanliness and order; .

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to capture and transmit accurate MDS (a clinical assessment tool) information to the Centers for Medicare and Medicaid Services (CMS-a Federal agency), for two of five residents (Resident 3 and Resident 36) reviewed for Resident Assessment. This failure had the potential to affect the care and services provided to Resident 3 and Resident 36. Findings: 1. Resident 3 was re-admitted to the facility on [DATE], with diagnoses which include dementia (progressive memory loss) and schizoaffective disorder, (a mental disorder marked by schizophrenia symptoms such as hallucinations and delusions), per the facility's admission Records. On [DATE], Resident 3's clinical record was reviewed. The admission MDS, dated [DATE], Section I, did not identify the diagnosis of, Schizophrenia: (i.e. schizoaffective and schizophreniform disorder). On [DATE] at 9:35 A.M., an interview and record review was conducted with MDSN 2. MDSN 2 stated on admission, the MDSN would review the resident's history & physical, physician orders, nurses notes, and the admission assessment to gather information for MDS coding. The MDSN reviewed Resident 3's admitting diagnoses and the triggered active diagnoses in the admission MDS, dated [DATE]. The MDSN stated there was a diagnosis of schizophrenia on the admission Record and it was not listed on the MDS as an active diagnosis. The MDSN stated since the MDS diagnoses was not correct when transmitted, CMS did not have the correct information on Resident 3's current health status and I missed it. The MDSN continued, stated it was important for CMS to know the admitting diagnoses and status of each resident, so they were aware of the current care being provided. 2. Resident 36 was admitted to the facility on [DATE], with a diagnosis of Parkinson's disease (a progressive neurological disease), per the facility's admission Record. On [DATE], Resident 36's clinical record was reviewed. According to the physician's order dated [DATE], CPR (cardio-pulmonary resuscitation) was listed, indicating if Resident 36 were to go into cardiac arrest (when heart stops beating), the staff were to perform full resuscitation (life-saving) measures. According to Resident 36's electronic record, an Advanced Directive, (a legal document listing the resident's wishes for life supporting measures), dated [DATE], was scanned into the Documents electronic section on [DATE], indicating, Do not resuscitate, no life supporting measures. According to the quarterly MDS, dated [DATE], titled Advanced Directive, no choices for life-sustaining treatment was completed. All sections were left blank. On [DATE] at 9:06 A.M., an interview and record review was conducted with MDSN 1. The MDSN 1 stated she routinely checked the resident's records and physician orders when submitting Physician's Orders for life Sustaining Treatment (POLST) and Advanced Directive information to CMS. The MDSN 1 reviewed Resident 36's admission MDS, dated [DATE], and the last quarterly MDS dated [DATE]. The MDSN 1 stated the admission and the quarterly MDS was not completed for Section S, titled California POLST/Advanced Directive. The MDSN 1 reviewed Resident 36's electronic record for an Advanced Directive, stating it was scanned in on [DATE], and she was never informed. The MDSN 1 stated as a result, the POLST and Advanced Directive were not captured. The MDSN 1 stated because it was not captured, CMS and the facility was unaware of what the resident's resuscitative wishes were. On [DATE] at 8:34 A.M., an interview was conducted with the DON. The DON stated she expected an accurate assessment of all residents, because the facility and CMS needed to be aware of the residents wishes for resuscitative efforts. According to the MDS 3.0 Resident Assessment Instrument [NAME], dated [DATE], Resident Assessment Protocols (RAPs) are reviewed following the completion of the MDS portion of the RAI (Resident Assessment Instrument) for comprehensive assessments in order to identify the resident's strengths, problems, and needs. This decision-making process is documented on the Resident Assessment Protocol Summary .The comprehensive RAI is considered complete on the date the RN (registered nurse) Coordinator indicates completion of the RAPs .The quarterly assessment is used to track the resident's status between comprehensive assessments, and to ensure monitoring of critical indicators of the gradual onset of significant changes in resident status .

CONCERN (D)

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review Level 2 (PASARR- a Federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) was completed after a new diagnoses of schizophrenia was made for one of one resident (Resident 3) reviewed for PASARR. As a result, there was potential for Resident 3 to be improperly placed at the facility where necessary services were not available. Findings: 1. Resident 3 was re-admitted to the facility on [DATE] with diagnoses which included dementia (progressive memory loss) and schizoaffective disorder, (a mental disorder that is marked by schizophrenia symptoms such as hallucinations and delusions), per the facility's admission Records. On 2/13/24, Resident 3's clinical record was reviewed. The admission MDS, dated [DATE], Section I, did not include the diagnoses of Schizophrenia (i.e. schizoaffective and schizophreniform disorder). The original PASARR Level 1 was completed as Negative on 9/14/20. On 2/14/24 at 9:35 A.M., an interview and record review was conducted with MDSN 2. MDSN 2 stated on admission, she reviewed the resident's history & physical, physician orders, nurse's notes, and the admission assessment to gather information for MDS coding. The MDSN reviewed Resident 3's admitting diagnoses and the triggered active diagnoses listed in the admission MDS. The MDSN stated there was a diagnosis of schizophrenia on the admission Record and it was not listed on the MDS as an active diagnosis. The MDSN stated since the MDS diagnoses were not correct when transmitted, CMS did not have the correct information on Resident 3's current health status and stated, I missed it. The MDSN 2 continued, stated the original PASARR Level 1 was completed at the hospital, and once she came to their facility, she was later diagnosed with Schizophrenia. The MDSN 2 stated on the re-admission, it should have triggered another PASARR to be completed which would have triggered as, Positive, since she had the diagnoses of schizophrenia. The MDSN 2 stated when a PASARR Level 1 was positive, the State was notified, and someone would come within days to assess the resident. The MDSN 2 stated the assessment was to ensure the resident was appropriate for this setting and to provide outside services to enrich her quality of life, such as classes. The MDSN 2 stated since she missed the diagnoses of schizophrenia, it did not prompt her to complete an additional PASARR Level One, which was mandated. The MDSN 2 stated because this was completely missed, The Centers for Medicare and Medicaid Services (CMS, a Federal agency) and the State were unaware of the current care provided and unable to determine if this was appropriate for her diagnoses. On 2/15/24 at 8:34 A.M., an interview was conducted with the DON. The DON stated MDS assessments needed to be accurate on admission to ensure the residents were getting the care and services they required. On 2/27/24 at 12:46 P.M., the Admin emailed a copy of Resident 3's PASARR Level 1, completed on 10/12/22, listing a Positive screening for, Suspected Mental Illness. The Admin could not provide any documented proof a PASARR Level 2 was completed by the State, or that the facility followed up with the State to ensure a PASARR Level 2 was completed in a timely manner. According to the facility's policy, titled Pre-admission Screening Resident Review (PASARR), dated January 2012, .1V. Level 1 screening for Residents who experience a significant change in condition: A. If any facility resident experiences a significant change in condition in health status that raises the possibility of a change in the residents MI/MR [mental illness/mental retardation], status or physical status, the Facility must compete a new PASARR 1 Screening Document. B. If the Level I screening indicates the need for a Level 2 screening, contact the appropriate State agency for a Level 2 determination .

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to update and revise individualized care plans for two of 18 residents sampled (Residents 19, 21). These failures had the potential for the residents to not receive the care and services needed to preserve optimal health status and prevent further decline. Findings: 1. Resident 19 was admitted to the facility on [DATE] with diagnoses to include dementia (a loss of memory, language, problem-solving and other thinking abilities that interfere with daily life), per a facility admission Record. On 2/12/24 at 11:46 A.M., Resident 19 was observed in his room, in bed. Resident 19's mattress had bolsters on each side, approximately four inches high, four inches wide, and 36 long. The bolsters were attached to the mattress, and were covered with a fitted sheet. In addition, fall mats were on the floor on either side of the bed. Resident 19 indicated, using gestures, that the bolsters were to prevent him from falling. On 2/12/24 at 11:55 A.M., an interview was conducted with LN 1. LN 1 stated she was not sure what the bolsters were for, but she was aware Resident 19 had fallen in the past and she thought the bolsters were placed to prevent the resident from falling out of bed. LN 1 stated the care plan would be her resource for information on the bolsters. On 2/20/24 a record review was conducted. Resident 19's MDS (an assessment tool), dated 1/1/24, listed a cognitive score of 3, indicating severely impaired cognition. The MDS indicated he had fallen two times or more since admission, with no injury sustained. Resident 19's care plan, initiated 9/21/23, indicated Resident 19 was at high risk for falls. The care plan did not include the bolsters. On 2/20/24 at 4 P.M., a concurrent interview and record review was conducted with the ADON. Per the ADON, the care plan did not include the bolsters. The ADON stated staff should be aware of Resident 19s fall history. The ADON stated the care plan should have been updated to include the use of the bolsters so staff had a clear understanding of the plan to protect the resident. Per the ADON, The bolsters are for safety, but it should be care planned. 2. Resident 21 was admitted to the facility on [DATE] with diagnoses to include dementia (the loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life) and protein-calorie malnutrition (a type of undernutrition that occurs when not enough protein and calories were eaten), per the facility's admission Record. On 2/12/24 at 12:40 P.M., an observation of Resident 21 was conducted during lunch. Resident 21 had consumed less than half of the foods provided on the tray. Resident 21 was wheeling away from the tray, and indicated he did not want more food by waving his hand at it as he wheeled away. On 2/13/24 at 8:32 A.M., an observation of Resident 21 was conducted during breakfast. Resident 21 had eaten less than half of the foods provided on his breakfast tray. Resident 21 stated he was finished and did not want more food. On 2/20/24, a record review was conducted. On 11/29/23, Resident 21s MDS (an assessment tool), listed cognitive score was 12, indicating moderately impaired. The nutrition section indicated Resident 21 had weight loss of 5% or greater of his body weight in the last month, a loss of 10% or greater of his body weight in the last six months, and was not on a prescribed weight loss regimen. On 7/30/23, a care plan for weight loss was initiated. Multiple goals were established, including the resident was to consume >75% of his meals, supplements and snacks. The interventions were to, see RD recommendation 7/28. On 2/20/24 at 11:55 A.M., a telephone interview was conducted with the RD. The RD stated she was familiar with Resident 21. Per the RD, care plans could be implemented by either the RD or the nurse. The RD stated care plans were very important, as they gave a summary of important nutrition interventions for each resident. The RD stated it was not appropriate to reference a Nutrition progress note rather than document the interventions on the care plan. Per the RD, the lack of a care plan could result in further weight loss. On 2/20/24 at 12:26 P.M., a concurrent interview and record review was conducted with the ADON. The ADON reviewed the nutrition care plan and stated interventions should have been revised with specific interventions, rather than referencing the RD note. Per the ADON, the care plan was important to communicate issues that were interdisciplinary, such as weight loss and diet changes. The ADON stated the current nutrition care plans needed to reflect the current nutrition goals for Resident 21, but did not. Per a facility policy, revised November 2018 and titled Comprehensive Person-Centered Care Planning, Purpose: To ensure that a comprehensive person centered care plan is developed for each resident .I. c. The baseline care plan must .include interventions that address his or her needs .IV. a .All goals, objectives, interventions, etc. from the current baseline care plan will be included in the resident's comprehensive care plan. b. Additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident .

CONCERN (D)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a recommendation for diet changes related to weight loss was followed up for one of three residents reviewed for nutrition (Resident 21). This failure had the potential to affect the health and well-being of Resident 21. Findings: Resident 21 was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss) and protein-calorie malnutrition (a type of undernutrition that occurs when not enough protein and calories were eaten), per the facility admission Record. On 2/12/24 at 12:40 P.M., an observation of Resident 21 was conducted during lunch. Resident 21 had consumed less than half of the foods provided on the tray. Resident 21 was wheeling away from the tray, and indicated he did not want more food by waving his hand at it as he wheeled away. Dining room staff offered Resident 21 a nutritional supplement (NS, a drink which provides protein and calories) but Resident 21 refused. On 2/13/24 at 8:32 A.M., an observation of Resident 21 was conducted during breakfast. Resident 21 had eaten less than half of the foods provided on his breakfast tray. Resident 21 stated he was finished and did not want more food. On 2/20/24, a record review was conducted. On 11/29/23, Resident 21s Minimum Data Set (MDS, an assessment tool), Brief Interview for Mental Status (BIMS) score was 12, indicating moderate cognitive impairment. The nutrition section of the MDS indicated Resident 21 had lost 5% or more of his body weight in the last month, or a loss of 10% or more of his body weight in the last six months, and not on a prescribed weight loss regimen. Per the physician orders, dated 11/22/23, Resident 21 was prescribed a carbohydrate controlled diet (CCHO, a diet low in simple sugars, used for diabetes management), with a NS three times each day with meals. On 8/20/23, RD 1 documented Resident 21 had had significant weight loss over the previous four months, calculating a loss of 5% of his body weight over the previous month, a loss of 8.7% body weight over the previous three months, and a loss of 15.3% body weight over the previous four months (since admission). RD 1 recommended the removal of the CCHO diet to allow Resident 19 more choices of foods to encourage improved intake. On 9/29/23, RD 1 recommended reducing the supplements to one a day at breakfast to reduce the risk of supplement fatigue and encourage the intake of whole foods. On 2/20/24 at 11:55 A.M., a telephone interview was conducted with RD 2. RD 2 stated she was familiar with Resident 21. RD 2 stated if she wanted to make diet changes, she would leave a note with her recommendations for the physician to sign, or get a nurse to write a diet order. RD 2 stated she was not aware of RD 1's suggestion to liberalize the CCHO diet, or to reduce the amount of supplements. RD 2 stated she had no knowledge of why the recommendations to change the diet and supplement were not completed. Per RD 2, Weight loss can have dire consequences in this population. On 2/20/24 at 12:26 P.M., a concurrent interview and record review was conducted with the ADON. The ADON stated when a RD made a recommendation, it should be communicated to the nurses. Then the nurse would call the physician to obtain an order. The ADON stated if the physician had said no to the recommendation, the nurse would inform the RD. Per the ADON, she could not speak to why the RD recommendations were not implemented. The ADON stated she did not know who called the physician to request the diet changes, but the changes had not been made. On 2/20/24 at 4:28 P.M., an interview was conducted with Resident 21's physician (MD 2). MD 2 stated neither the RD or a nurse had contacted him about Resident 21's weight loss, or dietary recommendations. MD 2 stated he was not sure Resident 21 was still assigned to him, and stated he had not ordered any labs in awhile to assess nutritional status. MD 2 stated he typically ordered whatever the RD recommended. Per a facility policy, revised June of 2018 and titled Nutritional Status Evaluation Committee, .The weight of residents will be monitored for variance and the Nutritional Status Evaluation Committee .will intervene when appropriate .V. Objectives of the Nutritional Status Evaluation Committee .B. Evaluating changes in diet, food preferences, and increased caloric intake .G. Identifying behaviors in the feeding environment that may be contributing to weight loss .

CONCERN (D)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to date and time enteral tube feedings (a method of delivering nutrition in liquid form into the stomach through a tube), feeding for two of two residents (Resident 49 and Resident 81), reviewed for tube feedings. As a result, there was the potential for Resident 49 and 81 to have complications related to the tube feedings and/or risk for infections. Findings: 1. Resident 49 was admitted to the facility on [DATE], with diagnosis which included hemiplegia (weakness on one side of the body), following cerebral infarction (stroke), affecting the left side and moderate protein-calorie malnutrition, per the facility's admission Record On 2/12/24 at 8:46 A.M., during initial tour, an observation was conducted of Resident 49 in his room. Resident 49 was restless in bed and non-verbal. The head of the bed was elevated at 30 degrees and next to the bed was an enteral pump (a machine that delivers tube feeding formula at a specific rate/per hour to the gastrointestinal tract). The pump was off and hanging above the enteral pump, was a clear plastic bag labeled Jevity 1.5. (a nutritional formula). Inside the clear plastic bag was brown formula remaining, measuring at 550 cubic centimeters (cc) on the bag's measuring line. Next to the formula was another clear bag which contained 525 cc of clear flush solution. The two bags labeled Jevity and flush, were not labeled or dated of when they were first hung or administered. On 2/12/24 at 3:00 P.M., an observation and interview was conducted with LN 11. LN 11 stated Resident 49's tube feeding was hung at 10 P.M., each night at 60 cc hour and was turned off at 8 A.M., the following morning. LN 11 observed Resident 49's tube feeding in his room, which was not infusing at the time. LN 11 stated the tube feeding bag was not dated and timed of when it was hung, and the flush fluid was also not labeled. LN 11 stated if the bags were not labeled, LNs did not know how long they have been hanging and might be past the allowable time frame. LN 11 stated the formula could grow bacteria and cause an infection to the resident's intestinal tract, if infused. LN 11 stated it was a nursing standard of practice to label, date and time any fluids that were infused into the body. On 2/12/24 at 3:05 P.M., an interview was conducted with the ADON. The ADON stated all enteral formulas needed to be labeled with the date and time when they were first administered, so it would not extend over 24 hours. The ADON stated dating and timing a formula was a quality and safety issue to prevent bacteria growth. On 2/13/24, Resident 49's clinical record was reviewed: According to the physician's order, dated 9/17/23, provide and serve supplements as ordered: Jevity 1.5 at 60 cubic centimeters (cc) an hour for 10 hours a day. Water flush: 60 cc an hour for 10 hours a day = 600 cc a day of water. The quarterly MDS (a clinical assessment tool), dated 1/19/24, listed a cognitive score of 00, indicated cognition was severely impaired. 2. Resident 81 was readmitted to the facility on [DATE] with diagnosis to include stroke, dysphagia (difficulty swallowing) and moderate protein-calorie malnutrition, per the facility admission Record. On 2/12/24 at 10:31 A.M., Resident 81 was observed asleep in bed, with a tube feeding container hanging on his right side. The tube feeding was not infusing. Approximately 500 milliliters (ml) remained in the 1000 ml container. The tube feeding product was labeled by the manufacturer with the product name. A second white label was on the bag, with three lines for rate, start time/date, and end time/date. The white label had Resident 81's name written, but the rate, start time/date and end time/date were blank. A second bag of water hung next to the tube feeding bag, containing approximately 1000 ml of water. The bag of water had a white label indicating Resident 81's name but the rate, start time and end time were blank. On 2/12/24, Resident 81's clinical record was reviewed. Per a physician's order, dated 12/27/23, Resident 81 was to receive a tube feeding at 70 ml of tube feeding every hour between 12 P.M. and 8 A.M. The water flush was indicated as 30 ml every hour until 600 ml had infused. Per a RD note, dated 12/6/23, Resident 81 would meet his estimated nutritional and fluid needs with the tube feeding running as ordered. On 2/12/24 at 10:59 A.M., an interview was conducted with LN 2. LN 2 stated Resident 81's tube feeding had been started the previous day at 12 P.M., and was turned off at 8 A.M. that day. LN 2 stated the label did not have the information needed to know if Resident 81 had received the tube feeding. LN 2 stated, We cannot tell if he got the tube feeding or not, because the dates are not on the label. LN 2 stated the previous nurse had not written the time he started the tube feeding or the water bag. LN 2 stated it was important to write the start time and date to confirm Resident 81 received the nutrition the physician had ordered. On 2/12/24 at 11:45 A.M., an interview was conducted with the DON. The DON stated it was her expectation all nurses wrote start date and time, as well as end date and time for all tube feedings and water flushes. The DON stated it was important to ensure the tube feeding was dated to prevent infection, and to ensure the residents received their tube feeding as ordered. On 2/15/24 at 9:35 A.M. an interview was conducted with the DSD. The DSD stated she could not locate any documentation that the facility had provided tube feeding training or any in-services to the LNs for the past two years. According to the facility's policy, titled Enteral Feeding-Closed, dated January 2012, .VIII. Label the formula container and tubing with date and time hung .

CONCERN (D)

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

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to identify a resident's source of pain for one of one residents reviewed for pain management (Resident 7). This failure had the potential for Resident 7 to experience unrelieved pain. (Cross Reference F656) Findings: A review of Resident 7's admission Record indicated Resident 7 was admitted to facility on 4/1/23 with diagnoses that included a history of dementia (memory loss) and a left humerus (upper arm bone) fracture. A record review of Resident 7's Minimum Data Set (MDS- an assessment tool) dated 12/26/23, indicated Resident 7's cognitive skills to make daily decisions was moderately impaired. On 2/15/24 at 10:48 A.M., an observation of Resident 7 was conducted. Resident 7 could be heard yelling from the hallway several rooms away. Resident 7 was in bed, lying down. Resident 7 continued yelling, and waving her hands. On 2/15/24 at 10:48 A.M., a concurrent observation and interview was conducted with CNA 22 in Resident 7's room. CNA 22 stated Resident 7 yelled when she wanted something, such as being repositioned for comfort. On 2/15/24 at 10:55 A.M., an interview was conducted with LN 22. LN 22 stated Resident 7 complained about pain during transfers and showers. LN 22 stated he had not administered any pain medications recently to Resident 7. On 2/15/24 at 2:44 P.M., a joint interview and record review was conducted with LN 22. LN 22 stated Resident 7 participated in the Restorative Nursing Assistant (RNA, specialized CNA) program, and usually complained of left arm and left knee pain. LN 22 referred to Resident's 7's physician order dated 5/11/23 and stated that Resident 7 had an order for Tylenol (medication for pain) as needed, but Resident 7 had not been medicated for pain in some time. LN 22 stated it would be beneficial for Resident 7 to be pre-medicated for pain management prior to RNA program. A joint interview and record review was conducted on 2/20/24 at 8:24 A.M., with MDSN 1 (a nurse that conducts long term care assessments). MDSN 1 stated she did not know Resident 7 complained of pain during transfers and movement of her upper and lower extremities. MDSN 1 stated all residents should have pain assessments on admission, every three months, and when a change of condition was identified. MDSN 1 was not able to identify any pain assessments. An interview with the DON was conducted on 2/20/24 at 9:15 A.M. The DON stated pain should be evaluated and addressed, including indicators such as body language, facial expressions and mood. The DON stated Resident 7's pain and pain triggers were not identified. A review of facility's policy titled, Pain Management dated 2022 indicated under .2. Pain Management . i. The IDT will review the residents Pain Management and make changes to the care plan as needed . 4. Documentation . c. The Licensed Nurse will update the Care Plan for pain management with any change in treatment and/or medication.

CONCERN (D)

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

Deficiency F0710 (Tag F0710)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the physician (MD 2) supervised and managed the care of one of three residents reviewed for nutrition (Resident 21). This failure had the potential for Resident 21 to experience additional weight loss and other medical complications affecting his overall well-being. Cross reference: F692, F657 Findings: Resident 21 was admitted to the facility on [DATE] with diagnoses to include dementia (memory loss), protein-calorie malnutrition (a type of undernutrition that occurs when not enough protein and calories were eaten), and diabetes (a condition that affects how the body turns food into energy), per the facility admission Record. On 2/12/24 at 12:40 P.M., an observation of Resident 21 was conducted during lunch. Resident 21 had consumed less than half of the foods provided on the tray. Resident 21 was wheeling away from the tray, and indicated he did not want more food by waving his hand at it as he wheeled away. Dining room staff offered Resident 21 a nutritional supplement (NS, a drink which provides protein and calories) but Resident 21 refused. On 2/13/24 at 8:32 A.M., an observation of Resident 21 was conducted during breakfast. Resident 21 had eaten less than half of the foods provided on his breakfast tray. Resident 21 stated he was finished and did not want more food. On 2/20/24, a record review was conducted. On 11/29/23, Resident 21s Minimum Data Set (MDS, an assessment tool), Brief Interview for Mental Status (BIMS) score was 12, indicating moderate cognitive impairment. The nutrition section of the MDS indicated Resident 21 had lost 5% or more of his body weight in the last month, or a loss of 10% or more of his body weight in the last six months, and was not on a prescribed weight loss regimen. Per the physician orders, dated 11/22/23, Resident 21 was prescribed a carbohydrate controlled diet(CCHO, a diet low in simple sugars, used for diabetes management), with a NS three times each day with meals. On 8/20/23, RD 1 documented Resident 21 had had significant weight loss over the previous four months, calculating a loss of 5% of his body weight over the previous month, a loss of 8.7% body weight over the previous three months, and a loss of 15.3% body weight over the previous four months (since admission). RD 1 recommended the removal of the CCHO diet to allow Resident 19 more choices of foods to encourage improved intake. On 9/29/23, RD 1 recommended reducing the supplements to one a day at breakfast to reduce the risk of supplement fatigue and encourage the intake of whole foods. On 5/30/23, a Nurse Practitioner (NP), working with MD 2, documented a progress note for Resident 21. The progress note indicated Resident 21 had had no new decline or emergencies, and had no concerns. The NP documented Resident 21 was stable. There was no documentation regarding weight loss or poor intake. On 8/7/23, MD 2 documented Resident 21 had no injury, and planned to continue his current care. There was no documentation regarding weight loss or poor intake. On 11/29/23, the NP documented Resident 21 had no wounds and was stable. The NP documented, Per staff no concerns. Per the NP, Resident 21 had gone to the emergency room due to low blood sugar when he had not eaten well one evening, but returned to the facility when stabilized. There was no documentation regarding weight loss or poor intake, or any discussion regarding diet changes. On 2/20/24 at 11:55 A.M., a telephone interview was conducted with RD 2. RD 2 stated she was familiar with Resident 21. RD 2 stated if she wanted to make diet changes, she would leave a note with her recommendations for the physician to sign, or get a nurse to write a diet order. RD 2 stated she was not aware of RD 1's suggestion to liberalize the CCHO diet, or to reduce the amount of supplements. RD 2 stated she had no knowledge of why the recommendations to change the diet and supplement were not implemented. Per RD 2, Weight loss can have dire consequences in this population. On 2/20/24 at 12:26 P.M., a concurrent interview and record review was conducted with the ADON. The ADON stated when a RD made a recommendation, the RD could call the physician and ask a nurse to take an order, or the RD could ask a nurse to contact the physician with the recommendations. The ADON stated if the physician had said no to the recommendation, the nurse would inform the RD. Per the ADON, she could not speak to why the RD recommendations were not implemented. The ADON stated she did not know who called the physician to request the diet changes, but the changes had not been made. On 2/20/24 at 4:28 P.M., an interview was conducted with Resident 21's physician (MD 2). MD 2 stated neither the RD or a nurse had contacted him about Resident 21's weight loss, or dietary recommendations. MD 2 stated he was not sure Resident 21 was still assigned to him, and stated he had not ordered any labs in awhile to assess nutritional status. MD 2 stated he typically ordered whatever the RD recommended. Per a facility policy, revised June of 2018 and titled Nutritional Status Evaluation Committee, .The weight of residents will be monitored for variance and the Nutritional Status Evaluation Committee .will intervene when appropriate .V. Objectives of the Nutritional Status Evaluation Committee .B. Evaluating changes in diet, food preferences, and increased caloric intake .G. Identifying behaviors in the feeding environment that may be contributing to weight loss .

CONCERN (D)

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure staff were competent in managing residents with diabetes (abnormal blood sugar levels) for one of three residents reviewed for closed record review (Resident 51). This failure had the potential to negatively affect Resident 51's health. Findings: A review of Resident 51's admission Record indicated Resident 51 was admitted in the facility on 1/10/24 with a diagnosis that included diabetes. An interview was conducted on 2/14/24 at 8:27 A.M., with LN 1. LN 1 stated Resident 51 was sent to the hospital on 1/31/24 due to a low blood sugar of 43 milligrams per deciliter (mg/dl, where a normal range is approximately 70 - 110). LN 1 stated, it was very important to check residents' blood sugars to prevent episodes of high or low blood sugars. LN 1 stated the physician should be notified for any blood sugar results that were outside of the normal range. LN 1 stated she had been employed by the facility for one year. On 2/14/24 at 4:25 P.M., an interview and record review of the Medication Administration Record (MAR) with LN 22 was conducted. LN 22 stated if no blood sugars were documented in the MAR, as ordered by the physician, then there was no evidence it was completed. LN 22 stated all of his diabetic training was from nursing school, and he had not received any education or training while employed at the facility. LN 22 stated she had been employed by the facility for one year. On 2/20/24 at 8:43 A.M., an interview and joint record review was conducted with LN 34. LN 34 stated if the blood sugar was 70 mg/dl or below, the facility's low blood sugar protocol instructed the LNs to give orange juice, milk, or soft drinks until blood sugars were above 70. LN 34 stated LNs should then repeat the blood sugar test every 15 minutes until it was within the normal range. LN 34 stated abnormal blood sugars and patient's response should be documented in the nursing progress notes. LN 34 stated the nurse should inform the physician for any abnormal blood sugars. LN 34 stated she had her diabetes training while she was in nursing school, and she had not received any education or training while employed at the facility. LN 34 stated she had been employed by the facility for about one year. An interview and record review on 2/20/24 at 11:14 A.M., with the DON was conducted. The DON stated we had their last annual skills check (a competency training) in September 2022, which included diabetes management. The DON stated staff competency training should be completed upon hire, and annually afterwards. A review of the facility's policy, dated 3/17/2022, and titled Staff Competency Assessment, .Competency assessments will be performed upon hire during the employee's 90-day employment period, annually .VI. The annual evaluation of an employee will include review of completed competency assessments which may have been done throughout the year .

CONCERN (D)

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

Staffing Information (Tag F0732)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure the nurse staffing data was posted and readily accessible to the residents and public, and to accurately document the total number and actual hours worked by the nursing staff. As a result, staff and the public were unaware of the daily facility staffing. Findings: On 2/12/24 at 10:37 A.M., during an initial tour of the facility, the posted staffing data reflected a date of 2/7/24 (five days prior). Staffing data is required to be posted daily for public view. On 2/14/24 at 3:26 P.M., during an interview with the DSD, the DSD stated the staff posting was missed and had not been posted from 2/8/24 through 2/12/24. The DSD stated she was responsible for the staff posting, but she had been off work for the past five days. The DSD stated in her absence, she expected the staffing to be posted by team leaders. The DSD stated it was important the staff data be posted to let the residents and visitors know they had sufficient nursing staff available. On 2/14/24 at 3:35 P.M., during an interview with the DON, the DON stated it was important to have a staff posting displayed in public for all to see. A review on the facility's policy revised 7/2018, and titled Nursing Department-Staffing, Scheduling & Posting indicated, .Nurse Staffing Posting . A. The facility will post the following information on a daily basis: I. Facility name, II. The current date, III. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff responsible for resident care per shift . B. Posting requirements . I. The Facility will post the nurse staffing data specified above, on a daily basis at the beginning of each shift .

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to label and store medications properly when: 1. A medication was left unsecured and unmonitored at a nurses station, 2. A medication was stored improperly within a medication cart, and 3. An Automated Drug Dispensing System (ADDS) was not being monitored for temperature controls. These failure had the potential for accidental ingestion of an unprescribed medication, and for medications to be at risk for degradation. Findings: 1. On 2/12/24 at 12:48 P.M., an observation and interview was conducted at the east wing nursing station with LN 23. An unattended and unlabeled medication cup with two Tylenol (a medication used for pain management) pills was left at the edge of the nursing station table within wheelchair height. LN 23 acknowledged that that unattended medication was meant for a co-worker who was complaining of a headache. LN 23 stated that medications should not have been left unattended due to the safety concerns for facility residents, staff and visitors to easily reach medications while unattended with the potential for medication errors or safety concerns. An interview with the DON was conducted on 2/20/24 at 9 A.M. The DON stated that medications should not have been left unattended due safety concerns for medication errors, adverse reactions and misuse of medication. Review of facility's policy and procedure revised 10/2018, Ron's Pharmacy Policy and Procedure, indicated . Drugs shall be accessible only to personnel designated in writing by the licensee . 2. On 2/14/24 at 9:58 A.M., a concurrent observation and interview was conducted with Licensed Nurse (LN) 1. LN 1 opened a locked drawer on a medication cart to demonstrate where inhalers were stored. One medication, Breztri Aerosphere inhaler, was removed. LN 1 read the instructions printed on the Breztri box, which indicated to write a date on the box of when the foil pouch had been opened. Per LN 1, no date had been written. LN 1 read the instructions, which were to discard the inhaler when either the inhaler was empty, or within three months of opening the foil pouch, whichever comes first. LN 1 stated she would not know when the inhaler was opened as there was no date written on the box, and the foil pouch was missing. LN 1 stated not storing the medication properly could mean the resident was given a medication that was not effective due to being outdated. On 2/14/24 at 10:10 A.M., an interview was conducted with the Director of Nursing (DON). The DON stated it was her expectation nursing staff followed all instructions on medications. The DON stated if medications were not stored properly, they might not provide work as intended by the ordering physician. Per the DON, the facility utilized the Ron's Pharmacy Policy and Procedure Manual. Per the facility's reference, Ron's Pharmacy Policy and Procedure Manual, revised 10/2019, .XI. Medication Labeling & Proper Storage: All medications .must be properly labeled . Per the Breztri Aerosphere packaging insert, revised 1/2022, .Breztri Aerosphere should be discarded when the dose indicator display window shows zero .or 3 months .after removal from the foil pouch, whichever comes first . 3. On 2/15/24 at 9:05 A.M., a concurrent observation of the ADDS and interview with the Assistant Director of Nursing (ADON) was conducted. The ADDS was located within a nursing station. No thermometer or temperature monitoring sheet was observed. The ADON stated she was not aware of whether the facility monitored the temperature of the area. Per the ADON, the medications within the ADDS would be the same temperature as the nursing station. On 2/15/24 at 10 A.M., an interview was conducted with the Pharmacy Consultant (PC). The PC stated the medications within the ADDS needed to be maintained at an appropriate temperature. The PC stated maintaining temperatures where the ADDS was located was how the facility would ensure the medications were safe. The PC stated she was not aware of the facility's policy regarding checking the temperature surrounding the ADDS. On 2/15/24 at 11:07 A.M., an interview was conducted with the Director of Maintenance (DM). The DM stated he took temperatures each day in resident rooms, but did not take temperatures in the nurses station. Per the facility Ron's Pharmacy Policy and Procedure, revised 10/2018, .K. Temperature of Medications: Drugs shall be stored in appropriate temperatures. A. Drugs required to be stored at room temperature shall be stored at a temperature between .59 degrees F (Fahrenheit) and 86 degrees F. 1. Recommend a temperature log for daily documentation .

CONCERN (D)

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

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow food preferences during meal service for one of two residents, (Resident 73) reviewed for choices. As a result, Resident 73 felt ignored and disrespected. Findings: Resident 73 was admitted to the facility on [DATE] with diagnoses which include malignant neoplasm (cancer) of head, neck and face, per the facility's admission Record. On 2/12/24 at 11:52 A.M., an observation was conducted of Resident 73 in the dining room. Resident 73 was sitting with others at a table, drinking coffee, and waiting for lunch to arrive. On 2/12/24 at 12:07 P.M., the lunch trays arrived in the dining room and were delivered individually by staff. On 2/12/24 at 12:28 P.M., an observation and interview were conducted with Resident 73 while in the dining room. Resident 73's meal ticket was viewed, which read Dislikes: milk (milk substitutes okay to provide). On Resident 73's lunch tray was a full, untouched glass of milk. Resident 73 stated they served her milk with every meal, despite her request to not have milk. Resident 73 stated she never drank the milk served and believed it was wasteful to keep serving it and then throwing it away. Resident 73 stated the facility was not acknowledging her dislike of milk and she felt disregarded. On 2/13/24, Resident 73's clinical record was reviewed: According to the physician's order, dated 10/2/23, the diet was listed as mechanical soft, (soft, cut up with small bite sizes) texture regular/thin consistency, for difficulty swallowing due to malignancy. The quarterly MDS (a clinical assessment tool), dated 12/25/23, listed a cognitive score of 12, indicating cognition was intact. On 2/13/24 at 10:13 A.M., an interview was conducted with the DSS. The DSS stated the kitchen does not have any milk substitutes. On 2/13/24 at 1:17 P.M., an interview was conducted with Resident 73. Resident 73 stated they still gave her milk last night, this morning, and again at lunch. Resident 73 stated It's like they don't read dislikes and it makes me angry. On 2/14/24 at 12:48 P.M., an interview was conducted with the RD-C. The RD-C stated resident preferences and dislikes should be honor. The RD-C stated he spoke to Resident 73 on 2/12/23 and asked if she would like soy milk or lactose milk instead, which she said she was willing to try. The RD-C stated he had not implemented an alternate milk substitute yet. On 2/14/23 at 12:51 P.M., an interview was conducted with the DSS. The DSS stated Resident 73's preferences were not being followed and they needed to be honored it, because was a resident's right. On 2/15/24 at 8:45 A.M., an interview was conducted with the DON. The DON stated she expected all resident food preferences to be honor and respected. The DON stated following resident food preferences was a resident's right. According to the facility's policy, titled Dietary Profile and Resident Preference Interview, dated April 2022, .III. Resident Preferences will be reflected in the medical record and tray-card and updated in a timely manner .

CONCERN (D)

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

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to store, date, and protect food under sanitary conditions in one of two freezers (mobile kitchen freezer), reviewed for kitchen sanitation. This improper food safety practice had the potential to cause foodborne illness and/or food contamination. Findings: On 2/12/24 at 8:19 A.M., during initial kitchen tour with the DSS, an observation was conducted in the mobile kitchen freezer. On the left side of the freezer, on a middle shelve was a clear plastic bag of approximately 10 dinner rolls. The plastic bag was knotted, and contained no date or label of when the bag was opened. On the same shelve was a partially opened bag of parmesan cheese. An expiration date could not be seen on the commercial bag of cheese. On 2/12/24 at 8:20 A.M., an interview was conducted with the DSS. The DSS stated the dinner rolls and parmesan were not sealed and dated and they should have been. The DSS stated the foods could have caused foodborne illness if served to residents. On 2/13/24 at 9:52 A.M., an interview was conducted with the RD-C. The RD-C stated all freezer and refrigerator items needed to be dated when opened, so staff were aware of when they should be discarded. The RD-C stated food packages needed to sealed before placing them in the freezer to preserve the taste, quality, and to prevent freezer burn. On 2/15/24 at 8:45 A.M., an interview was conducted with the DON. The DON stated she expected the kitchen staff to promote safe food practices and to store food according to the guidelines. According to the facility's policy, titled Receiving Food and Supplies, dated June 2023, Food and supply items will be received and handled in accordance with recommended sanitary practices to prevent foodborne illnesses.

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure one Staff 21 adhered to proper glove use and hand hygiene (acceptable methods for cleaning hands such as handwashing or using hand sanitizer) while bringing soiled linens into the facility laundry. This deficient practice had the potential to spread harmful microorganisms around the facility which could lead to residents developing infections. Findings: On 2/15/24 at 3:12 P.M., an observation was conducted in the hallway near the laundry room. Staff 21 was observed entering the facility's back entrance wearing a personal protection gown and gloves. Staff 21 was pushing a barrel containing soiled linens into the building. Staff 21 stopped at the back entrance and applied hand sanitizer to her gloved hands. Staff 21 then continued to push the linen barrel into the building and into the laundry room. On 2/15/24 at 3:15 P.M., an interview was conducted with Staff 21. The housekeeping supervisor (HS) was also present. Staff 21 stated she should not have used hand sanitizer on her gloves. On 2/15/24 at 3:24 P.M., a joint interview was conducted with the HS and the ADON. The ADON stated applying hand sanitizer to gloves was not an acceptable hand hygiene or glove use practice. The ADON stated, If you need to put sanitizer on them [gloves] then take them off and throw them away. Then use hand sanitizer on your hands. On 2/20/24 at 3:35 P.M., an interview was conducted with the DON. The DON stated, It's never acceptable to hand sanitize your gloves. A review of the facility's documents titled Inservice Meeting Minutes for Hand Hygiene and Washing Before and After dated 8/25/23, Wear of Gloves [sic] and Hand Hygiene dated 9/27/23, and Covid Isolation Disinfectant/Hand hygiene dated 1/23/24, indicated Staff 21 had attended the inservice trainings. The lesson plan for the inservices included, Do's & Don'ts for Wearing Gloves in the Healthcare Environment .Don't re-use or wash gloves . Don't substitute glove use for hand hygiene .Don't forget to remove and dispose of gloves properly A review of the facility's policy titled Hand Hygiene revised September 1, 2020, indicated, .The facility considers hand hygiene the primary means to prevent the spread of infections. Hand hygiene means cleaning your hands by handwashing (washing hands with soap and water), antiseptic hand wash or antiseptic hand rub . B. Wearing gloves does not replace the need for hand hygiene

CONCERN (E)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of Resident 7's admission Record indicated the resident was admitted in the facility on 4/1/23 with diagnoses to include dementia (a condition that affects a person's memory, thinking and ability to perform everyday activities) and left humerus (upper arm bone) fracture. A record review of Resident 7's MDS (an assessment tool) dated 12/26/23, indicated Resident 7's cognitive skills to make daily decisions was moderately impaired (decisions poor; cues/supervision required). On 2/15/24 at 10:48 A.M., an interview with CNA 22 was conducted. CNA 22 stated Resident 7 yelled when she wanted something, such as repositioning for comfort. On 2/15/24 at 10:55 A.M., an interview and record review was conducted with LN 22. LN 22 stated Resident 7 complained about pain during transfers, showers, and during exercises. LN 22 was unable to locate a care plan related to pain. On 2/15/24 at 2:15 P.M., an observation of Resident 7 was conducted. Resident 7 was yelling out and could be heard from the hallway. A joint interview and record review of Resident 7 was conducted on 2/20/24 at 8:24 A.M., with MDSN 1 (nurses who specialized in assessing the needs of long-term care residents). MDSN 1 stated there was no pain care plan developed for Resident 7. MDSN 1 stated that she did not know Resident 7 complained of pain during transfers and movement of upper and lower extremities (refers to arms and legs) and should be addressed as part of Resident 7's care plan for pain. An interview with the DON was conducted on 2/20/24 at 9:15 A.M. The DON stated Resident 7's care plan for pain should have been developed to address Resident 7's pain triggers. The DON acknowledged pain indicators such as body language, facial expressions and mood should have been included in a person-centered care plan to identify Resident 7's pain and discomfort. The DON stated a care plan for pain had not been developed. A review of the facility's policy, revised November 2018 and titled Comprehensive Person-Centered Care Planning, indicated, Purpose .to ensure that a comprehensive person-centered care plan is developed for each resident. Procedure 1 a it should address resident- specific health and safety concerns to prevent injury, identify needs for supervision, and assistance with activities of daily living, as necessary . Findings: 1) A review of Resident 14's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis which included End Stage Renal Disease (kidney failure) and Dependence on Renal Dialysis (a process to filter the blood of toxins). An interview and observation with Resident 14 was conducted on 2/12/24 at 12:29 P.M. Resident 14 stated he went to dialysis three times a week. A shunt (access site for dialysis) on his right upper arm was observed. A joint interview and record review on 2/14/24 at 4:39 P.M., was conducted with LN 31. LN 31 stated there was no care plan for dialysis. LN 31 stated it was important for a dialysis care plan to have been developed and implemented, as it could affect Resident 14's care. An interview and record review was conducted on 2/15/24 at 7:40 A.M., with LN 35. LN 35 stated a care plan had not been developed for dialysis for Resident 14. LN 35 stated a care plan directed and guided the healthcare staff to provide dialysis care of Resident 14. A joint interview and record review was conducted on 2/20/24 at 3:50 P.M., with the DON. The DON indicated there was no active dialysis care plan in Resident 14's medical record. The DON stated it was important for a care plan to be developed so the healthcare staff knew what specific care and treatment Resident 14 required for dialysis treatment. 2) A review of Resident 51's admission Record indicated Resident 51 was admitted to the facility on [DATE] with diagnosis that included Diabetes Mellitus (abnormal blood sugar levels). A joint interview and record review on 2/14/24 at 4:50 P.M., was conducted with LN 31. LN 31 stated Resident 51's care plan on diabetes did not contain resident-specific interventions including monitoring for abnormal blood sugar levels. An interview and record review was conducted on 2/15/24 at 9:37 A.M., with the ADON. The ADON stated Residents 51's care plan was not individualized and did not include monitoring for abnormal blood sugar levels. Based on observation, interview and record review, the facility failed to develop and implement individualized care plans for three of 18 residents sampled (Residents 14, 51, 7). These failures had the potential for the residents to not receive the care and services needed to preserve optimal health status and prevent further decline.

CONCERN (E)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3a. On 2/20/24, a review of Resident 22's admission Record indicated Resident 22 was admitted in the facility on 12/7/20 with diagnoses that included a history of hemiplegia (paralysis of one side of the body) following cerebral infarction (stroke). Resident 22's document titled, Smoking Evaluation, dated 12/10/21, indicated Resident 22 was a smoker and supervision with smoking was required. There was no documented evidence any additional smoking evaluations were completed. 3b. On 2/20/24 a review of Resident 60 admission Record indicated Resident 60 was admitted to the facility on [DATE] with diagnoses that included paraplegia (paralysis of the lower part of the body). Resident 60's document titled, Smoking Evaluation dated 3/21/23 indicated a Resident 60 was a smoker. There was no documented evidence any additional smoking evaluations were completed. 3c. On 2/20/24 a review of Resident 5's admission Record indicated Resident 5 was admitted on [DATE] with diagnoses that included a history of hemiplegia (paralysis of one side of the body) following cerebral infarction (stroke). Resident 5's document titled, Smoking Evaluation, dated 11/29/21 indicated Resident 5 was a smoker and was unable to light a cigarette safely. There was no documented evidence any additional smoking evaluations were completed. 3d. On 2/20/24 a review of Resident 21's admission Record indicated Resident 21 was admitted to the facility on [DATE] with diagnoses that included a history of cerebral infarction (stroke). Resident 21's document titled, Smoking Evaluation dated 6/8/22 indicated Resident 21 was a smoker and was unable to light cigarettes safely, extinguish and use an ashtray to extinguish a cigarette. There was no documented evidence any additional smoking evaluations were completed. 3e. On 2/20/24, a review of Resident 26's admission Record indicated Resident 26 was admitted to the facility on [DATE] with diagnoses that included a history of chronic obstruction pulmonary disease (a lung disease). Resident 26's document titled, Smoking Evaluation dated 10/30/23 indicated Resident 26 was a smoker and was unable to light cigarettes safely and extinguish safely. There was no documented evidence any additional smoking evaluations were completed. On 2/20/24 at 8:09 A.M., a joint interview and record review was conducted with MDSN 1. MDSN 1 stated smoking assessments should be completed on a quarterly basis (every three months). MDSN 1 stated it was important to re-evaluate any residents who smoked due to safety reasons. MDSN 1 stated quarterly assessments were needed because changes to a resident's condition could happen, for example their ability to hold a cigarette. An interview with the DON was conducted on 2/20/24 at 8:47 A.M. The DON stated it was her expectation the quarterly evaluations for smoking be conducted for all residents who smoke. The DON stated safety concerns could result due to a lack of ongoing smoking assessments. A review of facility's policy titled, Smoking by Residents, revised January 2017 indicated, Procedure . VI. Using the Resident Smoking Assessment ., the Licensed Nurse will assess residents who express a desire to smoke, upon admission quarterly, annually and upon significant change of condition identification . 1b. Resident 49 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (weakness on one side of the body), following cerebral infarction (stroke) affecting the left side, per the facility's admission Record. On 2/12/24 at 11:36 A.M., an observation was conducted of Resident 49 during initial tour, while he laid in bed. Resident 49 was restless and moving around in bed. The head of the bed was elevated at 30 degrees. The bed was in a low position and fall mats were on both sides of the bed. Resident 49 did not respond to questions, and seemed to become more agitated when spoken to, responding in unintelligible grunts. On 2/13/24, Resident 49's clinical record was reviewed: The quarterly MDS (a clinical assessment tool), dated 1/19/24, listed a cognitive score of 00, indicated cognition was severely impaired. The functional abilities assessment indicated extensive staff assistance was required for transfers, personal care, and activities of daily living. The care plan, titled tendency to lose balance during transfers and decreased safety awareness, dated 8/8/23, listed an intervention of physical therapy to treat as indicated and safety awareness training. The fall risk assessment score at the time was 17, indicating a high risk for falls. According to the nurse's progress note, dated 9/8/23 at 9:17 A.M., Resident 49 had an unwitnessed fall (Fall #1) in his room and had minor bleeding from the mouth. Resident 49 was transported to the hospital for evaluation. A Post (after) Fall Risk Evaluation was completed on 9/8/23 at 10:31 A.M., leaving the fall risk score the same at 17. Per the nurses note, dated 9/8/23 at 4:17 P.M., the resident returned to the facility with no new physician orders. There was no documented evidence a post fall Care Conference (when department heads meet to discuss a change in condition and to implement more care interventions to prevent future falls) meeting was conducted. A care plan, titled High Risk for Falls, date 9/8/23, (not actual fall), listed interventions such as anticipate the needs of the resident, floor mats x 2, physical therapy to evaluate and treat, implement safety precautions. According to the nurses note, dated 9/28/23 at 6:18 A.M., Resident being monitored for witnessed fall. (Fall #2) A hospital transfer form, dated 9/28/23, indicated Resident 49 was transported to the hospital for evaluation after a fall. There was no documentation of how the resident fell or when. There was no documented evidence a post fall Care Conference was conducted or a Post Fall Risk Evaluation. There was no change in the High Risk for Falls care plan. According to the nurse's notes dated 10/9/23 at 3:55 P.M., Resident 49 had an unwitnessed fall (Fall #3) in his room and was found on the fall mat. A Post Fall Risk Evaluation was not completed. There was no documented evidence a post fall Care Conference was conducted. A care plan was developed, titled Actual Fall, dated 10/9/23, with interventions of floor mats x 2, continue interventions on the at-risk plan, maintain bed at low position, and determine and address causative factors of the fall. According to the nurse's notes dated 10/19/23 at 1:05 A.M., Resident 49 was found lying on floor in his room (Fall #4). The resident was moved to a room closer to the nurse's station. The Post Fall Risk Evaluation score remained the same at 17 and no post fall Care Conference was completed. The fall was added to care plan, titled Actual Fall, dated 10/9/23, with no changes or revisions in fall interventions. According to the nurse's notes dated, 10/21/23 11:34 P.M., Resident 49 had an unwitnessed fall in his room (Fall #5) and was found sitting on the floor mat next to his bed. A right elbow skin tear was noted and the resident was sent to the hospital for evaluation. A Post Fall Evaluation was conducted on 10/21/23 at 11:42 P.M., and the fall risk score was lowered from 17 to 15. There was no documented evidence a post fall Care conference was conducted. The care plan, titled Actual Fall, did not document the fall on 10/21/23, and fall interventions were not revised or added to prevent future falls. According to the nurse's notes, dated 11/4/23 at 10:31 P.M., Resident 49 was found on the floor in his room (Fall #6). The Post Fall Risk Evaluation, dated 11/4/23, score was lowered from 15 to 11. A post fall Care Conference was completed which listed interventions of: Physician/Psychiatrist to evaluate medications, nursing to make rounds every shift x 72 hours and perform urinalysis to rule out urinary tract infection. According to the Post Fall Evaluation, dated 11/13/23 at 11:55 P.M., Resident 49 had an unwitnessed fall in his room (Fall # 7). A Post Fall Risk Evaluation score was lowered again from 11 to 7. The Post Fall Care Conference listed interventions of: Physician/Psychiatrist to evaluate medications, nursing to make rounds every shift x 72, physical therapy to continue, notify State representative. According to the nurses note dated 11/19/23 at 9:15 A.M., Resident 49 had an unwitnessed fall in his room (Fall #8). The Post Fall Risk Evaluation score was increased from 7 to 9. The Post Fall Care Conference listed interventions of, Physician/Psychiatrist to evaluate medications, nursing to make rounds every shift x 72, pending psych evaluation, frequent checks by staff to ensure safety. According to Post Fall Evaluation, dated 12/10/23 at 2 A.M., Resident 49 had an unwitnessed fall in his room (Fall #9). The Post Fall Evaluation had pre-fall assessment score of 11, and a post fall assessment score of 11, with no change in the risk level. The resident had a right elbow skin tear and was transported to the hospital for evaluation. The post fall Care Conference listed interventions of safety precautions, psych evaluation, physician to increase Buspar (a mind-altering medication that treats anxiety) and to re-start Lorazepam (a mind-altering medication that treats anxiety). According to the nurse's notes, Resident 49 had additional unwitnessed falls in his room on 12/26/23 at 1:50 A.M. (Fall #10) and again on 1/24/24 at 12:23 A.M. (Fall #11) There was no documented evidence Post Fall Risk Evaluations were completed. The post fall Care Conference listed interventions of Visual checks every 30 minutes, safety precautions, call light in place, bed in low position, physician to increase Lorazepam. On 2/14/24 at 8:04 A.M., an interview was conducted with CNA 11. CNA 11 stated if a resident was found on the floor, she would stay with the resident and call for help. CNA 11 stated the LNs would come and assess the resident to make sure no injuries occurred. CNA 11 stated the LNs were responsible calling the physician and notifying the family. On 2/15/24 at 7:50 A.M., an interview was conducted with LN 1. LN 1 stated if a resident fell, the LNs were responsible for documenting the fall, such as when, where, how etc. and notifying the physician and family. The LNs would then perform Post Fall Risk Evaluation, to determine the risk of future falls. LN 1 stated, if residents had falls, the fall risk score should increase each time, because the risk is higher based on the actual falls. LN 1 stated with each fall, more interventions should be put in place, in order to prevent future falls. LN 1 stated after each fall, the department heads would meet in a care conference to discuss the fall and to determine why it happened and what they could do to prevent future falls. LN 1 stated Post Fall Risk Evaluations and Care Conferences were automatically performed after every fall. On 2/15/24 at 8:17 A.M., an interview was conducted with the ADON. The ADON stated Care Conferences were important to complete after falls to determine the cause, and to implement new interventions. The ADON stated Post Fall Risk Evaluation scores should go up, indicating a higher risk, and should never go down in score. On 2/20/24 at 8:23 A.M., an interview and record review was conducted with the DON. The DON stated whenever a resident had a fall, she expected LNs to perform a Post Fall Risk Evaluation, which tallied factors and provided a score risk for future falls. The DON stated the higher the score, the higher the fall risk. The DON stated anyone with a score over 10 was considered a high risk, and it triggered fall interventions to be put in place to prevent future falls. The DON stated after falls, the care conference team should meet for a fall Care Conference to determine the root cause of the fall and to discuss interventions to prevent future falls. The DON reviewed Resident 49's fall history. The fall on 9/8/23, had no post fall Care Conference and the Post Fall Risk Evaluation score did not increase, but stayed the same at 17. The fall on 9/28/23, had no post fall Care Conference and no Post Fall Risk Evaluation was competed. The fall on 10/19/23, had no post fall Care Conference and no Post Fall Risk Evaluation completed. The fall on 10/21/23, had no post fall Care conference and the Post Fall Risk Evaluation score went down to 15, instead of up. The fall on 11/4/23 had a post fall Care conference, but the Post Fall Risk Evaluation score dropped down from 15 to 11. With the fall on 11/13/23, the Post Fall Risk Evaluation dropped to 7, meaning he was no longer a high risk. On the 11/19/23 fall, the Post Fall Risk Evaluation went up to 9, with post fall Care Conference being completed for the remaining falls on 12/10/23, 12/26/23, and 1/24/24, and eventually the Post Fall Risk Evaluation returning to 17, as high fall risk. The DON continued, stating they tried a one-to one sitter for Resident 49, but did not document that in the notes, care conferences or on the intervention, which would have been important to show they were trying to prevent the falls. The DON stated she expected Care Conferences to be done after all falls and post Fall Risk Evaluations to be accurate. According to the facility's policy, titled Fall Management Program, dated March 2021, .D. The IDT (Interdisciplinary Team ie. Care Conference) will initiate, review and update the resident's fall risk status and care plan .upon identification of a significant change of condition, post falls, and as needed .Post Fall Response: A. Following every resident fall, the licensed nurse will perform a post-fall evaluation and update, initiate and revise the Resident care plan as necessary .C. The IDT will investigate the fall including a review of the Resident's medical record .Based on observation, interview and record review, the facility failed to: 1. Consistently evaluate Fall Risk Assessments and conduct Care Conferences after each resident fall, in order to prevent future falls for two of four residents (Residents 19, 49), reviewed for falls, and 2. Complete continuous quarterly safety smoking evaluations for five of five residents reviewed for smoking (Resident 22, Resident 60, Resident 5, Resident 21, and Resident 26). As a result, there was the potential for additional falls with possible injuries and for residents who smoked to be at risk for smoking-related burn injuries. Findings: 1a. Resident 19 was admitted to the facility on [DATE] with diagnoses to include dementia (the loss of the ability to think, remember and reason, to levels that affect daily life and activities), per the facility admission Record. On 2/12/24 at 11:46 A.M., Resident 19 was observed in his room, in bed. Resident 19's mattress had bolsters on each side, approximately four inches high, four inches wide, and 36 long. The bolsters were attached to the mattress, and were covered with a fitted sheet. In addition fall mats were on the floor on either side of the bed. Resident 19 indicated, using gestures, that the bolsters were to prevent him from falling. On 2/20/24 a record review was conducted. Resident 19's MDS, (an assessment tool) listed a cognitive score of 3, indicating severely impaired cognition. Resident 19's was coded for two or more falls since admission. Per the documentation, Resident 19 fell on the following dates: 9/21/23 9/28/23 10/11/23 12/5/23 12/11/23 1/22/24 Resident 19's numeric fall risk assessment was completed on 9/20/23. Resident 19's Fall Risk Assessment score was 23, indicating high risk for falls. Resident 19's initial care plan, dated 9/21/23, indicated Resident 19 was at high risk for falls. The interventions included fall mats and frequent monitoring. Later on 9/21/23, Resident 19 had a fall. No Post Fall Risk Evaluation scores were documented. After the fall on 9/28/23: Post (after) Fall Risk Evaluation score was lowered from 23 to 13. No new interventions were implemented on the fall care plan. After the fall on 10/11/23: Post Fall Risk Evaluation score remained the same at 13, with no new interventions implemented on the fall care plan. After additional falls on 12/5/23, 12/11/23, and 1/22/24, No Post Fall Risk Evaluation scores were documented. No new interventions were implemented on the fall care plan.

CONCERN (E)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of Resident 10's clinical record titled, admission Record indicated Resident 10 was admitted to the facility on [DATE] with diagnoses which included a history of depression. A record review of Resident 10's Minimum Data Set (MDS- a nursing assessment tool) dated 1/17/24 , indicated Resident 10 had a Brief Interview for Mental Status of 4 (BIMS - score 0 to 7 suggested severe cognitive impairment). On 2/14/24 at 4:29 P.M., a record review of Resident 10's Medication Regimen Review (MRR) was conducted from November 2023 thru January 2024. The MRR for Resident 10's Sertraline indicated, Please add behavior monitoring for the resident. On 2/14/24 at 4:30 P.M., a record review of Resident 10's clinical record titled, Psychiatric F/U (follow up) Note, dated 1/2/24 indicated, Resident 10 was on Sertraline (medication used for mood disorders, which can positively affect mood) 150 mg (milligrams). The Psychiatric F/U Note stated .I recommend decreasing Sertraline to 125mg . On 2/14/24 at 4:31 P.M., a review of Resident 10's record for Sertraline medication was conducted. There was no evidence of documentation that Sertraline was decreased per the psychiatrist recommendation. An interview and joint record review of Resident 10's clinical record with the DON was conducted on 2/20/24 at 10:38 A.M. The DON stated that Resident 10's MRR for behavior monitoring was not followed up due to missed psychotropic meetings. The DON stated it was important to monitor behaviors to determine recommendations for the psychiatrist to review the appropriateness for GDRs. A review of facility's policy and procedure dated November 2018 titled, Behavioral/Psychotropic Drug Management, indicated B. Psychoactive Drug Interventions . d. Psychopharmacological medications (other than antipsychotropics and sedative hypnotics) .GDR in two separate quarters (with at least one month between attempts) . F. Any order for psychoactive medication should include . Specific behavior manifested . Based on observation, interview, and record review, the facility failed to document non-pharmaceutical interventions or gradual dose reductions (GDR) for three of five residents (Resident 3, 42, and 10) reviewed for unnecessary medication review. As a result, Resident's 3, 42 and 10 did not have non-pharmaceutical interventions attempted and Gradual Dose Reductions were not initiated per Federal and State regulations. Findings: 1. Resident 3 was re-admitted to the facility on [DATE], with diagnoses which include dementia (progressive memory loss) and schizoaffective disorder, (a mental disorder that is marked by schizophrenia symptoms such as hallucinations and delusions), per the facility's admission Records. ` On 2/13/24, Resident 3's clinical record was reviewed. According to the quarterly MDS, dated [DATE], a cognitive score of 3 was listed, indicating cognition was severely impaired. According to the physician orders, dated 11/22/23, Memantine (medication for memory loss) 10 milligrams (mg) two time a day for monitoring related to dementia, Mirtazapine (Medication to treat depression and obsessive-compulsive disorder) 30 mg at bedtime for depression, and Seroquel 50 (medication used for schizophrenia) mg two times a day for mental disorders. Monitor for episodes of extrapyramidal symptoms (impaired motor control), depression (sadness) and for side effects. Hallucinations (hearing voices or seeing things that are not there) and for physician listed side effects. According to the Medication Administration Records, (MAR) from January 1, 2024 through February 15, 2024, Resident 3 displayed no episodes of specific behaviors and did not exhibit any side effects. The care plan titled, Psychotropic medications dated 9/12/23, listed interventions of: Consult with pharmacy, MD to consider dosage reduction, Discuss with MD, family re: ongoing need for the use of medication. Review behaviors, interventions and alternate therapies attempted, Monitor/record occurrence of target behavior symptoms. The Medication Regimen Review (MRR- when a consulting pharmacist (CP) makes medication recommendations on a monthly basis) was reviewed from [DATE] through January 2024. The following CP recommendations were made for Resident 3, during the December 2023 review: Metazeptine 30 mg tab at night time, please assess for annual assessment: target behavior Irritable behavior, episodes so far this month, zero, side effect so far this month, zero. Dose reduction recommended at this time, please document rationale if you disagree. There was no documented evidence that the physician agreed or disagreed and the CP recommendation of a GDR, and it did not appear it was acted on. 2. Resident 42 was re-admitted to the facility on [DATE], with diagnoses which included dementia (progressive memory loss) with behavior disturbances, per the facility's admission Record. On 2/13/24, Resident 42's clinical record was reviewed. According to the quarterly MDS, dated [DATE], a cognitive score of 3 was listed, indicating severely impaired cognition. The physician's order dated 9/12/23, listed Citalopram (medication for depression) 20 mg every day, Rexulti (medication for antipsychotic-mood disorder) 0.5 mg every day and Trazadone (medication for (anxiety/depression) 50 mg at nighttime. Monitor for episodes of behaviors, depression (sadness) and for listed side effects. Hallucinations (hearing voices or seeing things that are not there) and for side effects, an anxiety or restlessness. According to the Medication Administration Records, (MAR) from January 1, 2024, through February 15, 2024, Resident 42 displayed no episodes of specific behaviors and did not exhibit any side effects. The care plan titled antidepressant, Citalopram, dated 9/12/23, listed interventions of Monitor behaviors and Monitor/report behaviors side effects. The care plan, titled psychotropic, Rexulti, dated 9/12/23, listed interventions of Consult with pharmacy, MD to consider drug dosage reduction, discuss with MD/family regarding the ongoing need for use of medication, monitor and document any adverse reactions. The MRR was reviewed from [DATE] through January 2024. The following CP recommendations were made for Resident 42 during the November 2023 review, Rexulit 0.5 mg and Trazadone 50 mg at night, please assess for annual assessment: target behavior psychosis and depression, episodes so far this month, zero, side effect so far this month, zero. Dose reduction recommended at this time, please document rationale if you disagree. There was no documented evidence that the physician agreed or disagreed with the CP recommendation of a GDR, and it did not appear it was acted on. On 2/15/24 at 9:43 A.M., an interview was conducted with the SSD. The SSD stated they previously were doing psychotropic medication reviews every month and she was responsible for scheduling and organizing the meetings. The SSD stated the psychotropic medication care conferences consisted of the Admin, MD, DON, ADON, and the SSD. The SSD stated the last psychotropic care conference conducted was in April 2023, and none had not been performed since then. The SSD stated when the facility merged with the hospital in April 2023, other issues took precedent. The SSD stated over the past 10-months, she had informed the three previous Administrators and the current one, to let them know psychotropic review was a Federal and State requirement and needed to be performed. The SSD continued, stating during a psychotropic medication care conference, they evaluate the medication, number of behaviors displays, side effects and non-pharmaceutical interventions preformed. The purpose of these care conference to was to determine if the medication was still necessary or could the dosage be reduced, because psychotropic medications could be harmful. The SSD stated the harm to the resident could result from the medication or the dose of medication was no longer required. On 2/15/24 at 10:28 A.M., an interview was conducted with LN 13. LN 13 stated staff monitored resident behaviors and signs of possible signs side effects daily for all resident's on psychotropic medication. LN 3 stated monitoring was important so the psychotropic committee could evaluate the necessity of the medication and if the dosage should be increased or decreased, based on the behavior monitoring. LN 13 stated it was the MD who changed the medication dosage after discussing it with the family and evaluating the necessity for change. On 2/15/24 at 2:46 P.M. an interview and record review was conducted with LN 14. LN 14 stated LNs should attempted non-pharmaceutical interventions first, before administering a psychotropic medication for a behavior outburst. LN 14 stated non-pharmaceutical interventions were things like, placing the resident in a quiet room, play soft music, hold their hand, or turn off the lights. LN 14 reviewed Resident 3 and Resident 42's MAR from January 1, 2024 through February 15, 2024 for non-pharmaceutical interventions attempts. LN 14 stated no nonpharmological interventions were attempted or documented. LN 14 noted Resident 3 received a one time injection of Ativan 2 (an antianxiety medication) mg on 1/16/24, to treat aggression, but it was not documented as a behavior and no nonpharmological interventions were documented prior to the injection. On 2/20/24 at 7:45 A.M., an interview was conducted with the MD. The MD stated he managed the psychotropic medication review care conference and they were normally meet every month to discuss issues. The MD stated he would change medication dosages based on review of the resident's medical record and discussing with the rest of the committee members. The MD stated they have not had any care conferences for psychotropic medication review for several months. The MD stated the committee was, behind the boat and residents could be taking higher dosage then they needed, because gradual dose reductions were not being attempted. The MD stated with the facility change in April 2023, the psychotropic medications were not a primary focus, and it should have been. On 2/20/23 at 8:23 A.M., an interview was conducted with the DON. The DON stated care conference for psychotropic review was important to evaluate behaviors, side effects, dose reductions, and non-pharmaceutical interventions. The DON stated the since these reviews were not being conducted, there was a break in the system for evaluating the necessity of psychotropic medications. The DON stated the harm could be that the resident may no longer require the higher dose, since their health was declining, and the behaviors were diminishing. According to the facility's policy titled, Behavior/Psychotropic Drug Management, dated November 2018, II Interventions: A Non-pharmacological interventions .ii. The Licensed nurse will notify and collaborate with the Attending Physician/Prescriber, family member, resident, Responsible Party and/or IDT members regarding the identified contributing to the resident's mood/behavior problems .iii. The Licensed Nurse will document the interventions taken and recommendations in the resident's Care Plan.B. Psychotropic Drug Interventions .v. Dosage reduction or re-evaluation are provided according to OBRA regulations .a .1. If the anti-psychotic Antipsychotic was initiated within the last year, the facility has attempted a gradual dose reduction (GDR) in two separate quarters (with at least one month between attempts) .3. If no antipsychotic GDR has been attempted, the prescriber has documented a tapering is clinically contraindicated .

CONCERN (E)

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

Deficiency F0837 (Tag F0837)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility did not ensure Governing Body had an effective oversight and necessary resources for resident care services. Governing Body (the entity responsible for establishing and implementing facility policies) failed to ensure effective oversight and necessary resources to ensure resident care services were met to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident. This failure had the potential to affect the quality of care to residents. Cross Reference: F726, F732, F841 and HSC 1418.8, F865, F867, F868, F880, F887, Title 22 72541 Findings: On 2/15/24, a record review of facility documents was conducted. An undated document, titled Governing Body Preparation and Review, indicated: Items to review prior to the Governing Body Meeting for Discussion: .QAPI Plan .B. Review of internal reportable events: pressure ulcers that occurred or worsened, .falls with significant injury .equipment malfunction .Discuss any revisions needed to Facility Assessment .Discuss Performance Improvement Projects (PIPs) in place (QAPI) and progress, Look at training and in-service provided for QAPI program, Discuss facility leadership challenges . An undated Organizational Chart indicated the Nursing Home Administrator directly reported to Chief Executive Officer. Per a facility policy, revised 5/18/22 and titled Standardization of District Policies and Procedures, 1.0 Purpose: 1.1 To establish processes for the development, revision, approval and implementation of policies and procedures in a standardized format throughout Pioneers Memorial Healthcare District (PMHD) 3.11 Imperial Heights Healthcare and Wellness Center (the former name of Pioneers Memorial Skilled Nursing Center) 3.11.1 This facility will establish policies and procedures that will give guidance for quality oversight; resident and operational practices; and regulatory compliance. 3.11.3 Oversight: 3.11.3.1 PMHD will have a representative at the facility's Policy and Procedures Committee . Per a facility policy, revised 5/18/22 and titled Organization Performance Improvement Plan, 1.0 Purpose: 1.1 To provide a formal ongoing process by which the organization and stakeholders utilize objective measures to monitor and evaluate quality of service, patient safety and risk reduction strategies .3.2.4 PMHD Board of Directors and Senior Leadership are accountable and responsible for establishing a culture of continual improvement by dedicating adequate resources for measuring, assessing, improving and sustaining organizational quality, safety, and risk reduction .3.8 Maintaining Accreditation and Regulatory Compliance Committee (MARCC), a multidisciplinary committee with representatives from the Administrative Team .functions to: 3.8.1 Direct continuous survey readiness activities and monitors effectiveness, .3.8.2 Focus on evaluation/'improvement of a specifically identified processes or care practice 3.8.3 Collaborate and approve policies . On 2/20/24 at 5:08 P.M., an interview was conducted with the Admin, DON, ADON and Regional Consultant (RC). Per the Admin, the Governing Body met monthly. The Admin stated he had last met with the Governing Body two weeks prior. Per the ADON, We are all still learning how to communicate with each other .

CONCERN (E)

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

Deficiency F0841 (Tag F0841)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility's Medical Director (MD 1) did not oversee care area concerns related to psychotropic drug (mind-altering drugs) use and Gradual Dose Reductions (GDR) for 38 out of 83 residents, listed on the facility Matrix currently receiving psychotropic medications. As a result, 38 residents were not having their psychotropic medications evaluated monthly, and their care needs were not addressed in a timely manner such as no psychotropic care conferences and no GDR were attempted for nine months. (Cross reference to F-758 and H&S Code 1418.8) Findings: On 2/20/24 at 7:45 A.M., an interview was conducted with the facility's MD 1. MD 1 stated he was in charge of the management team for all residents receiving psychotropic medication. MD 1 stated the management team was expected to meet monthly, evaluate nonpharmacological interventions, determine the amount of behaviors exhibited, the number of side effects displays, and to determine if the medication was still required or could the dose be reduced. MD 1 stated the Consulting Pharmacist (CP) also reviewed each resident's medication regime on a monthly basis and send recommendations to him for review. MD 1 stated if he agreed with the recommendation, such as a GDR, he would sign it and sent it to the DON and the order would be changed to what the physician thought was appropriate. If the MD disagreed, he was required to write a justification of why he disagreed, and the document would also be sent to the DON. MD 1 continued, stating he was the primary person reviewing and handling the psychotropic medications at the facility. MD 1 stated they had not had any psychotropic committee conferences for several months and that included GDR's. MD 1 stated the facility got behind and the psychotropic reviews were not being done, which could be harmful to residents. MD 1 stated reviews and GDRs were important because the medications had side effects that could be harmful. MD 1 stated facility's committee was, behind the boat and residents could be taking higher dosage then they needed. MD 1 stated since the facility changed ownership, psychotropic medications were not a primary focus, and it should have been. According to the facility's Medical Directorship Agreement, dated August 1, 2023, .2. Directorship Services provided herein shall include the following: a. Supervision and Oversite. Director will supervise and oversee the health services provided at the SNF (skilled nursing facility) as outlines in Exhibit B (Medical Director Duties). According to the Exhibit B, titled Medical Director Duties, undated, The responsibilities of the Director shall include, but not limited to the following: 1. Provide medical direction and coordination for the health care activities and services provided by the health care staff. 2. Implement and review resident care .integrated delivery of care . 3. (2) review residents' condition and program of care at each visit, including medications and treatment .

CONCERN (E)

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

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to: 1. Offer/re-offer/administer COVID-19 vaccinations to five residents (56, 30, 73, 52, 55) sampled for COVID-19 vaccination and 34 residents (64, 55, 81, 85, 193, 2, 22, 84, 40, 19, 15, 76, 79, 1, 26, 83, 39, 56, 11, 5, 33, 23, 67, 80, 17, 51, 78, 82, 44, 31, 36, 190, 240, 192) newly admitted to the facility after 9/14/23. 2. Accurately document COVID-19 vaccination refusals on the facility's vaccination tracking list. 3. Implement their policy and procedure titled COVID-19 Vaccination Program. As a result of this deficient practice, there was the potential for residents, staff, and visitors to be placed at risk for COVID-19 infection. Findings: A review of the facility's document titled All Admissions, dated 2/20/24, indicated there were a total of 36 residents (64, 55, 81, 85, 193, 2, 22, 84, 40, 19, 15, 76, 79, 1, 26, 83, 39, 56, 11, 5, 33, 23, 67, 80, 17, 51, 78, 82, 44, 31, 36, 190, 240, 192, 30, 56) newly admitted after the facility reopened on 9/14/23 (to current date 2/20/24). A review of the facility's document titled Infection Control Surveillance dated January 2024, indicated 50 residents had tested positive for COVID-19. Of the 36 residents admitted to the facility after 9/14/23, twenty residents (81, 85, 30, 193, 84, 19, 76, 79, 1, 26, 39, 56, 5, 33, 23, 17, 78, 82, 44, 36) had tested positive for COVID-19 in January 2024. A review of the facility's undated and untitled resident vaccination tracking log, indicated there were 57 residents listed as having refused the COVID-19 vaccine. Upon further review, Resident 56 was identified on the vaccine tracking log as having refused the COVID-19 vaccine. On 2/15/24 at 8:35 A.M., an interview was conducted with Resident 56 while inside the resident's room. Resident 56 stated he had been a resident in the facility for about four months. Resident 56 stated he had not been offered the COVID-19 vaccine upon admission nor during his stay in the facility. Resident 56 stated he had not received the COVID-19 vaccine, was never offered it, and did not refuse it. Resident 56 stated he would like to receive it. On 2/20/24 at 7:50 A.M., a joint interview was conducted with the ADON and IPN 22. IPN 23 joined the interview by telephone. IPN 23 stated the facility had a COVID-19 vaccination clinic in March 2023, and that was the last time the facility had offered COVID-19 vaccinations to its residents. IPN 23 stated when the facility reopened in September 2023, she had not offered/re-offered/administered COVID-19 vaccines to residents who were readmitted . IPN 23 stated the facility began admitting new residents starting September 2023 and they had also not been offered/administered COVID-19 vaccinations. IPN 23 stated the facility had a COVID-19 outbreak in January 2024. IPN 23 stated COVID-19 vaccinations should have been offered/re-offered/administered to residents to prevent COVID-19 infections and outbreaks. IPN 23 further stated she had documented on her vaccination tracking log that residents had refused COVID-19 vaccines. IPN 23 stated she had done that because she had not offered them to residents. On 2/20/24 at 3:35 P.M., an interview was conducted with the DON. The DON stated when the facility reopened in September 2023, they should have started offering/re-offering/administering COVID-19 vaccinations to the readmitted residents. The DON stated residents who were newly admitted to the facility should have also been offered/administered COVID-19 vaccinations. A review of the facility's policy titled COVID-19 Vaccination Program revised March 15, 2022, indicated, .The facility will offer SARS-CoV-2 [COVID-19 virus] vaccinations (including additional and booster doses) to all residents . A. the resident's vaccination status will be evaluated upon admission. I. If the resident has not been vaccinated prior to admission they will be provided with vaccine information and offered the vaccine within seven days of admission. II. If the resident is partially vaccinated, the date of the next dose (if required) or a booster dose (if requested) will be added to the vaccine administration log

CONCERN (F)

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

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected most or all 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 care and services to maintain the highest quality of life, when haircuts were not provided for one of two resident (Resident 42) reviewed for Activities of Daily Living (ADL-basic daily care such as showers, grooming, dressing, nail care, and personal hygiene). The facility failed to ensure a system was in place to address the haircut needs for all 83 residents in the facility, when haircutting services were not offered or provided by the facility from April 1, 2023 through February 14, 2024 (a 10-month period). As a result, all residents had the potential for diminished dignity and self-esteem. Findings: A review of Resident 42's admission record was conducted. Resident 42 was readmitted to the facility on [DATE], with diagnoses which included dementia (progressive memory loss). On 2/12/24 at 9:36 A.M., an observation was conducted of Resident 42, during initial tour. Resident 42 was sitting in a wheelchair in the physical therapy room. Resident 42's hair was past hanging down on the sides, below his ears, and the back of the hair was long, past his neck. On 2/12/24 at 3:42 P.M., a telephone family interview was conducted with Resident 42 daughter. The daughter was informed of Resident 42's long hair and the family member was asked if Resident 42 would want his haircut. Resident 42's daughter stated, My father always likes to keep his hair very short and trimmed, so yes, he would want to have his haircut. On 2/13/24, Resident 42's clinical record was review: The facility's admission Record had a picture of the Resident 42 with short hair, located in the upper left corner of the with admission Record. The quarterly Minimum Data Set (MDS-a clinical assessment tool), dated 1/13/24, listed a cognitive score of 3, indicating cognition was severely impaired. The functional abilities section indicated Resident 42 required supervision and assistance with personal hygiene, such as combing hair, shaving, washing hands. On 2/14/24 at 7:37 A.M., an interview was conducted with Resident 42, with the assistance of the Medical Record Director (MRD), for Spanish interpretation. Resident 42 was dressed, sitting in a wheelchair in his room. When asked if he wanted a haircut, Resident 42 answered, yes. On 2/14/24 at 9:52 A.M., an interview was conducted with the Activity Director (AD). The AD stated she was responsible for coordinating and scheduling haircut appointments for all the residents. The AD stated they had been looking for a certified barber/beautician since their facility had a change of ownership (transfer of ownership from one entity to another), in April 2023, and was taken over by the hospital. The AD stated the last time a barber or beautician was in the facility to cut residents' hair was in March 2023, before the change of ownership. The AD continued, stating the hospital (new owner) informed the facility, the hospital wanted to vet, (the process of thoroughly investigating an individual, company before deciding to move forward) a new barber or beautician, before hiring someone to cut resident hair. The AD was asked how the facility was supplying haircuts, while waiting for the vetting to occur. The AD stated they did not have anyone to cut hair, so some family members were bringing in their own hairdressers, to cut their loved one's hair. The AD stated the hairdressers coming in, would bring their own supplies and the haircut would occur outside the facility's in their courtyard. The AD stated residents without any family members to help, had not been getting their haircut. The AD stated since the building was taken over as a D/P (Distinct Part: a hospital-based facility usually operated in a designated unit within a hospital), in April 2023, no haircuts have been provided. The AD stated she called the hospital in May, August, October, and December 2023, to inquire with how the hiring process was going and was told by the hospital, they were still working on it. The AD stated she was frustrated with the delay and the negative impact it could have on all the residents, because it was a dignity and self-esteem issue. The AD stated the residents and their families were not supposed to provide their own haircuts by outside sources, because it was the facility's responsibility and duty to provide that duty. The AD stated she was aware Resident 42 preferred his hair short and his family had also told her that in the past. On 2/15/24 at 8:30 A.M., an interview was conducted with the DON. The DON stated, I could not tell you when the last time someone was in the building to cut the residents' hair. The DON stated she was aware it was an issue and resident haircuts had not been performed for a long time. The DON stated the AD routinely was trying to get the hospital to finish their contract process, so someone could be hired, because the residents needed their haircuts. The DON stated not having someone to groom and cut hair, could affect a resident's self-esteem and dignity, because their ADL needs were not being met. On 2/15/24 a record viewed was conducted of the facility's policy, titled Resident Rights-Quality of Life, dated March 2017, Each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect, individuality and received services in a person-centered manner .1. Resident are groomed as they wish . On 2/15/24 an additional record review was conducted of the facility's policy, titled Resident Rights-Accommodation of Needs, dated January 2012, .1. Residents' individual needs and preferences are accommodated to the extent possible . On 2/15/25 an interview was conducted with the Medical Records Director (MRD). The MDR stated she unable to locate facility policies related to Haircuts or Activities of Daily Living.

CONCERN (F)

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

Deficiency F0865 (Tag F0865)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility failed to develop an effective Quality Assurance Performance Improvement (QAPI) program, when the committee did not consistently track, address, and follow up on quality issues affecting the residents as follows: 1. The call light system was not functional for several days. Cross reference: Title 22, 72541 2. Infection control practices were not implemented when Covid immunizations were not offered to residents. Cross reference F887 3. A pressure ulcer worsened for a resident. Cross reference F686 4. Haircuts were not offered to residents over an 10-month period. Cross reference F676 5. A resident with diabetes had unidentified hypoglycemia for two days, leading to a 10-day hospitalization. Cross reference F684 6. Gradual Dose Reductions (GDRs) were not routinely performed for residents on antipsychotic medications. Cross reference F758, HSC 1418.8 7. The Medical Director failed to provide oversite regarding GDR's. Cross Reference F841 These failures placed all residents at risk for accidents, infections, worsening physical and psychosocial harm. Findings: On 2/20/24, a record review was conducted. A facility policy, revised 1/1/12 and titled, Quality Assessment and Assurance Committee - Composition & Duties, indicated, Purpose: To promote the quality of resident care by overseeing, identifying, tracking, addressing and follow-up on all quality issues .Procedure: I. Meetings and Minutes A. The QAA Committee meets monthly . Per a facility documented, updated 11/17/20 and titled QAPI Plan, .The QAPI plan will guide the facility's performance improvement efforts .Purpose of Facility's QAPI Plan: Our facility's written QAPI plan provides guidance for our overall quality improvement program .Decisions will be made to promote excellence in quality of care, quality of life, resident choice, person directed care .Focus areas will include all systems that affect resident and family satisfaction, quality of care and services provided, and all areas that affect the quality of life for persons living and working in our facility .The administrator has responsibility and is accountable to the governing body for ensuring that QAPI is implemented throughout our facility .Our facility will conduct Performance Improvement Projects (PIP) that are designed to take a systematic approach to revise and improve care or services in areas that we identify as needing attention . On 2/20/24 at 5:08 P.M., an interview was conducted with the Admin, DON, ADON, and Regional Consultant (RC). Per the Admin, the last QAPI meeting had been on 10/10/23. The Admin stated the QAPI members had identified problems, but had not sat down formally to conduct a proper QA meeting. Regarding the malfunctioning call light system, the Admin stated QAPI was aware of the problem but had not determined a Performance Improvement Plan and the facility had not reported the issue to CDPH or implemented a safety watch. The DON and ADON stated the QAPI meeting in October had reviewed infection rates, but was not made aware of the lack of Covid vaccines being offered. Per the RC, pressure ulcers were a part of the QAPI committee discussion, and improvement had been seen. The Admin stated offering haircuts was part of their routine care, but since the hospital had acquired the facility, a contract was necessary and had not been arranged. The Admin stated the haircuts should have been included in QAPI, but they had not escalated the concern to the status it needed to be resolved. The DON stated diabetes management should have been a QAPI discussion, as well as staff training and education. The DON stated GDRs were identified as an issue for QAPI, but the previous administrator had no plan developed. The Admin stated more QAPI interventions would have been appropriate to help identify problems and solutions.

CONCERN (F)

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

QAPI Program (Tag F0867)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility failed to have an effective Quality Assurance Performance Improvement (QAPI) program, when the committee did not consistently track, address, and follow up on quality issues affecting the residents as follows: 1. The call light system was not functional for several days. Cross reference Title 22 72541 2. Infection control practices were not implemented when Covid immunizations were not offered to residents. Cross reference F887 3. A pressure ulcer worsened for a resident. Cross reference F686 4. Haircuts were not offered to residents over an 11-month period. Cross reference F676 5. A resident with diabetes had unidentified hypoglycemia for two days, leading to a 10-day hospitalization. Cross reference F684 6. Gradual Dose Reductions (GDRs) were not routinely performed for residents on antipsychotic medications. Cross reference F758, HSC 1418.8 7. The Medical Director did not provide oversite to the identification of problem-prone QAPI interventions. Cross Reference F841 These failures placed all residents at risk for accidents, infections, worsening physical and psychosocial harm. Findings: On 2/20/24, a record review was conducted. A facility policy, revised 1/1/12 and titled Quality Assessment and Assurance Committee - Composition & Duties, indicated, Purpose: To promote the quality of resident care by overseeing, identifying, tracking, addressing and follow-up on all quality issues .Procedure: I. Meetings and Minutes A. The QAA Committee meets monthly . Per a facility documented, updated 11/17/20 and titled QAPI Plan, .The QAPI plan will guide the facility's performance improvement efforts .Purpose of Facility's QAPI Plan: Our facility's written QAPI plan provides guidance for our overall quality improvement program .Decisions will be made to promote excellence in quality of care, quality of life, resident choice, person directed care .Focus areas will include all systems that affect resident and family satisfaction, quality of care and services provided, and all areas that affect the quality of life for persons living and working in our facility .The administrator has responsibility and is accountable to the governing body for ensuring that QAPI is implemented throughout our facility .Our facility will conduct Performance Improvement Projects (PIP) that are designed to take a systematic approach to revise and improve care or services in areas that we identify as needing attention . On 2/20/24 at 5:08 P.M., an interview was conducted with the Admin, DON, ADON, and Regional Consultant (RC). Per the Admin, the last QAPI meeting had been on 10/10/23. The Admin stated the QAPI members had identified problems, but had not sat down formally to conduct a proper QA meeting. Regarding the malfunctioning call light system, the Admin stated QAPI was aware of the problem but had not determined a Performance Improvement Plan and the facility had not reported the issue to CDPH or implemented a safety watch. The DON and ADON stated the QAPI meeting in October had reviewed infection rates, but was not made aware of the lack of Covid vaccines being offered. Per the RC, pressure ulcers were a part of the QAPI committee discussion, and improvement had been seen. The Admin stated offering haircuts was part of their routine care, but since the hospital had acquired the facility, a contract was necessary. The Admin stated the haircuts should have been included in QAPI, but they had not escalated the concern to the status it needed to be resolved. The DON stated diabetes management should have been a QAPI discussion, as well as staff training and education. The DON stated GDRs were identified as an issue for QAPI, but the previous administrator had no plan developed. The Admin stated more QAPI interventions would have been appropriate to help identify problems and solutions.

CONCERN (F)

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

Deficiency F0868 (Tag F0868)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility Quality Assurance Performance Improvement (QAPI) committee failed meet at least quarterly, and as needed to develop meaningful activities that identified areas for improvement. This failure had the potential to affect the safety and quality of care provided to residents. Cross reference: Title 22 72541, F887, F686, F676, F684, F758, HSC 1418.8. Findings: On 2/20/24, a record review was conducted. Per a facility documented, updated 11/17/20 and titled QAPI Plan, .The QAPI plan will guide the facility's performance improvement efforts .Framework for QAPI: .The QAA committee will meet a minimum quarterly and as needed . On 2/20/24 at 5:08 P.M., an interview was conducted with the Admin, DON, ADON, and Regional Consultant (RC). Per the Admin, the last QAPI meeting had been on 10/10/23. The Admin stated the QAPI members had identified problems, but had not sat down formally to conduct a proper QA meeting. Per the Admin, .I can't deny more QAPI committee meetings would be helpful . A facility policy, revised 1/1/12 and titled Quality Assessment and Assurance Committee - Composition & Duties, indicated, Purpose: To promote the quality of resident care by overseeing, identifying, tracking, addressing and follow-up on all quality issues .I. Meetings and Minutes A. The QAA Committee meets monthly .

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0911 (Tag F0911)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assure that resident rooms housed no more than four residents. Two rooms had the potential to accommodate five residents in each room (rooms [ROOM NUMBERS]). Seven rooms had the potential to accommodate six residents in each room (Rooms 2, 3, 4, 5, 13, 15, and 18). As a result, the potential existed to impact resident care and quality of life. Findings: On 2/12/24 through 2/20/24, observations were conducted during the course of the annual recertification survey at the facility. Additionally, interviews and records reviews were conducted. There were no observed quality of care or quality of life concerns related the number of residents in the rooms. A continuance of the waiver (variation) from the requirements of 42 CFR section 483.70(d)(1)(i) as granted pursuant to a letter from the Centers for Medicare and Medicaid Services (CMS), dated January 25, 2019, and allowing more than four residents per room, is hereby recommended. This recommendation is also made with the expectation that the facility will obtain a timely renewal of the current waiver (variation) granted by CMS as reflected in the January 25, 2019 letter to the facility from CMS.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0912 (Tag F0912)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assure that resident rooms measured at least 80 square feet per resident in resident room [ROOM NUMBER]. As a result the potential existed to impact resident care and quality of life. Findings: On 2/12/24 through 2/20/24, observations were conducted during the course of the annual recertification survey at the facility. The facility had one multiple resident room (room [ROOM NUMBER]) which did not meet the minimum 80 square feet per resident. room [ROOM NUMBER] measured 479 square feet and had the potential to house six residents. The allocated space for each resident would measure 79.83 square feet. The six residents occupying the room had no complaints. There were no observed quality of care or quality of life concerns that negatively impacted the residents residing in the identified room. A continuance of the waiver (variation) from the requirements of Code 42 of the Federal Regulations (CFR) section 483.70(d)(1)(ii) as granted pursuant to a letter from the Centers for Medicare and Medicaid Services (CMS), dated January 25, 2019, and allowing less than 80 square feet per resident per room per room, is hereby recommended. This recommendation is also made with the expectation that the facility will obtain a timely renewal of the current waiver (variation) granted by CMS as reflected in the January 25, 2019 letter to the facility from CMS.

Aug 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0557 (Tag F0557)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the staff followed their policy and procedure on receiving and returning personal belongings for three of three sampled residents (Resident 1, 2 and 3). As a result, there was a potential the residents' belongings were not returned to the family after discharge from the facility. Findings: 1) Resident 1 was admitted to the facility on [DATE] per the facility ' s admission Record. A review of records was conducted. The document titled Resident Inventory dated 8/1/22, indicated Resident 1 had personal belongings listed on admission. There were no signatures or dates from the resident/representative and the staff certifying the belongings were received by the facility on admission and received by the resident/representative upon Resident 1 ' s transfer to the hospital or discharge from the facility. On 7/18/23 at 1:25 P.M., an interview with the Medical Records (MR) staff was conducted. The MR stated there was no documentation in Resident 1 ' s chart the belongings were returned to the family upon Resident 1 ' s discharge from the facility. 2) Resident 2 was admitted to the facility on [DATE] per the facility ' s admission Record. A review of records was conducted.The document titled Resident Inventory dated 7/26/22, indicated Resident 2 had personal belongings listed on admission. There were no signatures or dates from the staff certifying the belongings were received by the facility on admission and received by the patient/representative upon Resident 2 ' s transfer to the hospital or discharge from the facility. 3) Resident 3 was admitted to the facility on [DATE] per the facility ' s admission Record. A review of records was conducted.The document titled Resident Inventory dated 7/11/22, indicated Resident 3 had a personal belonging listed on admission. There were no signatures or dates from the staff certifying the belonging was received by the facility on admission and received by the patient/representative upon Resident 3's discharge from the facility. On 8/1/23 at 8:37 A.M., an interview with the previous Assistant Director of Nursing (ADON) was conducted. The previous ADON stated when a resident was admitted to the facility, the Certified Nurse Assistant (CNA) conducts an inventory of the personal belongings, the nurse signs the paperwork and the resident had to sign the inventory form when they come back and picked up their belongings. On 8/1/23 at 9:01 A.M., an interview with the Social Services Assistant (SSA) was conducted. The SSA stated the resident ' s inventory was done and signed by the CNA or the nurse upon receipt and when the resident was discharged from the facility. On 8/1/23 at 10:23 A.M., an interview with the Nurse Consultant (NC) 2 was conducted. NC 2 stated when the resident ' s family received a resident ' s personal belongings back, they have to sign the inventory form. NC 2 stated the staff needed to document what the resident or the family wanted to do with the belongings upon discharge. On 8/1/23 at at 4:41 P.M., an interview with LN 1 was conducted. LN 1 stated the staff was supposed to fill out and sign the inventory sheet of residents ' personal belongings upon receipt and when they were discharged from the facility. On 8/1/23 at 5:16 P.M., an interview with CNA 1 was conducted. CNA 1 stated an inventory of personal belongings was checked on admission of a resident and documented on an inventory sheet. CNA 1 stated the resident or the family needed to sign the form that the staff documented the belongings. CNA 1 stated upon the resident ' s discharge from the facility, the staff and the resident/family had to sign the inventory sheet to verify they received the belongings back. Per the facility ' s policy and procedure titled Personal Property, revised 7/14/17, .Procedure .II. Upon admission, the CNA/designee will conduct a personal property inventory of the resident ' s property .IV. Upon discharge home, the resident/resident representative will review the Resident Inventory to ensure all personal items are taken. The resident/resident representative will sign the inventory indicating that all personal property is released to them . Based on interview and record review, the facility failed to ensure the staff followed their policy and procedure on receiving and returning personal belongings for three of three sampled residents (Resident 1, 2 and 3). As a result, there was a potential the residents' belongings were not returned to the family after discharge from the facility. Findings: 1) Resident 1 was admitted to the facility on [DATE] per the facility's admission Record. A review of records was conducted. The document titled Resident Inventory dated 8/1/22, indicated Resident 1 had personal belongings listed on admission. There were no signatures or dates from the resident/representative and the staff certifying the belongings were received by the facility on admission and received by the resident/representative upon Resident 1's transfer to the hospital or discharge from the facility. On 7/18/23 at 1:25 P.M., an interview with the Medical Records (MR) staff was conducted. The MR stated there was no documentation in Resident 1's chart the belongings were returned to the family upon Resident 1's discharge from the facility. 2) Resident 2 was admitted to the facility on [DATE] per the facility's admission Record. A review of records was conducted.The document titled Resident Inventory dated 7/26/22, indicated Resident 2 had personal belongings listed on admission. There were no signatures or dates from the staff certifying the belongings were received by the facility on admission and received by the patient/representative upon Resident 2's transfer to the hospital or discharge from the facility. 3) Resident 3 was admitted to the facility on [DATE] per the facility's admission Record. A review of records was conducted.The document titled Resident Inventory dated 7/11/22, indicated Resident 3 had a personal belonging listed on admission. There were no signatures or dates from the staff certifying the belonging was received by the facility on admission and received by the patient/representative upon Resident 3's discharge from the facility. On 8/1/23 at 8:37 A.M., an interview with the previous Assistant Director of Nursing (ADON) was conducted. The previous ADON stated when a resident was admitted to the facility, the Certified Nurse Assistant (CNA) conducts an inventory of the personal belongings, the nurse signs the paperwork and the resident had to sign the inventory form when they come back and picked up their belongings. On 8/1/23 at 9:01 A.M., an interview with the Social Services Assistant (SSA) was conducted. The SSA stated the resident's inventory was done and signed by the CNA or the nurse upon receipt and when the resident was discharged from the facility. On 8/1/23 at 10:23 A.M., an interview with the Nurse Consultant (NC) 2 was conducted. NC 2 stated when the resident's family received a resident's personal belongings back, they have to sign the inventory form. NC 2 stated the staff needed to document what the resident or the family wanted to do with the belongings upon discharge. On 8/1/23 at at 4:41 P.M., an interview with LN 1 was conducted. LN 1 stated the staff was supposed to fill out and sign the inventory sheet of residents' personal belongings upon receipt and when they were discharged from the facility. On 8/1/23 at 5:16 P.M., an interview with CNA 1 was conducted. CNA 1 stated an inventory of personal belongings was checked on admission of a resident and documented on an inventory sheet. CNA 1 stated the resident or the family needed to sign the form that the staff documented the belongings. CNA 1 stated upon the resident's discharge from the facility, the staff and the resident/family had to sign the inventory sheet to verify they received the belongings back. Per the facility's policy and procedure titled Personal Property, revised 7/14/17, .Procedure .II. Upon admission, the CNA/designee will conduct a personal property inventory of the resident's property .IV. Upon discharge home, the resident/resident representative will review the Resident Inventory to ensure all personal items are taken. The resident/resident representative will sign the inventory indicating that all personal property is released to them .

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

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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 fall risk care plan was developed and implemented for one of three sampled residents (Resident 1) with a high risk for falls. As a result, Resident 1 had an unwitnessed fall at the facility. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses which included history of falling per the facility ' s admission Record. On 7/6/23, a review of Resident 1 ' s records was conducted. A Fall Risk Evaluation dated 8/1/22 indicated Resident 1 had a score of 20, indicating she was at risk for falls due to level of consciousness (intermittent confusion), history of 1-2 falls in the past 3 months, ambulation/elimination status (chair bound and requires assist with elimination), and multiple medications and diagnoses. A progress note dated 8/4/22 and authored by the previous Assistant Director of Nursing (ADON), indicated Resident 1 was transferred to the hospital after an unwitnessed fall at the facility. There was no documentation a care plan for risk for falls for Resident 1 was developed. On 8/1/23 at 8:37 A.M., an interview with the previous ADON was conducted. The previous ADON stated a care plan was supposed to have been created immediately once Resident 1 has been assessed on admission. On 8/1/23 at 9:01 A.M., an interview with the Social Services Assistant (SSA) was conducted. The SSA stated a care plan was needed for residents with fall risk. On 8/1/23 at 10:23 A.M., an interview with the Nurse Consultant (NC) 2 was conducted. NC 2 stated a fall risk score of 10 and above was considered high risk. NC 2 stated there should have been a fall risk care plan for Resident 1. On 8/1/23 at at 4:41 P.M., an interview with LN 1 was conducted. LN 1 stated a fall risk score of 20 indicated Resident 1 was a high risk for falls. LN 1 stated a care plan for risk for falls should have been developed for Resident 1. On 8/1/23 at 5:16 P.M., an interview with Certified Nurse Assistant (CNA) 1 was conducted. CNA 1 stated a care plan should have been created for Resident 1 since she was a high fall risk on admission. Per the facility ' s policy and procedure titled Fall Management Program revised 3/13/21, .Procedure .Fall Risk Evaluation .C. The Interdisciplinary Team (IDT)/or the licensed nurse will develop a care plan according to the identified risk factors .

Apr 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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe location for Resident 5 after being physically hit by Resident 3. As a result, Resident 5 had the potential to endure mental anguish and emotional distress by not being separated from another resident who had physically hit him. Findings: CDPH was notified of a resident-to-resident altercation that occurred on 3/3/23 at 9 P.M. The report indicated Resident 4 had hit Resident 5 two times. Resident 4 resided in the same room as Resident 5. On 3/9/23 at 9:30 A.M., a facility census sheet was reviewed. Resident 4 and Resident 5 were assigned to the same room. On 3/9/23 at 10:53 A.M., an observation of Resident 5 and Resident 4 was conducted. Resident 4 was observed lying in bed across from Resident 5 in the same room. Resident 4's records were reviewed. Per the facility admission sheet, Resident 4 was admitted to the facility on [DATE] with a diagnosis of dementia. Per Resident 4's history and physical, dated 7/2/22, the resident did not have the capacity to make his own decisions. Per Resident 4's nursing progress notes, dated 3/3/23 at 2:46 A.M, 1:52 P.M. and 3/9/23 at 3:45 P.M. the resident displayed aggressive, hitting behaviors. Resident 5's records were reviewed. Resident 5 was admitted to the facility on hospice due to terminal cancer and need for comfort care. Per Resident 5's hospice plan of care, dated 11/1022, the resident required staff assistance to stand, transfer, and ambulate due to poor coordination, weakness, and unsteady gait. On 3/9/23 at 11:09 A.M., an interview with CNA 3 and an observation of Resident 5 and Resident 4 was conducted in both resident's room. CNA 3 stated both residents were to stay in the same room because they were both a fall risk. Resident 4 and Resident 5 were observed lying in their beds across from each other. On 3/9/23 at 3:30 P.M., an interview was conducted with CNA 5. CNA 5 stated that Resident 4 was very confused and did not know what he was doing. On 3/9/23 at 3:45 P.M., an interview was conducted with the SSA. The SSA stated it was the facility's policy was to keep the resident safe but that the facility had not assessed the risk of Resident 4 hitting Resident 5 again. The SSA confirmed that they were still in the same room together because the IDT team decided Resident 5 was a fall risk. On 3/9/23 at 4:15 P.M., an interview was conducted with CNA 4 who observed Resident 4 hitting Resident 5 on 3/3/23. CNA 4 stated Resident 4 hit Resident 5 twice and they were still in the same room together. On 3/9/23 at 4:15 P.M., an interview was conducted with the DON. The DON stated the facility's policy was to keep the resident safe but that the facility had not assessed the risk of Resident 4 hitting Resident 5 again. The DON stated the IDT team did not want to move Resident 5 because he was a fall risk and so he remained in the same room. Per the facility policy, dated 11/1/2015, titled Resident to Resident Altercations, .the facility acts promptly and conscientiously to prevent and address altercations between residents .

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected multiple 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 assure that nursing staff assessed resident needs and provided resident centered care for 3 residents (1, 2, 4) diagnosed with dementia (impaired reasoning and communication) and 1 resident with terminal illness (5). As a result, the residents were kept from accessing the facility hallways, eating in the dining room, ambulating freely, participating in activities outside their room, and getting out of bed. Findings: 1.Per the facility's admission sheet, Resident 1 was admitted to the facility on [DATE] with a diagnosis of dementia. Per Resident 1's history and physical, dated 6/4/22, the resident did not have the capacity to make her own decisions Per Resident 1's undated plan of care for dementia, the staff were to ask the resident questions to determine and meet her needs. During an observation and interview with Resident 1 in her room on 3/9/23 at 10:50 A.M., the resident was observed sitting in a chair moving all extremities in a restless manner, first moving legs and down, and then upper arms. Resident 1 would not give eye contact and grimaced. When Resident 1 tried to move her wheelchair forward, CNA 1 instructed resident to stop and blocked Resident 1 from moving her wheelchair. Resident 1 shrugged her shoulder when asked if she was okay. During an interview with CNA 1 on 3/9/23 at 10:55 A.M., CNA 1 stated Resident 1 had to stay in the room where she could watch and observe Resident 1. CNA 1 stated Resident 1 was a fall risk. CNA 1 stated she was responsible for the six residents located in the same room because they were all fall risks, and the residents were not to leave the room. CNA 1 stated all residents stayed in the room because they were not allowed to go outside of the room because she had to monitor and care for all of them because they were a fall risk. During an interview with LN 1 on 3/9/23 at 11:12 A.M., LN 1 stated the staff determined Resident 1's daily routine because she could not verbalize her needs. 2. Per the facility admission record, Resident 2 was admitted to the facility on [DATE] with a diagnosis of dementia. Per Resident 2's history and physical, dated 6/4/22, the resident did not have the capacity to make her own decisions. Per Resident 2's undated plan of care, the staff were to ask the resident questions to determine her needs and wants. During an observation and interview with Resident 2 on 3/9/23 at 10:58 A.M., the resident stated she wanted to get out of bed and into the wheelchair. Resident 2 was sitting on the side of the bed struggling to get out of bed and into the wheelchair. Resident 2 grimaced and stated, They will not help me. During an interview and observation of CNA 2's intervention with Resident 2 on 3/9/23 at 11 A.M., CNA 2 stated the resident was not to get out of bed. CNA 2 instructed Resident 2 to stay in bed and stood in front of the resident. CNA 2 stated Resident 2 could not get out of bed and this time was Resident 2's rest period. CNA 2 stated she was assigned to six residents in the room because they were fall risks and they were not to leave the room. CNA 2 stated that Resident 2 was allowed to get up for meals, but all meals were served in their room and not the dining room. During an interview with LN 1 on 3/9/23 at 11:15 A.M., LN 1 stated Resident 2 was able to verbalize her needs and could tell the staff what she wanted but staff determined the course of care because she was a fall risk. 4. Per the facility admission sheet, Resident 4 was admitted to the facility on [DATE] with a diagnosis of dementia. Per Resident 4's history and physical, dated 7/2/22, the resident did not have the capacity to make his own decisions. Per Resident 4's undated plan of care the staff were to determine the resident's needs and wants. During an interview with CNA 3 and observation of Resident 4 on 3/9/23 at 11:09 A.M., CNA 3 stated she watched six residents at risk for falls in one room and the residents were not to leave the room. CNA 3 stated the room was dark so that the residents would not get agitated. CNA 3 stated Resident 4 was not to leave the room. Resident 4 was observed lying in bed with eyes closed. CNA 3 stated Resident 4 got up for meals, but all meals were served in their room and not the dining room. During an interview with LN 1 on 3/9/23 at 11:16 A.M., LN 1 stated Resident 4 could not verbalize his needs and or tell the staff what he wanted, but he liked to get up in his wheelchair and wheel down the hallway. 5. Per the facility admission sheet, Resident 5 was admitted to the facility on [DATE] with terminal cancer. Per Resident 5's active physician orders for March 2023, Resident 5 was able to make his own decisions. Per Resident 5's active physician orders for March 2023, the resident had orders for hospice (medical treatment of a dying person that honors their wishes and assures maximum comfort). Per Resident 5's hospice plan of care, dated 12/14/22, the facility had not identified the resident's wishes. During an observation and attempted interview with Resident 5 on 3/9/23 at 10:55 A.M., the resident declined to speak when the CNA positioned herself at the foot of Resident 5's bed during the resident interview. During an interview with CNA 3 on 3/9/23 at 11:09 A.M., CNA 3 stated she watched six residents at risk for falls in one room and the residents were not to leave the room. CNA 3 stated the room was dark so that the residents would not get agitated. CNA 3 stated all of the residents in the room were a fall risk and it was her job to monitor them. CNA 3 stated Resident 5 was not to leave the room. CNA 3 stated Resident 5 got up for meals, but the meals were served in the bedroom (Not in the main dining room with the other residents). During an interview with CNA 1 on 3/9/23 at 4:01 P.M., CNA 1 stated she did not know how to communicate with a resident or determine their needs if they had dementia. During an interview with CNA 2 on 3/9/23 at 4:03 P.M., CNA 3 stated that residents with dementia got agitated a lot but could not understand the reason residents with dementia became agitated. During an interview with CNA 3 on 3/9/23 at 4:05 P.M., CNA 3 stated that residents with dementia were agitated a lot but she did not understand them. During an interview with the DSD on 3/9/23 at 4:14 P.M., the DSD stated that the nursing staff had not been trained on how to identify the cause of resident behavior or modify the resident's routine to meet their needs or preferences and diminish agitation or aggression. During an interview with the DON on 3/9/23 at 4:42 P.M., the DON stated dementia residents usually have unmet needs and we should assess and address their unmet needs such as relevant activities, mobilizing outside the room, and resident preferences. Per the facility policy, revised 10/2017, titled Dementia Care, .the IDT will seek to identify and address the root cause of challenging resident behaviors . develop plans of care and interventions in an attempt to understand and address behaviors as a form of communication and modify the environment and daily routines to meet the resident needs/preferences .the resident plan of care will be communicated across shifts and among caregivers . Per the facility policy, revised July 2018, titled Abuse Prevention, Training, and Screening Program, .the facility maintains adequate staffing on all shifts to ensure each resident's needs are reasonably met .

Feb 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to treat one of one sampled residents with dignity when a Certified Nursing Assistant (CNA) provided dressing and grooming without privacy and respect (Resident 1). As a result, Resident 1 was at risk for emotional distress and embarrassment when dressed in front of other residents. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses to include difficulty walking and muscle weakness, per the facility admission Record. On 1/30/23 at 10:30 A.M., an interview was conducted with the Facility Manager (FM). The FM stated two CNA students had reported witnessing CNA 1 on 1/24/23: 1. Change Resident 1 ' s shirt without pulling a privacy curtain in a room with six residents, 2. Used inappropriate language towards Resident 1, 3. Wiping Resident 1 ' s face roughly with a disposable washcloth, and, 4. Using a beverage (lemonade) to wet Resident 1 ' s hair. On 1/30/23, a record review was conducted. Per the Minimum Data Set (MDS, an assessment tool), dated 12/30/22, Resident 1 had a Brief Interview for Mental Status (BIMS) staff assessment indicating moderately impaired cognition. Section G indicated Resident 1 was totally dependent on staff for dressing and personal hygiene. On 1/30/23 at 4:19 P.M., an observation of Resident 1 was conducted. Resident 1 was in bed, alert and dressed neatly. Resident 1 did not respond to questions. Five other residents shared the room with Resident 1. Privacy curtains were hung between beds but not pulled, and no personal care was being provided. CNA 1 was not available for interview. On 1/31/23 at 3:45 P.M., an interview was conducted with CNA 2. CNA 2 stated she was familiar with Resident 1 ' s care needs and was assigned to her occasionally. CNA 2 stated Resident 1 needed assistance with everything, like dressing, eating, and bathing. CNA 2 stated when dressing Resident 1 or any other resident, it was important to pull the privacy curtain. CNA 2 stated, I wouldn ' t want to get dressed in front of other people, we have to treat the residents with respect. If the resident doesn ' t want me to do something, like comb their hair, I should stop and let the nurse know. CNA 2 stated it was never acceptable to swear or use bad language in front of residents. On 1/31/23 at 9:40 A.M., an interview was conducted with the FM. Per the FM, Our goal is to treat residents with dignity and respect. They have rights we have to protect. This did not happen at all here. On 1/31/23 at 9:52 A.M., an interview was conducted with the DON. The DON stated, This allegation, the alleged wiping of the face, etc, is unacceptable. We would not want any resident to be treated in this manner whatsoever. On 1/31/23 at 1:15 P.M., an interview was conducted with CNA Instructor (CNAI) 1. CNAI 1 stated the two CNA students had reported no privacy had been provided for Resident 1 when changing her shirt, as the privacy curtain had not been pulled so Resident 1 was within view of the other residents. Per CNAI 1, the CNA students had reported Resident 1 did not seem to like the water and lemonade dripped on her head, or the disposable washcloth used on her face. The CNA students reported Resident 1 had pulled away and made noises to indicate her dislike. CNAI 1 stated according to the CNA students, CNA 1 had used a derogatory word in another language when Resident 1 objected to the care provided. CNAI 1 stated the students were taught they were Mandated Reporters (people required by law to report suspected or known instances of abuse or neglect) so reporting their observations to the facility was, The right thing to do. On 2/13/23 at 10 A.M., an interview was conducted with the FM. The FM stated CNA 1 ' s employment had been terminated due to the incident. The FM stated CNA 1 was terminated for poor job performance. Per a facility policy, revised January 1, 2012 and titled Resident Rights, .Employees are to treat all residents with kindness, respect, and dignity .I. State and federal laws guarantee basic rights to all residents of the Facility. These rights include .a residents right to: .D. Privacy and confidentiality .III. Each resident is allowed to choose .health care .including .B. Personal care needs, such as bathing methods, grooming styles and dress .

Dec 2022 10 deficiencies

CONCERN (D)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have a call light assessable to activate for one of one resident (Resident 39) reviewed for accommodation of needs. As a result, there was the potential for Resident 39 to not have her needs met. Findings: Resident 39 was re-admitted to the facility on [DATE], with diagnoses which included quadriplegia (paralysis resulting in the inability to move from the neck down), per the facility's admission Record. On 12/12/22 at 10:04 A.M., 11:27 A.M., and 3:24 P.M., an observation was conducted of Resident 39 as she laid in bed. Resident 39 was able to move her head only and the call light pad (a flat push pad that a resident uses to notify staff when assistance is needed, by using the side off her head or chin to activate a light), was positioned above the resident's head out of visual and physical range. On 12/13/22 at 8:30 A.M., 11:39 A.M., and 1:04 P.M., an observation was conducted of Resident 39 as she laid in bed. The call light push pad was positioned above the head on the right side of the bed and was out of visual and physical range. On 12/13/22 at 1:04 P.M., an observation and interview was conducted with CNA 16 of Resident 39's call light pad placement. CNA 16 viewed the call light pad and stated the resident could not activate the pad because it was out of reach. CNA 16 stated the call light pad should be positioned directly next to her head, so she could activate it. CNA 16 stated with the call light pad being out of reach, the resident was unable to make her needs known. On 12/13/22 at 1:12 P.M., an interview was conducted with LN 16. LN 16 stated Resident 39 needed to have her call light pad placed properly at all times, so she could call for help if needed. LN 16 stated all staff were responsible for ensuring the call light pad was within the resident's reach. LN 16 stated when the call light pad was out of reach, the resident could not let her needs be known to staff. On 12/13/22 at 1:30 P.M., an interview was conducted with the DON. The DON stated Resident 39 was completely dependent on staff and her call light pad should always be within reach. The DON stated if the call light pad was not positioned within reach, the resident needs could not be met. According to the facility's policy titled Communication-Call system, dated January 2012, .The facility will provide a call system to enable residents to alert nursing staff from their rooms . III. Nursing staff will answer call lights promptly .

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Physicians Orders for Life Sustaining Treatment (POLST-a form which indicated a resident's code status) forms and the code status (the level of medical interventions a person wishes to have if their heart or breathing stops) order was available to the staff for two of three residents reviewed for Advanced Directives (Residents 42 and 46). This failure had the potential for Resident 42 and Resident 46 to receive incorrect care in the event of a medical emergency. Findings: 1. Resident 42 was readmitted to the facility on [DATE] with diagnoses which included end stage renal disease (ESRD, chronic kidney disease), per the facility's admission Record. On 12/12/22, a review of Resident 42's record was conducted. There was no POLST in Resident 42's paper chart or in the electronic record. There was no code status in the physician's order upon Resident 42's admission. On 12/12/22 at 3:03 P.M., a joint review of Resident 42's record and an interview with LN 1 was conducted. LN 1 stated the process was when a resident was admitted to the facility, the LN admitting the resident should have verified the code status of the resident. LN 1 stated there was no POLST in the resident's chart or in the electronic record and no code status order for Resident 42. LN 1 stated there should have been a code status for Resident 42 to provide her wishes in case of emergency. On 12/14/22 at 2:07 P.M., an interview with the DON was conducted. The DON stated the LNs should have clarified the code status of the residents to provide them with their wishes in case of emergency. A review of the facility's policy titled Physicians Orders for Life Sustaining Treatment (POLST), revised 6/3/20, indicated, Purpose: To help ensure that the facility honors residents' treatment wishes concerning resuscitation and life-sustaining treatment, Policy .III. The POLST form .C. Is legally recognized as a physician order .Procedure .III. Initiating a POLST .C. Completion of a POLST form will reflect a process of careful decision making by the resident, the resident's legally recognized health care decision maker if the resident lacks decision making capacity, and the attending physician, physician assistant or nurse practitioner, regarding the resident's medical condition and known treatment preferences . 2. Resident 46 was readmitted to the facility on [DATE], with diagnoses which included COVID-19 (communicable disease) per the facility's admission Record. On 12/12/22, a review of Resident 46's record was conducted. There was no POLST in Resident 42's paper chart or in the electronic record. There was no code status in the physician's order upon Resident 46's admission. On 12/12/22 at 3:03 P.M., a joint review of Resident 46's record and an interview with LN 1 was conducted. LN 1 stated the process was when a resident was admitted to the facility, the LN admitting the resident should have verified the code status of the resident. LN 1 stated there was no POLST in the resident's chart and in electronic record and no code status order for Resident 46. LN 1 stated there should have been a code status for Resident 46 to provide her wishes in case of emergency. On 12/14/22 at 2:07 P.M., an interview with the DON was conducted. The DON stated the LNs should have clarified the code status of the residents to provide them their wishes in case of emergency. A review of the facility's policy titled Physicians Orders for Life Sustaining Treatment (POLST), revised 6/3/20, indicated, Purpose: To help ensure that the facility honors residents' treatment wishes concerning resuscitation and life-sustaining treatment, Policy .III. The POLST form .C. Is legally recognized as a physician order .Procedure .III. Initiating a POLST .C. Completion of a POLST form will reflect a process of careful decision making by the resident, the resident's legally recognized health care decision maker if the resident lacks decision making capacity, and the attending physician, physician assistant or nurse practitioner, regarding the resident's medical condition and known treatment preferences .

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop person-centered comprehensive care plans for two of six residents (Resident 22 and Resident 39), reviewed for care plans. As a result, there was a potential for inconsistent care and for the needs of Resident 22 and 39's to not be met. 1. Resident 22 was admitted to the facility on [DATE] with diagnoses which included left hemiplegia (left sided weakness) following a cerebral infarction (stroke), per the facility's admission Record. On 12/15/22, Resident 22's clinical record was reviewed. According to the physician's order, dated 12/9/22, the resident was admitted to hospice (end of life, comfort care). There was no documented evidence a hospice care plan had been developed. On 12/15/22 at 9:26 A.M., an interview was conducted with LN 17. LN 17 stated when a resident was admitted to hospice, the LN should immediately develop a care plan for the hospice care. LN 17 stated care plans acted as a means of communication among staff and guided the resident's care. On 12/15/22 at 9:28 A.M., an interview was conducted with LN 3. LN 3 stated care plans for hospice were important so all staff were aware and provided the same care. LN 3 stated it was the responsibility of the LNs to develop the care plan, when the resident was admitted to hospice. On 12/15/22 at 9:36 A.M., an interview and record review was conducted with the DON. The DON stated Resident 22 should have had a care plan for hospice developed and there was not one. The DON stated care plans were integrated so all staff were on the same page, when providing care. According to the facility's policy titled Hospice Care of Residents, dated January 2012, .III B. The Hospice and Facility will collaborate on a Care Plan for the resident . According to the facility's policy titled, Comprehensive Person-Centered Care Planning, dated November 2018, .IV. Comprehensive Care Plan .c. The comprehensive care plan will be periodically be reviewed and revised .i. Onset of new problems; ii. Change of condition . 2. Resident 39 was re-admitted to the facility on [DATE], with diagnoses which included quadriplegia (paralysis resulting in the inability to move from the neck down), per the facility's admission Record. On 12/13/22 Resident 39's clinical record was reviewed. The MDS, (a clinical assessment tool) dated 7/15/22, listed the resident's Functional Status as totally dependent for mobility, personal hygiene, dressing, and eating. There was no documented evidence a care plan had been developed for Activities of Daily Living (ADL), indicating the resident's total dependency for care. On 12/13/22 at 11:33 A.M., an interview and record review was conducted with LN 4. LN 4 stated Resident 39 was completely dependent on staff for all care and there should be a care plan for ADL care. LN 4 stated care plans were important because it was a communication tool and informed the staff of the resident's routine and preferences. LN 4 reviewed Resident 39's clinical record and stated there was no care plan for ADL, so there was no consistency in care being provided. On 12/13/22 at 1:12 P.M., an interview and record review was conducted with LN 16. LN 16 stated Resident 39 had a care plan for impaired mobility, but she should also have a specific care plan for ADL care and she did not. LN 16 stated an ADL care plan was important for staff, so the care was being consistently provided. On 12/13/22 at 1:30 P.M., an interview and record review was conducted with the DON. The DON stated care plans were important because it guided the residents plan of care and provided a means of communication between staff. The DON reviewed Resident 39's clinical record and stated an ADL care plan was never developed and it should have been. According to the facility's policy titled, Comprehensive Person-Centered Care Planning, dated November 2018, .IV. Comprehensive Care Plan .c. The comprehensive care plan will be periodically be reviewed and revised .i. Onset of new problems; ii. Change of condition .

CONCERN (D)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to consistently provide catheter (a tube inserted into the bladder) care for one of four residents (44) reviewed for catheter. This failure had the potential to increase the risk of urinary infection for Resident 44. Findings: Resident 44 was admitted to the facility on [DATE], with diagnoses which included obstructive uropathy (condition in which the flow of urine is blocked), per the facility's admission Record. A review of Resident 44's History and Physical dated 7/2/22, indicated the attending physician documented Resident 44 did not have the capacity to understand and make decisions. A review of Resident 44's physician order was conducted. There was no catheter care order for Resident 44. A review of Resident 44's laboratory results, dated 12/9/22, indicated Resident 44 had more than 100,000 organisms (possible infection) in his urine. On 12/12/22 at 9:47 A.M., an observation and interview of Resident 44 was conducted. Resident 44 was lying in bed and did not respond when his name was called. Resident 44 had a foley catheter draining a dark yellow urine output into a urine bag. On 12/13/22 at 2:43 P.M., an interview with CNA 1 was conducted. CNA 1 stated Resident 44 was alert and confused at times. CNA 1 stated Resident 44 had a catheter from the time of his admission to the facility and he yanked it at times. CNA 1 stated she did peri-care (personal hygiene) to Resident 44. CNA 1 stated she did not know what other staff provided as far as care in regards to Resident 44's catheter. On 12/14/22 at 10:33 A.M., a joint review of Resident 44's record and an interview with LN 2 was conducted. LN 2 stated Resident 44 was sent to the emergency room on [DATE] and was discharged back to the facility on [DATE] with diagnosis of urinary tract infection (UTI). LN 2 stated Resident 44 was started on an antibiotic medication on 12/10/22. LN 2 stated there was no catheter care order for Resident 44. LN 2 stated I just check the flow and the kink for patency. On 12/13/22 at 11:38 A.M., a joint observation, interview and record review was conducted with LN 3. LN 3 stated Resident 44 always had the catheter because of uropathy. LN 3 stated catheter care was performed by the wound treatment nurses and the responsibility was transferred to the floor (medication pass) nurses a month or two months ago. LN 3 stated there was a catheter care order for Resident 44 on 8/18/22, and was discontinued on 9/16/22. A new order for catheter care was started on 9/16/22 and was discontinued on 10/10/22. LN 3 stated there was no current physician's order for catheter care. LN 3 stated catheter care was important for residents with foley catheters to prevent urinary tract infection. On 12/14/22 at 1:36 P.M., an interview with LN 4 was conducted. LN 4 stated the wound treatment nurses used to do catheter care for residents with foley catheter. LN 4 stated months ago the responsibility of catheter care was transferred to the floor nurses. LN 4 stated the floor nurses should have ensured there was a physician's order for catheter care and they (floor nurses) should have implemented to residents with catheter. LN 4 stated Ever since the catheter care was taken from my to do list, I have not been doing that. On 12/14/22 at 2:07 P.M., an interview with the DON was conducted. The DON stated the expectations was for the residents with catheter, the nurses were to provide catheter care to prevent urinary tract infection. A review of the facility's policy titled Catheter - Care of, revised 6/10/21, indicated, Purpose: To prevent catheter - associated urinary tract infections .Policy .II. Residents with foley catheters will be cared for .to prevent Urinary Tract Infections .

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow a physician's order related to oxygen use for one of one resident (12) reviewed for respiratory care. This failure had the potential for Resident 12 to develop oxygen toxicity (an adverse effect). Findings: Resident 12 was admitted to the facility on [DATE], with diagnoses which included respiratory failure and was dependent on supplemental oxygen (O2), per the facility's Record of Admission. A review of Resident 12's history and physical dated 10/30/22 indicated the physician documented Resident 12 had a fluctuating capacity to understand and make decisions. A review of Resident 12's MDS (an assessment tool) Special Treatment, Procedures, and Programs, dated 10/31/22, indicated Resident 12 was on oxygen therapy. A review of Resident 12's physician's order dated 10/18/22, indicated, Oxygen at 2 L/min (liters per minute) via NC (nasal cannula, a device used to deliver supplemental oxygen) . On 12/12/22 at 8:35 A.M., an observation and interview of Resident 12 was conducted. Resident 12 was lying in bed, with O2 with a flow rate of 4 L/min via NC. Resident 12 stated she was fine. On 12/13/22 at 10:37 A.M., and at 2:25 P.M., an observation of Resident 12 was conducted. Resident 12's oxygen flow rate was at 4 L/min via NC. On 12/13/22 at 2:25 P.M., an interview with CNA 2 was conducted. CNA 2 stated Resident 12 was always on O2 and that LNs were in-charge of it. On 12/13/22 at 3:01 P.M., a joint observation of Resident 12's oxygen flow rate, a review of Resident 12's physician order and an interview with LN 2 was conducted. LN 2 stated Resident 12's O2 flow rate was 4 L/min via NC. LN 2 stated the physician's order was 2 L/min via NC. LN 2 stated we were not following the O2 flow rate order for Resident 12. LN 2 stated not following the physician's order was considered a medication error and could cause oxygen toxicity. On 12/14/22 at 2:07 P.M., an interview with the DON was conducted. The DON stated the expectation was for the LNs to check the physicians oxygen order and follow the physician's order for resident safety. A review of the facility's policy titled Oxygen Therapy, revised November 2017, indicated, Purpose: To ensure the safe storage and administration of oxygen in the facility. Policy: Oxygen is administered under safe .conditions to meet resident needs. Licensed Nursing staff will administer oxygen as prescribed .

CONCERN (D)

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure dialysis (the process of cleaning the blood through a machine) access site was properly cared for timely for one of one resident investigated for dialysis (37). The deficient practice had a potential for Resident 37's dialysis access to clot. Findings: Resident 37 was readmitted to the facility on [DATE], with diagnoses that included End Stage Renal Disease (kidney failure), per the facility's admission Record. A review of Resident 37's history and physical dated 9/15/22, indicated Resident 37 had the capacity to understand and make decisions. On 12/12/22 at 11:20 A.M., an observation of Resident 37 was conducted. Resident 37 wheeled himself into his room with left upper arm pressure dressings over his dialysis access site. On 12/12/22 at 3:10 P.M., an observation and interview of Resident 37 was conducted. Resident 37 was sitting up in bed, watching a movie. Resident 37 stated he returned from dialysis. Resident 37 stated his schedule for dialysis were early mornings on Mondays, Wednesdays and Fridays. Resident 37 showed his dialysis access site on his left upper arm with pressure dressings on it. On 12/13/22 at 8:40 A.M., a joint observation of Resident 37's dialysis access site and an interview with LN 5 was conducted. LN 5 stated the pressure dressings on Resident 37's dialysis access site should have been removed after six hours to prevent clogging of the access and infection of the access site. On 12/14/22 at 10:17 A.M., a review of Resident 37's record and an interview with LN 6 was conducted. LN 6 stated the process was for the LNs to check the dialysis access site of residents who came from dialysis. LN 6 stated the pressure dressings on residents' access site should have been removed after four to six hours to prevent clogging of the dialysis access site. On 12/14/22 at 2:07 P.M., an interview with the DON was conducted. The DON stated the LNs were to check residents' dialysis access site after dialysis to ensure there were no complications. The DON stated the LNs should have removed the pressure dressings timely to prevent clotting of the access and infection of the access site. On 12/15/22 at 9:03 A.M., a telephone interview with the Dialysis Registered Nurse (DRN) was conducted. The DRN stated the licensed nursing staff at the facility should have removed the pressure dressings from Resident 37's access site after four hours to check if the bleeding had stopped and to prevent clotting of the access. A review of the facility's policy titled Dialysis Care, revised 10/1/18, indicated, Purpose: To provide dialysis care for residents in renal failure and those residents who require ongoing dialysis treatments .Procedure .III. Dialysis Care .D. Ateriovenous [sic] (Arteriovenous [AV] - surgical connection of artery to a vein used as a vascular access in patients receiving dialysis) shunt .ii. AV shunt site will be inspected for functionality and sign and symptoms of complication .

CONCERN (D)

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

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility did not ensure proper food storage's were met when expired food were found in the refrigerator. This failure has the potential to result in harmful bacteria growth and cross contamination that could lead to foodborne illnesses to residents in the facility. Findings: On 12/12/22 at 8:45 A.M., a concurrent observation and interview with the CDM of the kitchen refrigerator was conducted. The top shelf of the refrigerator had a five (5) pound bag of grated parmesan cheese with an opened date of 11/28/22 and a use by date of 5/27/22. The CDM validated the above findings. The CDM stated the refrigerator should not have expired food in it to prevent potential cross contamination and foodborne illnesses being passed to the residents. 12/12/22 at 2:33 P.M., an interview with the RD was conducted. The RD stated, the refrigerator should not have any expired food in it. The RD stated, it is the expectation for the staff to follow the guidelines for expired foods, and should have discarded any expired foods from the refrigerator when found. The RD further stated, it is important for the staff to follow the guidelines to prevent any potential foodborne illnesses to residents. According to the 2017 US Food and Drug Administration Food Code, section 3-502.12, Manufacturers use by date: It is recommended that food establishments consider the manufacturer's information as good guidance to follow to maintain the quality (taste, smell, and appearance) and salability of the product. If the product becomes inferior quality-wise due to time in storage, it is possible that safety concerns are not far behind . The facility did not have a policy for expired foods.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple 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 ensure staff followed infection control practices and appropriate transmission-based precautions when: 1. An ice scoop was found laying on top of the ice in the ice chest in one of two nursing stations (Station A). 2. A resident (Resident 55) was observed crossing into and out of a red zone area (a designated Isolation area). 3. Two of eight urinary catheter drainage bags were in contact with the floor. ( Resident 26 and 61). 4. A staff member did not don (to put on) PPE (personal protective equipment) when entering one of one transmission based isolation room. 5. A licensed nurse (LN) did not perform hand hygiene or change gloves during medication administration. These failures had the potential to increase the risk of infection to residents and staff within the facility due to cross - contamination. Findings: 1. On 12/12/22 at 10 A.M., an observation of an ice chest was conducted. The ice chest located on station A when inspected had an ice scoop laying on top of the ice inside the ice chest. On 12/12/22 at 10:01 A.M., a concurrent observation and interview was conducted with CNA 11. CNA 11 stated the ice scoop was left sitting on top of the ice inside the ice chest. CNA 11 stated the ice scoop should not be inside the ice chest on top of the ice. CNA 11 stated the reason the ice scoop is not supposed to be left in the ice chest, was it could be dirty from staff touching it and it could make the residents sick. CNA 11 immediately removed the ice scoop from the ice chest. On 12/12/22 at 10:16 A.M., an interview with LN 1 was conducted. LN 1 stated, the ice scoop is not to be stored in the ice chest to prevent contamination of the ice and was a potential transmission of infection to residents. LN 1 immediately removed the ice chest from the unit. On 12/12/22 at 10:31 A.M., an interview with the ICN was conducted. The ICN stated it was the expectation that staff stored the ice scoop outside the ice chest. The ICN further stated it was important to prevent the transmission of infection to residents. According to the 2017 US Food and Drug Administration Food Code, section 3-304.12, In-use utensils properly stored . In-use utensils may not be stored in chemical sanitizer or ice between uses. Ice scoops may be stored handles up in an ice bin except for an ice machine . During a review of the facility's policy titled, Ice Machines and Ice Storage chests, Revised October 1, 2014, indicated, To help prevent contamination of ice machines and ice chests / containers or ice, facility staff take the following precautions .E. Keep the ice scoop / bin in a covered container when not in use . 2. On 12/13/22 at 10:44 A.M., Resident 55 was observed entering and exiting the red zone. LN 12 was observed escorting Resident 55 out of the red zone to a chair in the main hallway. The red zone area had red tape across the floor at the entrance of the isolation area. Resident 55 was admitted to the facility on [DATE], with a diagnosis which included cancer of the lungs, per the admission Record. A review of Resident 55's MDS (assessment tool), dated 10/24/22, indicated that the resident had a BIMS (a cognitive assessment) score of fifteen (indicating no cognitive impairment). Per the Functional Status, Resident 55 required oversight only and was not dependent on staff for mobility. On 12/13/22 at 10:46 A.M., an interview with Resident 55 was conducted. Resident 55 stated, he was not aware that he was going into an isolation area, because he was looking for someone. Resident 55 stated he never saw any signs that indicated not to enter the area. Resident 55 further stated the staff never told him he could not go into that section of the hallway. On 12/13/22 at 10:51 A.M., an interview with LN 2 was conducted. LN 2 stated Resident 55 should not be in the red zone as it was the designated area for covid (a highly contagious virus) positive residents and Resident 55 did not have covid. LN 2 stated it was important to observe transmission-based precautions to prevent the spread of covid in the facility. On 12/13/22 at 10:57 A.M., an interview with the ICN was conducted. The ICN stated, it was the expectation that staff were following the facility policy and procedure for infection control by monitoring the red zone and implementing isolation precautions to prevent the spread of infection. The ICN stated it was important to mitigate the spread of covid to residents and staff, by utilizing good infection control practices. The ICN further stated the staff need to follow the facility policy and procedure for infection control, and they were not. During a review of the facility's policy titled, Infection Control, Revised January 1st, 2012, indicated, . The Facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage the transmission of diseases and infections .C. Establish guidelines for implementing isolation precautions, including standard and transmission-based precautions . During a review of the facility's Covid 19 Mitigation Plan section titled, .Additional Cohorting Guidance, Revised October 8th, 2022, indicated, .Clear signage designating the area should be used separate the areas and indicate the direction of movement from one designated area to another . 4. Resident 37 was readmitted to the facility on [DATE], with diagnoses which included enterocolitis (inflammation of the digestive tract) due to clostridium difficile (C-diff, bacteria that causes diarrhea and enterocolitis), per the facility's admission Record. A review of Resident 37's history and physical dated 9/15/22, indicated Resident 37 had the capacity to understand and make decisions. A review of Resident 37's laboratory results dated [DATE], indicated C-diff was detected from Resident 37's stool specimen. On 12/12/22 at 3:07 P.M., an observation of Resident 37 was conducted. There was a poster by Resident 37's door that indicated Resident 37 was on contact isolation, Personal Protective Equipment (PPE-such as gown, gloves, face shield/ goggles and N95 mask) and performed hand hygiene were required before entering and exiting the resident's room. On 12/12/22 at 3:07 P.M., an observation of CNA 3 was conducted. CNA 3 was inside Resident 37's room touching Resident 37's belongings without donning a gown and gloves. On 12/12/22 at 3:09 P.M., an interview of CNA 3 was conducted. CNA 3 stated Resident 37 was on isolation, but she did not know what kind of infection he had. CNA 3 stated she did not wear gown or gloves when entering Resident 37's room. CNA 3 stated she should have worn full PPE for protection and prevention of spread of infection. On 12/14/22 at 2:01 P.M., an interview with ICN was conducted. The ICN stated the expectations was for the staff to wear full PPE when entering residents' room on isolation to prevent infection and cross contamination. On 12/14/22 at 2:07 P.M., an interview with the DON was conducted. The DON stated the expectation was for staff to read the posters and follow precautions for donning and doffing for infection control. A review of the facility's policy titled, Resident Isolation - Initiating Transmission- Based Precautions, revised 4/22/16, indicated, Purpose: To ensure the use of transmission-based precautions when a resident has a communicable infectious disease .Procedure .V. When transmission-based precautions are implemented .A. Ensures that protective equipment (i.e., gloves, gowns, mask, etc.) is maintained . so that everyone entering the room can access .B. Posts the appropriate notice .so that all personnel are aware of precautions . 5. Resident 11 was readmitted to the facility on [DATE] with diagnoses which included gastrostomy (g-tube, a surgical insertion of a tube for administration of fluids, foods, and medications), per the facility's admission Record. On 12/13/22 at 9:49 A.M., an observation of medication (med) administration for Resident 11 was conducted with LN 5. LN 5 prepared Resident 11's eight types of meds, placed the meds into med cups, placed the med cups in a tray, went into Resident 11's room, and placed the tray in the bedside table. LN 5 picked up a plastic pack of wipes from the floor, picked up the fall mats from the floor, moved them away, drew the privacy curtain, then took the syringe from the equipment pole, and checked Resident 11's g-tube using the same gloves. LN 5 did not perform hand hygiene and did not change gloves in between the tasks. On 12/13/22 at 10:22 A.M., an interview with LN 5 was conducted. LN 5 stated she did not change her gloves or performed hand hygiene after picking up the supplies and equipment from the floor. LN 5 stated she should have performed hand hygiene and changed gloves to prevent Resident 11 from getting an infection. On 12/14/22 at 2:01 P.M., an interview with ICN was conducted. The ICN stated the LNs should have performed hand hygiene and changed gloves after touching anything for infection control and prevent cross contamination. On 12/14/22 at 2:07 P.M., an interview with the DON was conducted. The DON stated LN 5 should have performed hand hygiene and changed gloves after touching contaminated items to prevent cross contamination and prevent introducing bacteria into Resident 11's g-tube. A review of the facility's policy tilted, Feeding Tube- Administration of Medication, revised November 2018, indicated, Purpose: Medications are administered appropriately and safely when the resident has a feeding tube in place .Procedure .II. Wash hands before and after procedure . 3. a. Resident 26 was readmitted to the facility on [DATE], with diagnoses which included obstructive and reflux uropathy (a medical condition of when the urine flow is blocked), per the facility's admission Record. On 12/12/22, at 3:09 P.M., an observation was conducted of Resident 26, as he laid in bed. Resident 26's urinary catheter drainage bag was visible from the door and connected to the right side of the bed frame. The bottom of the urinary drainage bag was touching the floor, causing the urinary bag to lean sideways. On 12/13/22 at 8:52 A.M., an observation was conducted of Resident 26, as he laid in bed. The bottom of Resident 26's urinary catheter drainage bag was resting on the floor. On 12/13/22, Resident 26's clinical record was reviewed. According to the physician's order, dated 10/18/22, .Foley (brand name) Catheter FR #18 (size) connected to drainage bag via gravity . 3. b. Resident 61 was admitted to the facility on [DATE], with diagnoses which included functional quadriplegia (the inability to move due to another medical condition), per the facility's admission Record. On 12/12/22 at 11:49 A.M., and 3:09 P.M., an observation was conducted from the hallway of Resident 61 room, as he laid in bed. A urinary catheter drainage bag was clipped to the right side of the bed frame. The bottom of the drainage bag was in contact with the floor. On 12/14/22, Resident 61's clinical record was reviewed. The physician's order, dated 11/16/22, .insert a new Foley FR 18 with 30 cc (cubic centimeters) balloon at gravity . On 12/13/22 at 8:20 A.M., an observation was conducted of Resident 61 as he laid in bed. Resident 61's urinary catheter drainage bag was hanging from the right side of the bed, and the bottom of the drainage bag was in contact with the floor. On 12/13/22 at 8:37 A.M., an observation and interview of Resident 26 and 61's catheter drainage bag was conducted with CNA 17. CNA 17 viewed Resident 26's catheter drainage bag and immediately repositioned it, stating catheter bags should never be in contact with the floor, it's an infection control issue. CNA 17 viewed Resident 61's urinary catheter drainage bag and stated, everyone was responsible for ensuring the bags were not in contact with the floor. On 12/13/22 at 8:44 A.M., an interview was conducted with CNA 18. CNA 18 stated if urinary catheter drainage bags were in contact with the floor, bacteria could travel up from the floor and enter the residents, resulting in an infection. CNA 18 stated urinary drainage bags should never be in contact with the floor. On 12/13/22 at 8:51 A.M., an interview was conducted with LN 16. LN 16 stated urinary drainage bags should never touch the floor. LN 16 stated if the bags had contact with the floor, residents were at a higher risk of infection from the bacteria on the floor. On 12/13/22 at 9:26 A.M., an interview was conducted with the DON. The DON stated she expected all staff to prevent catheter drainage bags from touching the floor, because if touching, it increased the residents' risk of infection. On 12/13/22 at 2:06 P.M., an interview was conducted with the ICN. The ICN stated catheter drainage bags should never be in contact with the floor. The ICN stated the floor were dirty and it placed the residents with catheters at a high risk for getting an infection. The ICN stated staff should be conducting regular rounds and placing eyes on the residents to prevent this. According to the facility's policy titled Indwelling Catheter, dated September 2014, there were no instructions for keeping the catheter drainage bag off the floor. According to the facility's policy titled Infection Control-Policies & Procedures, dated January 2012, .I. The Facility's infection Control policies and procedures apply equally to all Facility Staff .II. Objective: A. Prevent, detect, investigate, and control infections in the Facility .

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0911 (Tag F0911)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assure that resident rooms housed no more than four residents. Two rooms had the potential to accommodate five residents in each room (rooms [ROOM NUMBERS]). Seven rooms had the potential to accommodate six residents in each room (Rooms 2, 3, 4, 5, 13, 15, and 18). As a result, the potential existed to impact resident care and quality of life. Findings: On 12/12/22 through 12/15/22, observations were conducted during the course of the annual recertification survey at the facility. Additionally, interviews and records reviews were conducted. There were no observed quality of care or quality of life concerns related the number of residents in the rooms. A continuance of the waiver (variation) from the requirements of 42 CFR section 483.70(d)(1)(i) as granted pursuant to a letter from the Centers for Medicare and Medicaid Services (CMS), dated January 25, 2019, and allowing more than four residents per room, is hereby recommended. This recommendation is also made with the expectation that the facility will obtain a timely renewal of the current waiver (variation) granted by CMS as reflected in the January 25, 2019 letter to the facility from CMS.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0912 (Tag F0912)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assure the resident rooms measured at least 80 square feet per resident in resident room [ROOM NUMBER]. As a result, the potential existed to impact resident care and quality of life. Findings: On 12/12/22 through 12/15/22, observations were conducted during the course of the annual recertification survey at the facility. The facility had 1 multiple resident room (room [ROOM NUMBER]) that did not meet the minimum 80 square feet per resident. room [ROOM NUMBER] measured 479 square feet and had the potential to house 6 residents. The allocated space for each resident would measure 79.83 square feet. The five residents occupying the room had no complaints. There were no observed quality of care or quality of life concerns that negatively impacted the residents residing in the identified room. A continuance of the waiver (variation) from the requirements of Code 42 of the Federal Regulations (CFR) section 483.70(d)(1)(ii) as granted pursuant to a letter from the Centers for Medicare and Medicaid Services (CMS), dated January 25, 2019, and allowing less than 80 square feet per resident per room per room, is hereby recommended. This recommendation is also made with the expectation that the facility will obtain a timely renewal of the current waiver (variation) granted by CMS as reflected in the January 25, 2019 letter to the facility from CMS.

Nov 2022 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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple 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 ensure the residents (1, 2, 3, 4, 5, 6, 7, 8) were free from diversion of their controlled medications ([meds]medications that can cause physical and mental dependence and are regulated by the Drug Enforcement Administration) when the controlled medications were unaccounted for the month of May 2022. This had the potential for affected residents' medication to not be available in the event they were needed. There were no missed doses for the affected residents. Findings: On 5/31/22, the Department received a complaint related to pharmaceutical services. On 6/9/22, an unannounced onsite visit to the facility was conducted. A review of the residents' record were as follows; 1.Resident 1 was admitted to the facility on [DATE], with diagnoses which included muscle weakness, per the facility's admission Record. A review of the pharmacy packing slip dated 5/13/22, indicated the facility's licensed nurse (LN) had received 25 tablets of hydrocodone/ Acetaminophen (APAP) 5/325 mg [sic- milligrams] tablets. A review of Resident 1's physicians order dated 5/11/22 indicated, Hydrocodone- Acetaminophen 5-325 mg [sic- milligram] tablet, give 1 tablet by mouth every 6 hours PRN [sic- as needed] for severe pain. A review of the medication administration record (MAR- the report that serves as a legal record of the drugs administered to a patient at a facility by a health care professional) for the month of May 2022 indicated Resident 1 had received 21 tablets of Hydrocodone- Acetaminophen 5-325 mg from 5/13/22 through 5/31/22. There was no medication count sheet provided on 6/9/22. On 6/9/22 at 12:42 P.M., an observation and interview of Resident 1 was conducted. Resident 1 was sitting in a wheelchair outside her room. Resident 1 stated she was not able to walk. Resident 1 stated she had no issues with her pain meds. 2. Resident 2 was readmitted to the facility on [DATE], with diagnoses which included generalized muscle weakness, per the facility's admission Record. A review of the pharmacy packing slip dated 5/11/22 indicated the facility's LN had received 90 tablets of hydrocodone/ Acetaminophen (APAP) 5/325 mg [sic- milligrams] tablets. A review of Resident 2's physicians order dated 4/13/22 indicated, Hydrocodone- Acetaminophen 5-325 mg tablet, give 1 tablet by mouth every 6 hours PRN [sic- as needed] for severe pain. A review of the medication administration record MAR for the month of May 2022 indicated Resident 2 had received two tablets of Hydrocodone- Acetaminophen 5-325 mg from 5/1/22 through 5/31/22. There was no medication count sheet provided on 6/9/22. On 6/9/22 at 12:27 P.M., an observation and interview of Resident 2 was conducted. Resident 2 gazed unattentively when name was called and did not answer. 3. Resident 3 was admitted to the facility on [DATE], with diagnoses which included right pubic fracture (break in bone), per the facility's admission Record. A review of the pharmacy packing slip dated 5/24/22 indicated, the facility's LN had received 120 tablets of hydrocodone/ Acetaminophen (APAP) 5/325 mg [sic- milligrams] tablets. A review of Resident 3's physicians order dated 4/21/22 indicated, Hydrocodone- Acetaminophen 5-325 mg tablet, give 1 tablet by mouth every 6 hours PRN [sic- as needed] for severe pain related to fracture . A review of the medication administration record MAR for the month of May 2022 indicated Resident 3 had not received the medication from 5/1/22 through 5/31/22. There was no medication count sheet provided on 6/9/22. On 6/9/22 at 12:22 P.M., an interview with Resident 3 was conducted. Resident 3 stated was only taking acetaminophen. 4. Resident 4 was readmitted to the facility on [DATE], with diagnoses which included cerebral palsy (weakness or problems with using the muscles), per the facility's admission Record. a.A review of the pharmacy packing slip dated 5/3/22 indicated the facility's LN had received 60 tablets of hydrocodone/ Acetaminophen (APAP) 5/325 mg [sic- milligrams] tablets. A review of Resident 4's physicians order dated 4/12/22 indicated, Hydrocodone- Acetaminophen 5-325 mg tablet, give 1 tablet via g-tube ([sic] gastrostomy tube- tube inserted through the wall of the abdomen directly into the stomach and used to administer food, medication). every 6 hours PRN [sic- as needed] for moderate, severe pain. A review of the medication administration record MAR for the month of May 2022 indicated Resident 4 had received three tablets of hydrocodone /APAP 5-325 mg from 5/1/22 through 5/31/22. There was no medication count sheet provided on 6/9/22. b. A review of the pharmacy packing slip dated 5/5/22 indicated the facility's LN had received 60 tablets of oxycodone/ Acetaminophen (APAP) 5/325 mg [sic- milligrams] tablets. A review of Resident 4's physicians order dated 4/12/22 indicated, Oxycodone- Acetaminophen 5-325 mg tablet, give 1 tablet via g-tube ([sic] gastrostomy tube- tube inserted through the wall of the abdomen directly into the stomach and used to administer food, medication). every 8 hours PRN [sic- as needed] for moderate, severe pain. A review of the medication administration record MAR for the month of May 2022 indicated Resident 4 had received 14 tablets of oxycodone/APAP 5-325 mg from 5/1/22 through 5/31/22. There was no medication count sheet provided on 6/9/22. On 6/9/22 at 12:33 P.M., an observation and interview of Resident 4 was conducted. Resident 4 was lying in bed with both hands contracted (tightening of muscles) and did not respond when name was called. 5. Resident 5 was admitted to the facility on [DATE], with diagnoses which included fracture of the right femur (broken thighbone), per the facility's admission Record. A review of the pharmacy packing slip dated 5/5/22 indicated the facility's LN had received 90 tablets of hydrocodone/ Acetaminophen (APAP) 5/325 mg [sic- milligrams] tablets. A review of Resident 5's physicians order dated 4/13/22 indicated, Hydrocodone- Acetaminophen 5-325 mg tablet, give 1 tablet by mouth every 6 hours PRN [sic- as needed] for moderate pain related to fracture . A review of the medication administration record MAR for the month of May 2022 indicated Resident 5 had received seven tablets of Hydrocodone- Acetaminophen 5-325 mg from 5/1/22 through 5/31/22. There was no medication count sheet provided on 6/9/22. On 6/9/22 at 12:30 P.M., an observation and interview of Resident 5 was conducted. Resident 5 was seated in a wheelchair with a staff with her. Resident 5 did make a sound but did not answer accurately to questions. Resident 5 stated she fell in a train wreck. 6. Resident 6 was admitted to the facility on [DATE], with diagnoses which included cord compression (a condition that puts pressure on your spinal cord, one symptom is pain), per the facility's admission Record. a.A review of the pharmacy packing slip dated 5/5/22 indicated the facility's LN had received 60 tablets of oxycodone/ Acetaminophen (APAP) 5/325 mg [sic- milligrams] tablets. b. A review of the pharmacy packing slip dated 5/24/22 indicated the facility's LN had received 60 tablets of oxycodone/ Acetaminophen (APAP) 5/325 mg [sic- milligrams] tablets. A review of Resident 2's physicians order dated 4/12/22 indicated, oxycodone/ Acetaminophen (APAP)5-325 mg tablet, give 1 tablet by mouth every 4 hours PRN [sic- as needed] for moderate, severe pain. A review of the medication administration record MAR for the month of May 2022 indicated Resident 6 had received five tablets of oxycodone/ Acetaminophen (APAP)5-325 mg tablet from 5/1/22 through 5/31/22. There was no medication count sheets for the two deliveries provided on 6/9/22. On 6/9/22 at 12:34 P.M., an observation and interview of Resident 6 was conducted. Resident 6 was lying in bed, stated he had pain on both of his legs. Resident 6 stated he had not missed any pain medications. 7. Resident 8 was admitted to the facility on [DATE], with diagnoses which included fibromyalgia (a disorder characterized by widespread musculoskeletal pain), per the facility's admission Record. A review of the pharmacy packing slip dated 5/15/22 indicated the facility's LN had received 18 tablets of hydrocodone/ Acetaminophen (APAP) 5/325 mg [sic- milligrams] tablets. A review of the medication count sheet indicated Resident 8 had received 7 tablets of hydrocodone from 5/17/22 through 5/22/22. The narcotic sheet indicated there were 11 tablets remained in the med bubble pack (packaging in which a product is sealed between a cardboard backing and clear plastic cover). The bubble pack was not found in the med cart on 6/9/22. A review of Resident 8's physicians order dated 5/15/22 indicated, Hydrocodone- Acetaminophen 5-325 mg tablet, give 1 tablet by mouth every 8 hours PRN [sic- as needed] for pain. On 6/9/22 at 12:45 P.M., Resident 8 was not available for observation and interview. 8. Resident 9 was readmitted to the facility on [DATE], with diagnoses which included aftercare following surgery of the digestive system, per the facility's admission Record. A review of the pharmacy packing slip dated 5/10/22 indicated the facility's LN had received 18 tablets of hydrocodone/ Acetaminophen (APAP) 5/325 mg [sic- milligrams] tablets. A review of the medication count sheet indicated Resident 9 had received 12 tablets of hydrocodone from 5/10/22 through 5/30/22. The medication count sheet indicated there were six tablets remained in the med bubble pack (packaging in which a product is sealed between a cardboard backing and clear plastic cover). The bubble pack was not found in the med cart on 6/9/22. On 6/9/22 at 12:45 P.M., Resident 9 was not available for observation and interview. On 6/9/22 at 9:46 A.M., an interview with the Infection Preventionist Nurse (IPN) was conducted. The IPN stated LN 1 took controlled medications from the med carts. The IPN stated upon their investigation, there were total of nine residents involved. The IPN stated some medications were just refilled because it was the end of the month of May and the pharmacy refilled them for the month of June 2022. The IPN stated the facility re-ordered the controlled medications for the involved residents. On 6/9/22 at 10:22 A.M., an interview with Certified Nursing Assistant (CNA) 1 was conducted. CNA 1 stated on 5/30/22, Licensed Nurse (LN) 1 came into the facility on her day off. CNA 1 stated, she asked LN 2 to sign CNA 1's residents shower sheets. CNA 1 stated while she was with LN 2, LN 1 went to LN 2 and took the keys for medication (med) cart # 2. CNA 1 stated LN 1 then moved the cart facing the resident's room and looked through the medications in the med cart. CNA 1 stated LN 2 did not know what LN 1 was doing. CNA 1 stated LN 3 and LN 4 were asked What was she doing? CNA 1 stated she left from there. CNA 1 stated also, she worked on 5/29/22 and saw LN 1 came to the facility on her day off and went to med cart # 2. CNA 1 stated she did not see what she did and had not heard what LN 1 said to her. CNA 1 stated LN 2 worked also on 5/29/22. CNA 1 stated Mostly if we are not in uniform or scrub suits, they don't let us go in. They usually ask us what we need, we only come on our days off when there's a meeting or to get our paycheck. On 6/9/22 at 11:12 A.M., an interview with LN 2 was conducted. LN 2 stated LN 1 came to the facility in her casual wear, went to the med cart # 2 and asked her for the keys to the med cart. LN 2 stated she gave the key and followed her to the medication cart. LN 2 stated she was signing the residents' shower sheets with CNA 1 when LN 1 approached her. LN 2 stated LN 1 moved the cart facing the resident's room (room #) so LN 2 thought it was suspicious. LN 2 stated while LN 1 was leaving, LN 2 talked to LNs 4 and 5 on what LN 1 did. LN 1 then left with the full med bubble packs (packaging in which a product is sealed between a cardboard backing and clear plastic cover) of controlled medications and the controlled medication sheets. LN 2 stated she did not know who owned the controlled medications that LN 1 took. LN 2 stated she called the management and the police station to report. LN 2 stated LN 1 was picked up right after she exited the facility. LN 2 stated I shouldn't have given the keys, I trusted her because she was a sweet girl and she trained me, this was a big lesson learned. On 6/9/22 at 11:46 A.M., an interview with the Director of Nursing (DON) was conducted. The DON stated the staff saw LN 1 coming on her day off but there was no med discrepancy reported. On 7/11/22, attempted to interview LNs 4 and 5, but did not return calls. On 11/23/22 at 3:28 P.M., a telephone interview with the Quality Assurance Nurse (QAN) was conducted. The QAN stated LNs were responsible of the med carts they were assigned, they should not be giving out the keys of the medication carts because they were accountable to it. The QAN stated the residents might not get their medications if were not there. A review of the facility's undated policy titled Controlled Medication Accountability was conducted. The policy did not indicate measures to prevent licensed nurse to have access into the medication carts when they were not scheduled to work.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• 37% turnover. Below California's 48% average. Good staff retention means consistent care.

Concerns

• Multiple safety concerns identified: 2 harm violation(s), $52,435 in fines, Payment denial on record. Review inspection reports carefully.
• 62 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
• $52,435 in fines. Extremely high, among the most fined facilities in California. Major compliance failures.
• Grade F (20/100). Below average facility with significant concerns.

Bottom line: Trust Score of 20/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Pioneers Memorial Skilled Nursing Center's CMS Rating?

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

How is Pioneers Memorial Skilled Nursing Center Staffed?

CMS rates PIONEERS MEMORIAL SKILLED NURSING CENTER's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 37%, compared to the California average of 46%. This relatively stable workforce can support continuity of care. RN turnover specifically is 67%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Pioneers Memorial Skilled Nursing Center?

State health inspectors documented 62 deficiencies at PIONEERS MEMORIAL SKILLED NURSING CENTER during 2022 to 2025. These included: 2 that caused actual resident harm, 54 with potential for harm, and 6 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Pioneers Memorial Skilled Nursing Center?

PIONEERS MEMORIAL SKILLED NURSING CENTER is owned by a government entity. Government-operated facilities are typically run by state, county, or municipal agencies. The facility operates independently rather than as part of a larger chain. With 99 certified beds and approximately 72 residents (about 73% occupancy), it is a smaller facility located in BRAWLEY, California.

How Does Pioneers Memorial Skilled Nursing Center Compare to Other California Nursing Homes?

Compared to the 100 nursing homes in California, PIONEERS MEMORIAL SKILLED NURSING CENTER's overall rating (1 stars) is below the state average of 3.1, staff turnover (37%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Pioneers Memorial Skilled Nursing Center?

Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.

Is Pioneers Memorial Skilled Nursing Center Safe?

Based on CMS inspection data, PIONEERS MEMORIAL SKILLED NURSING CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in California. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Pioneers Memorial Skilled Nursing Center Stick Around?

PIONEERS MEMORIAL SKILLED NURSING CENTER has a staff turnover rate of 37%, which is about average for California nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Pioneers Memorial Skilled Nursing Center Ever Fined?

PIONEERS MEMORIAL SKILLED NURSING CENTER has been fined $52,435 across 1 penalty action. This is above the California average of $33,603. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.

Is Pioneers Memorial Skilled Nursing Center on Any Federal Watch List?

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

Facility Details

Beds: 99
Avg. Residents: 72
Occupancy: 73.3%
Ownership: Government - Hospital district
Chain: Independent
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
2 Actual Harm citations: -10
62 Deficiencies: -10
Fines ($52,435): -10
Final Score: 20/100

Nearby Alternatives

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Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 555557