OAK GLEN POST ACUTE
For profit - Limited Liability company
59 Beds
PACS GROUP
Data: November 2025
Trust Grade
55/100
#640 of 1155 in CA
Photo by Oak Glen Post Acute
Photo by Oak Glen Post Acute
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Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Oak Glen Post Acute in Cherry Valley, California, has a Trust Grade of C, indicating it is average and positioned in the middle of the pack among nursing homes. It ranks #640 out of 1155 in California and #24 out of 53 in Riverside County, placing it in the bottom half of facilities in the state and county. The facility is improving, having reduced the number of issues from 15 in 2024 to 8 in 2025. Staffing is below average with a rating of 2 out of 5 stars, but the turnover rate is a favorable 30%, which is lower than the state average. Although there have been no fines, the facility has concerning RN coverage, ranking below 92% of other California facilities. However, there are significant weaknesses to consider. An incident reported in March 2024 involved a failure to protect residents from inappropriate sexual behavior by another resident, impacting multiple individuals. Additionally, the kitchen has been cited for unsanitary food storage and preparation practices, which could lead to foodborne illnesses among residents. These findings highlight the need for careful consideration when choosing this facility.
- Trust Score
- C
- In California
- #640/1155
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ○ Average
- 30% turnover. Near California's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most California facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 16 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 37 deficiencies on record. Higher than average. Multiple issues found across inspections.
55/100
Bottom 45%
Needs review
15 → 8 violations
★★★☆☆
3.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 15 issues
2025: 8 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (30%)
18 points below California average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
3-Star Overall Rating
Near California average (3.1)
Meets federal standards, typical of most facilities
Staff Turnover: 30%
16pts below California avg (46%)
Typical for the industry
Chain: PACS GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 37 deficiencies on record
1 actual harm
Aug 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure the residents' room temperatures were monitored and recorded for three days in July 2025.This failure had the potential to prevent t...
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Based on interview and record review, the facility failed to ensure the residents' room temperatures were monitored and recorded for three days in July 2025.This failure had the potential to prevent the facility from identifying whether the air conditioning system was functioning properly, which could result in residents experiencing discomfort or unsafe heat-related conditions. Findings:A review of the facility documents titled, Room and Hallway Temperature Log, Month of July 2025, indicated missing temperature entries on the following dates:- July 4, 2025- July 5, 2025; and- July 6, 2025On July 15, 2025, at 10:10 a.m., an interview was conducted with the Maintenance Director (MTD). The MTD stated the compressor for the facility's air conditioning (AC) system broke down on July 11, 2025. The MTD stated this was the only day the AC unit had malfunctioned. The MTD stated he immediately placed a call with their vendor who helped with their AC maintenance, and they came to check the units that same day and provided an estimate of cost for the replacement of the compressors. The MTD stated, meanwhile, he placed fans in each resident room and an industrial cooling unit in the hallway.On July 15, 2025, at 10:29 a.m., an interview was conducted with Resident 3. Resident 3 stated on July 5, 2025, she noticed the building temperature felt warmer than usual and suspected the AC unit had broken down. Resident 3 further stated she notified staff but wasn't sure if repairs were being made.On July 15, 2025, at 3:34 p.m., a concurrent interview and record review of the facility's resident room temperature logs was conducted with the Maintenance Director (MTD). The MTD stated the facility's protocol was to monitor resident room temperatures daily, including on weekends. The MTD stated he did not work from July 4, 2025, to July 6, 2025, and in his absence, the temperatures were not checked on those days. The MTD stated the room temperatures should have been checked to ensure they were not too high as elevated temperatures could cause discomfort and place residents at risk of unsafe heat related conditions.On July 15, 2025, at 4:45 p.m., a concurrent interview and record review of the facility's resident room temperature logs was conducted with the Administrator (ADM). The ADM stated to ensure resident safety, MTD staff were responsible for monitoring and recording resident room temperatures daily, including weekends. The ADM further stated, MTD staff should have checked and logged the temperatures on July 4 to 6, 2025, to ensure the AC was functioning properly and that the room temperatures were not elevated, to prevent residents from experiencing discomfort or conditions such as heat stroke or dehydration. A review of facility's policy and procedure titled, Homelike Environment, dated 2001, indicated, .residents are provided with a safe, clean, comfortable and homelike environment and.the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting.these characteristics include.comfortable and safe temperatures (71 -81 F (Fahrenheit [temperature scale]).A review of facility's policy and procedure titled, Maintenance Service, dated 2001, indicated, .maintenance service shall be provided to all areas of the building, grounds, and equipment .functions of the maintenance personnel include, but are not limited to .maintaining the heat/cooling system .
May 2025
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 15's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses whic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 15's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses which included aphasia (a language disorder that affects a person's ability to communicate) following non-traumatic intracerebral hemorrhage (bleeding inside the brain that does not result from trauma or injury).
On May 22, 2025, at 9:41a.m., in a concurrent interview and record review with the Social Services Director (SSD), the SSD stated a review of Resident 15's Advance Directive Acknowledgement Report indicated, Resident 15 had executed an Advance Directive on admission, however; the SSD stated a copy of the AD was not found in Resident 15's record. The SSD further stated the AD should be in the resident's record available for nurses and physician to access to have information how the resident wants to be cared for when he is held unconscious. The SSD stated if the AD was not available there is a potential that interventions provided would go against his wish.
A review of the facility policy and procedure titled, Advance Directives, dated 2016, indicated, .Social service director or designee will inquires of the resident .about the existence of any written advance directive .If a resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives .Staff will document in the medical record the offer to assist and the resident decision to accept of decline assistance .
Based on interview and record review, the facility failed to ensure the following for two of six residents (Residents 5 and 15) reviewed for Advance Directive (AD - written statement of a person's wishes regarding medical treatment):
1. For Resident 5, the resident or the resident's representative had been provided information and education regarding the formulation of an AD; and
2. For Resident 15, a copy of the AD was available in the resident's record.
These failures had the potential to lead to the residents' wishes regarding medical treatment being unknown and ultimately not honored.
Findings:
1. A review of Resident 5's admission Record, indicated Resident 5 was admitted to the facility on [DATE].
A review of Resident 5's History and Physical dated April 29, 2025, indicated Resident 5 has fluctuating capacity to understand and make decisions.
On May 20, 2025 at 1:46 p.m., during an interview with Resident 5, he stated he did not know if he has an AD or what is the AD.
On May 22, 2025, at 9:49 a.m., during a concurrent interview and review of Resident 5's medical record with the Social Service Director (SSD), she stated if a resident did not have an AD, she would offer resources and education to the resident or the resident representative. The SSD stated it was important for residents to be educated and have the opportunity to formulate an AD in the event the resident were unable to make decisions in the future. The SSD stated Resident 5 had no AD, was not provided education, and was not reviewed for AD. The SSD further stated she should have followed up and provided AD education to Resident 5 or the resident's representative.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two residents reviewed (Resident 159), ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two residents reviewed (Resident 159), was receiving oxygen treatment in accordance with the care plan developed by the facility.
This failure had the potential for the staff to be unaware whether the resident is consistently receiving the appropriate supplemental oxygen which could negatively impact the resident's overall health.
Findings:
On May 19, 2025, at 10:06 a.m., Resident 159 was observed turning off the oxygen concentrator after an alarm had sounded. Resident 159 stated, oh that happens a few times a day, and if I turn it off and back on it will stop.
On May 19, 2025, between 9:45 a.m. to 11:45 a.m., Resident 159 was observed to have turned the oxygen concentrator on and off on two occasions, and again between 1:45 p.m. to 3:45 p.m., for a total of four occasions. At no time during the observations were staff observed to enter the room to address Resident 159 about the oxygen concentrator or the need for use of the oxygen.
On May 20, 2025, at 10:30 a.m., an observation and interview was conducted with Resident 159. Resident 159 was alert and sitting up in bed. The oxygen concentrator was observed to be turned off and the nasal cannula (a plastic tubing that delivers oxygen) was not placed in the appropriate area, along the face and nasal passage. Resident 159 stated, oh I turned it off because it made a noise, but you can turn it back on if you want.
A review of Resident 159's record, indicated she was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure with hypoxia (shortness of breath, associated with a weakening of the lungs capacity to produce oxygen), and heart failure (a weakend ability of the heart to pump blood throughout the body)
Resident 159's history and physical dated May 12, 2025, indicated she did have the capacity to understand and make decisions.
A review of the physicians order dated May 11, 2025, indicated, .Oxygen at ___2liters / min (a unit of measure) or__90_% via [specify delivery system] Nasal Cannula, Humidification: [specify] Yes Frequency: [Continuously] - every shift for CHF AND as needed .
A review of Resident 159's Care Plan indicated, .Care plan: Oxygen: Resident requires the use of oxygen r/t (related too) congestive heart failure. Start date. May 11, 2025 .Goal .will be compliant with oxygen therapy .Intervention .monitor oxygen saturation via pulse oximetry every (specify) .administer oxygen at___L via (specify) .
On May 20, 2025, at 10:35 a.m., an interview was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated it was the nurses responsibility to conduct morning rounds for the residents on oxygen to check the oxygen flow rates, dates of the tubing and assess the residents for shortness of breath. LVN 1 stated she did not check on Resident 159 today and she was not aware if Resident 159 was receiving oxygen or at what rate. LVN 1 stated Resident 159 had a behavior of turning the machine on and off and was able to 'reset it' on her own without the assistance of staff. LVN 1 further stated Resident 159 had the ability to tell when she needed the oxygen.
On May 22, 2025, at 1:41 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated there should be a care plan developed for Resident 159's behaviors of turning off the oxygen concentrator and the nurses should be checking the oxygen rate, tubing, and should be assessing the residents each shift. The DON further stated there was a risk for the resident not to receive the necessary oxygen needed which could cause unwanted signs and symptoms such as shortness of breath.
A review of the facility policy and procedure titled, Care Plans, Comprehensive Person-Centered dated 2016, indicated, .the comprehensive, person-centered care plan will .incorporate identified problem areas .incorporate risk factors associate with identified problems .aid in preventing or reducing decline in the resident's functional status and/or functional levels .identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure nutritional care and services were provided, f...
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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 nutritional care and services were provided, for one of two residents reviewed for nutrition (Resident 41).
This failure had the potential for the resident to continue having weight loss due to the delay in provision of appropriate intervention.
Findings:
On May 20, 2025, at 2:57 p.m. an interview was conducted with Resident 41. Resident 41 stated she only enjoyed a small portion of the meals provided and that she had lost weight because of it. Resident 41 could not recall her current weight.
A review of Resident 41's record was conducted. Resident 41 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (the inability to regulate sugar in the body), and muscle wasting and atrophy (decreased strength of the muscles causing weakness).
Resident 41's history and physical dated April 7, 2025, indicated she did have the capacity to understand and make decisions.
A review of the dietary notes dated April 21, 2025, indicated, .residents weight loss of -4 lbs (pounds - a unit of measure) within 1 week. Recommendations to change diet to fortified. Referred to (physicians name) and agreed with orders to change diet to fortified. Orders noted and carried out .
A review of the change of condition notice dated April 25, 2025, indicated, .Resident with a -4 lb weight loss in 1 week. Resident had a -4 lb weigh loss on 4/18/25. Seen by RD (Registered Dietitian) Resident's average intake is <75%, HS snack offered daily. Resident has a preference of small portions. RD previous recommendation to add fortified foods to current diet order. MD (physician) .Will monitor resident and encourage meals with any supplemental meals offered if refuses meals .
A review of the weekly weights indicated on May 2, 2025, Resident 41 weighed 110 lbs. On May 9, 2025, and on May 16, 2025, the resident weighed 105 pounds which is a -5 lbs Loss.
A review of the care plan initiated April 9, 2025, indicated, .Resident has Type 2 diabetes mellitus without complications. interventions .monitor for signs of hyper/hypoglycemia (i.e weight loss).
A review of the care plan initiated April 16, 2025, indicated, .Resident has nutritional problem or potential nutritional problem r/t anxiety, T2DM interventions .Monitor record/report to MD PRN s/sx of malnutrition: Emaciation (cachexia), muscle wasting, significant weight loss >5% in 1 month .provide and serve diet as ordered (Registered Dietitian) RD to evaluate and make diet change recommendations PRN .
A review of the progress notes, dietary notes, nutritional notes, did not indicate discussion on the weight loss of the resident from May 9 to May 16, 2025.
On May 22, 2025, at 10:31 a.m., an interview and record review was conducted with the RD. The RD stated the weight for Resident 41 was addressed on April 28, 2025. The RD stated she would do monthly notes for residents with BMI and age related weight loss and that she did not make a note for Resident 41. The RD stated she was not aware of the weight loss for Resident 41 in May and that the DS should bring to her attention any concerns for residents and communicate any changes.
On May 22, 2025, at 2:51 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated she was not aware of the 5 lbs. weight loss for Resident 41. The DON stated a change of condition should have been made for Resident 41 from May 2 to the May 9, 2025 weight change and the RD and the DS should have been made aware. The DON further stated the nurse aide and nurse assigned to the resident should have documented and communicated a weight change with the RD, the DS, and the charge nurse.
On May 22, 2025, at 2:57 p.m. an interview was conducted with the DS. The DS stated she would consider a weight loss of 5 lbs in one week to be reportable to the RD so an evaluation could be made. The DS stated changes in weight should be communicated to the RD, so the RD could conduct an evaluation and a weight variance meeting. The DS stated she was not made aware of the recent weight loss for Resident 41 and the nursing staff should have informed her when it was identified on May 9, 2025.
A review of the facility policy and procedure titled, Weight Assessment and Intervention, dated 2008, indicated, .the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents .negative trends will be evaluated by the treatment team .care planning shall address .identified causes of weight loss .monitoring and reassessment .
A review of the facility policy and procedure titled, Change in a Resident's Condition or Status, dated 2017, indicated, .nurse will notify the resident's attending physician on call when there has been .significant change in the resident's physical/emotional/mental condition .impacts more than one area of the residents health status .a comprehensive assessment of the resident's condition will be conducted .
A review of the facility policy and procedure titled, Charting and Documentation, dated 2022, indicated, .changes in the residents condition .the assessment data and/or any unusual findings obtained .notification of family, physician, or other staff .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three residents reviewed for respirator...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three residents reviewed for respiratory care (Resident 159) , received respiratory treatment in accordance with the physician order.
This failure has the potential to result in Resident 159 not to receive the necessary oxygen treatment which could negatively impact the resident's already compromised health.
Findings:
On May 19, 2025, at 10:06 a.m., a concurrent observation and interview was conducted with Resident 159. Resident 159 was alert and sitting up in bed. She was observed to be using oxygen through a nasal canula (NC - a device to deliver oxygen using a plastic tubing placed in the nostrils) at four liters per minute (LPM - unit of measurement). Oxygen tubing was observed to have a label, dated May 18, 2025. Resident 159 stated she had been using oxygen since she was admitted . Resident 159 was observed turning off the oxygen concentrator after an alarm had sounded. Resident 159 stated, oh that happens a few times a day, and if I turn it off and back on it will stop. Resident 159 stated she was unsure if four liters of oxygen was the correct amount she needed.
On May 20, 2025, at 10:30 a.m., a follow up observation and interview was conducted with Resident 159. Resident 159 was alert and sitting up in bed. The oxygen concentrator was observed to be turned off and the NC was not on the nostrils. Resident 159 stated oh I turned it off because it made a noise, but you can turn it back on if you want.
On May 20, 2025, at 10:35 a.m., a concurrent observation, interview and record review was conducted with LVN 1 at the bedside of Resident 159. LVN 1 stated it was the nurses responsibility to conduct morning rounds for the residents on oxygen to check the oxygen flow rates, dates of the tubing and assess for adverse signs and symptoms and that she checks to see if Resident 159 was using her oxygen or at what rate. A review of the physicians order with LVN 1 indicated Resident 159 was to receive oxygen at a rate of two LPM continuously and as needed. LVN 1 stated it can be either one. LVN 1 stated Resident 159 should be receiving oxygen at a rate of two LPM. LVN 1 observed the oxygen concentrator at the bedside of Resident 159 and noted the oxygen concentrator was turned off. LVN 1 stated Resident 159 had a behavior of turning the machine on and off and was able to 'reset it' on her own without the assistance of staff. LVN 1 further stated that Resident 159 had the ability to tell when she needed the oxygen. LVN 1 turned the oxygen concentrator on and observed the rate was set to four LPM. LVN 1 stated she should not be on four but she should be on two. LVN 1 further stated staff should have checked the rate of oxygen and followed the physicians orders.
On May 22, 2025, at 1:41 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated the physicians order for oxygen administration should have been clarified by the nurse to indicate the proper flow rate, and the frequency and that it should not have read both continuous and as needed. The DON stated nurses should be checking the oxygen flow rates each shift. The DON stated the nurses should be assessing for the oxygen use to make sure the correct setting for the oxygen is in place each shift. The DON further stated the nurses should have followed the orders and conducted assessments so that there are no risks of the residents to not receive the inadequate oxygen levels.
A review of Resident 159's record, indicated she was admitted to the facility on [DATE], with diagnoses which included acute respiratory failure with hypoxia (shortness of breath, associated with a weakening of the lungs capacity to produce oxygen).
Resident 159's history and physical dated May 12, 2025, indicated she did have the capacity to understand and make decisions.
A review of the physicians order dated May 11, 2025, indicated, .Oxygen at ___2liters / min (a unit of measure) or__90_% via [specify delivery system] Nasal Cannula (NC) , Humidification: [specify] Yes Frequency: [Continuously] - every shift for CHF AND as needed .
A review of the nursing weekly summary dated May 19, 2025, indicated, .Oxygen saturation .Method .Oxygen via Nasal .Respiratory .Continuous .liters per minute .2 .route .NC .
A review of the nursing weekly summary dated May 21, 2025, indicated, .Oxygen use .any changes in oxygen use .NO .
A revieww of Resident 159's Care plan: Oxygen: Resident requires the use of oxygen r/t congestive heart failure. Start date. May 11, 2025 .Goal .will be compliant with oxygen therapy .Intervention .monitor oxygen saturation via pulse oximetry every (specify) .administer oxygen at___L via (specify) .
A review of the facility policy and procedure titled, Oxygen Administration, dated 2010 indicated, .verify that there is a physician's order for this procedure .review the physician's orders or facility protocol for oxygen administration .review the resident's care plan to assess for any special needs of the resident .the nasal cannula is a tube that is placed .into the residents nose, held in place by an elastic band placed around the resident's head .while the resident is receiving oxygen therapy, assess for the following .oxygen saturation .documentation .the rate of oxygen flow, rout, and rationale .frequency and duration of the treatment .if the resident refused the procedure, the reason(s) why and the intervention taken .report other information in accordance with facility policy and professional standards of practice .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on interview and record review the facility failed to ensure multiple unused non-controlled medications were disposed in accordance with the policy and procedure. The medication disposition was ...
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Based on interview and record review the facility failed to ensure multiple unused non-controlled medications were disposed in accordance with the policy and procedure. The medication disposition was not witnessed by two staff.
This failure had the potential for medication diversion (the removal of a prescription drug from its intended path from the manufacturer to the patient).
Findings:
On May 21, 2025, at 12:21 p.m., during a concurrent interview and record review, the Director of Nursing (DON) stated the medication will be destroyed in a designated white receptacle and this will be witnessed by two staff. The DON further stated there was a potential for staff to use it for themselves and diversion to occur if theses procedure was not followed.
The DON stated for the disposition on May 20, 2025, the disposition of the following non- controlled medications (medications not considered to have a significant potential for abuse or dependence), was not witnessed by two staff.
a. 3 - carvedilol 25 mg tab (tablet);
b. 31- potassium cl (chloride) ER (extended- release) 20 meq (milliequivalent, a unit of measurement);
c. 11- metformin 500 mg tabs;
d. 13- pantoprazole dr 40 mg (milligram, a unit of measurement) tab;
e. 30- amiodarone 200 mg tab;
f. 155- divalproex dr (delayed- release) 125 mg cap;
g. 31- sertraline 25 mg tab;
h. 19- tamsulosin 0,4 mg cap;
A review of the facility policy and procedure titled, Discarding and Destroying Medications, dated April 2019, indicated .Medications will be destroyed in accordance federal, state, and local regulations of non- hazardous pharmaceuticals .controlled substance .for unused non hazardous .take the medication .mix the medication with either liquid or solid undesirable substance .place the waste mixture in a sealable bag .dispose .in the presence of two witness .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On May 19, 2025 at 10:45 a.m., during observation, two empty antibiotic (ceftriaxone and vancomycin ) bags labeled May 14, 20...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On May 19, 2025 at 10:45 a.m., during observation, two empty antibiotic (ceftriaxone and vancomycin ) bags labeled May 14, 2025, were left hanging on an IV (intravenous) pole.
In a concurrent interview and observation with LVN 4, LVN 4 stated that the empty bags and IV lines should have been removed immediately after they were consumed and discarded properly. LVN 4 further stated there was a potential for cross contamination.
On May 22, 2025, at 8:39 a.m., during an interview with the IP, the IP stated empty IV antibiotics should be removed from the IV pole and from the room and discarded in an appropriate way. The IP stated empty antibiotic bags could be a source of infection gathering more bacteria.
3. On May 19, 2025, at 1:04 p.m., in front of Resident 107's room, two transporter, non-staff, entered a room with EBP signage without wearing proper PPE when attempting to transfer a resident.
A concurrent interview was conducted with the IP, the IP stated the the transporter should have worn the proper PPE when transferring a resident.
A review of Resident 107's admission Record indicated Resident 107 was admitted to the facility May 4, 2025, with diagnoses which included ESRD (end stage renal disease-inability of the kidney to make urine and remove waste from the blood).
A review of Resident 107's care Plan titled Enhanced Barrier Precautions (EBP), dated May 5, 2025, indicated .EBP during high contact resident care due to preesence of indwelling catheter .Place EBP notification/signage to alert staff/visitors of precautions .Utilize PPE (gloves, gown , etc) .during high contact resident care activities (when transferring) .
A review of the facility policy and procedure titled, Isolation-Categories of Transmission-Based Precautions, dated 2022, indicated, .transmission-based precautions are additional measures that protect staff, visitors, and other residents from becoming infected .appropriate notification is placed on the room entrance door and on the front of the cart so that personnel and visitors are aware of the need for and the type of precaution .the signage informs the staff of the type of precautions, instruction for use of PPE, and /or instructions to see a nurse before entering the room .Enhanced Barrier Precautions .visitors should wear gowns and gloves if participating in high-contact care activities .assistance with bathing , toileting .transferring .especially if interacting with multiple residents .
Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when:
1. There was no signage for Enhanced Barrier Precaution (EBP) posted near Resident 40's room. In addition, there was no available personal protective equipment (PPE) supplies for the staff near the resident's room on EBP.
2. Two empty medication bags were not discarded in accordance with the standard of practice; and
3. Two non-staff transporters did not follow the proper isolation precautions for Resident 107.
These failures had the potential to result in cross contamination which could cause illnesses to a vulnerable population.
Findings:
1. On May 19, 2025, at 11:11 a.m., a concurrent interview and record review, was conducted with Licensed Vocational Nurse (LVN) 4 stated Resident 40 was on EBP, and there was no signage of what PPE to wear, and there was no PPE cart by the doorway. LVN 4 stated if there is no signage, staff and non staff would not know what PPE to wear prior to entering the room.
A review of Resident 40's admission Record indicated Resident 40 was admitted to the facility on [DATE], with diagnoses which included paraplegia (inability to voluntarily move the lower parts of the body).
A review of Resident 40's Care Plan titled, Enhanced Barrier Precautions (EBP), dated April 30, 2025, indicated .EBP during high contact resident care due to presence of indwelling catheter .Place EBP notification/signage near resident room .items for following EBP are in place (gloves, gown , etc) .
On May 21, 2025, at 9:15 a.m., a concurrent observation and interview was conducted with LVN 3. LVN 3 stated the staff should wear the appropriate PPE (gown, gloves, and face mask) before entering the room to conduct wound care, because the residents receiving wound care were at risk for infection.
On May 21, 2025, at 9:48 a.m., a follow up interview was conducted with LVN 3. LVN 3 was asked how the staff were made aware of a resident on EBP precautions. LVN 3 stated a sign indicating EBP should be placed near the door frame that indicates the bed number of the resident on EBP and the type of PPE to wear. LVN 3 observed there was no signage posted on the door frame for the resident on EBP and stated you would not know because there is no signage posted. LVN 3 further stated if a sign was not posted within view the resident could be at risk for infection if no PPE was worn.
On May 21, 2025, at 10:06 a.m., with the infection preventionist (IP). The IP observed there was no sign for EBP within view for a resident on EBP precautions. The IP stated all isolation precautions including EBP should have a sign posted within view so that all staff and non-staff could be aware of the necessary PPE to wear prior to entry into the room. The IP further stated if there were no sign posted indicating the proper PPE then a resident could be at risk for infection.
On May 21, 2025, at 10:33 a.m., during a concurrent interview and observation of Resident 40's doorframe with the IP, the IP stated the EBP signage should have been posted, along with the required PPE on the doorframe for the staff and non staff to see before they enter the room.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when:
1. Crumbs and debris were found on the fl...
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Based on observation, interview and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when:
1. Crumbs and debris were found on the floor under the storage shelves in the storeroom;
2. Four clear food storage container had white debris on the top lid;
3. Four multiple canned goods white residue on it;
4. A walk- in refrigerator had dried dark red residue, crumbs and grime were on the floor;
5. The freezer in the disaster supply room had crumbs, and grime on its side and back;
6. Crumbs and debris found under the shelves in the disaster supply room;
7. One fan that was used in the kitchen had white debris on the blades and cover; and
8. Three Cutting boards were found without a smooth surface.
These failures had the potential to cause food contamination and pest infestation leading to food borne illness (stomach illness acquired from ingesting contaminated food) in a vulnerable population of 57 residents who received food prepared in the kitchen.
Findings:
On May 19, 2025, between 8:20 a.m. and 8:40 a.m., a concurrent observation and interview was conducted with the Director of Dietary Services (DDS) in the kitchen. The following areas were discussed:
A.
Crumbs, white debris, and trash were found under the storage shelves in the store room.
The DDS stated the storeroom should be kept clean to prevent pest infestations.
B.
Four clear storage container lids had white debris.
The DDS stated the food storage containers should not be dusty to prevent cross-contamination, which could lead to food borne illness to the residents.
C.
Multiple can goods on the shelf had white residues on it.
The DDS stated the white residue was a cake mix that spilled and should be wiped clean immediately to prevent cross-contamination, which could lead to food borne illness to the residents.
D.
Inside the walk-in refrigerator, dried dark red residue, crumbs and grime where on the floor.
The DDS stated the floor should be kept clean to prevent cross-contamination, which could lead to food borne illness to the residents.
E.
The freezer had crumbs, debris, and grime on its sides and back.
The DDS stated it should be kept clean to prevent pest infestation which could lead to food borne illness to the residents.
F.
Crumbs, debris were found under the shelves on the floor in the disaster supply room.
The DDS stated it should be kept clean to prevent pest infestation which could lead to food borne illness to the residents.
G.
One black fan was observed to have white debris on the blades and cover.
The DDS stated the fan had dust buildup and should be cleaned more frequently to avoid cross-contamination of food which could cause food borne illness.
A review of the facility's policy and procedure titled, Sanitization, dated 2008, indicated, .1 .all kitchen, kitchen areas and dining areas shall be kept clean, free from litter and rubbish .2 all utensils, counters, shelves and equipment shall be kept clean .18 .The Food services staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task .
On May 21, 2025, at 8:50 a.m., a concurrent observation and interview was conducted with the Director of Dietary Services (DDS) in the kitchen. Three cutting boards (brown, green and red color measuring at 24 inches [(a unit measurement of length)] in width and 18 inches in length) were observed with deep indentations and rough surfaces. The DDS stated, the cutting boards had indentations and should have had smooth surfaces to prevent microorganisms (germs) from growing in the grooves, which could lead to foodborne illness among residents.
A review of the U.S FDA Food Code 2022, Section 4-501.12 Cutting Surfaces, indicated, .Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to foods that are prepared on such surfaces .
On May 22, 2025, at 10:30 a.m., an interview was conducted with the Registered Dietitian (RD). The RD stated the storage shelves in the storage rooms, walk-in refrigerator and freezer should not have any grime, white buildup, dirt and should be kept clean to prevent cross-contamination which could cause food borne illness. The RD further stated the cutting boards should not have deep scratches and the fans should not have dust buildup, to prevent cross-contamination, which could cause food borne illness.
A review of the facility's policy and procedure titled, Sanitization, dated 2008, indicated, .1 .all kitchen, kitchen areas and dining areas shall be kept clean, free from litter and rubbish .2 all utensils, counters, shelves and equipment shall be kept clean .18 .The Food services staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task .
Dec 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to:
1. Complete baseline care plans (Initial care plans, including men...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to:
1. Complete baseline care plans (Initial care plans, including mental, physical & psychosocial care needs, based on current health status) within 48 hours of admission for two out of three sampled residents (Residents 1 and 2), and
2. Provide resident and/or resident representative a copy of their baseline care plans, for two out of three sampled residents (Residents 1 and 3).
This failure had the potential to result in a lack of communication between staff and residents, leading to inconsistencies in delivery of care.
Findings:
On December 6, 2024, an unannounced visit was made to the facility for a quality-of-care issue.
1. On December 9, 2024, at 6:09 p.m., an interview was conducted with the Director of Nursing (DON), who stated, baseline care plans were to be completed, within 48 hours of the resident ' s admission. The DON further stated, the members of the IDT, (Interdisciplinary team -Social Services, Rehabilitation, Dietary & Activity department supervisors) completed their portions of the baseline care plans separately, within the 48-hour time frame.
a. A review of Resident 1's medical records, titled, Resident Information, dated, December 11, 2024, indicated, the resident was admitted to the facility on [DATE], with a diagnosis of muscle wasting, and a Brief Interview for Mental Status ({BIMS}- A cognitive assessment) score of 10 (Moderate cognitive impairment). Further review indicated, a representative was legally appointed to make Resident 1's medical care decisions.
A review of Resident 1's Baseline Care Plans, initiated on November 25, 2024, at 10:10 p.m., indicated, the care plans were not completed within 48-hours of admission, as Rehabilitation and Dietary services, had not completed their baseline care plans, until November 30, 2024.
On December 10, 2024, at 8:19 a.m., a concurrent interview with the Rehabilitation Director (RD), and review of Resident 1's rehabilitation evaluation, & baseline care plans were conducted. The RD stated, it was the facility policy to complete baseline care plans within 48 hours of a resident ' s admission. The RD stated, his process for completing his portion of a resident's baseline care plans involved completing a rehabilitation evaluation within 24 hours of admission and then using the evaluation to complete the baseline care plans within 48 hours. The RD stated, Resident 1 was admitted to the facility on [DATE], and he did not complete Resident 1's baseline care plans until November 30, 2024. The RD stated he should have completed the resident ' s baseline care plan within 48 hours.
On November 10, 2024, a concurrent interview with the Dietary Supervisor (DS), and review of Resident 1's baseline care plans were conducted. The DS stated, it was the facilities policy to complete baseline care plans within 48 hours. The DS stated, her process involved completing a dietary evaluation within 24 hours of a resident ' s admission and then using that information to complete the baseline care plans. The DS stated, she completed Resident 1 ' s baseline care plans late, as the resident was admitted on [DATE], and the care plan was not completed until November 30, 2024. The DS stated, she completed the baseline care plan past the 48-hour time frame.
b. A review of Resident 2's medical records, titled, Resident Information, dated, December 11, 2024, indicated, resident was admitted to the facility on [DATE], with a diagnosis of history of falling.
A review of Resident 2's, Baseline Care Plans, initiated on, December 4, 2024, at 9:44 p.m., indicated, the RD and the Social Service Director had not completed the baseline care plan within 48 hours.
On December 10, 2024, at 8:19 a.m., a concurrent interview with the RD, and review of Resident 2's rehabilitation evaluation, & baseline care plans were conducted. The RD stated, it was the facility policy to complete baseline care plans, within 48 hours of admission. The RD stated, his process for completing baseline care plans included completing a rehabilitation evaluation within 24 hours and then using the evaluation to complete the baseline care plans within 48 hours. The RD stated, Resident 2 was admitted to the facility on [DATE] and Resident 2's baseline care plans were not completed until December 7, 2024 (past the 48 hour time frame).
On December 10, 2024, at 9:21 a.m., a concurrent interview with SSD, and review of Resident 2's baseline care plans were conducted. The SSD stated, it was the facility's policy to complete baseline care plans within 48 hours of a resident's admission. The SSD further stated, she meets with the resident/representative within 48 hours of their admission, then uses that information to complete the baseline care plans. The SSD stated, Resident 2 was admitted to the facility on [DATE], and she had not yet completed resident ' s baseline care plans.
A review of the facility Policy, titled, Care Plans - Baseline, revised, March 2022, indicated, . A baseline plan of care to meet the resident ' s immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission .
2. On December 9, 2024, at 6:09 p.m., an interview was conducted with the DON, who stated, it is her expectations all IDT members to give a copy of their completed portion of the resident ' s baseline care plans, to the resident/representative at their initial IDT conference. The DON stated, the process of the initial IDT conference includes, being held within 7-days of the resident 's admission, at which time, the resident 's care plans & goals are discussed. DON further stated, she would expect IDT members to document in a progress note, if a copy of the resident 's baseline care plans were given, and/or offered to the resident/representative, during their initial IDT conference.
a. A review of Resident 1's medical records, titled, Resident Information, dated, December 11, 2024, indicated, the resident was admitted to the facility on [DATE], with a diagnosis of muscle wasting, and a BIMS score of 10 (Moderate cognitive impairment). Further review indicated, a Representative was legally appointed to make Resident 1's medical care decisions.
A review of Resident 1's initial, IDT meeting, dated, November 27, 2024, at 5:16 p.m., indicated, IDT met to discuss plan of care .
Further review of Resident 1's records indicated, there was no documentation, verifying a copy of the residents baseline care plans, was provided/offered to resident/representative during the IDT meeting.
b. A review of Resident 3's medical record titled, Resident Information, dated, December 11, 2024, indicated, resident was admitted to the facility on [DATE], with a diagnosis of a fractured left (Hip), and a BIMS score of 12 (moderate cognitive impairment).
A review of Resident 3's, initial IDT meeting, dated, November 21, 2024, at 2:35 p.m., indicated, . IDT meeting held with resident . (Plan of care) reviewed . Further review indicated, there was no documentation, verifying a copy of the residents baseline care plans were provided/offered to resident/representative during the IDT meeting.
On December 10, 2024, at 8:02 a.m., an interview was conducted with the Activities Director (AD), who stated, she evaluates a resident within 24 hours of their admission, then she uses the information to complete the activities portion of the resident's baseline care plans. AD verified, she does not provide a copy of the activities baseline care plans to the resident/representative and does not provide a copy at their initial IDT conference.
On December 10, 2024, at 8:19 a.m., an interview was conducted with the RD, who stated, he does not provide a copy of the rehabilitation's portion of the resident's baseline care plans to the resident/representative, and does not provide a copy at their initial IDT conference.
On December 10, 2024, at 8:52 a.m., an interview was conducted with the DS, who stated, the dietary portion of the resident's baseline care plans, are reviewed at the resident's initial IDT meeting, and she does not provide a copy of the baseline care plans to the resident/representative and does not provide a copy at their initial IDT conference.
On December 10, 2024, at 9:21 a.m., an interview was conducted with the SSD, who stated, the Social Services portion of the resident's baseline care plans are reviewed at the resident ' s initial IDT meeting. SSD further stated, she does not provide a copy of the resident baseline care plans to the resident/representative at their initial IDT meeting.
On December 10, 2024, 3:41 p.m., an interview was conducted with the DON, who verified, a copy of the resident's baseline care plans, is currently not being given/offered to the resident/representative, during the resident's initial IDT conference.
A facility Policy, titled, Care Plans - Baseline, revised, March 2022, indicated, . 1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standard of quality care and must include the minimum healthcare information necessary to properly care for the resident . 4. The resident and /or representative are provided a written summary of the baseline care plan (in a language that the resident/representative can understand) . 5. Provision of the summary to the resident/and or resident representative is documented in the medical record .
Sept 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
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a copy of the transfer/discharge notice was sent to the repr...
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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 copy of the transfer/discharge notice was sent to the representative of the Office of the State Long-Term Care Ombudsman (LTC Ombudsman) for one of three sampled residents (Resident 1).
This failure has the potential for the Ombudsman not to be able to advocate for the resident in protecting his rights from inappropriate transfer and discharge.
Findings:
On September 4, 2024, Resident 1's record was reviewed. Resident 1 was admitted to the facility on [DATE], with diagnoses which included muscle wasting (loss of muscle strength) and atrophy (thinning of muscles).
A review of Resident 1 ' s History and Physical, dated April 4, 2024, indicated Resident 1 can make decisions.
A review of Resident 1's Minimum Data Set (MDS-an assessment tool), dated June 27, 2024, indicated, Resident 1 had Brief Interview of Mental Status (BIMS-a tool to measure cognitive function in older adults), score of 14 (cognitively intact).
A review of Resident 1 ' s SNF/NF to Hospital Transfer Form, dated July 15, 2024, indicated, .Sent to (name of hospital) .Reinsertion of dislodged suprapubic catheter (medical device that drains urine from bladder) .
There was no documented evidence indicating the facility mailed or faxed a copy of the transfer notice to the LTC Ombudsman.
On September 4, 2024, at 2:36 p.m., during a concurrent interview and review of Resident 1 ' s medical records with the Director of Nursing (DON), she stated the process for transfer or discharge was the resident would be given the notice upon transfer or discharge from the facility and the Social Service Director (SSD) will send the discharge notice to the LTC Ombudsman within 30 days. The DON stated Resident 1 was transferred to the hospital on July 15, 2024, and the discharge notice was not sent to the LTC Ombudsman. The DON further stated the SSD should have sent the notice to the Ombudsman.
On September 4, 2024, at 2:56 p.m., during a concurrent interview and review of Resident 1 ' s medical records with the SSD, she stated for residents who transferred or discharged from the facility, the LTC Ombudsman is sent a letter to notify of the resident discharge within 30 days. The SSD further stated notification is important for resident safety and continuity of care.
The SSD stated Resident 1 was transferred to the hospital on July 15, 2024, and was discharged from the facility. The SSD further stated she did not send the discharge notice to the LTC Ombudsman, she further stated I did not know I have to send it when a resident is transferred. The SSD stated she should have sent Resident 1 ' s transfer/discharge notice to the LTC Ombudsman.
A review of the facility policy and procedure titled, Transfer or Discharge Notice, dated March 2021, indicated, .Residents and/or representatives are notified in writing, and in a language and format they understand, at least thirty days (30) days prior to a transfer or discharge .A copy of the notice is sent to the Office of the State Long -Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative .If the information in the notice changes prior to the transfer or discharge, the recipients of the notice are updated as soon as practicable .
Jul 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
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide a comfortable environment for the residents, when the temperature level for one of the four residents' rooms and in t...
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Based on observation, interview, and record review, the facility failed to provide a comfortable environment for the residents, when the temperature level for one of the four residents' rooms and in the facility hallway was above 81 degrees Fahrenheit (°F -temperature scale).
This failure had the potential to cause discomfort, irritability, sleep disruption, and could lead to health problems.
Findings:
On July 9, 2024, at 4:15 p.m., an unannounced visit to the facility was conducted to investigate a physical environment issue.
On July 9, 2024, at 4:20 p.m., the Resident Representative (RR) was interviewed. The RR stated, on July 6, 2024, the air conditioning was not functioning and the staff had indicated it would be fixed. The RR, who visits the facility daily, stated, facility was hot. The RR stated, last night Resident A woke up soaking wet. The RR stated, the facility air conditioning unit was in poor condition.
On July 9, 2024, at 4:30 p.m., the Maintenance Director (MD) was interviewed. The MD stated he was unaware that the air conditioning was not working last Saturday (July 6, 2024). The MD stated he checked the airconditioning this morning and found the airconditioning system lacking sufficient freon (essential for cooling process).The MD further stated the regular comfortable temperature ranges from 71- 81°F (Fahrenheit).
On July 9, 2024, at 4:45 p.m., the Maintenance Assistant (MA) was interviewed. The MA stated, the staff did not report to him on Saturday (July 6, 2024) that the airconditioning was not working. The MA stated the staff should have called him.
On July 9, 2024, at 5:15 p.m., a concurrent observation of the hallway and Resident A's room was conducted with the MD. The MD stated, the temperature for the hallway and Resident A's room was 83°F. The MD further stated the temperature was high.
On July 9, 2024, at 5:40 p.m., the Certified Nursing Assistant (CNA) was interviewed. The CNA stated he would report to Maintenance immediately if the facility temperature was hot. The CNA stated he would ensure the resident's comfort.
On July 9, 2024, at 6:15 p.m., a concurrent observation and interview with the DON were conducted. The DON stated, the temperature in the hallway was 83°F. The DON stated the comfortable temperature should be 71- 81°F .
A review of the facility policy and procedure titled, Quality of Life- Homelike Environment, dated May 2017, indicated .Comfortable and safe temperature- (71°F to 81°F) .
Apr 2024
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure for one of 16 sampled residents (Resident 54),...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure for one of 16 sampled residents (Resident 54), the call light was within the resident's reach.
This failure had the potential to result in Resident 54 not being able to call for staff assistance when needed.
Findings:
On April 9, 2024, at 8:01 a.m., Resident 54 was lying in bed. The call light was observed not within reach by Resident 54, it was on his right side hanging in between the floor and the bed. Resident 54 stated he could not call for assistance. Resident 54 stated, the call light was not by his side.
On April 9, 2024, at 8:33 a.m., during a concurrent interview and observation in Resident 54's room with CNA 1, CNA 1 stated, Resident 54's call light was not within reach. CNA 1 further stated, the call light should be placed within easy reach of the resident.
A review of Resident 54's admission Record, dated April 10, 2024, indicated the resident was admitted to the facility on [DATE], with diagnoses which included cerebral infarction (stroke- occurs as a result of disrupted blood flow to the brain) and left hemiplegia (left sided paralysis).
A review of Resident 54's Minimum Data Set (MDS- an assessment tool), dated March 6, 2024, indicated, Resident 54 had a Brief Interview of Mental Status (used to assess cognitive status in elderly) score 14 (cognitively intact).
A review of the facility policy and procedure titled, Answering the Call Light, dated October 2010, indicated, .When the resident is in bed or confined to a chair be sure the call is within easy reach to the resident .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a copy of the Advance Directive (AD - written ...
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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 copy of the Advance Directive (AD - written statement of a person's wishes regarding medical treatment) was available in the resident's record readily accessible to the staff, for one of three residents reviewed for AD (Resident 49).
This failure had the potential for Resident 49's AD to not be readily retrievable by the staff and the physician, making them unaware of, and unable to honor the residents' wishes regarding their medical treatment.
Findings:
On April 10, 2024, Resident 49's record was reviewed. Resident 49 was admitted to the facility on [DATE].
A review of Resident 49's Minimum Data Set (an assessment tool), dated March 14, 2024, indicated Resident 49 had severe cognitive impairment.
A review of Resident 49's Advance Directive Acknowledgement, dated January 22, 2024, indicated Resident 49 had executed an Advance Directive.
There was no documented evidence a copy of the AD was provided in Residents 49's medical record.
On April 10, 2024, at 09:40 a.m., during a concurrent interview and review of Resident 49's record with the Social Service Director (SSD), the SSD stated if a resident had an AD, a copy of the AD would be obtained and placed in the resident's record. The SSD stated, Resident 49's AD was not available in the resident's record. The SSD further stated, Resident 49 had an AD that should have been available and accessible to the staff and physician.
The facility Policy and Procedure titled, Advance Directive, dated December 2016, indicated .Prior to or upon admission of a resident, the Social Service Director .Will inquire of the resident .family members .legal representative .about existence of any written advance directive .Information about .an advance directive shall be displayed prominently in the medical record .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow up Level II Preadmission Screening and Residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow up Level II Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) evaluation from the appropriate State-Designated Authority (SDA) upon admission, for two of four residents (Residents 42 and 44).
This failure had the potential for Residents 42 and 44 not to receive the services required in an appropriate setting as determined by the SDA.
Findings:
1. On April 10, 2024, Resident 42's record was reviewed. Resident 42 was admitted to the facility on [DATE], with diagnoses which included major depressive disorder and mild neuro cognitive disorder (types of mental disorders).
A review of Resident 42's PASARR Level 1 Screening document dated March 21, 2024, indicated, .Level 1 - Positive .Result: Positive for suspected MI (sic) (Mental Illness) .Level II Mental Health Evaluation Referral: Required .
Further review of Resident 42's record indicated there was no documented evidence the PASARR Level II was followed up as required by PASARR Level 1 screening.
On April 10, 2024, at 9:28 a.m., during a concurrent interview and review of Resident 42's PASARR with the Director of Nursing (DON), the DON stated all residents admitted to the facility should be screened for PASARR. The DON stated, nursing should follow up if the screening indicated positive for PASARR Level I.
The DON stated Resident 42's initial PASARR Level 1 screening resulted positive and a PASARR Level II is required. The DON further stated, Resident 42's PASARR Level II was not followed up as indicated.
2. On April 10, 2024, Resident 44's record was reviewed. Resident 44 was admitted to the facility on [DATE], with diagnoses which included schizoaffective disorder (type of mental disorder).
A review of Resident 44's PASARR Level 1 Screening document dated December 6, 2022, indicated, .Level 1 - Positive .Result: Positive for suspected MI .Level II Mental Health Evaluation Referral: Required .
Further review of Resident 44's record indicated, there was no documented evidence the PASARR Level II was followed up as required by PASARR Level 1 screening.
On April 10, 2024, at 10:04 a.m., during a concurrent interview and review of Resident 44's PASARR with the DON, she stated Resident 44's initial PASARR Level 1 Screening resulted positive and a PASARR Level II is required. The DON further stated, Resident 44's PASARR Level II was not followed up as indicated.
The DON stated the facility and nursing should have followed up for Resident 42 and 44's PASARR Level II screening. The DON further stated it is important for PASARR Level II to be followed up to determine the appropriate care and setting for residents with mental disorders and for the safety of the other residents in the facility.
The facility's policy and procedure titled, admission Criteria, dated March 2019, indicated, .All new admission and readmissions are screened for Mental Disorders (MD) .per the Medicaid Pre-admission Screening and Resident Review (PASARR) process .If level 1 screen indicates that the individual may meet the criteria for MD .he or she is referred to the state PASARR representative for Level II (evaluation and determination) screening process .
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed for one of 16 residents reviewed for quality of care (Re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed for one of 16 residents reviewed for quality of care (Resident 10) to ensure resident was monitored for signs and symptoms of bleeding or bruising (discoloration and tenderness of the skin resulting from pooling of blood beneath the skin) and the physician was notified.
This failure had the potential for delayed treatment and management.
Findings:
On April 9, 2024, at 8:51 a.m., a concurrent observation and interview with Resident 10, in his room, was conducted. Resident 10 was observed with skin discoloration (bruising) approximately three centimeters (cm) by 0.5 cm. on the right upper arm. Resident 10 stated she could not remember when she got it. Resident 10 stated she could have gotten it from wheeling her wheelchair.
A review of Resident 10's admission Record, indicated , she was admitted to the facility on [DATE], with diagnoses which included cerebro-vascular accident (stroke- a result of disrupted blood flow to the brain).
A review of Resident 10's Physician Order, dated February 26, 2024, indicated:
- Clopidogrel Bisulfate (Plavix- anticoagulant) Oral Tablet 75 MG (milligram- unit of measurement) Give 1 tablet by mouth two times a day for CVA .
- Eliquis (Apixaban- anticoagulant) Oral Tablet 5 MG (unit of measurement) Give 1 tablet by mouth two times a day for CVA .
A review of Resident 10's Care Plan, dated March 14, 2024, indicated, .Focus: Medication-anticoagulant - Resident is at risk for potential bleeding and bruising due to anticoagulant therapy secondary to history of CVA .Interventions .Administer medication as ordered .Monitor for bruising or bleeding .Report abnormal findings to physician .
During a concurrent observation in Resident 10's room and interview with Certified Nurse Assistant (CNA) 1 on April 12, 2024, at 9:21 a.m., CNA 1 stated Resident 10 had a discoloration (bruise) on her right upper arm. CNA 1 stated she was not aware of the resident's bruise. CNA 1 stated, if she observed the bruise she should have reported it to the licensed nurse.
During an interview with Licensed Vocational Nurse (LVN) 1 on April 12, 2024, at 9:27 a.m., LVN 1 stated the CNA should report to the licensed nurse any skin changes. LVN 1 further stated the licensed nurse should assessed any skin issue.
During an interview with LVN 2, on April 12, 2024, at 9:42 a.m., LVN 2 stated, if a resident developed bruise, the resident should have been monitored and the physician should have been notified.
During a concurrent interview and review of Resident 10's record with LVN 2 on April 12, 2024, at 9:52 a.m., LVN 2 stated, the resident is at increased risk for bruises, bleeding, skin discoloration and should have been monitored every shift. LVN 2 stated, there were no documentation Resident 10 was monitored for signs and symptoms of bleeding or bruising for the past two weeks.
During a concurrent interview and observation of Resident 10's right upper arm with LVN 2 on April 12, 2024, at 9:56 a.m., LVN 2 stated Resident had a right upper arm discoloration measuring 0.5 x 3 cm (centimeter- unit of measurement). LVN 2 stated Resident 10 should have been monitored for bruising and bleeding and the licensed nurse should have notified the physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to follow the menu for a Fortified (a food that has extra nutrients added to it or has nutrients added that are not normally the...
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Based on observation, interview, and record review, the facility failed to follow the menu for a Fortified (a food that has extra nutrients added to it or has nutrients added that are not normally there) NAS (no added salt) Mechanical Soft with chopped meat- diet, for one of 16 residents (Resident 33).
This failure had the potential to not meet the resident's nutritional needs.
Findings:
On April 10, 2024, at 11:54 a.m., the FNSD was interviewed. The FNSD stated for fortified diet, the [NAME] should add extra gravy to make it fortified.
A review of Resident 33's meal tray card, for lunch, indicated Mechanical Soft/chopped meats, Fortified NAS.
During a concurrent observation and interview, on April 10, 2024, at 12:14 p.m., during lunch tray line in the kitchen with the Cook, the [NAME] was observed not adding extra gravy to Resident 33's lunch meal tray. The [NAME] placed Resident 33's lunch meal tray onto the meal delivery cart, ready to serve. The [NAME] was asked about Resident 33's lunch meal tray, the [NAME] stated he did not add another scoop of gravy to Resident 33's meal tray. The [NAME] stated, Resident 33's meal tray card indicated, Mechanical Soft/chopped meats, Fortified NAS. The [NAME] stated adding another scoop of gravy would make it a fortified diet.
During a review of Resident 33's Weight Change Note, dated January 16, 2024, indicated .RD (Registered Dietician) NOTE .CBW 205 # (pounds- unit of measurement) Weight Change-8# /3.7% x 1 week .RD Recs. (sic) (recommendations) Fortify current diet order .
A review of Resident 33's Order Summary Report, dated March 5, 2024, indicated, .Fortified NAS diet Mechanical Soft with chopped meat texture .
During a review of the facility's policy and procedure (P&P) titled, FORTIFICATION OF FOOD, dated 2018, the P&P indicated, The goal is to increase the calorie and /or protein of the foods commonly consumed by the resident to promote improvement in their nutrition status .EXTRA GRAVY AND SAUCES .Adds 20-50 calories/item .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed for one of seven residents (Resident 159), to accommodate Resident 159's food preference for no fish, when Resident 159 was serv...
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Based on observation, interview, and record review, the facility failed for one of seven residents (Resident 159), to accommodate Resident 159's food preference for no fish, when Resident 159 was served fish.
This failure resulted in Resident 159's food preference not being honored, potentially leading to the resident not consuming the food served and having the potential for weight loss.
Findings:
A review of the facility document titled, Cooks Spreadsheet, for Week 3 Wednesday, indicated, .SPRING MENUS .Garden Fresh Meatloaf .
A review of the facility document titled, Good For Your Health Menus, for April 8-14, 2024, indicated, .Wednesday April 10 .Garden Fresh Meatloaf .
During tray line observation in the kitchen on April 10, 2024, at 12:45 p.m., the ktichen was observed to run out of meatloaf while serving meal trays. The [NAME] was observed preparing chicken and fish replacing meatloaf. Seven residents were not served meatloaf.
In a concurrent interview with the Cook, the [NAME] stated, the facility ran out of meat loaf. The [NAME] stated, seven residents were not served meatloaf and were served fish or chicken instead.
On April 11, 2024, at 9:33 a.m., Resident 159 was interviewed. Resident 159 stated she was served fish for lunch. Resident 159 stated, she had food preference of no fish.
During a concurrent interview and review of Resident 159's meal service card, on April 11, 2024, at 11:09 a.m., with the Food and Nutrition Service Director (FNSD), the FNSD stated, on the dietary meal service card, Resident 159 dislikes fish. The FNSD stated she should not have been served fish for lunch.
During a review of the facility policy and procedure titled FOOD PREFERENCES, dated 2018, indicated .Resident Food preferences will be adhered to within reason .Substitutes for all food disliked will be given from the appropriate food group .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure that leftover food brought by visitors or family members was stored properly when the temperature of the refrigerator ...
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Based on observation, interview, and record review, the facility failed to ensure that leftover food brought by visitors or family members was stored properly when the temperature of the refrigerator was at 44 degree F (Farenheit - unit of measurement). In addition, food found inside the refrigerator at the nurses' station was not labeled.
This failure had the potential for residents to be exposed to foodborne illness.
Findings:
On April 10, 2024, at 8:50 a.m., during a concurrent observation of the resident's refrigerator at nurses' station 2 and an interview with the Food and Nutrition Service Director (FNSD), it was observed that the residents' refrigerator was 44°F (degrees fahrenheit - a scale for measuring temperature). Inside the refrigerator, a cup of soup was observed, which was not labeled with a name or date. The FNSD stated, the food should be labeled with the resident's name and a use- by date. The FNSD stated, the refrigerator temperature should be below 41°F.
The facility document policy and procedure titled, Foods Brought by Family/Visitor, dated October 2017, indicated .Family /visitors are asked to prepare and transport food using safe food handling practices including .holding temperature (below 41 F) .Perishable foods must be stored .Containers will be labeled with the resident's name, the item and the use by date .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected 1 resident
Based on interview and record review the facility failed to ensure one of two staff reviewed was offered the COVID-19 (a respiratory infection caused by a virus) vaccination and provided education reg...
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Based on interview and record review the facility failed to ensure one of two staff reviewed was offered the COVID-19 (a respiratory infection caused by a virus) vaccination and provided education regarding the benefits and risks of the COVID-19 vaccine.
This failure had the potential for the staff not to have guidance and information regarding the COVID-19 vaccine.
Findings:
On April 11, 2024, at 2:45 p.m., during a concurrent interview and review of CNA 2's Employee Onboarding File, with the Director of Staff Development (DSD), the DSD stated, CNA 2 was hired on March 19, 2024. The DSD stated, CNA 2's COVID-19 vaccination was on February 10, 2022 (2 years ago). The DSD stated, she should have offered COVID-19 vaccine to CNA 2 upon hire.
On April 11, 2024, at 3:09 p.m., during a concurrent interview and review of CNA 2's Employee Onboarding File, with the Infection Preventionist (IP), the IP stated, CNA 2 was not offered the COVID-19 vaccine and was not educated on COVID-19 immunization upon hire. The IP further stated, she is responsible for offering the COVID-19 vaccination to facility staff upon hire and annually.
The IP stated, she should have offered CNA 2 the COVID-19 vaccination and provided education on COVID-19 immunization. The IP further stated, offering Covid-19 vaccinations and educating staff were important to protect the vulnerable residents of the facility and prevent the spread of infections.
A reviewof the facility's policy and procedure titled, Coronavirus Disease (COVID-19) - Vaccination of Staff, dated May 2017, indicated, .Staff are educated about benefits and risk .of COVID-19 vaccine .Staff are offered vaccination against COVID-19 .Each staff member is provided with education regarding the benefits and risks .If the vaccination requires multiple doses of vaccine, staff are again provided with education regarding the benefits .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure the dietary staff performed testing of the sanitizing solution according to manufacturer's instructions.
This failure ...
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Based on observation, interview, and record review, the facility failed to ensure the dietary staff performed testing of the sanitizing solution according to manufacturer's instructions.
This failure had the potential to cause foodborne illness (illness that comes from eating contaminated food) among the 56 vulnerable residents in the facility.
Findings:
During a concurrent observation, interview, and review of the manufacturer's instruction for testing QUAT concentration, on April 10, 2024, at 8:26 a.m., the [NAME] was observed to had dipped the strip into sanitizing solution for five seconds, then compare the strip to a color scale found on the strip container. The [NAME] stated according to the manufacturer's instruction, dip the test strip for 1-2 seconds, and then compare within 10 seconds the strip with the color scale. The [NAME] stated he dipped the strip for five seconds and did not follow the manufacturer's instruction. The [NAME] further stated he should have followed the manufacturer's instruction. The [NAME] stated, otherwise it would not reveal an accurate result and would promote the growth of bacteria that could cause food borne illness.
A review of the manufacturer's instruction in testing the QUAT concentration of the sanitizer, indicated, .CONTROL TESTING .QAC QR Test Strip .Dip test strip into test solution for 1-2 seconds. Within 10 seconds, compare the test pad with color scale .
During a review of the facility policy titled, QUATERNARY AMMONIUM LOG POLICY, dated 2018, indicated, .Follow container and test strip instructions .A high concentration may be potentially hazardous and may be a chemical contaminate of food .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure food items were stored, prepared, and served under sanitary conditions when:
1. The fifteen pounds of bacon were thawe...
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Based on observation, interview, and record review, the facility failed to ensure food items were stored, prepared, and served under sanitary conditions when:
1. The fifteen pounds of bacon were thawed and were refrozen; and
2. There was no thawing log available for review in accordance to the facility's policy and procedure.
These failures had the potential to result in food borne illnesses (illness that comes from eating contaminated food) to 56 medically vulnerable residents.
Findings:
1. On April 8, 2024 at 9:08 a.m., during initial tour of the kitchen with the Food and Nutrition Service Director (FNSD), inside the freezer, four-one-gallon plastic bags containing bacon were observed not frozen solid. A concurrent interview was conducted with the FNSD, FNSD stated the bags of bacon were not in their original container. The FNSD further stated the bacon should be frozen solid, when stored in the freezer.
On April 10, 2024, at 8:06 a.m., during an interview with the FNSD, the FNSD stated, the fifteen pound bacon in original container was thawed and placed in the walk-in refrigerator. The FNSD stated, the cook took a portion of the thawed bacon and placed the remaining portion of the thawed bacon back in the freezer. The FNSD stated, the cook should have thawed only the necessary portion of bacon, and the remaining portion should have been placed back in the freezer. The FNSD stated, once the meat was thawed, the meat should not be refrozen, to prevent bacterial growth that could cause food borne illness.
A review of the U.S FDA (Food and Drug Administration) Food Code 2022, Annex 3 Section 3-501.11 Frozen Food, the Food Code indicated, Freezing prevents microbial growth in foods, but usually does not destroy all microorganisms. Improper thawing provides an opportunity for surviving bacteria to grow to harmful numbers and/or produce toxins. If the food is then refrozen, significant numbers of bacteria and/or all preformed toxins are preserved.
2. On April 10, 2024, at 8:16 a.m., the [NAME] was interviewed. The [NAME] was asked about the facility's thawing process. The [NAME] stated when thawing meat, the frozen meat would be placed inside the walk-in refrigerator for 3 days. The [NAME] stated, the thawed meat should have a pull out date and use-by date. The [NAME] further stated, they did not have a thawing log. The [NAME] stated there should be a thawing log, to keep track of food being thawed, to ensure the food stay within safe range (out of Danger Zone- 41-135 degree F).
During a review of the facility policy and procedure titled, FOOD PREPARATION .FOOD DEFROSTING METHODS, dated 2018, indicated .The preferable method of defrosting frozen perishable food is to defrost in the refrigerator and kept refrigerated until completely thawed. Food must be labeled and dated with item name, pull date and use-by date no more than three days past use by date .
Mar 2024
1 deficiency
1 Harm
SERIOUS
(H)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's rights to be free from sexual abuse (non-con...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's rights to be free from sexual abuse (non-consensual sexual contact of any type such as unwanted touching, groping or any other sexual activity forced upon a person without their consent) by a resident (Resident 1), for four of five sampled residents, (Residents 2, 3, 4, and 5), when the facility failed to reevaluate existing interventions to address Resident 1's inappropriate sexual behavior.
This failure resulted in repeated incidents of inappropriate sexual behavior of Resident 1 towards multiple residents (Residents 2, 3, 4, and 5).
Findings:
On January 10, 2024, at 10:50 a.m., an unannounced visit was conducted to investigate an allegation of sexual abuse.
A review of Resident 1's document titled admission RECORD, undated, indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included major depressive disorder (persistent feeling of sadness, hopelessness, and loss of interest).
A review of Resident 1's Progress Notes, indicated:
- Dated September 27, 2023, at 7:13 p.m., .Resident was seen kissing resident (Resident 3) who is confused .
- Dated September 29, 2023, at 2:48 p.m., .he was noted to walk up and down the halls and was seen by the CN (charge nurse) looking into a female room (Resident 6 and 7's room) .
- Dated October 8, 2023, at 10:18 p.m., .@ 1612 hrs. (at 4:12 pm.) Resident had a (sic) episode of inappropriate behavior of kissing resident (Resident 4) early this shift. CNA (Certified Nursing Assistant) saw resident by the lobby caught in the act of about kissing another resident (Resident 4) .
- Dated October 13, 2023, at 2:12 p.m., .Res (resident) was seen attempting to touch a female resident (Resident 5) by the nursing station .
- Dated October 17, 2023, at 2:02 p.m., .Monitoring res for sexually inappropriate behavior. 1 (one) episode noted this shift. Res was seen by staff almost about to pull down his pants and show his private area to another res (Resident 5) .
- Dated October 19, 2023, at 4:14 p.m., .resident was seen and heard asking a different female resident (Resident 3) if she wants a kiss .
- Dated December 28, 2023, at 3:30 p.m., .Resident seen by staff at nurse ' s station standing over another resident (Resident 5) who was sitting in a wheelchair. Resident was seen kissing resident (Resident 5) and inappropriately touching on the outside of her clothes .
- Dated January 5, 2024, at 12:15 p.m., .this CN (charge nurse) was walking past room (Resident 1's) when this CN saw through the crack in the door, (name of Resident 1) was bent over his roommates bed .saw (name of Resident 1)'s hand on his roommates (Resident 2) penis and (name of Resident 1) was stroking his roommates penis .His roommate was laying in bed with his underwear on, pants off, and his eyes were closed .
A review of Resident 1's Psychiatry Note, indicated the following:
- Dated October 10, 2023, at 10:10 a.m., .discussed incident in which pt (patient) witnessed kissing another female peer (Resident 3) .During the incident, pt's pers (sic) was noted wandering the hall and entering his room. Staff followed peer and witnessed pt kissing female peer (Resident 3). Staff also reported pt masturbating in the restroom and smearing semen on the walls and doorknobs .
- Dated January 3, 2024, at 3:40 p.m., .Pt disclosed kissing a female peer (Resident 5) and admitted that it was unwanted .I don ' t know why I kissed her. I just did it and I knew it was wrong but I just didn't (did not) care. It's no big deal .
On January 10, 2024, at 1:50 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated, she witnessed the incident between Resident 1 and Resident 2 on January 5, 2024. LVN 1 stated, she saw Resident 1 leaning over Resident 2, and rubbing Resident 2 ' s private area, while Resident 2 was sleeping. LVN 1 stated, Resident 1 had previous incidents with two female residents (Residents 3 and 5), where Resident 1 kissed both female residents, on September 27, 2023 and December 28, 2023. LVN 1 stated Resident 3 was incoherent, and Resident 5 had dementia (memory loss).
On January 10, 2024, at 2:20 p.m., the Social Service Director (SSD) was interviewed. The SSD stated, she was familiar with Resident 1. The SSD stated, Resident 1 was caught kissing a female resident (Resident 5) on December 28, 2023. The SSD stated, it was not the first time, Resident 1 had previous incidents, where Resident 1 kissed a female resident (Residents 3), few months ago (September 27, 2023). The SSD stated, Resident 1 had another incident with a male resident, Resident 2, on January 5, 2024. The SSD stated the staff were monitoring Resident 1 every hour.
During a review of Resident 1 ' s Care Plan (CP), the CP indicated:
- Dated September 27, 2023, .Problem .Exhibits inappropriate behavioral symptoms .CNA (Certified Nursing Assistant)/SSA (Social Service Assistant) observed resident (Resident 1) kissing another resident (Resident 3) in his room .Monitoring whereabouts every 15 mins (minutes) x (for) 72 hrs (hours) then re-eval (re-evaluate) .
- Dated January 5, 2024, .Problem .Exhibits behavioral symptoms of allegedly inappropriate sexual touching and kissing of male resident (Resident 2) .Intervention .Administer medication as ordered. Monitor for side effects and notify the physician if observed .Observed and document changes in behavior, including frequency of occurrence and potential triggers .
Further review of Resident 1's Care Plan, indicated Resident 1's care plan did not reflect appropriate intervention to prevent Resident 1's inappropriate behavior. There was no documentation the Interdisciplinary Team (IDT - team members from different discipline working together to assess, coordinate, and manage each resident's care) re-evaluated Resident 1's frequency monitoring.
On January 10, 2024, at 4:20 p.m., during a concurrent interview and review of Resident 1's Care Plan, dated September 27, 2023, with the Interim Director of Nursing (IDON), the IDON stated, when the current interventions were not working, the IDT had to reevaluate and changed the interventions. The IDON stated, Resident 1's care plan should have been updated to reflect the changes in resident's condition. The IDON stated, the IDT was responsible for making sure the interventions were implemented and reevaluated.
On January 11, 2024, at 11:12 a.m., the Mental Health Doctor (MHD) was interviewed. The MHD stated, he was familiar with Resident 1. The MHD stated, he told the staff to keep an eye on him for risk of Resident 1 doing inappropriate behaviors to other residents.
On January 11, 2024, at 11:39 a.m., CNA 2 was interviewed. CNA2 stated, she cared for Resident 1 and she monitored the resident every hour. CNA2 stated, she would not know what the resident was doing in between each hour and when she was doing care to other residents. CNA2 stated, Resident 1 walked around the facility. CNA2 stated, when Resident 2 (who was kissed by Resident 1 on September 27, 2023) passed away in December 2023 (December 11, 2023), we stopped monitoring Resident 1.
On January 19, 2024, at 2:50 p.m., during a concurrent interview and review of Resident 1's Care Plan, dated September 28, 2023 and January 5, 2024, with the Minimum Data Set Nurse (MDSN), the MDSN stated, she was part of the IDT. The MDSN stated, Resident 1 ' s care plan did not reflect the appropriate interventions for resident 's inappropriate behavior. The MDSN stated, the interventions implemented were not effective since Resident 1 had repeated inappropriate behavior which affected two female residents (Residents 3 and 5) on September 27, 2023, and December 28, 2023, and one male resident (Resident 2) on January 5, 2024. The MDSN stated, the IDT should have revised the care plan if the interventions were not effective.
On February 20, 2024, at 1:11 p.m., Licensed Vocational Nurse (LVN) 1 was interviewed. LVN 1 stated, she observed Resident 1 trying to peek at female residents' rooms, watching female residents (Residents 6 and 7).
On February 20, 2024, at 3:11 p.m., CNA 3 was interviewed. CNA 3 stated, Resident 1 was keeping an eye on all the ladies, following the female residents. CNA 3 stated, Resident 1 would sneak when the staff were not watching. CNA 3 stated, Resident 4 reported that Resident 1 was trying to kiss her.
On February 20, 2024, at 4 p.m., LVN 2 was interviewed. LVN 2 stated, Resident 1 was like a ticking time bomb, taking opportunities to attack. LVN 2 stated, even though the staff was monitoring Resident 1's behavior, they could not control the resident. LVN 2 stated, he noticed the gap with the monitoring, which could give opportunities for the resident to do his inappropriate behavior.
A review of Resident 1 ' s Monitoring Log, indicated the following:
- From September 27 to September 30, 2023, Resident 1 was monitored every 15 minutes
- From September 30 to October 31, 2023, Resident 1 was monitored every hour
- From December 28, 2023, to January 3, 2024, Resident 1 was monitored every hour.
Further review of Resident 1's Monitoring Log, indicated there was no documented evidence Resident 1 was monitored from November 1, 2023, to December 28, 2023.
On February 20, 2024, at 4:30 p.m., during a concurrent interview and review of Resident 1's Monitoring log, the IDON stated, there was no documentation Resident 1's whereabouts were monitored from November 1, 2023, to December 27, 2023. The IDON stated, the IDT should think of an approach for the resident's inappropriate behavior. The IDON stated, if the resident had behavior, the frequency of monitoring should be adjusted.
A review of the facility policy and procedure titled, Resident to Resident Altercations, dated September 2022, indicated, .All altercations, including those that may represent resident to resident abuse, are investigated and reported .Behaviors that may provoke a reaction by resident or others include .sexually aggressive behavior such as making sexual comments, inappropriate touching/grabbing .If two residents are involved in an altercation, staff .make any necessary changes in the care plan approaches to any or all of the involved individuals .document in the resident's clinical record all interventions and their effectiveness .
A review of the facility policy and procedure titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2021, indicated, .Residents have the right to be free from abuse Protect resident from abuse .by anyone including but not necessarily limited to .other residents .
Jan 2024
1 deficiency
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to ensure infection control policy and procedures for Covid-19 (a highly infectious respiratory illness) were implemented, for o...
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Based on observation, interview, and record review, the facility failed to ensure infection control policy and procedures for Covid-19 (a highly infectious respiratory illness) were implemented, for one of six employees reviewed, when:
1. For Certified Nurse Aide (CNA) 1, the Employee's Screening Sheet (a log that employees fill out to self-report temperature, hand hygiene, fever or chills, cough, short of breath/difficulty breathing, fatigue, muscle or body aches, head ache, sore throat, new loss of taste/smell, congestion/runny nose, nausea/vomiting, diarrhea, pink eye, not feeling well) was accurately completed.
2. The Dietary Supervisor (DS) was sent home when she had signs and symptoms of respiratory illness (body aches, headache, sore throat, cough, and runny nose) on January 9, 2024, and January 10, 2024;
These failures had the potential to increase staff and resident exposure and transmission of Covid-19 and/or other respiratory illnesses.
Findings:
1. On January 17, 2024, the Employee's Screening Sheet, dated January 10, 2024, was reviewed. CNA 1, who worked the night shift, wrote just her first name on the log, no last name was entered. The screening for Covid-19 symptoms was left blank. There was no documented evidence a follow up assessment on CNA 1 was conducted by the IP or IP designee.
On January 17, 2024, at 4:45 p.m., an interview with a concurrent record review was conducted with the Infection Preventionist (IP). The IP stated, during a facility Covid-19 outbreak, the Employee's Screening Sheet was expected to be filled out by every employee at the entrance to the facility prior to the start of their shift. The IP stated, the Employee's Screening Sheet was used to check for signs and symptoms of Covid-19 infection. The IP stated the employee should document and/or report symptoms of Covid-19 infection. The IP sated, if the employee failed to complete the screen, the IP or IP designee should re-assess the employee and either document accurate information to the screening log and/or send the employee home, if exhibiting signs and symptoms of respiratory illness.
On January 22, 2024, at 10:05 a.m., during an interview with the IP, the IP stated the Employee's Screening Sheet is important to help them keep track of employees that have signs or symptoms of Covid-19 infection so they can get a rapid antigen Covid-19 test done. This is why all employees are expected to fill it out prior to every shift, if an employee has symptoms, a covid-19 rapid antigen test would be performed, and the employee sent home.
On January 22, 2024, at 10:41 a.m., an interview with a concurrent record review was conducted with the Director of Staff Development (DSD). The DSD stated she was the IP designee when the IP was unavailable. The DSD stated she reviewed the Employee's Screening Sheet on the shifts when the IP was unavailable to follow up with employees who marked Yes to symptoms of Covid-19 illness, or if the employee did not complete Covid-19 screening on the log.
The DSD stated she was not in the facility when CNA 1 failed to complete the screening sheet on January 10, 2024. The DSD stated the IP or IP designee should have reviewed the Employee's Screening Sheet the following morning on January 11, 2024.
2. On January 17, 2024, at 10:10 a.m., an interview was conducted with the Infection Preventionist (IP). The IP stated, she had a total of eight residents who tested positive for Covid-19, one resident was positive on admission, the other seven residents had facility acquired Covid-19. The IP stated, one resident was hospitalized for respiratory related complications. The IP stated, seven staff members acquired Covid-19 during the outbreak. IP stated, she informed the county health department of the outbreak starting January 10, 2024.
On January 17, 2024, at 4:45 p.m., an interview and concurrent record review was conducted with the Infection Preventionist (IP). The IP stated, during the facility Covid-19 outbreak, the Employee's Screening Sheet was expected to be filled out by every employee at the entrance to the facility prior to the start of their shift. The IP stated, the Employee's Screening Sheet was used to check for signs and symptoms of Covid-19 infection. The IP stated, the employee should document and/or report any symptoms of a respiratory infection. The IP stated, the IP or IP designee should assess the employee and document any follow through directly on the screening sheet and/or send the employee home, if exhibiting signs and symptoms of a respiratory illness.
On January 17, 2024, the Employee's Screening Sheet, dated January 9, 2024, and January 10, 2024, was reviewed. The screening sheet indicated, the Dietary Supervisor (DS) marked yes to symptoms for muscle or body aches, headaches, sore throat, congestion, and runny nose.
The note at the top of the Employee Screening Sheet indicated, .Any temperature >99.0 F and /or presence of symptom(s) will not be allowed to past [sic] the screening station; HCP (health care personnel) should leave the premises immediately .
There was no documented evidence to indicate the IP or IP designee assessed the Dietary Supervisor and the DS worked both of her shifts.
On January 22, 2024, at 10:05 a.m., an interview and concurrent record review was conducted with the IP. The IP stated the Employee's Screening Sheet is important to help them keep track of employees that have signs or symptoms of the Covid-19 infection, and perform a rapid antigen Covid-19 test, to ensure a staff member has not tested positive for Covid-19. The IP stated, all employees are expected to fill in the Employee's Screening Sheet in its entirety prior to every shift, if an employee has symptoms, a rapid antigen test would be performed and if the results are positive, the employee is sent home. The IP stated, the DS marked the Employee's Screening Sheet, for January 09, 2024, and January 10, 2024, Yes to multiple symptoms. The IP stated, yes, there should have been a follow up with the staff member at the time of the screening. The IP stated, no one followed up on the staff member per facility protocol.
On January 22, 2024, at 10:25 a.m., an interview and concurrent record review was conducted with the Director of Staff Development (DSD). The DSD stated, she was the IP designee when the IP was not in the facility. The DSD stated, she reviewed the Employee Screening Sheet on the shifts the IP was unavailable to follow up with employees who marked Yes to symptoms of Covid-19 illness. The DSD stated, the IP or IP designee should have reviewed the Employee Screening Sheet the following morning on January 11, 2024, and followed up with the employee.
A review of the facility's policy titled Infection Prevention and Control Program, dated October 2018, indicated .infection prevention and control program (IPCP) is .to help prevent the development and transmission of communicable diseases and infections .The program is based on accepted national infection prevention and control standards .is a facility-wide effort involving all disciplines and individuals .elements .consist of coordination/oversight, policies/procedures, surveillance .outbreak management, prevention of infection, and employee health and safety .The infection prevention and control committee is responsible for .documented IPCP incidents and corrective actions taken .whether there is appropriate follow-up of acute infections .Policies and procedures reflect the current infection prevention and control standards of practice .updating and supplementing policies and procedures as needed; Assessment of staff compliance with existing policies and regulations .Process surveillance .monitoring employee infection, monitoring adherence to infection prevention and control practices .Standard criteria are used to distinguish community-acquired from facility-acquired infections .following established general and disease-specific guidelines such as those of the Center for Disease Control (CDC) .Monitoring Employee Health and Safety. The facility has established policies and procedures regarding infection control among employees .should report their infections or avoid the facility .
During a review of the facility's policy and procedure titled, Coronavirus Disease 2019 (COVID-19) Mitigation Plan for Skilled Nursing Facilities, dated July 2023, indicated, .The facility screens and documents every individual entering the facility (including staff) for COVID-19 symptoms and temperature . symptomatic residents and staff, document the date(s) and time(s) of the identification of signs or symptoms, when testing was conducted, when results were obtained, and the actions the facility took based on the results .to prevent Covid-19 transmission and infection .
During a review of the Centers for Disease Control and Prevention (CDC) guidance titled, CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, dated November 29, 2022, indicated, .5e. Minimizing Potential Exposures- Develop and implement systems for early detection and management .of potentially infectious persons at initial points of patient encounter .
Nov 2022
14 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 43's record was reviewed. Resident 43 was admitted to the facility on [DATE], with diagnoses which included dementia...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 43's record was reviewed. Resident 43 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss) and adult failure to thrive (a syndrome of weight loss, decreased appetite, and inactivity).
A review of Resident 43's Minimum Data Set (an assessment tool), indicated, Resident 43 required supervision (oversight, encouragement, or cueing) with eating.
On November 7, 2022, at 12:08 p.m., during dining observation, Resident 43 was served lunch in bed. Resident 43 was observed seated at the edge of the bed. Resident 43 was observed not seated in a comfortable position while eating.
On November 7, 2022, at 12:27 p.m., Resident 43 was interviewed. She stated the tray was way too far and difficult for her to eat. Resident 43 stated she has concerns she might spill her food.
On November 8, 2022, at 12:24 p.m., during a second dining observation, Resident 43 was served a meal in a wheelchair. Resident 43 was observed pulling her tray closer. In a concurrent interview with Resident 43, she stated she preferred to eat in bed. Resident 43 stated she was told she needed to sit in the wheelchair. Resident 43 further stated she had to adjust her tray so she can eat her food.
On November 10, 2022, at 10:40 a.m., Certified Nursing Assistant (CNA) 2 was interviewed. CNA 2 stated the resident should be positioned and the tray should be close as possible to the resident.
On November 10, 2022, at 3:11 p.m., the Quality Assurance Nurse (QAN) was interviewed. She stated the meal tray should be close to the resident. The QAN stated the resident should be positioned comfortably by making sure the resident's body is in alignment and the overbed table should be in front of the resident.
A review of the policy and procedure titled Eating Support, dated 2018, indicated, .Place tray directly in front of the resident .Assist resident to proper sitting position .Leave resident in a comfortable position .
Based on observation, interview, and record review, the facility failed for two of 50 residents reviewed for resident rights (Residents 34 and 43), during dining observation:
1.For Resident 34, the staff member was not positioned according to facility standards; and
2.For Resident 43, the resident was not positioned according to facility standards.
These failures had the potential for Resident 34 and 43, to not attain their highest practicable mental, physical, and psychosocial well-being.
Findings:
1. Resident 34's record was reviewed. Resident 34 was admitted to the facility on [DATE], with diagnosis which included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions) and anemia (low red blood cells).
A review of Resident 34's Minimum Data Set (an assessment tool) dated September 27, 2022, indicated, Resident 34 required extensive assistance (staff provided weight bearing-support) with eating.
On November 7, 2022, at 12:51 p.m., the during dining observation, Resident 34 was inside her room, assisted in her feeding by Certified Nurse Assistant (CNA 1). CNA 1 was observed standing over the resident while feeding Resident 34.
On November 7, 2022, at 2:15 p.m., in an interview with CNA1, he stated, he was not able to find a chair. CNA 1 further stated, he should be feeding the resident while seated.
On November 10, 2022, at 3:30 p.m., during an interview with Licensed Vocational Nurse (LVN 1), she stated it is the resident's right of dignity to be fed by staff in an appropriate manner. The staff should be seated by her side at eye level.
A review of facility policy and procedure titled, Long Term Care Clinical Procedures .Eating Support, dated 2018, indicated, .Sit so you are at the same level as the resident .
A review of the facility policy and procedure titled, Resident [NAME] of Rights, dated May 2011, indicated .To be treated with consideration, respect and full recognition of dignity, and individuality .in care of personal needs .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written Skilled Nursing Facility Advanced Beneficiary Not...
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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 a written Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN- a notice to provide information to residents/beneficiaries if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility) for one of three residents reviewed for SNF ABN (Resident 39).
This failure had the potential to result in the resident to not be informed about the potential liability for payment in non-covered Medicare Part A services in writing.
Findings:
Resident 39's record was reviewed. Resident 39 was admitted to the facility on [DATE] with a diagnosis which included hemiplegia and hemiparesis (weakness on one side of the body). Resident 39's Medicare Part A started on September 13, 2022, & ended October 20, 2022. The resident continued to stay in the facility for long term care.
There was no documented evidence the resident/beneficiary received a written SNF ABN.
On November 10, 2022, at 2: 50 p.m., in an interview with the Accounts Receivable Representative (ARR), he was not aware SNF Beneficiary Protection Notification should be provided to Resident 39 or to the resident's representative when Resident 39 continued to stay in the facility.The ARR further stated he should have provided the SNF ABN to give the resident information of her potential financial liability when Medicare will not pay for the skilled service.
On November 10, 2022, at 3 p.m., in an interview with Administrator, she stated they don't have the form SNF ABN, and they do not have the policy and procedure on SNF ABN.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR - a f...
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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 Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) was updated for one of four residents reviewed for PASARR (Resident 25). Resident 25 had developed a new diagnosis and was provided antipsychotic (a class of psychotropic [drugs that affecta person's mental state]) medication on September 14, 2021.
This failure had the potential for the resident to be inapproriately placed in the facility, and not receive the treatment and services to meet the resident's needs.
Findings:
A review of Resident 25's record indicated, Resident 25 was admitted to the facility on [DATE], with diagnosis which included dementia (memory loss) and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly).
A review of Resident 25's PASARR dated June 9, 2021, indicated, .Initial Preadmission Screening .Level 1 - Negative .Section V - Mental illness .Psychotropic Medication .No .Has the resident been prescribed psychotropic medications? No .In addition, the mental health disorder results in functional limitation in major life activities within the past 6 months .
On November 9, 2022, at 10:18 a.m., Licensed Vocational Nurse (LVN) 2 was interviewed. He stated the Director of Nursing (DON), himself, and the Registered Nurse Supervisor were responsible for completing and updating the PASARR. LVN 2 stated Resident 25's PASARR was not updated. He stated Resident 25 had a new diagnosis of Schizophrenia and was started on Seroquel (an antipsychotic medication). LVN 2 stated the PASARR should have been updated.
On November 9, 2022, at 10:31 a.m., the DON was interviewed. She stated the PASARR should be updated when the resident had a new diagnosis and prescribed a new antipsychotic medication. The DON stated Resident 25's PASARR was not updated and should have been updated.
A review of the facility policy and procedure titled, Behavioral Assessment, Intervention and Monitoring, dated March 2019, indicated, .New onset or changes in behavior that indicate newly evident or possible serious mental disorder, intellectual disability, or a related disorder will be referred for a PASARR Level II evaluation .Current Level II residents will be referred for an additional PASARR Level II evaluation upon a significant change in status assessment .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure for two of 15 residents reviewed for care planning (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 for two of 15 residents reviewed for care planning (Residents 25 and 36), when:
1. For Resident 25, the care plan was initiated for wandering and elopement; and
2. For Resident 36, the care plan intervention for Lance Adam's Syndrome (generalized muscle jerks) was implemented. This failure had the potential to result in injury when resident experienced uncontrollable movements.
Findings:
1. A review of Resident 25's record indicated Resident 25 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss).
A review of Resident 25's physician order dated November 6, 2022, indicated the following:
- Monitor resident for episodes of elopement and encourage in group activities to stay in the dining room and participate .
- Monitor for episodes of wandering and encourage in group activities to stay in the dining room and participate or activity of choice .
There was no care plan initiated for elopement and wandering.
On November 10, 2022, at 10:47 a.m., in a concurrent interview and record review of Resident 25, the Quality Assurance Nurse (QAN) stated the care plan should be initiated when a change of condition was observed. The QAN stated residents should have a care plan to provide the necessary care for the resident. The QAN stated Resident 25 had no care plan initiated for wandering and elopement.
2. On November 7, 2022, at 11:12 a.m., Resident 36 was observed in bed. The right bed rail was observed with padding and the left bed rail was without padding. In a concurrent interview with Resident 36, he stated there was padding on both side rails before. Resident 36 stated he did not know why the left side rail was missing a pad.
On November 9, 2022, at 10:59 a.m., Resident 36 was observed in bed. There was no padding on the left side rail and there was padding on the right-side rail.
On November 9, 2022, at 11:03 a.m., in a concurrent observation of Resident 36 and interview with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 36 had no padding on the left side. LVN 1 stated there should be padding on both side of the bed rails for resident's safety.
A review of Resident 36's record indicated Resident 36 was admitted to the facility on [DATE], with diagnoses which included Lance [NAME] Syndrome.
A review of Resident 36's physician order dated December 28, 2021, indicated, .1/4 PADDED SIDERAILS UP X (times) 2 FOR MOBILITY, REPOSITIONING AND SAFETY .
A review of Resident 36's care plan dated April 19, 2019, indicated, .Chronic post-hypoxic myoclonus, also known as Lance-[NAME] syndrome (LAS) is a neurological complication characterized by uncontrolled myoclonic jerks .Interventions .1/4 padded SIDERAILS X 2 FOR MOBILITY .
On November 9, 2022, at 11:51 a.m., LVN 2 was interviewed. He stated he was responsible for initiating and updating residents' care plans. LVN 2 stated when there was an update in the care plans, new interventions should be communicated to the staff and implemented by the licensed nurses. LVN 2 stated the padded side rails for Resident 36 was for his safety. LVN 2 stated Resident 36 had uncontrollable movements due to diagnosis of Lance Adam's Syndrome.
On November 10, 2022, at 2:45 p.m., the Director of Nursing (DON) was interviewed. She stated the nursing staff should ensure the plan of care was implemented for all residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure for one of 50 residents (Resident 17), care an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure for one of 50 residents (Resident 17), care and services were provided according to accepted standards of clinical practice when the resident was allowed to self-administer her medications. This failure had the potential to result in unsafe adminstration of medication.
Findings:
On November 7, 2022, at 9:45 a.m., during a concurrent observation and interview with Resident 17, a green tablet was observed inside the medication cup, on the overbed table. Resident 17 stated the nurse gave her two tablets this morning after breakfast for her upset stomach. Resident 17 stated she took one tablet, and she told the nurse she would take the other tablet later. Resident 17 stated the nurse left the other tablet for her to take later.
On November 7, 2022, at 10:31 a.m., during a concurrent observation and interview with Resident 17 and Licensed Vocational Nurse (LVN) 2, LVN 2 stated he did not see the medication at bedside. Resident 17 stated she already took the other tablet.
A review of Resident 17's record indicated the resident was admitted to the facility on [DATE], with diagnoses which included colon cancer (a disease in which cells in the colon or rectum grow out of control) and gastroesophageal reflux (chronic disease that occurs when stomach acid flows into the food pipe and irritates the food pipe lining).
A review of Resident 17's physician order dated August 5, 2021, indicated, Tums Tablet Chewable 500 MG (milligrams) (Calcium Carbonate Antacid) Give 2 tablet by mouth three times a day related to GASTRO-ESOPHAGEAL REFLUX DISEASE .
A review of Resident 17's record titled SELF-ADMINISTRATION OF MEDICATION, dated November 1, 2018, indicated, Resident 17 chose not to self-administer medication.
There was no documentation Resident 17 was assessed to self-administer medications by the Interdisciplinary Team.
On November 9, 2022, at 11:13 a.m., Licensed Vocational Nurse (LVN) 3 was interviewed. LVN 3 stated when administering medications, she would not leave medications at bedside. LVN 3 stated she made sure that resident take their medications before leaving the room. LVN 3 stated there should be an assessment before allowing resident to self-administer medications.
On November 9, 2022, 11:29 a.m., in a concurrent interview and review of Resident 17's record with Registered Nurse Supervisor (RNS) 1, RNS 1 stated there should be a physician order to self-administer medications. RNS 1 stated Resident 17 had no physician order to self-administer the medication. RNS 1 stated Resident 17 should not be allowed to self-administer her medications and the medications should not be left at bedside.
On November 9, 2022, at 3:04 p.m. LVN 4 was interviewed. He stated he left the medication at the resident's bedside. LVN 4 stated he was aware and should have not left the medication at bedside for the resident to self-administer.
On November 10, 2022, at 2:45 p.m., the Director of Nursing (DON) was interviewed. The DON stated if the resident wanted to self-administer her own medications, licensed nurses should assess the resident and notify the physician. The DON stated medications should be not be left at resident's bedside.
A review of the facility policy and procedure titled, Self-Administration of Medications, dated February 2021, indicated, .Residents have the right to self-administer medications if the interdisciplinary team had determined that it is clinically appropriate and safe for the resident to do so .the interdisciplinary team (IDT) assessed each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident .
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure treatment and care were provided in accordance...
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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 treatment and care were provided in accordance with professional standards of practice, for two of 15 residents residents reviewed for quality of care (Residents 25 and 32) when:
1. For Resident 25, the blood work was completed according to the physician order on September 2022; and
2. For Resident 32, the physician order was followed for administration of Resource 2.0 (a nourishment to increase caloric intake).
These failures had the potential for Resident's orders to not be followed resulting in a delay of care and physical well being.
Findings:
1. A review of Resident 25's record indicated Resident 25 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss).
A review of Resident 25's physician order dated April 11, 2021, indicated Resident 25 was to have routine blood work (Complete blood Count and Comprehensive Metabolic Panel) every three months on March, June, September, and December 2022.
There was no documentation Resident 25 had her blood work completed on September 2022.
On November 9, 2022, at 9:30 a.m., in a concurrent interview and record review of Resident 25 with Registered Nurse Supervisor (RNS) 2, she stated Resident 25 had a blood work order for September 2022. She stated she could not find documentation Resident 25's blood work for September 2022 was done. RNS 2 stated it was the desk nurse responsibility to complete blood work order by the physician. RNS 2 stated blood work should have been done for Resident 25 as ordered by the physician.
On November 11, 2022, at 2:45 p.m., the Director of Nursing (DON) was interviewed. The DON stated the night shift licensed nurses check the routine blood work for the residents. She stated the Medical Records staff made an audit of the routine blood work for residents. The DON stated the blood work scheduled for September 2022 for Resident 25 was missed.
2. On November 7, 2022, at 12:10 p.m., during dining observation, Resident 32 did not touch the meal plate served. In a concurrent interview with Resident 32, she stated she did not like the food served.
On November 7, 2022, at 12:22 p.m., Certified Nursing Assistant (CNA) 3 was interviewed. She stated Resident 32 did not like meat and ice cream, but she ate two packs of crackers.
A review of Resident 32's record indicated the resident was admitted to the facility on [DATE], with diagnoses which included Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).
A review of Resident 32's physician order dated November 15, 2021, indicated, Monitor meal intake and give 120 cc (cubic centimeter) resource for meal intake less than 50%.
A review of Resident 32's document titled Task: NUTRITION - Amount Eaten, from October 11 to November 9, 2022, was compared to Resident 32's Medication Administration Record (MAR) for October and November 2022. The intake documented by the Certified Nursing Assisstants (CNAs) did not correlate with the intake documented by the licensed nurses in the MAR which resulted for Resident 32 to not receive Resource 2.0.
- October 12, 2022, the CNA documented the resident ate 20-50% at breakfast. The licensed nurse documented resident ate 60% at breakfast. Resident 32 was not given Resource 2.0.
- October 13, 2022, the CNA documented the resident ate 20-50% at breakfast, lunch, and dinner. The licensed nurse documented the resident ate 60% at breakfast, lunch, and dinner. Resident 32 was not given Resource 2.0.
- October 14, 2022, the CNA documented the resident ate 20-50% at lunch and dinner. The licensed nurse documented the resident ate 60% at lunch and dinner. Resident 32 was not given Resource 2.0.
- October 15, 2022, the CNA documented the resident ate 20-50% at dinner. Thelicensed nurse documented the resident ate 60% at dinner. Resident 32 was not given Resource 2.0.
- October 16, 2022, the CNA documented the resident ate 20-50% at dinner. The licensed nurse documented the resident ate 60% at dinner. Resident 32 was not given Resource 2.0.
- October 20, 2022, the CNA documented the resident ate 20-50% at lunch. The licensed nurse documented the resident ate 40%. Resident 32 was not given Resource 2.0.
- October 26, 2022, the CNA documented the resident ate 25-50% at dinner. The licensed nurse documented the resident ate 55%. Resident 32 was not given Resource 2.0.
- October 31, 2022, the CNA documented the resident ate 25-50% at breakfast. The licensed nurse documented the resident ate 70% at breakfast. Resident 32 was not given Resource 2.0.
- November 1, 2022, the CNA documented the resident ate 25-50% at breakfast. The licensed nurse documented the resident ate 75% at breakfast. Resident 32 was not given Resource 2.0.
- November 2, 2022, the CNA documented the resident ate 25-50% at lunch. The licensed nurse documented the resident ate 60% at lunch. Resident 32 was not given Resource 2.0.
- November 7, 2022, the CNA documented the resident ate 0-25% at lunch. The licensed nurse documented the resident ate 75% at lunch. Resident 32 was not given Resource 2.0.
On November 9, 2022, at 2:59 p.m., Certified Nursing Assistant (CNA) 3 was interviewed. CNA 3 stated she communicates meal intake with licensed nurses and documents the percentage in the electronic record.
On November 9, 2022, at 3:10 p.m., in a concurrent interview and record review with Licensed Vocational Nurse (LVN) 5, she stated she documented in the MAR what the CNA reported. LVN 5 stated Resident 23's meal percentage did not match the amount of intake in the MAR. She stated Resident 32 was not given Resource 2.0 as per physician order. LVN 5 stated Resident 32 should have been given Resource 2.0 since resident ate less than 50% on November 7, 2022.
On November 10, 2022, at 2:45 p.m., the Director of Nursing (DON) was interviewed. The DON stated the CNA would report to the charge nurse the amount eaten by the residents and the licensed nurses would document the amount eaten in the MAR. The DON stated the licensed nurse should follow what is indicated in the physician order. In a concurrent review of Resident 32's record, the DON stated the physician order to give Resource 2.0 for meal intake of less than 50% for Resident 32 was not followed.
A review of the facility policy and procedure titled, PHYSICIAN'S ORDERS, ACCEPTING, TRANSCRIBING, AND IMPLEMENTING (NOTING), undated, indicated, .Qualified nursing personnel will ensure that telephone and verbal orders will be recorded and implemented. All physician's order are to be complete and clearly defined to ensure accurate implementation .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed for one of seven residents reviewed for unnecessary medications (Resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed for one of seven residents reviewed for unnecessary medications (Resident 34) to ensure that the pharmacy recommendation for September 23, 2022, regarding the use of Atarax (hydroxyzine-is used to relieve itching caused by allergic skin reactions) was acted upon promptly.
This failure had the potential for Resident 34 to experience the adverse side effect such as sedation.
Findings:
A review of Resident 34's record indicated Resident 34 was admitted to the facility on [DATE], with diagnoses which included Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions)
A review of Resident 34's record titled, Consultant Pharmacist's Medication Regimen Review, dated September 23, 2022, indicated the resident is currently on Morphine pm (narcotic analgesics -pain medicines), Depakene (valproic acid- antiepileptic used to treat various types of seizure disorders, Pamelor (Nortriptyline- used to treat the symptoms of depression) and Hydroxyzine. Caution for adverse side effects such as but not limited to excess sedation, lethargy, ataxia, drowsiness, dizziness, respiratory depression and fall. Inform hospice MD (physician) .
A review of the facility document titled Physician order, dated April 7, 2022, indicated, .Hydroxyzine HCl tablet 25 MG (milligram) Give 25 mg by mouth two times a day for itchiness r/t (related to) dermatitis.
There was no documented evidence the pharmacy recommendation was acted upon.
A review of Resident 34's Progress Note, dated October 16, 2022, indicated, .Daughter (name of daughter) visited earlier today around 10 a.m., concerned of mom is sleepy today. Reviewed medications that may cause drowsiness and informed of resident's usual behaviors. Resident is usually awake and talking in the morning. Spoke to CM (case manager) (name of hospice) .received order from (name of doctor) discontinue Hydroxyzine .
Hydroxyzine was discontinued three weeks after the pharmacy recommendation.
A review of A review of the facility document titled Physician order, . DISCONTINUE datedOctober 16, 2022 .,
On November 10, 2022, at 1:45 p.m., in an interview with the Director of Nursing (DON), she stated pharmacist recommendation are acted upon by the DON within a week.
The drug regimen review policy and procedure (P&P) was requested from the DON, the facility do not have the P&P on drug regimen review.
A review of the facility undated policy and procedure titled, CONSULTANT PHARMACIST RESPONSIBILITIES, indicated, .Consulting pharmacist shall review of each patient at least monthly .The consultant pharmacist identifies inappropriate and unnecessary drugs .The drugs are identified to the facility and the attending physician for follow-up .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of seven residents (Resident 25), was assessed by the ph...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of seven residents (Resident 25), was assessed by the physician for the use of antipsychotic medication.
This failure had the potential to result in unnecessary use of antipsychotic medication for Resident 25.
Findings:
A review of Resident 25's record indicated Resident 25 was admitted to the facility on [DATE], with diagnoses which included dementia (memory loss).
A review of the document titled, INITIAL HISTORY and PHYSICAL, dated July 22, 2022, indicated Resident 25 had a diagnosis of dementia. There was no indication in the physician progress notes Resident 25 had a diagnosis of Schizophrenia. There was no documentation the physician assessed Resident 25's behaviors.
A review of the document titled, Order Summary Report, for the month of November 2022, indicated, .SEROquel Tablet (QUEItapine Fumarate) Give 75 mg (milligram) by mouth two times a day for schizophrenia .
On November 9, 2022, at 9:30 a.m., Registered Nurse Supervisor (RNS) 2 was interviewed. She stated Resident 25 started Seroquel on September 13, 2021. RNS 2 stated Resident 25 was having behaviors and Seroquel was prescribed. RNS 2 stated the process of the facility before starting antipsychotic medication was to assess the resident, monitor resident's behavior, and notify the physician. The RNS 2 stated once the physician ordered an antipsychotic medication, she would verify the consent for the use of antipsychotic medication with the family. RNS 2 stated before making a diagnosis and giving the antipsychotic medication, the doctor should assess the resident.
In a concurrent review of Resident 25's record, RNS 2 stated there was no assessment by the physician before prescribing the antipsychotic medication. RNS 2 stated there was no diagnosis of schizophrenia in the physician's progress notes. RNS 2 stated after an evaluation of the psychologist, Resident 25 was not diagnosed with Schizophrenia.
On November 9, 2022, at 9:51 a.m., the Resident Representative (RR) was interviewed. She stated the facility staff informed her that Resident 25 was prescribed Seroquel. The RR stated she was informed Resident 25 had schizophrenia. The RR stated she was not aware of previous diagnosis of Schizophrenia.
On November 9, 2022, at 11:39 a.m., a Medical Doctor (MD) was interviewed. He stated he had to assess the resident first before making a diagnosis and prescribing medications.
On November 9, 2022, at 12:03 p.m., the Social Service Director (SSD) was interviewed. The SSD stated if the resident was having behavior, the licensed nurses will provide non-pharmacologic interventions and monitor resident's behavior. The SSD stated if the resident continued having behavior, the licensed nurses would call the physician and the physician would prescribe the medication. In a concurrent review of Resident 25's record, the SSD stated she could not find the assessment of the physician prior to prescribing medications. The SSD stated an assessment should be completed by the physician before making a diagnosis and prescribing medications.
On November 10, 2022, at 9:18 a.m., the SSD was again interviewed. She stated Resident 25 was not seen by the physician due to authorization issue. The SSD stated the resident was started on an antipsychotic medications without being assessed by the physician.
A review of the facility policy and procedure titled, Behavioral Assessment, Intervention, and Monitoring, dated March 2019, indicated, .The faciity will comply with regulatory requirement related to the use of medications to manage behavioral changes .Behavior can be a way for an individual in distress to communicate unmet need, indicate discomfort, or express thoughts that cannot be articulated .Behavioral or Psychological Symptoms of Dementia (BPSD) describes behavioral symptoms in individuals with dementia that cannot be attributed to a specific medical or pyschiatric cause .Appropriate assessment and treatment of behavioral symptoms that can be managed by treating underlying factors .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the licensed nurse administered medications ac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the licensed nurse administered medications according to the physician's order when two medications were not administered for one of four residents observed during medication pass (Resident 5).
These failures resulted in a medication error rate of 7.69 percent and increased the potential of harm to residents due to medications not being administered as prescribed by the physician.
Findings:
On November 9, 2022, at 8:23 a.m., during medication pass observation with Licensed Vocational Nurse ( LVN) 3,
the following medications were administered:
1. Lovaza (omega 3- supplement for managing high triglycerides [a type of body fat in the blood]) one gram (gm) two capsules by mouth;
2. Spirinolactone (used to treat high blood pressure) 25 mg (milligram) one tablet by mouth;
3. Gabapentin (nerve oain medication) 100 mg one tablet by mouth;
4. Escitalopram (used to treat depression [persistent feeling of sadness and loss of interest] and anxiety [feeling of worry]) 20 mg one tablet by mouth;
5. Advair (used to prevent asthma [disease that affects the lungs] attacks) 1 puff by mouth;
6. Cranberry (supplement) one tablet by mouth;
7. Vitamin D3 (supplement) one [NAME] by mouth;
8. Diphenhydramine (for allergies) 25 mg one tablet by mouth;
9. Vitamin C (supplement) 500 mg one tablet by mouth;
10. Klonopin (to treat anxiety) 0.5 mg one tablet by mouth.
A review of Resident 5's record, indicated Resident 5 was admitted to the facility on [DATE], with diagnoses which included chronic obstructive lung disease (COPD- a respiratory problem), constipation, and allergies.
During medication reconciliation, two medications were prescribed and were not administered:
- Lactulose Solution 10 GM (gram)/ 15 ML (milliliter). Give 15 ml by mouth one time a day for constipation. Hold if loose stools.
- Claritin tablet 10 MG (Loratadine) Give 1 tablet my mouth one time a day for allergies.
On November 9, 2022, at 11:01 a.m., in an interview with LVN 3, she stated Resident 5 had no loose stools that is why Lactulose was not given. LVN 3 also stated the Claritin should have been given.
A review of the facility policy and procedure titled, Medication Administration, General, dated 2018, indicated, .PURPOSE .Safely and accurately administer physician-ordered medication to each resident .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure for one of 50 residents (Resident 22), an identified concern regarding missing personal belongings was tracked, reviewed, and follow...
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Based on interview and record review, the facility failed to ensure for one of 50 residents (Resident 22), an identified concern regarding missing personal belongings was tracked, reviewed, and followed by the committee. This failure resulted in an unsettled resolution to the identified concern affecting the quality of care, quality of life, and resident safety.
Findings:
On November 7, 2022, at 3:06 p.m., Resident 25 was observed in the room holding a stuffed toy. The name identified on the label of the stuffed toy did not match the resident in possession of the toy.
On November 9, 2022, at 3:36 p.m., in a concurrent observation and interview with Certified Nursing Assistant (CNA) 1, he stated he recognized the stuffed toy in Resident 25's room. CNA 1 stated the stuffed toy belonged to Resident 22. CNA 1 reviewed Resident 22's personal belongings list and stated Resident 22 had eight toys and only one stuffed toy was in Resident 22's room. CNA 1 stated it could be that during room change, the resident's personal belongings were lost during the transfer. CNA 1 stated he was not aware that the resident's stuffed toy would be in another room.
On November 10, 2022, at 9:18 a.m., the Social Service Director (SSD) was interviewed. She stated the staff should inform her of resident's missing personal belongings. She stated she was not aware of the missing stuffed toys of Resident 22. The SSD stated this problem had been identified by the QAPI (Quality Assurance Performance Improvement) committee since May 2022.
On November 10, 2022, at 4:25 p.m., the Administrator (Adm) was interviewed. The Adm stated missing personal belongings was a topic discussed during Quality Assessment and Assurance meeting in May 2022. The Adm stated an issue brought to her attention would be discussed and included in QAPI. The Adm stated the team would discuss the problems, follow-up the results if the team reached their goal. The Adm was asked for the result of the QAPI, the Adm could not provide documentation that the goal was reached last quarter regarding missing belongings. The Adm stated the QAPI should be revised if there was no improvement with the plan on a quarterly basis.
A review of the facility policy and procedure titled, Quality Assurance Performance Improvement (QAPI) Policy and Procedure, dated October 16, 2022, indicated, .The facility will develop, implement, and maintain a QAPI program that is effective, date derived, comprehensive and will focus on the outcomes of care and quality of life .The plan will describe the process of identifying and correcting quality deficiencies by .tracking and measuring performance .Monitoring effectiveness of the corrective actions .
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure the menu was being followed for the therapeutic diet and portion sizes for lunch on November 7, 2022, and lunch on Nov...
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Based on observation, interview, and record review, the facility failed to ensure the menu was being followed for the therapeutic diet and portion sizes for lunch on November 7, 2022, and lunch on November 8, 2022, when:
1. Resident 30 was on CCHO (consistent carbohydrate, a diet treatment for diabetes), NAS (no added salt), Renal (a diet treatment for chronic kidney disease or end stage kidney disease) with finger food (food items that are in bite size and can pick up by fingers to consume) did not receive a wheat roll as indicated on the menu;
2. Three residents (Resident 8, 22, and 304) received incorrect portion sizes, when:
a. Resident 8 was on regular diet with mechanical soft texture (a diet with food texture modified into a soft, chopped, or ground consistency for person who has chewing or swallowing difficulties) and dislike spinach who received three ounces (oz.) of corn (substitute of spinach) instead of four oz.;
b. Resident 22 was on regular diet with mechanical soft texture and large portion who received three oz. of broccoli and three oz. of pasta instead of four oz of broccoli and four oz. of pasta, and
c. Resident 304 was on Renal diet who received three oz. of broccoli instead of four oz.
These failures had the potential for residents to receive incorrect food item may interrupt the treatment of therapeutic diet and the wrong caloric intake with incorrect portion sizes when not following the menu, which may further compromise the medical status for those four residents.
Findings:
1. During a dining observation on November 7, 2022, at 12:09 p.m., noted Resident 30 was on CCHO, NAS, Renal diet with finger food received a bowl of sweet corn salad instead of a wheat roll.
A concurrent review of undated facility document, titled, Fall Menus, Week 2 Monday, showed Renal and finger food diet should receive a wheat roll.
During an interview on November 7, 2022, at 12:36 p.m., the Food Service Manager (FSM) acknowledged Resident 30 received a bowl of corn and confirmed that he should have received a wheat roll when she reviewed the menu. She stated the staff should follow the menu.
During an interview on November 10, 2022, at 9:35 a.m., the Registered Dietitian (RD) stated the kitchen staff should follow the menu. She stated residents with Renal diet which was therapeutic diet to control or treat medical condition.
2. During an observation of lunch service on November 8, 2022, beginning at 11:35 a.m., it was noted the [NAME] did not serve the portion sizes correctly for three residents when:
a. Resident 8 was on regular diet with mechanical soft texture, large portion and dislike spinach who received three oz. of corn instead of four oz.
A concurrent review of facility document titled, Fall Menu, Week 2 Tuesday, showed regular diet with mechanical soft texture and large portion should have four oz. of corn as vegetable substitute of spinach.
b. Resident 22 was on regular diet with mechanical soft texture and with finger food who received three oz. of broccoli and three oz. of pasta instead of four oz of broccoli and four oz of pasta.
A concurrent review of facility document titled, Fall Menu, Week 2 Tuesday, showed regular diet with mechanical soft texture and finger food should have four oz. of broccoli and four oz. of pasta.
c. Resident 304 was on Renal diet who received three oz. of broccoli instead of four oz.
A concurrent review of facility document titled, Fall Menu, Week 2 Tuesday, showed Renal diet should have four oz. of broccoli.
During an interview on November 8, 2022, at 12:50 p.m., the FSM acknowledged the kitchen staff served the incorrect portion sizes for those three residents. She stated the kitchen staff should follow the menu and provide correct portion sizes.
During an interview on November 10, 2022, at 9:35 a.m., the RD stated those residents should receive the portion as indicated in the menu. She stated incorrect portion size may affect the nutrition content of the meal.
A review of facility document titled, Job Description, Position: FNS Food and Nutrition Services) Director, dated 2018, it indicated the FSM was responsible for the preparation and service of all food and ensured that approved menus and recipes were followed
A review of facility policy and procedure titled, Food Preparation: Portion Control, dated 2018, it showed, .provide specific portion control .to be sure portions served equal portion sizes listed on the menu, portion control equipment must be used .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food in accordance wit...
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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 store, prepare, and distribute food in accordance with professional standards for food service safety when:
1. There was no thawing and handling system for frozen nutritional supplement drinks (health shake);
2. The ice machine was not cleaned and sanitized properly per manufacturer's guidance, and
3. The foodservice department had no system for ambient food (food that can be safely stored at room temperature in a sealed container, for example, canned tuna fish) cooling down process.
These failures had potential to cause foodborne illness in a highly susceptible population of 50 out of total census of 50 residents who received food from the kitchen of the facility.
Findings:
1. During an observation in the walk-in refrigerator on November 7, 2022, at 9:35 a.m., there was a box of nutritional supplement drinks (health shakes, the drinks that provide additional nutrients and are perishable) did not indicated any date of pulled from the freezer or used-by date after thawed. A concurrent interview with the Food Service Manager (FSM), she stated she could not determine when the kitchen staff started thawing the health shakes with no dates on them. She stated the kitchen did not a system in place to thaw and handle the health shakes.
During a review of instruction located on the carton of the health shake on November 7, 2022, at 9:40 a.m., it showed the shakes had to store frozen and once thawed in the refrigerator to use within 14 days. A concurrent interview with the FSM, she stated she was not aware of the storage and handling instruction of the Health Shakes.
During an interview on November 10, 2022, at 9:35 a.m., the facility Registered Dietitian (RD). The RD stated the kitchen staff needed to follow the food storage guideline policy and should have a system to identify the thaw date and use-by date per the Health Shake's manufacturer's instruction.
A review of facility policy and procedure titled, Refrigerated Storage Guide, dated 2018, indicated the nutritional supplement shakes should be dated from the frozen and thawed in the refrigerator as soon as they were placed in the refrigerator. In addition, the staff should follow the manufacturer's specifications for the Health Shakes' shelf life.
2. An observation of the facility ice machine and concurrent interview with the FSM and the Maintenance Supervisor (MS) was conducted on November 7, 2022, at 10:16 a.m. Upon the MS took the top machinery part of the ice machine apart, noted there was a significant amount of white and yellow substances buildup on the side of the ice drop opening (the opening where the ice maker makes ice and drop the ice through the opening to the ice storage bin). The FSM and the MS confirmed the substances buildup. The MS stated the buildup was calcium deposit.
The FSM stated dietary was responsible for cleaning outside of the ice machine monthly and maintenance was responsible for the deep cleaning inside of the ice machine monthly.
The MS explained the steps of the cleaning and sanitizing of the ice machine. He stated he used bleach to clean and used sanitizer to sanitize the ice machine. A concurrent review of cleaning and sanitizing instructions at the back of ice machine front panel, and it stated using scale remover mixed with water as a descale and cleaning solution for the ice machine. The MS stated he was not aware of using scale mover to descale and clean the ice machine. He stated he had been using bleach to clean the ice machine since he started his position in the facility.
A review of ice machine user's manual, dated October 2014, it indicated to use the scale remover solution to clean and descale the ice machine.
According to the 2017 FDA Food Code, equipment such as ice [NAME] and ice machines shall be cleaned at a frequency necessary to preclude accumulation of soil or mold.
3. During the kitchen tour on November 7, 2022, at 3:15 p.m., an interview of ambient food cooling process was conducted with [NAME] (C) 1. C1 stated the process of making tuna salad, and he would take the temperature before putting the tuna salad in the refrigerator but did not monitor the temperature after. He added he did not record any temperature for the cooling down process of any ambient food that he made.
During an interview with C2 on November 9, 2022, at 9:10 a.m., C2 stated she made tuna salad few times per week and stated she did not write any temperature on the cooling log. She stated she was not aware that she needed to monitor and log the temperature of the ambient food for the cooling down process.
During an interview with the FSM on November 9, 2022, at 9:55 a.m., the FSM stated the kitchen staff did not do any ambient food cooling down process and they did not have a system.
During an interview with the RD on November 10, 2022, at 9:35 a.m., the RD stated the kitchen should have a system in place for the ambient food cooling down to monitor the temperature to prevent foodborne illness.
A review of facility policy and procedure titled, Cooling and Reheating Potentially Hazardous Foods (PHF) also called Time/Temperature Control for Safety (TCS), dated 2018, it showed, .When cooling down food, use the cool down log to document proper procedure .ambient temperature food .shall be cooled within 4 hours to 41 degrees Fahrenheit (F) or less if prepared from ingredients at ambient temperature .
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected most or all residents
Based on observation, interview and record review, the facility failed to provide a clean environment for the residents and visitors. One out of two garbage disposal bins located outside by the kitche...
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Based on observation, interview and record review, the facility failed to provide a clean environment for the residents and visitors. One out of two garbage disposal bins located outside by the kitchen had trash inside and was not securely closed with the dumpster lid.
This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility.
Findings:
During the kitchen initial tour observation on November 7, 2022, at 10:09 a.m., one out of two dumpsters located outside nearby facility kitchen had trash inside and not securely closed by the dumpster lid.
A concurrent interview with the Food Service Manager (FSM), she confirmed the dumpster was not securely closed with the lid. She agreed it was not acceptable and stated the dumpster lid should be closed tightly all the time.
During an interview with the Registered Dietitian (RD) on November 10, 2022, at 9:35 a.m., she stated the dumpsters should be closed at the time to prevent pest and rodent infestation.
A review of undated facility policy and procedure, titled Dumpster Care, it stated the door or lid of the garbage disposal bin should be closed when the dumpster is not in use.
According to Federal Food Code 2017, the receptacles (containers) and waste handling units for refuse, recyclables, and returnables used with materials containing food residue and used outside the food establishment must be designed and constructed to have tight-fitting lids, doors, or covers.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when:
1. A staff member did not perform handwashing according to facility...
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Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when:
1. A staff member did not perform handwashing according to facility protocol;
2. The facility did not implement Legionella (a bacteria that can cause legionnaire's disease [a type of pneumonia]) water management program policy and procedure; and
3. A licensed nurse did not sanitize blood pressure equipment in between use.
These failures had the potential to result in cross contamination which could cause illnesses to a vulnerable population.
Findings:
1. On November 9, 2022, at 9:41 a.m., Certified Nursing Assistant (CNA) 3 was observed performing handwashing at the nurses' Station 1. CNA 3 completed her handwashing in less than 20 seconds. In a concurrent interview with CNA 3, CNA 3 stated the duration of handwashing should be one minute. She stated she did not perform handwashing properly.
On November 10, 2022, at 12:43 p.m., the Infection Preventionist (IP) was interviewed. She stated handwashing surveillance was performed randomly by her. The IP stated the proper handwashing was to wash hands with soap and water for 20 seconds.
A review of the facility policy and procedure titled, Standard Precautions, dated 2020, indicated, .It is the policy of this facility that hand hygiene procedures will be adhered to in order to prevent the transmission of pathogens .Rubbing hands together vigorously for at least .20 seconds .
2. On November 10, 2022, at 1:40 p.m., Maintenance Supervisor (MS) was interviewed. MS stated he was responsible for monitoring the water system of the facility. The MS stated he was not aware that he had to assess the water system where Legionella or any microorganisms could grow. The MS stated he did not have measures to prevent the growth of Legionella or other microorganisms in the facility's water system.
A review of the facility policy and procedure titled, Legionella Water Management Program, dated July 2017, indicated, .Our facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella .The purpose of the water management program is to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of legionnaire's disease .
3. On November 9, 2022, at 8:24 a.m., during med pass observation, the Licensed Vocational Nurse (LVN 3) was observed taking Resident 5's blood pressure. LVN 3 was not observed sanitizing the BP equipment after using it with Resident 5.
On November 9, 2022, at 8:54 a.m., LVN 1 was taking Resident 18's blood pressure using the same equipment, without sanitizing the BP equipment in between use.
On November 9, 2022, at 11:01 a.m., in an interview with LVN 1, she stated she forgot about sanitizing the equipment before using it to another resident.
On November 10, 2022, at 12:43 p.m., in an interview with the Infection Preventionist (IP), the IP stated the licensed nurse should sanitize with the BP equipment with the sanitizing wipe after each use.
A review of the facility undated policy and procedure titled, INFECTION CONTROL-POLICY FOR CLEANING & DISINFECTING BLOOD PRESSURE MACHINE AND BLOOD PRESSURE CUFF, indicated, .The blood pressure cuff and gauge will be cleaned after each use with a disinfectant wipe .
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
- • No fines on record. Clean compliance history, better than most California facilities.
- • 30% turnover. Below California's 48% average. Good staff retention means consistent care.
Concerns
- • 37 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade C (55/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 55/100. Visit in person and ask pointed questions.
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About This Facility
What is Oak Glen Post Acute's CMS Rating?
CMS assigns OAK GLEN POST ACUTE an overall rating of 3 out of 5 stars, which is considered average nationally. Within California, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Oak Glen Post Acute Staffed?
CMS rates OAK GLEN POST ACUTE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 30%, compared to the California average of 46%. This relatively stable workforce can support continuity of care. RN turnover specifically is 57%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Oak Glen Post Acute?
State health inspectors documented 37 deficiencies at OAK GLEN POST ACUTE during 2022 to 2025. These included: 1 that caused actual resident harm and 36 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Oak Glen Post Acute?
OAK GLEN POST ACUTE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by PACS GROUP, a chain that manages multiple nursing homes. With 59 certified beds and approximately 55 residents (about 93% occupancy), it is a smaller facility located in CHERRY VALLEY, California.
How Does Oak Glen Post Acute Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, OAK GLEN POST ACUTE's overall rating (3 stars) is below the state average of 3.1, staff turnover (30%) is significantly lower than the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Oak Glen Post Acute?
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 Oak Glen Post Acute Safe?
Based on CMS inspection data, OAK GLEN POST ACUTE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-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 Oak Glen Post Acute Stick Around?
OAK GLEN POST ACUTE has a staff turnover rate of 30%, 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 Oak Glen Post Acute Ever Fined?
OAK GLEN POST ACUTE has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Oak Glen Post Acute on Any Federal Watch List?
OAK GLEN POST ACUTE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.