How many inspection deficiencies does NEWPORT SUBACUTE HEALTHCARE CENTER have?

NEWPORT SUBACUTE HEALTHCARE CENTER has 110 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at NEWPORT SUBACUTE HEALTHCARE CENTER?

NEWPORT SUBACUTE HEALTHCARE CENTER has a two-star staffing rating from CMS with 0.55 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is NEWPORT SUBACUTE HEALTHCARE CENTER located?

NEWPORT SUBACUTE HEALTHCARE CENTER is located in COSTA MESA, CA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does NEWPORT SUBACUTE HEALTHCARE CENTER have?

NEWPORT SUBACUTE HEALTHCARE CENTER has 139 certified beds.

Who owns NEWPORT SUBACUTE HEALTHCARE CENTER?

NEWPORT SUBACUTE HEALTHCARE CENTER is a for profit - corporation facility and operates independently (not part of a chain).

NEWPORT SUBACUTE HEALTHCARE CENTER

Name: NEWPORT SUBACUTE HEALTHCARE CENTER
Address: 2570 NEWPORT BLVD, COSTA MESA, CA, 92627, US
Telephone: (949) 631-4282
Rating: 1.0

2570 NEWPORT BLVD, COSTA MESA, CA 92627 · (949) 631-4282

For profit - Corporation 139 Beds Independent Data: November 2025

Trust Grade

35/100

#1074 of 1155 in CA

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NEWPORT SUBACUTE HEALTHCARE CENTER nursing home in COSTA MESA, CA - Photo 1 of 2

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Last Inspection: August 2025

Inspected within the last 6 months. Data reflects current conditions.

Overview

Newport Subacute Healthcare Center has received a Trust Grade of F, which indicates significant concerns about the facility's overall quality and care. They rank #1074 out of 1155 facilities in California, placing them in the bottom half, and #70 out of 72 in Orange County, suggesting very few local options are better. The facility's situation is worsening, with reported issues increasing from 36 in 2024 to 48 in 2025. Staffing is somewhat stable, with a turnover rate of 35%, which is below the California average, but their overall staffing rating is only 2 out of 5 stars. There are no fines on record, which is a positive sign, but the facility has faced serious incidents, including a resident falling from a mechanical lift due to inadequate assistance, resulting in serious injuries, and failures in maintaining kitchen sanitation and infection control practices that could lead to health risks. While there are some strengths, such as good quality measures and lower turnover, these weaknesses raise significant concerns for families considering this nursing home.

Trust Score: F
In California: #1074/1155
Safety Record: Moderate
Inspections: Getting Worse
Staff Stability: 35% turnover. Near California's 48% average. Typical for the industry.
Penalties: No fines on record. Clean compliance history, better than most California facilities.
Skilled Nurses: Each resident gets 32 minutes of Registered Nurse (RN) attention daily — about average for California. RNs are the most trained staff who monitor for health changes.
Violations: 110 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★★★★☆

4.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

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Stable

2024: 36 issues

2025: 48 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 (35%)
13 points below California average of 48%

Facility shows strength in quality measures, fire safety.

The Bad

1-Star Overall Rating

Below California average (3.1)

Significant quality concerns identified by CMS

Staff Turnover: 35%

11pts below California avg (46%)

Typical for the industry

The Ugly 110 deficiencies on record

1 actual harm

Sept 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary treatment and services to maintain the highest practicable well-being for one of twelve sampled residents (Resident 10). * The facility failed to monitor Resident 10 who was on antibiotic treatment for UTI. In addition, the facility failed to ensure Resident 10's plan of care was updated to address Resident 10's treatment interventions and management of the UTI. This failure had the potential for the delay of the identification of the adverse effects related to the resident's use of antibiotic treatment and for the resident to not receive the appropriate and individualized care that could potentially affect the resident's health and well-being. Findings: Review of the facility's P&P titled Care Planning-Interdisciplinary Team revised 3/2022 showed a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident. Review of the facility's P&P titled Change in a Resident's Condition or Status revised 4/2021 showed a significant change in condition is a major decline or improvement in the resident's status that requires interdisciplinary review and or revision to the care plan; and the nurse will record in the resident's medical record information relative to changes in resident's medical/mental condition or status. According to CDC Healthy Habits: Antibiotic Do's Administrator Don'ts dated 9/23/25, showed the common side effects of antibiotics range from minor to severe health problems and can include rash, dizziness, nausea, diarrhea, yeast infection. The more serious side effects can include C. diff infection which causes diarrhea that can lead to severe colon damage and death and severe and life threatening allergic reactions. Medical record review for Resident 10 was initiated on 9/17/25. Resident 10 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 10's H&P examination dated 8/10/25, showed Resident 10 required assistance to make medical decisions. Review of Resident 10's Order Summary Report showed the following physician's orders:- dated 7/20/25, for Ceftriaxone (an antibiotics) sodium solution reconstituted 1 gram, to give 1 gram intravenously every 24 hours for infection for five days and discontinued on 7/21/25; and- dated 7/22/25, for Ertapenem sodium (an antibiotics) injection solution reconstitute 1 gram, to give 1 gram intravenously one time a day for UTI until 7/27/25. a. Review of Resident 10's nursing assessment dated [DATE] at 1508 hours, showed Resident 10 was noted with a change of condition including tachycardia (increased heart rate). The physician was notified and ordered urinalysis stat and antibiotic treatment of Ceftriaxone 1 gm IV every 24 hour for five days. Review of Resident 10's Change of Condition Report dated 7/21/25 at 1600 hours, showed Resident 10 with a change of condition related to urinary tract infection as evidenced by the urinalysis result with an order for antibiotic therapy initiation. However, further review of Resident 10's medical record failed to show if the resident's change in condition was monitored after the initiation of the antibiotic therapy. b. Review of Resident 10's plan of care failed to show a care plan problem was developed related to the treatment interventions and management of the UTI. On 9/17/25 at 1615 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified Resident 10's care plan was not updated to include the treatment interventions and management of the UTI. RN 2 verified that there was no documented evidence to show Resident 10's condition and antibiotic therapy were monitored. RN 2 further stated for the residents on the antibiotics treatment, the residents should have been monitored every shift during the entire course of antibiotic therapy plus three additional days after the completion of the antibiotic therapy. On 9/19/25 at 1345 hours, the Administrator and DON were informed and acknowledged the above findings.

Aug 2025 29 deficiencies

CONCERN (D)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to properly obtain the informed consent (permission granted in the knowledge of the possible consequences) for the use of psychotropic medications (medications affecting brain activity) and bedrails from the residents or from the responsible party (person designated to make decisions on behalf of the residents). The facility failed to obtain the informed consent for the psychotropic medications for three of five sampled residents (Residents 3, 20, and 70) reviewed for unnecessary medications and one nonsampled resident (Resident 24) reviewed for the use of the bedrails. * The facility failed to obtain renew the informed consents for the Abilify (antipsychotic medication) and Prolixin (antipsychotic medication) medications after six months for Resident 3. * The facility failed to renew the informed consents for the divalproex sodium (used to treat seizures and bipolar disorder), buspirone (antianxiety medication), Remeron (antidepressant), Neudexta (used to treat a neurological condition that causes sudden, frequent, and involuntary episodes of crying or laughing), and Seroquel (antipsychotic medication) medications for Resident 20 six months after the previous informed consents were obtained. * The facility failed to obtain the informed consents for the bilateral 1/4 side rails for Resident 24. The informed consent obtained for the use of the side rails for Resident 24 was for the bilateral 1/2 side rails. * The facility failed to obtain the informed consents for the sertraline (antidepressant), olanzapine (antipsychotic), and trazodone (antidepressant) medications for Resident 70. These failures posed the risk for the residents and or their responsible parties to not be informed of their medications and the potential side effects, and the use of bedrails and the risks of their usage.Findings: Review of the AFL 24-07 titled AB 48 – Nursing Facility Resident Informed Consent Protection Act of 2023 dated 2/28/24, showed the following: - Facilities must renew the written informed consent every six months. At that time, the facility must provide the residents with any recommended dosage adjustments and the option of revoking consent; and - Facilities must review and revise their P&Ps to ensure compliance with the new law. The P&P must specifically consider and plan for how the facility will verify that the resident provided informed consent or refused treatment or a procedure pertaining to the administration of psychotherapeutic drugs. Review of the facility's P&P titled Restraint Assessment: Chemical (Psychotropic) Meds and Physical (undated) showed each resident or responsible party will give consent for the purposes of prescribing and administering psychotherapeutic medications for the purpose of chemically restraining a resident. 1. Medical record review for Resident 20 was initiated on 8/27/25. Resident 20 was admitted to the facility on [DATE]. Review of Resident 20's H&P examination dated 12/11/24, showed Resident 20 had no capacity to understand and make decisions. Review of Resident 20's Order Summary Report for August 2025 showed the following physician's orders: - dated 10/8/24, to administer Remeron 7.5 mg one tablet orally at bedtime for major depressive disorder manifested by poor appetite. - dated 2/10/25, to administer buspirone HCL oral tablet 10 mg by mouth three times per day for anxiety manifested by screaming. - dated 3/26/25, to administer Nuedexta oral capsule 20-10 mg by mouth two times a day for pseudobulbar affect (neurological condition that causes sudden, frequent, and involuntary episodes of crying or laughing) manifested by inappropriate laughing and crying. - dated 4/15/25, to administer divalproex sodium oral capsule delayed release 250 mg twice a day for unspecified mood disorder manifested by constant screaming/yelling; - dated 4/15/25, to administer Seroquel 25 mg by mouth two times a day for psychosis manifested by talking to unseen others. Review of Resident 20's informed consents showed the following: - the Seroquel medication consent was obtained on 4/18/24; - the Remeron medication consent was obtained on 10/3/24; - the buspirone HCL medication consent was obtained on 11/8/24; - the Nuedexta medication consent was obtained on 2/12/25; and - the divalproex medication consent was obtained on 2/24/25. However, further review of Resident 20's informed consents for the above psychotropic medications showed the informed consents were past the six-month mark and required a renewal for the informed consents to be current and active. On 8/28/25 at 1347 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the informed consents for the five listed psychotropic medications for Resident 20 were not current and needed to be renewed after six months from when the informed consent was obtained. 2. Review of the AFL 24-07 titled AB 48 - Nursing Facility Resident Informed Consent Protection Act of 2023 dated 2/28/24, showed the following: - Before prescribing a psychotherapeutic drug, the prescriber must personally examine the resident and obtain informed written consent signed by the resident or the resident's representative along with the signature of the health care professional declaring the required material information has been provided. If the resident or resident's representative cannot sign the form, a licensed nurse can sign the form and document the name of the person who gave consent and the date. The personal exam and the signatures of the prescriber, resident, or representative can be completed and signed using remote technology. - The signed written consent must be recorded in the resident's medical record. Before initiating treatment with psychotherapeutic drugs, facility staff must verify that the resident's health record contains written informed consent with the required signatures. For a prescription written prior to facility admission, the facility staff must verify that the resident or the resident's representative gave informed consent and make a notation in the resident's records. The record does not need to be checked every time the drug is administered. Review of the facility’s P&P titled Restraint Assessment: Chemical (Psychotropic Meds) and Physical (undated) showed the facility shall verify that the attending physician of a resident has obtained consent for the purposes of prescribing and ordering the use of a physical or chemical restraints on a resident, (or increasing an order for antipsychotic medication). This shall be documented in the resident’s health record. Medical record review for Resident 70 was initiated on 8/25/25. Resident 70 was admitted to the facility on [DATE]. Review of Resident 70's Order Summary Report showed the following physician's orders: - dated 8/7/25, to administer olanzapine 10 mg via GT at bedtime; - dated 8/7/25, to administer sertraline 100 mg via GT one time a day; and .- dated 8/7/25, to administer trazodone 50 mg via GT at bedtime. Review of Resident 70’s H&P examination dated 8/12/25, showed Resident 70 had fluctuating capacity to understand and make medical decisions. Review of Resident 70’s MDS admission assessment dated [DATE], showed Resident 70 has a BIMS score of 15, indicating cognitively intact. Further review of Resident 70’s medical record failed to show the informed consents for the above psychotropic medications were obtained from the resident and/or their responsible party. On 8/27/25 at 1212 hours, an interview and concurrent medical review was conducted with RN 2. RN 2 verified there were no informed consents obtained for Resident 70’s use of the olanzapine, sertraline, and trazodone medications. RN 2 stated if the resident’s responsible party was not present in the facility, there should be two licensed nurses to verify the verbal consent was obtained. RN 2 further stated the facility should not have administered the olanzapine, sertraline, and trazodone medications until the informed consents were obtained from the resident or their responsible party. On 8/27/25 at 1518 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. The DON stated the psychotropic medications should not have been administered if there were no informed consents obtained from the resident or their responsible party. 3. Medical record review for Resident 3 was initiated on 8/25/25. Resident 3 was readmitted to the facility on [DATE]. Review of Resident 3’s Order Summary Report showed the following physician’s orders: - dated 2/9/24, to administer Abilify 30 mg one tablet by mouth a day; and - dated 7/23/25, to administer fluphenazine (Prolixin) 5 mg by mouth at bedtime. Review of Resident 3’s MAR for August 2025 showed the following: - Resident 3 was administered the Abilify medication from 8/1 to 8/10, and 8/12 to 8/27/25 at 0900 hours; and - Resident 3 was administered the fluphenazine medication from 8/1 to 8/26/25 at 2100 hours. Review of Resident 3’s Informed Consent Verification dated 2/9/24, showed the informed consent for Abilify was obtained from Resident 3. Review of Resident 3’s Informed Consent Verification dated 7/3/24, showed the informed consent for Prolixin was obtained from Resident 3. Further review of Resident 3’s medical record failed to show documented evidence the informed consents for Abilify and Prolixin were renewed after six months. On 8/27/25 at 1149 hours, an interview and concurrent medical record review for Resident 3 was conducted with RN 1. RN 1 verified the informed consents for Abilify and Prolixin medications for Resident 3 were not renewed after six months. RN 1 stated the informed consents for psychotropic medications were not renewed after six months, unless the resident was discharged then readmitted with a new chart. On 8/28/25 at 1051 hours, an interview and concurrent medical record review for Resident 3 was conducted with the DON. The DON verified the informed consents for Abilify and Prolixin medications for Resident 3 were not renewed after six months. The DON stated when the facility conducted the quarterly IDT meetings, they also checked the informed consent, to which the medical records department would inform the nursing department about the informed consents needed to be renewed. 4. On 8/27/25 at 0907 hours, on 8/28/25 at 0957 and 1120 hours, Resident 24 was observed lying in bed with bilateral ¼ (quarter) side rails elevated. Review of Resident 24’s Order Summary Report showed a physician’s order dated 8/13/25, for bilateral ¼ side rails. Review of Resident 24’s Informed Consent Documentation (undated) showed the informed consent obtained was for bilateral ½ (half) side rails. On 8/27/25 at 1204 hours, an interview and concurrent medical record review for Resident 24 was conducted with RN 1. RN 1 verified the above findings. On 8/28/25 at 1029 hours, the DON was informed and verified the above findings.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0573 (Tag F0573)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility document review, the facility failed to ensure the copy of the resident's medical record was provided upon request within two working days for one of three residents reviewed for closed records (Resident 101). * The facility failed to provide Resident 101's requested medical record and facility documents to the legal representative until 13 days after the initial request was received. In addition, the facility's resident care policies and daily posting of the staffing record were not provided as requested to Resident 101's legal representative. This failure had the potential for violating Resident 101's and their legal representative rights to access their medical health information.Findings: On [DATE] at 1038 hours, a telephone interview was conducted with the Legal Assistant. The Legal Assistant stated Resident 101 expired on [DATE] in the facility, so the resident's representative had filed a case through the Law Firm. The Legal Assistant stated the Law Firm required Resident 101's medical record, facility's resident care policies, and the posting of the staffing data for each day of the last 18 months. The Legal Assistant further stated resident's representative had signed the written authorization to release the medical record for Resident 101. The Legal Assistant stated she first mailed the request on [DATE], via federal express and it was hand delivered to the facility staff on [DATE]. The Legal Assistant stated it had been more than 13 days since she requested the records but had not received the requested records from the facility. On [DATE] at 1529 hours, a follow up telephone interview was conducted with the Legal Assistant. The Legal Assistant stated she made multiple attempts to request the medical record for Resident 101. The Legal Assistant stated after she mailed the initial request, she called the facility and left a voice message on 8/14, 8/18, and [DATE]. The Legal Assistant further stated she also emailed the Director of Medical Records on [DATE], regarding the same request but had not received the records yet. Closed medical record review of Resident 101 was initiated on [DATE]. Resident 101 was admitted to the facility on [DATE], and expired on [DATE]. Review of Resident 101's MDS assessment dated [DATE], showed Resident 101 had moderately impaired cognitive function. Review of Resident 101's admission Record dated [DATE], showed Resident Representative 1 had the Power of Attorney for Health Care for Resident 101. Review of Law firm's Medical request dated [DATE], showed the following records were requested:- - Resident 101's medical records, billing records, photographs, charts and writings. In addition, all admission agreements, reviews, utilization review committee records, and x-rays;- - Facility's resident care policies and procedure; and- - Posted nurse staffing data for each day of the eighteen months prior to the date of the letter. Further review of the Law Firm medical record request showed Resident Representative 1 electronically signed the authorization for the release of Resident 101's medical information. On [DATE] at 0815 hours, an interview and concurrent closed medical record review for Resident 101 was conducted with the Director of Medical Records. The Director of Medical Records stated the residents and/or resident's legal representatives were entitled to access their medical records, patient care policies, and posted staffing data. The Director of Medical Records further stated the medical records department would assist with providing the residents and/or their representatives with the copies of the requested records. The Director of Medical Records stated she received the above medical request for Resident 101 on [DATE], and verified Resident Representative 1 had the power of attorney for Resident 101. The Director of Medical Records verified Resident Representative 1 signed the authorization for the release of Resident 101's medical information. The Director of Medical Records verified the above request for the records was not provided to the Law Firm and it was 13 days overdue. The Director of Medical Records stated the above requested records, including Resident 101's medical record, should have been provided to the Law Firm within two working days as per the regulation. On [DATE] at 1133 hours, an interview with the DON was conducted. The DON was informed and acknowledged the above findings.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the written information regarding how to formulate an advanced directive for five of 16 final sampled residents (Residents 5, 6, 8, 83, and 90) reviewed for advanced directives. * The facility failed to provide the written information and assistance regarding how to formulate the advanced directive for Residents 5 and 90. * The facility failed to inform, provide, and document the written information regarding the residents' right to formulate the advanced directives for Residents 6 and 83. * The facility failed to provide the written information regarding the right to formulate the advanced directive for Resident 8. These failures had the potential for the residents to receive inaccurate and delayed treatment compatible with the residents' wishes during an emergency.Findings: Review of the facility's P&P titled Advance Directives revised on 9/2022 showed the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. The Determining Existence of Advanced Directive section showed the following: - The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advanced directive if he or she chooses to do so; - Written information about the right to accept or refuse medical or surgical treatment, and the right to formulate an advance directive is provided in a manner that is easily understood by the resident or representative; and - If the resident is incapacitated und unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident’s legal representative. If the resident becomes able to receive and understand this information later, he or she will be provided with the same written materials as described above, even if his or her legal representative has already been given the information. 1. Medical record review for Resident 5 was initiated on 8/26/25. Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's MDS assessment dated [DATE], showed Resident 5 had moderate cognitive impairment. Review of Resident 5's POLST dated 12/20/24, showed under Section D-Information and Signatures, Resident 5 had no advanced directive. Further review of Resident 5's medical record failed to show the documented evidence the facility followed up with Resident 5 and/or the resident's representative to provide the information and assistance on formulating the advance directive. 2. Medical record review for Resident 90 was initiated on 8/26/25. Resident 90 was readmitted to the facility on [DATE]. Review of Resident 90's H&P examination dated 3/31/25, showed Resident 90 had the capacity to understand and make decisions. Review of Resident 90's MDS assessment dated [DATE], showed Resident 90 was cognitively intact. Review of Resident 90's POLST dated 8/21/24, showed under Section D-Information and Signatures, Resident 90 had no advanced directive. Further review of Resident 90's medical record failed to show the documented evidence the facility followed up with Resident 90 to provide the information and assistance on formulating the advanced directive. On 8/27/25 at 1536 hours, an interview and concurrent medical record review for Residents 5 and 90 was conducted with the MDS Coordinator. The MDS Coordinator stated she just started following up with the residents regarding their advanced directives two weeks ago when the primary staff who was responsible for following up with the advanced directives left. The MDS Coordinator stated she met with the resident and resident’s representative upon admission to discuss the POLST and the advanced directive with them. The MDS Coordinator stated the resident or the resident’s representative would complete the POLST and when the Section D- Information and Signatures showed discussed with the resident or legally recognized decision maker, it meant the information regarding the formulation of the advanced directive was provided. The MDS Coordinator acknowledged the POLST did not show any documented evidence a written information was provided to Residents 5 and 90 regarding how to formulate an advanced directive in a manner that was easily understood by the residents. On 8/29/25 at 1440 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings for Residents 5 and 90. 3. Review of Resident 6's medical record was initiated on 8/25/25. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's H&P examination dated 5/20/25, showed Resident 6 had the capacity to understand and make medical decisions. Review of Resident 6's POLST dated 5/17/25, failed to show under Section D for Information and Signatures, if Resident 6 had an advanced directive. Review of Resident 6's Social Services progress notes dated 5/27/25, failed to show documented evidence if the formulation of an advance directive was offered to Resident 6 and/or his representative. Further review of Resident 6's medical record failed to show the Advance Directive Acknowledgment form was completed for Resident 6. On 8/28/25 at 1329 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator. The MDS Coordinator acknowledged the above findings and stated the advanced directive was completed upon the resident's admission to the facility by the Social Services staff. The MDS Coordinator stated the facility currently had no SSD and the POLST was completed by the licensed nurses. In addition, MDS Coordinator stated she was unsure if the Advance Directive Acknowledgment form was used in the facility. On 8/28/25 at 1539 hours, the DON was informed and verified the above findings. 4. Medical record review for Resident 83 was initiated on 8/25/25. Resident 83 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 83's POLST dated 5/24/19, failed to show under Section D for Information and Signatures, if Resident 83 had an advanced directive. Review of Resident 83's Social Services progress notes dated 7/16/24, showed the POLST was discussed with the resident's family member who had pending conservatorship. However, the progress notes failed to show further Social Services documentation to follow up if the advance directive formulation was offered to Resident 83’s responsible party. Review of Resident 83's H&P examination dated 8/22/25, showed Resident 83 had anoxic brain injury (condition where the brain is deprived of oxygen for a period of time) and was in persistent vegetative state, contracted, unable to communicate, track, or make needs known. Further review of Resident 83's medical record failed to show the Advance Directive Acknowledgment form was completed for Resident 83. On 8/28/25 at 1313 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator. The MDS Coordinator acknowledged the above findings. On 8/28/25 at 1539 hours, an interview was conducted with the DON. The DON was informed and verified the above findings. 5. Medical record review for Resident 8 was initiated on 8/27/25. Resident 8 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 8's POLST dated 7/15/25, showed under Section D, “No” was marked for the Advanced Directive. Review of Resident 8's H&P examination dated 7/17/25, showed Resident 8 had no capacity to understand and make decisions. Further review of Resident 8’s medical record failed to show documented evidence the advanced directive was offered and discussed with the resident’s representative. On 8/27/25 at 1552 hours, an interview and concurrent medical record review was conducted with MDS Coordinator for Resident 8’s advanced directive. The MDS Coordinator verified there was no documentation of the acknowledgment to show the advanced directive was offered or discussed with the resident’s representative. On 8/27/25 at 1604 hours, an interview was conducted with the DON. The DON verified there was no advanced directive, acknowledgment and/or documentation in the resident’s medical records to show if the advanced directive was offered or discussed with the resident’s representative.

CONCERN (D)

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to immediately notify the physician and family of a change in condition for one of four final sampled residents (Resident 9) reviewed for pressure ulcers. * The facility failed to notify Resident 9's physician and resident representative regarding Resident 9's change of condition when Resident 9 developed MASD (Moisture-Associated Skin Damage, general term for inflammation or skin erosion caused by prolonged exposure to a source of moisture such as urine, stool, sweat, wound drainage) to the coccyx (tailbone). This had the potential to negatively impact Resident 9's physical wellbeing and prevent the resident 's representative from being fully aware and understand the resident's treatments and course of actions. Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised February 2021 showed the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Medical record review for Resident 9 was initiated on 8/25/25. Resident 9 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 9's Change of Condition dated 8/9/25, showed under the Situation section, the resident had a MASD to the coccyx . Under the Recommendation section showed the following:- Plan of Care: to monitor and report worsening signs and symptoms;- MD Orders: Cleanse with normal saline, pat dry, apply zinc oxide (used to treat or prevent skin irritation) and cover with dry dressing. However, the assessment failed to show if the physician and/or resident's representative were notified regarding the resident's change of condition. The assessment failed to show which physician gave the wound care order documented under the Recommendation section. On 8/28/25 at 1457 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 stated when the resident had a change of condition, the physician and family must be informed. RN 2 stated the physician for Resident 9 had not been involved in resident's care since there was a lack of wound care notes from the physician. RN 2 further stated the treatment nurses would at times place the wound care order on the resident's medical record. Additionally, RN 2 verified the resident's physician and resident representative were not notified regarding Resident 9's change of condition. On 8/29/25 at 1119 hours, an interview and concurrent medical record review was conducted with RN 3. RN 3 stated the resident's physician and resident's responsible party or family were not notified of Resident 9's change in condition. Additionally, RN 3 stated the treatment nurses put in the wound care orders themselves in the resident's medical record. On 8/29/25 at 1412 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 9 had a change in the resident's skin condition on 8/9/25. When asked about the facility's expectation for reporting the resident's change of condition, the DON stated the licensed nurses should notify the resident's physician for interventions and the family or the resident's responsible party also needed to be informed. The DON verified the resident's physician and family member were not notified regarding the resident's change of condition on 8/9/25.

CONCERN (D)

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

Deficiency F0605 (Tag F0605)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure three of five unnecessary medication sampled residents (Residents 2, 20, and 24) were free from unnecessary psychotropic drugs. * The facility failed to ensure Resident 24 was monitored for the behavior manifestation per the physician's order for Risperdal (antipsychotic medication) and failed to monitor the orthostatic hypotension related to the use of antipsychotic medication. In addition, the facility failed to monitor the number of hours of sleep for Resident 24 related to the use of trazodone (antidepressant medication). * The facility failed to ensure the nonpharmacological interventions for the use of the Remeron (antidepressant medication), divalproex (bipolar medication), Nuedexta (used to treat neurological condition that causes uncontrollable episodes of laughing and/or crying), Seroquel (antipsychotic medication) and buspirone HCL (antianxiety medication) medications were provided to Resident 20. In addition, the facility failed to complete the monthly behavior monitoring summaries for the listed medications since April 2025. Furthermore, the facility failed to ensure the side effects for the Remeron, divalproex sodium and Nuedexta medications were monitored. * The facility failed to ensure the nonpharmacological interventions for the use of the buspirone HCL and Seroquel medications were provided to Resident 2. In addition, the facility failed to complete the monthly behavior monitoring summaries for the listed medications since April 2025. These failures had the potential to place the residents at risk of receiving unnecessary medications and an increased risk of serious medication adverse reactions, which could negatively impact the residents' well-being.Findings: 1. Review of the facility’s P&P titled Antipsychotic Medication Use revised 7/2022 showed the following: - Antipsychotic medications will not be used if the only symptoms are one or more of the following: wandering, poor self-care, restlessness, impaired memory, mild anxiety, insomnia, inattention or indifference to surroundings, sadness or crying alone not related to depression or other psychiatric disorders, fidgeting, nervousness, or uncooperativeness; and - Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician the cardiovascular side effects such as orthostatic hypotension, and arrhythmias. Medical record review for Resident 24 was initiated on 8/25/25. Resident 24 was admitted to the facility on [DATE]. Review of Resident 24’s Order Summary Report showed the following physician’s orders dated: - 7/18/25, to monitor for restlessness every shift; - 7/18/25, to monitor for behavior related to insomnia (difficulty falling or staying asleep) every shift; - 7/23/25, to administer Risperdal 2 mg via GT one time a day for psychosis manifested by agitation, kicking staff and pulling tubes; - 7/23/25, to administer Risperdal 3 mg via GT at bedtime for psychosis manifested by agitation, kicking staff and pulling tubes; and - 7/23/25, to administer trazodone 25 mg via GT at bedtime for depression manifested by inability to sleep. Review of Resident 24’s MAR for August 2025 showed the following: - Resident 24 was administered the Risperdal 2 mg medication on 8/1 to 8/8, 8/10, 8/12 to 8/21, and 8/24 to 8/27/25 at 0900 hours; - Resident 24 was administered the Risperdal 3 mg medication on 8/1 to 8/20, and 8/22 to 8/26/25 at 2100 hours; - Resident 24 was monitored for restlessness on 8/1 to 8/27/25 for the day shift, and from 8/1 to 8/26/25 for the night shift; - Resident 24 was administered the trazodone 25 mg medication from 8/1 to 8/26/25 at 2100 hours; and - Resident 24 was monitored for the behavior related to insomnia from 8/1 to 8/27/25 for the day shift, and from 8/1 to 8/26/25 for the night shift. However, the monitoring did not show the number of hours Resident 24 slept. Further review of Resident 24’s medical record did not show Resident 24 was monitored for the orthostatic hypotension related to the use of antipsychotic medication. On 8/27/25 at 1204 hours, an interview and concurrent medical record review for Resident 24 was conducted with RN 1. RN 1 verified the above findings. RN 1 stated Resident 24 was monitored for restlessness related to the use of the Risperdal medication, instead of the manifestations of agitation, kicking staff, and pulling the tubes per the physician's order . RN 1 verified Resident 24 was also not monitored for the orthostatic hypotension related to the use of the Risperdal medication. RN 1 further verified Resident 24 was not monitored for the number of hours of sleep related to the use of the trazodone medication. RN 1 stated the licensed nurses should have specified the number of hours of sleep, instead of placing checkmarks in the resident's MAR. On 8/28/25 at 1029 hours, an interview was conducted with the DON. The DON stated the behavior monitoring for Resident 24 related to the use of the Risperdal medication should have included the behaviors specific for the medications, as stated in the physician’s order. The DON stated the orthostatic hypotension was one of the side effects of the antipsychotic medication. The DON further stated the monitoring for the sleep should include the number of hours of the resident slept to determine if Resident 24 had insomnia. 2. Medical record review for Resident 20 was initiated on 8/27/25. Resident 20 was admitted to the facility on [DATE]. Review of Resident 20's H&P examination dated 12/11/24, showed Resident 20 had no capacity to understand and make decisions. Review of Resident 20's Order Summary Report for August 2025 showed the following physician’s orders: - dated 10/8/24, to administer Remeron 7.5 mg one tablet orally at bedtime for major depressive disorder manifested by poor appetite. - dated 2/10/25, to administer buspirone HCL oral tablet 10 mg by mouth three times per day for anxiety manifested by screaming. - dated 3/26/25, to administer Nuedexta oral capsule 20-10 mg by mouth two times a day for pseudobulbar affect manifested by inappropriate laughing and crying. - dated 4/15/25, to administer Seroquel 25 mg by mouth two times a day for psychosis manifested by talking to unseen others. - dated 4/15/25, to administer divalproex sodium oral capsule delayed release 250 mg twice a day for unspecified mood disorder manifested by constant screaming/yelling. Further review of Resident 20’s medical record review failed to show the documented evidence the nonpharmacological interventions were provided to Resident 20 related to the use of the divalproex sodium, Remeron, Nuedexta, Seroquel, and buspirone HCL medications. In addition, there was no documented evidence the the Monthly Psychotherapeutic Drug Summary Sheets for the listed medications were completed for Resident 20 since April 2025. Furthermore, there was no documented evidence the side effects were monitored for the Remeron, divalproex sodium and Nuedexta medications. 3. Medical record review for Resident 2 was initiated on 8/27/25. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's H&P examination dated 4/14/25, showed Resident 2 had the capacity to understand and make decisions. Review of Resident 2's Order Summary Report for August 2025 showed the following physician’s orders: - dated 4/15/25, to administer buspirone HCL oral tablet 15 mg by mouth two times per day for anxiety manifested by chronic irritability. - dated 4/15/25, to administer Seroquel 100 mg by mouth one time a day for schizophrenia manifested by paranoid delusions. Further review of Resident 2’s medical record review failed to show the nonpharmacological interventions were provided to Resident 2 related to the use of the above medications. In addition, there was no documented evidence the Monthly Psychotherapeutic Drug Summary Sheets for Resident 2 since April 2025. On 8/28/25 at 1347 hours, an interview and concurrent medical record review was conducted with the DON for Residents 2 and 20. The DON acknowledged and verified the above findings.

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to develop and implement the comprehensive person-centered plan of care to reflect the individual care needs for four of 21 final sampled residents (Residents 8, 68, 70, and 99), one of five residents (Resident 20) reviewed for unnecessary medications, and one of three closed record residents (Resident 10) reviewed. * The facility failed to develop a care plan to address Resident 8's use of an enteral feeding. * The facility failed to implement the care plan intervention of checking Resident 10's blood pressure every 12 hours to address Resident 10's hypotension diagnosis. * The facility failed to develop the comprehensive person-centered care plan to address Resident 20's use of divalproex sodium, Remeron, and Nuedexta medications. * The facility failed to develop a care plan to address Resident 68's use of insulin medication. * The facility failed to ensure to develop the comprehensive person-centered care plan to address Resident 70's use of olanzapine (antipsychotic), sertraline (antidepressant), trazodone (antidepressant) and apixaban(anticoagulant) medication. * The facility failed to develop a care plan to address Resident 99's use of anticoagulant medication. These failures had the potential to cause inconsistent, inappropriate and inadequate plans of care for residents in a vulnerable population and result in suboptimal outcomes for the affected residents.Findings: 1. Review of facility’s P&P titled Care Plans, Comprehensive Person-Centered revised 3/2022 showed a comprehensive, person- centered care plan that includes measurable objectives and timetables to meet the resident’s physical, psychosocial and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment (Minimum Data Set- standardized assessment tool used in long-term care facilities to collect information about the health and function of residents to provide comprehensive picture of each resident’s need) and no more than 21 days after admission. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Medical record review for Resident 20 was initiated on 8/27/25. Resident 20 was admitted to the facility on [DATE]. Review of Resident 20's H&P examination dated 12/11/24, showed Resident 20 had no capacity to understand and make decisions. Review of Resident 20's Order Summary Report for August 2025 showed the following physician’s orders: - dated 10/8/24, to administer Remeron 7.5 mg one tablet orally at bedtime for major depressive disorder manifested by poor appetite. - dated 3/26/25, to administer Nuedexta oral capsule 20-10 mg by mouth two times a day for pseudobulbar affect manifested by inappropriate laughing and crying. - dated 4/15/25, to administer divalproex sodium oral capsule delayed release 250 mg twice a day for unspecified mood disorder manifest by constant screaming/yelling. Review of Resident 20’s plan of care failed to show a care plan problem addressing the resident’s use of the above psychotherapeutic medications. On 8/28/25 at 1347 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 20’s plan of care failed to address the resident’s use of the psychotherapeutic medications. 2. Medical record review for Resident 70 was initiated on 8/25/25. Resident 70 was admitted to the facility on [DATE]. Review of Resident 70’s H&P examination dated 8/12/25, showed the resident had fluctuating capacity to understand and make medical decisions. Review of Resident 70’s admission MDS assessment dated [DATE], showed Resident 70 had a BIMS score of 15, indicating cognitively intact. Review of Resident 70's Order Summary Report showed the following physician's orders: - dated 8/7/25, to administer olanzapine (antipsychotic medication) 10 mg via GT at bedtime; - dated 8/7/25, to administer sertraline (antidepressant) 100 mg via GT one time a day; - dated 8/7/25, to administer trazodone (antidepressant) 50 mg via GT at bedtime, and - dated 8/7/25, to administer apixaban (blood thinner) 2.5 mg via GT two times a day. Review of Resident 70's plan of care failed to show documented evidence the care plans were developed to address the resident's use of the olanzapine, sertraline, trazodone, and apixaban medications as ordered by the physician. On 8/27/25 at 1212 hours, an interview and concurrent medical record review was conducted with RN 2 for Resident 70. RN 2 verified there were no comprehensive care plans were developed for the use of the olanzapine, sertraline, trazodone, and apixaban medications. On 8/27/25 at 1518 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. Cross reference to F757, example #2. 3. On 8/26/25 at 1100 hours, an observation and concurrent interview was conducted for Resident 99. Resident 99 was observed awake and lying in bed. Resident 99 stated she had a stroke in 2016 and had been taking blood thinner since then. Resident 99 stated she had not experienced having episodes of bleeding. Medical record review for Resident 99 was initiated on 8/26/25. Resident 99 was admitted to the facility on [DATE]. Review of Resident 99's Order Summary Report showed a physician's order dated 8/21/25, to administer apixaban oral tablet 5 mg one tablet by mouth two times a day for anticoagulant. Review of Resident 99's H&P examination dated 8/22/25, showed Resident 99 had the capacity to understand and make decisions. Further review of Resident 99’s medical record failed to show documented evidence a care plan was developed for the use of the apixaban medication. On 8/26/25 at 1404 hours, an interview and concurrent medical record review for Resident 99 was conducted with LVN 9. LVN 9 stated a care plan should be initiated for any problems identified for the residents, to have a course of actions to follow and help resolve the issues. LVN 9 verified there was no care plan developed for Resident 99 related to the use of the apixaban medication. On 8/29/25 at 1440 hours, an interview was conducted with the DON. The DON stated the care plan was a guide which could direct the facility staff regarding which interventions to implement for the residents to achieve the goal of resolving the problems identified for the residents. The DON was informed and acknowledged the above findings for Resident 99. Cross reference to F757, example # 1. 4. Medical record review for Resident 68 was conducted on 8/27/25. Resident 68 was admitted to the facility on [DATE]. Review of Resident 68’s Order Summary report dated 8/28/25, showed a physician’s order dated 7/24/25, to administer NPH insulin (Neutral Protamine [NAME]-intermediate acting insulin) 5 units subcutaneously one time a day, 30 minutes before meal related to Type 2 Diabetes Mellitus (a disease that results in too much sugar in the blood). Review of Resident 68’s plan of care failed a care plan problem was developed related to the resident’s use of the insulin. On 8/27/25 at 1426 hours, an interview and concurrent medical record review was conducted with RN 2 for Resident 68. RN 2 reviewed Resident 68’s plan of care and verified there was no comprehensive care plan problem developed for the use of the insulin medication. On 8/27/25 at 1437 hours, an interview and concurrent medical record review was conducted with the DON. The DON reviewed Resident 68’s plan of care and verified there was no care plan problem developed for the use of the insulin medication. The DON stated the resident’s care plan should have been developed to ensure the appropriate interventions were implemented. 5. Medical record review for Resident 8 was conducted on 8/28/25. Resident 8 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 8’s Order Summary report dated 8/28/25, showed a physician’s order to administer Nepro with Carb Steady (type of enteral feeding) 1.8 at 67 ml/hr for 16 hours to provide 1830 calorie per 1072 ml or until dose is completed by enteral feeding pump. On 8/28/25 at 0955 hours, an observation was conducted inside Resident 8’s room. Resident 8 was observed with a GT, connected to a formula via an enteral pump (medical device to deliver liquid formula directly into a person’s digestive tract through feeding tube at a controlled, steady rate). Review of Resident 8’s plan of care failed to show a care plan problem was developed to address the resident’s enteral feeding. On 8/28/25 at 1100 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified there was no comprehensive care plan problem developed to address Resident 8’s enteral feeding. On 8/28/25 at 1116 hours, an interview was conducted with the DON. The DON verified the above findings and stated the facility should have developed a care plan problem addressing the resident’s enteral feeding. 6. Review of the facility’s P&P titled Care Plans – Comprehensive revised 9/2010 showed the facility would develop an individualized comprehensive care plan to meet the resident’s medical, nursing, mental and psychological needs for each resident. Each resident’s comprehensive care plan is designed to incorporate identified problem areas and reflect treatment goals, timetables, and objectives in measurable outcomes. Closed medical record review for Resident 10 was initiated on 8/27/25. Resident 10 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 10’s plan of care revised 7/16/25, showed a care plan problem addressing Resident 10’s hypotension diagnosis. The interventions included to check Resident 10’s blood pressure every 12 hours. Review of Resident 10’s MDS assessment dated [DATE], showed Resident 10 had a medical diagnosis of hypotension (low blood pressure). Review of Resident 10’s Blood Pressure Summary for August 2025 showed the following blood pressure readings for Resident 10: - on 8/2/25 at 2317 hours, a blood pressure reading of 124/68 mmHg; - on 8/12/25 at 0650 hours, a blood pressure reading of 130/64 mmHg; - on 8/16/25 at 1603 hours, a blood pressure reading of 130/60 mmHg; and - on 8/18/25 at 1500 hours, a blood pressure reading of 66/33 mmHg. On 8/27/25 at 1330 hours, an interview and concurrent closed medical record review for Resident 10 was conducted with RN 1. RN 1 stated the purpose of the resident's care plans were to ensure the nursing interventions correlated with the resident's diagnoses and to ensure the facility staff knew what interventions needed to be implemented for the resident. RN 1 verified the above findings. On 8/27/25 at 1400 hours, an interview and concurrent closed medical record review for Resident 10 was conducted with the DON. The DON stated the facility staff were expected to implement the interventions in the residents’ care plan. The DON verified the above findings. On 8/29/25 at 1440 hours, a follow-up interview was conducted with the DON. The DON was informed and acknowledged the above findings.

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development or worsening of the pressure injuries (localized area of skin damage and underlying tissues caused by prolonged pressure or shear forces) for three of four final sampled residents (Residents 9, 62 ,and 83) reviewed for pressure injuries. * The facility failed to ensure the licensed nurses accurately documented the assessment of Resident 9's MASD to the coccyx. * The facility failed to ensure the low air loss mattress setting was consistent with Resident 62's weight and set on the alternate mode setting. * The facility failed to ensure Resident 83's low air loss mattress setting was accurate per the physician's order. In addition, the facility failed to reposition Resident 83 at least every 2 hours per Resident 83's care plan intervention. These failures placed the residents at risk of developing new pressure injuries and/or worsening of the existing ones.Findings: Review of the facility’s P&P titled Charting and Documentation dated 2001 showed the documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. Medical record review for Resident 9 was initiated on 8/26/25. Resident 9 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 9’s Change of Condition dated 8/9/25, showed Resident 9 had MASD to coccyx. However, review of Resident 9’s Subacute Nursing Assessment showed the licensed nurses documented the resident had bilateral buttocks pressure injuries on the following: - 8/9/25 at 2223 hours; - 8/10/25 at 2219 hours; - 8/15/25 at 2235 hours; - 8/18/25 at 2307 hours; - 8/19/25 at 2322 hours; - 8/21/25 at 2149 hours; - 8/27/25 at 2142 hours; and - 8/30/25 at 1950 hours. On 8/28/25 at 1457 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified the above findings. RN 2 verified the inaccurate documentation of Resident 9’s skin condition and stated the correct documentation was for the MASD to the coccyx. On 8/29/25 at 1030 hours, an observation and concurrent interview was conducted with LVN 16. LVN 16 stated Resident 9 had an MASD to the coccyx. During the observation of Resident 9’s MASD to the coccyx with LVN 16, no sign of a pressure injury was observed. On 8/29/25 at 1412 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the documentation of an assessment should be based on what the licensed nurse assessed and observed. The DON verified the examples of the documentation inaccuracy for Resident 9’s Subacute Nursing Assessment listed above. 2. Review of the National Pressure Ulcer Advisory Panel’s (NPIAP) Guideline titled Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline 2025, under the Repositioning for Pressure Injury Prevention section showed extended periods of lying or sitting on a particular part of the body without redistribution of the pressure could lead to a pressure injury. Furthermore, repositioning and mobilization were essential preventative measures for reducing pressure injury occurrences. The Support Surfaces section showed to follow the manufacturers’ recommendations for the use of full body surfaces according to the individual’s weight and height. Review of the Invacare User Manual for Micro Air MA60 Series (undated) showed the Micro Air MA65 system came with a powered mattress and control unit that provided low air loss, alternate and static pressure redistribution therapy. In addition, under the operation instructions, the patient’s weight determined the comfort pressure level setting on the control unit. Medical record review for Resident 83 was initiated on 8/28/25. Resident 83 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 83’s Pressure Ulcer Risk Assessment 2.0 dated 6/30/25, showed Resident 83 had a score of 16, which indicated a high risk for pressure ulcers due to factors such as his fragile skin, poor activity and mobility, and poor general physical condition. Review of Resident 83’s H&P examination dated 8/22/25, showed Resident 83 was in a persistent vegetative state, contracted (a stiffening at any joint, that reduced the joint’s range of motion), and unable to communicate, track or make needs known. The H&P examination further showed Resident 83 had a diagnosis of anoxic brain injury (a condition where the brain was deprived of oxygen for a period of time) and quadriplegia (paralysis from the neck down, including legs and arms). On 8/28/25 at 1047, 1324, and 1452 hours, Resident 83 was observed lying in his bed in a supine position on a LAL (Low Air Loss) mattress. The control unit for the LAL mattress was set at level 4. Level 4 was for residents who weighed between 175 to 210 pounds. On 8/29/25 at 1022 hours, Resident 83 was observed lying in his bed in a supine position on a LAL mattress. The control unit for the LAL mattress was set at level 4. a. Review of Resident 83’s Order Summary dated 11/19/24, showed a physician's order for the LAL mattress setting at level 3 every shift for maintenance and preventative measures. Review of Resident 83’s Weight Summary dated 8/7/25, showed Resident 83 weighed 130 pounds. On 8/29/25 at 1402 hours, an observation, interview, and concurrent medical record review for Resident 83 was conducted with LVN 3. LVN 3 stated the purpose of the LAL mattresses was to prevent the development of pressure ulcers. LVN 3 further stated the weight of each resident determined the setting of the comfort pressure level. LVN 3 verified Resident 83’s comfort pressure level setting was set at level 4, but the physician’s order showed a setting of level 3. On 8/29/25 at 1440 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. b. Review of Resident 83’s plan of care for altered neurological status related to anoxic brain damage revised on 7/8/24, showed the intervention to reposition Resident 83 at least every two hours. Furthermore, review of Resident 83’s plan of care for ADL self-care performance deficit related to limited mobility, ROM (Range of Motion), and musculoskeletal impairment showed the intervention for the staff participation to reposition and turn Resident 83 in bed. Review of Resident 83’s Documentation Survey Report V2 for August 2025 Section - Turn and Reposition every two hours while in bed, showed Resident 83 was not turned in bed every two hours. For example, the following dates and times showed when Resident 83 was turned in bed: - dated 8/1/25 at 0046, 0421, 1430, 1842, and 2222 hours; - dated 8/10/25 at 0312, 0610, 1345, 1505, and 2047 hours; and - dated 8/23/25 at 0413, 1313, 1955, 2018 and 0026 hours. On 8/29/25 at 1000 hours, an interview and concurrent medical record review for Resident 83 was conducted with the Case Manager. The Case Manager stated Resident 83 was a bedbound with multiple contractures. Furthermore, Resident 83 had crucial interventions to prevent skin issues from occurring, such as turning and repositioning him while in bed. Additionally, the Case Manager stated if the interventions were included in the resident’s care plan, the interventions should be implemented. The Case Manager verified the above findings. On 8/29/25 at 1028 hours, an interview was conducted with CNA 6. CNA 6 stated she could not reposition Resident 83 because it was too hard to move him. CNA 6 further stated she had not notified the licensed nurses because she was too busy with her workload. On 8/29/25 1440 hours, an interview was conducted with the DON. The DON stated she expected the facility staff to inform the licensed nurses if they could not complete the assigned tasks for the resident. The DON was informed and acknowledged the above findings. 3. Review of the facility P&P titled Support Surface Guidelines dated 2001 showed the purpose of this procedure is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. On 8/25/25 at 1133 hours, during the initial tour of the facility, Resident 62 was observed positioned on her back and lying on a LAL mattress (Drive [NAME] Air) on static mode with the weight setting between 200 to 250 pounds. Medical record review for Resident 62 was initiated on 8/25/25. Resident 62 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 62's H&P examination dated 6/12/25, showed Resident 62 had no capacity to make medical decisions. Review of the Quarterly MDS assessment dated [DATE], showed Resident 62 had short-term and long-term memory problem. Review of Resident 62's Order Summary Report for August 2025 showed a physician's order dated 8/25/25, for the LAL mattress per the resident’s weight (149 pounds) every shift for maintenance and preventative measures. On 8/25/25 at 1207 hours, an observation and concurrent interview was conducted with LVN 12 inside Resident 62's room. Resident 62 was observed lying on the LAL mattress on static mode with the weight setting between 200 to 250 pounds. LVN 12 verified the findings and stated the LAL mattress should have been on the alternate mode setting. On 8/27/25 at 1604 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 was informed of the above findings and stated the LAL mattress should have been checked by all the staff daily. RN 2 stated the LAL mattress should not have been on static mode and the setting should have been based on the resident’s weight. In addition, RN 2 stated the discrepancies in the LAL mattress setting defeated the purpose of the LAL mattress. On 8/28/25 at 1539 hours, an interview was conducted with the DON. The DON was informed and verified the above findings.

CONCERN (D)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to assess the appropriateness and continued use of the indwelling urinary Foley catheter (flexible tube that passes through the urethra and into the bladder to drain urine) for one of two final sampled residents (Resident 37) reviewed for urinary catheter. * The facility failed to ensure Resident 37 was assessed for the appropriateness and continued use of the indwelling urinary Foley catheter. This failure had the potential to predispose Resident 37 to catheter associated urinary tract infection.Findings: Review of the Centers for Disease Control and Prevention's article titled Clinical Safety: Preventing Catheter-Associated Urinary Tract Infection (CAUTIs) dated 6/27/25, showed a UTI is an infection that involves any of the organs or structures of urinary tract (e.g., kidneys, ureters, bladder and urethra). A CAUTI occurs when germs (usually bacteria) enter urinary tract through the urinary catheter and cause infection. Under the section recommendation to all healthcare facilities showed to only use urinary catheter when needed, to place catheters using proper germ-free techniques with sterile equipment, to maintain the catheters closed sterile drainage system, and to remove catheter as soon as patient no longer need them. Further review of the article showed prolonged use is the most important risk factor for CAUTIs. On 8/26/25 at 0836 hours, Resident 37 was observed lying in bed with the indwelling urinary Foley catheter bag hanging on the right side of Resident 37's bed. Medical record review for Resident 37 was initiated on 8/26/25. Resident 37 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 37's MDS assessment dated [DATE], showed Resident 37 was cognitively intact. Review of Resident 37's Order Summary Report showed a physician's order dated 8/11/25, for Foley catheter size FR 16/10 ml attached to bedside closed drainage system. Further review of the physician's order failed to show the indication for Resident 37's indwelling urinary Foley catheter. Review of Resident 37's H&P examination dated 8/12/25, showed Resident 37 had the capacity to understand and make medical decisions. Review of Resident 37's admission Record dated 8/28/25, showed Resident 37 had diagnoses of urinary tract infection and retention of urine with the onset date of 7/8/25. Further review of Resident 37 medical record failed to show if the facility assessed Resident 37 for the appropriateness and continued use of the Foley catheter. On 8/27/25 at 1427 hours, an interview and concurrent medical record review for Resident 37 was conducted with RN 1. RN 1 stated the practice of the facility was to clarify the use of the indwelling urinary Foley catheter with the physician. RN 1 stated the diagnosis of the urinary retention alone was not an adequate indication for the continued use of the indwelling urinary Foley catheter. RN 1 verified the above findings and stated Resident 37 had the diagnosis of urinary retention and urinary tract infection with the onset date of 7/8/25. RN 1 stated she was not able to find the documentation if Resident 37 required the continued use of the indwelling urinary Foley catheter and if any assessment was done to attempt to remove the indwelling urinary Foley catheter. RN 1 further stated Resident 37 should have been reassessed for the removal of the indwelling urinary Foley catheter. RN 1 stated the use of the indwelling urinary Foley catheter without the proper indication could unnecessarily expose Resident 37 to catheter associated urinary tract infection. On 8/28/25 at 1438 hours, an observation and concurrent interview was conducted with Resident 37. Resident 37 was observed lying in bed with the urinary bag hanging on the right lower side of the bed. Resident 37 stated he had the indwelling urinary Foley catheter because he could not urinate by himself and he did not remember how long his had the indwelling urinary Foley catheter in. When asked if the facility attempted to remove the indwelling urinary Foley catheter to assess if he could urinate on his own, the resident stated facility did not attempt to remove his indwelling urinary Foley catheter. On 8/28/25 at 1133 hours, an interview with the DON was conducted. The DON was informed and acknowledged the above findings.

CONCERN (D)

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

Deficiency F0694 (Tag F0694)

Could have caused harm · This affected 1 resident

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CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary respiratory care services for four of four final sampled (Residents 3, 9, 68, and 70), and two nonsampled resident (Residents 24 and 100) reviewed for respiratory care. * The facility failed to administer the oxygen to Resident 3 per the physician's order and failed to ensure the oxygen concentrator was functioning properly. In addition, the facility failed to ensure Resident 3's nasal cannula was dated and labeled and changed weekly. * The facility failed to ensure Resident 9's oxygen tubing was changed and dated. * The facility failed to ensure Resident 24's set-up bag for the Yankauer (a rigid tonsillar suction device used for suctioning the mouth and oropharynx) suction was changed weekly. * The facility failed to ensure the suction bacterial filter was changed every month for Resident 68. * The facility failed to ensure Resident 70's oxygen and nebulizer tubing were labeled with the date, and the prefilled humidifier was changed as per the physician's order. * The facility failed to ensure a physician's order for Resident 100 was obtained prior to the administration of the oxygen therapy. In addition, the facility failed to ensure Resident 100's nasal cannula tubing was labeled and dated. These failures had the potential for the residents not to receive appropriate respiratory care and for increased risks of infection.Findings: 1. According to UCSF (University of California San Francisco) Health article titled Patient Education: Your Oxygen Equipment (undated) showed to maintain the oxygen equipment, the nasal cannula should be changed every week. a. Medical record review was initiated on 8/25/25. Resident 3 was readmitted to the facility on [DATE]. Review of Resident 3’s Order Summary Report showed a physician’s order dated 12/21/23, to apply oxygen via nasal cannula at two liters per minute. May titrate up to five liters to maintain oxygen saturation above 90%. On 8/25/25 at 0839 hours, during the initial tour of the facility, Resident 3 was observed in bed and receiving two liters of oxygen via nasal cannula. The nasal cannula was unlabeled and undated, and the set-up bag was dated 7/7/25. Resident 3 stated he wore the nasal cannula all the time. On 8/25/25 at 0911 hours, an observation for Resident 3 and concurrent interview was conducted with the Case Manager. The Case Manager verified Resident 3 received oxygen via nasal cannula. The Case Manager verified the nasal cannula was undated and the set-up bag was dated 7/7/25. The Case Manager stated the nasal cannula with the set-up bag was supposed to be changed weekly, the nasal cannula should be dated, and in a new set-up bag to prevent cross-contamination. b. On 8/27/25 at 1054 and 1059 hours, Resident 3 was observed in bed receiving one liter of oxygen via nasal cannula. Review of Resident 3’s Weights and Vitals Summary did not show Resident 3’s oxygen saturation was consistently monitored. Further review of Resident 3’s medical record did not show the administration of oxygen was documented consistently. On 8/27/25 at 1109 hours, an interview was conducted with LVN 3. LVN 3 stated Resident 3 was on continuous oxygen, and the licensed nurses checked Resident 3’s oxygen saturation if the resident was off the oxygen. LVN 3 stated Resident 3 had a “drop in oxygen saturation” but was only monitoring him as a nursing intervention and there was no documentation every shift. On 8/27/25 at 1111 hours, an observation for Resident 3 and concurrent interview with LVN 3 was conducted. Resident 3 was observed in bed receiving one liter of oxygen via nasal cannula. LVN 3 checked Resident 3’s oxygen saturation and was observed at 86 to 88%. LVN 3 was observed increasing Resident 3’s oxygen to three liters per minute. LVN 3 checked Resident 3’s oxygen saturation again and was observed at 87 to 89%. LVN 3 was then asked why she was not increasing Resident 3’s oxygen when the oxygen saturation was below 90%. LVN 3 stated the oxygen concentrator could only go up to three liters per minute. LVN 3 attempted to increase the setting by dialing the flow control knob, but the dial only went up to three liters, although the oxygen concentrator had a maximum capacity of five liters per minute. LVN 3 stated the oxygen concentrator was not working and had to replace it. 2. On 8/25/25 at 0833 hours, during the initial tour of the facility, Resident 24 was observed in bed. A Yankauer suction dated 8/25/25, was observed at bedside, however, the set-up bag was not dated and labeled. On 8/25/25 at 0910 hours, an observation for Resident 24 and concurrent interview was conducted with the Case Manager. The Case Manager verified Resident 24’s Yankauer suction was dated 8/25/25, however, the set-up bag was not dated and labeled. The Case Manager stated the facility had to make sure everything was changed including the Yankauer suction with the set-up bag. The Case Manager stated it could be a risk for infection when a new item was placed in an old bag. Medical record review was initiated on 8/25/25. Resident 24 was admitted to the facility on [DATE]. Review of Resident 24’s Order Summary Report showed a physician’s order dated 8/8/25, to suction as needed for excessive secretions every two hours as needed for productive coughing. Review of Resident 24’s MAR for August 2025 did not show Resident 24 was suctioned. On 8/28/25 at 1051 hours, an interview and concurrent medical record review for Residents 3 and 24 was conducted with the DON. The DON verified the above findings. The DON stated the respiratory supplies including nasal cannula, Yankauer suction with the set-up bag should labeled and dated, and changed weekly every Sunday by the charge nurses on the night shift. The DON further stated the oxygen concentrator should be checked by the charge nurses every shift. 3. Review of the facility’s P&P titled Oxygen Administration revised 10/2010 showed the oxygen devise (nasal cannula, mask and nasal catheter) is changed weekly and dated with the date of change. Medical record review for Resident 70 was initiated on 8/25/25. Resident 70 was admitted to the facility on [DATE]. Review of Resident 70’s H&P examination dated 8/12/25, showed the resident had fluctuating capacity to understand and make medical decisions. Review of Resident 70’s admission MDS assessment dated [DATE], showed Resident 70 has a BIMS score of 15, indicating cognitively intact. Review of Resident 70's Order Summary Report showed the following physician's orders: - dated 8/7/25, to change the medication nebulizer set up every Monday and as needed to prevent infection; - dated 8/7/25, to change the oxygen tubing every Friday night shift; and - dated 8/7/25, to change the prefilled humidifier every 3 days during the night shift and as needed. On 8/25/25 at 0830 hours, an observation and concurrent interview was conducted with Resident 70. Resident 70 was observed sitting on his bed and eating breakfast, with a T-bar (a T-shaped piece of tubing or a T-bar assembly used in medical oxygen delivery systems) oxygen at three liters per minute. The oxygen tubing and nebulizer bag were observed not labelled with the date the equipment was changed. The prefilled humidifier bottle was observed with a date 8/16/25. Resident 70 stated he did not know when the equipment was changed. On 8/25/25 at 0920 hours, an observation and concurrent interview for Resident 70 was conducted with LVN 6. LVN 6 verified the oxygen tubing and nebulizer bag were not labeled with the date the equipment was changed, and the prefilled humidifier bottle was dated 8/16/25. LVN 6 stated that oxygen tubing and nebulizer should be changed weekly to prevent infection. On 8/28/25 at 1506 hours, an interview was conducted with the Administrator and DON was conducted. The Administrator and DON were informed and acknowledged the above findings. 4. Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed the purpose of this procedure is to provide guidelines for safe oxygen administration. Verify that there is a physician’s order for this procedure. Review the physician’s orders or facility protocol for oxygen administration. Assemble the equipment and supplies as needed. On 8/25/25 at 1454 hours, during the initial tour of the facility, Resident 100 was observed lying in bed and receiving oxygen at two liters per minute via nasal cannula, which was attached to the oxygen machine concentrator. In addition, the nasal cannula was undated and unlabeled. Medical record review for Resident 100 was initiated on 8/25/25. Resident 100 was admitted to the facility on [DATE]. Review of Resident 100's admission MDS assessment dated [DATE], showed Resident 100 had a BIMS score of 10, indicating moderate cognitive impairment. Review of Resident 100's Order Summary Report for August 2025 failed to show a physician’s order for the oxygen administration. Review of Resident 100's MAR and TAR for August 2025 failed to show a physician’s order for the oxygen administration. On 8/27/25 at 0837 hours, an observation and concurrent interview was conducted with LVN 10. LVN 10 verified Resident 100's nasal cannula was unlabeled and undated, and there was no physician's order for the oxygen administration. LVN 10 stated there should have been a physician's order for the oxygen usage. LVN 10 stated she was unsure how often nasal cannula should be changed. On 8/27/25 at 1521 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 was informed of the above findings and stated there should have been a physician’s order for the oxygen administration. RN 2 stated the licensed nurses were responsible for changing the nasal cannula weekly and the nasal cannula should have been labeled and dated for infection control purposes. On 8/28/25 at 1539 hours, an interview was conducted with the DON. The DON was informed and verified the above findings. 5. On 8/26/25 at 0944 hours, an observation was conducted for Resident 9. Resident 9’s oxygen tubing was observed without a date. On 8/27/25 at 0946 hours, a follow up observation was conducted for Resident 9. Resident 9’s oxygen tubing was observed without a date. On 8/27/25 at 0946 hours, an interview was conducted with RT 1. RT 1 stated Resident 9’s oxygen tubing was scheduled to be changed every Friday night, and the oxygen adapter should be dated. RT 1 stated every piece of equipment that was changed would have a date on the equipment itself. RT 1 verified Resident 9’s oxygen adapter was dated 8/12/25, and the oxygen tubing was missing the date it was last changed. RT 1 stated both equipment should have been changed out on 8/15 and 8/22/25. On 8/29/25 at 1412 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 6. On 8/27/25 at 1058 hours, an observation and concurrent interview was conducted with LVN 7 for Resident 68. Resident 68 was observed lying on his bed with the tracheostomy tube (medical device inserted into the trachea -windpipe- to provide a temporary or permanent airway for breathing) connected to the oxygen concentrator. A suction machine was observed at the bedside with the tubing connected to the canister (part of suction machine that collects the suctioned secretions), and the suction bacterial filter was dated 7/23/25. LVN 7 verified the suction bacterial filter was dated 7/23/25. When LVN 7 was asked when the suction canister should be changed, LVN 7 stated his understanding was to change the suction canister every week. Review of Resident 68’s Order Summary dated 8/28/25, showed a physician’s order dated 8/16/25, to change the suction filter every first of the month and PRN to prevent infection (7 am-7 pm). On 8/27/25 at 1114 hours, an observation and concurrent interview was conducted with RT 1. RT 1 verified the suction bacterial filter was dated 7/23/25 and should be changed at least every month or every first day of the month. RT 1 called the RT Supervisor to verify. On 8/27/25 at 1118 hours, an observation and concurrent interview was conducted with the RT Supervisor. The RT Supervisor verified the above findings. The RT Supervisor stated it was the facility’s protocol to change the suction bacterial filter every month, as needed and/or every first day of the month. When the RT Supervisor was asked about the importance of changing the filter at least every month, RT Supervisor stated it was to prevent possible infection going into the machine, which may infect the resident when suctioned. On 8/27/25 at 1123 hours, an interview was conducted with the DON. The DON verified the above findings. The DON stated the bacterial filter should have been changed at least monthly and every first of the month.

CONCERN (D)

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the appropriate dialysis care was provided for four of five final sampled residents (Residents 9, 37, 68, and 99) and two nonsampled residents (Residents 67 and 100) reviewed for dialysis services. * The facility failed to ensure Resident 9's physician's order to obtain the pre and post weights on the dialysis days were followed. Resident 9's post dialysis weights were not obtained on the dialysis days. * The facility failed to ensure the emergency dialysis kit kept at bedside was complete and included clamp scissors for Residents 37 and 100. * The facility failed to ensure a dialysis e-kit was available at bedside for Residents 67 and 99. * The facility failed to ensure the emergency dialysis kit was kept at Resident 68's bedside. In addition, the facility failed to ensure the licensed staff did not monitor and document the presence of bruit and thrill for Resident 68's central venous catheter in the dialysis communication record. These failures had the potential for the residents to experience medical complications.Findings: Review of the facility’s P&P titled Pre/Post Dialysis assessment dated 9/2017 showed prior to the initiation of treatment, the patient will be assessed regarding any physical complaints such as chest pain, difficulty breathing, bleeding, or any problems that may prohibit or complicate the dialysis treatment. If such symptoms or complaints are present, the nurse in charge will be notified prior to the initiation of treatment. 1. Medical record review for Resident 68 was initiated on 8/25/25. Resident 68 was admitted to the facility on [DATE]. Review of Resident 68’s H&P examination dated 7/25/25, showed Resident 68 needed assistance with his decision-making capabilities. Review of Resident 68’s admission MDS assessment dated [DATE], showed Resident 68 had a BIMS score of 13, indicating cognitively intact. a. Review of Resident 68's Order Summary Report showed the following physician's order dated 7/23/25, to observe/monitor for tenderness, redness, or bleeding at the site of the Quinton catheter (type of Central Venous Catheter) every shift. On 8/25/25 at 1222 hours, during the initial tour of the facility, Resident 68 was observed awake lying on his bed. Resident 68 was observed with the left upper chest Quinton catheter. Resident 68 stated that he was getting his dialysis every Monday, Wednesday and Friday in the facility. However, there was no dialysis emergency kit observed at the resident’s bedside. On 8/25/25 at 1228 hours, an observation and concurrent interview for Resident 68 was conducted with LVN 14. LVN 14 verified there was no available dialysis emergency kit at Resident 68's bedside. On 8/27/25 at 1518 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and acknowledged the above findings. The DON stated the residents who were on dialysis needed to have a dialysis kit at the bedside. b. Review of facility’s P&P titled Home Dialysis Center; Pre & Post Dialysis Assessments, dated 9/2017 showed in partial, establishment of the resident’s baseline status at the beginning of the treatment allows basis for safe and accurate treatment and provides a measurable guideline to ensure stability at the end of the treatment. These assessments also provide information necessary to individualize the treatment to meet identified patient outcomes. Pre and post dialysis assessment will include but not limited to the following: complaints/response to last treatments, heart: rate, rhythm, sounds; lungs: rate of breath, sounds, effort of breathing, access: patency, signs of infection. Review of Resident 68’s physician order showed an order dated 7/23/25, for dialysis schedule every Monday, Wednesday, and Friday at the facility with the address, telephone number of the facility and Nephrologist name documented. Review of Resident 68’s Pre (before) and Post (after) Dialysis Communication forms for July and August 2025 showed the licensed nurses documented “Yes” for the presence of bruit (abnormal sound caused by turbulent blood flow within an artery) and thrill (a rumbling sensation that can feel from a dialysis access site) for the resident’s dialysis access site/ central venous catheter (a thin, flexible tube inserted into a large vein in the chest) on the following dates: - on 7/25 and 7/28/25, for the pre and post dialysis; and - on 7/30, 8/4, 8/6, 8/15 and 8/22/25, for the pre-dialysis. On 8/27/25 at 1359 hours, an interview and concurrent medical record review was conducted with RN 2 for Resident 68. RN 2 reviewed Resident 68’s Pre and Post Dialysis forms for July and August 2025 and verified the above findings. RN 2 stated the licensed nurses should not have documented for presence of bruit and thrill for the resident’s dialysis access site because it was a central catheter. RN 2 stated only the peripheral access sites needed to be checked for the bruit and thrill. On 8/27/25 at 1425 hours, an interview was conducted with the DON. The DON verified the findings and stated the facility staff should not be documenting the bruit and thrill if the dialysis access site was centrally located, like Resident 68’s left upper chest central catheter. 2. On 8/25/25 at 1137 hours, during the initial tour of the facility, Resident 67 was observed awake and lying on the bed. Resident 67 was observed with AV shunt in the left upper arm. Resident 67 stated he had dialysis in the facility every Monday, Wednesday, and Friday. Further observation of Resident 67’s room failed to show a dialysis emergency kit was available. On 8/25/25 at 1202 hours, an observation and concurrent interview for Resident 67 was conducted with the Case Manager. The Case Manager stated the dialysis emergency kit should always be available and accessible at the resident’s bedside in the event the resident would bleed from the dialysis access site. The Case Manager verified there was no available dialysis emergency kit at Resident 67’s bedside. 3. On 8/25/25 at 1054 hours, during the initial tour of the facility, Resident 99 was observed awake, lying on the bed, and currently having dialysis at bedside, which was provided by an affiliated dialysis company. Resident 99 stated she had been in the facility for a few days only. Further observation of Resident 99’s room failed to show a dialysis emergency kit was available. On 8/25/25 at 1205 hours, an observation and concurrent interview for Resident 99 was conducted with the Case Manager. The Case Manager searched Resident 99’s room and verified there was no available dialysis emergency kit at the bedside for the resident. The Case Manager stated the dialysis emergency kit should be available for residents who were on dialysis. On 8/29/25 at 1440 hours, an interview was conducted with the DON. The DON stated the residents who had dialysis should always be checked for bleeding at the dialysis access site. The DON further stated the dialysis emergency kit was important to always be available and accessible in the resident’s room for any complications observed in the dialysis access site. The DON was informed and acknowledged the above findings for Residents 67 and 99. 4. Medical record review for Resident 37 was initiated on 8/25/25. Resident 37 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 37's H&P examination dated 8/12/25, showed Resident 37 had the capacity to understand and make medical decisions. In addition, Resident 37 had a diagnosis of ESRD (End-Stage Renal Disease, which describes the point where a person's kidneys have failed and can no longer filter waste, excess fluid, and toxins from the blood effectively) with a right Permacath (a type of central venous catheter used for long-term, needle-free access to the bloodstream) access and on renal dialysis. Review of Resident 37's Order Summary Report for August 2025 showed a physician's order dated 8/11/25, for hemodialysis every Monday, Wednesday, and Friday within the facility. Furthermore, a physician’s order dated 8/11/25, showed to observe, monitor for tenderness, redness, or bleeding at the site of the Quinton catheter every shift. On 8/25/25 at 1536 hours, an observation and concurrent interview was conducted with LVN 11 for Resident 37. Resident 37 was observed with a dialysis kit at the bedside. However, the dialysis kit did not include clamp scissors to prevent bleeding. LVN 11 verified the findings and stated the dialysis kit was incomplete because it did not include clamp scissors. On 8/27/25 at 1556 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 was informed and acknowledged the above findings. RN 2 stated the dialysis kit should have include clamp scissors to prevent bleeding. 5. Medical record review for Resident 100 was initiated on 8/25/25. Resident 100 was admitted to the facility on [DATE]. Review of Resident 100’s admission MDS dated [DATE], showed Resident 100 had a BIMS of 10, indicating moderate cognitive impairment. Review of Resident 100's Order Summary Report for August 2025 showed a physician's order dated 8/12/25, for hemodialysis every Monday, Wednesday, and Friday within the facility. In addition, a physician’s order dated 8/12/25, showed to observe, monitor for tenderness, redness, or bleeding at the site of the Quinton catheter every shift. On 8/25/25 at 1510 hours, an observation and concurrent interview was conducted with RN 1 for Resident 100. Resident 100 was observed with a dialysis kit at the bedside. However, the dialysis kit did not include clamp scissors to prevent bleeding. RN 1 verified the findings and stated the dialysis kit was incomplete and did not include clamp scissors. On 8/27/25 at 1521 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 was informed and acknowledged the above findings. RN 2 stated the dialysis kit should have included clamp scissors to prevent bleeding. On 8/28/25 at 1539 hours, an interview was conducted with the DON. The DON was informed and verified the above findings for Residents 37 and 100. 6. Medical record review for Resident 9 was initiated on 8/25/25. Resident 9 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 9’s H&P examination dated 6/12/25, showed Resident 9 had a diagnosis of ESRD with a hemodialysis catheter to the right upper chest wall. Review of Resident 9’s Order Summary Report on 8/28/25, showed a physician’s order dated 6/11/25, to obtain Resident 9’s pre and post dialysis weight every day shift on Monday, Wednesday, and Friday. On 8/28/25 at 1049 hours, an interview and concurrent facility documents review was conducted with RNA 1. RNA 1 stated Resident 9’s pre dialysis weights were obtained and documented on the days of dialysis (Monday, Wednesday, and Fridays). However, RNA 1 stated Resident 9’s post dialysis weights were taken every Thursday. On 8/29/25 at 0954 hours, an interview and concurrent facility document review was conducted with RN 3. RN 3 reviewed Resident 9’s physician’s orders and verified the resident’s order to obtain the pre and post weight on the dialysis days. RN 3 also stated the importance of obtaining the pre and post weight was to provide the dialysis RN with how much fluid the resident was retaining so the RN could gauge how much fluid to safely remove. RN 3 verified the dialysis weight log showed the post weight was to be obtained on Thursdays for Resident 9. On 8/29/25 at 1412 hours, an interview and concurrent medical record review was conducted with the DON. The DON stated the residents’ weight should be obtained before and after dialysis treatment. The DON also stated the RNA obtained the residents’ weight before and after dialysis. The DON verified the RNA obtained the resident’s post dialysis weight every Thursdays.

CONCERN (D)

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

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure three of three final sampled residents (Residents 6, 37 and 99) and one nonsampled residents (Resident 67) remained free from accident hazards due to the use of the side rails. * The facility failed to ensure the physician's order was obtained for the use of bilateral half side rails for Resident 6. In addition, the facility failed to ensure a care plan was developed to address the use of the bilateral half side rails for Resident 6. * The facility failed to ensure the less restrictive interventions were completed prior to the use of the half side rails for Residents 37 and 67. * The facility failed to ensure a physician's order and consent were obtained prior to the use of bilateral side rails for Resident 99. In addition, no care plan was developed to address the use of bilateral side rails for the resident. These failures had the potential to put the residents at risk for entrapment and serious injuries. Findings: Review of the facility's P&P titled Bed Safety and Bed Rails revised date 8/2022 showed the resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bed rails is prohibited unless the criteria for use of bed rails have been met. The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 3/2022 showed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. Review of Resident 6's medical record was initiated on 8/25/25. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's Informed Consent Documentation dated 5/19/25, showed an informed consent from Resident 6’s responsible party and a physician's order for the use of side rails as enabler were obtained. Review of Resident 6's H&P examination dated 5/20/25, showed Resident 6 had the capacity to understand and make medical decisions. Review of Resident 6's Order Summary Report dated 8/28/25, failed to show a physician's order for the use of the bilateral half side rails. Review of Resident 6's plan of care failed to show a care plan intervention for the use of the bilateral half side rails. On 8/25/25 at 1047 hours, during an initial tour of the facility, Resident 6's bed was observed with the bilateral half side rails elevated at the head of the bed. On 8/27/25 at 0907 hours, Resident 6 was observed lying on the bed with the bilateral half side rails elevated. On 8/28/25 at 1428 hours, an interview and concurrent medical record review was conducted with RN 4. RN 4 verified the above findings and stated there should be a physician’s order for the resident's bilateral side rails. RN 4 stated the care plan should have been initiated for the use of side rails. On 8/28/25 at 1539 hours, an interview was conducted with the DON. The DON was informed and verified the above findings. Cross reference to F909, example #3. 2. Review of the facility's P&P titled Bed Safety and Bed Rails revised 8/2022 showed the use of bed rails is prohibited unless the criteria for use of bed rails have been met. The Use of bed rails section showed: - Prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted. Alternatives may include roll guards, foam bumpers, lowering the bed, and/or use of concave mattresses to reduce rolling off the bed; - If attempted alternatives do not adequately meet the resident's needs the resident may be evaluated for the use of bed rails. This interdisciplinary evaluation includes an evaluation of the alternatives to bed rails that were attempted and how these alternatives failed to meet the resident's needs, the resident's risk associated with the use of bed rails, input from the resident and/or representative, and consultation with the attending physician; and - Before using bed rails for any reason, the staff should inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent: the assessed medical needs that will be addressed with the use of bed rails, the resident's risks from the use of bed rails and how these will be mitigated, the alternatives that were attempted but failed to meet the resident's needs, and the alternatives that were considered but not attempted and the reasons. On 8/26/25 at 0845 hours, an observation and concurrent interview was conducted for Resident 37. Resident 37 was observed awake and lying on the bed with the bilateral half side rails elevated. Resident 37 stated he could turn in the bed but needed assistance from the staff and used the side rails to grab and turn. Medical record review for Resident 37 was initiated on 8/26/25. Resident 37 was readmitted to the facility on [DATE]. Review of Resident 37’s Bed Safety Rail assessment dated [DATE], failed to show the least restrictive alternatives were attempted prior to Resident 37’s bilateral side rails use. Review of Resident 37's H&P examination dated 8/12/25, showed Resident 37 had the capacity to understand and make medical decisions. Review of Resident 37's Order Summary Report showed a physician's order dated 8/13/25, for the use of the bilateral half side rails as enabler/feelings of safety per patient’s request. On 8/27/25 at 1130 hours, an observation and concurrent interview for Resident 37 was conducted with CNA 12. Resident 37 was observed sleeping on the bed with the bilateral half side rails elevated. CNA 12 stated Resident 37 needs assistance from the staff with turning and getting out of bed. CNA 12 further stated Resident 37 used the side rails to grab and help turn. 3. On 8/26/25 at 0830 hours, an observation and concurrent interview was conducted for Resident 67. Resident 67 was observed awake and lying on the bed with the bilateral half side rails elevated. Resident 67 stated he could turn in the bed, and used the side rails to grab while turning. Resident 67 further stated he needed the facility staff's assistance to get out of bed. Medical record review for Resident 67 was initiated on 8/26/25. Resident 67 was admitted to the facility on [DATE]. Review of Resident 67’s Bed Safety Rail assessment dated [DATE], failed to show the least restrictive alternatives were attempted prior to Resident 67’s bilateral side rails use. Review of Resident 67's H&P examination dated 7/22/25, showed Resident 67 needed assistance with decision making. Review of Resident 67's Order Summary Report showed a physician's order dated 7/22/25, for the use of the bilateral half side rails as enabler per resident's request. On 8/27/25 at 1140 hours, an observation and concurrent interview for Resident 67 was conducted with CNA 12. Resident 67 was observed having dialysis at the bedside. CNA 12 stated Resident 67 was able to grab the rails when being turned or cleaned. CNA 12 further stated Resident 67 could not get out of bed related to the resident's knee surgery. 4. On 8/26/25 at 1100 hours, an observation and concurrent interview was conducted for Resident 99. Resident 99 was observed awake and lying on the bed with the bilateral half side rails elevated. Resident 99 stated she could turn by herself and grab the side rails but needed the facility staff to be there when she was turning in the bed for her safety. Medical record review for Resident 99 was initiated on 8/26/25. Resident 99 was admitted to the facility on [DATE]. Review of Resident 99’s Bed Rail assessment dated [DATE], showed the side rails/assist bars were indicated and served as an enabler to promote independence. Review of Resident 99's H&P examination dated 8/22/25, showed Resident 99 had the capacity to understand and make decisions. Further review of Resident 99's medical record showed no documented evidence a physician's order and/or informed consent were obtained. In addition, there was no care plan problem initiated to address the use of the side rails for Resident 99. On 8/27/25 at 1205 hours, an observation and concurrent interview for Resident 99 was conducted with CNA 12. Resident 99 was observed awake, lying on the bed with the bilateral side rails elevated. CNA 12 stated Resident 99 was a new resident in the facility. CNA 12 stated she was able to take care of Resident 99. CNA 12 stated Resident 99 needed two-person assistance with turning but the resident could help as well. CNA 12 stated Resident 99 used the side rails to grab on to, and the resident felt safe holding to it. On 8/28/25 at 1045 hours, an interview and concurrent medical record review was conducted with RN 4. RN 4 stated upon admission to the facility, the resident was assessed for the need of the side rails. RN 4 stated the side rails were used only as enabler and the facility usually used the half upper side rails. RN 4 stated some residents would request the use of the side rails. RN 4 stated the least restrictive alternatives would be attempted prior to the use of the side rails. RN 4 stated some examples of the least restrictive alternatives were lowering the bed to the floor, providing frequent staff monitoring to anticipate the needs of the resident, providing assisted toileting, ensuring the call light was within the resident’s reach and frequently reminding the resident to use the call light for assistance. RN 4 stated if these alternatives were not helpful or effective then the licensed nurse would obtain an order from the physician for the use of the side rails. RN 4 stated an informed consent would be obtained from the resident or resident’s representative, after explaining the risks and benefits of the side rails. RN 4 further stated a care plan should be initiated addressing the use of the side rails. RN 4 verified the least restrictive alternatives were not attempted prior to the use of side rails for Residents 37 and 67. RN 4 further verified there was no physician’s order and informed consent, and care plan problem initiated to address the use of side rails for Resident 99. On 8/29/25 at 1440 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. Cross reference to F900, examples # 1 and 2.

CONCERN (D)

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of 21 final sampled residents (Residents 70 and 99) were free from the unnecessary medications. * The facility failed to ensure Resident 70 who was on apixaban (medication used to prevent blood clots) was monitored for signs and symptoms of bleeding. * The facility failed to monitor Resident 99 for the signs and symptoms of bleeding related to the use of apixaban medication (medication used to prevent blood clots). These failures had the potential for the residents to receive unnecessary medications and develop significant adverse effects.Findings: According to the FDA the approved Highlights of Prescribing Information for apixaban issued on 04/2025 showed the most common adverse reaction in adult patients are related to bleeding. Review of the facility's P&P titled Anticoagulation – Clinical Protocol revised 11/2018 under the Monitoring and Follow-Up section, showed for the staff and physician to monitor for possible complications in individuals who were being anticoagulated and would manage related problems. If an individual on anticoagulation therapy showed signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse would discuss the situation with the physician before giving the next scheduled dose of anticoagulant. The physician would order measures to address any complications, including holding or discontinuing the anticoagulant as indicated. 1. On 8/26/25 at 1100 hours, an observation and concurrent interview was conducted for Resident 99. Resident 99 was observed awake and lying in bed. Resident 99 stated she had a stroke (when blood flow to the brain is interrupted, causing brain cells to die) in 2016 and had been taking blood thinner since then. Resident 99 stated she had not experienced having episodes of bleeding. Medical record review for Resident 99 was initiated on 8/26/25. Resident 99 was admitted to the facility on [DATE]. Review of Resident 99's Order Summary Report showed a physician's order dated 8/21/25, to administer apixaban 5 mg one tablet by mouth two times a day for anticoagulant. Review of Resident 99's H&P examination dated 8/22/25, showed Resident 99 had the capacity to understand and make decisions. Further review of Resident 99's medical record did not show documented evidence Resident 4 was observed or monitored for the signs and symptoms of bleeding. On 8/26/25 at 1404 hours, an interview and concurrent medical record review for Resident 99 was conducted with LVN 9. LVN 9 stated the residents who were getting anticoagulant medications should be monitored for the signs and symptoms of bleeding, like unusual bruising, bleeding from the gums or nose, and any signs and symptoms of blood in the urine or stool. LVN 9 further stated the residents who were taking the anticoagulation medications, especially for a long time, could potentially bleed out from inside the body and should be reported immediately to the physician for further evaluation and/or recommendations. LVN 9 verified Resident 99 was not being monitored for the signs and symptoms of bleeding related to the use of apixaban. On 8/29/25 at 1440 hours, an interview was conducted with the DON. The DON stated continuous monitoring of the signs and symptoms of bleeding for those residents who were receiving anticoagulant medications was important to prevent complications and alert the licensed nurses to provide interventions and notify the physician immediately if the signs and symptoms of bleeding were. The DON was informed and acknowledged the above findings for Resident 99. Cross reference to F656, example #3. 2. Medical record review for Resident 70 was initiated on 8/25/25. Resident 70 was admitted to the facility on [DATE]. Review of Resident 70's Order Summary Report showed a physician's order dated 8/7/25, to administer apixaban 2.5 mg via GT two times a day for atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). Review of Resident 70’s H&P examination dated 8/12/25, showed the resident had fluctuating capacity to understand and make medical decisions. Review of Resident 70’s admission MDS assessment dated [DATE], showed Resident 70 had a BIMS score of 15, indicating cognitively intact. Review of Resident 70's plan of care failed to show documented evidence a care plan problem was developed to address the resident’s use of the apixaban medication as ordered by the physician. Further review of Resident 70's medical record did not show documented evidence Resident 70 was being observed or monitored for the signs and symptoms of bleeding. On 8/25/25 at 0830 hours, during the initial tour of the facility, Resident 70 was observed sitting and eating his breakfast. Resident 70 stated he was taking a blood thinner medication twice a day. On 8/26/25 at 1430 hours, an interview and concurrent medical review for Resident 70 was conducted with LVN 2. LVN 2 verified the above findings. LVN 2 stated Resident 70 was taking an anticoagulant medication. LVN 2 stated the resident would be at risk for bleeding and should be monitored every shift, with the finding documented in the resident’s medical record. On 8/27/25 at 1518 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified there was no documented evidence to show Resident 70 was monitored for the signs and symptoms of bleeding related to the resident’s use of the apixaban medication. The DON stated the residents who take blood thinner medications should have a monitoring for signs and symptoms of bleeding. On 8/28/25 at 1506 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. Cross reference to F656, example #2.

CONCERN (D)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 12.5%. Two of two licensed nurses (LVNs 3 and 12) were found to have made errors during the medication administration to two nonsampled residents (Residents 54 and 89). * LVN 3 failed to properly administer the potassium chloride tablet (supplement) as per the physician's order to Resident 89 when LVN 3 crushed the potassium chloride tablet and using an improper amount of water to reconstitute the medication. The physician's order specified to dissolve the potassium chloride medication with 60 ml of water, however, LVN 3 only used 10 ml. * LVN 3 failed to properly administer the crushed multivitamin with minerals (supplement) as per the physician's order to Resident 89 when LVN 3 left an excessive amount of residue in the medication cup, after administering the medication through the resident's GT. * LVN 12 failed to properly administer Resident 54's lactulose (used to treat constipation) 20 gm medication when LVN 12 only administered 10 gm. * LVN 12 failed to properly administer Resident 54's vitamin D (supplement) 400 IU medication when LVN 12 administered 1000 IU instead. These failures had the potential to negatively affect the residents' health conditions and posed the risk for possible complications or delay in interventions. Findings: Review of the facility's P&P titled Administering Medications revised April 2019 showed the medications are administered in accordance with prescriber orders, including any required time frames. 1. a. According to DailyMed, an online reference for clinical drug information, the residents should take potassium chloride medication without crushing, chewing or sucking the tablets. If those residents are having difficulty swallowing whole tablets, an alternative method of administration would include preparing an aqueous (water) suspension by placing the whole tablet in approximately 1/2 of water. On 8/25/25 at 0831 hours, a medication administration observation for Resident 89 was conducted with LVN 3. LVN 3 prepared and administered Resident 89's medications, which included the physician's order to dissolve the potassium chloride 10 mEq in 60 ml of water and administer via GT. During the medication administration observation, LVN 3 crushed the potassium chloride tablet and dissolved the crushed potassium chloride in 10 ml of water and administered it to Resident 89. On 8/25/25 at 1142 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 verified she crushed the potassium chloride medication and then dissolved it in 10 ml of water. LVN 3 verified the physician's order specified to dissolve the medication in 60 ml of water. b. On 8/25/25 at 0831 hours, a medication administration observation for Resident 89 was conducted with LVN 3. LVN 3 prepared and administered Resident 89's medications, which included the physician's order for the multivitamin with minerals via GT. LVN 3 placed the crushed multivitamin with minerals medication in a medication cup, then dissolved it in 10 ml of water and administered it to Resident 89. After the medication administration, the medicine cup was observed with an excessive amount of medication residue. On 8/25/25 at 1142 hours, an interview was conducted with LVN 3. LVN 3 verified she did not fully administer the multivitamin with minerals medication because there was an excessive amount of medication residue left in the medicine cup after the administration. 2. a. On 8/25/25 at 0926 hours, a medication administration observation for Resident 54 was conducted with LVN 12. LVN 12 prepared and administered Resident 54's medications, which included the physician's order to administer lactulose 20 gm by mouth daily. During the medication observation, LVN 12 prepared and administered 10 gm of the lactulose medication to Resident 54. On 8/25/25 at 1200 hours, an interview and concurrent medical record review was conducted with LVN 12. LVN 12 verified Resident 54's physician's order showed to administer lactulose 20 gm, but she administered 10 gm. b. On 8/25/25 at 0926 hours, a medication administration observation for Resident 54 was conducted with LVN 12. LVN 12 prepared and administered Resident 54's medications, which included the physician's order to administer vitamin D 400 IU by mouth daily. During the medication observation, LVN 12 prepared and administered 1000 IU of the vitamin D medication to Resident 54. On 8/26/25 at 1407 hours, an interview and medical record review was conducted with DON. The DON verified the physician's order for Resident 54 showed to administer vitamin D 400 IU daily.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to provide the necessary pharmacy services to ensure the proper storage, labeling, and disposal of medications. * The facility failed to remove expired medical supplies from Medication Room A. * The facility failed to ensure two prescription topical medications were labeled with the physician's order in Medication Cart A. In addition, the facility failed to ensure the facility staff's over-the-counter medications were not stored in Medication Cart A with the facility's house wound supplies. * The facility failed to ensure two prescription inhalational medications were labeled and dated in Medication Cart B. * The facility failed to ensure an opened insulin vial, and two opened insulin pens were labeled with the date opened in Medication Cart C. * The facility failed to ensure the facility staff's personal item was not stored in Dialysis Cart A. *The facility failed to ensure Resident 68's Venelex wound dressing ointment (used for wound management) and Sea-Clens wound cleanser spray were stored properly and safely. * The facility failed to ensure safe storage of medication observed at the bedside for Resident 73. These failures had the potential to alter the efficacy of the stored medications, pose an infection risk to the residents and result in inappropriate administration of prescription medication.Findings: Review of the facility's P&P titled Storage of Medications revised 1/2018 showed medications and biologicals are stored and labeled safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 1. On [DATE] at 0817 hours, an observation of Medication Room A and concurrent interview was conducted with RN 2. The following was observed: - A box of BD Precision Glide needles had expired on [DATE]; and - a box containing approximately 80 Luer Lok Red Caps had expired on [DATE]. RN 2 verified the findings and stated the medical supplies had expired and should have been discarded. 2. On [DATE] at 0838 hours, an observation of Medication Cart A and concurrent interview was conducted with LVN 13. The following was observed: - A tube of Venelex (prescription-strength topical ointment used as a wound dressing) was observed opened and unlabeled. - Two unopened tubes of prescription medication Derma Syn/Ag (a silver antibacterial hydrogel wound dressing that creates a moist environment, aids healing and helps manage bacteria) were observed unlabeled. - An opened, half empty bottle calcium carbonate antacid (treats upset stomach caused by too much stomach acid) tablets was stored with several containers of topical house wound supplies. LVN 13 stated the Venelex and Derma Syn/Ag medications were house supply. LVN 13 verified the the Venelex and Derma Syn/Ag medications were prescription medications and stated the medications should not have been in Medication Cart A without a physician’s order. LVN 13 verified the calcium carbonate antacid were her own and stated the medication should not have been in Medication Cart A. 3. On [DATE] at 0838 hours, an observation of Medication Cart B and concurrent interview was conducted with RT 2. The following was observed: - Approximately 15 ampules of prescription inhalational medication Combivent (used to prevent tightening and narrowing of the airways) were observed opened and unlabeled/undated. Approximately 15 ampules of prescription inhalational medication Proventil (used to treat and prevent breathing difficulties) were observed unopened and unlabeled. RT 2 verified the above medications were opened, unlabeled, and removed from the original package. RT 2 verified per the manufacturer’s package insert, any ampules taken from the original package were to be dated and discarded two weeks from the opening date. 4. On [DATE] at 0838 hours, an observation of Medication Cart C and concurrent interview was conducted with LVN 2. The following was observed: - An opened, unlabeled half empty multi-dose vial of Humulin (medication used to lower blood sugar) insulin; - An opened, undated Lantus (medication used to lower blood sugar) insulin pen with Resident 4’s resident label affixed to it; and - An opened, undated lispro (medication used to lower blood sugar) insulin pen with Resident 61’s resident label affixed to it. LVN 2 verified the above findings and stated the multi-dose vial of insulin and single resident insulin pens should have been labeled with the open date. On [DATE] at 1115 hours, an interview was conducted with the DON. The DON was informed and verified the above findings. 5. On [DATE] at 1145 hours, during an interview with one of the facility’s staff, the Dialysis Technician was observed opening the fourth lowest drawer of Dialysis Cart A. A big black purse was observed inside the fourth lowest drawer of the Dialysis Cart A. The Dialysis Technician was observed removing something out from the big black purse, closing the drawer, locking Dialysis Cart A with the purse still inside the drawer, and leaving. On [DATE] at 1155 hours, an observation and concurrent interview was conducted with the Dialysis Technician and LVN 3. The Dialysis Technician verified the cart was Dialysis Cart A and the big black purse was hers. The Dialysis Technician stated the reason why she kept the purse inside Dialysis Cart A was because she had her wallet in the purse. LVN 3 stated Dialysis Cart A contained items or equipment used for dialysis and no personal items should be kept inside the cart because it could cross contamination the supplies. On [DATE] at 1158 hours, an interview was conducted with the Dialysis RN Supervisor. The Dialysis RN Supervisor stated they were an affiliated dialysis company for the facility. The Dialysis RN Supervisor stated an in-service training was recently provided to the dialysis team regarding only storing the supplies used for dialysis in the dialysis cart and no personal items should be kept inside the dialysis carts. The Dialysis RN Supervisor stated the infection risk of the dialysis residents was high because of their compromised health status. The Dialysis RN Supervisor further stated by having the dialysis staff’s personal items or belongings inside the dialysis cart violated the infection control measures due to cross contamination to the sterile supplies used for dialysis. On [DATE] at 1434 hours, an interview was conducted with the IP and the DON. The IP and DON were informed and acknowledged the above findings. 6. Review of the facility’s P&P titled Bedside Medications Storage revised 2/2018, showed the following: - Bedside medication storage is permitted for resident who wish to self-administer medications, upon the written order of the prescriber and once self administration skills have been assessed and deemed appropriate in the judgement of the facility’s interdisciplinary resident assessment team. - A written order for the bedside storage of medication is present in the resident’s medical record. - All nurses and aides are required to report to the charge nurse on duty any medications found at the bedside not authorized for bedside storage and to give unauthorized medication to the charge nurse for return to the family or responsible party. Families or responsible parties are reminded of this procedure and related policy when necessary. Medical record review for Resident 68 was initiated on [DATE]. Resident 68 was admitted to the facility on [DATE]. Review of Resident 68’s H&P examination dated [DATE], showed Resident 68 needed assistance with decision making capabilities. Review of Resident 68’s admission MDS assessment dated [DATE], showed Resident 68 has a BIMS score of 13, indicating cognitively intact. On [DATE] at 1222 hours, during the initial tour of the facility, Resident 68 was observed lying on his bed. One tube of Velenex wound dressing ointment and one spray bottle of Sea-Clens wound cleanser were observed at the bedside table. Resident 68 stated he was not aware of the medications stored at the bedside table. On [DATE] at 1228 hours, an observation, interview and concurrent medical record review for Resident 68 was conducted with LVN 14. LVN 14 verified the above findings and stated Resident 68's medical record failed to show documented evidence of the physician’s orders for the Venelex wound dressing ointment and Sea-Clens wound cleanser. LVN 14 further stated Resident 68 should not have any medications at the bedside. On [DATE] at 1518 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and acknowledged the above findings. The DON stated no medications needed to be at the resident’s bedside. 7. On [DATE] at 0859 hours, during the initial tour of the facility, Resident 73 was observed in bed, and a bottle of Forze VF Gold (multivitamin supplement) was observed at the bedside. On [DATE] at 0917 hours, an observation for Resident 73 and concurrent interview was conducted with the Case Manager. The Case Manager verified a bottle of Forze VF Gold was at Resident 73’s bedside. The Case Manager stated the medications should not be left at the bedside, unless the resident was assessed properly and authorized to take their own medications. The Case Manager further stated the resident could overdose from the medication if the resident grabbed and took all the medications at once. The Case Manager added there was a high risk of the resident overmedicating or overdosing himself, and since Resident 73 had a GT, he could potentially choke from the medication. Medical record review for Resident 73 was initiated on [DATE]. Resident 73 was readmitted to the facility on [DATE]. Review of Resident 73’s H&P examination dated [DATE], showed Resident 73 had no capacity to understand make decisions. Review of Resident 73’s Order Summary Report failed to show a physician’s order for the Forze VF Gold medication. Further review of Resident 73’s medical record failed to show documented evidence Resident 73 could keep medications at the bedside. On [DATE] at 1526 hours, an interview and concurrent medical record review was conducted with the DON and Administrator. The DON and Administrator verified the above findings. The DON stated for the resident to keep the medication at the bedside, the facility needed to obtain a physician’s order, and the resident needed to be assessed to make sure the resident could “tolerate” it.

CONCERN (D)

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

Garbage Disposal (Tag F0814)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and facility P&P review, the facility failed to ensure the garbage was properly stored in two of two garbage dumpsters. * The facility failed to ensure the lids for the two garbage dumpsters were fully closed. This failure had the potential to attract pest/rodents that carried diseases.Findings: Review of the facility's P&P titled Garbage and Trash dated 2023 showed all the food waste must be placed in sealed leak-proof, non-absorbent, tightly closed containers (i.e., plastic bags) and shall be disposed of as necessary to prevent a nuisance or unsightliness. Adequate, clean, vermin-proof areas must be provided for storage of garbage and rubbish. Garbage and trash cans must be inspected daily that no debris is on the ground or surrounding area, and that the lids are closed. The trash collection area is a potential feeding ground for vermin and rodents and must be kept clean. According to the USDA Food Code 2022 Section 5-501.15 Outside Receptables, the receptables and waste handing units for refuse, recyclables, and returnable used with materials containing food residue and used outside the food establishment shall be designed and constructed to have tight-fitting lids, doors and covers. On 8/25/25 at 0928 hours, an observation and concurrent interview was conducted with the Maintenance Supervisor of the facility's two of two outside garbage dumpsters. The garbage dumpsters were observed with the lids partially propped open by the trash bags preventing the lids from fully closing. In addition, there was a bag of trash on the ground. The Maintenance Supervisor verified the findings and stated the dumpster lids should be completely closed at all times for infection control purposes.

CONCERN (D)

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

Deficiency F0849 (Tag F0849)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary hospice services for one of one final sampled resident (Residents 11) reviewed for hospice services . * The facility failed to ensure Hospice A's plan of care including the physician's orders were integrated into Residents 11's care. * The facility failed to ensure the complete documentation of the hospice staff visits were available for Resident 11. * The facility failed to ensure Resident 11's IDT meeting included the hospice staff. These failures posed the risk for the delay in communication and provision of the hospice care between the hospice provider and facility.Findings: Review of the facility's P&P titled Hospice Program (undated) showed when a resident participates in the hospice program, a coordinated plan of care between the facility, Hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms. The care plans shall be revised and updated as necessary to reflect the resident's current status. a. Medical record review for Resident 11 was initiated on 8/25/25. Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's H&P examination dated 5/1/25, showed Resident 11 had no capacity to understand and make decisions. Further review of the Resident 11's plan of care failed to show the hospice care plan was incorporated in the facility's plan of care for the resident. b. Review of Resident 11's Hospice A Current Treatment / Medication/ DME list showed the following Hospice A physician's orders:- dated 4/1/25, to administer ondansetron (medication used to prevent nausea and vomiting) 4 mg orally every four hours as needed for nausea and/or vomiting; and- dated 4/1/25, for the RN to visit once every two weeks for supervisory visits. Review of Resident 11's Order Summary Report showed the following physician's orders:- dated 4/1/25, to admit Resident 11 to Hospice A.- dated 4/1/25, for the Skilled Nursing Visit once a week and one more visit as needed for symptom management. Certified Home Health Aide (CHHA) visit twice a week for hygiene and activities of daily living. However, further review of Resident 11's Order Summary Report did not show Hospice A physician's orders for the ondansetron medication and frequency of hospice RN visit to the facility. c. Review of Resident 11's Hospice A Monthly Schedule showed the following:- Hospice A's LVN to visit on 8/4 and 8/18/25- Hospice A's RN to visit on 8/14 and 8/28/25.- Hospice A's CCHA to visit on 8/5, 8/7, 8/12, 8/14, 8/19, 8/21, 8/26, and 8/28/25. However, review of Resident 11's Hospice A's Clinical Progress Notes showed notes made by Hospice A staff on 8/5, 8/9, 8/12, 8/14, 8/19, 8/23, 8/26, 8/27, and 8/28/25. Further review of the clinical progress notes did not show the professional designation of the hospice staff documenting the notes. In addition, the clinical progress notes did not show if Resident 11 was visited by Hospice A's LVN, RN, and CCHA as scheduled in the monthly schedule. d. Review of Resident 11's Interdisciplinary Team Conference Review showed following:- on 7/2/25 at 1505 hours, the quarter review of the IDT note showed an entry from the nursing, activities, and dietary department. However, further review of the IDT note failed to show if the staff from Hospice A were present in the IDT meeting.- on 5/21/25, the annual review of IDT team participation professional showed the signature of the activities, food and nutrition, and other departments. However, there was no signature on the section for the hospice. Further review of the document failed to show if the staff from Hospice A were present in the IDT meeting. On 8/28/25 at 1026 hours, an interview and concurrent medical record review for Resident 11 was conducted with the MDS Coordinator. The MDS Coordinator stated the care for the residents on hospice should be coordinated with the hospice provider and the care plan including the physician's orders from the hospice provider needed to be incorporated into the resident's care. The MDS Coordinator further stated the hospice staff should be included in every IDT meeting for the residents who were receiving services from the hospice provider and the facility needed to ensure the hospice staff visited the residents as ordered and scheduled by the hospice provider. The MDS Coordinator verified Resident 11 was admitted under the hospice services on 4/1/25, and verified the above findings. The MDS Coordinator verified the care plan from Hospice A was not incorporated into the facility's care plan for Resident 11 and Hospice A physician's orders for the ondansetron medication, and the schedule for RN visits were not included in the facility's physician's orders. The MDS Coordinator also verified the IDT meeting for Resident 11 on 5/21 and 7/2/25, did not include the staff from Hospice A. The MDS Coordinator verified the clinical progress notes entered by the Hospice A staff did not show the professional designation of the hospice staff making the entry on the resident's clinical progress notes. In addition, the MDS Coordinator was not able to show if the staff from Hospice A visited Resident 11 as scheduled in the monthly schedule and as ordered by the physician. On 8/28/25 at 1133 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

CONCERN (D)

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

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to monitor and address the use of the antibiotics for two final sampled residents (Residents 68 and 90) and one nonsampled resident (Resident 26) reviewed for antibiotic stewardship. * The facility failed to ensure the McGeer's criteria assessment was completed in a timely manner for Resident 26 when the resident was started with antibiotics on 7/18/25. * The facility failed to ensure the McGeer's criteria were assessed for Residents 68 and 90 when the residents were prescribed with antibiotics. These failures had the potential for the antibiotics to be used when they were not indicated and the development of antibiotic-resistant bacteria.Findings: Review of the facility's P&P titled Antibiotic Stewardship - Orders for Antibiotics revised 12/2016 showed the antibiotics will be prescribed and administered to residents under the guidance of the facility's Antibiotic Stewardship Program and in conjunction with the facility's general policy for Medication Utilization and Prescribing. The Policy Interpretation and Implementation section showed the following:- Appropriate indications for use of antibiotics include criteria met for clinical definition of active infection or suspected sepsis and pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending);- Empirical use of an antibiotic based on clinical criteria of suspected sepsis may be appropriate. The staff and practitioner will document the specific criteria that support the suspicion in the resident's clinical record;- If a resident is admitted from an emergency department, acute care facility, or other care facility, the admitting nurse will review discharge and transfer paperwork for current antibiotic/anti-infective orders. Discharge or transfer medical records must include all the above drug and dosing elements; and- When antibiotics are prescribed over the phone, the primary care practitioner will assess the resident within 72 hours of the telephone order. 1. Medical record review for Resident 68 was initiated on 8/28/25. Resident 68 was admitted to the facility on [DATE]. Review of Resident 68's Order Summary Report showed a physician's order dated 8/26/25, to administer vancomycin hydrochloride (antibiotic) oral suspension 50 mg/ml, give 5 ml by mouth four times a day for c-diff (clostridium difficile, a bacterium that could cause an infection of the large intestines causing diarrhea) for seven days. Review of Resident 68's MAR for August 2025 showed Resident 68 received the vancomycin medication on 8/26/25 at 2100 hours, on 8/27/25 at 0900, 1300, 1700, and 2100 hours, and on 8/28/25 at 0900 and 1300 hours. 2. Medical record review for Resident 90 was initiated on 8/26/25. Resident 90 was readmitted to the facility on [DATE]. Review of Resident 90's Order Summary Report showed a physician's order dated 8/22/25, to administer sulfamethoxazole-trimethoprim (antibiotic) oral tablet 800-160 mg one tablet by mouth two times a day for prevention of infection for seven days until finished. Review of Resident 90's MAR for August 2025 showed Resident 90 received the sulfamethoxazole-trimethoprim medication on 8/22/25 at 1700 hours, from 8/23 to 8/27/25 at 0900 and 1700 hours, and on 8/28/25 at 0900 hours. 3. Medical record review for Resident 26 was initiated on 8/28/25. Resident 26 was readmitted to the facility on [DATE]. Review of Resident 26's Order Summary Report showed a physician's order dated 7/17/25, to administer linezolid (antibiotic) oral tablet 600 mg via GT every 12 hours for urinary tract infection for four days. Review of Resident 26's MAR for July 2025 showed Resident 26 received the linezolid medication from 7/18 to 7/21/25 at 0900 and 2100 hours. Review of the facility's document titled Surveillance Data Collection Form showed a surveillance data was completed for Resident 26 on 7/29/25. The Urinary Tract Infection section showed the onset date of the symptoms was on 7/11/25, and the resident had a temperature of 100.3 degree F. The Residents with an Indwelling urinary catheter section showed Resident 26 only met the criteria listed for #1 (fever, rigors or new onset hypotension, with no alternate site of infection) and did not meet the criteria listed for #2 (urinary catheter specimen culture which indicated n/a). Further review of the surveillance data failed to show documented evidence the surveillance data collection or McGeer's criteria was completed for Residents 68 and 90 when the residents were started with antibiotics. On 8/28/25 at 1554 hours, an interview, medical record review and concurrent facility document review was conducted with the IP. The IP stated he used the Surveillance Data Collection Form to determine if the resident on antibiotic medications met or not the McGeer's criteria for a true infection. The IP stated he was notified during the morning huddle by the licensed nurses if the resident had a new physician's order for antibiotic medications. The IP stated he could also check the PCC for the list of the residents with the antibiotic medications. The IP stated he completed the surveillance infection data or screening as soon as possible, once the order for antibiotic medication was received or within the next 24 hours. The IP stated for the residents admitted from the acute care hospital with antibiotic medications, the McGeer's criteria still had to be assessed. The IP stated the first part of the surveillance data form (boxes 1 and 2) was completed by the licensed nurses with their signature, name, title and the date it was completed. The IP would then follow up, recheck the assessment, complete the Section B and countersign and date the form. The IP stated the resident must meet both criteria listed for #s1 and 2 to be considered for a true infection. The IP stated no matter what the result was, the facility would notify the physician and implement the orders. The IP stated if the resident did not meet the McGeer's criteria and if the physician still wanted to continue with the antibiotic medications, the notification and continuation of the antibiotic medication should be documented in the resident's progress note. The IP verified the McGeer's criteria was not assessed for Residents 68 and 90 when the residents were started with the antibiotic medications. The IP verified the McGeer's criteria for Resident 26 was completed after the resident completed the course of antibiotics and the resident did not meet the criteria in #2 for the urinary catheter specimen culture which indicated n/a. The IP further verified there was no documented evidence the result was communicated with the physician. On 8/29/25 at 1440 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

CONCERN (D)

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

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to administer the pneumococcal vaccine (a vaccine given to protect the resident from pneumococcal disease) to one of five final sampled residents (Resident 35) reviewed for immunizations. * Resident 35's medical record failed to show documented evidence Resident 35 was administered with the pneumococcal vaccine or had refused the pneumococcal vaccine. This failure increased the resident's risk of being infected by the pneumococcal disease and its associated complications.Findings: Review of facility's P&P titled Pneumococcal Vaccine revised 10/2019 showed all the residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Assessments of the pneumococcal vaccination status will be conducted with in five (5) working days of the resident's admission if not conducted prior to admission. Before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effect of the pneumonia vaccine. Provision of such education shall be documented in the resident's medical record. Pneumococcal vaccine will be administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician-approved pneumococcal vaccination protocol. Residents/ representative have the right to refuse vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusals of the pneumococcal vaccination. Medical record review for Resident 35 was initiated on 8/28/25. Resident 35 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 35's H&P examination dated 12/20/24, the resident had capacity to understand and make decisions. Review of Resident 35's Health Status Note dated 2/13/25 at 1502 hours, showed the facility staff approached the resident at the bedside to obtain the consent for the influenza, pneumococcal, and Covid-19 vaccines. The note showed the resident consented verbally and she wants them all. However, further review of Resident 35's medical record failed to show documented evidence Resident 35 was administered with the pneumococcal vaccine or had refused the pneumococcal vaccine. On 8/29/25 at 1325 hours, an interview and concurrent medical record review was conducted with the DON and IP. The IP verified the pneumococcal vaccine was not administered to Resident 35. The IP stated the resident had the possible risk of getting infected when the resident was exposed to someone with the pneumonia infection. The DON verified the pneumococcal vaccine was not administered to Resident 35. The DON was observed instructing the IP to ask Resident 35 if the pneumococcal vaccine could be administered.

CONCERN (D)

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

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to administer the COVID-19 (infectious disease caused by the SARS-CoV-2 virus- Severe Acute Respiratory Syndrome Corona virus 2 that causes COVID 19) vaccine to one of five sampled residents (Resident 35) reviewed for COVID-19 vaccination. * The facility failed to ensure COVID-19 vaccine was administered to Resident 35. This failure increased the resident's risk of being infected by the COVID-19 disease and its associated complications.Findings: Review of facility's P&P titled Covid Vaccine Policy and Procedure, undated, showed in part, to establish the process to comply with the Federal mandate that all staff are vaccinated against COVID-19 unless they have a medical or religious exemption to help reduce the risk residents and staff have of contracting and spreading COVID-19. COVID-19 vaccinations will be offered to all staff and residents (or their representatives if they cannot make health care decisions.) unless such immunization is medically contraindicated, per CDC (Center for Disease Control and Prevention) guidance, or the individual has already been immunized. All staff and residents / representatives will be educated on the COVID-19 vaccine they are offered, in a manner they can understand, including information on the benefits and risks consistent with CDC information. The facility will maintain documentation for all residents and staff on COVID-19 vaccination. For residents, the information will be documented in her medical record. Medical record review for Resident 35 was initiated on 8/28/25. Resident 35 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 35's H&P examination dated 12/20/24, showed the resident had capacity to understand and make decisions. Review of Resident 35's Health Status Note dated 2/13/25 at 1502 hours, showed the facility staff approached the resident at the bedside to obtain the consent for the influenza, pneumococcal, and Covid-19 vaccines. The note showed the resident consented verbally and she wants them all. Further review of Resident 35's medical record failed to show documented evidence Resident 35 refused the COVID-19 vaccine. On 8/29/25 at 1325 hours, an interview and concurrent medical record review was conducted with the IP and DON. The IP verified the COVID-19 vaccine was not given to Resident 35. The IP stated the resident had the potential risk of getting the virus if exposed to someone with the COVID-19 infection. The DON verified the COVID-19 vaccine was not given to Resident 35.

CONCERN (D)

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

Deficiency F0909 (Tag F0909)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the resident's zone entrapment assessment was completed and the measurements were recorded upon installation during the admission when identifying areas of possible entrapment with the use of side rails for two final sampled residents (Residents 6 and 37) and one nonsampled resident (Resident 67) reviewed for the use of the side rails. * The facility failed to ensure Residents 6, 37, and 67's entrapment assessments were completed upon the installation of the residents' bilateral half side rails. These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapment may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is potential for entrapment are: - Zone 1: within the rail; - Zone 2: under the rail, between the rail supports or next to a single rail support; - Zone 3: between the rail and the mattress; - Zone 4: under the rail, at the ends of the rail; - Zone 5: between split bed rails; - Zone 6: between the end of the rail and the side edge of the head or foot board; and - Zone 7: between the head or foot board and the mattress end. Review of the facility's P&P titled Bed Safety and Bed Rails revised 8/2022 showed the use of bed rails is prohibited unless the criteria for use of bed rails have been met. The Policy Interpretation and Implementation section showed the following: - Regardless of mattress type, width, length, and/or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident's head or body. Any gaps in the bed system are within the safety dimensions established by the FDA; - Maintenance staff routinely inspect all beds and related equipment to identify risks and problems including potential entrapment risks; - Bed rails are properly installed and used according to the manufacturer's instructions, specifications and other pertinent safety guidance to ensure proper fit (e.g., avoid bowing, ensure proper distance from the headboard and footboard, etc.); and - Additional safety measures are implemented for residents who have been identified as having a higher than usual risk for injury including bed entrapment. 1. On 8/26/25 at 0845 hours, an observation and concurrent interview was conducted for Resident 37. Resident 37 was observed awake and lying in bed with bilateral 1/2 side rails elevated. Resident 37 stated he could turn in bed but needed assistance and he used the side rails to grab. Medical record review for Resident 37 was initiated on 8/26/25. Resident 37 was readmitted to the facility on [DATE]. Review of Resident 37's MDS assessment dated [DATE], showed Resident 37 needed substantial to maximal assistance with mobility. Review of Resident 37's H&P examination dated 8/12/25, showed Resident 37 had the capacity to understand and make medical decisions. Review of Resident 37's Order Summary Report showed a physician's order dated 8/13/25, for the use of bilateral ½ (half) side rails as enabler/feelings of safety per patient’s request. On 8/27/25 at 1130 hours, an observation and concurrent interview for Resident 37 was conducted with CNA 12. Resident 37 was observed sleeping in the bed with bilateral ½ side rails elevated. CNA 12 stated Resident 37 needs assistance with turning and getting out of bed. CNA 12 further stated Resident 37 used the side rails to grab. 2. On 8/26/25 at 0830 hours, an observation and concurrent interview was conducted for Resident 67. Resident 67 was observed awake and lying in bed with bilateral 1/2 side rails elevated. Resident 67 stated he could turn in bed, and he used the side rails to grab while turning. Resident 67 further stated he needed someone’s assistance to get out of bed. Medical record review for Resident 67 was initiated on 8/26/25. Resident 67 was admitted to the facility on [DATE]. Review of Resident 67's H&P examination dated 7/22/25, showed Resident 67 needed assistance with decision making. Review of Resident 67's Order Summary Report showed a physician's order dated 7/22/25, for the use of bilateral ½ side rails as enabler per the resident's request. Review of Resident 67's MDS assessment dated [DATE], showed Resident 67 needed substantial to maximal assistance with mobility. On 8/27/25 at 1140 hours, an observation and concurrent interview for Resident 67 was conducted with CNA 12. Resident 67 was observed having dialysis at the bedside. CNA 12 stated Resident 67 was able to grab rails when being turned or cleaned. CNA 12 further stated Resident 67 could not get out of bed related to knee surgery. On 8/29/25 at 1350 hours, an interview and concurrent facility document review for Residents 37 and 67 was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated his department was the one responsible for installing the side rails. The Maintenance Supervisor stated the nurses informed him if the resident had an order for the side rails. The Maintenance Supervisor stated after verifying the order for the resident’s side rails, he installed it and completed the zone entrapment assessment. The Maintenance Supervisor stated he checked the residents’ bed and bed rails every month to ensure proper functioning, and the gaps needed to check from the side rails met the proper measurement. Review if the facility's document titled Bed Safety Checklist for Residents with Bed Rails for June and July 2025 failed to show documented evidence the zone entrapment assessment was completed for Residents 37 and 67. The Maintenance Supervisor verified the findings. The Maintenance Supervisor stated it was important to complete the zone entrapment assessment for the side rails to avoid any accident because the resident’s head or arms could be entrapped between the mattress/bed and side rails. On 8/29/25 at 1440 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings for Residents 37 and 67. Cross reference to F700, examples #2 and 3. 3. Review of the facility's P&P titled Bed Safety and Bed Rails date revised 8/2022 showed the use of bed rails is prohibited unless the criteria for use of bed rails have been met. The Policy Interpretation and Implementation section showed the following: - Bed frames, mattresses and bed rails are checked for compatibility and size prior to use. - Regardless of mattress type, width, length, and/or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident's head or body. Any gaps in the bed system are within the safety dimensions established by the FDA. - Maintenance staff routinely inspect all beds and related equipment to identify risks and problems including potential entrapment risks. - Bed rails are properly installed and used according to the manufacturer's instructions, specifications and other pertinent safety guidance to ensure proper fit (e.g., avoid bowing, ensure proper distance from the headboard and footboard, etc.). - Additional safety measures are implemented for residents who have been identified as having a higher than usual risk for injury including bed entrapment. Review of the facility’s Bed Safety Checklist for Residents with Bed Rails for the months of June and July 2025 failed to show documented evidence the zone entrapment assessment was completed for Resident 6. Review of Resident 6's medical record was initiated on 8/25/25. Resident 6 was admitted to the facility on [DATE]. Review of the H&P examination dated 5/20/25, showed Resident 6 had the capacity to understand and make medical decisions. Review of Resident 6's Order Summary Report dated 8/28/25 failed to show a physician's order for the use of bilateral half side rails. Review of Resident 6's plan of care failed to show a care plan intervention for the use of bilateral half side rails. On 8/25/25 at 1047 hours, during an initial tour, Resident 6's bed was observed with bilateral half side rails elevated at the head of the bed. On 8/27/25 at 0907 hours, Resident 6 was observed lying in bed with bilateral half side rails elevated. On 8/28/25 at 1528 hours, an interview with concurrent facility record review was conducted with the Maintenance Supervisor. The Maintenance Supervisor acknowledged the findings and stated there was no physician’s order for the use of side rails, if there was a physician's order he would follow the process of entrapment assessment and would have measured the zones using a tape measure. On 8/28/25 at 1539 hours, the DON was informed and verified the above findings. Cross reference to F700, example #1.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen. * The facility failed to ensure the sanitary condition of the hood over the stove was maintained. * The facility failed to ensure the kitchen utensils had a smooth cleanable surface and in good condition. * The facility failed to ensure the kitchenware and kitchen utensils were clean and free of food particles or residue. * The facility failed to ensure the cutting boards were kept in a sanitary condition and with a cleanable surface. * The facility failed to ensure the heavy-duty blender used for puree preparation was air dried and free of food residue prior to storing and stacking. * The facility failed to ensure the ice machine drainpipes had an air gap and not touching the drains. * The facility failed to ensure the kitchen staff performed hand hygiene during dishwashing. These failures had the potential for cross contamination and foodborne illnesses to the residents consuming the food prepared in the facility's kitchen.Findings: Review of the facility's Diet Type Report dated 8/25/25, showed 54 of 91 residents consumed the food prepared in the kitchen. 1. Review of the facility's P&P titled Hoods, Filters, and Vents dated 2023 showed the hoods must be cleaned every two weeks and must be free of dust and grease. According to the USDA Food Code 2022 Section 4-204.11 Ventilation Hood Systems, Drip Prevention, the dripping of grease or condensation onto food constitutes adulteration and may involve contamination of the food with pathogenic organisms. Equipment, utensils, linens, and single service and single use articles that are subjected to such drippage are no longer clean. On 8/25/25 at 0833 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. The kitchen hood over the stove had black and dirt residue. The DSS acknowledged the findings. The DSS stated the dietary staff cleaned the hood every two weeks and was also cleaned by an outside company every six months. The DSS stated the kitchen hood should not be greasy due to fire hazard. 2. Review of the facility's P&P titled Sanitation dated 2023 showed all the utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. The plastic ware, China, and glassware that becomes unsightly, unsanitary, or hazardous because of chips, cracks, or loss of glaze shall be discarded. The plastic ware is bleached as necessary to prevent staining. According to the USDA Food Code 2022 Section 4-502.11 Good Repair and Calibration, utensils shall be maintained in a state of repair and condition that complies with the requirements specified under Parts 4-1 and 4-2 or shall be discarded. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition. On 8/25/25 at 0833 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. The following was observed and verified by the DSS:- Basting brush used to spread butter was observed with the bristles frayed, discolored and worn out.- Three stainless steel scoops for food portioning were observed with the cream colored handles discolored and peeling.- Two stainless steel scoops for food portioning were observed with the gray colored handles worn out and peeling.- One stainless steel scoop for food portioning was observed with the black colored handle worn out and peeling.- One dough cutter was observed with the wooden handle discolored and deformed at the corners. The DSS acknowledged the above findings and stated the worn out utensils should have been replaced and discarded. 3. Review of the facility's P&P titled Dishwashing dated 2023 showed gross food particles shall be removed by careful scraping and pre-rinsing in running water. The dishes are to be racked loosely without overlapping. Appropriate chemicals will be used to wash, de-stain, and rinse dishes. The flatware is to be pre-soaked in a solution of water and detergent per manufacturer's instructions. According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2017, 4-602.13, Non- Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On 8/25/25 at 0833 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. The following was observed and verified by the DSS:- One heavy duty blender for puree preparation was observed with white food residue inside.- Two stainless steel slotted scoops were observed with the red handles fuzzy with dry crusted food particles and cloudy film.- Two stainless steel scoops were observed with the red handles with dry white, crusted residue.- One stainless steel slotted scoop was observed with the green handle with dry, crusted residue and cloudy film.- One stainless steel slotted scoop was observed with the black handle with dry, crusted residue and cloudy film.- One stainless steel slotted scoop was observed with the cream handle with dry, crusted residue and cloudy film.- One stainless steel slotted scoop was observed with the blue handle with dry, crusted residue and cloudy film.- Three stainless steel scoops were observed with the blue handle with dry, crusted residue and cloudy film- Three stainless steel scoops for food portioning were observed with the cream handles with dry watermarks.- Two stainless steel scoops for food portioning was observed with the gray handles with dry, crusted residue and watermarks.- One stainless steel scoop for food portioning was observed with the black handle with dry watermarks.- One stainless steel scoop for food portioning was observed with the yellow handle with dry watermarks and cloudy film.- Seven stainless steel scoops were observed with dry, crusted residue, watermarks and cloudy film. The DSS acknowledged the above findings and stated all the dirty and crusted kitchen utensils should have been rewashed for infection control purposes. 4. Review of the facility's P&P titled Sanitation dated 2023 showed separate chopping boards are to be used for preparing meats and vegetables. After each use, chopping boards shall be thoroughly cleaned and sanitized. According to the USDA Food Code 2022, Section 4-501.12, Cutting Surfaces, for 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 the foods that are prepared on such surfaces. On 8/25/25 at 0833 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. The brown, yellow, green and blue cutting boards were observed fuzzy, heavily marred and had deep groves. The DSS verified the findings and stated the cutting boards should have been replaced. 5. Review of the facility's P&P titled Dishwashing dated 2023 showed the dishes are to be air dried in racks before stacking and storing. According to the USDA Food Code 2022, 4-901.11, Equipment and Utensils, Air-Drying Required, that after cleaning and sanitizing, equipment, and utensils shall be air-dried or used after adequate draining before getting in contact with food. According to the USDA Food Code 2022, 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, cleaned equipment and utensils shall be stored in a self-draining position that allows air drying. On 8/25/25 at 0833 hours, during the initial kitchen tour, an observation and concurrent interview was conducted with the DSS. One heavy-duty blender used for puree preparation stored on the countertop shelf was observed to be wet with visible water and white food residue inside. The DSS verified the findings and stated all the kitchen utensils and dirty equipment should have been washed and air dried to prevent bacteria growth. 6. Review of the facility's P&P titled Accident Prevention- Safety Precautions dated 2023 showed an air gap between the water supply inlet (drain pipe) and the flood level rim of the plumbing fixture (floor sink drain), equipment or non-food equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch. According to the USDA 2017 Food Code, Section 5-202.13, Backflow Prevention, Air Gap, an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment, shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). On 8/25/25 at 0908 hours, during the initial kitchen tour, an inspection of the ice machine in the kitchen and concurrent interview was conducted with the Maintenance Supervisor. The ice machine drainpipe was observed touching the drain, there was no air gap observed between the ice machine drainpipe and the drain. The Maintenance Supervisor acknowledged the findings and stated the drainpipe needed to be fixed to prevent back flow. 7. Review of the facility's P&P titled Sanitation dated 2023 showed all Food and Nutrition Services staff shall know the proper handwashing technique. Review of the facility's P&P titled Hand Washing Procedure dated 2023 showed hands needed to be washed after handling soiled dishes and utensils. According to the USDA Food Code 2022 2-301.14, When to Wash, food employees shall clean their hands and exposed portions of their arms after engaging in other activities that contaminate the hands. According to the USDA Food Code 2022 2-301.11, Clean Condition, the hands are particularly important in transmitting foodborne pathogens. Food employees with dirty hands and/or fingernails may contaminate the food being prepared. Therefore, any activity which may contaminate the hands must be followed by thorough handwashing in accordance with the procedures outlined in the Code. On 8/27/25 at 0938 hours, an observation and concurrent interview was conducted with the Dietary Aide during dishwashing. The Dietary Aide was observed wearing gloves and scraping the food from the dirty plates and meal trays for dishwashing. While wearing the same pair of gloves, the Dietary Aide was observed handling the clean dishes from the dishwashing machine. The Dietary Aide then touched the dishwashing racks with clean dishes and utensils with the same gloves. The Dietary Aide verified the findings and stated she rinsed her gloves prior to touching the clean dishes. On 8/27/25 at 0940 hours, an interview was conducted with the DSS. The DSS was informed of the above findings. The DSS stated the Dietary Aide should have performed hand hygiene and changed her gloves to prevent cross contamination. On 8/28/25 at 1539 hours, an interview was conducted with the DON and DSS. The DON and DSS were informed and verified the above findings.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain the infection control program and practices to help prevent the development and transmission of diseases and infections. * The facility failed to ensure an infection control surveillance report/log and mapping were completed for the months of May and June 2025. * The facility failed to ensure Resident 24 was placed on EBP (Enhanced Barrier Precautions) per the physician's order. * The facility failed to ensure an EBP sign was placed outside of Room C for Resident 37 who had a Quinton catheter and indwelling urinary catheter, and for Resident 67 who had an AV fistula. * The facility failed to ensure the facility staff did not refill the residents' water from the bathroom sink. In addition, the facility failed to ensure the trash was emptied when filled and a used washable gown was discarded properly for Room B. * The facility failed to ensure Resident 65's water jug was not kept on the floor. * The facility failed to ensure to the licensed nurse donned the proper PPE and performed hand hygiene after picking up the dropped medication cup from the ground during the medication administration observation. These failures had the potential for the facility to not accurately identify, investigate, and prevent new infections from developing within the facility, and posed the risk of the transmission of communicable diseases to the residents and employees throughout the facility.Findings: Review of the facility's P&P titled Antibiotic Stewardship – Review and Surveillance of Antibiotic Use and Outcomes revised 12/2016 showed the antibiotic usage and outcome data will be collected and documented using a facility-approved antibiotic surveillance tracking form. The data will be used to guide decisions for the improvement of individual resident antibiotic prescribing practices and facility-wide antibiotic stewardship. The Policy Interpretation and Implementation section showed all resident antibiotic regimens will be documented on the facility-approved antibiotic surveillance tracking form. The intonation gathered will include resident name and medical record number, unit and room number, date symptoms appeared, name of antibiotic, start date of antibiotic, pathogen identified, site of infection, date of culture, stop date, total days of therapy, outcome, and adverse events. Review of the facility's P&P titled Infection Control Guidelines for All Nursing Procedures revised 8/2012 showed under the General Guidelines all employees must wear personal protective equipment as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials and must wash their hands for ten to fifteen seconds using antimicrobial or nonantimicrobial soap and water under the following conditions: - Before and after direct contact with residents; - When hands are visibly dirty or soiled with blood or other body fluids; - After contact with blood, body fluids, secretions, mucous membranes, or non-intact skin; - After removing gloves; - After handling items potentially contaminated with blood, body fluids, or secretions; - Before eating and after using a restroom; and - When there is likely exposure to spores. 1. On 8/28/25 at 1554 hours, an interview and concurrent facility document review was conducted with the IP. Review of the Infection Control Surveillance binder failed to show the infection control surveillance report/log and mapping were completed for May and June 2025. The IP verified these findings and stated he just started a month ago as the IP in the facility. The IP stated he reviewed all the reports from the previous months and did not have the chance to update all the reports or logs for the infection control surveillance. The IP stated without the surveillance report, the facility would not be able to identify the infection within the facility. The IP further stated it was important to complete the infection surveillance report for each month to be able to see the pattern of a certain infection, which would help the facility plan what observations, interventions, and/or in-service trainings to be provided to prevent or control the increased number of infections. On 8/29/25 at 1440 hours, an interview was conducted with the DON. The DON stated it was very important to complete the infection control surveillance and mapping for each month because it would help the facility to identify the infections in the facility. The DON stated the infection surveillance report and mapping could also be used to help the facility complete a root cause analysis, to investigate the causes of the infections present in the facility. This in turn they could plan interventions to prevent or limit those infections from spreading throughout the facility. 2. According to the CDC, assuming contact precautions do not otherwise apply, EBP is recommended for residents with any of the following: 1) infection or colonization with a MDRO or 2) a wound or indwelling medical device, even if the resident is not known to be infected or colonized with a MDRO (Multi-Drug Resistant Organism infection is a serious illness caused by microorganisms, primarily bacteria, that have developed resistance to multiple antibiotics, making them difficult or impossible to treat with standard medications). Examples of indwelling medical devices include, but are not limited to, central vascular catheters including hemodialysis catheters, peripherally inserted central catheters, indwelling urinary catheters, feeding tubes, and tracheostomy tubes. EBP involves gown and glove use during high-contact resident care activities such as dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use and wound care. The EBP signs are intended to signal to individuals entering the room the specific actions they should take to protect themselves and the residents. a. Medical record review for Resident 37 was initiated on 8/26/25. Resident 37 was readmitted to the facility on [DATE]. Review of Resident 37's Order Summary Report showed the following physician's orders: - dated 8/11/25, to observe/monitor for tenderness, redness, or bleeding at site of Quinton catheter; and - dated 8/11/25, for indwelling urinary Foley catheter care every shift. b. Medical record review for Resident 67 was initiated on 8/26/25. Resident 67 was admitted to the facility on [DATE]. Review of Resident 67's Order Summary Report showed a physician's order dated 8/18/25, to may place the resident on EBP related to an indwelling medical device: hemodialysis, and wound management every shift; to wear the proper PPE during high contact activities. On 8/27/25 at 1420 hours, an observation for Residents 37 and 67 and concurrent interview was conducted with CNA 12. Residents 37 and 67 were observed lying in the bed in Room C. There was no sign observed outside the door of Room C to indicate the residents were on EBP. An isolation cart containing gowns and gloves was observed outside the room. CNA 12 was observed assisting Resident 67 with turning, wearing only a mask and gloves, and not a gown. CNA 12 acknowledged she did not wear a gown and only donned the mask and gloves when turning Resident 67. CNA 12 stated Residents 37 and 67 were just moved to Room C and she missed donning the gown because there was no EBP sign outside the room. CNA 12 stated she knew both residents had dialysis, but she did not know about the type of dialysis access they had. CNA 12 stated for the residents with a Foley catheter, she had to wear the gown, gloves and mask when she had to empty the drainage bag. On 8/27/25 at 1440 hours, an observation for Room C, interview and concurrent medical record review were conducted with the IP. The IP verified there was no EBP sign outside the door of Room C. The IP stated the residents with wounds, surgical stitches, GT, any indwelling medical devices, any dialysis access, and any central lines should be placed on EBP to prevent the spread of MDROs. The IP stated an EBP sign was placed outside the door to remind the facility staff and visitors the residents were on EBP, to wash their hands when going in and out of the room, and for the facility staff to wear the proper PPE when providing high-contact activities such as changing linen, showering, hygiene care to the residents on EBP. On 8/29/25 at 1440 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. 3. Medical record review for Resident 24 was initiated on 8/25/25. Resident 24 was admitted to the facility on [DATE]. Review of Resident 24’s Order Summary Report showed a physician’s order dated 8/2/25, to may place the resident on EBP related to the medical indwelling device: PEG/GT. On 8/27/25 at 0907 and 1011 hours, and on 8/28/25 at 0857 hours, Resident 24 was observed in bed. There was no sign observed outside the door of Resident 24’s room to indicate the resident was on EBP. An isolation cart containing gowns, and gloves was observed inside the room. On 8/27/25 at 1011 hours, CNA 4 was observed assisting Resident 24, and changing Resident 24’s incontinence brief. CNA 4 was observed wearing a mask and gloves, however, CNA 4 was not observed wearing a gown. On 8/28/25 at 1120 hours, an observation for Resident 24 and concurrent interview was conducted with CNA 4. Resident 24 was observed in bed. There was no sign observed outside the door of Resident 24’s room to indicate the resident was on EBP. An isolation cart containing gowns, and gloves was observed inside the room. CNA 4 verified the above findings. CNA 4 acknowledged she did not wear a gown but only mask and gloves when providing care to Resident 24. CNA 4 stated she did not receive any information that the resident was on EBP, nor the need to wear a gown when providing high-contact activities to Resident 24. CNA 4 stated she would know a resident was on EBP by looking at the sign outside the door. On 8/28/25 at 1122 hours, an observation for Resident 24, interview, and concurrent medical record review was conducted with the IP. The IP verified there was no EBP sign outside the door of Resident 24’s room. The IP stated the residents with wounds and medical dwelling devices such as a catheter, GT, and fistula were placed on EBP to prevent the spread of the MDROs. The IP stated an EBP sign was placed outside the door to remind the facility staff and visitors the residents were on EBP, to wash their hands when going in and out of the room, and for the facility staff to wear the proper PPE when providing high-contact activities such as changing linen, showering, hygiene care to the residents on EBP. 4. According to the CDC article titled Considerations for Reducing Risk: Water in Healthcare Facilities dated 10/24/24, water can carry germs that threaten resident safety and spread antimicrobial-resistant pathogens or cause HAIs. One of the considerations included healthcare facilities can reduce splashing from sinks and drains that can expose people to pathogens. Splashes can occur when water hits the contaminated drain cover, or a person flushes a toilet or hopper. Splashes can spread droplets containing OPPP (opportunistic premise plumbing pathogens, which are microorganisms that live and grow in building water systems. These infections primarily affect individuals with weakened immune systems) to the surrounding environment, residents and providers. Recent evidence indicates sinks and other drains, such as toilets or hoppers, in healthcare facilitate can become contaminated with MDROs. One of the ways to reduce the risk of OPPP exposure through sinks and drains in healthcare facilities is to avoid placing resident care or personal items on counters next to sink. a. On 8/29/25 at 1006 hours, an interview was conducted with Resident Representative 2. Resident Representative 2 stated she was concerned about the source of water given to Resident 66. Resident Representative 2 stated she asked one of the charge nurses who worked last night if she could refill Resident 66’s water from the water dispenser at the nursing station, but she was told to get the water from the bathroom sink. Resident Representative 2 stated she asked the CNAs where they got the water, and she was told they got the water from the kitchen. On 8/29/25 at 1023 hours, an interview was conducted with Resident 35, with Resident Representative 2 present. Resident 35 stated she walked to the nursing station to ask the facility staff to refill her water pitcher from the water dispenser in the nursing station, however, she had seen the facility staff refill Resident 66’s water pitcher from the bathroom sink. b. On 8/29/25 at 1030 hours, an observation for Residents 32 and 66 in Room B was conducted. Residents 32 and 66 were observed asleep in bed. [NAME] water pitchers were observed at the bedside for Residents 32 and 66. A trash bin was observed full, and a used washable gown was observed on top of the trash bin inside Room B. On 8/29/25 at 1037 hours, an observation for Room B and concurrent interview was conducted with LVN 8. LVN 8 verified the trash bin in Room B was full, and the used washable gown was on top of the trash bin. On 8/29/25 at 1045 hours, an interview was conducted with CNA 2. CNA 2 stated the residents in Room B were part of his assignment. CNA 2 stated all the residents with GT have a water pitcher at the bedside for the licensed nurses to use when flushing the GT, or for the residents to drink if the residents did not have the GT. CNA 2 stated the night shift CNAs changed and refilled the water pitchers every night, then when it was empty, the morning CNAs would refill them by getting the water from the bathroom sink. CNA 2 stated they only got ice and water from the kitchen when the residents wanted cold water. On 8/29/25 at 1054 hours, an observation for Room B and concurrent interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor verified the trash bin in Room B was full and a used washable gown was on top of the trash bin. The Maintenance Supervisor stated the housekeeping staff were in charge of emptying the trash bin, and the trash bin should be emptied twice in the morning shift. On 8/29/25 at 1336 hours, a telephone interview was conducted with CNA 7. When asked where he got the water for the residents, CNA 7 stated he would get the water from the water dispenser in the nursing station. When asked where he would get the water if the water ran out at during the night, CNA 7 stated he would get the water from the residents' bathroom sink. On 8/29/25 at 1350 hours, an interview was conducted with the DSD and IP. The DSD stated the kitchen staff set up the water dispenser in the nursing station, and the night shift nurse refilled the water pitchers by getting the water from the kitchen. The DSD stated the water dispenser in the nursing station was also refilled by the kitchen staff, and the facility staff also transported the water dispenser from the nursing station near the resident rooms to refill the water pitchers for the residents. The DSD stated the kitchen had been opened for the facility staff to access the water from the kitchen, however, the new DSS had been locking the kitchen. The DSD and IP were informed the water pitchers for the residents were being refilled with the water from the bathroom sink. The IP stated the water pitchers for the residents should not be refilled with the water from the bathroom sink because of cross-contamination (bacteria, E.Coli, feces or urine in the sink could be transferred to the water pitchers). 5. According to the American Journal of Infection Control article titled “Are Hospital Floors an Underappreciated Reservoir for Transmission of Healthcare-Associated Pathogens?” dated 2017, the resident rooms were frequently contaminated with healthcare-associated pathogens, and it was not uncommon for high-touch objects such as medical devices, personal items, and linens to be in direct contact with the floor. Touching these objects frequently resulted in the transmission of pathogens to hands, and because floors are frequently contaminated, it would be reasonable to educate health care personnel and residents to avoid placing high-tough objects on the floor when possible. On 8/25/25 at 0831 hours, during the initial tour of the facility, Resident 65 was observed in bed. A water jug was observed on the floor near the resident's bed. Medical record review for Resident 65 was initiated on 8/25/25. Resident 65 was admitted to the facility on [DATE]. Review of Resident 65’s H&P examination dated 5/15/25, showed Resident 65 had the capacity to understand and make medical decisions. On 8/25/25 at 0907 hours, an observation for Resident 65 and concurrent interview was conducted with the Case Manager. Resident 65 was observed in bed, and a water jug was observed on the floor. The Case Manager verified the above findings. The Case Manager was observed picking up the water jug from the floor and placing it on the bedside table, without wiping the water jug clean. The Case Manager acknowledged she did not wipe the water jug before placing it on the bedside table. The Case Manager stated the water jug on the floor was an infection control issue and could be a trip hazard as well. On 8/28/25 at 1445 hours, an interview with the IP was conducted. When asked what the facility's expectation was for the storage of the residents’ personal belongings on the floor, the IP stated the residents’ personal belongings should not be kept on the floor. When asked if the water jug could be placed on the floor, the IP stated the water jug should not be on the floor due to infection control and cross-contamination. On 8/28/25 at 1526 hours, an interview was conducted with the Administrator and DON. The Administrator and DON acknowledged the above findings. 6. Review of the facility's P&P titled Administering Medications revised April 2019 showed all staff must follow established facility infection control procedures such as handwashing, aseptic technique and isolation precautions when administering medications. Failure to follow these infection control procedures has the potential to compromise highly vulnerable residents’ health. On 8/25/25 at 0831 hours, a medication administration observation was conducted with LVN 3 for Resident 89. Resident 89 had a GT with an EBP signage and PPE cart outside of the resident’s door. LVN 3 was observed administering the resident’s medication via the GT, without donning the gown. In addition, during the medication administration observation, LVN 3 dropped a medication cup on the ground. LVN 3 then retrieved the medication cup from the ground with her gloved hand and continued with the medication administration, without removing her soiled gloves, performing hand hygiene and donning clean gloves. On 8/25/25 at 1142 hours, an interview was conducted with LVN 3. LVN 3 verified she failed to wear the ordered PPE (gown) during the medication administration for Resident 89. LVN 3 also verified she retrieved the dropped medication cup from the floor with her gloved hand and did not remove her soiled gloves, perform hand hygiene and don clean gloves before continuing the medication administration. On 8/29/25 at 1115 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

MINOR (B)

Minor Issue - procedural, no safety impact

Resident Rights (Tag F0550)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to promote the dignity and respect for two of 21 final sampled resident (Residents 3 and 51). * The facility failed to ensure CNA 8 was seated at an eye-level while assisting Resident 3 with his meal. * The facility failed to ensure CNA 9 was seated at eye-level while assisting Resident 51 with his meal. These failures posed the risk of not treating the residents with the dignity and respect.Findings: 1. Review of the facility's P&P titled Resident Rights revised 10/2010 showed the facility will make every effort to assure the resident is always treated with respect, kindness and dignity. Medical record review for Resident 3 was initiated on 8/25/25. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's plan of care showed a care plan problem dated 12/21/23, addressing the resident's ADL self-care performance deficit related to blindness to one eye and limited mobility. The interventions included partial assistance with eating. Review of Resident 3's H&P examination dated 12/27/24, showed Resident 3 had the capacity to understand and make medical decisions. On 8/25/25 1239 hours, an observation for Resident 3 and concurrent interview with was conducted with CNA 8. CNA 8 was observed standing next to Resident 3's bedside assisting him with feeding. CNA 8 verified the above findings and stated she should have sat at an eye level with Resident 3 while feeding the resident to ensure the resident was observed more closely. 2. Medical record review for Resident 51 was initiated on 8/25/25. Resident 51 was admitted to the facility on [DATE]. Review of Resident 51's physician's order dated 4/10/21, showed the resident had a Controlled Carbohydrates (CCHO) diet, puree texture and thin consistency, with instructions for one-to-one feeding (aspiration precaution) for breakfast, lunch, and dinner. Review of Resident 51's H&P examination dated 3/27/25, showed Resident 51 had no capacity to understand and make medical decisions. On 8/25/25 1251 hours, an observation for Resident 51 and concurrent interview was conducted with CNA 9. CNA 9 was observed standing next to Resident 51's bedside assisting him with feeding. CNA 9 verified the above findings. CNA 9 stated there was a chair available, however, he did not use it while feeding Resident 51. CNA 9 stated he should have been seated at an eye level at the resident's bedside during the feeding of the resident. On 8/27/25 at 1553 hours, an interview for Residents 3 and 51 was conducted with the DSD. The DSD stated the CNAs and RNAs were expected to sit beside the residents at an eye level when assisting the residents with feeding. The DSD stated the CNAs and RNAs needed to be at an eye level and not hover over them to maintain the residents' dignity. When asked if she provided in-services to the facility staff on dignity or respect since starting at the facility, the DSD stated she had not. On 8/28/25 at 1526 hours, an interview was conducted with the Administrator and DON. The DON stated she expected the facility staff to maintain an eye level while feeding the residents. The Administrator and DON were informed and acknowledged the above findings.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0582 (Tag F0582)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility document review, the facility failed to provide the written Notice of Medicare Non-coverage (NOMNC) form CMS-10123, and the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) form CMS-10055 for one of four residents (Resident 37) reviewed for beneficiary notification. The NOMNC and SNFABN forms are used to inform the residents of their potential financial liability, appeal rights, and protection should they wish to receive care and services that may not be covered by Medicare. This failure had the potential of not allowing Resident 37 and/or their representative to make an informed decision regarding their Medicare servicesFindings: Medical record review for Resident 37 was initiated on 8/28/25. Resident 37 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 37's H&P examination dated 8/12/25, showed the resident had the capacity to understand and make medical decisions. Review of the facility's Beneficiary Notice - Residents discharged Within Last Six Months showed Resident 37 was to be discharged from the Medicare Covered Part A stay on 8/26/25, and would remain in the facility using private pay insurance. Review of Resident 37's NOMNC (undated) showed the effective date coverage of Resident 37's skilled nursing service would end on 8/26/25. The section for the signature of the resident or representative was blank. The document also showed the Business Office Manager left a voice message for Resident 37's responsible party, notifying the responsible party of the Medicare Covered Part A stay was ending on 8/26/25. Review of Resident 37's SNF ABN showed Medicare doesn't pay for everything even some care that you and your health care provider think you need. The Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage or its utilization review committee believes that the care listed below does not meet the Medicare coverage requirement. Beginning 8/27/25, you may have to pay out of pocket for this care if you do not have insurance that may cover those costs. Further review of the document did not show the signature of Resident 37 and/or the resident's representative. Further review of Resident 37's medical record failed to show if Resident 37 and/or the resident's representative were provided with a copy of the NOMNC and SNF ABN when Resident 37 was to be discharged from Medicare Part A services and remain in the facility. On 8/28/25 at 1350 hours, an interview was conducted with the Business Office Manager. The Business Office Manager stated she tried to to give the notice to Resident 37, but he was not available. The Business Office Manager stated she called the resident's responsible party on 8/22/25, and left a voice message to notify her the resident's Medicare Covered Part A services were going to be ending. The Business Office Manager stated she did not have any documentation to show she mailed the NOMNC and/or SNF ABN forms to the resident's responsible party to review, and sign. On 8/28/25 at 1411 hours, a telephone interview was conducted with Resident Representative 3. Resident Representative 3 stated she had not received the NOMNC and SNF ABN written notices in the mail. Resident Representative 3 also stated she did not recall being told by the Business Office Manager she could appeal, or what the appeal process would be. On 8/29/25 at 1440 hours, an interview was conducted with the DON. The DON was notified and acknowledged the above findings.

MINOR (B)

Minor Issue - procedural, no safety impact

Safe Environment (Tag F0584)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a clean, sanitary and homelike environment for one final sampled resident (Resident 35) and four nonsampled residents (Residents 25, 32, 66, and 93) * Residents 25 and 93 were observed in Room A, and Residents 32, 35, and 93 were observed in Room B. The bathroom shared between Rooms A and B was observed with a hole on the wall, under the bathroom sink. This failure posed the risk of unsanitary conditions and an entry for pests into the facility, which could negatively affect the residents' well-being.Findings: On 8/29/25 at 1006 hours, an interview was conducted with Resident Representative 2. Resident Representative 2 stated she was concerned about the flies observed inside Room B, because the flies could enter the mouths of Residents 32 and 66 who sleep with their mouths open. Resident Representative 2 stated she told the lead maintenance person about the flies, and she was told the flies were a problem in the facility, and the flies were coming from outside. On 8/29/25 at 1023 hours, an interview was conducted with Resident 35. Resident 35 stated she saw flies in the room, and she had been watching her roommates (Residents 32 and 66) because their mouths were open, and the flies could enter their mouths. a. Medical record review for Resident 35 was initiated on 8/25/25. Resident 35 was readmitted to the facility on [DATE]. Review of Resident 35's H&P examination dated 12/20/24, showed Resident 35 had the capacity to understand and make decisions. On 8/30/25 at 1030 hours, an observation was conducted for Residents 32 and 66, and Room B. Residents 32 and 66 were observed asleep in bed. The bathroom shared between Rooms A and B was observed with a hole on the wall located underneath the bathroom sink, and adjacent to the plumbing pipes. b. Medical record review for Resident 32 was initiated on 8/25/25. Resident 32 was admitted to the facility on [DATE]. Review of Resident 35's Progress Note H&P examination dated 7/3/25, showed Resident 32 needed assistance with decision-making capabilities. c. Medical record review for Resident 66 was initiated on 8/25/25. Resident 66 was readmitted to the facility on [DATE]. Review of Resident 66's H&P examination dated 7/15/25, showed Resident 66 had no capacity to understand and make decisions. On 8/30/25 at 1032 hours, an observation was conducted for Residents 25 and 93, and Room A. Residents 25 and 93 were observed asleep in bed. d. Medical record review for Resident 25 was initiated on 8/25/25. Resident 25 was admitted to the facility on [DATE]. Review of Resident 25's H&P examination dated 6/24/25, showed Resident 25 had no capacity to understand and make decisions. e. Medical record review for Resident 93 was initiated on 8/25/25. Resident 93 was readmitted to the facility on [DATE]. Review of Resident 93's SNF H&P examination dated 6/22/25, showed Resident 25 had no capacity to understand and make decisions. On 8/29/25 at 1054 hours, an observation of the bathroom shared between Rooms A and B, and concurrent interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor verified the hole on the wall underneath the bathroom sink. The Maintenance Supervisor stated the maintenance staff had to open the plumbing from the wall last week to fix the clogged toilet but left the hole on the wall open. The Maintenance Supervisor stated the flies could get inside the facility from the opened windows, opened sliding doors, and gaps in the restroom sink.

MINOR (B) 📢 Someone Reported This

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

Minor Issue - procedural, no safety impact

Deficiency F0628 (Tag F0628)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to notify the resident and/or their representative of the transfer and reasons for the transfer, and the facility's bed hold policy in writing when the resident was transferred to the acute care hospital for one of three final sampled residents (Resident 37) reviewed for acute care hospitalization. This failure had the potential for the resident and/or their representative of not knowing about the appeal process and the circumstances of the resident's transfer/discharge should the resident and/or their representative believe the transfer or discharge was inappropriate or involuntary, and to be unaware of their rights to request a bed hold and return to the first available bed should the resident's acute care hospital stay exceed the seven-day bed-hold period. Findings: a. Review of the facility's P&P titled Transfer or Discharge, Facility -Initiated (undated) showed the notice of transfer and discharge is provided to the resident and resident representative as soon as practicable before the transfer and to the long-term care Ombudsman when practicable. Notices are provided in a form and manner that the resident can understand, taking into account the resident educational level, language, communication barriers, and physical or mental impairments. Medical record review for Resident 37 was initiated on 8/26/25. Resident 37 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 37's physician's order dated 8/8/25, showed to transfer Resident 37 to the acute care hospital for evaluation related to a fall. Review of Resident 37's progress notes dated 8/8/25 at 0639 hours, showed Resident 37 was sent to the acute care hospital. Review of Resident 37's Notice of Transfer/discharge date d 8/8/25, showed the transfer location as the acute care hospital and the reason for the transfer was for Resident 37's welfare and Resident 37's needs could not be met in the facility. Under the section for the resident or resident representative signature showed Resident 37 was unable to sign at the time. Further review of Resident 37's medical record failed to show if Resident 37 or their representative were provided with the written notice of transfer when Resident 37 was transferred to the acute care hospital on 8/8/25. Review of Resident 37's H&P examination dated 8/12/25, showed Resident 37 had the capacity to understand and make medical decisions. b. Review of the facility's P&P titled bed Hold and Returns dated October 2022 showed all the residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided with written notice about these policies at least twice: - Notice 1: well in advance of the transfer (e.g. in the admission packet); and - Notice 2: at the time of transfer (or, if the transfer was emergency within 24 hours). Further review of the P&P showed multiple attempts to provide the resident representative with notice too should be documented in cases where the staff were unable to reach and notify the representative timely. Review of Resident 37's Bed Hold Informed Consent showed Resident 37 was transferred to the acute care hospital on 8/8/25, and the resident representative for Resident 37 was notified; however, the informed consent did not show the signature of Resident 37 or their representative on 8/8/25. Further review of the Bed Hold Informed Consent showed, you will have the absence of requesting a seven (7) day bed hold to keep a bed vacant and available for return to this facility. Non-Medi-Cal beneficiaries are responsible for reasonable cost not to exceed the beneficiaries daily room rate. Insurance may or may not cover such charges. Medical will cover the cost of the bed if the residence here of cost has been satisfied for the month, unless we receive return notice from the attending physician that they stay in the hospital is expected to exceed seven days. If you desire this option, the facility must be notified within 24 hours of transfer. Further review of Resident 37's medical record for Resident 37 did not show if Resident 37 or their representative was notified in writing of the facility's bed hold policy when Resident 37 was transferred to the acute care hospital on 8/8/25. On 8/27/25 at 1403 hours, an interview and concurrent medical record review for Resident 37 was conducted with RN 1. RN 1 verified Resident 37 was transferred to the acute care hospital on 8/8/25. RN 1 verified Resident 37's representative was informed regarding the bed hold, however, she was not able to find the documentation if the facility's bed hold policy was provided to Resident 37 or their representative in writing. RN 1 further stated the medical records department kept the transfer notices provided to the residents. RN 1 stated she was not sure how the facility provided the transfer/discharge notices, and bed hold policies in writing, when the resident was not able to sign the document and the resident representative was not available at the time of the transfer. On 8/27/25 1415 hours, an interview and concurrent medical record review for Resident 37 was conducted with the Director of Medical Records. The Director of Medical Records verified there was no signature of Resident 37 and/or their representative on the transfer/discharge notice and bed hold informed consent, when Resident 37 was transferred to the acute care hospital on 8/8/25. The Director of Medical Records further stated she was not able to find documentation if Resident 37 or their representative was provided with the transfer/discharge notice, and the facility's bed hold policy in writing. In addition, the Director of Medical Records stated the facility did not mail or email the facility's bed hold policy and transfer/discharge notice to the residents and/or their representative, when resident was not able to sign the document and their representatives were not available to sign at the time of the transfer. On 8/28/25 at 0954 hours, an interview was conducted with Resident 37. Resident 37 stated he was transferred to the acute care hospital on 8/8/25. When asked if he received the transfer/discharge notification and facility's bed hold policy in writing at the time of the transfer, Resident 37 stated no and he did not remember receiving any paper at the time of the transfer. On 8/28/25 at 1133 hours, an interview with the DON was conducted. The DON was informed and acknowledged the above findings.

MINOR (B)

Minor Issue - procedural, no safety impact

Tube Feeding (Tag F0693)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review and facility P&P review, the facility failed to provide the appropriate care and services for the use of the GT for one of five final sampled residents (Resident 72) and one nonsampled resident (Resident 45) reviewed for the GT feeding. * The facility failed to ensure the GT feeding formula was not stored at bedside and the GT formula label was accurate and matched the physician's orders for Residents 45. * The facility failed to ensure the GT feeding Jevity 1.5 Cal (a calorically dense, high-protein, fiber-fortified liquid formula which provides complete, balanced nutrition) was not left unattended at the bedside for Resident 72. These failures posed the risk of complications related to the use of the GT for Residents 45 and 72.Findings: 1. Review of the facility’s P&P titled Enteral Tube Feeding via Gravity Bag revised 11/2018 showed the following: - Check on the enteral nutrition label against the order before administration. Check the following information: (a) Resident name, ID and room number; (b) Type of formula; (c) Date and time formula was prepared. - On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order. Medical Record Review for Resident 45 was initiated on 8/25/25. Resident 45 was readmitted in the facility on 8/8/25. Review of Resident 45’s Order Summary Report showed a physician's order dated 8/9/25, to administer the bolus enteral feeding with Glucerna 1.5 (type of GT feeding formula), give 237 ml five times a day at 0600, 0900, 1300, 1700, and 2100 hours. Review of Residents 45’s H&P examination dated 8/10/25, showed Resident 45 had no capacity to understand and make decisions. On 8/25/25 at 0925 hours, during the initial tour of the facility, an observation was conducted in Resident’s 45 room. Resident 45 was observed lying in her bed and a bottle of Glucerna 1.5 with 800 ml left in the bottle was observed on the over bed table. The feeding formula bottle was not labeled with resident's name or with the date/time the bottle was open. On 8/25/25 at 1114 hours, an observation and concurrent interview was conducted for Resident 45 with LVN 5. LVN 5 verified Resident 45 was receiving the bolus GT feeding of the Glucerna 1.5. LVN 5 verified the feeding formula bottle on the over bed table was for Resident 45's bolus GT feeding. LVN 5 stated the GT feeding formula bottle should have Resident 45's name and the date/time it was open. On 8/27/25 at 1407 hours, an interview and concurrent medical record review for Resident 45 was conducted with RN 2. RN 2 stated Resident 45 was receiving the bolus GT feeding and the licensed nurses needed to use the GT formula in a can and/or Tetra Pak (aseptic packaging cartons that keep products safe and shelf-stable without refrigeration) for the bolus GT feeding to ensure the resident received the accurate GT feeding amount as ordered. On 8/28/25 at 1506 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were informed and acknowledged the above findings. 2. According to [NAME] Nutrition manufacturer’s Product Information for Jevity 1.5 Cal, under the Preparation of Tube Feeding section, follow healthcare professional instruction for flow rate, volume and need for additional fluids, and care should be taken to prevent contamination during preparation and administration. On 8/25/25 at 0851 hours, during the initial tour of the facility, Resident 72 was observed in bed receiving Jevity 1.5 cal via GT. Another bottle of Jevity 1.5 cal was also observed at bedside. Medical record review for Resident 72 was initiated on 8/25/25. Resident 72 was readmitted to the facility on [DATE]. Review of Resident 72’s Order Summary Report showed a physician’s order dated 6/29/25, to administer Jevity 1.5 Cal at 63 ml/hr for 20 hours to provide 1890 kcal/1260 ml or until dose is completed via GT by enteral feeding pump. On 8/25/25 at 0913 hours, an observation for Resident 72 and concurrent interview was conducted with the Case Manager. The Case Manager verified a bottle of Jevity 1.5 Cal was observed at Resident 72’s bedside. The Case Manager stated when the tube feeding formula was finished, it needed to be replaced with a clean new bottle of the enteral tube feeding formula. The Case Manager stated an extra bottle of tube feeding formula should not be left at the bedside because “anyone can touch it.”

MINOR (B)

Minor Issue - procedural, no safety impact

Staffing Information (Tag F0732)

Minor procedural issue · This affected multiple residents

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Based on interview and facility document review, the facility failed to ensure the posted staffing information included the total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care. In addition, the staffing information did not include actual DHPPD (Direct Care Services Hours Per Patient Day) and CNA DHPPD. This failure had the potential to result in an incomplete staffing information provided to the public.Findings: Review of the AFL 18-27 dated 6/29/18, showed beginning 7/1/18, the facility shall either create a census and DHPPD form or use the Census and Direct Care Service Hours per Patient Day (CDPH 612 and instructions) to report daily DHPPD. The DON (or designee) must sign the form verifying the information is true and accurate. The census and DHPPD form must be typed or printed legible. If the facility chooses to create a form, it must contain substantially similar information to the attached CDPH 612 and instructions. The form must include the following:1. Facility name, address, and license number.2. Patient day date and the patient day start time.3. Total licensed SNF beds.4. Name of administrator and the DON or designee.5. Patient census at start of patient day.6. Scheduled nursing hours and the scheduled DHPPD.7. For the designated census periods: a. Beginning census b. Admissions c. Transfers in d. Other intakes that occurred e. Discharges f. Transfers out g. Deaths, and h. Other decreases that occurred8. Total actual/final nursing hours at the end of each census period.9. Average census.10. The actual/final total nursing hours.11. Actual/Final DHPPD.12. An attestation statement signed by the DON or designee verifying they have reviewed the patient census and nursing hours information and acknowledge the information is true and correct. Review of the facility's document titled Census and Direct Care Service Hours Per Patient Day (DHPPD) for the skilled nursing and subacute unit of the facility from 7/1 to 7/31/25, showed the scheduled direct care service hours, total CNA direct care service hours, beginning patient census, scheduled DHPPD, and scheduled CNA DHPPD. Under the section of the actual direct care service hours showed the average patient census, however, the document did not show the actual total direct care service hours, actual total CNA direct care service hours, actual DHPPD, and actual CNA DHPPD for the month of July 2025 (31 days). On 8/28/25 at 1513 hours, an interview and concurrent facility document review was conducted with the DSD. The DSD verified the above findings and stated the facility had no system that automatically populated the actual hours in the Census and Direct Care Service Hours Per Patient Day form, and she had to manually enter the actual hours at the end of the day. The DSD stated she did not get a chance to enter the actual total direct care service hours, actual total CNA direct care service hours, actual DHPPD, and actual CNA DHPPD for July 2025. On 8/29/25 at 1529 hours, an interview was conducted with the Administrator. The Administrator was informed and acknowledged the above findings.

Aug 2025 4 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0604 (Tag F0604)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 1) was free from physical restraints. * The Facility failed to ensure Resident 1 had a physician's order, consent, and completed assessment prior to the use of the right hand mittens. Additionally, the facility failed to initiate a care plan when the right hand mitten was provided to Resident 1. These failures posed the risk for Resident 1 and her responsible party not to be informed of her treatment and potentially compromising the resident's independence and psychosocial well-being.Findings: Review of the facility's P&P titled Use of Restraints revised 12/2007 showed the restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. Examples of the devices that are/may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, geri-chairs, and lap cushions and trays that the resident cannot remove.Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms.Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following:a. The specific reason for the restraint (as it relates to the resident's medical symptom);b. How the restraint will be used to benefit the resident's medical symptom; andc. The type of restraint, and period of time for the use of the restraint.Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptom(s). Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use. On 8/6/25 at 1320 hours, Resident 1 was observed in bed with bilateral bedrails by the head of the bed and had a mitten on the right hand. On 8/6/25 at 1325 hours, an interview was conducted with CNA 2. CNA 2 stated Resident 1 had been using the right hand mitten to prevent the resident from pulling her tracheostomy. Medical record review for Resident 1 was initiated on 8/6/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 5/29/25, showed Resident 1 had no capacity to understand and make decisions. Review of Resident 1's MDS assessment dated [DATE], showed the resident had no functional limitation in her range of motion in both upper and lower extremities. Review of Resident 1's Health Status Notes dated 8/1/25 at 1115 hours, showed the resident had hand mitten on. Review of Resident 1 Order Summary Report dated 8/6/25, failed to show a physician's order for Resident 1's use of the right hand mittens. Further review of Resident 1's medical records failed to show documentation if Resident 1 was assessed and any least restrictive measures were implemented prior to the application of the right hand mitten. Additionally, there was no care plan problem initiated when Resident 1 was provided with the right hand mitten. On 8/6/25 at 1441 hours, an interview and a concurrent record review was conducted with RN 1. RN 1 verified Resident 1's medical record failed to show a consent was obtained, an assessment was completed, and the least restrictive measures were provided prior to the use of the right hand mitten. RN 1 also verified a care plan was not developed to address Resident 1's use of the right hand mitten. On 8/8/25 at 1035 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated when she went to visit Resident 1, Resident 1 already had a right hand mitten on. Family Member 1 further stated she did not give any consent for the staff to apply the right hand mitten to Resident 1. On 8/8/25 at 1145 hours, an interview was conducted with the Administrator and DON. The Administrator and DON was informed and acknowledged the above findings.

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to develop the comprehensive plan of care to reflect the individualized respiratory care needs for one of five sampled residents. * The facility failed to ensure a plan of care was developed to address Resident 1's episodes of pulling out the tracheostomy tube, putting the nasal cannula in the mouth, biting the cannula, and chewing the oxygen tubing. This failure had the potential for not providing Resident 1 the appropriate, consistent, and individualized care and negatively impact the resident's health and well-being.Findings: Review of the facility's P&P titled Care Plan (undated) showed the facility develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs. The comprehensive care plan has been designed to:a. Incorporate identified problem areas;b. Incorporate risk factors associated with identified problems;c. Build on the resident's strengths;d. Reflect treatment goals and objectives in measurable outcomes;e. Identify the professional services that are responsible for each element of care;f. Prevent declines in the resident's functional status and/or functional levels; andg. Enhance the optimal functioning of the resident by focusing on a rehabilitation program. Medical record review for Resident 1 was initiated on 8/6/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 5/29/25, showed Resident 1 had no capacity to understand and make decisions. The H&P examination further showed Resident 1 had tracheostomy and using supplemental oxygen. Review of Resident 1's Health Status Notes showed the following:- dated 7/27/25 at 1827 hours, resident self-decannulated; - dated 7/28/25 at 0112 hours, since initial night rounds resident was observed biting own cannula multiple times and had caused a displacement of the oxygen;- dated 7/28/25 at 0213 hours, resident was observed chewing the oxygen tubing; - dated 7/30/25 at 1815 hours, the RT observed a white cap in the resident's back of the throat; however, two other RT came to help and saw nothing;- dated 7/30/25 at 1837, the RT reported about the patient possibly chewing and swallowing the trach lavage port;- dated 8/1/25 at 1115 hours, Resident 1's tracheostomy tube was found halfway out; and- dated 8/2/25 at 1429 hours, the white cap were found on 7/31/25 in the resident's mouth. Review of Resident 1's plan of care failed to show if the facility developed a care plan problem to address resident's behavior of pulling out the tracheostomy tube, putting nasal cannula in the mouth, biting the cannula, and chewing the oxygen tubing. On 8/6/25 at 1120 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated when she visited Resident 1 on 7/27/25 at 1730 hours, Resident 1 was observed with excessive respiratory secretion and coughing more than usual. Family Member 1 stated she called the RT to suction the resident. The RT came and found Resident 1's tracheostomy tube was out and did not know for how long. Family Member 1 stated the RT was unable to put the tracheostomy tube back because the stoma had closed. Family Member 1 further stated when she visited Resident 1 on 7/31/25, she observed Resident 1 was chewing on something. She had called for the RT to check the resident and found a piece of white cap inside the resident's mouth. On 8/6/25 at 1441 hours, an interview and a concurrent record review was conducted with RN 1. RN 1 verified resident got decannulated on 7/27/25. RN 1 verified Resident 1's plan of care failed to show a care plan was developed to address Resident 1's pulling out the tracheostomy tube, putting nasal cannula in the mouth, and biting own cannula, and chewing the oxygen tubing. On 8/6/25 at 1510 hours, an interview and a concurrent record review was conducted with the DON. The DON verified Resident 1's Health Status Notes as above and there was no care plan developed to address the concerns regarding Resident 1's respiratory supplies. The DON stated a care plan should have been developed to ensure the appropriate care was provided for Resident 1. On 8/8/25 at 1145 hours, an interview was conducted with the Administrator and DON. The Administrator and DON was informed and acknowledged the above findings.

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the necessary care and services was provided to one of five sampled residents (Resident 1) who was at risk for fall. * The facility failed to notify the physician and responsible party, and initiate a care plan when Resident 1 had an incident where her head was found hanging on the bed. This failure had the potential for the delay in providing the necessary care and services and posed a risk for Resident 1 to sustain serious injury.Findings: Review of the facility's P&P titled Accidents and Incidents - Investigating and Reporting (undated) showed all accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The following data, as applicable, shall be included on the Report of Incident/Accident form:a. The date and time the accident or incident took place;b. The nature of the injury/illness (e.g., bruise, fall, nausea, etc.);c. The circumstances surrounding the accident or incident;d. Where the accident or incident took place;e. The name(s) of witnesses and their accounts of the accident or incident; Review of Facility's P&P titled Change in a Resident's Condition or Status revised 12/2016 showed the facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and /or status. The nurse will notify the resident's Attending Physician or physician on call when there has been an accident or incident involving the resident. Review of the facility's P&P titled Falls and Fall Risk, Managing revised on 03/2018 showed based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. The section for Resident-Centered Approaches to Managing Falls and Fall Risk showed the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. Medical record review for Resident 1 was initiated on 8/6/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 5/29/25, showed Resident 1 had no capacity to understand and make decisions. On 8/7/25 at 1147 hours, an interview was conducted with CNA 1. CNA 1 stated on 7/29/25, he remembered Resident 1 was leaning towards the right side of the bed and the RT asked for his assistance to reposition Resident 1. CNA 1 thinks the medication nurse was aware. When asked for Resident 1's position, CNA 1 stated the head and chest towards the right side, leaning close towards the bed. CNA 1 further stated he did not remember everything. On 8/7/25 at 1200 hours, an interview was conducted with LVN 4. LVN 4 stated Resident had no episode of fall in his shift and did not hear or received a report of Resident 1 falling. On 8/7/25 at 1205 hours, a telephone interview was conducted with Family Member 1. According to Family Member 1, she was informed by a family member who stated, Resident 1 was left with her head hanging on the floor and the legs were still on the bed on 7/27/25 at approximately 1840 hours. Family Member 1 further stated she was not informed of the incident until 8/6/25. On 8/7/25 at 1357 hours, an interview was conducted with Family Member 2 who visited a resident in the same room as Resident 1. Family Member 2 stated on 7/29/25 as he walked in the room, he saw a medical personnel went out of the room. He observed Resident 1 with her head hanging off the bed and touching the floor. Family Member 2 stated no one had returned to the room after 10 minutes, and the resident head was still hanging; he thought the medical personnel called for help for the resident. Family Member 2 further stated he went out the door to call for someone to help Resident 1. Family member 2 stated two facility staff came in to assist the resident. Family Member 2 further stated he reported the incident to the Administrator a day or two after, then to the DON the following day. Review of Resident 1's Health Status Notes showed the following:- dated 8/6/25 at 1932 hours, Family Member 1 reported an incident to the nurse. According to Family Member 1 she was told by a visitor of an incident where Resident 1's head tilted downwards and dangling from the bed, after several minutes the facility staff came and repositioned Resident 1 back to bed in safe position. The note further showed the RN and LVN completed a full body assessment and there were no new findings to report;- dated 8/6/25 at 1951 hours, the nurse was told by Family Member 1 Resident had a fall on a Tuesday (7/29/25) evening around 1900 hours. The note further showed a body assessment was performed on Resident 1 and there were no new visible wounds, swelling or bruising; and- dated 8/6/25 2100 hours, a new order was received from the physician for Resident 1 to go to the acute care hospital for further evaluation of the neck. Further review of Resident 1's medical record failed to show documentation of a fall incident on either 7/27/25 or 7/29/25. In addition, the medical record failed to show if the physician and responsible party were notified, and a care plan was initiated when Resident 1 had an incident where her head was found hanging on the side of the bed. On 8/7/25 at 1610 hours, an interview was conducted with the Administrator. The Administrator stated he was informed by Family Member 2 about Resident 1 was observed with the head hanging on the floor. The Administrator stated Family Member 2 told him Resident 1 was assisted already by the nurses. The Administrator further stated he checked, and the resident was in bed already. The Administrator acknowledged he did not check or asked a nurse of what had happened or if Resident 1 was assessed or the physician and family was informed. On 8/8/25 at 1145 hours, an interview was conducted with the Administrator and DON. The Administrator and the DON was informed and acknowledged the above findings.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care/services were performed prior to the use of the bedrails for one of five sampled resident (Resident 1). * The facility failed to ensure Resident 1 had a physician's order, consent, and assessment prior to the use of the bilateral upper bedrails. Additionally, the facility failed to initiate a care plan when the bilateral upper bedrails were provided to Resident 1. These failures had the potential to put Resident 1 at risk for serious injury.Findings: Review of the facility's P&P titled Proper Use for Bed Rails revised 8/2022 showed the use of the bed rails is prohibited unless the criteria for use of the bed rails have been met. The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. Prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted. The resident assessment also determines potential risks to the resident associated with the use of bed rails, including the following:a. Accident hazards:(1) The resident could attempt to climb over, around, between, or through the rails, or over the foot board; and/or (2) A resident or part of his/her body could be caught between rails, the openings of the rails, or between the bed rails and mattress.b. Restricted mobility:(1) Hinders residents from independently getting out of bed thereby confining them to their beds; (2) Creates a barrier to performing routine activities such as going to the bathroom or retrieving items in his/her room, eating, hydration and/or walking; (3) Decline in resident function, such as muscle functioning/balance; and/or( 4) Skin integrity issues.c. Psychosocial outcomes: (1) Creates an undignified self-image and alters the resident's self-esteem; (2) Contributes to feelings of isolation; and/or (3) Induces agitation or anxiety.Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent:a. The assessed medical needs that will be addressed with the use of bed rails;b. The resident's risks from the use of bed rails and how these will be mitigated;c. The alternatives that were attempted but failed to meet the resident's needs; andd. The alternatives that were considered but not attempted and the reasons. On 8/6/25 at 1320 hours, Resident 1 was observed in bed with the bilateral upper bedrails elevated. On 8/6/25 at 1325 hours, an interview was conducted with CNA 2. CNA 2 stated Resident 1 had been using the bilateral upper bedrails to prevent Resident 1 from falling. Medical record review for Resident 1 was initiated on 8/6/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 5/29/25, showed Resident 1 had no capacity to understand and make decisions. Review of Resident 1's MDS assessment dated [DATE], showed resident had no functional limitation in her range of motion in both upper and lower extremities. Review of Resident 1's Order Summary Report dated 8/6/25, failed to show a physician's order for Resident 1's use of the bilateral upper bedrails. Further review of Resident 1's medical records failed to show documentation if Resident 1 was assessed and any least restrictive measures were implemented prior to the application of the bilateral upper bedrails. Additionally, there was no care plan problem initiated to address Resident 1's use of the bilateral upper bedrails. On 8/7/25 at 1426 hours, an interview and concurrent record review was conducted with the DON. The DON verified Resident 1's medical record failed to show documentation of the assessment, physician's order, and informed consent prior to Resident 1's use of the bilateral upper bedrails. On 8/8/25 at 1145 hours, an interview was conducted with the Administrator and DON. The Administrator and DON was informed and acknowledged the above findings.

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and medical record review, the facility to ensure the safe practices were followed for Resident 1 when the facility failed to provide the required two-person assistance as required during a resident transfer for Resident 1. As a result, Resident 1 sustained an assisted fall and an abrasion to the left upper back. This failure placed Resident 1 at risk for serious injuries. Findings: Medical record review for Resident 1 was initiated on 7/31/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 2/11/25, showed Resident 1 had no capacity to make decisions. Review of Resident 1's Quarterly MDS assessment dated [DATE], showed Resident 1 had severely impaired cognition and was dependent on the facility staff for ADLs care. The MDS assessment further showed Resident 1 required the assistance of two or more facility staff during chair/bed to chair transfer (ability to transfer to and from a bed to a chair) and tub/shower transfer (ability to get in and out of a tub/shower). Review of Resident 1's progress notes dated 7/24/25, showed the CNA was observed on top of the bed, holding Resident 1's left upper arm to prevent the resident from falling completely to the floor. Resident 1's head was protected with cushion to prevent any injury and the was slowly and safely assisted to a laying position on the floor. The progress notes further showed there was an abrasion to the resident's left upper back. On 7/31/25 at 1022 hours, a telephone interview was conducted with CNA 1. CNA 1 was asked about Resident 1's fall incident. CNA 1 stated Resident 1 required total assistance from staff with ADLs care, including the transfers. CNA 1 stated Resident 1 was on the shower bed when she brought the resident back to his room after his shower. CNA 1 stated she asked the other facility staff for help to get the resident transferred back to the bed for almost 30 minutes wait time. CNA 1 stated she then transferred Resident 1 back to the bed by herself by trying to slide the resident from the shower bed to his bed. CNA 1 stated she was aware Resident 1 required the Hoyer lift with two-person assistance for transfers. On 7/31/25 at 1245 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DSD. The DSD stated she observed CNA 1 with Resident 1 on the shower bed, inside the resident's room. The DSD stated she instructed another facility staff to bring the Hoyer lift to Resident 1's room to assist CNA 1 with the transfer. The DSD stated she did not understand why CNA 1 was unable to wait for the staff assistance before attempting to transfer Resident 1 alone. On 8/4/25 at 0955 hours, an interview was conducted with the DON. The DON acknowledged Resident 1 sustained a fall during a transfer from the shower bed to his bed with CNA 1. The DON verified CNA 1 should have waited for a second facility staff to assistance with the transfer as required.

Jul 2025 1 deficiency 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the safe practices were followed for two of four sampled residents (Residents 1 and 2) when: * The facility failed to provide two staff's assistance as required during a mechanical lift for Resident 1. As a result, Resident 1 fell from the mechanical lift and sustained the acute spinal processes fractures in the cervical and thoracic spines. * The facility failed to ensure the facility's P&P for safe transfers was followed when Resident 2's shower bed was not locked during the resident's transfer from bed to the shower bed. These failures resulted in the actual harm for Resident 1 and placed Resident 2 at risk of serious injuries.Findings: Review of the facility's P&P titled Hoyer Lift dated 2001 showed at least two nursing assistants are needed to safely move a resident with a mechanical lift. Prepare the environment: clear an unobstructed path for the lift machine, ensure there is enough room to pivot, position the lift near the receiving surface, and place the lift at the correct height; place the sling under the resident. Visually check the size to ensure it is not too large or too small; lower the sling bar closer to the resident; attach sling straps to sling bar, according to the manufacturer's instructions; make sure the sling is securely attached to the clips and that it is properly balanced; check to make sure the resident's head, neck and back are supported; before the resident is lifted, double check the security of the sling attachment; examine all hooks, clips or fasteners; check the stability of the straps; and ensure the sling bar is securely attached and sound. 1. Medical record review for Resident 1 was initiated on 7/15/25. Resident 1 was admitted to the facility on [DATE], and discharged to an acute care hospital on 6/28/25. Review of Resident 1's Quarterly MDS assessment under Section GG dated 5/13/25, showed Resident 1 was dependent on the staff's assistance for ADL care. Review of Resident 1's Fall Risk assessment dated [DATE], showed Resident 1 was at high risk for falls. Review of Resident 1's Progress Note dated 6/28/25 around 0845 hours, showed the staff was preparing the medications by the medication cart in front of Room A when the staff had witnessed the resident falling from the sling while being transferred to the shower bed via Hoyer lift by one CNA. Review of Resident 1's Progress Note dated 6/28/25 at 1921 hours, showed in subsequent conversation, the CNA reported she had already transferred Resident 1 from the bed to the Hoyer lift sling and was navigating the lift to position the resident to be transferred to the shower bed when through the momentum of the movement, the sling swung enough to tip Resident 1 out of the sling and on to the floor. The LVN reported being at the medication cart with her back at the resident's room preparing the medications when a loud noise and CNA's voice alerted her. The LVN turned around and witnessed the resident falling from the sling and landing directly on the floor on her back. Review of Resident 1's IDT note dated 6/30/25, showed on 6/28/25 around 0845 hours, while the CNA was preparing the resident for the shower, the resident fell from the Hoyer lift. Upon the investigation, according to the CNA, while she was checking the hook of the sling attached to the Hoyer lift, Resident 1 made a big wiggle of her shoulder and body. The sling made a big swing, resulting in Resident 1 falling on the floor. Review of Resident 1's Hospitalist Discharge Summary note from the acute care hospital dated 7/7/25, showed Resident 1 was being lifted with a lift and accidentally dropped on her back. Upon the evaluation in the acute care hospital, Resident 1 was discovered to have the acute spinal processes fractures in the cervical and thoracic spines. On 7/15/25 at 0950 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON was asked about Resident 1's fall from the mechanical lift used during the transfer on 6/28/25. The DON stated CNA 1 was working with the Hoyer lift and had transferred Resident 1 from the bed to the shower bed by herself. The DON stated there must be two people when transferring a resident using the Hoyer lift. CNA 1 told her that she should have called another staff member for help. On 7/15/25 at 1200 hours, Resident 1 was observed lying on a low air-loss mattress and appeared to be overweight. Resident 1 stated she was back from the acute care hospital. Resident 1 stated she fell from the mechanical lift. Resident 1 was asked if the staff were transferring her with a mechanical lift. Resident 1 stated one staff member was trying to transfer her from the bed to the shower bed with the lift and she fell on her back. On 7/15/25 at 1215 hours, an interview was conducted with LVN 1. LVN 1 stated the resident was bedbound and totally dependent on the staff's assistance for care, including transfers. On 7/15/25 at 1240 hours, an interview and concurrent medical record review for Resident 1 was conducted with the MDS Coordinator. The MDS Coordinator stated Resident 1 was totally dependent on the staff's assistance for care and needed two or more people's assistance for transfers. The MDS Coordinator further stated for Resident 1 using a mechanical lift for transfers, there should have had two people transfer the resident. On 7/15/25 at 1530 hours, an interview and concurrent medical record review for Resident 1 was conducted with CNA 1. CNA 1 was asked about Resident 1's fall. CNA 1 stated Resident 1 requested to have a shower, and CNA 1 transferred Resident 1 from the bed to the shower bed using a mechanical lift. CNA 1 stated Resident 1 made a shaking movement when she was lifted and the sling was moving, then the resident was out of the sling. CNA 1 also stated Resident 1 was big and fell on the ground. CNA 1 further stated she did not ask another nurse to help because she thought LVN 3 was in the room. When asked if LVN 3 assisted CNA 1 with the mechanical lift, CNA 1 stated LVN 3 was working with Resident 1's roommate. In addition, CNA 1 stated she was aware Resident 1 needed two people to transfer using a mechanical lift. On 7/15/25 at 1645 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON was asked for a care plan to address the assistance needed for Resident 1's transfers and bed mobility and if there was a plan of care developed status post fall on 6/28/25. The DON was not able to provide any documentation. The DON verified the findings. 2. Medical record for Resident 2 was initiated on 7/15/25. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's care plan dated 3/11/24, showed the resident had ADL self-care performance deficits related to fatigue, limited mobility, limited range of motion, musculoskeletal impairment, and stroke. The care plan showed for the interventions, Resident 2 required total assistance for two persons with transfers. On 7/15/25 at 0845 hours, Resident 2 was observed being transferred from the bed to the shower bed. RNA 1 was observed lifting Resident 2 using a mechanical lift. CNA 2 was standing at the head of the shower bed and CNA 3 on the other side of the shower bed further away from Resident 2. Both CNAs tried to reposition the shower bed. CNA 3 was observed not in close proximity to Resident 2 while RNA 1 was maneuvering the Hoyer lift with the resident in the sling. RNA 1 was observed lowering Resident 2 to the shower bed and the shower bed was observed in an unlocked position. CNA 2 elevated the rail of the shower bed when Resident 2 was lying in the shower bed. The shower bed was observed with little movement while in an unlocked position. On 7/15/25 at 0905 hours, an interview was conducted with RNA 1 and CNA 2. Both RNA 1 and CAN 2 were informed of the observation regarding no other staff monitoring Resident 2 in close proximity while the resident was being transferred in a sling, using a mechanical lift. Both staff members acknowledged they should have had one staff member close to the resident to monitor the resident in a sling while RNA 1 was controlling the mechanical lift. Both staff also acknowledged and stated they should have locked the shower bed while Resident 2 was being transferred to the shower bed. RNA 1 and CNA 2 verified the findings. On 7/15/25 at 1435 hours, an interview was conducted with the DSD. The DSD was asked about the safe transfers for the residents using the mechanical lift. The DSD stated they must have two people transfer the residents using the mechanical lift. One person would be doing the maneuvering and controlling the mechanical lift, and another person needed to touch and monitor the sling and be close to the resident. The DSD stated the shower bed should be in a locked position when transferring the resident to the shower bed.

Jul 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the services to attain or maintain the highest practicable well-being for one of three sampled residents (Resident 1). * Resident 1 made an allegation of abuse on 7/5/25; however, the facility failed to initiate the change of condition assessment and monitoring of Resident 1 every shift for 72 hours. This failure had the potential for the resident to not receive the appropriate care and monitoring to prevent the development of complications and/or delayed medical treatments related to the allegation of abuse. Findings: Review of the facility's P&P titled Acute Condition Changes- Clinical Protocol dated 2001 showed the physician will help identify individuals with a significant risk for having acute changes of condition during their stay. The physician will help identify and authorize appropriate treatments. The staff will monitor and document the resident's progress and responses to treatment, and the physician will adjust treatment accordingly. The physician will help the staff monitor a resident with a recent acute change of condition until the problem or condition has resolved or stabilized. Medical record review for Resident 1 was initiated on 7/7/25. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's H&P examination dated 7/31/24, showed Resident 1 had no capacity to make medical decisions. Review of the facility's SOC 341 form dated 7/5/25, showed Resident 1 had reported an allegation of physical abuse by a CNA. Upon assessment, Resident 1 had a skin tear to the left arm and pain. Review of Resident 1's care plan showed a care plan problem dated 7/5/25, addressing Resident 1's risk for emotional distress related to the allegations of possible physical abuse by a staff. The interventions included to monitor Resident 1 for signs and symptoms of emotional distress. Review of Resident 1's Progress Notes showed a nursing entry dated 7/5/25 at 0800 hours, documenting the CNA reported to the charge nurse that Resident 1 was complaining about the care received on 7/4/25. When the charge nurse went into the room, Resident 1 was noted with a skin tear on the left forearm. Per Resident 1, the CNA was too rough with him. The RN Supervisor was made aware, and the wound care nurse provided the treatment. According to the RN Supervisor, the DON, Administrator, and police were contacted for the suspected abuse. Further review of Resident 1's Progress Notes showed the following nursing entries: - dated 7/5/25 at 1031 hours, documenting the 72-hour monitoring status post suspected victim of physical abuse. - dated 7/6/25 at 0443 hours, documenting Resident 1 was received in bed with no distress noted. Resident 1 was on the monitoring for refusing medications, no episodes noted at this time, resting well, no complaints of pain or discomfort, all needs attended to. - dated 7/6/25 at 1504 hours, documenting Resident 1 was on monitoring for refusal of medications, and had no episodes observed at this time . Continued monitoring will be maintained. - dated 7/8/25 at 0347 hours, documention showed the resident was currently on monitoring for a skin tear on the left forearm with no active bleeding. Further review of Resident 1's Progress Notes failed to show the licensed nurse's entries documenting the monitoring of Resident 1 on 7/6/25 during the 1900 to 0700 hours shift, and on 7/7/25 during the 0700 to 1900 hours shift. Inaddition, review of Resident 1's medical record failed to show the change of condition assessment was initiated when Resident 1 made an allegation of abuse on 7/4/25. On 7/8/25 at 1130 hours, a phone interview was conducted with LVN 2. LVN 2 stated the change of condition assessment was initiated whenever there was a change from the baseline in the resident's condition. LVN 2 stated when there was a change of condition, the change of condition assessment should be completed to ensure the licensed nurses would follow up and monitor the resident every shift for 72- hours. LVN 2 stated a resident's allegation of physical abuse was considered a change of condition for the resident. LVN 2 stated on 7/5/25, she was informed by CNA 2 of her concern of suspected abuse towards Resident 1. LVN 2 stated she did not complete the change of condition assessment for Resident 1 following the allegation of physical abuse and only documented in Resident 1's progress notes. LVN 2 stated the change of condition assessment should have been completed for the resident's allegation of physical abuse to ensure Resident 1 was monitored. On 7/8/25 at 1250 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON was asked about the facility's protocol for an allegation of abuse. The DON stated for the allegation of abuse, the licensed nurse was responsible for completing the facility's internal incident report, the change in condition assessment, and developing a care plan. The DON stated for the abuse victim, a change of condition assessment should be completed, and the resident should be monitored for emotion distress by the licensed nurses, every shift for 72 hours. The DON reviewed Resident 1's medical record and verified the above findings. The DON stated a change of condition assessment for Resident 1's allegation of abuse by the CNA was not completed. On 7/8/25 at 1426 hours, a follow-up interview was conducted with the DON. The DON stated a change of condition was any situation outside of the resident's normal status or baseline. The DON stated when there was a change in condition for a resident, the facility's protocol was to assess the resident and inform the physician and resident's responsible party of the change in condition. The DON stated the documentation for a change in the resident's condition included completing a change of condition assessment. The DON stated the purpose of a change of condition assessment was to ensure the problem would be addressed. The DON further stated the change of condition assessment would initiate the monitoring of the resident on every shift for 72 hours. The DON stated an allegation of abuse was considered a change in condition. On 7/8/25 at 1530 hours, the Administrator and DON were informed and acknowledged the above findings.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 2) was free from the unnecessary medications. * The facility failed to follow the physician's order to hold the midodrine (blood pressure support) medication when Residents 2's SBP was greater than 120 mmHg. This failure had the potential for Resident 2 to develop significant side effects. Findings: Review of the facility's P&P titled Administering Medications revised 4/2019 showed the medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with the prescriber's orders, including any required time frame. The following information is checked/verified for each resident prior to administering the medications: a. allergies to medications; and b. vital signs, if necessary. Medical record review for Resident 2 was initiated on 7/7/25. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 2's plan of care showed a care plan problem dated 5/13/25, addressing Resident 2's hypotension. The interventions showed to administer midodrine 10 mg as ordered. Review of Resident 2's Order Summary Report dated 7/8/25, showed a physician's order dated 5/12/25, to administer midodrine 10 mg by mouth every 12 hours for hypotension and hold the medication for the SBP greater than 120 mmHg. Review of Resident 2's MAR for 6/2025 and 7/2025 showed documentation Resident 2 was administered midodrine 10 mg on the following dates and times when Resident 2's SBP was greater than 120 mmHg: - On 6/1/25 at 0900 hours, when Resident 2's SBP was 121 mmHg. - On 6/11/25 at 2100 hours, when Resident 2's SBP was 122 mmHg. - On 6/18/25 at 0900 hours, when Resident 2's SBP was 122 mmHg. - On 6/28/25 at 0900 hours, when Resident 2's SBP was 121 mmHg. - On 7/4/25 at 0900 hours, when Resident 2's SBP was 122 mmHg. - On 7/5/25 at 2100 hours, when Resident 2's SBP was 132 mmHg. On 7/8/25 at 1130 hours, a telephone interview was conducted with LVN 2. LVN 2 stated for the administration of the BP medications to the residents, the licensed nurse would check the resident's BP prior to administering the BP medication. LVN 2 stated if the BP reading was within the parameters as ordered by the physician, LVN 2 would then administer the medication. LVN 2 stated if the BP reading was outside of the ordered parameters, the medication would be held. LVN 2 further stated after the administration of the medication, she would document in the MAR. When asked, LVN 2 stated a check mark in the MAR indicated the medication was administered to the resident on the indicated date and time. On 7/8/25 at 1324 hours, an interview and concurrent medical record review for Resident 2 was conducted with the DON. The DON stated for the administration of the BP medications, the licensed nurse should check the physician's order to determine if there were any BP parameters. The DON stated if there were ordered BP parameters, the licensed nurse was expected to obtain the resident's BP and administer the BP medication if the BP reading was within the ordered parameters. The DON further stated after the administration of the medication, the licensed nurse was expected to document the medication administration in the MAR. The DON stated the check marks in the MAR indicated the medication was administered to the resident. The DON reviewed Resident 2's medical record and stated Resident 2 was administered the midodrine medication for low BP. The DON reviewed Resident 2's MAR for 6/2025 and 7/2025 and verified the above findings. The DON stated the midodrine medication should have been held on the above dates and times for the documented SBP readings. On 7/8/25 at 1530 hours, the Administrator and DON were informed and acknowledged the above findings.

Jul 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary G-tube care and services for three of six sampled residents (Residents 4, 5, and 6 ) reviewed for enteral feeding. * The facility failed to ensure Residents 4 and 5's G-tube medication ports were kept clean and patent. * The facility failed to ensure the physician's orders to flush enteral feeding with 30 ml before and after medication were followed for Resident 6. These failures posed the risk of developing complications related to enteral feeding. Findings: Review of the facility's P&P titled Maintaining Patency of a Feeding Tube (Flushing) revised 11/2018 showed the purpose of this procedure is to maintain patency of a feeding tube. The person performing this procedure should record the following information in the resident's medical record: 1. The date and time the procedure was performed. 2. Verification of tube placement. 3. Total amount used to flush tube. 4. The name and title of the individual(s) who performed the procedure. 5. All assessment data obtained during the procedure. 6. How the resident tolerated the procedure. 1. Medical record review for Resident 4 was initiated on 7/2/25. Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 4's Order Summary Report showed the following orders: - dated 11/24/20, may change the G-tube feeding administration sets with each bottle as needed. On 7/2/25 at 0850 hours, an observation and concurrent interview for Resident 4 was conducted with CNA 1. Resident 4 was observed lying in bed with a G-tube feeding. The medication port on the G-tube tubing was observed with black substance inside the tubing. CNA 1 stated she did not know about it and verified the findings. On 7/2/25 at 0930 hours, an observation and concurrent interview for Resident 4 was conducted with LVN 1. Resident 4 was observed lying in bed with a G-tube feeding. The medication port on the G-tube tubing was observed with black substance inside the tubing. LVN 1 stated she did not give the medications to Resident 4 this morning and stated the tubing's medication port should be kept clean and needed to be changed. LVN 1 verified the findings. 2. Medical record review for Resident 5 was initiated on 7/2/25. Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 5's H&P examination dated 3/23/25, showed Resident 5 had a G-tube. On 7/2/25 at 1120 hours, an observation and concurrent interview for Resident 5 was conducted with LVN 5. Resident 5 was observed sitting up in bed with a G-tube feeding. The G-tube tubing, specifically the medication port, was observed with black substances inside the tubing. LVN 5 stated the black substances were possibly from the medication stains. LVN 5 stated the G-tube tubing should be changed or kept clean. LVN 5 verified the findings. 3. Medical record review for Resident 6 was initiated on 7/2/25. Resident 6 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 6's physician's order dated 7/30/24, showed the enteral tubing: flush tubing with 50 ml of water before and after tube feeding two time a day. May use carbonated liquid if water flush is ineffective as needed. Review of Resident 6's physician's order dated 4/15/25, showed the enteral tubing: flush tubing with 30 ml of water before and after medications. Review of Resident 6's MAR for 4/2025 failed to show documentation Resident 6's G-tube was flushed with 30 ml of water before and after medications as ordered by the physician on 4/15/25. Review of Resident 6's physician's order dated 5/14/25, showed to discontinue the order to flush the enteral tubing with 30 ml of water before and after medications. Review of Resident 6's MAR for 5/2025 failed to show documented evidence the staff had flushed the enteral feeding with 30 ml of water before and after the medication administration from 5/1 to 5/10/25. On 7/2/25 at 1300 hours, an interview and concurrent medical record review for Resident 6 was conducted with RN 2. RN 2 stated the admission orders were clarified with Resident 6's physician and carried out by the admission nurse. On 7/2/25 at 1400 hours, an interview and concurrent medical record review for Resident 6 was conducted with the DON. The DON stated there was a physician's order to flush tubing with 30 ml of water before and after medications on 4/15/25, and the order to discontinue was received on 5/14/25. The DON stated the licensed nurse who entered the order should have entered the frequency for the flush and clarified the order with Resident 6's physician. The DON was unable to locate documentation of the 30 ml flush before and after medication from 4/15/25 to 5/9/25. The DON acknowledged the licensed nurse should have documented when they flushed the water and followed the physician's order. Resident 6 was sent out to the acute care hospital on 5/10/25. The DON stated the purpose of the water flush before and after medication administration was to maintain the patency and prevent clogging of the enteral tubing. The DON verified and acknowledged the above findings.

Jun 2025 4 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0604 (Tag F0604)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medial record review, and facility P&P review, the facility failed to ensure one of nine sampled residents (Resident 5) was provided an environment free from the physical restraints. * Resident 5 was observed multiple times with a soft mitten restraint to his right hand. There was no active physician's order, updated informed consent, and updated care plan for the soft mitten on Resident 5's right hand. * There was no appropriate assessment completed prior to placing a soft mitten restraint on Resident 5. * Resident 5 was not monitored for the use of the restraints. These failures had the potential to negatively affect Resident 5's physical mobility and psychosocial well-being. Findings: Review of the facility's P&P titled Use of Restraints revised 4/2017 showed restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives been tried. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the lease amount of time necessary, and the ongoing re-evaluation for the need for restraints will be documented. Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. On 6/19/25 at 1259 hours, an observation was conducted of Resident 5 in his room. Resident 5 was lying in his bed with a soft mitten restraint to his right hand. Medical record review for Resident 5 was initiated on 6/19/25. Resident 5 was admitted to the facility on [DATE]. Resident 5 had diagnoses including CVA and left-sided hemiparesis. Review of Resident 5's Physician's Order dated 3/24/17, showed an order to apply the right hand mitten as needed related to pulling out medical devices and release every two hours to check for CMS (circulatory, motor, sensory). Review of Resident 5's H&P examination dated 2/23/25, showed Resident 5 had no capacity to understand and make decisions. Review of Resident 5's Care Plan Report dated 3/14/25, showed for the right hand mitten as needed related to pulling our medical devices and to release every two hours to check for CMS was resolved on 5/31/17. Review of Resident 5's Informed Consent Verification (undated) showed the physical restraint for the right-hand mitten was discontinued on 5/31/17. Review of Resident 5's MAR for June 2025 did not show Resident 5 was currently being monitored for the use of the soft mitten restraint. On 6/19/25 at 1425 hours, a concurrent observation, interview, medical record review was conducted with LVN 1. When asked why Resident 5 had a soft mitten present on his right hand, LVN 1 stated I think its because he pulls and grabs things. When asked what the policy was for a soft mitten restraint, LVN 1 stated the policy would be to obtain a physician's order, consent from the family, and to check for circulation and discoloration. When asked how long Resident 5 was wearing the soft mitten restraint, LVN 1 stated they were not sure, and only saw a care plan from two years ago, and consents and discontinued orders were from 2017. LVN 1 verified Resident 5 had no active physician's order, an active informed consent, and updated care plan for the use of the soft mitten restraints. LVN 1 further verified there was currently no monitoring conducted for Resident 5's use of the restraints. On 6/20/25 at 1511 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated the soft mittens were considered restraints, and the policy for the use the restraints included requiring for a physician's order, consent from the resident's family, care plan, and monitoring the limb by removing the restraint every two hours to assess for circulation, skin discoloration, and mobility. RN 1 verified the findings. On 6/23/25 at hours, an interview was conducted with the Administrator. The Administrator acknowledged the above findings.

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the reporting of a reasonable suspicion of a crime was completed in a timely manner for one of nine sampled residents (Resident 2). * The facility failed to ensure Resident 2's allegation of neglect against RT 1 was reported timely to the CDPH L&C Program and local law enforcement agency. This failure had the potential for abuse and injury to go unreported and uninvestigated timely. Findings: Review of the facility's P&P titled Abuse Investigation and Reporting dated 1/1/24, showed the following: - All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility Administrator, or his/her designee, to the following persons or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. The P&P further showed alleged abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported within two hours if the alleged events have resulted in serious bodily injury .if events that cause the allegation do not involve abuse or not resulted in serious bodily injury, the report must be made within twenty-four hours. Review of the facility's SOC 341 form dated 6/9/25, showed there was an allegation of neglect when RT 1 allegedly did not provide Resident 2 a breathing treatment and disconnected the oxygen concentrator. Medical record review for Resident 2 was initiated on 6/20/25. Resident 2 was admitted to the facility on [DATE]. On 6/20/25 at 1418 hours, a telephone interview was conducted with the RT Supervisor. The RT Supervisor stated RT 2 notified her about the neglect allegation against RT 1 via text on 6/3/25. The RT Supervisor confirmed the incident reported regarding RT 2 was negligence and abuse. The RT Supervisor stated the abuse allegation should have been reported immediately and the timeframe for reporting was as soon as possible, but no later than 24 hours. The RT Supervisor also confirmed reporting six days after the incident occurred was considered late reporting. On 6/20/25 at 1511 hours, an interview was conducted with RN 1. RN 1 confirmed leaving a respirator disconnected when a resident (Resident 2) needed it was considered a neglect. RN 1 stated the Administrator needed to be notified regarding the neglect abuse allegation immediately. RN 1 confirmed the neglect allegation was reported late. On 6/23/25 at 1000 hours, an interview was conducted with the ADON. The ADON verified any abuse or neglect allegation needed to be reported right away. On 6/23/25 at 1043 hours, an interview was conducted with the Administrator. The Administrator stated he was informed of the neglect allegation on 6/9/25. The Administrator verified the neglect allegation was reported late.

MINOR (B) 📢 Someone Reported This

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

Minor Issue - procedural, no safety impact

Deficiency F0573 (Tag F0573)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to fulfill a medical record request in a timely manner for one of nine sampled residents (Resident 3). This failure had the potential to violate the resident's rights. Findings: Review the facility's P&P titled Resident/Resident Representative Access to Protected Health Information dated 11/2017 showed the following: 1. The facility shall allow an adult resident or resident representative to inspect or receive copies of his/her protected health information (PHI) in a designated record set with an oral or written request. 2. The requested PHI shall be provided timely, when appropriate as follows: Note: Facility may withhold photocopies if resident or resident representative fails to pay charges that are due after giving due notice. a. discharged resident: Providing copies: within 15 calendar days after receipt of written request. Closed medical record review for Resident 3 was initiated on 6/19/25. Resident 3 was admitted to the facility on [DATE], and discharged from the facility on 4/9/25. Review of the facility's document titled General Record Release Log dated May 2025 showed the following: - dated 5/6/25, Resident 1's legal services requested for the resident's medical records - dated 6/11/25, date approved by Administrator - dated 6/11/25, medical records reviewed by DNS (Director of Nursing Services) prior to copy - dated 6/19/24, date provided or mailed On 6/19/25 at 1350 hours, an interview and concurrent facility document review was conducted with the Medical Records Supervisor. The Medical Records Supervisor stated the timeline for processing the requests for the medical records for a resident would be 48 business hours and 15 business days if the request was from a responsible party. The Medical Records Supervisor verified the medical records request for Resident 3 were provided late (45 calendar days, and 32 business days). On 6/23/25 at 1631 hours, an interview was conducted with the Administrator. The Administrator acknowledged the above findings.

MINOR (B) 📢 Someone Reported This

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

Minor Issue - procedural, no safety impact

Respiratory Care (Tag F0695)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the respiratory services were provided as ordered for one of nine sampled residents (Resident 2). This failure had the potential to result in negative health outcomes for the resident. Findings: Review of the facility's P&P titled Oxygen Administration with revision date of October 2010 showed to adjust the oxygen delivery device on the resident (i.e., mask, nasal cannula and/or catheter). Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. Lastly, to observe the resident upon setup and periodically thereafter to be sure oxygen is being tolerated. Medical record review for Resident 2 was initiated on 6/20/25. Resident 2 was admitted to the facility on [DATE], with diagnoses including acute respiratory distress syndrome and chronic respiratory failure with hypoxia (lack of oxygen). Review of Resident 2's Order Summary Report dated 6/16/25, showed an order for Ipratropium-Albuterol (breathing treatment medication) Inhalation Solution 0.5-2.5 3 mg/3 ml, one vial inhale orally via nebulizer every four hours for acute respiratory distress syndrome. Review of Resident 2's MAR for June 2025 showed the Ipratropium-Albuterol Inhalation Solution 0.5-2.5 3 mg/3 ml was not administered to Resident 2 on 6/9/25 at 1300 hours as ordered. On 6/20/25 at 1418 hours, a telephone interview and concurrent medical record review was conducted with the RT Supervisor. The RT Supervisor verified Resident 2 did not receive the Ipratropium-Albuterol breathing treatment on 6/9/25 at 1300 hours and verified the MAR had a blank entry. On 6/20/25 at 1511 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 2 was not given his breathing treatment per the MAR on 6/9/25 at 1300 hours. On 6/23/25 at 1002 hours, an interview and concurrent medical record review was conducted with the ADON. The ADON verified Resident 2 was not given his breathing treatment per the MAR on 6/9/25 at 1300 hours On 6/23/25 at 1043 hours, an interview was conducted with the Administrator. The Administrator verified the findings.

Jun 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0628 (Tag F0628)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the written information on the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which received such requests to the residents and/or their representatives; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request upon the resident transferring to an acute care hospital for three of three sampled residents (Residents 1, 2, and 3) reviewed for discharge. This failure had the potential for the residents to not receive accurate information to determine if they wanted to appeal the transfer or discharge and return to the facility. Findings: Review of the facility's P&P titled Transfer or Discharge Documentation revised December 2016 showed if a resident exercises his or her right to appeal a transfer or discharge notice he or she will not be transferred or discharged while the appeal is pending, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. When a resident is transferred or discharged from the facility, an appropriate notice is provided to the resident and/or legal representative. a. Closed medical record review for Resident 1 was initiated on 5/23/25. Resident 1 was admitted to the facility on [DATE], and transferred to the acute care hospital on 4/27/25. Review of Resident 1's H&P examination dated 3/4/25, showed the resident did not have the capacity to make decisions. Review of Resident 1's medical record failed to show documented evidence the resident and/or their family member wereprovided the written information of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests. On 5/30/25 at 1216 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified she filled out the Notice of Transfer/Discharge form; however, she did not mail or provide a copy to the family or the resident at the time of the transfer or after the transfer. RN 2 further stated she did not know if someone else provided a written notice or had mailed the copy to the family member. On 6/4/25 at 1038 hours, a telephone interview was conducted with Family Member 3. Family Member 3 stated she did not receive any written information about the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives the requests. Family Member 3 further stated she was not aware that the facility would not readmit the resident to the facility after discharged to the acute care hospital. Family Member 3 stated Resident 1 was in the acute care hospital until she could find a facility to accept the resident. b. Medical record review for Resident 2 was initiated on 6/4/25. Resident 2 was admitted to the facility on [DATE], and transferred to acute care hospital on 5/2/25. Resident 2 returned to the facility on 5/16/25. Review of Resident 2's H&P examination dated 5/2/25, showed the resident needed assistance in the capacity to make decisions. Review of Resident 2's medical record failed to show documented evidence the resident was provided the written information of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which received such requests. On 6/3/25 at 1530 hours, an interview and concurrent medical record review was conducted with the Subacute Supervisor. The Subacute Supervisor verified Resident 2 was transferred to the acute care hospital on 5/2/25. The Subacute Supervisor verified the Notice of Transfer/Discharge form was filled out; however, it was not signed by the resident or their representative. The Subacute Supervisor stated he did not mail or provide the copy to the resident at the time of the transfer or after the transfer. The Subacute Supervisor further stated he did not know if the MRD provided the written notice of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests or had mailed the copy to the resident or resident's representative. c. Medical record review for Resident 3 was initiated on 6/4/25. Resident 3 was admitted to the facility on [DATE], and transferred to theacute care hospital on 4/6/25. Resident 3 returned to the facility on 4/18/25. Review of Resident 3's H&P examination dated 3/4/25, showed the resident did not have the capacity to make decisions. Review of Resident 3's medical record failed to show documented evidence the resident and/or their representative was provided the written information of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests. On 6/3/25 at 1121 hours, an interview and a concurrent medical record review was conducted with the Subacute Supervisor. The Subacute Supervisor verified Resident 3 was transferred to the acute care hospital on 4/6/25, and Notice of Transfer/ Discharge form was filled out; however, it was not signed by the resident's representative. The Subacute Supervisor stated the original copy of the Notice of Transfer/Discharge form was sent to the acute care hospital and the duplicate copy was left in the resident's medical record. The Subacute Supervisor stated he did not mail or provide the copy to the resident'srepresentative at the time of the transfer or afterthe transfer. The Subacute Supervisor further stated he did not know if the resident's representative was provided with a written notice about a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests, or if the MRD had mailed a copy to the resident representative. On 6/3/25 at 1325 hours, an interview was conducted with the MRD. The MRD verified Resident 1 was transferred to acute care hospital on 4/27/25, and a copy of the Notice of Transfer/ Discharge form was in Resident 1's medical record. The MRD verified Resident 2 was transferred to the acute care hospital on 5/2/25, and a copy of the Notice of Transfer/ Discharge form was in the resident's medical record. The MRD verified Resident 3 was transferred to the acute care hospital on 4/6/25, and a copy of the Notice of Transfer/Discharge form was in the resident's medical record. The MRD stated the original copy of the Notice of Transfer/Discharge form was sent to the acute care hospital when Residents 1, 2, and 3 were transferred. The MRD further stated the duplicate copy was filed in Residents 1, 2 and 3's medical records. The MRD stated she did not provide any written copy or mail a copy of the Notice of Transfer/Discharge form to Residents 1, 2 and 3 and/or their responsible parties. On 6/3/25 at 1505 hours, a telephone interview was conducted with Family Member 2. Family Member 2 stated he was not provided the written notice about a statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests. Family Member 2 further stated the transfer to the acute care hospital was not always clear. The facility would notify him when the resident was already transferred and sometimes, he believed the transfer to the acute care hospital might not have been necessary. On 6/3/25 at 1624 hours, an interview was conducted with the Administrator. The Administrator was informed and acknowledged the above findings.

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to follow their post fall protocol for two of 10 sampled residents (Residents 8 and 9). * Resident 8 experienced the falls on 4/20 and 4/22/25. The facility did not implement additional interventions for fall prevention after Resident 8's second fall on 4/22/25. Additionally, Resident 8's post fall neurological assessments were not completed as ordered for the fall on 4/20/25. * Resident 9's post fall neurological assessments were not completed as ordered for falls on 5/16 and 5/29/25. These failures had the potential for the residents to experience additional preventable falls and a potential delay in identification and interventions for post fall head injuries. Findings: 1. Review of thefacility's P&P titled Falls and Fall Risk, Management revised March 2018 showed if fall recursdespite initial interventions, staff will implement additional interventions or indicate why the current approach remains in relevant. Closed medical record review for Resident 8 was initiated on 5/8/25. Resident 8 was admitted to the facility on [DATE], and transferred to an acute care hospital on 4/23/25. a. Review of Resident 8's Health Status Note dated 4/20/25 at 0835 hours, showed at 0750 hours, the resident was found on the floor with his head by his nightstand. Review of Resident 8's Health Status Note dated 4/22/25 at 2215 hours, showed RN 1 was informed by a staff thatthe resident was found on the floor. Review of Resident 8's Health Status Note dated 4/23/25 at 0850 hours, showed the resident was found on the floor. Review of Resident 8's Care Plan Report showed a focus care plan problem initiated on 4/18/25, for a high risk for falls. The care plan problem was revised on 4/20/25, for the resident's bed to be at the lowest position, and for floor mats to be utilized. The care plan problem was revised on 4/21 and 4/23/25, after the resident's third fall. Review of Resident's 8 medical record failed to show additional fall prevention interventions were implemented or indicate showingwhy the current approach remained in use as per the facility's P&P after the resident's second fall on 4/22/25. On 6/4/25 at 1118 hours, an interview and concurrent medical record review was conducted with the Subacute Supervisor. The Subacute Supervisor verified Resident 8's medical record failed to show additional fall prevention interventions were implemented after the resident's second fall on 4/22/25. On 6/4/25 at 1154 hours, a telephone interview was conducted with RN 1. RN 1 stated she did not recall the resident and the falls specifically, but stated her process was to document fall interventions. b. Review of Resident 8's Health Status Note dated 4/20/25 at 0835 hours, showed at 0750 hours, the resident was found on the floor with his head by his nightstand. The Health Status Note further showed the physician was notified and ordered a 72-hour neurological assessment. Review of Resident 8's Physicians' Orders showed an order dated 4/20/25, for post-fall neurological assessments to be completed for 72 hours. Review of Resident 8's Health Status Note dated 4/20/25 at 1241 hours, showed the resident was transferred to the acute care hospital for post fall evaluation due to new complaint of a headache. Review of Resident 8's Health Status Note dated 4/20/25, showed at 1700 hours, the resident returned to the facility. Review of Resident 8's Neuro Assessment form initiated 4/20/25, showed the post fall neurological assessments were to be completed at the scheduled times from 4/20/25 at 0750 hours, through 4/22/25 at 2020 hours, for a total of 48 hours. The log showed Resident 8 was at the acute care hospital for the scheduled assessments at 1420 and 1620 hours. The next scheduled neurological assessment at 2020 hours, was not completed when Resident 8 returned to the facility at 1700 hours. In addition, the Neuro Assessment log schedule only was up to 48 hours, not 72 hours, as per the physician's order. On 6/4/25 at 1056 hours, an interview and concurrent medical record review was conducted with the Subacute Supervisor. The Subacute Supervisor verified Resident 8's scheduled post fall neurological assessment was not completed as scheduled on 4/20/25 at 2020 hours, and should have been done. The Subacute Supervisor was unable to find whether the neurological assessment was completed elsewhere in the resident's medical record. On 6/4/25 at 1118 hours, a follow-up interview and concurrent medical record review was conducted with the Subacute Supervisor. The Subacute Supervisor verified Resident 8's Physicians' Orders dated 4/20/25, showed to complete post fall neurological assessments for 72 hours, and the Neuro Assessment log was only up to 48 hours. 2. Medical record review for Resident 9 was initiated on 6/3/25. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's Change of Condition (New) assessments showed the following: - on 5/16/25 at 0715 hours, the resident had an unwitnessed fall. - on 5/29/25 at 1828 hours, the resident had a fall. Review of Resident 9's Physicians' Orders showed the following: - dated 5/16/25, for 72-hour post-fall neurological assessments. - dated 5/29/25, for 72-hour post-fall neurological assessments. Review of Resident 9's Neuro Assessment log initiated 5/16/25 at 0600 hours, showed the final neurological assessment was completed on 5/18/25 at 0600 hours, for a total of 48 hours of neurological assessments, not 72 hours as ordered. Review of Resident 9's Neuro Assessment log initiated 5/29/25 at 1830 hours, showed the following: - For the three scheduled assessments to be completed every two hours, starting at 2200 hours, the next assessment was completed at 0100 hours (one hours after the scheduled 2400 hours), and the final one was at 0400 hours (three hours later). - The final neurological assessment was completed on 5/31/25 at 1630 hours, 46 hours after the first assessment, not 72 hours as ordered. On 6/4/25 at 1056 hours, an interview and concurrent medical record review was conducted with the Subacute Supervisor. The Subacute Supervisor verified Resident 9's scheduled post fall neurological assessment (for the fall on 5/29/25) was not completed timely. On 6/4/25 at 1118 hours, a follow-up interview and concurrent medical record review was conducted with the Subacute Supervisor. The Subacute Supervisor verified Resident 9's physician's orders dated 5/16 and 5/29/25, for thepost fall neurological assessments to be completed for 72 hours, and verified the Neuro Assessment log only went up to 48 hours.

Apr 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the needs for one of three sampled residents (Resident 3). * The facility failed to ensure Resident 3's medication was administered as ordered. This failure had the potential for Resident 3 to experience adverse effects. Findings: Review of facility's P&P titled Medication Orders revised 1/2018 showed the medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. The prescriber is contacted by nursing for direction when delivery of a medication will be delayed, or the medication is not or will not be available. Review of facility's P&P titled Medication Administration General Guidelines revised 12/2019 showed the medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Medical record review for Resident 3 was initiated on 4/18/25. Resident 3 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 3's H&P examination dated 3/23/25, showed Resident 3 had the capacity to make decisions. Review of Resident 3's MDS Quarterly assessment dated [DATE], showed the resident's BIMS score was 15 indicating the resident was cognitively intact. Review of Resident 3's Order Summary dated 4/22/25, showed a physician's order dated 1/25/25, to administer Xopenex (bronchodilator) Inhalation Nebulization Solution 0.63 mg/3ml onevial via ventilator four times a day. Review of Resident 3's Respiratory Therapy Administration Record for April 2025 showed the Xopenex Inhalation Nebulization Solution 0.63 mg/3ml onevial via ventilator was not administered on 4/11/25 at 1800 hours. Further review of Resident 3's medical record failed to show the physician was notified the medication was not administered on 4/11/25 at 1800 hours. On 4/22/25 at 1237 hours, an interview was conducted with Resident 3. Resident 3 stated on 4/11/25, he was left with no RT for hours. Resident 3 stated the assigned RT left early and did not give his breathing medication until midnight. Resident 3 further stated he needed the breathing medication for his lungs not to close. Resident 3 stated he was afraid for not being able to breathe and could die because he did not receive his breathing treatment on time. On 4/22/25 at 1410 hours, an interview and a concurrent medical record review was conducted with RT 1. RT 1 stated she left at 1530 hours on 4/11/25 and someone was supposed to come in early to cover for her shift. RT 1 verified the Xopenex Inhalation Nebulization Solution 0.63 mg/3ml was not administered to Resident 3 on 4/11/25 at 1800 hours on the Respiratory Therapy Administration Record. On 4/22/25 at 1445 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the Xopenex Inhalation Nebulization Solution 0.63 mg/3ml was not administered on 4/11/25 at 1800 hours, on the Respiratory Therapy Administration Record. On 4/22/25 at 1640 hours, an interview was conducted with the DON. The DON stated the RN Supervisor should have given the medication to Resident 3 when the RT could not administer the medication. The DON was informed and acknowledged the above findings.

Feb 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review and facility document review, the facility failed to ensure to conduct an investigation for an abuse allegation was completed in a timely manner, report the results of the abuse investigation to the CDPH, L&C Program within five working days and inform Resident 2's family member of the results of the investigation for one of the two sampled residents (Resident 2). * Family Member 1 reported to the facility CNA 3 pinched Resident 2 on 2/13/25. The facility submitted the results of the investigation on 2/21/25, eight days after the incident had occurred. This failure posed the risk for Resident 2 to not be protected against the alleged abuse and placed other vulnerable residents at risk for abuse. Findings: Review of the facility's P&P titled Abuse Investigations revised 12/2006 showed the Administrator will inform the resident and his/ her representative of the results of investigation and corrective action taken after completion of the investigation. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by the state or local laws, within five working days of the reported incident. Review of the facility's SOC 341 dated 2/13/25, showed Resident 2 was allegedly pinched by CNA 3 after provided with care as reported by Family Member 1. Medical record review for Resident 2 was initiated on 2/21/25. Resident 2 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of Resident 2's H&P examination dated 6/10/24, showed the resident had no capacity to make medical decisions. Review of Resident 2's Health Status Note dated 2/13/25 at 1714 hours, showed at 1500 hours, Family Member 1 reported to staff Resident 2 was allegedly pinched by CNA 3. On 2/21/25 at 0945 hours, an observation and concurrent interview was conducted with Resident 2. Resident 2 was observed lying on bed watching TV. An alphabetical communication board was at bedside. Resident 2 was able to read type written words and answer questions by nodding head indicating yes or can shake head sideways indicating no. Resident 2 was able to spell pinch using the communication board. Resident 2 was able to nod head indicating yes when asked if someone had pinched him. Resident 2 nodded head when asked if he was pinched after changing his diaper. Resident 2 was able to identify in the right upper arm by nodding his head when the right arm was touched. Resident 2 spelled I was crying in the communication board. On 2/21/25 at 1445 hours, an interview was conducted with Family Member 1 via language line. Family member 1 stated when she visited Resident 2 on 2/13/25, Resident 2 informed her a CNA pinched Resident 2 because he refused to take a shower. Family Member 1 stated the resident did not want to take his feedings and medications after the incident because Resident 2 was angry. Family Member 1 stated she encouraged the resident to not refuse his nutrition and medications. Family Member 1 further stated the facility stated they would investigate the alleged incident but was not notified of any update or result of the investigation. Family Member 1 stated no one had contacted her from the facility since she reported the incident. On 2/21/25 at 1615 hours, an interview was conducted with the DON. The DON stated the investigation was not complete as of this time. The DON stated she had tried to contact the alleged perpetrator, but they did not respond yet. The DON verified she had not informed the family member with regards to the progress of the investigation. Review of the facility's investigation conclusion summary dated 2/21/25, showed the abuse investigation result was sent to the CDPH, L&C Program on 2/21/25 at 1752 hours, eight days after the incident occurred. On 2/25/25 at 1033 hours, an interview was conducted with the DON. The DON verified the investigation results was sent to CDPH, L&C on 2/21/25. On 2/25/25 at 1515 hours, an interview was conducted with the Administrator. The Administrator was informed and acknowledged the above findings.

MINOR (B) 📢 Someone Reported This

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

Minor Issue - procedural, no safety impact

Transfer Requirements (Tag F0622)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of three sampled residents (Resident 1) was properly discharged from the facility. This failure had the potential to place Resident 1 at risk for not receiving continuity of care in the hospital. Review of facility's P&P titled Transfer or Discharge, Facility-Initiated revised 10/2022 showed in the Orientation for Transfer or Discharge (Emergent or Therapeutic Leave) section showed in part for an emergency transfer or discharge to a hospital or other acute care institution, implement the following procedures: Orient/ prepare the resident for transfer; and prepare for medical record transfer. Sufficient preparation and orientation for the resident prior to an immediate facility-oriented transfer or discharge includes explaining to the resident where he/ she is going and why and taking steps to minimize anxiety or depression. Information conveyed to receiving provider includes the specific resident needs that cannot be met, special instructions or precautions for on going care as appropriate, all other information necessary to meet the resident's need, a copy of resident's discharge summary and any other documentation as applicable to ensure a safe and effective transition of care. Documentation of Facility-Initiated Transfer or Discharge section showed when a resident is transferred or discharged from the facility, the following information is documented in the medical record, the basis of transfer, date and time of transfer, the mode of transportation, summary of the resident's overall medical, physical, and mental condition and others as appropriate or as necessary. Closed medical record review for Resident 1 was initiated on 2/20/25. Resident 1 was admitted on [DATE]. Review of the Resident 1's H&P examination dated 12/11/24, showed the resident had the capacity to understand and make decisions. Review of Resident 1's Order Summary as of February 2025 showed an order dated 2/16/25 at 1418 hours, may transfer the resident to the acute care hospital on 2/16/25, for non-emergent nausea, vomiting, and diarrhea. Review of Resident 1's Health Status Note dated 2/16/25 at 1420 hours, showed may send the resident to the acute care hospital for nausea, vomiting, and diarrhea. Further review of Resident 1's Health Status Note failed to show documentation for the date and time of the transfer, mode of transportation, and summary of the resident's overall medical, physical, and mental condition. Further review of Resident 1's closed medical record failed to show the Resident Transfer Record and Notice of Transfer/ Discharge forms were filed for the transfer to the acute care hospital on 2/16/25. On 2/20/25 at 1445 hours, an interview and a concurrent closed medical record review was conducted with RN 2. RN 2 stated a Resident Transfer Record and Notice of Transfer/ Discharge forms were filled out by the nurses when transferring a resident to the acute care hospital. A copy of the forms should had been retained in the resident's medical records for the facility's copy. RN 2 verified there were no Resident Transfer Record and Notice of Transfer/ Discharge forms in Resident 2's medical records. On 2/20/25 at 1448 hours, an interview was conducted with the DON. The DON stated she expected the nurses to consistently complete the Resident Transfer Record and Notice of Transfer/ Discharge forms when the residents were going to the acute care hospitals for transfers to assess the resident's physical and skin condition. On 2/20/25 at 1615 hours, an interview and concurrent closed medical record review was conducted with the MRD. The MRD stated the nurses should complete the Resident Transfer Record and Notice of Transfer/ Discharge forms upon the transfer of a resident to the acute care hospital and placed a copy in the resident's chart. The MRD verified the Resident Transfer Record and Notice of Transfer/ Discharge forms for Resident 1 on 2/16/25, when the resident was transferred out to the acute care hospital were not in the Resident 1's medical record. The MRD stated the nurse might have not completed the forms if the forms were not in Resident 1's medical record. On 2/20/25 at 1638 hours, an interview was conducted with the DON. The DON was informed of the findings as above. The DON stated the nurse might have been so busy with a lot of things going on. The DON stated she would provide the in-services to the licensed nurses regarding the compliance for the residents who would be transferring or discharging from the facility. On 2/25/25 at 1515 hours, an interview was conducted with the Administrator. The Administrator was informed and acknowledged the above findings.

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to protect the resident's rights to be free from the physical abuse by staff for one of four sampled residents (Resident 1). * Resident 1's hands were held down and tapped by CNA 5 while being fed by CNA 5. This failure had the potential to cause the injury and physical and/or psychosocial harm to the resident. Findings: Review of the facility's P&P titled Abuse and Neglect-Clinical Protocol revised 7/2017 showed the Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, or mental anguish, or deprivation of an individual, including a caretaker, of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. Review of the facility's SOC 341 Report of Suspected Dependent Adult/Elder Abuse dated 9/12/24, showed an abuse allegation reported by CNAs 3 and 4 who had observed CNA 5 trying to force to feed Resident 1 by holding the resident's hands down and tapped on the hands. Review of the facility's Investigative Summary report dated 9/17/24 and revised 9/19/24, showed the facility had substantiated the allegation of abuse for Resident 1. Medical record review for Resident 1 was initiated on 9/18/24. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's H&P examination dated 6/21/24, showed Resident 1 was unable to make medical decisions. Review of Resident 1's MDS dated [DATE], showed the resident had severely impaired cognition and required extensive one-person physical assistance with bed mobility, transfers, dressing, toilet use, personal hygiene, and eating. On 9/18/24 at 1620 hours, a concurrent observation and interview was conducted with CNA 1. CNA 1 stated Resident 1 was not verbally responsive but could follow commands and was cooperative. CNA 1 further stated when she fed Resident 1, the resident did not fight and if Resident 1 did not want to eat anymore, Resident 1 would close her mouth and turn her face away. On 9/19/24 at 1222 hours, a concurrent observation and interview was conducted with LVN 1. LVN 1 stated Resident 1 was totally dependent with daily care but was able to follow the simple directions and cooperative. LVN 1 further stated Resident 1 never had a behavior issue of being combative or agitated. On 9/19/24 at 1246 hours, an interview was conducted with CNA 3. CNA 3 stated on 9/12/24 around 1200 hours, as she was walking in the dining area, CNA 3 observed CNA 5 blocking her body against Resident 1's right shoulder and upper body part. When CNA 3 came close to the table where Resident 1 was sitting, she observed CNA 5 holding down the resident's hands and forced to feed her. CNA 3 further observed when Resident 1 was trying to move her hands from being held down, CNA 5 started tapping on the resident's hands. CNA 3 stated she told CNA 5 to stop with what she was doing, but CNA 5 stated it was her job and to let her do her job. CNA 3 stated that was when she started asking for help, and CNA 4 responded and she also reported the incident to the RN supervisor and DON. On 9/19/24 at 1300 hours, an interview was conducted with CNA 4. CNA 4 stated on 9/12/24 around 1200 hours, CNA 4 observed CNA 5 holding the hands of Resident 1 down. CNA 4 stated she also observed Resident 1 swaying her head from side-to-side while being fed by CNA 5. CNA 4 stated she told CNA 5 to stop what she was doing, but CNA 5 continued to hold the resident's hands down and was tapping on the residents' hands. On 9/19/24 at 1545 hours, a concurrent interview and facility document review was conducted with the DON and Administrator. The DON and Administrator both acknowledged the above findings. The DON further stated CNA 5 was first suspended on 9/12/24, and finally terminated on 9/17/24.

Aug 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and medical record review, the facility failed to ensure privacy was provided to one of three sampled residents (Resident 3) as evidenced by: * Resident 3's privacy curtain was not pulled while providing the ADL care and assessment. This failure posed the risk to negatively affect the dignity of Resident 3 and violate Resident 3' rights to privacy. Findings: On 8/8/24 at 1408 hours, an observation was conducted with LVN 1 and CNA 2. Resident 3's privacy curtain was observed only providing privacy to one side of the bed and around the foot of the bed. The privacy curtain was not long enough to be pulled all the way around Resident 3's bed. LVN 1 and CNA 2 were observed assessing Resident 3's body during a head-to-toe assessment. Resident 3's body was visible from the right side of his bed and from Bed A's bed. On 8/9/24 at 1017 hours, an observation and concurrent interview was conducted with CNA 2 for Resident 3. CNA 2 was observed transferring Resident 3 back to his bed after his shower with the Hoyer lift (mechanical lift to allow a person to be lifted and transferred with minimal physical effort). Resident 3's privacy curtain was observed to be pulled around the left side of Resident 3's bed. Resident 3's body was visible from the right side of his bed and from Bed A's bed. CNA 2 stated she closed Resident 3's room door because the Resident 3's privacy curtain could not be pulled all the way around Resident 3's bed. On 8/9/24 at 1100 hours, an interview was conducted with CNA 2. CNA 2 verified Resident 3's privacy curtain was not long enough to provide full coverage when pulled. When asked about Resident 3's privacy curtain, CNA 2 stated she did not inform anybody about Resident 3's privacy curtain not providing full coverage for Resident 3.

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to consistently provide a safe environment for the residents, staff, and visitors as evidenced by: * Two of the six facility doors were observed unlocked. This failure resulted in an unauthorized person entering a resident's room, which posed the risk of an unsafe environment for the residents, staff, and visitors. Findings: On 7/30/24 at 1350 hours, an observation and concurrent interview was conducted with the Maintenance Director. A door located on the lower level and to the side of the facility was observed open. This door led to a hallway next to the facility's laundry room and to another unlocked door with stairs that led up to Resident Room A. The Maintenance Director verified the finding. On 7/30/24 at 1403 hours, an interview was conducted with Resident 1. Resident 1 statedon 7/24/24, Resident 1 saw a transient (a person who moves from place to place/homeless person) woman looking through his window. At around 1845 hours on 7/24/24, the same transient woman entered Resident 1's room and placed a cup and a box on Resident 1's overbed table. Resident 1 stated he felt unsafe with the transient woman in his room. Resident 1 stated he activated his call light and called out for the staff. On 7/30/24, at 1645 hours, an interview was conducted with CNA 1. When asked about the incident involving the transient woman, CNA 1 stated she heard Resident 1 screaming her name and around 2000 hours, she observed the transient woman walking near Station B not wearing shoes. CNA 1 stated the transient woman was then escorted out of the facility. Medical record review for Resident 1 was initiated on 7/30/24. Resident 1 was readmitted to the facility on [DATE]. Review of Resident 1's H&P examination dated 3/26/24, showed Resident 1 had the capacity to make decisions. Resident 1's diagnoses included muscular dystrophy (disease characterized by wasting of muscles) and functional quadriplegia (paralysis of all four limbs). Resident 1 was bed bound and dependent on a ventilator for his breathing needs. On 8/7/24 at 1240 hours, an interview and concurrent observation was conducted with the Maintenance Director. When asked about the facility's doors, the Maintenance Director stated all the facility doors should remain locked and the staff had the keys to the doors or could ring the doorbell to be let in to the facility. The Maintenance Director verified the door from the laundry room hallway leading up to Resident Room A did not have a lock on it. On 8/8/24 at 0930 hours, a side door near Resident Room B was observed unlocked and no facility staff was observed. On 8/8/24 at 1047 hours, an observation and concurrent interview was conducted with Admissions Staff 1. Admissions Staff 1 verified the side door near Resident Room B was unlocked. On 8/8/24 at 1103 hours, an interview was conducted with the Administrator. When asked about the transient woman incident, the Administrator stated he was notified of the incident. The Administrator statedafter the incident, in-services were conducted for all the staff to keep the facility entrances secured properly. The Administrator was informed of the above findings. On 8/14/24 at 1142 hours, an interview was conducted with the DON. The DON was informed of the above findings.

May 2024 27 deficiencies

CONCERN (D)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of five final sampled residents reviewed for unnecessary medications (Resident 4) and one of two residents reviewed for restraint use (Resident 4) were informed of the use of the psychotropic medication (medication affecting brain activities associated with mental processes and behavior) and restraint. * The facility failed to ensure the informed consents were obtained prior to administering the Seroquel (antipsychotic medication) and bilateral hand mittens for Resident 4. This failure had the potential for Resident 4 to not be informed of the potential risks and benefits of the medication and restraints. Findings: Review of the Health and Safety Code, Section 1418.8, showed the following: -(2) (A) If the physician and surgeon determine that the resident will suffer harm or severe and sustained emotional distress if the prescribed medical intervention is delayed at least five days, an interdisciplinary team review may occur if notice is provided to the resident and patient representative at least 24 hours prior to conducting an interdisciplinary team review. (B) The physician and surgeon shall document the determination that the resident will suffer harm or severe and sustained emotional distress if the prescribed intervention is delayed at least five days, and the basis for that determination, in the resident's medical record; -(e) (1) When a resident of a skilled nursing facility or intermediate care facility has been prescribed a medical intervention by a physician and surgeon that requires informed consent and the physician has determined that the resident lacks capacity to make health care decisions and the facility has determined that there is no legal decisionmaker, the facility shall, except as provided in subdivision (h), conduct an interdisciplinary team review of the prescribed medical intervention prior to the administration of the medical intervention. The interdisciplinary team shall oversee the care of the resident utilizing a team approach to assessment and care planning, and shall include the resident's attending physician, a registered professional nurse with responsibility for the resident, other appropriate staff in disciplines as determined by the resident's needs, and a patient representative, in accordance with applicable federal and state requirements. An interdisciplinary team review shall not occur without the participation of a patient representative and until the notice required by subdivision (d) has been provided to the resident and patient representative; -(e )(2) The interdisciplinary team review shall include all of the following: (A) A review of the physician's assessment of the resident's condition; (B) The reason for the proposed use of the medical intervention; (C) A discussion of the desires of the resident, if known. To determine the desires of the resident, the interdisciplinary team shall interview the resident, review the resident's medical records, consult with family members or friends, if any have been identified, and review any prior expressions of the resident's health care wishes, including checking registries for an advanced health care directive or physician's orders for life-sustaining treatment, as specified in Part 4 (commencing with Section 4780) of Division 4.7 of the Probate Code, executed prior to the physician's determinations in subdivision (b) and not executed by the resident during any period of incapacity, to the extent available and capable of being timely accessed. Any specific prior expression of the resident's health care wishes shall be afforded particular consideration unless the wishes are inconsistent with the best interests of the resident, require medically ineffective health care, or are contrary to generally accepted health care standards applicable to the health care provider, institution, or resident; (D) The type of medical intervention to be used in the resident's care, including its probable frequency and duration; (E) The probable impact on the resident's condition, with and without the use of the medical intervention; and (F) Reasonable alternative medical interventions considered or utilized and reasons for their discontinuance or inappropriateness Review of the facility's P&P titled Antipsychotic Medication Use revised 12/2016 showed the resident who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for appropriateness and indications for use. The IDT will: -(a) Complete PASRR (pre-admission screening for mentally ill and intellectually disabled individuals), if appropriate; or -(b) Re-evaluate the use of antipsychotic medication at the time of admission and/or within two weeks (at the initial MDS assessment) to consider whether the medication can be reduced, tapered, or discontinued; and -(c ) Based on assessing the resident's symptoms and overall situation, the physician will determine whether to continue, adjust, or stop existing antipsychotic medication. Review of the facility's P&P titled Use of Restraints revised 12/2008 under the section Informed Consent, showed the following: -Residents and/ or surrogate/ sponsor shall be informed about the potential risks and benefits of all options under consideration, including the use of restraints, not using restraints, and the alternatives to restraint use; and -Should a resident not be capable of making a decision, the surrogate or sponsor may exercise the right of the use or non-use of a restraint. Medical record review for Resident 4 was initiated on 4/30/24. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's H&P examination dated 3/14/24, showed Resident 4 had no capacity to make medical decisions. Review of Resident 4's Order Summary Report showed the following physician orders: - quetiapine 100 mg via PEG (percutaneous endoscopic gastrostomy, a surgery to place a feeding tube to allow nutrition through the stomach) tube every eight hours for schizophrenia manifested by pulling out medical devices; and - may apply bilateral hand mittens every shift for safety and prevent patient from pulling out medical devices. Review of Resident 4's MAR for March, April, and May 2024 showed the following: -Resident 4 received quetiapine 75 mg on 3/13/24 at 2200 hours; -Resident 4 received quetiapine 100 mg on 3/14 to 5/1/24 at 0600, 1400, 2200 hours, and on 5/2/24 at 0600 and 1400 hours; and -Resident 4 was applied with bilateral hand mittens from 3/13 to 5/1/24 every shift. Review of Resident 4's Informed Consent Verification - Verbal/ Telephone Nurse Verification dated 3/13/24, for Seroquel 75 mg showed the consent was obtained from Resident 4 and Resident 4's family member. Review of Resident 4's Informed Consent Verification - Physician/ Physician Assistant / Nurse Practitioner Verification dated 3/14/24, for Seroquel 100 mg showed the consent was obtained from Resident 4. Review of Resident 4's Informed Consent Verification - Verbal/ Telephone Nurse Verification dated 3/13/24, for the bilateral hand mittens showed the consent was obtained from Resident 4 and Resident 4's family member. Review of Resident 4's Progress Note dated 3/26/24, showed the IDT met to review plan of care. Attempted to contact Resident 4's family members but no answer. Review made of diagnosis, POLST, medications and treatments. Further review of Resident 4's medical records did not show the informed consents for the Seroquel medications and bilateral mittens were obtained from Resident 4's family member. In addition, when the physician determined Resident 4 lacked capacity to make healthcare decision, and the facility determined there was no legal decisionmaker, Resident 4's medical records did not show the IDT conducted a review of the prescribed medical intervention prior to the administration of the Seroquel medication and bilateral hand mittens. On 5/2/24 at 0938 hours, an interview and medical record review for Resident 4 was conducted with the SSD. When asked about the informed consent forms showing the consents were obtained from Resident 4 and Resident 4's family member, the SSD stated she did not know why the consents were obtained from Resident 4 and Resident 4's family member when the resident did not have the capacity to make medical decisions and Resident 4's family member could be reached. The SSD stated despite the facility's several attempts, she was not able to contact Resident 4's family member. The SSD stated Resident 4 did not have the capacity to make medical decisions and did not have a legally designated decisionmaker. When asked if the IDT met when the physician determined Resident 4 lacked capacity to make healthcare decision, and the facility determined Resident 4 did not have a legally designated decisionmaker, the SSD answered no. The SSD stated the IDT met to review Resident 4's plan of care and not specific for the Seroquel medication and the bilateral hand mittens. The SSD stated the IDT did not review the physician's assessment, reason for the proposed use of the Seroquel medication and the bilateral hand mittens, resident's desire based on resident interview, medical record review, type of medical interventions used in the resident care, impact on the resident's condition, and alternative medical interventions prior to the administration of the Seroquel medication and the bilateral hand mittens. On 5/2/24 at 1002 hours, an interview and concurrent medical record review for Resident 4 was conducted with RN 1. RN 1 verified the above findings. RN 1 verified he signed the informed consents for Seroquel 75 mg, and the bilateral hand mittens. RN 1 verified the physician was not able to obtain an informed consent from Resident 4 and/ or Resident 4's family member. RN 1 stated Resident 4 was admitted with the Seroquel medication and bilateral hand mittens, and Resident 4 and/ or Resident 4's family member was assumed to have given informed consent for the use of the Seroquel medication and the bilateral hand mittens. When asked for a documentation of the informed consent for the use of the Seroquel medication and the bilateral hand mittens from the acute care hospital for Resident 4, RN 1 could not provide any documentation.

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to offer and/or follow up on the advanced directive availability for two of 18 final sampled residents reviewed for advanced directives (Residents 6 and 12). * Resident 12 was not offered information to formulate an advanced directive. * The facility failed to ensure Resident 6 had an advance directive or a follow up was made to inquire whether or not Resident 6 had an advance directive. These failures had the potential for the residents' final wishes for medical treatment not being communicated with health care staff. Findings: Review of the facility's P&P titled Advanced Health Care Directive & POLST (Physician Orders for Life-Sustaining Treatment) reviewed 1/2022, showed the following: -The facility will make information available to residents on how to prepare an advance directive. -The SSD or designee will inquire if the resident has an advance directive and will request a copy. -If the resident is capable of making an advance directive, ask if they are interested in preparing one. -Social Services will review all related advance directive documents and ensure the information is complete. -Social Services should ensure the information was given to the resident on admission. 1. Medical record review for Resident 12 was initiated on 4/30/24. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's POLST dated 11/16/23, showed the resident did not have an Advance Directive. Review of Resident 12's MDS dated [DATE], showed Resident 12 was cognitively intact. Review of Resident 12's H&P examination dated 11/16/23, showed the resident had the capacity to understand and make medical decisions. Review of Resident 12's Skilled Nursing Progress Notes dated 12/14/23 and 4/19/24, showed the resident was able to make medical decisions. On 5/1/24 at 1434 hours, an interview was conducted with Resident 12. Resident 12 stated the facility staff did not ask if the resident wanted information about, or assistance with formulating an advance directive . On 5/2/24 at 0939 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD stated the nurse reviewed the POLST and advance directive with the resident on admission and the social service staff will follow-up with the resident, usually during the care plan meeting. If a resident wanted to formulate an Advance Directive, the SSD will call the Ombudsman to assist the resident in formulating one. The SSD stated she was not working at the facility when the resident was admitted ; however, reviewed Resident 12's medical record, verified the resident had the capacity to make medical decisions, and stated there was no documentation to show Resident 12 was offered information or assistance in formulating an Advance Directive. Surveyor: Sulio, Jeshirlen 2. Medical record review for Resident 6 was initiated on 4/30/24. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's H&P examination form dated 8/1/23, showed Resident 6 did not have the capacity to understand, and make decisions. Review of Resident 6's POLST dated 8/5/23, under Section D - Information and Signatures, failed to show whether Resident 6 had an advance directive or not. Review of Resident 6's Progress Notes dated 2/31/24, under IDT notes, showed POLST reviewed and remains full code but did not show whether Resident 6 had an advance directive or not, or a follow-up was made to inquire whether Resident 6 had an advance directive. Further review of Resident 6's medical record failed to show documented evidence a copy of Resident 6's advance directive was obtained, or a follow-up was made to obtain a copy of Resident 6's advance directive. On 5/1/24 at 1234 hours, an interview and concurrent medical record review for Resident 6 was conducted with RN 1. RN 1 verified the above findings. RN 1 verified Resident 6's medical record did not show whether Resident 6 had an advance directive or not, or a follow-up was made to inquire whether Resident 6 had an advance directive. RN 1 stated upon admission of the resident, the admitting nurse could ask the resident or the resident's family member, if any were present, regarding the resident's advance directive. RN 1 also stated if the resident did not have the capacity and there were no family members present during admission, the social worker also asked about advance directives during the care plan meeting where resident's family members were invited to attend. On 5/2/24 at 0938 hours, an interview and concurrent medical record review for Resident 6 was conducted with the SSD. The SSD verified the above findings. The SSD verified the IDT meeting for Resident 4 did not show a follow-up was made to inquire whether or not Resident 6 had an advance directive.

CONCERN (D)

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

Deficiency F0604 (Tag F0604)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review and facility P&P review, the facility failed to follow their P&P for two of two final residents reviewed for the hand mitten use (Residents 4 and 22). * Resident 22's order for documentation of releasing their hand mitten did not follow facility P&P. * The facility failed to ensure Resident 4's bilateral hand mittens were monitored every two hours, and release for 15 minutes as per the physician's order. These failures resulted in inaccurate documentation of hand mitten removal, which had the potential for a delay in identifying and documenting adverse outcomes from the hand mittens use. Findings: Review of the facility's P&P Hand Control Mitten Control undated showed to release the hand mitten every two hours and exercise the resident's hand for 10 minutes, and observe for edema, and to document the date and time the hand mitten is released. 1. Medical record review for Resident 22 was initiated on 4/30/24. Resident 22 was re-admitted to the facility on [DATE]. Review of Resident 22's Order Summary report dated 5/1/24, showed the following physician's orders: -An order dated 10/4/22, to apply a hand mitten to the resident's right hand. -An order dated 10/4/22, to remove the hand mitten and check the hand's color, movement, and skin every shift. Review of Resident 22's MAR for April 2024, showed to remove the hand mitten and check the hand's color, movement, and skin every shift, with a box for day shift and night shift. Each box had a check mark and corresponding staff initials. Review of Resident 22's medical records failed to show the resident's hand mitten was removed the hand mitten was removed every two hours and the hand was check the hand's color, movement, skin, and exercised for 10 minutes. On 5/2/24 at 1333 hours, an interview and concurrent record review were conducted with LVN 7. LVN 7 stated they were assigned to Resident 22 and were removing the hand mitten and checking for circulation, movement, and skin assessment every two hours. When asked to show documentation the mitten was removed every two hours, the LVN stated the record only showed it was released every shift. When asked how she knew when to release the hand mitten, the LVN stated she usually did it today on her first round, around 0730 hours, again at 0900 hours, then at 1100 hours, and last checked was around 1300 hours. LVN 7 stated there was not an alert every two hours in the electronic MAR like for the scheduled medications. It just popped up for the entire shift, and could be clicked on any time during the shift to close it out and mark as complete. On 5/3/24 at 0913 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated the facility protocol for the hand mittens was to remove the mitten every two hours and check the hand for circulation, movement, and skin changes. RN 1 reviewed Resident 22's physician orders and verified the order did not match the facility's P&P. RN 1 stated they used to document it on a paper log that it was being done every two hours, but switched to documenting in the EHR and must not have updated the order. 2. On 4/30/24 at 0849 hours, 5/1/24 at 0826 hours, 5/2/24 at 0811 hours, and 5/3/24 at 0835 hours, Resident 4 was observed in bed with bilateral hand mittens on. Medical record review for Resident 4 was initiated on 4/30/24. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's H&P examination dated 3/14/24, showed Resident 4 had no medical capacity to make medical decisions. Review of Resident 4's Order Summary Report dated 3/13/24, showed the following physician's orders dated: -3/13/24, may apply bilateral hand mittens every shift for safety and prevent resident from pulling out medical devices; and -3/13/24, to monitor for color, movement, and sensation every two hours, and may release for 15 minutes related to the bilateral hand mittens use every shift. Review of Resident 4's MAR for March, April, and May 2024 showed Resident 4 was applied with bilateral hand mittens from 3/13 to 5/1/24. In addition, the MAR showed the monitoring for color, movement, and sensation; and release for 15 minutes related to the use of bilateral hand mittens were done every shift. Further review of Resident 4's medical record did not show any documented evidence Resident 4 was monitored for color, movement, and sensation and release for 15 minutes related to the use of the bilateral hand mittens every two hours. On 5/3/24 at 1036 hours, an interview and concurrent medical record review for Resident 4 was conducted with RN 1. RN 1 verified the above findings. RN 1 verified Resident 4 was applied with the bilateral hand mittens. When asked about the monitoring related to the use of bilateral hand mittens, RN 1 stated Resident 4 was monitored for color, movement, and sensation every two hours related to the use of bilateral hand mittens, and the bilateral hand mittens were released for 15 minutes. When asked about the documentation, RN 1 verified there was no documentation to show the monitoring for color, movement, and sensation and release for 15 minutes related to the use of the bilateral hand mittens were done every two hours.

CONCERN (D)

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the splints (a medical device that stabilizes a part of your body and holds it in place) and orthosis (the correction of disorders of the limbs or spine by use of braces and other devices to correct alignment or provide support) were applied and the ROM exercises were provided to two of four final sampled residents reviewed for ROM functions(Residents 20 and 41). * The facility failed to ensure Resident 20 was provided with the restorative nursing services as ordered by the physician when the ROM exercises were not provided and the splint and orthosis were not applied. * The facility failed to ensure Resident 41's splint and orthosis were applied as ordered by the physician. These failures had the potential for decline in the residents' ROM and mobility. Findings: Review of the facility's P&P titled Contracture Care (undated) showed in order to provide comfort and maximum freedom, all splints and contracture braces will be placed on the resident by the CNA or RNA on the day shift and removed after four to six hours of use unless otherwise ordered, so that the residents will experience a contracture device resting period. 1. Medical record review for Resident 20 was initiated on 4/30/24. Resident 20 was admitted to the facility on [DATE]. Review of Resident 20's H&P examination dated 1/29/24, showed Resident 20 had fluctuating capacity to understand and make medical decisions. Review of Resident 20's Order Summary Report dated 5/1/24, showed the following physician's orders dated: - 2/20/23, for the RNA to provide the PROM or AROM exercises on the bilateral upper extremity and bilateral lower extremities every day five times per week or as tolerated during the day shifts every Monday, Tuesday, Wednesday, Thursday, and Friday. - 5/31/23, for the RNA to apply the bilateral WHFO (wrist hand finger orthosis) or bilateral elbow extension splints every day five times per week up to four hours as tolerated one time a day every Monday, Tuesday, Wednesday, Thursday, and Friday. - 6/20/23, for the RNA to apply the splint to both knees for up to three hours per day every day five times per week as tolerated every day shift every Monday, Tuesday, Wednesday, Thursday, and Friday. However, review of Resident 20's Restorative Nursing Orders record for April 2024 showed the missing RNA's initials on 4/26 and 4/29/24, to include the above treatmens to be provided to the resident. On 4/30/24 at 1530 hours, Resident 20 was observed laying in bed with no splint to both knees and no orthosis to both wrists and hands. On 5/1/24 at 0845 hours, Resident 20 was observed laying in bed with no splint to both knees and no orthosis to both wrists and hands. On 5/1/24 at 1150 hours, Resident 20 was observed laying in bed with no splint to both knees and no orthosis to both wrists and hands. On 5/1/24 at 1400 hours, Resident 20 was observed laying in bed with no splint to both knees and no orthosis to both wrists and hands. On 5/1/24 at 1404 hours, an interview was conducted with CNA 5. CNA 5 stated the RNA was responsible for applying the splints and orthosis for the residents. On 5/1/24 at 1415 hours, an interview was conducted with RNA 1. RNA 1 stated he was not able to perform the ROM exercises and apply the splints and orthosis to Resident 20 on 4/30 and 5/1/24, because he was busy. On 5/1/24 at 1424 hours, a concurrent interview and medical record review was conducted with RN 2. RN 2 verified the findings as above. On 5/3/24 at 1430 hours, an interview was conducted with RN 1. RN 1 was informed and acknowledged the findings as above. 2. Medical record review for Resident 41 was initiated on 4/30/24. Resident 41 was admitted to the facility on [DATE], and readmitted on [DATE]. Review or Resident 41's H&P examination dated 1/4/24, showed Resident 41 did not have the capacity to understand and make decisions. Review of Resident 41's Order Summary Report dated 5/1/24 showed the following physician's orders dated: - 1/15/24, for the licensed nurses to supervise the CNAs to apply the left upper hand splints up to three to five hours a day five times a week as tolerated during the day shifts every Monday, Tuesday, Wednesday, Thursday, and Friday. - 1/9/24, for the licensed nurses to provide the PROM or AROM exercises to both lower extremities everyday seven times a week or as tolerated every day shift - 1/13/24, for the licensed nurses to supervise the CNAs to don and doff theWHFO on the bilateral upper extremities everyday seven times a week up to four hours as tolerated every day. On 5/1/24 at 0845 hours, Resident 41 was observed laying in bed with no hand splint or WHFO splint. On 5/1/24 at 1104 hours, Resident 41 was observed laying in bed with no hand splint or WHFO splint. On 5/1/24 at 1150 hours, Resident 41 was observed laying in bed with no hand splint or WHFO splint. On 5/1/24 at 1400 hours, Resident 41 was observed laying in bed with no hand splint or WHFO splint. On 5/1/24 at 1439 hours, an interview was conducted with LVN 7. LVN 7 verified Resident 41 had the physician's orders for hand splint and WHFO. LVN 7 verified the hand splint and WHFO were not applied to Resident 41 as ordered. LVN 7 checked Resident 41's closet and was not able to find the hand splint and WHFO for Resident 41. LVN 7 stated she would ask the PT for the splint and WHFO. On 5/1/24 at 1450 hours, an interview was conducted with RN 1. RN 1 was informed and acknowledged the above findings.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the environment free from accident hazards. * The facility failed to ensure the fall mat was placed on the floor as ordered by the physician for one of one nonsampled resident (Resident 10). * The facility failed to ensure the doorway to Room A was free of obstruction. * The facility failed to ensure the smoking supplies were stored for safety and the quarterly smoking safety assessments for one of one final sampled resident reviewed for smoking (Resident 387) was completed timely. * The facility failed to ensure the cleaning solutions were safely stored. A bottle of Awesome Floor Cleaner was left on the floor beside Resident 837's bedside cabinet. These failures posed the risk for the unsafe environment and risk of accidents for the residents in the facility. Findings: Review of the facility's P&P titled Doorway and Resident Rool Door Policy dated 9/1/18, showed it is the policy of the facility to ensure the resident's rooms, doors, and doorways are to be clear of obstacles as to prevent accidents and provide emergency care. Doors will not be held open with any object such as trash containers, linen and plastic bags. 1. On 4/30/24 at 940 hours, during the initial tour of the facility, an observation and concurrent interview was conducted with LVN 1. A blue mat folded behind a trash bin next to the door of Room A. Resident 10 was observed asleep, turned to her right side, with both siderails up. Resident 10 was observed with a tab alarm clip attached to right upper arm sleeve with cord attached to the alarm mechanism placed inside Resident 10's bedside drawer. There was no fall mat observed next to Resident 10's bed. LVN 1 verified the folded blue mat was a fall mattress for Resident 10 because Resident 10 was a fall risk and had fallen before. LVN 1 further stated the fall mat should have been placed to the left of Resident 10's bed on the floor. Medical record review for Resident 10 was initiated on 4/30/24. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's Order Summary Report dated 5/1/24, showed a physician's order dated 2/15/24, to use the floor mat for safety precautions. Review of Resident 10's Plan of Care showed a care plan problem dated 2/14/24, for actual falls. The care plan showed an intervention dated 2/15/24, to use the floor mat for safety precautions. 2. On 4/30/24, at 0854 hours, a rolled sheet on the floor was observed in Room A wedged between the base of door and door frame, which was propping the door to keep partially open. On 4/30/24 at 0936 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified the findings identified in Room A and stated the rolled sheet should not have been used as a wedge between the door to keep the door open. LVN 1 further stated someone might fall and also it should not be there for infection control. LVN 1 also stated the resident in Bed C of Room A preferred the door closed, but the sheet was there to prevent the door from slamming and to keep it slightly open. 4. Review of the facility's P&P titled Chemical Handling and Storage dated 10/2/21, showed all the chemicals must be stored in a safe, secure location. On 4/30/24 at 0846 hours, during the initial tour of the facility, Resident 837 was observed lying in bed. A bottle of Awesome Floor Cleaner was observed on the floor beside Resident 837's bedside cabinet. Medical record review for Resident 837 was initiated on 4/3024. Resident 837 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 837's H&P examination dated 7/19/23, showed the resident did not have the capacity to understand and make decisions. On 4/30/24 at 1021 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified the bottle of Awesome Floor Cleaner on the floor beside Resident 837's bedside cabinet. LVN 1 stated Resident 837 can open the bottle of floor cleaner and put it in his mouth. LVN 1 stated the bottle of floor cleaner should not have been placed in Resident 837's room. On 5/3/24 at 1422 hours, an interview was conducted with the Administrator. The Administrator was informed and acknowledged the above findings. 3. Review of the facility's P&P Smoking Policy - Residents revised 4/2012 showed any smoking-related privileges, restrictions, and concerns shall be noted in the care plan, and all personnel caring for the resident shall be alerted to these issues. a. Medical record review for Resident 387 was initiated on 4/30/24. Resident 387 was admitted to the facility on [DATE]. Review of Resident 387's Plan of Care dated 12/18/23, showed the resident was safe to smoke independently in a community setting. The care plan interventions included to store the resident's smoking materials in the medication cart. On 4/30/24 at 1203 hours, an interview was conducted with Resident 387. Resident 387 stated the facility was a non-smoking facility, so she must go about 25 feet away from the building to smoke. The resident stated she smoked two to three cigarettes a day, one after lunch, one after dinner, and sometimes after breakfast. On 4/30/24 at 1642 hours and 5/2/24 at 0740 hours, Resident 387 was observed smoking in her wheelchair, located in the facility's parking lot by a small planter area. On 5/2/24 at 1056 hours, an interview and concurrent record review was conducted with LVN 1. LVN 1 was asked where Resident 387's cigarettes were located. LVN 1 stated the Social Services usually kept the resident's smoking supplies. When asked if he had any in his med cart, LVN 1 stated no. LVN 1 then reviewed Resident 387's care plan and stated it showed the resident's smoking supplies should be kept in the medication cart. LVN 1 stated they had been Resident 387's nurse for the 0700-to-1500 hours shift the past three days. On 5/2/24 at 1106 hours, and interview was conducted with Resident 387 at bedside. Resident 387 stated they did not have any smoking supplies left, and her friend was going to be bringing more supplies this weekend. When asked where they got the cigarette from this morning, the resident replied it was from half a cigarette she had leftover from the prior day, and had kept it in her robe pocket. On 5/2/24 at 1124 hours, an interview was conducted with the SSD. The SSD stated they did not store any smoking supplies for the residents. b. Review of Resident 387's Plan of Care showed a focus initiated on 12/18/23, showed the resident was safe to smoke independently in a community setting. Interventions included to reassess the resident's smoking safety quarterly. Review of Resident 387's Smoking Risk Management 2.0 assessment dated [DATE], showed it was completed by the MDS Coordinator. Review of Resident 387's Smoking Risk Management 2.0 assessment dated [DATE], showed it was completed by the SSD, 43 days after the next quarterly assessment was due to be completed. On 5/2/24 at 1340 hours, an interview and concurrent record review was conducted with the MDS Coordinator. The MDS Coordinator stated they completed Resident 387's smoking safety evaluation on 12/18/23 and completed the care plan for smoking. When asked who was responsible for completing the smoking safety assessment, the MDS Coordinator stated the SSD was responsible. On 5/2/24 at 1353 hours, an interview and concurrent record review was conducted with the SSD. The SSD stated they completed Resident 387's Smoking Risk Management 2.0 assessment dated [DATE]. The SSD stated the smoking safety assessments should be completed quarterly, and verified 4/30/24's assessment for Resident 387 was not completed timely and should have been completed around 3/18/24. The SSD stated they were not responsible to complete the smoking safety assessments, but noticed on the day the recertification survey started, Resident 387's quarterly smoking assessment was not completed and decided to complete it to help.

CONCERN (D)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the necessary GT care and services for two of eight final sampled residents reviewed for GT care (Residents 4 and 6). * The facility failed to ensure Residents 4 and 6 were positioned safely at 30 to 45 degrees during the enteral feeding via GT. This failure posed the risk for developing complications related to the residents' GT. Findings: According to Taylor's Fundamentals of Nursing seventh edition, Nursing Considerations with Tube Feeding, to make sure the resident is as upright as possible during feeding. If the resident is in bed during feedings, elevate the head of the bed at least 30 degrees during feeding and for one hour afterward to prevent reflux (occurs when stomach acid repeatedly flows back into the esophagus or the tube connecting your mouth and stomach) and aspiration. 1. Medical record review for Resident 4 was initiated on 4/30/24. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's Order Summary Report showed the following physician's order dated 3/13/24: -To administer Pulmocare (a high-calorie, low carbohydrate formula designed to help reduce carbon dioxide production for residents with respiratory disease) 1.5 cal/ml at 55 ml per hour for 20 hours to provide 1650 calories per 1100 ml or until dose is completed via enteral feeding pump. Starts at 1200 hours and ends at 0800 the next day; and -To elevate head of the bed between 30 to 45 degrees at all times. On 5/2/24 at 0811, 0820, and 0830 hours, Resident 4 was observed lying flat in bed. Resident 4's GT feeding Pulmocare was observed infusing via a feeding pump at 55 ml per hour. On 5/2/24 at 0834 hours, an observation for Resident 4 and concurrent interview was conducted with LVN 9. Resident 4 was observed lying flat in bed with the GT feeding pump turned on. LVN 9 verified the above findings. 2. Medical record review for Resident 6 was initiated on 4/30/24. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's Order Summary Report showed the following physician's orders dated -9/27/23, to administer Nepro with Carb Steady (a therapeutic nutrition formula especially designed for residents with kidney disease) 1.8 cal/ml at 55 ml per hour for 16 hours to provide 1584 calories per 880 ml or until dose is completed via enteral feeding pump. Starts at 1600 hours and ends at 0800 hours the next day; and -8/1/23, to elevate head of the bed between 30 to 45 degrees at all times. On 5/2/24 at 0805, 0815, and 0822 hours, Resident 6 was observed lying flat in bed. Resident 6's GT feeding Nepro was observed infusing via a feeding pump at 55 ml per hour. On 5/2/24 at 0832 hours, an observation for Resident 6 and concurrent interview was conducted with LVN 9. Resident 6 was observed lying flat in bed with the GT feeding pump turned on. LVN 9 verified the above findings.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary and safe respiratory care services to meet the needs of one of three final sampled residents reviewed for respiratory care (Resident 838). This failure had the potential to affect the resident's respiratory health and well-being. Findings: Review of the facility's P&P titled Oxygen Administration revised 10/2010 showed the oxygen devise (nasal cannula, mask, or nasal catheter) is changed weekly and dated with the date of change. On 4/30/24 at 0906 hours, during the initial tour of the facility, Resident 838 was observed lying in bed. Resident 838's nebulizer mask was observed in a transparent bag, unlabeled, and undated. Medical record review for Resident 838 was initiated on 4/30/24. Resident 838 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 838's Order Summary Report dated 5/1/24, showed a physician's order dated 11/28/23, for ipratropium-Albuterol (medication to help control the symptoms of lung disease) inhalation solution 0.5-2.5 (3) mg/3 ml (Ipratropium-Albuterol) one inhalation orally every four hours as needed for pneumonia (an inflammation and fluid in the lungs caused by a bacterial, viral, or infection). On 4/30/24 at 1011 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified Resident 838's nebulizer mask was undated and unlabeled. LVN 1 stated the nebulizer mask should have been dated and labeled. On 5/3/24 at 1422 hours, an interview was conducted with the Administrator. The Administrator was informed and acknowledged the above findings.

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmaceutical services to meet the needs of the residents. * The emergency kits for the facility's oral medications and intravenous medications were not replaced in a timely manner for two of seven emergency kits (Emergency Kit 1 and Emergency Kit 2) inspected in the facility. This failure had the potential to contribute to a decreased availability of medications in an emergency. Findings. Review of the facility's P&P titled Medication Ordering and Receiving from Pharmacy revised January 2018 showed the emergency needs for medication are met by using the facilities approved emergency medication supply or by special order from the provider pharmacy. The provider pharmacy supplies emergency medication including emergency drugs and antibiotics, control substances, products for infusion in limited quantities in portable sealed containers and automated dispensing system (ADS). Further review of the P&P showed if exchanging emergency kits, open kits are replaced with sealed kits with in 72 hours of opening, if replacing used medication, the replacement doses are added to the kit within 72 hours of opening. Kits opened during the weekend or on holidays are reported to the pharmacy immediately/the following Monday or the first working day after the kit is opened. On 4/30/24 at 1152 hours, during the inspection of Medication Storage room [ROOM NUMBER] with LVN 2, the Emergency Kit 1 for the oral medications was observed to be locked with a red zip tie. LVN 2 stated the emergency kit locked with red zip tie was once opened and meant to alert the staff it needed to be replaced. The emergency kit dose log for Emergency Kit 1 showed the medication sodium polystyrene sulfonate suspension (medication used to treat a high level of potassium in blood) was removed on 4/24/24. LVN 2 verified the observation and stated the Emergency Kit 1 was opened since 4/24/24. LVN 2 stated the staff who opened the emergency kit should have notified the pharmacy immediately after opening and the pharmacy should replace the emergency kit within 72 hours. On 4/30/24 at 1213 hours, during the inspection of Medication Storage room [ROOM NUMBER] with LVN 2, the Emergency Kit 2 for the intravenous medications was observed to be locked with a red zip tie. The emergency kit dose log for Emergency Kit 2 showed the following: - Invanz 4 gm (antibiotic) was removed on 4/25/24; - Normal saline (mixture of sodium chloride and water) 500 ml was removed on 4/25/24; and, - Normal saline 1 liter was removed on 4/26/24. LVN 2 verified the observation and stated the Emergency Kit 2 was opened since 4/25/24. LVN 2 stated the staff who opened the Emergency Kit 2 should have notified the pharmacy immediately after opening and the pharmacy should have replaced the Emergency Kit 2 within 72 hours. On 4/30/24 at 1240 hours, a telephone interview was conducted with the Pharmacy Technician. The Pharmacy Technician stated the emergency kit should be replaced the same day or the next day after opening. The Pharmacy Technician was informed of the above findings and verified the pharmacy did not receive the notification for the Emergency Kits 1 and 2 to be replaced in the facility when Emergency Kit 1 was opened on 4/24/24, and Emergency Kit 2 was opened on 4/25/24. On 4/30/24 at 1129 hours, an interview was conducted with RN 1. RN 1 was informed and acknowledged the above findings.

CONCERN (D)

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure three of five final sampled residents (Residents 6, 15, and 937) reviewed for unnecessary medications were properly monitored for their medications. * Resident 15 was administered Humulin N insulin (an intermediate acting insulin, a medication used to lower blood glucose or sugar) without monitoring Resident 15's blood sugar as per the physician's order. * Resident 937 was administered hydralazine (medication to treat high blood pressure) when Resident 937's blood pressure was below the parameter prescribed by the physician. * Resident 6 was administered metoprolol (medication to treat high blood pressure) when Resident 6's blood pressure was below the parameter prescribed by the physician. These failures had the potential for Residents 6, 15, and 937 to develop significant side effects from the medications. Findings: 1. Medical record review for Resident 15 was initiated on 4/30/24. Resident 15 was readmitted to the facility on [DATE]. Review of Resident 15's Order Summary Report showed a physician's order dated 2/6/24, to administer Humulin N (antidiabetic medication/insulin) 12 units subcutaneously (given in the fatty tissue, just under the skin) at bedtime. May hold if blood sugar below 90 mg/dl. Review of Resident 15's Insulin/BS Orders for March, April and May 2024 showed Resident 15 was administered Humulin N insulin from 3/1 to 5/1/24 at 2100 hours. However, Resident 15's blood sugar was not monitored prior to the administration of Humulin N insulin. Further review of Resident 15's medical record failed to show documented evidence Resident 15's blood sugar was monitored prior to the administration of Humulin N insulin at bedtime. On 5/3/24 at 1016 hours, an interview and concurrent medical record review for Resident 15 was conducted with RN 1. RN 1 verified the above findings. RN 1 verified Resident 15's blood sugar was not monitored prior to the administration of Humulin N insulin at bedtime. 2. Medical record review for Resident 937 was initiated on 4/30/24. Resident 937 was readmitted to the facility on [DATE]. Review of Resident 937's Order Summary Report showed a physician's order dated 9/23/22, to administer hydralazine (medication use for high blood pressure) 50 mg one tablet via GT every eight hours every Tuesday, Thursday, Saturday, and Sunday. May hold if the systolic blood pressure was below 120 mmHg and on the hemodialysis days. Review of Resident 937's MARs for March and April 2024 showed Resident 937 was administered the hydralazine medication when the resident's systolic blood pressure was below 130 mmHg as follows: - On 3/5/24 at 1400 hours, with a blood pressure of 114/64 mmHg; - On 3/12/24 at 0600 hours, with a blood pressure of 117/66 mmHg; - On 3/14/24 at 2200 hours, with a blood pressure of 111/61 mmHg; - On 3/16/24 at 0600 hours, with a blood pressure of 119/62 mmHg; - On 3/16/24 at 2200 hours, with a blood pressure of 114/64 mmHg; - On 3/23/24 at 0600 hours, with a blood pressure of 116/63 mmHg; - On 3/26/23 at 0600 hours, with a blood pressure of 119/72 mmHg; - On 4/2/24 at 2200 hours, with a blood pressure of 119/63 mmHg; - On 4/4/24 at 2200 hours, with a blood pressure of 118/67 mmHg; - On 4/6/24 at 0600 hours, with a blood pressure of 116/66 mmHg; - On 4/7/24 at 2200 hours, with a blood pressure of 114/60 mmHg; - On 4/18/24 at 2200 hours, with a blood pressure of 117/67 mmHg; - On 4/23/24 at 0600 hours, with a blood pressure of 115/63 mmHg; - On 4/23/24 at 1400 hours, with a blood pressure of 117/51 mmHg; - On 4/25/24 at 0600 hours, with a blood pressure of 119/62 mmHg; - On 4/28/24 at 0600 hours, with a blood pressure of 116/70 mmHg; and - On 4/30/24 at 0600 hours, with a blood pressure of 116/61 mmHg. On 5/3/24 at 1025 hours, an interview and concurrent medical record review for Resident 937 was conducted with RN 1. RN 1 verified the hydralazine medication was administered to Resident 937 when her blood pressure was below the parameter prescribed by the physician. 3. Medical record review for Resident 6 was initiated on 4/30/24. Resident 6 was admitted to the facility on [DATE]. Review of Resident 6's Order Summary Report showed a physician's order dated 8/1/23, to administer metoprolol 12.5 mg via GT every six hours. May hold if the systolic blood pressure was below 110 mmHg or heart rate was below 60 beats per minute. Review of Resident 6's MARs for March and April 2024 showed Resident 6 was administered the metoprolol medication when the resident's systolic blood pressure was below 110 mmHg or the heart rate was below 60 beats per minute as follows: - On 3/11/24 at 2400 hours, with a blood pressure of 98/73 mmHg; - On 3/11/24 at 0600 hours, with a blood pressure of 108/69 mmHg; - On 3/11/24 at 1800 hours, with a blood pressure of 102/61 mmHg; - On 3/18/24 at 2400 hours, with a blood pressure of 108/78 mmHg; - On 4/1/24 at 2400 hours, with a heart rate of 55 beats per minute; - On 4/2/24 at 2400 hours, with a blood pressure of 105/60 mmHg; - On 4/2/24 at 0600 hours, with a blood pressure of 105/65 mmHg; - On 4/12/24 at 2400 hours, with a blood pressure of 108/63 mmHg; - On 4/12/24 at 0600 hours, with a blood pressure of 104/65 mmHg; - On 4/14/24 at 1800 hours, with a blood pressure of 96/58 mmHg; - On 4/16/24 at 0600 hours, with a blood pressure of 107/65 mmHg; and - On 4/17/24 at 1800 hours, with a heart rate of 54 beats per minute. On 5/3/24 at 1030 hours, an interview and concurrent medical record review for Resident 6 was conducted with RN 1. RN 1 verified the metoprolol medication was administered to Resident 6 when her blood pressure and heart rate were below the parameters prescribed by the physician.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. On 4/30/24 0846 hours, during the initial tour of the facility, Resident 837 was observed lying in bed. One bottle of Guayabron Suplemento Alimentico (nutritional supplement) was observed on top of Resident 837's bedside cabinet. Medical record review for Resident 837 was initiated on 4/30/24. Resident 837 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 837's H&P examination dated 7/19/23, showed the resident did not have the capacity to understand and make decisions. On 4/30/24 at 1021 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified the findings. LVN 1 stated Resident 837's family member brought in the Guayabron Suplemento Alimentico. LVN 1 stated the medication should not have been left on top of Resident 837's bedside cabinet. On 5/3/24 at 1422 hours, an interview was conducted with the Administrator. The Administrator was informed and acknowledged the above findings. 5. Review of the facility's P&P titled Medication Storage in the Facility: Storage of Medications revised 1/2018 showed the medications and biologicals are stored safely, securely, and properly following the manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed personnel, pharmacy personnel, or staff members lawfully authorized to administer medications . On 4/30/24 at 0829 hours, during the initial tour of the facility, a medication cup containing white cream was observed to be on the bedside table of Resident 539. On 4/30/24 at 0939 hours, an interview and concurrent interview was conducted with LVN 3. LVN 3 verified the findings and stated it should not have been left on Resident 539's bedside table because anyone could have used it. Medical record review for Resident 539 was initiated on 4/30/24. Resident 539 was admitted to the facility on [DATE].Based on observation, interview, and facility P&P review, the facility failed to ensure the medications were safely and securely stored. * The facility failed to ensure the medication cart did not have an expired bottle of Dakins solution (wound cleanser) for one of seven medication carts (Treatment Cart 1). * The facility failed to ensure Medication Cart A was not left unlocked and unattended. * The facility failed to ensure the safe storage of a medication cup containing a white cream found at Resident 937's bedside. * The facility failed to ensure the safe storage of two opened packets of Vitamin A and D ointment found at Resident 19's bedside. * The facility failed to ensure safe storage of one bottle of Guayabron Suplemento Alimentico (nutritional supplement) found at Resident 837's bedside cabinet. These failures posed the risk of unauthorized access to the medications and had the potential for the residents to have received expired medications. Findings: Review of the facility's P&P titled Storage of Medications revised 11/2020 showed the facility stores all drugs and biologicals in a safe, secure, and orderly manner. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. 1. On 4/30/24 at 1451 hours, during the inspection of Treatment Cart 1 and concurrent interview with LVN 3, a bottle of Dakin's solutions with an expiration date of 12/2023, was observed in the bottom drawer of Treatment Cart 1. LVN 3 verified the observation and stated the expired bottle of Dakin's solutions should not have been stored in the treatment cart. 2. On 5/2/24 at 0755 and 0758 hours, Medication Cart A parked in the hallway was observed to be unlocked and unattended. Staff were observed passing by. On 5/2/24 at 0800 hours, an observation of Medication Cart A and concurrent interview was conducted with LVN 9. LVN 9 verified she left Medication Cart A unlocked and unattended. LVN 9 stated she forgot to lock Medication Cart A. 3. On 4/30/24 at 0823, 0830, and 0900 hours, during the initial tour of the facility, a medication cup containing a white cream was observed on the bedside table in Resident 937's room. On 4/30/24 at 0936 hours, an observation for Resident 937 and concurrent interview was conducted with LVN 2. A medication cup containing a white cream was observed on the bedside table in Resident 937's room. LVN 2 verified the above findings. LVN 2 stated he was not sure what the cream was inside the medication cup, and it should not have been left at Resident 937's bedside unattended. Medical record review for Resident 937 was initiated on 4/30/24. Resident 937 was admitted to the facility on [DATE], and readmitted on [DATE]. 4. On 4/30/24 at 0846, 0902 and 0912 hours, during the initial tour of the facility, two opened packets of Vitamins A and D ointment were observed on the bedside table in Resident 19's room. On 4/30/24 at 0930 hours, an observation for Resident 19 and concurrent interview was conducted with LVN 9. Two opened packets of Vitamins A and D ointment were observed on the bedside table in Resident 19's room. LVN 9 verified the above findings. LVN 9 stated she was not sure why there were opened packets of Vitamins A and D ointment at the resident's bedside, and the ointment packets should not have been left at Resident 19's bedside unattended. Medical record review for Resident 19 was initiated on 4/30/24. Resident 19 was admitted to the facility on [DATE], and readmitted on [DATE].

CONCERN (D)

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

Deficiency F0813 (Tag F0813)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the facility's P&P on Resident Food From Outside Sources was updated and followed as evidence by: * The facility failed to ensure food items in the residents' refrigerator was labeled and dated. * The facility failed to ensure the policy was updated to meet state regulations. * The facility failed to ensure the visitors and staff were educated on safe food handling of outside food. These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food brought from outside sources. Findings: 1. Review of the facility's P&P titled Bringing in Food for a Resident dated 2023 showed food or beverages should be labeled and dated to monitor for food safety. Food or beverages in the original containers marked with manufacturer expiration dates and unopened, need to be marked with resident's name. Food in unmarked or unlabeled containers will be marked with the current date and the resident's name. On 4/30/24 at 1115 hours, a concurrent observation and interview with LVN 8 was conducted. The following items were observed: - One container of sour cream and one packet of cream cheese not labeled or dated, marked 46 C - One carton of Silk soy milk not labeled or dated, marked 16 B - Two Siggis Yogurt not labeled or dated, marked 16 B - Two So Delicious dark chocolate truffle ice cream not labeled or dated, marked 16 B - One Bibigo Kimchi & Cheese [NAME] Ball not dated - One [NAME] Taco bag not labeled or dated - Four frozen cylinder-shaped packages of unknown origin not labeled or dated, marked 10 B LVN 8 verified the above findings. LVN stated the food brought from outside should be labeled with the resident's name and dated, not just the resident's room number. 2. Review of CMS S&C-09-39 dated 5/29/09, showed the residents have the right to choose to accept food from visitors, family, friends, or other guests according to their rights to make choices. Review of the state regulations dated 2/3/23, showed the facility must have a policy regarding use and storage of the foods brought to the residents by the resident's family and other visitors to ensure safe and sanitary storage, handling, and consumption. Review of the facility's P&P titled Food For Residents From Outside Sources dated 2023 showed prepared food brought in for the resident must be consumed within one hour of receiving it in an effort to prevent food borne illness. Unused food will be disposed of immediately thereafter. Review of the facility's P&P titled Bringing in Food for a Resident dated 2023 showed no food will be shared with other residents or staff, unless approved by a nurse or Food & Nutrition Services Director. On 5/2/24 at 1117 hours, an interview with the Administrator and DSS was conducted. The Administrator and DSS verified the findings and stated they were unaware the P&P for food brought from outside sources was outdated. The Administrator and DSS acknowledged the above findings. 3. Review of CMS S&C-09-39 dated 5/29/09, showed the residents have the right to choose to accept food from visitors, family, friends, or other guests according to their rights to make choices. The CMS guideline further shows the facility has the responsibility under the food safety regulation to help the visitors to understand safe food handling practices such as not holding or transporting foods containing perishable ingredients at temperatures above 41 degrees Fahrenheit. Further review of the facility's P&P titled Food For Residents From Outside Sources dated 2023 showed no documented evidence of a safe food handling instructions provided to the visitors or residents' family members in bringing food from outside. On 4/30/24 at 1128 hours, an interview with the DSD was conducted. When asked if she provided visitors information on safe food handling, the DSD verified she did not. The DSD stated the DSS provided the visitors education on safe food handling. On 4/30/24 at 1438 hours, an interview with the DSS was conducted. When asked if he provided the visitors or staff information on safe food handling of food brought from outside, the DSS verified he did not. On 5/2/24 at 1117 hours, an interview with the Administrator and DSS was conducted. The Administrator and DSS verified and acknowledged all of the above findings.

CONCERN (D)

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

Garbage Disposal (Tag F0814)

Could have caused harm · This affected 1 resident

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Based on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the facility's garbage and refuse was properly disposed as evidence by: * The facility failed to ensure two of two waste dumpsters were properly closed. * The facility failed to ensure the organic waste and recycling barrels were used as per state mandate SB1383. * The facility failed to ensure the area behind the waste dumpsters were free from debris. These failures had the potential to cause unsafe sanitary conditions and potential to harbor pests and rodents. Findings: 1. According to the USDA Food Code 2022, Section 5-501.11 Storing Refuse, Recyclables, and Returnables showed refuse, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. According to the USDA Food Code 2022, Section 5-501.113 Covering Receptacles: Receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered. (A) Inside the food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use (2) After they are filled; and (B) With tight-fitting or doors if kept outside the food establishment. Review of the facility's P&P titled Miscellaneous Areas - Trash Procedure dated 2023 showed the garbage and trash cans must be inspected daily that no debris is on the ground or surrounding area, and that the lids are closed. On 4/30/24 at 1049 hours, a concurrent observation and interview was conducted with the Maintenance Supervisor. One waste dumpster was propped open with an orange plastic stick and a second waste dumpster was overflowing with trash. The Maintenance Supervisor verified the findings and stated the waste dumpster lids should be closed. 2. Review of the Senate [NAME] (SB) 1383 regulation dated 1/1/22, showed every jurisdiction was to provide organic waste collection services to all residents and businesses. Jurisdiction includes city, county, a city and county, or a special district that provides solid waste collection services. Organic waste includes food, green material, landscape and pruning waste, organic textiles and carpets, lumber, wood, paper products, printing and writing paper, manure, biosolids, digestate, and sludges. On 4/30/24 at 1049 hours, a concurrent observation and interview was conducted with the Maintenance Supervisor. One organic waste barrel with a green lid and one recycle barrel with a blue lid were observed kept to the side of the wall adjacent to the two waste dumpsters. The Maintenance Supervisor stated the facility did not use the organic waste and recycle barrels because CNAs were using the barrels as regular trash can. The Maintenance Supervisor further stated it was too difficult to keep training the staff. 3. According to the USDA Food Code 2022, Section 5-501.115 Maintaining Refuse Areas and Enclosures showed a storage area and enclosure for refuse, recyclables, or returnables shall be maintained free of unnecessary items and clean. According to the USDA Food Code 2022, Section 5-501.116 Cleaning Receptacles: (B) Soiled receptacles and waste handling units for refuse, recyclables, and returnables shall be cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming attractants for insects and rodents. On 5/1/24 at 0928 hours, a concurrent observation and interview was conducted with the Maintenance Supervisor. Observed were debris including dried leaves, twigs, broken branches, and four unused laundry barrels were stored behind the two waste dumpsters. The Maintenance Supervisor stated the trees above the area were trimmed and the branches were not cleaned up. The Maintenance Supervisor verified the findings and stated the gardener was in charge of cleaning out the area. The Maintenance Supervisor further verified the potential for rodents and pests to harbor amongst the branches and leaves. On 5/2/24 at 1117 hours, an interview was conducted with the Administrator and DSS. The Administrator and DSS verified and acknowledged all of the above findings.

CONCERN (D)

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

Deficiency F0849 (Tag F0849)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure Resident 387's hospice visit notes and cares provided were part of the resident's medical record. This failure resulted in Resident 387's hospice schedule and provided cares not being communicated to the facility staff, which had the potential to negatively impact the resident's well-being. Findings: Medical record review for Resident 387 was initiated on 4/30/24. Resident 387 was admitted to the facility on [DATE]. Review of Resident 387's Order Summary Report dated 5/1/24, showed the following physician's orders: - dated 10/4/23, to admit the resident to hospice services. - dated 10/4/24, for a hospice nurse to drain Resident 387's Aspira drain (a tunneled drain used to drain accumulated fluid from the peritoneal cavity) monthly or as needed. - dated 10/4/24, for the hospice nurse to provide care for the resident's Aspira drain. - dated 10/4/24 for the hospice RN to visit twice a week, the health aid to visit twice a week, the social worker to visit once a month and the chaplain to visit once a month. Review of Resident 387's hospice POC (Plan of Care) Summary 9/20/23, showed the following: - HA twice a week for assistance with the ADL care. - Nursing staff twice a week to drain Aspira catheter (a tunneled, long-term catheter used to drain accumulated fluid from the pleural or peritoneal cavity to relieve symptoms associated with pleural effusion or malignant ascites) symptom management and three PRN (as needed) visits. -SW twice per month and two PRN visits (as needed). Review of Resident 387's Hospice Re-Cert assessment dated [DATE], showed Resident 387 needed a hospice aide for grooming and linen change. Review of Resident 387's Communication/Sign-In Sheets inside the hospice binder showed the hospice staff visits were conducted 65 times from 10/4/24 through 4/30/24. The log had areas for the date, time, staff name, discipline, and comments. Review of Resident 387's medical record and hospice binder failed to show the calendar of the hospice staff's planned visits and failed to show what cares were provided by the hospice staff on each visit, including when the resident's Aspira drain was drained, the amount and appearance of the drainage, as well as the drain's site appearance and maintenance. On 5/2/24 at 1056 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated he believed Resident 387's hospice nurses came weekly and the health aides came three times a week, sometimes two. When asked where their schedule was, LVN 1 reviewed Resident 387's medical record and hospice binder but was unable to locate a schedule for the hospice staff visits. LVN 1 stated usually the hospice aides did the showers on Monday, Wednesday, and Fridays, but sometimes they did not show up so he would ask the facility CNA to bathe the resident. LVN 1 stated the hospice aides would sometimes make the resident's bed and clean up the resident's room a little bit, but he was not aware of any other cares provided by the hospice aides . LVN 1 reviewed the Communication/Sign-In Sheets and verified the hospice staff visits. When asked where the detailed notes about the resident's cares and assessments were located, LVN 1 was unable to locate any in the resident's medical records and Communication/Sign-In Sheets.

CONCERN (D)

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

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected 1 resident

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Based on interview, facility document review, and facility P&P review, the facility failed to inform the physician of the residents with prescribed antibiotics with signs and symptoms not meeting McGeer's Criteria (criteria used by long-term care facilities to determine a true infection). This failure had the potential for antibiotics to be used when not indicated and development of antibiotic resistant bacteria. Findings: According to the Centers for Disease Control and Infection (CDC), an estimated 70% of nursing home residents receive one or more courses of antibiotics during a year. Studies have shown that 40% to 75% of the antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Frail and older adults are at significant risk of harm from antibiotic overuse including increased adverse drug events, increased drug interactions and infection with antibiotic-resistant organisms. The World Health Organization (WHO) cites antibiotic resistance as one of the three biggest threats to human health. Review of the facility's P&P titled Antibiotic Stewardship Orders for Antibiotics revised 12/2016 showed the antibiotics will be prescribed and administered to the residents under the guidance of the facility's antibiotic stewardship program. Appropriate indications for the use of antibiotics include criteria met for clinical definition of active infection. Review of the facility's P&P titled Antibiotic Stewardship Review and Surveillance of Antibiotic Use and Outcomes revised 12/2016 showed the Infection Preventionist will review the antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. At the conclusion of the review, the provider will be notified of the review findings. On 5/1/24 at 1354 hours, an interview and concurrent facility document review was conducted with the IP. The IP stated she completes the Surveillance Data Collection and the monthly Infection Control Surveillance. Review of the Surveillance Data Collection and the monthly Infection Control Surveillance from January to March 2024 showed mismatch of information in meeting the McGeer's criteria. The Infection Control Surveillance Data Collection from January through March 2024 showed the following residents with prescribed antibiotics and did not meet the Mcgeer's criteria on the following entry dates: a. Resident 1039 dated 1/9/24 b. Resident 387 dated 1/23/24 c. Resident 24 dated 1/11/24 d. Resident 1040 dated 1/18/24 e. Resident 1041 dated 1/18/24 f. Resdient 1042 dated 1/22/24 g. Resident 39 dated 1/4/24 h. Resident 1043 dated 2/6/24 i. Resident 838 dated 2/8/24 j. Resident 1044 dated 2/10/24 k. Resident 1045 dated 2/19/24 l. Resident 387 dated 2/19/24 m. Resident 388 dated 2/23/24 n. Resident 389 dated 2/29/24 o. Resident 1089 dated 2/3/24 p. Resident 42 dated 2/25/24 q. Resident 33 dated 3/1/24 r. Resident 389 dated 3/3/24 s. Resident 33 dated 3/20/24 t. Resident 1046 dated 3/1/4/24 u. Resident 26 dated 3/19/24 v. Resident 21 dated 3/25/24 x. Resident 26 dated 3/25/24 y. Resident 34 dated 3/26/24 z. Resident 1047 dated 3/28/24 aa. Resident 44 dated 3/19/24 bb. Resident 1048 dated 3/11/24 cc. Resident 39 dated 3/14/24 The IP stated as per the facility's P&P, the physicians should be notified of the residents who did not meet the McGeer's criteria as to avoid the unnecessary use of antibiotics. The IP stated the unnecessary antibiotic use could potentially result in adverse reactions to the medications and the development of MDRO's. The IP was asked to provide documentation if the physician was notified of the residents with prescribed antibiotics whose signs and symptoms had not met the McGeer's Criteria from January through March 2024. The IP was unable to provide any documentation the physician had been notified for the residents with prescribed antibiotics whose signs and symptoms had not met McGeer's Criteria from January through March 2024. The IP stated she had not informed the physician and should have when the McGeer's Criteria had not been met for residents prescribed antibiotics during from January through March 2024.

CONCERN (D)

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

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the pneumococcal vaccines were offered and administered to five of 11 final sampled residents reviewed for the pneumococcal vaccines (Residents 2, 6, 15, 16 and 937). This failure posed the risk for the residents to contract pneumonia. Findings: Review of the facility's P&P titled Pneumococcal Vaccine revised 3/2022 showed all the residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Before receiving a pneumococcal vaccine, the resident or legal representative will receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provisions of such education is documented in the resident's medical record. Residents/representatives have the right to refuse vaccination. If refused, appropriate information is documented in the resident's medical record indicating the date of the refusal of the pneumococcal vaccination. Medical record review for Residents 2, 6, 15, 16, and 937 were initiated on 5/1/24, and showed the following: - Resident 2 was admitted in the faclity 3/25/21 and was readmitted [DATE] - Resident 6 was admitted to the facility 8/1/23 - Resident 15 was admitted to the faility last 8/5/23 and was readmitted [DATE] - Resident 16 was admitted to the facility last 7/27/17 and was readmitted [DATE] - Resident 937 was admitted to the facility 7/21/22 and was readmitted [DATE] Review of Residents 2, 6, 15, and 16's medical records failed to show the consents for the pneumonoccal vaccines. There was no indication whether the pneumococcal vaccines were offerred to the residents. Review of Resident 937's medical record showed the resident last received the pneumococcal vaccine on 9/22/22, however there was no consent form in the medical record. On 5/1/24 at 1354 hours, an interview and concurrent medical record review was conducted with the IP. The IP verified there were no consent forms in Residents 2, 6, 15, 16, and 937's medical records, and the residents were not offerred the pneumococcal vaccines. The IP acknowledged all the residents should have consents for the pneumococcal vaccine to clearly indicate if a resident refused the pneumococcal vaccine or not.

CONCERN (D)

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

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected 1 resident

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Based on interview, medical record review, and facility P&P review, the facility failed to ensure three of five final sampled residents reviewed for Covid-19 vaccines (Residents 6, 15, and 16) were offered the Covid-19 vaccine. This failure resulted in the residents not receiving the vaccine in a timely manner once they were eligible to receive it, which had the potential to negavetively impact the residents' well-being. Findings: Review of the facility's P&P titled Vaccination of Residents revised October 2019, showed all the residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated. Provision of such education shall be documented in the resident's medical record. If vaccines are refused, the refusal shall be documented in the resident's medical record. If the resident receives a vaccine, at least the following information shall be documented in the resident's medical record: a. site of administration b. Date of administration; c. Lot number of the vaccine (located on the vial); d. expiration date ( located on the vial ; and e. Name of Person administering the vaccine. On 5/1/24 at 1354 hours, a concurrent interview and medical record review for Residents 6, 15, and 16 was conducted with the IP. The IP stated the facility had provided consents and vaccinations for Covid-19 to the residents. The IP verified Residents 6, 15, and 16's consents for Covid-19 were missing and the residents should have been offerred the vaccination. On 5/3/24 at 1440 hours, an interview was conducted with RN 1. RN 1 verified Residents 6, 15, and 16 did not have consents in their medical record to receive the Covid-19 vaccine. RN 1 further stated they should have been offerred the Covid-19 vaccines.

CONCERN (E)

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

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 5/3/24 at 1202 hours, Resident 7 was observed in bed with bilateral half side rails. Medical record review for Resident 7 was initiated on 4/30/24. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's medical record failed to show documented evidence the physician's order and informed consent were obtained prior to the use of the bilateral half side rails. Review of Resident 7's Bed Safety Rail assessment dated [DATE], showed Resident 7 was not likely to fall from bed, and rail may not be appropriate. Review of Resident 7's Risk and Benefits of Bedrails Review and Acknowledgement form dated 11/12/20, showed Resident 7 was not capable of independently releasing the bedrail. On 5/3/24 at 1203 hours, an observation and concurrent interview was conducted with LVN 10. LVN 10 verified Resident 7 had bilateral half side rails elevated while in bed. LVN 10 stated Resident 7 was unable to move in bed and the side rails would have to be removed from the bed. On 5/3/24 at 1222 hours, an interview and concurrent medical record review was conducted with the IP for Resident 7. The IP verified the above findings. On 5/3/24 at 1223 hours, an interview and concurrent medical record review was conducted with the DMR. The DMR verified there was no informed consent for Resident 7's side rails. On 5/3/24 1341 hours, a telephone interview was conducted with Conservator 1 for Resident 7. When asked if he was made aware by the facility staff about Resident 7's side rails, he stated, no. On 5/3/24 at 1401 hours, a telephone interview was conducted with RCC 1 for Resident 7. When asked asked if she was made aware by the facility staff about Resident 7's side rails, RCC 1 stated, I did not know that she had side rails. On 5/3/24 1408 hours, an interview and concurrent medical record review was conducted with RN 1 for Resident 7. RN 1 verified the above findings and stated the bed side rails for Resident 7 should not be elevated. RN 1 stated the assessments for side rails were completed on admission, quarterly and as needed. 4. On 5/3/24 at 1212 hours, an observation and concurrent interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor verified Resident 10 had bilateral half side rails. Medical record review for Resident 10 was initiated on 4/30/24. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's H&P examination dated 8/1/23, showed Resident 10 had did not have the capacity to understand and make decisions. Review of Resident 10's medical record failed to show documented evidence a physician's order and informed consent were obtained prior to the use of the bilateral half side rails. Review of Resident 10's Bed Safety Rail assessment dated [DATE], showed Resident 10 was likely to fall from bed, and clinical physical condition would increase the risk of entrapment or other injury. Review of Resident 10's Risk and Benefits of Bedrails Review and Acknowledgement form dated 8/2/23, showed the section for resident's surrogate decision maker/ legally recognized decision maker was blank and not signed. In addition, the boxes to show if an authorization was given or refused for the use of the bedrail(s) were not marked. On 5/3/24 at 1408 hours, an interview and concurrent medical record review were conducted with RN 1 for Resident 10. RN 1 verified the above findings. On 5/3/24 at 1422 hours, an interview was conducted with the Administrator. The Administrator was informed and acknowledged the above findings. 5. On 4/30/24 at 0829 hours, during the initial tour, Resident 539 was observed to be laying in bed with bilateral half side rails elevated. Medical record review for Resdient 539 was initiated on 5/3/24. Resident 539 was admitted to the facility on [DATE]. Review of Resident 539's H&P examination dated 9/3/23, showed Resident 539 had the capacity to understand and make decisions. Further review of Resident 539's medical record failed to show for the physician's order, informed consent, and careplan for the bilateral half side rails for Resident 539. On 5/3/24 at 1426 hours, an observation and concurrent interview was conducted with LVN 1. Resident 539 was observed laying in bed with bilateral half side rails elevated. LVN 1 verfied Resident 539's medical record did not have the physician's order, informed consent, and careplan for the bilateral half side rails. LVN 1 further stated Resident 539's family requested for the side rails to be up for safety, however, LVN 1 stated the physician's order, informed consent, and careplan should be completed. On 05/03/24 at 1443 hours, an interview was conducted with RN 1. RN 1 acknowledged and verified the above findings. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the assessment for the risk for entrapement, physician's order and informed consent were obtained prior to the use of side rails for five of 11 final sampled residents (Residents 20, 40, 8, 7, and 15) and two nonsampled (Residents 10 and 539) reviewed for side rails. This failure had the potential to place the residents at risk for entrapment and serious injury. Findings: Review of the facility's P&P titled Bed Safety and Bed Rails revised 08/2022 showed the following: - The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use of alternatives, interdisciplinary evaluation, resident assessment, and informed consent; and - Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent. The following information will be included in the consent: -(a) The assessed medical needs that will be addressed with the use of bed rails; -(b) The resident's risks from the use of bed rails and how there will be mitigated; -(c ) The alternatives that were attempted but failed to meet the resident's needs; and -(d) The alternatives that were considered but not attempted and the reasons. 1. On 5/1/24 at 0845 hours, 1150 hours, and 1400 hours, Resident 20 was observed laying in bed with the bilateral upper half side rails elevated. Medical record review was initiated on 4/30/24. Resident 20 was admitted to the facility on [DATE]. Review of Resident 20's H&P examination dated 1/29/24, showed Resident 20 had fluctuating capacity to understand and make medical decisions. Review of Resident 20's Order Summary Report as of 5/1/24, failed to show the physician's order for the use of bilateral half side rails. Review of Resident 20's Risk and Benefits of Bedrails Review and Acknowledgement form showed incomplete and undated form. The purpose of bedrail, type of bedrail, potential risk and potential benefits were not marked. The section for resident's surrogate decision maker/ legally recognized decision maker and the name/title of the license nurse were blank and not signed. Review of Resident 20's Bed Safety Rail assessment dated [DATE], showed Resident 20 was not likely to fall from bed. Review of Resident 20's Physical Restraint assessment dated [DATE], showed the IDT had no recommendation for any physical restraint. Further review of Resident 20's medical record failed to show the documented evidence of the siderail entrapment assessment was completed and documented. On 5/3/24 at 1028 hours, an interview was conducted with LVN 1. LVN 1 stated Resident 20 uses the bilateral upper half side rails when in bed for safety. On 5/3/24 at 1034 hours, an interview and concurrent medical record review were conducted with RN 3. RN 3 verified Resident 20's medical record failed to show a physician's order for the use of bilateral upper half side rails, and the plan of care failed to show interventions for the use of bilateral upper half side rails. RN 3 also verified Resident 20's Benefits of Bedrails Review and Acknowledgement form were incompletely filled out and had no date. On 5/3/24 at 1430 hours, an interview was conducted with RN 1. RN 1 was informed and acknowledged findings as above. 2. On 5/1/24 at 0815 hours, 5/2/24 at 0800 hours, and 5/3/24 at 0945 hours, Resident 40 was observed laying in bed with bilateral half side rails elevated. Medical record review for Resident 40 was initiated on 4/30/24. Resident 40 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 40's H&P examination dated 2/1/24, showed Resident 20 had the capacity to understand and make decisions. Review of Resident 40's admission MDS assessment dated [DATE], showed BIMS Summary Score of 12 (moderate impairment of cognition). The resident was able to make self-understood and understand others. Resident 40's functional abilities showed functional limitation impairment of one side of upper and lower extremity. Review of Resident 40's Order Summary Report as of 5/1/24 failed to show the physician's order for the use of bilateral half side rails. Review of Resident 40's Risk and Benefits of Bedrails Review and Acknowledgement form dated 2/1/24, showed the form was incomplete. The purpose of bedrail, type of bedrail, potential risk and potential benefits were not marked. The form showed checked mark on refuse to give my authorization for the use of the bedrail(s). The resident/ surrogate decision maker/ legally recognized decision maker was not signed by the resident. Review of Bed Safety Rail assessment dated [DATE], showed Resident 20 was not likely to fall from bed, rail may not be appropriate. Review of Physical Restraint assessment dated [DATE], showed the IDT had no recommendation for any physical restraint. On 5/3/24 at 0945 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 stated Resident 40 used the bilateral upper half side rails as enabler. LVN 4 verified Resident 40's medical record failed to show a physician's order for the use of bilateral upper half side rails, and the plan of care failed to show intervention for the use of bilateral upper half side rails. Resident 40's Benefits of Bedrails Review and Acknowledgement form was incompletely filled out and not signed by the resident. On 5/3/24 at 1430 hours, an interview was conducted with RN 1. RN 1 stated Resident 40 did not want the use of bed side rail at the time of the assessment and had been using the side rails recently. RN 1 stated he will update the assessment and get an order for the use of bilateral upper half side rails elevated when in bed. Cross reference to F909, examples #7 and #8. 6. On 4/30/24 at 0855 hours, Resident 8 was observed in bed with bilateral half side rails elevated. Medical record review for resident 8 was initiated on 5/1/24. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's Risks and Benefits of Bedrail Review and Acknowledgment dated 8/16/21, showed under potential benefits, it was the resident's preference for the use of bedrails. However, the acknowledgment form was not signed by the resident or the legally recognized decision maker. Review of the Physical Restraint assessment dated [DATE], showed no need for any physical restraints at this time. Review of the Bed Safety Rail assessment dated [DATE], showed Resident 8 was not likely to fall from bed and rail may not be appropriate. Further review of Resident 8's medical record failed to show documented evidence of signed informed consent, physician's order, and plan of care for the use of bilateral side rails. On 5/3/24 at 1043 hours, an interview and concurrent medical record review was conducted with RN 3. RN 3 stated Resident 8 used the bilateral side rails as an enabler. RN 3 verified the Risks and Benefits of Bedrail Review and Acknowledgment form was not signed by the resident or their legal representative. RN 3 also verified there were no physician's order, informed consent, and plan of care for the use of the bilateral side rails. Cross reference with F909, example #9. 7. On 4/30/24 at 0828 hours, during the initial facility tour, Resident 15 was observed sitting in the wheelchair. Bilateral half side rails were observed elevated. Resident 15 was observed eating by herself, and CNA 6 was observed at bedside. When asked about the bilateral half side rails, Resident 15 stated she used the side rails, and CNA 6 stated Resident 15 only used the left side rail. On 5/2/24 at 0741 hours, and 5/3/24 at 0837 hours, Resident 15 was observed in bed with left half side rails elevated. Medical record review for Resident 15 was initiated on 5/6/24. Resident 15 was readmitted to the facility on [DATE]. Review of Resident 15's H&P examination dated 12/3/23, showed Resident 15 had the capacity to understand make decisions. Review of Resident 15's Risks and Benefits of Bedrail Review and Acknowledgement dated 12/4/23, did not show whether Resident 15 consented to the use of side rail. In addition, the form did not show the type of bedrail, and potential risks and benefits related to side rail use. Review of Resident 15's Bed Safety Rail assessment dated [DATE], showed Resident 15 was not likely to fall from bed. The assessment form showed rail may not be appropriate. Review of Resident 15's Bed Safety Rail assessment dated [DATE], showed Resident 15 was not likely to fall from bed. The assessment form showed rail may not be appropriate. Review of Resident 15's Physical Restraint Assessment 2.0 dated 3/12/24, under Physical Restraint Assessment, showed the pillows were used as a less restrictive measure, and the IDT recommendation was no recommendation for any physical restraints at this time. Review of Resident 15's Order Summary Report showed a physician's order dated 5/2/24, to provide left half side rail every shift for feelings for safety. Further review of Resident 15's medical record did not show an informed consent was obtained from Resident 15 related to the use of side rails. In addition, there was no bed safety rail assessment and physician's order for the use of side rails, which was initially observed on 4/30/24. On 5/3/24 at 1016 hours, an interview and concurrent medical record review for Resident 15 was conducted with RN 1. RN 1 verified the above findings. RN 1 was informed Resident 15 was observed with bilateral half side rails during the initial facility tour on 4/30/24. RN 1 verified the physician's order for the side rails was dated 5/2/24. When asked about the Risks and Benefits of Bedrail Review and Acknowledgement dated 12/4/23, RN 1 verified it was incomplete. When asked about the Bed Safety Rail Assessment, RN 1 verified the assessment form showed side rail may not be appropriate. When asked if an IDT review for Resident 15 was conducted related to the use of side rail, RN 1 stated an IDT review would be conducted only if the side rails were being used as restraint. RN 1 stated Resident 15's side rails were used as enabler, and resident's preferences. When asked about the least restrictive measure used prior to the use of side rails, RN 1 stated the pillows were used for repositioning to which he showed the Physical Restraint Assessment 2.0 dated 3/12/24. When asked if a side rail was considered a restraint, RN 1 answered no, but verified the physical restraint assessment was conducted for Resident 15 related to the side rail use. Cross reference to F909, example #1.

CONCERN (E)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

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Based on observation, interview, facility P&P review, and facility document review, the facility failed to ensure 46 of 78 residents who received food from the kitchen received the proper diets and portion sizes when the facility's menus and recipes were not followed. * The facility failed to ensure the residents with mechanical soft diets received ground meat as shown on the Spring Cycle Menu Week 1 dated for 5/1/24. * The facility failed to ensure the finely chopped diet was on the diet manual or approved on the spread sheet and failed to ensure mechanical soft finely chopped diets were followed. * The facility failed to ensure the puree recipes for meats, vegetables, and potatoes were followed. * The facility failed to ensure 10 out of 10 residents with a CCHO diet (diet low in carbohydrates) received plain ice cream as shown on the Spring Cycle Menu Week 1 dated for 5/1/24. * The facility failed to ensure five out of five residents on renal diet (diet for residents with kidney disease, low in potassium, sodium and protein) received brown rice and did not receive fresh green salad as shown on the Spring Cycle Menu Week 1 dated for 5/1/24. * The facility failed to ensure the #12 (1/3 cup) serving scoop was used during the serving of the pureed vegetables. These findings had the potential for the residents on special diets to not receive the adequate nutritional and caloric intake as recommended on the recipes and menus. Findings: Review of the facility census on 4/30/24 showed there were 78 residents at the facility. The facility document titled Order Listing Report with diet orders provided on 5/1/24, showed the kitchen provided the diets to 46 residents in the facility. Further review of the Order Listing Report showed of the 46 residents receiving food prepared from the kitchen, 12 were on CCHO diet, five residents were on renal diet, five residents were on pureed diet, and two residents were on mechanical soft finely chopped diet. 1. The facility's P&P titled Food Preparation dated 2023 showed food shall be prepared by methods that conserve nutritive value, flavor, and appearance. The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared. The P&P further showed recipes are specific as to portion yield, method of preparation, quantities of ingredients, and time and temperature guidelines. Review of the facility's document from the Diet Manual binder titled Regular Mechanical Soft Diet dated 2020 showed the mechanical soft diet is designed for residents who experience chewing or swallowing limitations. The regular diet is modified in texture to a soft, chopped or ground consistency as per foods below. Other textures may be included such as a mechanical soft diet whith pureed meats if further texture reduction is required. Strive to individualize a resident's diet before going to a full pureed texture. The definition of ground to reduce to small fragments by friction. Recommend using a grinder/food processor to achieve the consistency of ground beef. The document further showed for meats, poultry and fish to allow ground with meat juices, gravy or sauce and to avoid whole or chopped meat. Document showed chopped meat only allowed when ordered by speech therapist and size of meat should be specified in diet order, such as less than half inch or less than one inch. Review of the Spring Cycle Menu Week 1 dated 5/1/24, showed the roast turkey with Bernaise sauce for the Mechanical Soft diet should be ground. On 5/1/24 at 1152 hours, an observation of the mechanical soft turkey meat shown to be cut into ½ (half) inch cubes. [NAME] 1 verified the mechanical soft turkey meat were cut in ½ inch cubes. On 5/1/24 at 1218 hours, a concurrent observation and interview with the DSS was conducted. The DSS verified the mechanical soft turkey meat were not considered ground as shown on the Spring Cycle Menu. On 5/2/24 at 0941 hours, a telephone interview with the RD was conducted. The RD stated the mechanical soft meat should be ground as directed on the spreadsheet and should be followed. 2. Review of the facility's document titled 2020 Diet Manual Table of Contents showed no documented evidence of a diet titled mechanical soft finely chopped. Furthermore, review of the Spring Cycle Menu Week 1 dated 5/1/24, showed no documented evidence of a mechanical soft finely chopped diet. Review of the Order Listing Report dated 5/1/24, showed Residents 1 and 21 with mechanical soft finely chopped diet orders. On 4/30/24 at 1526 hours, a telephone interview with the ST was conducted. The ST stated diet orders of mechanical soft finely chopped should have meats that are exactly how it sounds, should be finely chopped and minced to a smaller consistency. On 5/1/24 at 1218 hours, a concurrent observation and interview with the DSS was conducted. The observation of Resident 1 and 21's lunch trays showed the residents received turkey meat cut into ½ size cubes and fresh green salad not finely chopped and had the same consistency of the fresh green salads given to residents with regular diets. The DSS verified the findings and stated finely chopped diets should have the meats chopped further than the usual ½ inch. Moreover, the DSS stated the fresh green salad should have been chopped even more. 3. Review of the undated Healthcare menus Direct, L.L.C.'s Recipe: Pureed Meats, Pureed Vegetables, and Pureed Starch (Rice, Pasta, Potatoes) showed step number two was to puree on low speed to a paste consistency before adding any liquid. On 5/1/24 at 1032 hours, a concurrent observation and interview with [NAME] 1 was conducted during the puree preparation for pureed meats, pureed vegetables, and pureed potatoes. For the puree of meats, [NAME] 1 was observed adding six, three oz slices of turkey with 12 oz hot water and three teaspoon chicken stock together and then used a hand blender to blend to a puree consistency. For the puree of vegetables of cauliflower and peas, [NAME] 1 was observed adding six servings of vegetables with three oz of broth and then used a hand blender to blend to a puree consistency. For the puree of red potatoes, [NAME] 1 was observed adding six servings of red potatoes with 12 oz warm milk and then used a hand blender to blend to a puree consistency. [NAME] 1 verified the menus for pureed meat, vegetables, and potatoes showed to puree meat, vegetables, and potatoes on low speed to a paste consistency before adding any liquid. [NAME] 1 verified he did not follow the recipe as shown. 4. Review of the Spring Cycle Menu Week 1 dated 5/1/24, showed the regular CCHO menu included roast turkey with Bernaise sauce, herb roasted red potatoes, rosemary cauliflower and peas, parsley sprig, fresh green salad, dressing, plain ice cream, and milk. On 5/1/24 at 1216 hours, during the trayline observation, the Dietary Aide 1 verified she served all of the residents with CCHO diets with sherbert, instead of the plain ice cream listed on the Spring Cycle Menu Week 1. The Dietary Aide acknowledged she should have followed the menu. 5. Review of the Spring Cycle Menu Week 1 dated 5/1/24, showed the Renal menu included roast turkey with Bernaise sauce, brown rice with margarine, rosemary cauliflower and peas, parsley garnish, wheat bread, margarine, sherbet, and a beverage. On 5/1/24 at 1218 hours, a concurrent observation and interview with the DSS was conducted. The DSS verified the residents on renal diet did not receive brown rice as shown on the Spring Cycle Menu Week 1 and received fresh green salad that was not shown on the menu. The DSS acknowledged brown rice should have been served and menu followed as ordered. 6. Review of the Spring Cycle Menu Week 1 dated 5/1/24, showed the #12 (1/3 cup) scoop should be used for the serving of the pureed vegetables. On 5/1/24 at 1201 hours, [NAME] 1 was observed using the #8 (1/2 cup) scoop for the pureed vegetables. [NAME] 1 verified he was using the #8 scoop. On 5/2/24 at 0941 hours, a telephone interview with the RD was conducted. The RD verified the findings and stated the recipes and spreadsheet should be followed as shown. On 5/2/24 at 1117 hours, an interview with the Administrator and DSS was conducted. The Administrator and DSS verified and acknowledged all of the above findings.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the food safety and sanitary requirements were met in the kitchen when there were 46 of 78 residents receiving food from the kitchen. * The facility failed to ensure the cooling log was done for the egg salad and failed to ensure the cooling log for the roast beef was fully completed. * The facility failed to ensure the ice machine was properly cleaned. * The facility failed to ensure the temperature log for the resident refrigerator were completed. * The facility failed to ensure food preparation utensils and equipment were in good, sanitary, and cleanable working conditions: a. One blue and two green cutting boards were heavily marred b. Two rubber spatulas were chipped c. One small frying pan and one pot with black residue d. One can opener blade heavily worn and with brown residue * The facility failed to ensure staff's personal belongings were not stored on the food preparation table. * The facility failed to ensure the kitchen staff wore hair and beard restraint. * The facility failed to ensure the walk-in Refrigerator 1 was cleaned and free from brown residue on the walls and floor. * The facility failed to ensure the Freezer 1's door was cleaned and free from brown residue. * The facility failed to ensure the fan above food preparation table was cleaned without black residue. * The facility failed to ensure there was an air gap for the food preparation sink. * The facility failed to ensure the kitchen staff used a brush when washing fruits with rough surface like cantaloupes. *The facility failed to ensure the broom in the utility room was off the floor. These failures had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food prepared in the kitchen. Findings: 1. According to the USDA Food Code 2022, 3-501.14 Cooling: (A) Cooked time/temperature control for safety food shall be cooled: (1) Within two hours from 135 degrees Fahrenheit to 70 degrees Fahrenheit and (2) Within a total of six hours from 135 degrees Fahrenheit to 41 degrees Fahrenheit or less. (B) Time/temperature control for safety food shall be cooled within four hours to 41 degrees Fahrenheit or less if prepared from ingredients at ambient temperature, such as reconstituted foods and canned tuna. According to the USDA Food Code 2022, 2-103.11 Person in Charge: (G) Employees are cooking time/temperature control for safety food, being particularly careful in cooking those foods known to cause severe foodborne illness and death, such as eggs and comminuted meats, through daily oversight of the employees' routine monitoring of the cooking temperatures using appropriate temperature measuring devices properly scaled and calibrated. (I) Employees are properly maintaining the temperatures of time/temperature control for safety foods during hot and cold holding through daily oversight of the employees' routine monitoring of food temperatures. Review of the facility's document titled Good For Your Health Menus for March 11-17, 2024, showed the egg salad was scheduled on the dinner menu for Monday 3/11/24. Further review of the facility's document showed no documented evidence an egg salad cooling log was initiated. Review of the facility's document titled Monitoring Temperatures and Cool Down Log from Healthcare Menus Direct, LLC, dated 2023 showed to note the menu item, date, time, temperature, and cook's initials on the cool down log used. Review of the facility's document titled Cooling Log, undated showed an incomplete documentation for the roast beef. Further review of the facility document showed the date and temperature after four hours of cooling was not documented. On 5/1/24 at 1024 hours, a concurrent document review and interview with [NAME] 2 was conducted. [NAME] 2 verified missing documentations on the Cooling Log for the roast beef included the date and temperature after four hours after cooling. [NAME] 2 further verified there was no documented evidence a cooling log for the egg salad was initiated. [NAME] 2 stated a cooling log for egg salad should have been initiated. On 5/1/24 at 1520 hours, a concurrent record review and interview with the DSS was conducted. The DSS verified the cooling log for the roast beef was incomplete and verified there was no cooling log for the egg salad. The DSS acknowledged cooling logs should be completed and the egg salad should have a cooling log completed. On 5/2/24 at 0941 hours, a telephone interview with the RD was conducted. The RD stated cooling logs should be completed with the date and temperature documented. The RD also stated a cooling log was needed for the egg salad. 2. The facility's P&P titled Ice Machine Cleaning Procedures dated 2023 showed the ice machine needs to be cleaned and sanitized monthly. The internal components cleaned monthly or per manufacturer's recommendations, and the date recorded when cleaned. The P&P further showed to clean inside of ice machine with a sanitizing agent per the manufacturer's instructions. On 4/30/24 at 0921 hours, a concurrent observation and interview with the Maintenance Supervisor was conducted. [NAME] mineral deposit residue was observed on the inside cover of the ice machine. The Maintenance Supervisor verified the findings. 3. Review of the facility's P&P titled Food For Residents From Outside Sources dated 2023 showed food brought in from outside the facility kitchen for residents consumption will be monitored. On 4/30/24 at 4/30/24 at 1115 hours, a concurrent observation and interview with LVN 8 was conducted. An observation of the facility's documentation titled Residents Refrigerator Temperatures Form dated February 2024 showed an incomplete documentation of the refrigerator temperatures for the following dates: - 2/3, 2/4, 2/10, 2/11, 2/17, 2/18, 2/24, and 2/25/24. LVN 8 verified the above findings and stated NOC (night) shift nurses fill out the temperature logs. LVN 8 further stated residents' refrigerator log should be completed. On 5/1/24 at 1107 hours, a concurrent facility's document review and interview with the IP was conducted. The facility's document titled Residents Refrigerator Temperatures Form showed an incomplete documentation of the resident refrigerator temperatures for April and March 2024 on the following dates: - 4/6, 4/7, 4/13, 4/14, 4/20, 4/21, 4/27, 4/28, 3/2, 3/3, 3/9, 3/10, 3/16, 3/17, 3/23, 3/24, 3/30, and 3/31/24. The IP verified the above findings and stated the temperatures were not checked on the weekends because the DSS throws food out on Fridays. The IP further stated the DSS checks the temperatures during the weekdays from Monday to Friday. On 5/1/24 at 1133 hours, a concurrent facility's document review and interview with the DSS was conducted. The DSS verified he checks the resident's refrigerator temperatures daily except for the weekends. The DSS verified the facility did accept food on the weekends and stated the food were kept in the resident's refrigerator if it was still good for two days and will discard on Monday. The DSS stated if there was no date, the food was thrown out. The DSS further stated monitoring the residents' refrigerator temperatures were important to ensure food were kept within the right temperatures to keep the residents safe from illness. The DSS stated he will provide an in-service to his kitchen staff to assign a diet aide to monitor the residents' refrigerator temperatures on the weekends. 4. According to the USDA Food Code 2022, Section 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the USDA Food Code 2022 4-501.12, Cutting Surfaces, 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. The facility's P&P titled Sanitation dated 2023 showed all the equipment shall be maintained as necessary and kept in working orders. The P&P further showed all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seam, cracks, and chipped areas. a. On 4/30/24 at 0834 hours, a concurrent observation and interview was conducted with the DSS. One blue and two green cutting boards were observed heavily marred with dark discoloration knife marks. The DSS verified the findings and stated the cutting boards needed to be replaced. b. On 4/30/24 at 0834 hours, a concurrent observation and interview was conducted with the DSS. Two rubber spatulas were observed chipped. The DSS verified the findings and stated the rubber spatulas needed to be replaced. c. On 4/30/24 at 0848 hours, a concurrent observation and interview was conducted with the DSS. One small frying pan and one pot with black residue observed. The DSS verified findings. d. On 4/30/24 at 0848 hours, a concurrent observation and interview was conducted with the DSS. One can opener blade observed heavily worn with brown residue. The DSS verified findings. 5. The facility's P&P titled Employee Personal Items dated 2023 showed personal items brought in by the staff from outside will not be kept in the kitchen. On 4/30/24 at 0817 hours, a concurrent observation and interview with [NAME] 1 was conducted. One personal water bottle (black Yeti bottle) was observed on the food preparation table. [NAME] 1 verified it was his personal water bottle. On 5/1/24 at 1104 hours, a concurrent observation and interview with [NAME] 2 was conducted. One personal water bottle was observed on the food preparation table. [NAME] 2 verified it was his personal water bottle. 6. The facility's P&P titled Hair Restraint undated showed all nutritional services employees shall always wear protective hair restraints, while in the facility kitchen. The hair restrain must fully contain all scalp hair to prevent contamination. Employees shall be clean shaven or shall wear a facial hair guard/restraints. This includes perceivable facial hair on the lower portion of the face or sideburns extending below the earlobe. On 4/30/24 at 1440 hours, a concurrent observation and interview with the DSS and Dietary Aide 2 was conducted. An observation of Dietary Aide 2 showed her braided ponytail was not covered with a hair net. Dietary Aide 2 and DSS verified the findings. The DSS further stated the hair net should cover all hair. On 5/1/24 at 1029 hours, a concurrent observation and interview with [NAME] 1 was conducted. [NAME] 1 was observed wearing a face mask with facial hair exposed. [NAME] 1 verified he should have a beard restraint. On 5/1/24 at 1054 hours, an interview with the DSS was conducted. The DSS verified the findings and stated he will order beard restraints. 7. According to the USDA Food Code 2022, Section 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. On 4/30/24 at 0815 hours, the walk-in Refrigerator 1 was observed. Observation of brown residue resembling rust was noted on the walls and floor. On 4/30/24 at 0834 hours, a concurrent observation and interview with the DSS was conducted. The walk-in Refrigerator 1 was observed with brown residue resembling rust on the walls and floor. The DSS verified the findings and stated the brown residue has been there since he started. 8. According to the USDA Food Code 2022, Section 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Review of the facility's documented titled Maintenance Log from January to April 2024 showed no documented evidence the maintenance was notified of the freezer ice buildup. On 4/30/24 at 0902 hours, a concurrent observation and interview with the Maintenance Supervisor was conducted. The Maintenance Supervisor verified the brown residue on the freezer door and ice buildup. The Maintenance Supervisor wiped the brown residue from freezer door and residue came off. The Maintenance Supervisor further stated the freezer should not have ice buildup and it was not normal for the ice build up to form. 9. According to the USDA Food Code 2022, Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood -Contact Surfaces, and Utensils shows the objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted. The USDA Food Code further showed: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. On 5/1/24 at 1054 hours, a concurrent observation and interview with the DSS was conducted. The fan above the food preparation table observed with black residue. The DSS verified the findings and stated he will notify the maintenance to clean the fan. 10. According to the USDA Food Code 2022, Section 5-402.11 Backflow Prevention showed improper plumbing installation or maintenance may result in potential health hazards such as cross connections, back siphonage or backflow. These conditions may result in contamination of food, utensils, equipment, or other food-contact surfaces. It may also adversely affect the operation of equipment such as ware washing machines. According to the USDA Food Code 2022, Section 5-402.11 Backflow Prevention, Air Gap showed an air gap between the water supply inlet and the flood level rim of the plumbing, fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than one inch. On 4/30/24 at 0829 hours, an initial tour of the kitchen was conducted. The food preparation sink was observed with no air gap. On 4/30/24 at 0913 hours, a concurrent observation and interview with the Maintenance Supervisor was conducted. The Maintenance Supervisor stated the food preparation sink was connected to the drain and did not have an air gap. 11. According to the USDA Food Code 2022, Section 3-302.15 Washing Fruits and Vegetables showed pathogenic microorganisms, such as Salmonella spp. (bacteria spread through contaminated food or water affecting the intestinal tract), and chemicals such as pesticides, may be present on the exterior surfaces of raw fruits and vegetables. The USDA Food Code further showed scrubbing with a clean brush is only recommended for produce with a tough rind or peel, such as carrots, cucumbers or citrus fruits that will not be bruised easily or penetrated by brush bristles. Scrubbing firm produce with a clean produce brush and drying with a clean cloth towel or fresh disposable towel can further reduce bacteria that may be present. On 5/1/24 at 1204 hours, an observation of Resident 8's lunch tray was observed with cut pieces of cantaloupe and honeydew. On 5/2/24 at 0821 hours, an interview with [NAME] 1 was conducted. [NAME] 1 stated cantaloupes were washed under running water. [NAME] 1 denied using a produce brush for cleaning produce such as cantaloupes. On 5/2/24 at 0825 hours, an interview with the DSS was conducted. The DSS verified fresh cantaloupe was served for lunch on 5/1/24 and prepared in the kitchen. The DSS stated they did not have a brush for cleaning produce with tough rinds such as cantaloupes. The DSS stated the brushes were needed to ensure all the particles and dirt were removed by scrubbing the surface of the produce. The DSS stated he will get a produce brush. 12. According to the USDA Food Code 2022, Section 6-501.113 Storing Maintenance Tools: Maintenance tools such as brooms, mops, vacuum cleaners, and similar items shall be: (A) Stored so they do not contaminate food, equipment, utensils, lines, and single-service and single-use articles; and (B) Stored in an orderly manner that facilities cleaning the area used for storing the maintenance tools. On 4/30/24 at 0807 hours, an initial tour of the kitchen was observed. One broom was observed touching the floor in the utility room. On 4/30/24 at 0846 hours, a concurrent observation and interview with the DSS was conducted. The DSS verified the broom was touching the floor. The DSS further stated the broom should be off the floor and hanged up. On 5/2/24 at 1117 hours, an interview with the Administrator and DSS was conducted. The Administrator and the DSS verified and acknowledged all the above findings.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Review of the facility's P&P titled Laundry and Bedding, Soiled revised 9/2022 showed separate carts are used for transporting clean and contaminated linen. The policy also showed clean linen is stored separately, away from soiled linens, at all times. On 4/30/24 at 844 hours, an observation and concurrent interview was conducted with CNA 7. CNA 7 was observed pushing and transporting a hamper filled with stack of folded linen and pads in the hallway towards Room A. A stack of folded towels were placed directly on the lid of the hamper. CNA 7 verified the findings and stated the folded linen on the lid of the hamper were clean. CNA 7 stated the stack of clean linen should not be placed directly on the hamper lid. CNA 7 was then observed picking up the stack of clean linen from the hamper lid with gloved hands and proceeded to walk towards Room A. CNA 7 was stopped by the surveyor just before she entered Room A. When asked, CNA 7 stated she was taking the linen into Room A. However, CNA 7 was then observed placing the entire stack of linen inside the dirty hamper and stated these are dirty now. On 5/1/24 at 1141 hours, an interview was conducted with the IP. When asked, the IP stated it was ok to transport the clean linen inside a clean plastic bag. The IP also stated the clean linen should not be placed on the lid of the hamper because of the risk for infection and cross contamination. 7. Review of the facility's P&P titled Infection Control of Dropped Objects dated 2/24/20, showed upon finding an object that has fallen on the floor; the staff member should pick it up by wearing gloves and proceed to disinfect by using sterilizing wipes prior to returning to its original place. On 4/30/24 1215 hours, during the dining observation in the dining room, RNA 1 was observed bumping into Resident 1137's tray table with his right hip. A water bottle from Resident 1137's tray table dropped and rolled onto the floor. RNA 1 was then observed picking up the water bottle from floor with his non gloved right hand and placing it directly on Resident 1137's tray table, next to Resident 1137's meal. On 4/30/24 at 1216 hours, an interview was conducted with RNA 1. RNA 1 verified the above findings and stated he should have thrown the water bottle away. On 5/1/24 at 1139 hours, an interview was conducted with the IP. When asked if it was acceptable to pick up an object from the floor and place it on a resident's tray table next to their meal, the IP stated, No it's not. The IP stated, Anything that fell on the floor, things like the water bottle, the RNA should have thrown it away. Based on interview, facility document review, and facility P&P review, the facility failed to implement their infection control surveillance program in accordance with the facility's P&P. * The facility failed to maintain an accurate infection control surveillance program for January through March 2024. The facility used Surveillance Data Collection Form and Infection Control Surveillance form that showed inaccurate or missing information. This failure posed the risk for not identifying residents' infections and thereby, preventing the implementation of interventions to control the potential transmission of communicable diseases to other residents in the facility. * The facility failed to follow practices on handling, storing, and processing laundry so as to prevent the spread of infection. This failure posed the risk for transmission of disease-causing microorganisms. * The facility failed to ensure the staff disinfect the blood pressure monitoring instrument before and after use in between Residents 9 and 839. * The facility failed to ensure the staff performed hand hygiene before and after contact, and disinfect medication tray before and after use in between Residents 539 and 31. * The facility failed to ensure clean linen was protected from contamination during transport. * The facility failed to ensure the staff followed the facility's P&P when picking Resident 1137's water bottle from the floor. * Two CNAs failed to don the isolation gowns when providing care for Resident 22, who was on EBP. * CNA 6 failed to follow the contact isolation precautions when caring for Resident 15. * The facility failed to ensure the contact isolation precaution sign was posted outside Resident 937's room. In addition, the facility failed to ensure there were not two physician's orders for two different isolation precautions for Resident 937. * The facility failed to ensure the residents' basins, toothpastes, hairbrushes, and combs were stored in a sanitary manner. * The facility failed to ensure the urinary drainage bag was kept off the floor for Resident 8. * The facility failed to ensure the clean clothes cart was fully covered during transport. Thes failures posed the risk for not identifying, managing, containing and controlling the transmission of communicable diseases within the facility. Findings: Review of the facility's P&P titled Surveillance for Infections revised 9/2017, showed the facility will conduct ongoing surveillance for healthcare-associated infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and health-associated infections, to guide appropriate interventions, and prevent future infections. The infection preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data. The infection control committee and /or QAPI committee maybe involved in the interpretation of the data. The surveillance should include a review of any or all of the following information to help identify possible indicators of infections: a. Laboratory records; b. skin care sheets; c. Infection control rounds or interviews; d. Verbal reports from staff; e. Infection documentation records; f. Temperature logs; g. Pharmacy records; h. Antibiotic review; and i. Transfer log/summaries. Using the suggested criteria for definition of infection for surveillance, determine if the resident has a healthcare-associated infection. On 5/1/24 at 1354 hours, an interview and concurrent facility document review was conducted with the facility's IP. The IP was asked to describe the facility's infection surveillance program. The IP stated when a resident in the facility exhibits signs and symptoms of infection, the charge nurses use a communication tool titled Infection Control Surveillance that was handed to her to analyze the information. The IP further stated, after the collection and analysis of the communication tool, she was required to complete the Surveillance Data Collection and then document on the Monthly Infection Control Surveillance. The form titled Surveillance Data Collection showed an instructions for the Licensed Nurse to initiate and complete the top portion of this form, and the IP will complete the bottom portion of the form. The Surveillance Data Collection Form from January through March showed the following inaccurate information: a. For Resident 1039, an entry dated 1/9/24, showed the Description of Infection: Sternal wound Infection from Surgery. There was no documentation that included a review of the skin care sheet or any of information to help identify indicators of infection as per facility's P&P. The form showed to mark on new or increasing presence of at least 4 (four) of the following signs or symptoms sub-criteria but there were only two signs or symptoms were marked and checked, indicated it did not meet the Mcgeer's criteria. The facility's January 2024 Infection Control Surveillance form showed the Mcgeers criteria was met. Both records on the Mcgeer's criteria showed the details did not match. In addition section B of the Surveillance Data Collection showed marked Healthcare Associated Infection (HAI) however with documentation from an acute care hospital. The January 2024 Infection Control Surveillance form showed CAI (Community Acquired Infection). Both records showed inconsistent of documentation. The IP verified all the inaccurate information and acknowledged it should have been completed. b. For Resident 387, entry dated 1/23/24 showed Cellulitis, Soft Tissue or Wound Infection, however, no skin care sheets were included as a review or any information to help identify indicators of infection per facility's P&P. The form did not show whether the Mcgeer's criteria was met or not met but the facility's January 2024 Infection Control Surveillance form stated the Mcgeers criteria was met. Section B of Surveillance Data Collection form also had no information if Resident 387 had HAI or CAI. No mark on either HAI or CAI. The IP acknowledged and verified that the form had missing information, should be accurate and should be complete. c. For Resident 24, entry dated 1/11/24, showed Urinary Tract Infection, for the resident's with an indwelling urinary catheter. The form showed both criteria number 1 and 2 must be present, however only number 2 criteria was marked and checked, indicated that it did not met the Mcgeer's criteria. However, the facility's January 2024 Infection Control Surveillance form showed it Met the Mcgeer's criteria. Furthermore, on section B of the Surveillance Data Collection form, showed blank to determine if Resident 24 had HAI or CAI; however, the Infection Control Surveillance form showed HAI. The IP verified and acknowledged the information details were missed, inaccurate, and both forms should be completed also for the following residents: * For Resident 1040, entry dated 1/18/24, * For Resident 1041, entry dated 1/18/24 , * For Resident 1042, entry dated 1/22/24, * For Resident 39, entry dated 1/4/24, * For Resident 1043, entry dated 2/6/24 * For Resident 31, entry dated 2/6/24 * For Resident 838, entry dated 2/8/24 * For Resident 1044, entry dated 2/10/24 * For Resident 1045, entry dated 2/19/24 * For Resident 387, entry dated 2/19/24, * For Resident 388, dated 2/23/24, * For Resident 389, entry dated 2/29/24, * For Resident 937, entry dated 2/3/24, * For Resident 1089, entry dated 2/3/24, * For Resident 44, entry dated 2/11/24, * For Resident 42, entry dated 2/25/24, * For Resident 33, entry dated 3/1/24, * For Resident 389, entry dated 3/3/24, * For Resident 33, entry dated 3/20/24, * For Resident 1046, entry dated 3/14/2024, * For Resident 26, entry dated 3/19/24, * For Resident 1037, entry dated 3/20/24, . * For Resident 21, entry dated 3/25/24, * For Resident 26, entry dated 3/25/24, * For Resident 34, entry dated 3/26/24, * For Resident 9, entry dated 3/28/24, * For Resident 44, entry dated 3/19/24, * For Resident 1048 dated 3/11/24, and * For Resident 39, entry dated 3/14/24 The IP acknowledged the Surveillance Data Collection Form and Monthly Infection Control Surveillance form were not accurately completed and with inconsistent documentation between the two forms (examples a, b, and c). The IP reviewed the documents and acknowledged the above findings. 2. Review of the facility's P&P titled Laundry and Bedding, Soiled, revised 9/22 showed clean linens are stored separately, kept separately from contaminated linen, use of separate rooms, closets, or other designated spaces with a closing door are used to reduce the risk of accidental contamination. On 5/1/24 at 0812 hours, an observation of the laundry room and concurrent interview was performed with Maintenance Supervisor. Clean gowns used for Enhanced Precautions Rooms placed in transparent bags were observed to be laying on the floor. The Maintenance Supervisor verified the clean gowns placed in a clean transparent bags should not be laying on the floor. On 5/2/24 at 1440 hours, an interview was conducted with RN 1. RN 1 verified the clean gowns placed in a clean transparent bags should not be laying on the floor. 3. Review of the facility's P&P titled Hand Hygiene revised 8/19 showed the facility considers hand hygiene the primary means to prevent the spread of infection, all personnel should follow the handwashing hand hygiene procedures to help prevent the spread of infections to other personnel, residents and visitors. Use an alcohol based hand rub containing at least 62% alcohol;or alternatively, soap (antimicrobial or non antimicrobial) and water for the following situations: Before and after direct contact with residents, before and after eating or handling food; before and after assisting a resident with meals. On 4/30/24 at 0817 hours, during the initial tour of the facility, CNA 2 was observed to enter Resident 9's room, proceeded to grab a beverage drink from Resident 9's breakfast meal tray and offered to Resident 9 without performing hand hygiene. On 5/1/24 at 1354 hours, an interview was conducted with the IP. The IP verified CNA 2 should perform hand hygiene before entering the room and should perform hand hygiene before entering resident's room and before offering drink to the resident. On 5/3/24 at 1440 hours, an interview was conducted with RN 1. RN 1 verified CNA 2 should performed hand hygiene before and after direct contact with resident , before and after eating or handling food; before and after assisting a resident with meals. 11. On 4/30/24 at 0850 hours, during the initial tour of the facility, two stacks of basins, totaling six basins, two unlabeled hairbrushes, two unlabeled toothpastes, and one antidandruff shampoo were observed on the sink in the shared bathroom of Residents 41 and 42. On 4/30/24 at 0919 hours, an interview with LVN 2 was conducted. LVN 2 was unable to identify the residents who used the basins, hairbrushes, toothpastes, and the antidandruff shampoo stored in the shared bathroom. LVN 2 verified the items were not labeled. LVN 2 stated he would throw the items listed above since they were not labeled. LVN 2 further stated the basins and personal toiletries should not be stored in the bathroom. On 5/2/24 at 1315 hours, an interview was conducted with the DSD. The DSD stated the basins and toiletries should be labeled and be kept in the residents' nightstand. The DSD also stated the above items should not be stored in the bathroom to prevent the risk of infection. 12. Review of the facility's P&P titled Catheter Care, Urinary Policy and Procedure undated showed under the section of infection control, to maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. Be sure the catheter tubing and drainage bag are kept off the floor. On 4/30/24 at 0855 hours, Resident 8 was observed in bed. Resident 8's urinary drainage bag was observed resting directly on the floor. Medical record review for Resident 8 was initiated on 5/1/24. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's Order Summary Report showed a physician's order dated 11/13/23, for suprapubic catheter Fr 16/10 ml attached to a bedside closed drainage bag system. On 4/30/24 at 0855 hours, an interview was conducted with CNA 2. CNA 2 stated the urinary drainage bag should not be on the floor. On 4/30/24 at 0855 hours, an observation and concurrent interview was conducted with RN 1. RN 1 verified Resident 8's urinary drainage bag was on the floor. RN 1 stated the urinary drainage bag should not be on the floor because of infection control issues. 13. Review of the facility's P&P titled Departmental (Environment Services) - Laundry and Linen revised 1/2014 showed under the section washing and linen and other soiled items, clean linen will remain hygienically clean through measures designed to protect it from environmental contamination, such as covering clean linen carts. On 4/30/24 at 0909 hours, the clean clothes cart was observed uncovered at the SNF hallway. The drape/curtain covering the cart was pulled all the way to the side exposing the clean clothes inside the cart. When Laundry 1 was asked if the clothes should be exposed, Laundry 1 pulled the drapes/curtain halfway wherein several hangered clean clothes could still be seen. On 4/30/24 at 0909 hours, an observation and concurrent interview was conducted with the DSD. The DSD stated the clean clothes cart should not be half exposed and the drapes/curtain should be completely closed to prevent infection. On 4/30/24 at 0940 hours, an interview was conducted with the Maintenance Director. The Maintenance Director confirmed the clean clothes cart should not be exposed to prevent infection. 4. Review of the facility's P&P titled Cleaning and Disinfecting Resident Care Items and Equipment revised September 2022 showed non-critical items are those that come in contact with intact skin but not mucus membrane, non-critical resident care item includes bed pan, blood pressure cuffs, crutches, and computers. Noncritical environmental surfaces include bed rails, bedside tables etc. Noncritical items required cleaning followed by either low or intermediate level disinfection following manufacturers' instructions. Further review of the P&P showed reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscope, durable medical equipment). On 4/30/24 at 0811 hours, during the medication pass observation LVN 1 was observed taking the resident's blood pressure using the digital blood pressure monitoring instrument of Resident 9. LVN 1 then was observed coming out of Resident 9's room and performing hand hygiene. LVN 1 was not observed disinfecting blood pressure monitoring instrument. LVN 1 then proceeded to prepare and administered the medications for Resident 9. LVN 1 was then observed entering the room of Resident 839 with digital blood pressure monitoring instrument on his hand. LVN 1 was not observed sanitizing the digital blood pressure monitoring instrument before entering the room of Resident 839. LVN 1 was then observed explaining the procedure to Resident 839. Resident 839 was observed refusing the monitoring of the blood pressure. 5.a. On 4/30/24 at 0842 hours, during an observation, the following was observed: - LVN 1 was observed preparing oral medications in medication cups and entering the room with each medicine on the medication cups on the medication tray. LVN 1 placed the medication tray on Resident 539's overbed table and administered the oral medications. LVN 1 was observed coming out of the room, and preformed hand hygiene. LVN 1 was not observed disinfecting medication tray. LVN 1 proceeded to prepare medication for another resident on the same medication tray with out sanitizing the tray. LVN 1 then entered the room after performing hand hygiene to administer the medication to Resident 31, placed the medication tray on 31's overbed table and administered the resident's medication. b. Review of the facility's P&P titled Handwashing/Hand Hygiene revised August 2019 showed to use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap and water for the situations which included following: - Before and after direct contact with the residents; and, - After contact with Resident intact skin. On 4/30/24 at 0852 hours, during observation LVN 1 was observed preparing medication for Resident 31. LVN 1 was observed entering the room to administer the medication for Resident 31 after performing hand hygiene. LVN 1 was observed administering medication to Resident 31 and was observed touching Resident 31 on his hand during medication administration, LVN 1 was then observed assisting Resident 539 and touching Resident 539 on his shoulder without performing hand hygiene in between residents' contact. On 4/30/24 at 0854 hours, an interview was conducted with LVN 1. LVN 1 was informed of the above observations. LVN 1 acknowledged he did not disinfect the blood pressure monitoring instrument after he took the blood pressure of Resident 9, and he was about to take the blood pressure of Resident 839 at his room; however, Resident 839 refused to take the blood pressure. LVN 1 verified he did disinfect the blood pressure monitoring instrument before he attempted to take blood pressure of Resident 839. LVN 1 acknowledged he did not disinfect medication tray before and after use in between Residents 539 and 31. In addition, LVN 1 verified he did not perform hand hygiene when he assisted Resident 539, during medication administration for Resident 31. LVN 1 further stated he should have disinfected the blood pressure monitoring instrument and medication tray in between resident's use. LVN 1 acknowledged he should have performed hand hygiene in between care for Residents 31 and 539. On 4/30/24 at 1532 hours, an interview was conducted with RN 1. RN 1 was informed and acknowledged the above findings. 8. Review of the facility's P&P titled Enhanced Barrier Precautions dated 8/2022 showed EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Examples of high-contact resident care activities requiring use of gown and gloves for EBPs include: - dressing; - bathing/showering; - transfering; - providing hygiene; - changing linens; - changing briefs or assisting with toileting; - device care or use; and - wound care. Medical record review for Resident 22 was initiated on 4/30/24. Resident 22 was readmitted to the facility on [DATE]. Review of Resident 22's Order Summary Report dated 5/1/24, showed a physician's order dated 3/28/24, for the EBP and to follow the six moments of ESP for PPE posted on the door. On 4/30/24 at 1216 hours, an Enhanced Precautions sign was observed outside Resident 22's doorway, above an isolation cart with isolation gowns and hand sanitizer. The sign showed the staff performing in any of the listed resident care must also don gowns and gloves. The list included toileting and changing incontinent briefs. On 5/2/24 at 1319 hours, interviews and concurrent observations were conducted with CNAs 3 and 4 at Resident 22's bedside. CNAs 3 and 4 were observed at Resident 22's bedside, both wearing gloves and protective face masks. CNA 3 was observed putting the resident's acute care hospital gown in place. CNA 3 stated CNA 4 helped her reposition, perform the ROM exercises and change Resident 22's incontinent briefs. When asked if they needed to wear isolation gowns while providing care to Resident 22, both CNAs 3 and 4 stated they did not need to wear gowns because it was just for precautions. On 5/2/24 at 1325 hours, a follow up interview was conducted with CNA 3. CNA 3 stated she and CNA 4 had just changed Resident 22's incontinent brief. When asked to look and review the Enhanced Precaution signage outside of Resident 22's doorway, CNA 3 verified the signage showed to wear a gown when performing incontinent care. CNA 3 stated they should have worn an isolation gown. On 5/2/24 at 1327 hours, an interview was conducted with the IP. The IP stated for Resident 22, all staff should wear an isolation gown when touching the resident. The IP stated all staff have been trained and in-serviced on wearing gowns and gloves when touching any residents with ESP and EBP. 9. Review of the facility's document titled Contact Precautions (undated) showed anyone entering this room must follow the following precautions: -Hand hygiene before and after entering/ exiting the room; -Gloves prior to entering the room; and -Gown prior to entering the room. According to CDC, for Precautions to Prevent Transmission of Infectious Agents, Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings (2007) contact precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient's environment. Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination. Medical record review for Resident 15 was initiated on 4/30/24. Resident 15 was readmitted to the facility on [DATE]. Review of Resident 15's Order Summary Report showed a physician's order dated 12/12/23, to place on contact isolation precaution every shift for Candida Auris (a type of yeast that can cause severe illness and spreads easily among patients in healthcare facilities). On 5/2/24 at 0741 hours, a Contact Isolation Precaution sign was observed posted outside Resident 15's room alerting anyone to perform hand hygiene before and after entering/ exiting the room. The sign also alerted anyone to wear gloves and a gown prior to entering the room. A yellow sticker with a red dot was observed by Resident 15's door. A cart containing gowns and gloves was observed outside the room. CNA 6 was observed entering Resident 15's room with a meal tray. CNA 6 was not observed wearing a gown nor gloves. CNA 6 placed the meal tray on the bedside table and observed moving the bedside table away from the bed. Then CNA 6 was observed using the hand sanitizer and leaving the room. On 5/2/24 at 1122 hours, an observation for Resident 15 and concurrent interview was conducted with CNA 6. CNA 6 verified the above findings. CNA 6 verified the Contact Isolation Precaution sign placed outside Resident 15's room, with a yellow sticker with a red dot by the door. CNA 6 stated the yellow sticker with a red dot meant the residents in the room had Candida Auris, and the staff needed to wear a complete PPE, which meant to wear a gown and gloves. CNA 6 verified she delivered a meal tray to Resident 15 and moved the table away from the resident's bed. CNA 6 verified she was not wearing a gown and gloves when she went inside Resident 15's room. On 5/2/24 at 1320 hours, an interview was conducted with the IP. The IP verified the above findings. The IP verified the yellow sticker with a red dot meant the resident or residents in the room had Candida Auris. The IP stated the staff needed to do hand hygiene and wear a gown and gloves when entering the room on contact isolation, even when they were just delivering a meal tray. 10.a. On 5/2/24 at 1330 hours, a yellow sticker with a red dot was observed by Resident 937's door. A cart containing gowns and gloves was observed outside the room. There was no isolation precaution sign observed posted outside Resident 937's room. On 5/2/24 at 1336 hours, an observation of Resident 937's room and concurrent interview was conducted with LVN 3. There was no isolation precaution sign observed posted outside Resident 937's room, but there was a cart containing gowns and gloves observed outside the room. There was also a yellow sticker with a red dot observed by Resident 937's door. LVN 3 verified the above findings. LVN 3 stated the yellow sticker with a red dot meant the residents in the room had Candida Auris, and they were on contact isolation, so the staff needed to wear a gown and gloves. b. Medical record review for Resident 937 was initiated on 4/30/24. Resident 937 was readmitted to the facility on [DATE]. Review of Resident 937's Order Summary Report showed the following physician's orders dated: -8/24/23, Enhanced standard precaution related to Candida Auris. High risk exposure to MDRO (Multidrug-resistant organisms are organisms that are resistant to multiple antibiotics or antifungals) and indwelling devices. Please follow the six moments of Enhanced Standard Precautions. Signage posted on door; and -9/9/23, Contact isolation precautions related to Candida Auris. High risk exposure to MDRO and indwelling devices. No directions specified for order. On 5/2/24 at 1340 hours, an interview and concurrent medical record review for Resident 937 was conducted with the IP. The IP verified the above findings. The IP verified there were two isolation precaution orders for Resident 937. The IP stated Resident 937 was on contact isolation precaution, and the order for the enhanced standard precaution should have been discontinued.

CONCERN (E)

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

Room Equipment (Tag F0908)

Could have caused harm · This affected multiple residents

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Based on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the essential kitchen equipment was in the safe and operating condition as evidence by: * The facility failed to ensure one of one handwashing sink in the kitchen provided adequate water pressure and hot water. * The facility failed to ensure the walk-in Refrigerator 1 was absent of pooling water on the floor. * The facility failed to ensure the ice machine was properly cleaned as per the ice machine cleaning instruction. * The facility failed to ensure Freezer 1 door was absent of ice buildup. * The facility failed to ensure Freezer 1 door was free of caulking from peeling off with black residue and base board was not loose and free from black residue. These failures had the potential to spread infection and provide inadequate working equipments. Findings: Review of the facility census on 4/30/24 showed there were 78 residents at the facility. The facility document titled Order Listing Report with diet orders provided on 5/1/24, showed the kitchen provided the diets to 46 residents in the facility. Further review of the Order Listing Report showed of the 46 residents receiving food prepared from the kitchen. 1. According to the USDA Food Code 2022, Section 5-103.12 Pressure showed inadequate water pressure could lead to situations that place the public health at risk. For example, inadequate pressure could result in improper handwashing or equipment operation. Sufficient water pressure ensures that equipment such as mechanical warewashers operate according to manufacturer's specifications. According to the USDA Food Code 2022, Section 5-202.12 Handwashing Sink, Installation: (A) A handwashing sink shall be equipped to provide water at a temperature of at least 85 degrees Fahrenheit through a mixing valve or combination faucet. An inadequate flow or temperature of water may lead to poor handwashing practices by food employees. A mixing valve or combination faucet is needed to provide properly tempered water for handwashing. The International Plumbing Code (IPC) states that tempered water is having a temperature range between 85 degree Fahrenheit and 110 degree Fahrenheit. The facility's P&P titled Maintenance Service undated showed maintenance service shall be provided to all areas of the building, grounds, and equipment. The policy further showed maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working condition. The facility's document titled Maintenance Log dated from January 2024 to April 2024, showed no documented evidence the maintenance was notified of the inadequate water pressure or hot water in the kitchen's handwashing sink. On 4/30/24 at 0807 hours, an initial tour of the facility was conducted. The kitchen was observed with one handwashing sink with inadequate water pressure and no hot water noted. Temperature of water was 70.7 degree Fahrenheit. On 4/30/24 at 0834 hours, a concurrent observation and interview with the DSS was conducted. The DSS verified the inadequate water pressure and no hot water provided from the hand washing sink. The DSS stated to let the water run and it will turn hot. DSS verified water did not provide hot water. On 4/30/24 at 0902 hours, a concurrent observation and interview with the Maintenance Supervisor was conducted. The Maintenance Supervisor stated he was not informed of the weak water pressure and no hot water from the handwashing sink. The Maintenance Supervisor verified the findings and stated it was not normal to have low water pressure and no hot water available. On 5/2/24 at 0941 hours, a telephone interview with the RD was conducted. The RD stated she was at the facility on 4/30/24 and verified the inadequate water stream in the handwashing sink. 2. The facility's P&P titled Sanitation dated 2023 showed the Food and Nutrition Services Director (and/or cook in their absence) will report any equipment needing repair to the maintenance man. The P&P further showed the maintenance department will assist the Food and Nutrition Services as necessary in maintaining equipment and in doing janitorial duties which the Food and Nutrition Services employees cannot do a maintain maintenance records on all equipment. The facility's document titled Maintenance Log dated from January 2024 to April 2024, showed no documented evidence the maintenance department was notified of the pooling of water in the walk-in Refrigerator 1. Review of the RD's audit form and facility's document titled Sanitation and Food Safety Checklist dated 2/2024, 3/31, and 4/30/24, showed no documented evidence the RD had identified pooling of water in the walk in Refrigerator 1. On 4/30/24 at 0807 hours, an initial tour of the facility was conducted. The walk in Refrigerator 1 was observed with pooling water on the floor. On 4/30/24 at 0834 hours, a concurrent observation and interview with the DSS was conducted. The DSS verified the pooling of water on the floor of Refrigerator 1. The DSS stated the water was from the condensation from the freezer and has not informed the maintenance department. On 4/30/24 at 0902 hours, a concurrent observation and interview with the Maintenance Supervisor was conducted. The Maintenance Supervisor verified the walk-in Refrigerator 1 with pooling of water and measured the pooling of water with a measuring tape to 4 feet by 3.5 feet. 3. The facility's P&P titled Ice Machine Cleaning Procedures dated 2023 showed the ice machine needs to be cleaned and sanitized monthly. The internal components cleaned monthly or per manufacturer's recommendations, and the date recorded when cleaned. The P&P further showed to clean inside of ice machine with a sanitizing agent per the manufacturer's instructions. Review of the Cleaning Instructions for Ice Machines dated 11/2018, showed the proper cleaning of an ice machine requires two parts: descaling and sanitizing. Descaling dissolves the mineral deposits [and] removes scale, calcium, lime scale and other mineral buildup. The instructions further showed Nu-Calgon Nickel-Safe Ice Machine Cleaner Descaler Concentration Ratio included mixing five fluid oz per one gallon of water or 39 ml per one liter of water. Further review of the instructions showed sanitizing the ice machine is recommended after descaling. It is recommended to clean (descale and sanitize ) the storage means after cleaning the ice machine. On 4/30/24 at 0921 hours, an interview with the Maintenance Supervisor was conducted. The Maintenance Supervisor stated when cleaning the ice machine, he used nickel wash and sanitizer. The Maintenance Supervisor stated he did not mix the nickel wash or sanitizer with another solution. The Maintenance Supervisor further stated he cleans the ice bin with sanitizer; however, did not descale the ice bin as per cleaning instructions. The Maintenance Supervisor verified he should mix nickel wash and sanitizer with water and descale the ice bin as shown on the cleaning instructions for the ice machine. 4. According to the USDA Food Code 2022, Section 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (B) The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Review of the facility's documented titled Maintenance Log from January 2024 to April 2024 showed no documented evidence the maintenance department was notified of the freezer ice buildup. On 4/30/24 at 0902 hours, a concurrent observation and interview with the Maintenance Supervisor was conducted. Observation of Freezer 1 with ice buildup around the frame of the door. The Maintenance Supervisor verified findings. The Maintenance Supervisor stated the freezer should not have ice buildup and it was not normal for the ice build up to form. 5. According to the USDA Food Code 2022, Section 4-201.11 Durability and Strength showed equipment and utensils shall be designed and constructed to be durable and to retain their characteristics qualities under normal use conditions. According to the USDA Food Code 2022, Section 4-501.11 Good Repair and Proper Adjustment: (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) Equipment components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacture's specifications. According to the USDA Food Code 2022, Section 4-601.11, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils: (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch. (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. On 5/1/24 at 1100 hours, a concurrent observation and interview with the DSS was conducted. An observation of caulking at the door frame of Freezer 1 was noted peeling off with black residue. In addition, the base board adjacent to Freezer 1 was observed loose and with black residue. The DSS verified the findings. On 5/1/24 at 1117 hours, a concurrent observation and interview with the Maintenance Supervisor was conducted. The Maintenance Supervisor verified the caulking peeling off at the side door of Freezer 1 and the loose base board adjacent to Freezer 1 with black residue. The Maintenance Supervisor stated the caulking was coming off too much and stated area should be smooth. On 5/2/24 at 1117 hours, an interview with the Administrator and DSS was conducted. The Administrator and DSS verified and acknowledged all of the above findings.

CONCERN (E)

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

Deficiency F0909 (Tag F0909)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 10. Medical record review for Resident 7 was initiated on 4/30/24. Resident 7 was admitted to the facility on [DATE]. On 5/3/24 at 1202 hours, Resident 7 was observed in bed with bilateral half side rails. Review of Resident 7's medical record failed to show documented evidence a physician's order and informed consent weree obtained prior to the use of the bilateral half side rails. Further review of Resident 7's medical record failed to show an entrapment assessment was completed prior to the use of the bed rails. On 5/3/24 at 1203 hours, an observation and concurrent interview was conducted with LVN 10. LVN 10 verified Resident 7 had bilateral half side rails elevated while in bed. LVN 10 stated Resident 7 was unable to move in bed and the side rails would have to be removed from the bed. 11. Medical record review for Resident 10 was initiated on 4/30/24. Resident 10 was admitted to the facility on [DATE]. Review of Resident 10's Bed Safety Rail assessment dated [DATE], showed Resident 10 was likely to fall from bed, and clinical physical condition would increase the risk of entrapment or other injury. The assessment form showed the gaps were small enough to avoid an entrapment risk to the bed occupant, and the body or head was large enough not to pass between bars of the bed safety rail, through the gap between the rail and the side of the mattress, and between the headboard and bed safety rail. However, the assessment form did not show any measurements related to the entrapment zones. On 5/3/24 at 1212 hours, an observation and concurrent interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor verified Resident 10 had bilateral half side rails. The Maintenance Supervisor stated he did not perform a routine bed maintenance and inspections of the residents' beds with side rails. The Maintenance Supervisor stated he did not conduct any measurements of the side rails, mattress, headboard or the footboard. On 5/3/24 at 1217 hours, an interview and concurrent medical record review was conducted with the IP for Residents 7 and 10. The IP verified and stated there were no assessment for the risk of entrapment and no forms explaining the potential risks and benefits of the use of bed rails for both Residents 7 and 10. 5. On 4/30/24 0846 hours, during the initial tour of the facility, Resident 837 was observed lying in bed with the bilateral half side rails elevated. Medical record review for Resident 837 was initiated on 4/30/24. Resident 837 was readmitted to the facility on [DATE]. Review of Resident 837's Order Summary Report showed a physician's order dated 4/15/23, to have bilateral half side rails up per responsible party request (feeling of safety). Review of Resident 837's H&P examination dated 7/19/23, showed Resident 837 had no capacity to understand and make decisions. Review of Resident 837's Bed Safety Rail assessment dated [DATE], showed Resident 837 was not likely to fall from bed, and rail may not be appropriate. The assessment form showed the gaps were small enough to avoid an entrapment risk to the bed occupant, and the body or head was large enough not to pass between bars of the bed safety rail, through the gap between the rail and the side of the mattress, and between the headboard and bed safety rail. However, the assessment form did not show any measurements related to the entrapment zones. Review of Resident 837's Bed Safety Rail assessment dated [DATE], showed Resident 837 was not likely to fall from bed, and rail may not be appropriate. The assessment form showed the gaps were small enough to avoid an entrapment risk to the bed occupant, and the body or head was large enough not to pass between bars of the bed safety rail, through the gap between the rail and the side of the mattress, and between the headboard and bed safety rail. However, the assessment form did not show any measurements related to the entrapment zones. On 4/30/24 at 1021 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified Resident 837 had bilateral half side rails elevated while in bed. LVN 1 stated Resident 837's family member had requested the siderail for feelings of safety. 6. On 4/30/24 0906 hours, during the initial tour of the facility, Resident 838 was observed lying in bed with the bilateral half side rails elevated. Medical record review for Resident 838 was initiated on 4/30/24. Resident 838 was admitted to the facility on [DATE]. Review of Resident 838's Order Summary Report showed a physician's order dated 3/2/23, to have bilateral half side rails up per responsible party request (feeling of safety). Review of Resident 838's H&P examination dated 11/22/23, showed Resident 838 did not have the capacity to understand and make decisions. Review of Resident 838's Bed Safety Rail assessment dated [DATE], showed Resident 837 was not likely to fall from bed, and rail may not be appropriate. The assessment form showed the gaps were small enough to avoid an entrapment risk to the bed occupant, and the body or head was large enough not to pass between bars of the bed safety rail, through the gap between the rail and the side of the mattress, and between the headboard and bed safety rail. However, the assessment form did not show any measurements related to the entrapment zones. On 4/30/24 at 1021 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified Resident 838 had bilateral half side rails elevated while in bed. LVN 1 stated Resident 838's family member had requested the siderail for feelings of safety. On 5/2/24 at 0905 hours, an interview and concurrent facility record review was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated he did not routinely check the residents' beds. The Maintenance Supervisor further stated he had a maintenance log for the broken beds and siderails. When the nurse told him what was wrong with the siderail or bed, he would then replace or fix it. On 5/3/24 at 1422 hours, an interview was conducted with the Administrator. The Administrator was informed and acknowledged the above findings. 12. On 4/30/24 at 0838 hours, Resident 16 was observed laying in bed with the bilateral half siderails elevated. Medical record review for Resident 16 was initiated on 5/3/24. Resident 16 was admitted to the facility on [DATE]. Review of Resident 16's medical record failed to show documented evidence the bed side rail entrapment assessment was completed and documented. On 5/3/24 at 1440 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified there was no entrapment assessment for the bilateral half side rails completed for Resident 16. 7. Medical record review for Resident 20 was initiated on 4/30/24. Resident 20 was admitted to the facility on [DATE]. On 5/1/24 at 0845 hours, 1150 hours, and 1400 hours, Resident 20 was observed laying on bed with the bilateral upper half side rails elevated. Review of Resident 20's H&P evaluation dated 1/29/24, showed Resident 20 had fluctuating capacity to understand and make medical decisions. Review of Resident 20's Order Summary Report as of 5/1/24, failed to show the physician's order for the use of bilateral upper half side rails. Review of Resident 20's Risk and Benefits of Bedrails Review and Acknowledgement form, showed incomplete and undated form. The purpose of bedrail, type of bedrail, potential risk and potential benefits were not marked. The section for resident's surrogate decision maker/legally recognized decision maker and the name/title of the license nurse were blank and not signed. Review of Resident 20's Bed Safety Rail Assessment form dated 2/1/24, showed Resident 20 was not likely to fall from bed. Review of Resident 20's Physical Restraint assessment dated [DATE], showed the IDT had no recommendation for any physical restraint. Further review of Resident 20's medical record failed to show the documented evidence of the siderail entrapment assessment was completed and documented. On 5/3/24 at 1028 hours, an interview was conducted with LVN 1 . LVN 1 stated Resident 20 uses the bilateral upper half side rails when in bed for safety. On 5/3/24 at 1034 hours, an interview and concurrent medical record review were conducted with RN 3. RN 3 verified Resident 20's medical record failed to show a physician's order for the use of bilateral upper half side rails, and the plan of care failed to show interventions for the use of bilateral upper half side rails. RN 3 also verified Resident 20's Benefits of Bedrails Review and Acknowledgement form were incompletely filled out and had no date. RN 3 stated the bed is not being measured for entrapment when the residents require the side rails. RN 3 further stated she did not know how to measure the side rails for entrapment. On 5/3/24 at 1344 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated the beds were not routinely assessed for entrapment measurement for residents who require bed side rails. The Maintenance Supervisor further stated he only completes work on the resident's bed when there was a problem. On 5/3/24 at 1430 hours, an interview was conducted with RN 1. RN 1 was informed and acknowledged findings as above. 8. Medical record review for Resident 40 was initiated on 4/30/24. Resident 40 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 40's H&P evaluation dated 2/1/24, showed Resident 20 has the capacity to understand and make decisions. Review of Resident 40's admission MDS assessment dated [DATE], showed BIMS Summary Score of 12 (moderate impairment of cognition). The resident was able to make self-understood and understand others. Resident 40's functional abilities showed functional limitation impairment of one side of upper and lower extremity. Review of Resident 40's Order Summary Report as of 5/1/24 failed to show the physician's order for the use of bilateral upper half side rails. Review of Resident 40's Risk and Benefits of Bedrails Review and Acknowledgement form dated 2/1/24, showed incomplete. The purpose of bedrail, type of bedrail, potential risk and potential benefits were not marked. The form showed checked mark on refuse to give my authorization for the use of the bedrail(s). The resident/ surrogate decision maker/ legally recognized decision maker was not signed by the resident. Review of Bed Safety Rail assessment dated [DATE], showed Resident 20 was not likely to fall from bed, rail may not be appropriate. Review of Physical Restraint Assessment 2.0 dated 2/2/24, showed the IDT had no recommendation for any physical restraint. Further review of Resident 40's medical record failed to show documented evidence of the siderail entrapment assessment was completed and documented. On 5/1/24 at 0815 hours, 5/2/24 at 0800 hours, and 5/3/24 at 0945 hours, Resident 40 was observed laying on bed with bilateral upper ½ bed side rails were elevated. On 5/3/24 at 0945 hours, an interview and concurrent medical record review with LVN 4 was conducted. LVN 4 stated Resident 40 uses bilateral upper ½ bed side rails as enabler. LVN 4 verified Resident 40's medical record failed to show a physician's order for use of bilateral upper ½ bed side rails, and the plan of care failed to show intervention for the use of bilateral upper ½ bed side rails. The Resident 40's Benefits of Bedrails Review and Acknowledgement form were incompletely filled out the purpose of bedrail, type of bedrail, potential risk and potential benefits were not marked, the form showed checked mark on refuse to give my authorization for the use of the bedrail(s), and the resident/ surrogate decision maker/ legally recognized decision maker was not signed by the resident. On 5/3/24 at 1430 hours, an interview with RN 1 was conducted. RN 1 stated Resident 40 did not want the use of bed side rail at the time of the assessment and had been using the side rails recently. RN 1 stated he will update the assessment and get an order for the use of bilateral upper ½ side rails elevated when in bed. On 5/3/24 at 1344 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated the beds were not routinely assessed for entrapment measurement for residents who require bed side rails. The Maintenance Supervisor further stated he only completes work on the resident's bed when there was a problem. On 5/3/24 at 1430 hours, an interview with RN 1 was conducted. RN 1 was informed and acknowledged findings as above. Cross reference to F 700. 9. On 4/30/24 at 0855 hours, Resident 8 was observed in bed with bilateral half side rails elevated. Medical record review for Resident 8 was initiated on 5/1/24. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's Risks and Benefits of Bedrail Review and Acknowledgment dated 8/16/21, showed under potential benefits, it was the resident's preference for the use of bedrails. However, the acknowledgment form was not signed by the resident or the legally recognized decision maker. Review of Resident 8's Bed Safety Rail assessment dated [DATE], showed Resident 8 was not likely to fall from bed, and rail may not be appropriate. The assessment form showed the gaps were small enough to avoid an entrapment risk to the bed occupant, and the body or head was large enough not to pass between bars of the bed safety rail, through the gap between the rail and the side of the mattress, and between the headboard and bed safety rail. Further review of Resident 8's medical record failed to show documented evidence of any measurements related to the bed rail entrapment zones. On 5/3/24 at 1043 hours, an interview and concurrent medical record review was conducted with RN 3. RN 3 stated Resident 8 used the bilateral bed siderails as an enabler. On 5/3/24 at 1339 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated the rental company installed the beds and mattresses. If there were issues, the facility would call the rental company. The Maintenance Supervisor verified there were no measurements related to the bed rail entrapment zones. Cross reference with F700, example #6. 2. Medical record review for Resident 12 was initiated on 4/30/24. Resident 12 was admitted to the facility on [DATE]. Review of Resident 12's Order Summary report dated 5/1/24, showed a physician's order dated 11/15/23, for 1/2 (half) right side rail up while in bed. On 4/30/24 at 0848 hours, an observation and concurrent interview were conducted with Resident 12. Resident 12 was observed laying in bed, with the right upper side rail elevated. Resident 12 stated the faclity used the side rail to assist with bed mobility. 3. Medical record review for Resident 22 was initiated on 4/30/24. Resident 22 was re-admitted to the facility on [DATE]. Review of Resident 22's Order Summary report dated 5/1/24, showed a physician's order dated 10/3/22 that the facility may use bilateral half side rails. On 4/30/24 at 1215 hours, Resident 22 was observed laying in bed with the right upper side rail in use. 4. Medical record review for Resident 387 was initiated on 4/30/24. Resident 387 was admitted to the facility on [DATE]. Review of Resident 387's Order Summary report dated 5/1/24, showed a physician's order dated 10/4/23, for bilateral upper half side rails. On 4/30/24 at 1203 hours, an observation and concurrent interview were conducted with Resident 387. Resident 387 was observed lying in bed with the bilateral upper side rails elevated, and Resident 387 stated the facility used the side rails for bed mobility. On 5/3/24 at 0919 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated he did not do the routine maintenance and bed inspections on the beds with side rails. Based on observation, interview, medical record review, facility P&P review, and facility document review, the facility failed to conduct a regular bed inspection as part of a regular maintenance program to identify areas of possible entrapment for 12 of 12 residents reviewed for side rail use; 11 final sampled residents (Residents 7, 8, 12, 15, 16, 20, 22, 40, 387, 837, and 838), and one nonsample resident (Resident 10). These failures had the potential to negatively impact the residents resulting in possible entrapment, serious injury, and death. Findings: According to the Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, the term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rail, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. The seven areas in the bed system where there is a potential for entrapment are: - Zone 1: within the rail; - Zone 2: under the rail, between the rail supports or next to a single rail support; - Zone 3: between the rail and the mattress; - Zone 4: under the rail, at the ends of the rail; - Zone 5: between split bed rails; - Zone 6: between the end of the rail and the side edge of the head or foot board; and - Zone 7: between the head or foot board and the mattress end. Review of the facility's P&P titled Bed Safety and Bed Rails revised 8/2022 showed the following: -Resident beds meet the safety specifications established by the hospital bed safety workgroup. The use of bed rails is prohibited unless the criteria for use of bed rails have been met; -Bed frames, mattresses and bed rails are checked for compatibility and size prior to use; -Bed dimensions are appropriate for the resident's size; -Regardless of mattress type, width, length and/or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident's head or body. Any gaps in the bed system are within the safety dimensions established by the FDA; -Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks; and -The resident assessment also determines potential risks to the resident associated with the use of bed rails, including the following: (a) Accident hazards: (1) The resident could attempt to climb over, around, between, or through the rails, or over the foot board; and or (2) A resident or part of his/ her body could be caught between the rails, the opening of the rails or between the bed rails and mattress. A concurrent observation, medical record review, and facility document review for Residents 2, 12, 15, 16, 387, 837, and 838 showed there were no regular bed inspection conducted as part of a regular maintenance program, and the residents' bed entrapment assessments were not completed or the bed inspection gap measurements were not recorded. For example: 1. On 4/30/24 at 0828 hours, during the initial facility tour, Resident 15 was observed sitting in the wheelchair. Bilateral half side rails were observed elevated. Resident 15 was observed eating by herself, and CNA 6 was observed at bedside. When asked about the bilateral half side rails, Resident 15 stated she used the side rails, and CNA 6 stated Resident 15 only used the left side rail. On 5/2/24 at 0741 hours, and 5/3/24 at 0837 hours, Resident 15 was observed in bed with left half side rails elevated. Medical record review for Resident 15 was initiated on 5/6/24. Resident 15 was readmitted to the facility on [DATE]. Review of Resident 15's Order Summary Report showed a physician's order dated 5/2/24, to provide left half side rail every shift for feelings for safety. Review of Resident 15's Bed Safety Rail assessment dated [DATE], was incomplete. The assessment showed Resident 15 was not likely to fall from bed, and rail may not be appropriate. The assessment form did not show an answer to the question if the gaps were small enough to avoid an entrapment risk to the bed occupant; and no answer to the question if the body or head was large enough not to pass between bars of the bed safety rail, through the gap between the rail and the side of the mattress, and between the headboard and bed safety rail. Review of Resident 15's Bed Safety Rail assessment dated [DATE], showed Resident 15 was not likely to fall from bed, and rail may not be appropriate. The assessment form showed the gaps were small enough to avoid an entrapment risk to the bed occupant, and the body or head was large enough not to pass between bars of the bed safety rail, through the gap between the rail and the side of the mattress, and between the headboard and bed safety rail. Further review of the assessment form only showed Zones 1, 3, and 6 were checked. The assessment form did not show Zones 2, 4 and 7, which were applicable for Resident 15, were checked. In addition, the assessment form did not show any measurements related to the entrapment zones. On 5/3/24 at 0919 hours, an interview and concurrent facility record review for Resident 15 was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated he was responsible for the bed inspection in the facility, including checking the side rails, bed motor, brakes, wheels, and mattresses. When asked about the entrapment assessment, the Maintenance Supervisor stated he was not familiar with any entrapment assessment, and he was not familiar with the seven areas in the bed system where there was a potential for entrapment. When asked if he had conducted any measurements of the side rails, mattress, headboard or the footboard, the Maintenance Supervisor stated he did not measure because all the beds, mattresses and side rails were standard. When asked if he conducted a regular bed inspection all the beds in the facility, the Maintenance Supervisor answered no. The Maintenance Supervisor stated there was no regular bed inspection, but he would only check the beds when he was informed by the facility staff that a bed was needed to be inspected because it was broken, and he needed to fix it. The Maintenance Supervisor also stated he would do a bed inspection when the room was vacant, and they had to make sure the room was ready for admission. When asked for any documentation of the bed inspection conducted for any of the beds in the facility, the Maintenance Supervisor could not provide any documentation. On 5/3/24 at 1016 hours, an interview and concurrent facility record review for Resident 15 was conducted with RN 1. RN 1 verified the above findings. When asked about the entrapment assessment, RN 1 stated the nurses used the Bed Safety Rail Assessment form. RN 1 verified the Bed Safety Rail Assessment forms for Resident 15 were incomplete. RN 1 verified the assessment form did not show the seven areas in the bed system where there was a potential for entrapment. RN 1 also stated the nurses do not measure but would only do an observation to the resident and the bed with side rails. Cross reference to F700, example #7.

MINOR (B)

Minor Issue - procedural, no safety impact

Resident Rights (Tag F0550)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of two final sampled residents reviewed for resident rights (Resident 8) was provided care in a manner that prompted dignity and respect. * Resident 8's urinary drainage bag was not covered. This failure had the potential to diminish the resident's self-esteem and self-worth. Findings: On 4/30/24 at 0855 hours, during the initial tour, Resident 8's urinary drainage bag was observed not covered. The urinary drainage bag was easily seen from Resident 8's doorway. Review of the facility's P&P titled Resident Rights revised 11/2010 showed under the section assisting the residents in exercising rights, the facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. Medical record review for Resident 8 was initiated on 5/1/24. Resident 8 was admitted to the facility on [DATE]. Review of the Order Summary Report showed an order dated 11/13/23, for suprapubic catheter size Fr 16/10 ml attached to the bedside closed drainage bag system. On 4/30/24 at 0855 hours, an interview was conducted with RN 1. RN 1 stated the urinary drainage bag should be covered with a dignity bag.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0572 (Tag F0572)

Minor procedural issue · This affected multiple residents

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Based on interview, facility document review, and facility P&P review, the facility failed to accurately inform the residents of the language communication and their rights to speak the language of their choice. This failure posed the risk for minimizing the residents' quality of life and not informing them of the facility's rules and expectations on language communication while residing in the facility. Findings: Review of the facility's P&P titled Resident Communication Language dated 4/2019 showed it is the policy of this facility to communicate in the English language. Staff shall communicate with residents in English. When the resident is unable to speak English then the communication shall be done through an interpreter. If the caregiver is able to speak in the resident's language, it is permitted for staff to speak such as to provide the necessary care. Review of the forms titled Resident Council Minutes dated 2/28, 3/27, and 4/24/24, showed the residents' rights were discussed and the English speaking only policy was followed. On 5/1/24 at 1000 hours, a Resident Council meeting was conducted. The residents were asked if they were informed about the English speaking only policy in the facility. Seven of seven residents ( Residents 8, 21, 28, 1138, 1139, 1040, and 1140) who attended the residents' council meeting stated they were not informed of the facility's English only policy. When asked if the facility staff spoke to the residents in English, the residents stated yes, with some residents nodding their heads while stating yes. During the Resident Council meeting, Resident 1138, who was also the President of Resident Council, translated in Spanish for Residents 8 and 1140 who raised their hands and verbalized they only spoke in Spanish. When asked if an interpreter was offered to assist in translating Spanish to English, Resident 1138 stated, No they speak Spanish here. When asked if during the admission or during any meeting such as Resident Council, if any staff made the residents aware of the facility's rule and policy on speaking English only, Resident 28 stated, No, no it's not a rule. Seven of seven residents stated, no. On 5/1/24 at 1410 hours, an interview and concurrent facility document review was conducted with the AD. The AD verified the Resident Council Minutes dated 2/28, 3/27, and 4/24/24, showed the English speaking only policy was followed. The AD also reviewed and acknowledged the facility's P&P addressing the language communication in the facility. The AD stated the policy needed to be revised since there were multiple residents in the facility who spoke a different language as their primary language and who did not understand English.

MINOR (B)

Minor Issue - procedural, no safety impact

Comprehensive Care Plan (Tag F0656)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review for Resident 838 was initiated on 4/30/24. Resident 838 was admitted to the facility on [DATE]. Review of Resident 838's Order Summary Report showed a physician's order dated 3/2/23, may have bilateral 1/2 side rails up per responsible party request (feeling of safety). Review of Resident 838's plan of care failed to show a care plan addressing Resident 838's bilateral 1/2 side rails. On 4/30/24 at 1011 hours, an observation and concurrent interview was conducted with LVN 1. LVN 1 verified Resident 838's bilateral ½ side rails were elevated. On 5/2/24 at 1317 hours, an interview and concurrent medical record was conducted with RN 1. RN 1 verified there was no care plan developed for Resident 838's bilateral 1/2 upper side rail use. RN 1 stated Resident 838's care plan should have been developed by a licensed nurse. On 5/3/24 at 1422 hours, an interview was conducted with the Administrator. The Administrator was informed and acknowledged the above findings. Based on observation, interview and medical record review, the facility failed to develop the comprehensive plans of care to reflect the individual care needs for two of 18 final sampled residents (Residents 41 and 838). * The facility failed to develop a care plan problem to address Resident 41's activity participation. * The facility failed to ensure a care plan was developed to address Resident 838's bilateral 1/2 (half) side rails. These failures posed the risk of not providing appropriate, consistent, and individualized care to the residents. Findings: Review of the facility's P&P titled Care Plans, Comprehensive Person-Centered revised 3/2022 showed a comprehensive, person-centered care plan that includes measurable objectives and timetable to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. Review of Resident 41's medical record was initiated on 4/30/23. Resident 41 was admitted to the facility on [DATE], and readmitted on [DATE]. Review or Resident 41's H&P examination dated 1/4/24, showed Resident 41 did not have the capacity to understand and make decisions. Review of Resident 41's Order Summary Report dated 5/1/24, showed a physician's order dated 1/23/24, for may participate in planned activities. Review of Resident 41's admission MDS Assessment under section A dated 1/14/24, Section A showed resident 41's preferred language was Chinese. Review of Resident 41's Plan of Care failed to show documented evidence a care plan problem was developed to address Resident 41's activity participation. On 4/30/24 at 0850 hours, Resident 41 was observed in her room lying in bed with eyes open. On 5/2/24 at 0833 hours, a concurrent interview and medical record review with the AD was conducted. The AD verified Resident 41's plan of care failed to show a care plan was initiated to address the resident's needs for activities.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0657 (Tag F0657)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care for one of 18 final sampled residents reviewed for care plans (Resident 8) was revised to reflect the resident's current care needs and interventions. * The facility failed to revise the plan of care for Resident 8 to address the change in Resident 8's suprapubic catheter (a hollow flexible tube used to drain urine from the bladder through a cut in the abdomen) size. This failure posed the risk of not providing the resident with individualized and person-centered care. Findings: Review of the facility's P&P titled Care Planning - Interdisciplinary Team, undated showed the facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. Review of the facility's P&P titled Care Plans - Comprehensive revised 9/2010 showed the assessments of resident are ongoing and care plans are revised as information about the resident and the resident's condition change. Medical record review for Resident 8 was initiated on 5/1/24. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's Order Summary Report dated 5/1/24, showed a physician's order dated 11/13/23, to change the suprapubic catheter size Fr 16/10 ml on the 15th of the month and as needed when clogged, soiled, or pulled out. Review of the Treatment Administration Record for April 2024 showed Resident 8's suprapubic catheter size Fr 16/10 ml was changed on 4/15/24. Review of Resident 8's plan of care showed a care plan problem revised 8/17/21, to address Resident 8's suprapubic catheter. The intervention showed the resident had size Fr 18/30 ml suprapubic catheter. On 5/2/24 at 1404 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 verified Resident 8's suprapubic catheter size Fr 16/10 ml was ordered on 11/13/23, however, the care plan showed an intervention of suprapubic catheter for size Fr 18/30 ml. Furthermore, LVN 5 stated when the order was changed, the care plan should have been updated. On 5/2/24 at 1430 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 verified an order was placed on 11/13/23 to change the resident's suprapubic catheter to size Fr 16/10 ml every 15th of the month, however, the care plan showed Resident 8 had suprapubic catheter size Fr 18/30 ml. RN 2 stated the care plan should be updated.

MINOR (B)

Minor Issue - procedural, no safety impact

Medical Records (Tag F0842)

Minor procedural issue · This affected multiple residents

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Based on observation, interview, facility document review, and facility P&P review, the facility failed to maintain accurate medical records and ensure the residents' personal health information was kept private for their residents. * The facility failed to ensure the documents were free from the use of erasing materials such as white correction tape. * Two of two survey binders contained confidential resident information. These failures had the potential for the residents' care needs not being met as their medical information was inaccurate and could have potentially allowed unauthorized staff or visitors access to residents' confidential medical or personal information. Findings: 1. Review of the facility's P&P titled Record Quality Review dated 9/2023 showed it is the policy of the facility to record data in a proper and legible manner, free of errors and the non-use of erasing materials such as correction tape/liquids. On 5/1/24 at 1030 hours, during the resident council meeting, multiple documents in the Resident Council Binder were observed with white correction tape (used to correct errors). The following documents had white correction tape used: -Resident Council minutes form dated 2/28/24, under New Business number 7, any dignity issues showed correction tape was used next to answer option yes. -Under Departments/ Nursing section, observed white correction tape used to cover one entire line from far left margin of page all the way across to far right margin of page. -Under Activities section, observed on line number 4, white correction tape used underneath the words printed in black ink, 'Enrolling pt to OCTA. On 5/1/24 at 1414 hours, an interview and concurrent facility document review was conducted with the AD. When asked why the AD used correction tape on facility documents, the AD verified the above findings and acknowledged she was using the white correction tape. The AD stated she knew she was not supposed to use it but it was easier to use the correction tape. 2. On 5/3/23 at 1037 hours, two binders were observed on the front reception desk in the front lobby for public review. -The first binder, labeled California Department of Public Health (CDPH) 2022 Survey & Inspections, had a Confidential Resident Roster for CDPH's Recertification Survey completed on 3/11/22. The confidential roster showed 23 residents and their identifies. The roster was included with survey's statement of deficiencies, which included the resident identifier, related deficient practices with supporting medical records and protected health information. -The second binder, labeled CDPH 2022-2024 Inspections, had a document with the facility's header, addressed to CDPH's local district office. The document showed a facility reported incident (FRI) for Resident 1040. The record included Resident 1040's name, date of birth , date of admission, medical diagnoses, details of the residents incident and follow-up interventions including assessments and radiology results. A printed email correspondence from the DON to the Administrator was also with the document with Resident 1040's name in the subject line, with basic health information including the time of the incident, when the resident complained of pain, results of their radiology report and the acute care hospital they were transferred to. The bottom of the email showed a HIPAA (Health Insurance Portability and Accountability Act) Compliance Statement, that the communication may contain confidential protected health information and it is intended only for the use of the individual to which it was addressed. The recipient of this information is prohibited from disclosing this information to any other party unless required to do so by the law or regulation. On 5/3/24 at 1043 hours, an interview and review of the binders were conducted with the DSD. The DSD stated the two survey results binders were to be available for review by the public and should not contain any confidential or protected health information. The DSD verified the above records and stated should not have been placed in the binders for public review.

Mar 2024 1 deficiency

MINOR (B) 📢 Someone Reported This

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

Minor Issue - procedural, no safety impact

Medical Records (Tag F0842)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the medical record for one of five sampled residents (Resident 4) was accurate. This failure had the potential for the residents' care needs to not be met. Findings: Medical record review for Resident 4 was initiated on 3/12/24. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's Order Summary Report for active orders as of 3/12/24, showed the following physician's orders: - an order dated 8/27/23, for Insulin Lispro (diabetes medication) 100 units/ml with a sliding scale every midnight for diabetes mellitus - an order dated 4/20/23, for famotidine 20 mg one tablet orally twice a day for GERD - an order dated 4/20/23, for Mylanta Suspension 200-200-20 mg/5 ml orally twice a day for heartburn/indigestion - an order dated 5/2/23, for metoclopramide 10 mg one tablet orally four times a day for GERD Review of Resident 4's Medication Administration Record for March 2024 showed no licensed nurses' initials were documented to show the following medications were administered: - Insulin Lispro 100 units/ml with sliding scale on 3/8 and 3/9/24 - famotidine 20 mg on 3/10/24 - Mylanta Suspension 200-200-20 mg/5 ml on 3/10/24 - metoclopramide 10 mg on 3/10/24 On 3/12/24 at 1015 hours, an interview was conducted with LVN 3 who worked the night shift. LVN 3 stated she recalled giving all of the above medications to the resident. On 3/12/24 at 1330 hours, a concurrent interview and medical record review was conducted with the DON. The DON verified the above findings.

Feb 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to implement their P&P for ensuring the reporting of a reasonable suspicious of a crime in accordance with section 1150B of the Act when the facility did not report the allegation of abuse to the CDPH, L&C Program, Long-Term Care Ombudsman, and local law enforcement officials in timely manner for one of six sampled residents (Resident 1). The facility did not report Resident 1's allegations of abuse against the Activities Assistant to the CDPH L&C Program, Long-Term Care Ombudsman, and local law enforcement officials within two hours as per the facility's P&P within two hours. This failure had the potential to delay the investigation of the alleged physical abuse and for the staff to not take prompt and appropriate corrective actions to prevent further abuse. Findings: Review of the facility's P&P titled Abuse Investigations and Reporting, undated, showed all alleged violation involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported by the facility administrator, or his/her designee, to the following person or agencies: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The local/State Ombudsman; c. The Resident's Representative (Sponsor) of Record; d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's Attending Physician; and g. The facility Medical Director. Further review of the P&P showed suspected abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident's property) will be reported within two hours. On 2/9/24, the CDPH, L&C Program received an SOC 341 from the facility regarding the abuse allegation made by Resident 1. The SOC 341 dated 2/9/24, showed the Activity Assistant pushed Resident 1 on the table and reportedly pinched Resident 1 from behind on both shoulders causing her great pain on 2/7/24. Medical record review for Resident 1 was initiated on 2/15/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's History and Physical examination dated 9/13/23, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1's MDS dated [DATE], showed Resident 1 had moderate cognitive impairment. On 2/16/24 at 1046 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON stated on 2/7/24 around 1600 hours, Resident 1 reported to her that the Activity Assistant pushed Resident 1 to the table then pinched her from the back on her both shoulder that caused Resident 1 great pain. The DON then stated she reported the above allegation of physical abuse to the CDPH, L&C Program via telephone on 2/8/24 at around 1000 hours, 18 hours later. The DON verified the SOC 341 was faxed to CDPH, L&C Program, Long-Term Care Ombudsman, and local law enforcement officials on 2/9/24.

CONCERN (D) 📢 Someone Reported This

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

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to report the result of the investigation to the CDPH, L&C Program, Orange District Office within five working days for one of six sampled residents (Resident 1). This failure had the potential to not protect the residents from possible abuse and/or delay in providing the necessary care. Findings: Review of the facility's P&P titled Abuse Investigation and Reporting, undated, showed all reports of residents' abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of the unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulation) and thoroughly investigated by facility management. The P&P further showed findings of the abuse investigations will also be reported. The section for Reporting showed the administrator, or his/her designee, will provide the appropriate agencies with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. On 2/9/24, the CDPH, L&C Program received an SOC 341 from the facility regarding the abuse allegation made by Resident 1. The SOC 341 dated 2/9/24, showed the Activity Assistant pushed Resident 1 on the table and reportedly pinched Resident 1 from behind on both shoulders causing Resident 1 great pain on 2/7/24. Medical record review for Resident 1 was initiated on 2/15/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's History and Physical examination dated 9/13/23, showed Resident 1 had the capacity to understand and make decisions. Review of the facility's Follow-up Report of the alleged physical abuse showed the document was fax to the CDPH, L&C Program on 2/15/24. On 2/16/24 at 1046 an interview was conducted with the DON. The DON stated on 2/7/24 around 1600 hours, Resident 1 reported to her that Activity Assistant pushed Resident 1 to the table, then pinched her from the back on her both shoulder causing Resident 1 great pain. The DON stated the facility had completed the investigation and determined the above allegation reported by Resident 1 was unsubstantiated; however, the DON stated the facility did not submit the result of the investigation to the the CDPH, L&C Program, Orange District Office within five working days.

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the change in condition evaluation and monitoring was completed and the physician was notified of the allegation of physical abuse for one of six sampled residents (Resident 1). This failure had the potential for Resident 1 to not receive necessary services to meet highest practicable physical, mental, and psychosocial well-being. Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised February 2021 showed the facility promptly notified the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing payments, resident rights, etc.). The P&P further showed the nurse will notify the resident's attending physician or physician on call when there has been an accident or incident involving the resident. The nurse will record in the resident's medical record information relative to the changes in the resident medical/mental condition or status. On 2/9/24, the CDPH, L&C Program received an SOC 341 from the facility regarding the abuse allegation made by Resident 1. The SOC 341 showed the Activity Assistant pushed Resident 1 on the table and reportedly pinched Resident 1 from behind on both shoulders causing Resident 1 great pain on 2/7/24. Medical record review for Resident 1 was initiated on 2/15/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's History and Physical evaluation dated 9/13/23, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1's medical record failed to show the change in condition evaluation and monitoring was conducted on Resident 1 after the alleged physical abuse. Further review of Resident 1's medical record failed to show the physician was notified of the alleged physical abuse. On 2/16/24 at 1046 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON verified above findings. The DON stated on 2/7/24 around 1600 hours, Resident 1 reported to her that the Activity Assistant pushed Resident 1 to the table, then pinched her from the back on her both shoulder causing Resident 1 great pain. The DON verified the allegation of physical abuse reported by Resident 1 was a change of condition. The DON stated the change in condition evaluation, monitoring, and physician notification should have been completed after receiving the report of the allegation of physical abuse by Resident 1. On 2/16/24 at 1604 hours, a follow-up interview was conducted with the DON. The DON acknowledged the above findings.

Jan 2024 2 deficiencies

MINOR (B) 📢 Someone Reported This

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

Minor Issue - procedural, no safety impact

Quality of Care (Tag F0684)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Residents 2) received the medication as ordered by the physician. This failure had the potential to place Resident 2 at risk for medical complications. Findings: Review of the Facility's P&P titled Administering Medication dated 4/2019 showed the medications are administered within one hour of their prescribed time unless otherwise specified (for example, before and after the meal orders). Medical record review for Resident 2 was initiated on 1/17/24. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. On 1/17/24 at 1200 hours, an interview was conducted with Resident 2. Resident 2 stated LVN 4 administered his insulin late and did not wake him up for his medicine. Resident 2 reported this incident to RN 3. Review of Resident 2's Order Summary Report dated 1/17/24, showed the following physician's orders: * An order dated 5/16/23, to administer Insulin Glargine Subcutaneous Solution (anti-diabetic medication) 100 units/ml, give 35 units subcutaneously two times a day at 0900 and 2100 hours related to DM due to the underlying condition Review of Resident 2's Medication administration Record for December 2023 showed Insulin Glargine Subcutaneous Solution 100 unit/ml was administered on 12/21/23 at 2327 hours. On 1/22/24 at 1530 hours, an interview was conducted with LVN 4. LVN 4 was asked regarding Resident 2's insulin being administered late on 12/21/23. LVN 4 stated she remembered around mid-December 2023 about administering the insulin glargine with the midnight medicine. LVN 4 stated Resident 2 was asleep around 2100 hours, and she did not want to wake up the resident. LVN 4 stated she administered the medications to other residents and forgot to administer Resident 2's medication on time. LVN 4 stated she apologized to Resident 2. LVN 4 was asked if there was documentation regarding the incident. LVN 4 stated she did not document and verified the finding. On 1/23/24 at 1500 hours, an interview was conducted with RN 1. RN 1 was asked about the time frame to administer the medicine. RN 1 stated one hour before to one hour after the prescribed time. RN 1 stated if a medication was administered late, it should be documented in the progress notes. On 1/23/24 at 1530 hours, an interview and medical record review was conducted with the DON. The DON was asked about the medication administration for Resident 2 by LVN 4. The DON stated she interviewed LVN 4 and LVN 4 acknowledged the medication administration was late one time in December 2023. The DON verified the finding.

MINOR (B) 📢 Someone Reported This

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

Minor Issue - procedural, no safety impact

Medical Records (Tag F0842)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure the grievance form was completed to show the actions taken and follow up for one of two sampled residents (Resident 2). This failure had the potential for the resident to not be fully informed about the resolution to his grievance. Findings: Review of the facility's P&P titled SECTION 504 GRIEVANCE PROCEDURES (undated) showed the facility has adopted an internal grievance procedure providing for prompt and equitable resolution of complaints alleging any action prohibited by the U.S. Department of Health and Human Services regulations (45 CFR, Part 84). Medical record review for Resident 2 was initiated on 1/17/24. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the facility's Grievance form dated 1/7/24, showed Resident 2 stated after the trach suctioning, he asked to have his eyes wiped, but the RT did not wipe his eyes. It was not until five minutes later the nurse was able to wipe his eyes. Resident 2 stated it had been the second time for this occurrence. Resident 2 stated he did not want to have the same RT if she would not wipe his eyes after suctioning. The grievance form further showed the follow-up conference with the concerned party and the specific corrective action sections were blank. On 1/17/24 at 1200 hours, an interview was conducted with Resident 2. Resident 2 stated he expressed the concern regarding the RT not wiping his eyes after his trach was suctioned. Resident 2 reported this concern to RN 3. Resident 2 stated he did not want to work with the RT anymore. Resident 2 stated he had teary eyes after being suctioned. Resident 2 was asked if any other staff help him to wipe his eyes. Resident 2 stated the nurse came wiped his eyes after 20 minutes later. On 1/23/24 at 1510 hours, an interview was conducted with RN 3. RN 3 stated on that day, he was aware Resident 2 reported that his RT did not wipe his eyes after suctioning his trach. RN 3 stated he wrote a grievance form and gave it to RN 2. RN 3 was asked if he had followed up with Resident 2 about his grievance. RN 3 stated he had communicated this to the RT Supervisor who was aware of it. After discussing the grievance, RN 3 stated Resident 2 agreed to have the same RT take care of him along with a licensed nurse to wipe his teary eyes. RN 3 was asked if he could provide any documentation about his corrective action and follow up with the concerned party. RN 3 stated he was unable to provide the documentation. RN 3 verified the finding.

Oct 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of six sampled residents (Residents 1 and 3) and one nonsampled resident (Resident A) had the functioning call light buttons available or a way to call the staff. This failure had the potential for the residents to not be able to call for assistance and receive help in a timely manner. * Resident 1 was wheelchair bound and dependent on the staff for assistance in bed mobility, toileting, and transfers. Resident 1 did not have a functional call light and was unable to get a hold of staff when needed help. * Resident 3 was wheelchair bound and needed assistance with transfers, dressing, and eating. Resident 3 did not have a working call light button and had to wheel herself out of the room to call for help. * Resident A did not have a working call button and relied on Resident 3 to get staff, or to yell if she needed assistance. Findings: Review of the facility's P&P titled Call System, Residents, dated 9/2022 showed the residents should be provided with a way to call staff for assistance and the call system should remain functional at all times. 1. Medical record review for Resident 1 was initiated on 10/9/23. Resident 1 was admitted to the facility on [DATE]. Review Resident 1's H&P examination dated 4/20/23, showed Resident 1 had the capacity to understand and make medical decisions. Review of Resident 1's MDS dated [DATE], showed Resident 1 was cognitively intact and required extensive assistance for bed mobility, transfers, dressing, and toileting. On 9/27/23 at 1221 hours, an observation and concurrent interview was conducted with Resident 1. Resident 1 stated his call light did not work. Resident 1 pressed his call button and the light outside the door did not turn on. Resident 1 stated about a week ago, he needed someone to help him and to change his diaper. Resident 1 stated hecalled and called, but no one answered the phone. Resident 1 stated they did not answer the phone at night. Resident 1 stated they took care of the important people first but not him. 2. Medical record review for Resident 3 was initiated on 10/9/23. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 7/3/23, showed Resident 3 had the capacity to understand and make medical decisions. Review of Resident 3's MDS dated [DATE], showed Resident 3 was cognitively intact and needed assistance with transfers, dressing, and eating. On 9/27/23 at 0945 hours, an observation and concurrent interview with Resident 3 was conducted. Resident 3 was observed sitting in a wheelchair in her room. Resident 3 stated her call light did not work. Resident 3 wheeled herself over to the call light and pressed the button. The light above the door did not light up. Resident 3 stated when Resident A (her roommate) cried, she went outside the room to get help. On 9/27/23 at 0950 hours, an interview was conducted with CNA 6. CNA 6 stated she told Resident 3 to bang on something, bang on the table when Resident 3 needed help. 3. Medical record review for Resident A was initiated on 10/9/23. Resident A was admitted to the facility on [DATE]. Review of Resident A's H&P examination dated 9/27/23, showed Resident A did not have the capacity to understand and make medical decisions. The H&P examination also showed Resident A had a diagnosis of aphasia. Review of Resident A's MDS dated [DATE], showed Resident A was cognitively impaired. Review of Resident A's Care Plan showed a care plan problem dated 1/29/15, addressing a communication problem. The interventions included to provide a safe environment by ensuring the call light was within reach. On 9/27/23 at 0950 hours, a concurrent observation and interview was conducted with Resident A and CNA 6. Resident A was observed lying in bed with an adaptive call button next to her face. When Resident A was asked how she called for help, Resident A nudged the call button with her cheek. CNA 6 then stated Resident A's call light did not work. CNA 6 pressed Resident A's call button and the call light panel over Resident A's bed did not light up nor did the light outside the door turn on. On 9/27/23 at 1339 hours, an interview was conducted with the DON. The DON confirmed Resident 1's call light was not working but Resident 1 could use his personal mobile phone to call the nursing station. When asked about Resident 3 having to bang on something when Resident 3 needed help, the DON stated that was not right. Cross reference to F919.

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, medical record review, and facility P&P review, the facility failed to ensure one of six sampled residents (Resident 5) who received nutrition via a gastrostomy tube was not given food by mouth. This failure had the potential for Resident 5 to choke and have poor health outcomes. Findings: Review of the facility's P&P titled Assisting the Impaired Resident with In-Room Meals revised September 2013 showed the staff are to check the meal tray before serving it to the resident to ensure it is the correct ordered diet. Medical record review was initiated for Resident 5 on 10/3/23. Resident was readmitted to the facility on [DATE]. Review Resident 5's H&P examination dated 9/8/23, showed Resident 5 could make her needs known but could not make medical decisions. Resident 5 had a diagnosis of dysphagia. Review of Resident 5's MDS dated [DATE], showed the Resident 5 had severe cognitive impairment. Review of Resident 5's physician orders dated 9/15/23, showed an order for the resident to have liquid nutrition through a gastrostomy tube. On 10/3/23 at 1200 hours, an interview was conducted with LVN 1. LVN 1 stated on 9/28/23 at around 1730 hours, he was informed that CNA 5 had accidentally fed Resident 5. LVN 1 stated Resident 5 was not supposed to have a meal tray delivered to her room. LVN 1 stated the CNAs weresupposed to ask the charge nurses if a resident was supposed to eat. On 10/4/23 at 1029 hours, an interview was conducted with CNA 5. CNA 5 stated she found a meal tray in Resident 5's room. CNA 5 stated she fed Resident 5 about three small bites of food, then the resident started throwing up. CNA 5 stated she checked the name card on the meal tray afterwards and it had another resident's name on it. CNA 5 stated that was the mistake on her part because she should have checked it before.

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 F0919 (Tag F0919)

Could have caused harm · This affected multiple residents

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Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the call light system was functioning for 33 of 54 beds (Beds A, B, C, D, E, F, F, H, I, J, K, L, M, N, O, P, Q, R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, EE, FF, andGG.) This failure had the potential of an unsafe environment by endangering the health, safety, and welfare of the affected residents who were assigned to those beds. Findings: Review of the facility's P&P titled Call System, Residents dated 9/2022 showed the residents should be provided with a way to call staff for assistance and the call system should remain functional at all times. Review of the Call Light Ledger created 9/27/23, showed 33 beds had non-functioning call lights: Beds A, B, C, D, E, F, F, H, I, J, K, L, M, N, O, P, Q, R, S, T, U, V, W, X, Y, Z, AA, BB, CC, DD, EE, FF, and GG. Review of the Unusual Occurrence Letter dated 9/28/23, showed on 9/20/23, the facility's call light system stopped working in certain rooms and the service vendor was summoned immediately for the necessary repairs. On 9/27/23 at 1050 hours, an interview was conducted with the Maintenance Director. The Maintenance Director stated the problem was within the call light system. On 9/27/23 at 1321 hours, an interview was conducted with RN 3. RN 3 stated she was not sure which rooms did not have working call lights and not sure how long they had been broken. RN 3 stated if a resident did not have a working call light, they could call the nursing station using their cell phone or scream for help. RN 3 stated she was not sure if the residents had the phone number to the nursing station, but it was supposed to be provided to them during admission. On 9/27/23 at 1339 hours, an interview was conducted with the DON. The DON confirmed the call system was not functioning in all the rooms. On 9/28/23 at 0745 hours, an interview was conducted with RN 1. RN 1 stated the lights outside the rooms of the effected beds were not working, and the visual alert on the station monitors for those beds were not working. RN 1 stated we provided bells for all the residents yesterday and wererounding on them every 15 minutes. Cross reference to F558.

Sept 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure one of two sampled residents (Resident 1) received the appropriate care and services as ordered by the physician and as documented in the plan of care related to an indwelling urinary catheter. Resident 1 was observed to not have any urine output by CNA 1 during the night shift (2300 to 0700 hours); however,CNA 1 failed to report this finding to the licensed nurse. This failure had the potential to cause a delay in necessary care and services for Resident 1. Findings: Closed medical record review for Resident 1 was initiated on 9/7/23. Resident 1 was admitted to the facility on [DATE], and transferred to the acute care facility on 8/29/23. Review of Resident 1's Order Summary Report showed the following: - an order dated 6/6/23, for indwelling urinary catheter size FR 16/10 (with 10 ml balloon) attached to the bedside closed drainage bag system due to urinary retention. - an order dated 6/5/23, to monitor the indwelling urinary drainage bag every shift and document the following: O = Clear; S= Sediments; C = Cloudy; B = Bloody. Review of Resident 1's plan of care showed a care plan problem dated 6/6/23, for the indwelling urinary catheter due to urinary retention. The care plan interventionsincluded to monitor indwelling urinary catheter drainage bag every shift anddocument the following: O=clear S=sediment C=cloudy B=bloody. On 9/7/23 at 1120 hours, an interview and concurrent closed medical record review was conducted with LVN 2 and RN 1. LVN 2 was asked about Resident 1's transfer to the acute care facility. LVN 2 stated at 0745 hours on 8/29/23, CNA 3 reported to him that Resident 1 had unusual vital signs. LVN 2 stated he immediately checked on Resident 1 and found the resident's heart rate, blood pressure, and respirations elevated. LVN 2 stated he noticed Resident 1's urinary drainage bag was empty. LVN 2 stated he began the process to remove the resident's indwelling urinary catheter. LVN 2 stated Resident 1 had a thick, bright red [NAME] of blood come out of the indwelling urinary catheter tubing mixed with 400 to 500 ml of urine. LVN 2 stated he notified RN 1. RN 1 stated he assessed Resident 1 and found him to have a distended bladder and uncontrolled penile bleeding. RN 1 notified Resident 1's physician and received an order to send Resident 1 to the acute care facility for further treatment. Review of the Progress Notes dated 8/29/23, completed by the licensed nurses, showed the following: - at 0745 hours, a CNA informed LVN 2 of the unusual vital signs for Resident 1. The resident was noted with acute distress; the indwelling urinary bag clean and empty; the lower abdomen was hard and distended; [NAME] of thick and bright red blood came out of the indwelling urinary tubing line when the balloon was released; and the supervisor was notified. - at 0800 hours, the supervisor (RN 1) was notified of Resident 1's active bleeding to penile area; the bleeding was not controlled; the vital signs were unstable; 911 was called; and the physician was notified. - at 0832 hours, Resident 1 was transferred to the acute care facility. On 9/7/23 at 1252 hours, a telephone interview was conducted with CNA 1. CNA 1 stated he worked the night shift on 8/28/23, and was assigned to care for Resident 1. CNA 1 stated Resident 1 had an indwelling urinary catheter and he checked to empty it at the end of his shift around 0600 hours. CNA 1 stated he noticed there was no urine in the drainage bag when he checked. When asked if he reported the finding to the licensed nurse, CNA 1 stated no, because he thought maybe the licensed nurse had emptied it.

Sept 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the care plan of one of four sampled residents (Resident 1) was reviewed and revised after Resident 1 reported an abuse allegation toward CNA 1. This failure put Resident 1 at risk of not receiving resident-centered care. Review of the facility's P&P titled Care Planning - Interdisciplinary Team revised March 2022 showed assessments of residents are ongoing and care plans are revised as information about the resident and the residents' condition change. Medical record review for Resident 1 was initiated on 8/25/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Medical record review for Resident 1 was conducted on 9/1/23. Review of Resident 1's care plan dated 4/20/23, showed the resident had potential to demonstrate verbally abusive behaviors towards staff, and make false accusations by fabricating stories. Upon further review of Resident 1's care plans, there was no documented or revised care plan noted related to Resident 1's abuse allegation of CNA 1 hitting him on the back of the head while unplugging his fan. On 9/1/23 at 1023 hours, a concurrent interview and record review with RN 2 was conducted. RN 2 confirmed Resident 1 did not have a new or revised care plan to address the alleged abuse incident by CNA 1. RN 2 stated care plans were used to monitor resident's emotional, physical, and psychological needs. RN 2 further stated through care plans, staff could monitor if incidents had resolved. On 9/1/23 at 1033 hours, a telephone interview was conducted with RN 1. RN 1 stated no care plan was created or updated for the abuse allegation incident between Resident 1 and CNA 1. On 9/1/23 at 1110 hours, an interview with the DSD was conducted. The DSD verified care plans are created or updated for new incidents of abuse allegations and for any changes in approaches or goals. The DSD further stated care plans indicate how staff could resolve an issue. On 9/1/23 at 1230 hours, an interview with the DON was conducted. The DON stated RN 1 should have added the allegation of Resident 1 toward CNA 1 on Resident 1's current care plan. The DON verified RN 1 did not create, update, or revise Resident 1's care plan after the abuse allegation.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the presence of competent staffing to meet one of four sampled residents' (Resident 1) needs safely and in a manner to promote the resident's rights, physical, mental, and psychosocial well-being. * RN 1 failed to send CNA 1 home after the abuse allegation was made against CNA 1 as per the facility's P&P. * RN 1 failed to create or revise Resident 1's care plan after the abuse allegation. * RN 1 failed to document a Change of Condition of the abuse allegation. * The IDT meeting was not set up with Resident 1 after the abuse allegation These failures had the potential to result in serious injury and/or psychosocial harm to Resident 1 and other residents. Findings: 1. Review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigation revised September 2022 showed any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. Medical record review for Resident 1 was initiated on 8/25/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the progress note titled Health Status Note written by RN 1 on 8/24/23 at 0116 hours, showed CNA was removed from working with Resident 1 and reassigned. On 8/25/23 at 1227 hours, a telephone interview was conducted with RN 1. RN 1 verified CNA 1 was reassigned to other residents and was not sent home after the abuse allegation. When asked what the facility's protocol was for an abuse allegation when a staff was involved, RN 1 stated the staff would be reassigned. On 9/1/23 at 1230 hours, an interview with the DON was conducted. The DON verified CNA 1 was not sent home after the abuse allegation as per the facility's P&P and was reassigned to other residents. Cross reference to F610. 2. Review of the facility's P&P titled Care Planning - Interdisciplinary Team revised March 2022 showed assessments of residents are ongoing and care plans are revised as information about the resident and the residents' condition change. On 9/1/23 at 1033 hours, a telephone interview was conducted with RN 1. RN 1 stated no care plan was created or updated for the abuse allegation incident between CNA 1 and Resident 1. RN 1 further stated she was not aware that a care plan had to be completed or the current care plan updated. On 9/1/23 at 1230 hours, an interview with the DON was conducted. The DON stated RN 1 should have added the allegation of abuse of Resident 1 toward CNA 1 on Resident 1's current care plan. The DON verified RN 1 did not update or revise Resident 1's care plan after the abuse allegation. Cross reference F657. 3. Review of the facility's P&P titled Change in a Resident's Condition or Status revised in February 2021 showed the nurse will notify the resident's attending physician or physician on call when there has been a(an): Accident or incident involving the resident. The P&P further showed a significant change of condition is a major decline or improvement in the resident's status that: (c) requires interdisciplinary review and/or revision to the care plan. On 9/1/23 at 1005 hours, a concurrent interview and medical record review was conducted with LVN 3. LVN 3 verified Resident 1 did not have a COC documented for the abuse allegation involving CNA 1. On 9/1/23 at 1033 hours, a telephone interview with RN 1 was conducted. RN 1 stated she did not do a COC because Resident 1 showed, no symptoms. When asked if a COC would need to be completed for an abuse allegation between a staff to resident, RN 1 stated she did not know and would have to call the DON for the answer. On 9/1/23 at 1110 hours, an interview with the DSD was conducted. The DSD stated a COC would be created when there was an allegation of abuse, and the resident has a concern about a staff. On 9/1/23 at 1230 hours, an interview with the DON was conducted. The DON stated her expectation of her staff during a staff to resident abuse allegation was for the supervisors to begin their investigation, notify ombudsman, police, department of health, assess the resident, and expected the documentation to reflect the assessments. The DON verified RN 1 did not write a COC for the abuse allegation and stated RN 1 should have done a COC for Resident 1 to monitor the resident. 4. Review of the facility's P&P titled Interdisciplinary Team (IDT)/Resident Care Plan Conference Review (RCC) dated 7/2021 showed the IDT, in conjunction with the resident and/or resident representative, as appropriate, shall meet to develop a comprehensive person-centered care plan with quantifiable objectives for the highest level of functioning the resident may be expected to attain, to meet the resident's medical, nursing, mental, and psycho-social needs that are identified in the comprehensive assessment and CAA summary. The P&P further showed the IDT meetings are an ongoing process throughout a resident's stay and is an integral part of the daily IDT discussion/communication to best meet the needs of a resident. The P&P showed one of the purposes of an IDT is to update as the resident condition change and as revision(s) is needed. On 8/25/23 at 1618 hours, an interview with Resident 1 was conducted. Resident 1 stated he was interviewed about the incident by the Administrator and spoke to the Social Worker but denied participating in an IDT meeting about the abuse allegation. On 9/1/23 at 1230 hours, an interview with the DON was conducted. The DON verified an IDT was not conducted with Resident 1 after the abuse allegation. The DON stated the staff discussed it during their morning meeting; however, they did not document the discussion and facility interventions in Resident 1's medical record.

CONCERN (E) 📢 Someone Reported This

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

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the safety of one of four sampled residents (Resident 1) when the facility did not place the alleged staff on leave with no resident contact during an abuse allegation as per their P&P. This failure put Resident 1 and other residents at risk for further abuse. * Resident 1 alleged CNA 1 hit him on the back of the head while unplugging his fan. Resident 1 stated he had throbbing pain to the back of his head on the pain level of five to six (on a pain scale of 0-10 with 0 = no pain and 10 =worst pain); however, the alleged CNA (CNA 1) continued to stay at the facility and was reassigned to care for other residents. This failure had the potential to result in serious injury and/or psychosocial harm and put the vulnerable residents for further abuse. Findings: Review of the facility's P&P titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigation revised September 2022 showed any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete. On 8/25/23 at 1618 hours, an interview was conducted with Resident 1. Resident 1 stated he asked CNA 1 to turn off his fan and remove the plug when something hit him at the back of the head. Resident 1 stated feeling a five to six out of 10 throbbing pain to the back of the head; however, the resident denied pain medications. Furthermore, Resident 1 stated he then requested for the RN supervisor to contact a law enforcement to file a complaint against CNA 1. Medical record review for Resident 1 was initiated on 8/25/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the quarterly MDS dated [DATE], showed Resident 1 with a BIMS score of 15 (according to the MDS RAI Manual, a score of 13-15 indicates resident is cognitively intact). On 8/25/23 at 1044 hours, an interview was conducted with the DSD regarding CNA 1. The DSD stated it was the facility's policy to send the staff home and placed on suspension during an abuse allegation until the investigation was completed. On 8/25/23 at 1227 hours, a telephone interview was conducted with RN 1. RN 1 stated Resident 1 informed her that CNA 1 hit him on the back of the head and requested the law enforcement to be called to report the assault. RN 1 verified CNA 1 was reassigned to other residents and was not sent home after the abuse allegation. When asked what the facility's protocol was for an abuse allegation when a staff was involved, RN 1 stated the staff would be reassigned. On 8/25/23 at 1458 hours, an interview was conducted with LVN 1. LVN 1 stated the staff involved in a staff to resident abuse allegation was sent home until the investigation was completed to ensure the safety of the residents. On 9/1/23 at 1230 hours, an interview with the DON was conducted. The DON stated the facility removed CNA 1 from Resident 1's care and reassigned CNA 1 to another set of residents. The DON further verified CNA 1 was not sent home after the abuse allegation as per the facility's P&P.

Mar 2022 19 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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 17 final sampled residents (Resident 50) was treated with dignity. * CNAs 1 and 3 were talking to each other in a foreign language while providing ADL care to Resident 50 whose primary language was English. This failure resulted in not ensuring resident's rights to be treated with respect and dignity. Findings: Review of the facility's P&P titled Foreign Language dated 11/1/21, showed each resident shall be cared for in a manner that promotes and enhances their quality of life, dignity, respect and individuality. Staff are to communicate with the residents in their primary language, and to speak in English at all times unless they are speaking in the resident's primary language. Medical record review for Resident 50 was initiated on 3/8/22. Resident 50 was readmitted to the facility on [DATE]. Review of Resident 50's admission Record showed the resident's primary language was English. Review of Resident 50's MDS assessment dated [DATE], showed he was cognitively intact and dependent on staff for ADL cares. On 3/8/22 at 0928 hours, an interview was conducted with Resident 50. Resident 50 expressed his concerns about the staff speaking another language to each other while providing his care. Resident 50 stated he felt upset because he did not know if the staff were talking about him. On 3/10/22 at 1111 hours, an ADL care observation for Resident 50 was conducted with CNAs 1 and 3. CNAs 1 and 3 were observed talking to each other in a foreign language while providing care to Resident 50. On 3/10/22 at 1333 hours, an interview was conducted with CNA 1. When asked about the use of foreign language while providing care to Resident 50, CNA 1 acknowledged she was giving directions to CNA 3 in a foreign language. CNA 1 stated Resident 50 had asked CNA 3 to do something but CNA 3 did not respond. CNA 1 stated he translated Resident 50's request to CNA 3. When asked if he informed Resident 50 about going to translate his request, CNA 1 stated he did not. On 3/10/22 at 1427 hours, an interview was conducted with the DON. The DON stated the facility's policy was to only speak to or around the resident in the resident's primary language. When asked what the staff should do if they needed to communicate in a foreign language to safely complete resident cares, the DON stated the expectation would be for the staff to inform the resident that they would explain to the resident first about the need to speak in another language and what they would be saying.

CONCERN (D)

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

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide personal privacy for one nonsampled resident (Resident 52). * LVN 2 failed to close Resident 52's privacy curtain when she administered the medications via GT. Resident 52's abdomen was exposed during the procedure. In addition, RT 1 provided tracheal suctioning without provided privacy to Resident 52. These failures had the potential to expose the residents' uncovered body parts to the public view and affect self esteem and self-worth. Findings: Medical record review for Resident 52 was initiated on 3/9/22. Resident 52 was admitted to the facility on [DATE]. Review of Resident 52's MDS assessment dated [DATE], showed Resident 52 was cognitively impaired and totally dependent on staff for ADL care. Review of Resident 52's Annual History and Physical dated 1/28/22, showed Resident 52 was alert but unable to follow commands. On 3/9/22 at 0811 hours, a medication administration observation was conducted with LVN 2. LVN 2 exposed Resident 52's abdomen and administered the medications via GT. LVN 2 left the privacy curtain separating Residents 52 and 1 open, which allowed Resident 1 to observe Resident 52 during medication administration. On 3/9/22 at 0843 hours, during the medication administration observation for Resident 52, the Activity Assistant entered the room and and wrote the date on the white board located on the wall across from Resident 52. Resident 52's privacy curtain remained open exposing Resident 52's abdomen during the medication administration procedure. On 3/9/22 at 0905 hours, LVN 2 paused the medication administration and RT 1 performed tracheal tube suctioning on Resident 52. The privacy curtain between Residents 52 and 1 remained open, which allowed Resident 1 to observe Resident 52's medical procedures. On 3/9/22 at 1104 hours, an interview was conducted with LVN 2. LVN 2 verified the privacy curtain should have been used to provide privacy for Resident 52 during medication administration and tracheal tube suctioning.

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 36's medical record was initiated on 3/8/22. Resident 36 was readmitted to the facility on [DATE]. Review of the Order Summary Report dated 3/10/22, showed a physician's order dated 10/20/21, to provide Resident 36 with a mechanical soft texture diet (diet is designed for people who have trouble chewing and swallowing) with thin consistency and small portion meal at dinner. During the observation of the lunch meal in the dining room on 3/8/22 at 1214 hours, Resident 36 was observed sitting in a geri-chair using his bare hand to eat his lunch. Resident 36's lunch meal card showed Resident 36 was on a mechanical soft diet with thin liquids. Resident 36's lunch meal consisted of a hamburger cut in 4 square pieces, scalloped potatoes, and ice cream,. An interview was conducted with RNA 1. RNA 1 stated Resident 36 preferred to use his hands to eat. On 3/8/22 at 1544 hours, an interview with the RN 1 and concurrent review of Resident 32's medical record was conducted. RN 1 verified a care plan was not developed to address Resident 36's preference to use his bare hands to eat meals. On 3/9/22 at 0804 hours, an interview with the RN 2 and concurrent review of Resident 32's medical record was conducted. When asked if RN 2 was familiar with Resident 36's eating habits, RN 2 stated she thought Resident 36 was blind but was not able to describe Resident 32's eating habits. RN 2 verified a care plan was not developed to address Resident 36's preference to use his bare hands to eat his meals. RN 2 stated the CNAs helped Resident 36 with the meal set up. RN 2 then stated she did not know why Resident 36 used his bare hands to eat meals but thought it should be care planned. On 3/10/22 at 10:05 hours, an interview was conducted with the RD. The RD stated she was familiar with Resident 36's eating habits. The RD stated Resident 36 preferred to use his bare hands to eat due to visual impairment. The RD stated the nursing staff was responsible in developing a care plan to address Resident 36's eating habits. The RD acknowledged Resident 36's eating habits should have been addressed in his plan of care. Based on observation, interview, and medical record review, the facility failed to develop the plans of care to reflect the individual care needs for two of 17 sampled residents (Residents 3 and 36 ). * The facility failed to develop a comprehensive care plan to address Resident 3's use of Ativan (antianxiety medication) and the side effects of Ativan. * The facility failed to develop a care plan to address Resident 36's preference to use his bare hands to feed himself during meals. These failures posed the risk of not providing appropriate, consistent, and individualized care to the residents. Findings: 1. Medical record review for Resident 3 was initiated on 3/8/22. Resident 3 was readmitted to the facility on [DATE]. Review of Resident 3's Order Summary Report dated 3/9/22, showed a physician's order dated 3/5/22, to administer Ativan 0.5 mg one tablet by mouth every 12 hours for anxiety disorder manifested by yelling and screaming. Review of Resident 3's Order Summary Report dated 3/9/22, showed the physician's order dated 8/11/21, to address the side effect of the anxiety medication including monitoring for dry mouth, urinary retention, constipation, blurred vision, hypotension, tachycardia, palpitations, sedation, confusion, hallucination, excitement, restlessness, or depression every shift for Anxiety medication. Review of Resident 3's plan of care failed to show a care plan problem was developed to address the use of Ativan and the side effects of the medication. On 3/9/22 at 1419 hours, an interview and concurrent medical record review for Resident 3 was conducted with RN 2. RN 2 verified the plan of care did not address the use of Ativan to include the monitoring of its side effect for Resident 3.

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Assistive Devices and Equipment revised on January 2020 showed the facility maintains and supervises the use of Assistive devices and equipment for residents .recommendations for the use of devices and equipment are based on the comprehensive assessment and documented in the resident care plan .the following factors are addressed .appropriateness for resident condition .personal fit .device condition .staff practices . During the initial tour on 3/8/22 at 0750 hours, Resident 30 was observed lying in bed and wearing a splint on his left hand. Medical record review for Resident 30 was initiated on 3/8/22. Resident 30 was admitted to the facility on [DATE]. Review of the MDS assessment dated [DATE], showed Resident 30 was cognitively impaired and required extensive assistance with his ADL care. Further review of Resident 30's medical record did not show a physician's order for the use of left hand splint (used to support/immobilize the extremity). Review of Resident 30's plan of care failed to show a care plan problem addressing the use of left hand splint. In an interview with CNA 5 on 3/8/22 at 0807 hours, CNA 5 stated the staff applied the splint on Resident 30's left arm. During an observation on 3/9/22 at 0925 hours and 3/10/22 at 0826 hours, Resident 30 was observed lying in bed and wearing a splint on his left arm. On 3/10/22 at 0958 hours, a concurrent observation, interview and medical record review was conducted with LVN 5. LVN 5 verified Resident 30 was wearing a splint on his left hand. LVN 5 acknowledged he was not able to find a physician's order for Resident 30's left hand splint. On 3/10/22 at 1024 hours, a concurrent interview and medical record review was conducted with RN 2. RN 2 verified there was no physician's order for the use of splint on Resident 30's left hand. In an interview with the DON on 3/10/22 at 1034 hours, and 3/11/22 at 0820 hours, the DON acknowledged there was no physician's order for Resident 30's left hand splint. The DON further stated if the resident had a splint on, there should be an order for it. The DON stated she did not know how long the resident had been wearing a splint without an order, where the splint came from, or why he was wearing it. Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to ensure two of 17 final sampled residents (Residents 24 and 30) attained and maintained their highest practicable physical well-being. * The facility failed to ensure Resident 24 was up in a high back tilt wheelchair as tolerated on non-dialysis days as per the physician's order. This failure posed the risk for the resident to develop physical, psychosocial, emotional complication that may arise from being bed bound. *The facility failed to ensure Resident 30 had a physician's order for the use of splint on the left hand. This failure resulted in Resident 30 wearing a splint on his left hand without any indication, time frame for how long to wear the device, or monitoring. Findings: 1. On 3/08/22 at 0800, 1000, 1200, and 1430 hours, Resident 24 was observed resting in bed. On 3/10/22 at 0815 and 1315 hours, Resident 24 was observed resting in bed. Medical record review for Resident 24 was initiated on 3/8/22. Resident 24 was admitted to the facility on [DATE]. Resident 24 had a diagnosis of end stage renal disease which required hemodialysis. Review of Resident 24's MDS dated [DATE], showed Resident 32 was mildly cognitive impaired. Resident 24 required extensive one person assistance for bed mobility and was totally dependence on staff with two-persons assistance for transfers. Review of the Order Summary Report dated 3/10/22, showed a physician's order dated 2/18/22, showing Resident 24 could get up in high back tilt wheelchair on non-dialysis days with Hoyer lift (mechanical lift) as tolerated one time a day every Tuesday, Thursday, Saturday and Sunday. On 3/10/22 at 1315 hours, an interview was conducted with Resident 24 and his family member with the Activities Assistant at bedside. When asked if Resident 24 had been placed in his wheelchair during non dialysis days, Resident 24's family member stated no. Resident 24 spoke in a foreign language to his family member. Resident 24 stated he would like to be up in his wheelchair more. The Activities Assistant verified she did not see Resident 24 up in wheelchair for the past days. On 3/10/22 at 1325 hours, an interview was conducted with CNA 4 about getting Resident 24 up in his wheel chair. CNA 4 stated she was aware she needed to get Resident 24 up in wheelchair, but she was not able to find his high back tilt wheelchair. On 3/10/22 at 1346 hours, an interview and medical record review was conducted with RN 2 and LVN 1. RN 2 and LVN 1 verified the physician's order to sit Resident 24 up in his wheelchair when not in dialysis. RN 2 and LVN 1 acknowledged Resident 24 did not have any restrictions which would prevent him from sitting up in wheelchair.

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the necessary care and services were provided to prevent the development or worsening of pressure ulcers for two of 17 final sampled residents (Residents 6 and 58). * The facility failed to offload Resident 6's heels from pressure as ordered by the physician. * The facility failed to ensure Resident 58's low air loss mattress (pressure redistributing support surface) was set appropriately according to the resident's weight and physician's order. These failures had the potential of Residents 6 and 58 not receiving the appropriate care and services to promote healing or prevent the development of the pressure ulcers. Findings: 1. On 3/8/22 at 1604 hours, Resident 6 was observed lying on a low air loss mattress. Resident 6's heels were not offloaded and were observed resting directly on the mattress. Medical record review for Resident 6 was initiated on 3/8/22. Resident 6 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS assessment dated [DATE], showed Resident 6 was totally dependent on the staff for bed mobility (how the resident moved to and from a lying position, turned side to side, and positioned their body while in bed). Review of Resident 6's Pressure Ulcer Risk assessment dated [DATE], showed Resident 6 was at high risk for developing pressure ulcers. Review of the Order Summary Report showed a physician's order dated 2/28/22, to float (offload) Resident 6's heels. On 3/9/22 at 0735, 0817, and 1007 hours, Resident 6 was observed lying on a low air loss mattress. Resident 6's heels were not offloaded, and the heels were observed resting directly on the mattress. On 3/9/22 at 1006 hours, an observation of Resident 6 was conducted with LVN 3. LVN 3 stated Resident 6 was totally dependent on the staff for bed mobility and repositioning. LVN 3 verified Resident 6's heels were not offloaded, and the heels were resting directly on the mattress. LVN 6 verified the staff was supposed to offload the resident's heels to prevent the development of pressure ulcers. 2. On 3/8/22 at 0733, 0855, 1016, and 1545 hours, Resident 58 was observed lying on a low air loss mattress. The low air loss mattress was observed being set to 320 pounds. Medical record review for Resident 58 was initiated on 3/8/22. Resident 58 was admitted to the facility on [DATE]. Review of Resident 58's Wound Evaluation Flow Sheet dated 10/21/21, showed Resident 58 was admitted to the facility with a Stage 3 pressure ulcer to the sacrococcyx area. Review of Resident 58's Order Summary Report showed a physician's order dated 10/23/21, for a low air loss mattress for wound management with comfort settings of 1 to 2. Review of the MDS dated [DATE], showed Resident 58 was totally dependent on the staff for bed mobility. Medical record review showed Resident 58's weight was documented as 83 pounds on 3/7/22. On 3/9/22 at 0711 and 1359 hours, Resident 58 was observed lying on a low air loss mattress. The low air loss mattress was observed being set to 320 pounds. On 3/9/22 at 1404 hours, an observation of Resident 58 was conducted with CNA 3. CNA 3 verified Resident 58's low air loss mattress was set to 320 pounds. CNA 3 verified Resident 58 was not 320 pounds. On 3/9/22 at 1416 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 verified the low air loss mattress was supposed to be set to the resident's weight and not to 320 pounds. LVN 5 stated the comfort settings of 1 to 2 was for the residents who were 70 to 105 pounds.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the 72-hour neurological assessments were conducted completely for one of 17 final sampled residents (Resident 51) at the frequency as per the physician's orders after the resident had sustained three unwitnessed falls. This posed the risk for delayed recognition of a neurological change or injury. Findings: Medical record review for Resident 51 was initiated on 3/8/22. Resident 51 was admitted to the facility on [DATE]. a. Review of Resident 51's Progress Notes dated 12/22/21 at 1430 hours, showed Resident 51 reported to staff that he had a fall around 0030 hours. Resident 51 fell on his left side and complained of mild tenderness on his left rib area. A reddish discoloration on the left cheek was observed. The physician was informed and ordered for the staff to conduct a neurocheck (or neurological assessment-a set of neurological observations to collect data on the patient's neurological status to check for possible complications) for 72 hours on Resident 51. Review of the Prescriber Order dated 12/22/21, showed an order to perform the neurochecks on Resident 51 for 72 hours until 12/25/21. Review of Resident 51's Neuro Assessment log initiated 12/22/21, showed incomplete entries for pupil assessment (a part of the neurological assessment which determines the size, equality in size and reactivity to determine complications) for the following consecutive dates and times: on 12/22/21 at 1430, 1530, 1630, 1830, 2030, and 2230 hours; 12/23/21 at 0230, 0630, 1030, 1430, and 2230 hours; and 12/24/21 at 0630 hours. b. Review of Resident 51's Progress Notes dated 12/29/21 at 1528 hours, showed Resident 51 reported that he had a fall in the morning and sustained a scalp laceration (a cut or tear in the skin). Review of the Change of Condition dated 12/29/22. showed Resident 51 slipped from his bed and sustained a laceration on the right side of his head. Review of Resident 51's post-fall Neuro Assessment initiated on 12/29/21, showed only a check-mark on the space for the assessment of the right and left pupils for the following dates and times: on 12/20/21 at 2000 hours; 12/30/21 at 0000, 0400, and 1600 hours; and 12/31/21 at 0000 and 0800 hours. The assessment of the pupils section did not show if Resident 51's pupil were assessed for reactivity to light. c. Review of Resident 51's Progress Notes dated 3/8/22 at 0656 hours, showed Resident 51 was found on the floor by the staff. Resident 52 sustained a skin tear on his left forearm. Review of Resident 51's Neuro Assessment initiated on 3/8/22, showed incomplete entries on 3/8/22 from 0730 hours through 1730 hours (total of five scheduled assessments) and 3/9/22 from 1330 hours to 3/11 at 0530 hours (total of 6 assessments). On 3/10/22 at 1039 hours, an interview and concurrent record review were conducted with LVN 1. LVN 1 stated she was aware of Resident 51's fall episodes. LVN 1 verified the Neuro Assessment log was not completed. On 3/10/22 at 1130 hours and 1310 hours, an interview and concurrent record review were conducted with the DON. The DON stated 72 hour post-fall neurological assessments should be completed for all unwitnessed falls. The DON stated, check-marks were not acceptable in documenting the assessment for Resident 51's pupil response. The DON verified the post-fall Neuro Assessments logs for Resident 51's falls on 12/22/21, 12/29/21 and 3/8/21, were incomplete and should have been completed to ensure complications from falls were detected timely.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide safe respiratory care to meet the needs of one of 17 final sampled residents (Resident 6). * The facility failed to ensure Resident 6 was placed on the ventilator settings ordered by the physician. Changing the ventilator settings without the appropriate orders had the potential to result in poor health outcomes for the resident. Findings: On 3/8/22 at 0737 and 0842 hours, Resident 6 was observed in bed with a tracheostomy tube (breathing tube inserted through the neck into the airway to maintain an open airway) in place and connected to a mechanical ventilator (a machine that takes over the work of breathing when a person is not able to breathe enough on their own.). Resident 6's ventilator was observed setting for Assist Control mode (programmed to sense changes in the system pressure when a patient initiates a breath) with a rate of 18. Medical record review for Resident 6 was initiated on 3/8/22. Resident 6 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 6's Order Summary Report showed a physician's order dated 3/1/22, to place the resident on the ventilator settings of Assist Control mode with a rate of 14. On 3/8/22 at 1604 hours, an interview and concurrent medical record review was conducted with the RT Supervisor. The RT Supervisor verified Resident 6's ventilator was set at the rate of 18 this morning instead of the rate of 14 as per the physician's order. The RT Supervisor stated the nightshift RT changed the rate because the resident had a little shortness of breath. The RT Supervisor verified there was no physician order to change Resident 6's ventilator settings and no documentation showing Resident 6 had shortness of breath. The RT Supervisor verified ventilator setting changes required a physician's order.

CONCERN (D)

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

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure one of 17 final sampled residents (Resident 6) remained free from accident hazards related to the use of elevated side rails. Resident 6's assessments showed side rails were not appropriate or indicated; however, Resident 6 was observed with elevated side rails in place. This had the potential to place Resident 6 at risk for entrapment and serious injury. Findings: The FDA issued a Safety Alert entitled Entrapment Hazards with Hospital Bed rails. The safety alert document showed the residents most at risk for entrapment are those who are frail or elderly or those who have conditions such as agitation, delirium, confusion, pain, uncontrolled body movement, hypoxia, fecal impaction, or acute urinary retention, etc., that may cause them to move about the bed or try to exit from the bed. Entrapment may occur when a resident is caught between the mattress and bed rail or in the bed rail itself. On 3/8/22 at 0737, 0849, and 1555 hours, Resident 6 was observed lying in bed with bilateral side rails elevated by the head of the bed. Medical record review for Resident 6 was initiated on 3/8/22. Resident 6 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the MDS assessment dated [DATE], showed Resident 6 was totally dependent on the staff for bed mobility (how the resident moved to and from a lying position, turned side to side, and positioned their body while in bed). Review of the Bed Safety Rail assessment dated [DATE], showed side rails may not be appropriate. Review of the Risks and Benefits of Bedrail Review and Acknowledgement dated 2/28/22, showed side rails were not indicated for Resident 6. On 3/9/22 at 0725, 0817, and 1000 hours, Resident 6 was observed lying in bed with bilateral side rails elevated by the head of the bed. On 3/9/22 at 1006 hours, an observation of Resident 6 was conducted with LVN 3. LVN 3 verified Resident 6's side rails were elevated by the head of the bed. LVN 3 stated Resident 6 was totally dependent on the staff for bed mobility and could not use the side rails to assist with bed mobility. On 3/9/22 at 1105 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the side rails were not indicated for Resident 6 and stated the side rails should not be elevated.

CONCERN (D)

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, medical record review, and facility P&P review, the facility failed to ensure the physician's order for ferrous sulfate was complete for one nonsampled resident (Resident 52). This had the potential for the wrong dose being administered to the resident. Findings: Review of the facility's P&P titled Administering Medications revised April 2109 showed the medication label should be checked three times to verify the correct dose. According to Lexicomp (an online resource), ferrous sulfate is available in two strengths, 200 mg/5 ml and 300 mg/5 ml. Medical record review for Resident 52 was initiated on 3/9/22. Resident 52 was admitted to the facility on [DATE]. Review of Resident 52's Order Summary Report dated 3/9/22, showed a physician's order to administer ferrous sulfate (supplement) liquid 7.5 ml twice a day via gastric tube. Resident 52's physician order did not show the strength of the ferrous sulfate preparation to be administered. On 3/9/22 at 0811 hours, a medication administration observation was conducted with LVN 2. LVN 2 was administered ferrous sulfate 7.5 ml via GT to Resident 52. On 3/9/22 at 1104 hours, an interview and concurrent medical record review were conducted with LVN 2. When asked about the preparation strength for the ferrous sulfate administered to Resident 52, LVN 2 stated the preparation strength was 220 mg/5 ml. When asked what was prescribed by the physician, LVN 2 verified the physician's order did not include the strength for Resident 52's ferrous sulfate. LVN 2 stated it should have been included to ensure the dosage provided to Resident 52 was accurate.

CONCERN (D)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the medication error rate was below 5%. * The medication error rate was 22.58%. LVN 2 failed to administer the medications according to the physician's order and facility's P&P for Resident 52. This failure had the potential for drug interactions. Findings: The facility's P&P titled Administering Medications Though an Enteral Tube revised November 2018 showed if administering more than one medication, to flush with the prescribed amount of water between medications. On 3/9/22 at 0811 hours, a medication administration observation was conducted with LVN 2. LVN 2 prepared the following medications for GT administration to Resident 52. - one tablet of amlodipine (medication for hypertension) 10 mg - one tablet of sucralfate (antacid) 1 gram - one tablet of aspirin (medication to prevent clot formation) 81 mg - one tablet of hydralazine (medication for hypertension) 50 mg - one tablet of multivitamin with mineral (supplement) - one tablet of Oscal 500 mg plus vitamin D 5 mcg (supplement) - one tablet of sodium chloride 1 gram - one tablet of Vitamin C (supplement) 500 mg - one tablet of Vitamin D(supplement) 25 mcg 1000 IU - Miralax (stool softener) 17 mg diluted in water - 7.5 ml of ferrous sulfate (supplement) 220 mg/5 ml LVN 2 placed one tablet in each medication cup, crushed the medication, and added water to each cup. LVN 2 administered Resident 52's medications via GT. LVN 2 flushed Resident 52' GT with water, then administered Miralax. LVN 2 administered amlodipine, sucralfate, aspirin, hydralzine, sodium chloride, vitamin C and vitamin D one after another without flushing with water in between the medications. Medical record review for Resident 52 was initiated on 3/9/22. Resident 52 was admitted to the facility on [DATE]. Review of Resident 52's Order Summary Report dated 3/9/22, showed a physician's order to flush the enteral tube with 5 ml of water after each medication. On 3/9/22 at 1104 hours, an interview was conducted with LVN 2. LVN 2 verified she failed to flush the GT with water after administering each medication, and should have.

CONCERN (D)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menu was followed as evidenced by: * [NAME] 1 failed to follow the recipe for the pureed veal patty during the puree preparation process. * Resident 29 had a physician's order for a fortified mechanical soft, finely chopped diet; however, the resident was served a mechanical soft, finely chopped diet. These failures posed the risk of the residents' nutritional needs not being met. Findings: Review of the Form CMS-672 titled Resident Census and Conditions of Residents completed by the facility dated 3/9/22, showed 22 of 65 residents residing in the facility received food prepared in the kitchen. Review of the facility's P&P titled Puree Diet (undated), showed under Procedure for entrée with meat, place cooked entrée in the blender and add broth or sauce (3:1 ratio, i.e., three ounces meat with one ounce broth/ sauce/ au just (one)/ gravy). Blend mixed contents until smooth and add thickener if necessary. 1. Review of the facility's recipe titled Pureed Veal Patty undated, showed two ounces of cooked veal patty, two tablespoons of water or chicken broth, and ¼ slice of bread were to be blended together for one serving. On 3/9/22 at 0954 hours, an observation and concurrent interview was conducted with [NAME] 1 during the puree preparation process. [NAME] 1 was observed to place seven veal patties into the blender. [NAME] 1 then added two cups of tomato sauce to the blender containing the veal patties. As he continued with the puree preparation, [NAME] 1 was observed to add half a cup of water into the blender containing the veal patties, then blended the mixture. [NAME] 1 stated seven veal patties was used for about seven to eight portions of puree. On 3/10/22 at 1324 hours, an interview was conducted with the RD. The RD stated the recipe came with the menu and should be followed. 2. Review of the facility's document titled Fortified Meal Program dated 7/03 showed for breakfast, a fortified cereal (B-10, 252 Kcal) and whole milk, eight ounce is added. On 3/9/22 at 0655 hours, an observation of the tray line was conducted. Resident 29's meal tray had a meal card which showed a diet order of Fortified Mechanical soft, finely chopped (food with added nutrients and broken down for easy eating). Dislikes included milk, eggs, broccoli, spinach and cottage cheese. Resident 29's breakfast tray included a cup of [NAME] hot cereal, a portion of finely chopped sausage, a slice of baked French toast, eight ounces of orange juice, eight ounces of water, a thin slice of fresh orange, one syrup, and one margarine. On 3/9/22 at 0721 hours, an interview with [NAME] 1 was conducted. [NAME] 1 stated for a fortified diet, eight ounces of milk was added for breakfast and for the fortified cereal, an extra butter was added on the side. On 3/10/22 at 1005 hours, an interview and concurrent facility record review was conducted with the RD. The RD stated whole milk, fortified cereal with extra butter or health shakes were added on the fortified diet tray. The RD verified the spread sheet menu for the fortified diet tray included whole milk, fortified cereal, and health shakes with meals. The RD stated the previous DSS used health shake with meals because it was easier than doing the recipe.

CONCERN (D)

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

Deficiency F0813 (Tag F0813)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and facility P & P review, the facility failed to ensure the food items brought to the facility for the residents by the family or visitors were stored for future consumption. This failure posed the risk for 28 residents who were on an oral diet to not have a homelike environment. Findings: Review of the facility's P&P titled Foods Brought by Family/Visitors revised October 2017 showed 7. b. Perishable foods must be stored in re-sealable containers with tightly fitting lids in a staff refrigerator. The word staff was handwritten on the policy. Review of the facility's document titled Dietary Lesson Plan dated 8/4/21, provided by the DSD, showed the facility staff were inserviced on the Outside Prepared Food- policy which read, If food is not completely consumed the same day, then must be discarded immediately and not kept in the refrigerator. On 3/8/22 at 0848 hours, an interview was conducted with the IP. The IP stated the facility did not have a refrigerator for storage of food brought to the residents by the family or visitors. The IP stated any food brought to the residents must be eaten that same day and storing food was not allowed. On 3/8/22 at 1511 hours, an interview was conducted with the DON regarding food brought to the residents by the family or visitors. The DON stated food could be brought in for one meal only and must be commercial food, no home cooked foods allowed. The DON further stated the facility did not allow the residents to keep leftover food. The DON stated the facility started this process during the COVID-19 pandemic and decided to continue this practice because it was much easier. The DON stated the refrigerator located in the employee lounge was for employee food only. The DON stated the resident's food was not allowed to be in the employee refrigerator. The DON was asked to provide the facility's policy for food brought to the residents by the family or visitors. On 3/9/22 at 0801 hours, an observation of the refrigerator used to store the employees' food located in the break room was conducted. The refrigerator was filled with the employees' lunch boxes. No resident food was observed in the refrigerator. On 3/9/22 at 0804 hours, an interview was conducted with the RN 2 regarding food brought to the facility for the residents by the family or visitors. RN 2 stated only commercially prepared food was allowed to be brought to the residents. RN 2 stated storage of commercially prepared food brought for the residents by the family or visitors was not allowed. On 3/9/22 at 0820 hours, an interview was conducted with CNA 5. CNA 5 stated the facility was not storing food brought to the residents by the family or visitors. CNA 5 stated only commercially prepared food was allowed from the outside and no home cooked food was allowed. CNA 5 stated the facility previously stored food brought to the residents by the family or visitors. CNA 5 stated the refrigerator located in the storage room across from the nursing station was no longer being used to store food brought to the facility for the residents by the family or visitors. On 3/9/22 at 0913 hours, an interview was conducted with the DSD. The DSD stated an inservice was given last year to all employees regarding outside food brought to the residents. The DSD stated only commerically prepared food was allowed to be brought to the residents. The DSD added the residents' food items were not allowed to be stored in the refrigerator and leftover food items had to be discarded. On 3/10/22 at 0932 hours, a follow up interview was conducted with the DON regarding the policy titled Foods Brought by Family/Visitors revised October 2017. The DON confirmed the policy had been altered with the word staff added under the section 7. b. The DON was unable to confirm the altered policy had been revised and approved by the facility's QAPI committee.

CONCERN (D)

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

Deficiency F0849 (Tag F0849)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services for one of 17 final sampled residents (Resident 51) who received hospice services. * The facility failed to ensure Resident 51's hospice record included in the medical record. Resident 51's comprehensive plan of care, physician certification, hospice visitation calendars were not found in the medical record. This failure posed the risk for delay in the communication between the hospice provider and facility which may affect resident care. Findings: Review of the facility's contract with Hospice Provider A dated 10/5/21, showed the following: * The hospice physician would provide certification for the resident to participate in hospice services. * The hospice provider was responsible determining and scheduling services to be provided. * The hospice provider and the facility will work together to develop, review and revise the resident's plan of care. Medical record review for Resident 51 was initiated on 3/8/22. Resident 51 was admitted to the facility on [DATE]. Resident 51's Order Summary Report dated 3/9/21, showed an order dated 10/7/21, for hospice services with Hospice Provider A. Review of Resident 51's hospice records showed only the visitation calendars for October and November 2021 and an Integrated Care Plan for hospice care. Resident 51's hospice record did no include the calendars for January, February, and March 2022. Resident 51's comprehensive and updated plan of care were not included in the hospice records. Further review of the hospice records did not show Resident 50's physician certification for hospice benefits. On 3/9/22 at 0725 hours, a concurrent interview and medical record review were conducted with the Medical Records Director. The Medical Records Director acknowledged she just received Resident 51's hospice records, which included the hospice visit calendars for January, February, and March 2022, physician's certification for hospice benefits, and comprehensive plan of care. The Medical Records Director verified Resident 51's hospice documents were faxed to the facility on 3/8/22 at 1514 and 1544 hours, and were not included the resident's medical record. The Medical Records Director stated Resident 51's hospice records should have been integrated in the facility's medical records.

CONCERN (D)

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

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of 17 final sampled residents (Resident 58), was offered the influenza vaccine. This failure had the potential to negatively impact Resident 58's health. Findings: According to the facility's P&P titled Influenza, Prevention and control of Seasonal revised August 2014, The Infection Preventionist will promote and administer seasonal influenza vaccine .unless contraindicated, all residents and staff will be offered the vaccine . Medical record review for Resident 58 was initiated on 3/10/22. Resident 58 was admitted to the facility on [DATE]. Review of Resident 58's immunization record did not show any documentation as to whether Resident 58 was provided or had declined the influenza vaccine. In an interview with the IP on 3/10/22 at 1457 hours, the IP verified there was no record to show Resident 58 was offered or had declined the influenza vaccine. The IP stated the influenza vaccine should have been offered to Resident 58.

CONCERN (D)

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

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to provide a safe environment for one of 17 final sampled residents (Resident 33) and one nonsampled resident (Resident 1). * An exposed fluorescent light fixture was observed over Resident 33's bed. * The facility failed to ensure the electrical and antenna wall outlets with exposed wires were covered in Resident 1's room. These failures the potential for an unsafe environment for the residents. Findings: Review of the facility's P&P titled Hazardous Areas, Devices and Equipment revised July 2017 showed as a part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident's environment will be identified and addressed by the safety committee. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazard include equipment and devices that are left unattended or are malfunctioning. Review of Resident 33's medical record was initiated on 3/8/22. Resident 33 was admitted to the facility on [DATE]. Review of the MDS assessment dated [DATE], showed Resident 33 had cognitive impairment. On 3/8/22 at 0935 hours, during an initial tour, Resident 33 was observed laying in bed. An exposed fluorescent light fixture was observed by Resident 33's bed. The protective light fixture covering the fluorescent light was observed leaning against Resident 33's bed. On 3/8/22, at 0936 hours, a concurrent observation and interview was conducted with LVN 4. LVN 4 verified the exposed fluorescent light over Resident 33's bed. LVN 4 stated he was not sure who left the fluorescent tube light without a protective cover. LVN 4 stated the fluorescent light fixture should not have been left exposed and unattended at Resident 33's bedside to prevent accidents and injury. On 3/10/22, at 1304 hours, an interview was conducted with the DON. The DON verified and acknowledged the above findings.2. On 3/8/22 at 1430 hours, during the initial tour, two wall outlets were observed with broken covers hanging on the wall in Resident 1's room. Exposed electrical wires were observed from one of the outlets and the electric socket was observed sticking out from the other electric outlet. On 03/08/22 at 1645 hours, an interview was conducted with the Maintenance Assistant Supervisor The Maintenance Assistant Supervisor verified the above findings. The Maintenance Assistant Supervisor stated the outlet with the exposed socket was the antenna outlet and the outlet with exposed electrical wires was the electrical outlet. The Maintenance Assistant Supervisor stated these outlets should be covered to prevent the residents from electrocution.

CONCERN (E)

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

Deficiency F0801 (Tag F0801)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and facility document review, the facility failed to ensure a full-time supervisor to oversee the day-to-day operations of the food service department was employed. This failure posed a risk of lack of adequate supervision of the daily kitchen functions which could lead to food borne illness for the 28 residents who received food from the kitchen. Findings: Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 3/9/22, showed 28 of 65 residents received food prepared in the kitchen. Review of the facility's job description titled [NAME] showed the section titled Purpose of Your Job Position, the primary purpose of job position is to prepare food in accordance with current applicable federal, state, and local standards, guidelines and regulations Under the section titled Administrative Functions,assume authority, responsibility and accountability of Cook. Review of the facility's untitled document dated 12/6/21, showed an email from the previous DM showing her last day of employment with the facility was 12/6/21. Review of the facility's document titled Dietary Nov. 2021 Schedule dated November 2021 showed no updated kitchen schedule had been written for the Dietary department since November 2021. On 3/8/22 at 0724 hours, an interview was conducted with [NAME] 1. When asked who oversaw the kitchen, [NAME] 1 stated the facility had not had a DM since the previous DM left. [NAME] 1 stated all kitchen employees and the administrator shared the responsibilities in the kitchen. On 3/8/22 at 1030 hours, an interview was conducted with the Administrator. The Administrator stated [NAME] 2 who was the most senior of the cooks oversaw the day-to-day operations of the kitchen. The Administrator added the RD also helped oversee the kitchen. On 3/8/22 at 1429 hours, an interview was conducted with [NAME] 2 regarding his responsibilities in the kitchen. [NAME] 2 stated he was not responsible for the day-to-day operations of the kitchen and was only asked to order the food, which he did twice a week. [NAME] 2 added he had no other supervisory duties in the kitchen and did not supervise kitchen employees. On 3/9/22 at 1505 hours, during a follow-up interview with [NAME] 2, he stated he worked full time as a cook and the food orders for the kitchen added one hour to his work schedule. [NAME] 2 stated he tried to finish his duties as a cook before he completed the food orders. When asked who oversaw the scheduling of the kitchen, [NAME] 2 stated the kitchen did not have a schedule, all employees knew what days they worked. On 3/10/22 at 1005 hours, an interview was conducted with the RD. The RD stated she was a consultant for the facility and worked six to eight hours a week. When asked what her role was in the kitchen, the RD stated she did not oversee the day-to-day management of the kitchen and was not asked to complete additional managerial duties. The RD stated she completed a sanitation audit once a month and dealt with any resident issues. The RD stated her consulting hours for the facility had been decreased due to the COVID 19 pandemic which limited her time in the kitchen. On 3/10/22 at 1332 hours, an interview was conducted with the Administrator. The Administrator stated when the previous DM left, [NAME] 2 covered the kitchen scheduling, made sure diets were served appropriately and communicated any equipment issues. The Administrator added [NAME] 2 was given extra time for kitchen supervisory duties and had plenty of help from the other cooks. When asked how the RD assisted with the oversight of the kitchen, the Administrator stated he was not sure how many hours the RD worked each week, but she communicated any issues with the kitchen to the Administrator.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen as evidenced by the following: * The facility failed to ensure the food seasoning were stored in sanitary condition. * The facility failed to ensure the expired foods were discarded. * The facility failed to ensure the kitchen equipment and ice machine were maintained in sanitary condition. * The facility failed to ensure the kitchen staff performed hand hygiene. * The facility failed to ensure the kitchen equipment was air dried. * The facility failed to ensure the cutting boards were in sanitary condition and with cleanable surface. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the Form CMS-672 titled Resident Census and Conditions of Residents completed by the facility dated 3/9/22, showed 22 of 65 residents residing in the facility received food prepared in the kitchen. 1. According to the FDA Food Code Annex 4-602.13, the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. During the initial tour of the kitchen on 3/8/22 at 0724 hours, the following food item on the seasoning shelves were not clean: - one bottle of food seasonings (Kitchen Bouquet) had dried up sticky reddish/brownish residue at the rim and outside of the bottle. During the interview with the [NAME] 1 on 3/8/22 at 0749 hours, [NAME] 1 confirmed the seasoning bottle was not clean. 2. According to the FDA Food Code 2017, Section 3-501.17 Ready-To-Eat, Time/Temperature Control for Safety Food, Date Marking: Marking the date or day the original container is opened with a procedure to discard the food on or before the last date by which the food must be consumed. Review of the form titled [NAME] (brand name of vanilla milk shakes) showed the shelf life was one year from the production date in frozen state and once thawed, refrigerated shelf life is 14 days. During the initial kitchen tour on 3/8/22 at 0724 hours, the following spices on the spices shelves and food item in the refrigerator were expired: - one plastic container of ground sage leaves with an open date of 8/8/17, and the best by date of 5/17/20. - one plastic container of ground gloves with an open date of 9/23/19, and the best by date of 6/5/21. - one box of vanilla milk shakes stored in the walk-in refrigerator with a received date of 1/13/22, and a refrigerated date of 2/22/22. During the interview with [NAME] 1 on 3/8/22 at 0749 hours, [NAME] 1 verified the above spices and food item were expired and had to be discarded. 3. According to the FDA Food Code, 2017 4-601.11, it is the standard of practice to ensure non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the FDA Food Code Annex 4-602.13, the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. Review of the form titled Sanitation Survey Form dated 2/27/22, showed can opener was inspected and were clean. Portable fan were not included on the list. Review of the form titled Daily Cleaning Schedule Sanitation and Maintenance dated 1/08 did not show a portable fan was included on the list. Review of the form titled Ice Machine Preventive Maintenance Program with multiple dates showed inside and outside cleaning of ice machine was completed on 2/24/22, by the Maintenance Assistant Supervisor. a. During the initial kitchen tour on 3/8/22 at 0724 hours, the following was observed on the kitchen counter: - a can opener with dried and sticky white residue - a worn out blade - one portable black fan covered with dust and dirt Cook 1 verified the findings and stated it was not okay to be dirty. [NAME] 1 stated the dietary staff were responsible in cleaning it. b. On 3/8/22 at 1130 hours, an observation and concurrent interview was conducted with the Maintenance Assistant Supervisor. The ice machine was observed with hard water deposits on the curtain. The Maintenance Assistant Supervisor stated the ice machine was cleaned every month by the Maintenance Supervisor and was not sure on how to remove the hard water deposits on the ice machine curtain. On 3/10/22 at 1005 hours, an interview was conducted with the RD. The RD verified the finding and stated the Maintenance Supervisor cleaned the ice machine every month. The RD stated the Maintenance Supervisor had changed the ice machine setting to a self-cleaning. 4. Review of the facility's P&P titled, Handwashing/Hand Hygiene dated 8/19 showed all personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after eating or handling food. a. On 3/9/22 at 1028 hours, an observation was conducted with the kitchen staff during food preparation. Diet Aide 1, while wearing gloves, was observed tying the trash bag. Diet Aide 1 then touched the clean utensils with the same gloves. b. On 3/8/22 at 1214 hours, during dining observation, RNA 1 was observed assisting Resident 11 with her meals. RNA 1 was observed touching the meal card on Resident 11's meal tray. RNA 1 using his bare hands picked up the tortilla and fed Resident 11. Review of Resident 11's medical record was initiated on 3/8/22. Resident 11 was admitted to the facility on [DATE], and was readmitted to the facility on [DATE]. Review of Resident 11's Order Summary report dated 3/10/22, showed a physician's order for a regular diet, regular texture, thin consistency, small portion, CCHO diet, extra eggs with breakfast, soft meat, extra gravy with dry meat. On 3/9/22 at 1304 hours, an interview with the IP was conducted. The IP stated it was not okay to picked up ready to eat food with bare hands. 5. According to the USDA Food Code 2017, Section 4-901.11, Equipment and Utensils, Air-Drying Required, items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items prevents them from drying and may allow an environment where microorganism can begin to grow. During the initial kitchen tour on 3/8/22 at 0724 hours, a concurrent observation and interview was conducted with [NAME] 1. A blender was observed being stored in the upper shelves and was still wet inside. [NAME] 1 verified the finding and stated it is supposed to be air dried to prevent bacteria from the water growing. 6. According to the 2017 FDA Food Code Section 4-202.11, multi-use food contact surfaces shall be smooth; free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; free of sharp internal angles, corners, and crevices; and finished to have smooth welds and joints. During the initial kitchen tour on 3/8/22 at 0724 hours, the green, blue, and yellow cutting boards were observed with deep groves, marred, and fuzzy. [NAME] 1 verified the findings and stated the DSS was responsible in ordering the cutting boards

CONCERN (E)

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

Room Equipment (Tag F0908)

Could have caused harm · This affected multiple residents

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Based on observation, interview, facility document review, and manufacturer's guidelines review, the facility failed to ensure the facility equipment was maintained in safe operating condition when: * For Medication Cart 1, the glucometer's (a device that measures the amount of sugar in the blood) serial number did not match the serial number for the glucometer tested on the quality control log. The lot number for the glucometer test strips in Medication Cart 1 did not match the lot number on the quality control log for the cart. This failure had the potential risk of inaccuracy for the blood glucose test results. * The dish machine required minimum wash temperature and sanitizer concentration levels were not reached. This failure placed the 28 residents who received food from the kitchen at risk for food borne illness. Findings: 1. Review of the Assure Platinum (blood glucose monitoring system), Quality Assurance and Quality Control Reference Manual revised November 2009 showed to use Assure dose control solution to check if the meter and test strips are working correctly as a system. Perform control solution test whenever a new bottle of test strips is opened. On 03/10/22 at 1016 hours, an inspection of Medication Cart 1 was conducted with LVN 4. LVN 4 stated the licensed nurse should perform the glucometer quality control test every day to ensure accurate blood glucose result. Review of the facility's Assure Platinum Blood Glucose Monitoring System: Quality Control Record for March 2022 for Medication Cart 1 showed the quality control testing was performed on the glucometer with a serial number listed. LVN 4 verified the glucometer's serial number currently in use in Medication Cart 1 did not match with the serial number documented in the quality control record. LVN 4 verified the lot number of the test strip currently in use for the glucometer in Medication Cart 1 did not match the lot number documented on the Quality Control Record. LVN 4 stated they had been using the glucometer and test strips from Medication Cart 1 for testing five residents' blood sugar levels during the shift. On 3/10/22, at 1304 hours, an interview was conducted with the DON. The DON verified and acknowledged the above finding. 2. Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 3/9/22, showed 28 of 65 residents received food prepared in the kitchen. Review of the dish machine Operational Requirements sign posted on the side of the dish machine showed the minimum wash temperature is 120 degrees Fahrenheit (F), recommended 140 degrees F. Required sanitation concentration level is 50 PPM (part per million). On 3/08/22 at 0848 hours, an observation of the dish machine and concurrent interview was conducted with Diet Aide 2 and [NAME] 2. Diet Aid 2 stated the dishes were sanitized by the chemicals and the required wash temperature of the dish machine was 140 degrees F. Upon observation of the dish machine wash cycle, the temperature was at 115 degrees F. Diet Aide 2 was asked to test the sanitizer concentration level of the dish machine. Upon testing the sanitizer concentration, Diet Aide 2 stated the strip read 10 PPM. Diet Aide 2 stated the sanitizer concentration should be at least 50 PPM. Diet Aide 2 tested the sanitizer concentration a second time and the sanitizer concentration test strip showed less than 50 PPM. When asked what the process was if the dish machine did not reach the correct wash temperature or sanitizer concentration level, [NAME] 2 stated they would call the dish machine company. [NAME] 2 stated anyone could call the dish machine company. The dish machine wash cycle was observed a second time and the wash temperature was 110 degrees F. Diet Aid 2 stated the temperature was ok. When asked about the Operational Requirements sign posted on the side of the dish machine which showed the minimum wash temperature was 120 degrees F, recommended 140 degrees F and required sanitation concentration level of 50 PPM , [NAME] 2 acknowledged the current dish machine temperature was less than 120 degrees F and the sanitizer concentration level that was less than 50 PPM. [NAME] 2 stated they would run the dishes through the dish machine again. On 3/09/22 at 1505 hours, an interview was conducted with [NAME] 2. [NAME] 2 stated he had not contacted the dish machine company regarding the dish machine wash temperature that was less than 120 degrees F and the sanitizer concentration level that was less than 50 PPM. On 3/10/22 at 1005 hours, an interview was conducted with the RD. The RD confirmed the dish machine company should be contacted if the wash temperature or sanitation concentration levels were not met. On 3/10/22 at 13:32 hours, an interview was conducted with the Administrator. The Administrator stated he was responsible for ensuring the kitchen equipment was functioning properly. The Administrator stated he had contacted the dish machine company.

MINOR (B)

Minor Issue - procedural, no safety impact

Garbage Disposal (Tag F0814)

Minor procedural issue · This affected multiple residents

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Based on observation and interview, the facility failed to ensure the garbage and refuse were properly stored for two of two garbage dumpsters. The lids of the two garbage dumpsters were observed with gaps in between the lids covering the garbage dumpsters. This failure had the potential to harbor pests or rodents which carry diseases. Findings: According to the US Food Code 2013, 5-501.113, Covering Receptacles, receptacle units for refuse shall be kept covered with tight fitting lids after they are filled. On 3/9/22 at 1029 hours, an observation was conducted with the Maintenance Assistant Supervisor and Housekeeper 1. Two garbage dumpsters located outside of the facility adjacent to the side parking lot were observed to be partially open leaving a gap in between the lids. The Maintenance Assistant Supervisor and Housekeeper 1 acknowledged the above findings. On 3/9/22 at 1039 hours, an observation and concurrent interview was conducted with the Infection Preventionist. The Infection Preventionist verified the dumpster was partially open leaving a gap in between the lids. The Infection Preventionist stated the lids had to be fully closed to prevent racoons and other animals from getting to it.

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.
• 35% turnover. Below California's 48% average. Good staff retention means consistent care.

Concerns

• 110 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
• Grade F (35/100). Below average facility with significant concerns.

Bottom line: Trust Score of 35/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Newport Subacute Healthcare Center's CMS Rating?

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

How is Newport Subacute Healthcare Center Staffed?

CMS rates NEWPORT SUBACUTE HEALTHCARE CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 35%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Newport Subacute Healthcare Center?

State health inspectors documented 110 deficiencies at NEWPORT SUBACUTE HEALTHCARE CENTER during 2022 to 2025. These included: 1 that caused actual resident harm, 91 with potential for harm, and 18 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Newport Subacute Healthcare Center?

NEWPORT SUBACUTE HEALTHCARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 139 certified beds and approximately 82 residents (about 59% occupancy), it is a mid-sized facility located in COSTA MESA, California.

How Does Newport Subacute Healthcare Center Compare to Other California Nursing Homes?

Compared to the 100 nursing homes in California, NEWPORT SUBACUTE HEALTHCARE CENTER's overall rating (1 stars) is below the state average of 3.1, staff turnover (35%) is significantly lower than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Newport Subacute Healthcare Center?

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

Is Newport Subacute Healthcare Center Safe?

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

Do Nurses at Newport Subacute Healthcare Center Stick Around?

NEWPORT SUBACUTE HEALTHCARE CENTER has a staff turnover rate of 35%, 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 Newport Subacute Healthcare Center Ever Fined?

NEWPORT SUBACUTE HEALTHCARE CENTER 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 Newport Subacute Healthcare Center on Any Federal Watch List?

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

Facility Details

Beds: 139
Avg. Residents: 82
Occupancy: 59.0%
Ownership: For profit - Corporation
Chain: Independent
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
1 Actual Harm citation: -5
110 Deficiencies: -10
Final Score: 35/100

Nearby Alternatives

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Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 555751