What is GOLDEN PAVILION HEALTHCARE's CMS rating?

GOLDEN PAVILION HEALTHCARE has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

How many inspection deficiencies does GOLDEN PAVILION HEALTHCARE have?

GOLDEN PAVILION HEALTHCARE has 90 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at GOLDEN PAVILION HEALTHCARE?

GOLDEN PAVILION HEALTHCARE has a four-star staffing rating from CMS with 0.66 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 GOLDEN PAVILION HEALTHCARE located?

GOLDEN PAVILION HEALTHCARE is located in DALY CITY, CA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does GOLDEN PAVILION HEALTHCARE have?

GOLDEN PAVILION HEALTHCARE has 239 certified beds.

Who owns GOLDEN PAVILION HEALTHCARE?

GOLDEN PAVILION HEALTHCARE is a for profit - corporation facility and is part of the GOLDEN SNF OPERATIONS chain.

Is GOLDEN PAVILION HEALTHCARE safe?

GOLDEN PAVILION HEALTHCARE has a clean safety record with no substantiated abuse findings, no immediate jeopardy citations, and is not on any federal watch list.

Do nurses at GOLDEN PAVILION HEALTHCARE stick around?

GOLDEN PAVILION HEALTHCARE has average staff turnover at 47%, which is typical for the nursing home industry.

Was GOLDEN PAVILION HEALTHCARE ever fined?

Yes, GOLDEN PAVILION HEALTHCARE has been fined $182,396 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is GOLDEN PAVILION HEALTHCARE on any federal watch list?

No, GOLDEN PAVILION HEALTHCARE is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at GOLDEN PAVILION HEALTHCARE?

Medicare inspectors have found 90 deficiencies at GOLDEN PAVILION HEALTHCARE: 3 serious, 86 moderate, 1 minor. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting GOLDEN PAVILION HEALTHCARE?

Families visiting GOLDEN PAVILION HEALTHCARE should ask about what corrective actions were taken after fines. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does GOLDEN PAVILION HEALTHCARE compare to other nursing homes?

GOLDEN PAVILION HEALTHCARE has a 1-star overall rating, which is below average compared to other nursing homes in CA. Families should carefully review inspection findings and consider alternatives.

GOLDEN PAVILION HEALTHCARE | 10/100 (Grade F)

Jun 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Based on interviews and record reviews, the facility failed to provide an environment free from accident hazards for Resident 1, one of three sampled residents, when Resident 1 eloped from facility, t...

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Based on interviews and record reviews, the facility failed to provide an environment free from accident hazards for Resident 1, one of three sampled residents, when Resident 1 eloped from facility, twice, in the middle of the night, in her nightgown, exposing resident to risk of accidents, injury, or harm. The facility failed to supervise, protect, and monitor residents in their care. Findings: Resident 1 was admitted to facility on 3/31/2025 following hospitalization for Traumatic Brain Injury after assault. Resident's MDS (Minimum Data Set) an assessment tool, indicated resident did not speak or understand English, had unclear speech, was confused, had memory problems, and impaired cognition (thinking ability). Resident had lower leg impairment. During an interview on 5/5/2025 at 1:15 PM, LVN 1 (Licensed Vocational Nurse) stated when asked about checking functionality (working order) of Wanderguard alarm, I've never done that before. No body has shown me. I wasn't oriented. That night was the first time I took care of (resident) . Review of Inservice Compliance Training Record dated April 22, 2025 showed a printed signature of LVN 1's name in attendance at inservice given via phone. On April 22, 2025, the resident had already been discharged to home the day before the inservice. During a telephone interview on 6/19/2025 at 2:30 PM, a family member stated (resident) did not understand any English and spoke Cantonese only. Family member stated since (Resident 1's) brain injury, on 2/25/2025, she has been confused and not always understandable in Cantonese. He stated (Resident 1) eloped, the first time on 4/10/2025, on the night shift, wearing only the facility nightgown, and no sweater or jacket. The second time (Resident 1) eloped was on 4/21/2025, on the night shift, wearing only a facility nightgown, again no sweater or jacket. Police were notified. She was found on the shopping mall underpass, and was confused. She was taken to Chinese Hospital, family came and resident was discharged to home. During a telephone interview on 6/24/2025 at 10:25 AM, the Assistant Director of Nurses (ADON) stated residents first elopement was 4/10/2025. A Certified Nurse Assistant (CNA) reported Resident 1 missing at 4 AM, wearing a blue nightgown. Police were called. Police found resident at 5:50 AM in an apartment building across the street from the facility. Patient was confused. Wanderguard alarm order was obtained from physician and alarm applied to residents wrist. Resident was non-compliant and attempted to remove alarm from wrist. On second elopement, 4/21/2025, with resident wearing only a nightgown and Wanderguard alarm on ankle, resident was found at 4:30 AM, on the street, near shopping mall underpass. Staff had not checked for alarm functionality. Resident was taken to Chinese Hospital for further evaluation. Resident was discharged to home with family. ADON could not explain how resident walked by receptionist and out the front door without being seen or hearing door alarm. The ADON stated the receptionist goes home at 8 PM and Supervisor sits at the receptionist desk, when she has time, during night shift. Review of facility policy on Elopement/Wandering, updated on May, 2024, policy statement indicated, The center evaluates residents for wandering and/or exit seeking behavior and implements appropriate interventions as indicated via the evaluation process. Procedure: 1. At admission, the licensed nurse (LN) completes the Nursing admission Evaluation to determine the resident's risk for wandering/elopement. 2. If the data indicate further evaluation, the licensed nurse completes the Elopement /Exit-seeking Evaluation. 3. The LN gathers as much information as possible at the time of admission from the family, significant other or responsible party regarding previous elopement attempts or desire to leave the premises. 4. Based on the results of the Elopement/Exit-seeking Evaluation, care plan interventions to manage wandering and/or exit-seeking behaviors are initiated/implemented. The care plan addresses the resident's wandering behavior, potential to exit Center and/or actual episodes of elopement and the measures taken to manage those behaviors. 5. Resident's deemed at risk to elope, . or have cognitive deficit indicating poor safety awareness: .If staff are unable to keep the resident in line of sight, the resident is accompanied by a staff member assuring resident safety. 6 The care plan is reviewed and updated as appropriate. 7. The Elopement Risk Book is utilized to make staff aware of residents who are at risk of elopement. 8. A color picture is taken of resident on admission and photos are reviewed and updated at least quarterly. Place the picture on the Elopement Risk Identification Form in the Elopement Risk Book. An Elopement Risk Book is kept at each nursing station .If monitoring systems are used: .c. The LN also obtains an order to complete an evaluation for placement and function every shift . 2. The maintenance department or designee tests the monitoring system (at alarmed exits) on a daily basis using the manufacturer supplied device (as applicable) and documents the test. 3. In the event the monitoring system fails, the Center has the system evaluated for repair as soon as possible .

Jun 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of 3 sampled residents (Resident 1) when a scheduled fentanyl patch (a medicated adhesive patch that delivers fentanyl, a strong opioid painkiller, through the skin) was not applied to Resident 1 on 5/30/25 at 9 AM on time. This failure was likely to result in putting Resident 1 at risk for not meeting her pain control need. Findings: Review of Resident 1's clinical record indicated, Resident 1 was admitted to the facility with diagnoses including complex regional pain syndrome (CRPS, a chronic pain condition that causes intense pain, usually in the limbs, often following an injury, surgery, or stroke), functional quadriplegia (a state of complete immobility due to severe physical disability or frailty, without any underlying injury or damage to the brain or spinal cord), and generalized muscle weakness. Review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 9/30/24 indicated, Resident 1 was cognitively intact. Then her MDS dated [DATE] indicated, Resident 1 was cognitively moderately impaired. During a concurrent observation and interview on 6/5/25 at 10:57 AM, Resident 1 had a fentanyl patch which was dated as 6/5/25 on her left upper chest. Resident 1 stated, she was on pain medications because she had constant pain throughout her body due to CRPS. Resident 1 stated, her nurse forgot to apply her fentanyl patch for several hours on 5/30/25. Resident 1 stated, she did not have the fentanyl patch on time at 9 AM on 5/30/25, but received it in the afternoon on the same day. Resident 1 stated, she was concerned that if she did not take her medications on time, her pain might not be managed well. Review of Resident 1's Order Summary dated 4/12/25 indicated, fentaNYL Transdermal (through the skin) Patch 72 Hour (HR) 75 MCG (a unit of measurement used in medicine to express very small quantities of substances. It is one millionth of a gram)/HR (Fentanyl) . Apply 1 patch . every 72 hours for pain . Concurrent interview and record review on 6/5/25 at 1:05 PM with Licensed Vocational Nurse (LVN) 1, Resident 1's medication administration detail, titled, fentaNYL Transdermal Patch 72 Hour 75 MCG/HR (Fentanyl) undated was reviewed. Resident 1's medication administration detail indicated, . Administration History Scheduled For 0900 (9 AM) Effective Date 5/30/2025 . Code 9 ., entered by Registered Nurse (RN) 1. It further indicated, . Chart Codes: . 9-Other / See Progress Notes . LVN 1 stated, Code 9 meant the scheduled 9 AM dose of fentanyl transdermal patch was not given on time to Resident 1. Review of Resident 1's MEDICATION ADMINISTRATION RECORD (MAR) dated from 5/1/25 to 5/31/25 indicated, Resident 1 did not receive the fentanyl patch at 9 AM on 5/30/25. The MAR indicated, Resident 1 received her fentanyl patch at 6:18 PM on 5/30/25. Review of Resident 1's Nursing Progress Note dated 5/30/25 at 10:45 AM indicated, No C/O (complaint of) bladder pain . Review of Resident 1's MEDICATION ADMINISTRATION RECORD (MAR) dated from 5/1/25 to 5/31/25 indicated, Resident 1's pain scale was 0 (from 0 to 10 scale) in the day, evening, and night shifts on 5/30/25. Review of Resident 1's Nursing Progress Note dated 5/30/25 at 6:20 PM indicated, Patient did not receive her scheduled fentanyl patch this morning due to delayed delivery. MD (Doctor of Medicine) was notified and an order for one time fentanyl patch was obtained to maintain pain management. patch applied . During a concurrent interview and record review on 6/5/25 at 2:18 PM with Registered Nurse (RN) 1, Resident 1's medication administration detail titled, fentaNYL Transdermal Patch 72 Hour 75 MCG/HR (Fentanyl) undated was reviewed. RN 1 acknowledged, she did not apply the scheduled 9 AM dose of fentanyl patch on time on 5/30/25 to Resident 1. RN 1 stated, On May 29th at 7 AM Night nurse endorsed to me that despite ordering the patches 5 days earlier, they had still not arrived. She (Night shift nurse) informed me that she would call the pharmacy and check on the patches. On May 30th at 7 AM, the patch still had not arrived from pharmacy. Supervisor was immediately notified . I worked 7 AM to 3:30 PM and the patch did not arrive. RN 1 further stated, Resident 1 received the fentanyl patch on the same day after she left. RN 1 stated, There is a pharmacy refill sheet. You place the stickers from the prescription onto the sheet and fax the sheet to the pharmacy. You do this 5-7 days before the medication runs out, when asked about the facility's medication refill policy and procedure. During a concurrent interview and record review on 6/5/25 at 2:39 PM with Assistant Director of Nursing (ADON), the facility's document titled, REFILL REQUEST ONLY undated was reviewed. The document indicated, . Best Practice: . Fax refill request 3-5 days prior to supply depletion . ADON stated, this document is for the standard practice in the facility when they refill medications, and they fax the request 3-5 days before the medications run out. ADON stated, the facility did not have a policy and procedure regarding medication refill except REFILL REQUEST ONLY. During a concurrent interview and record review on 6/5/25 at 3:45 PM with ADON, Resident 1's document titled, LTCF (Long Term Care Facility) Patient dated 5/30/25 was reviewed. The document indicated, the fentanyl transdermal patch prescription was signed on 5/30/25. ADON stated, the facility's pharmacy was waiting for the doctor's signature for the form before delivering the fentanyl patch in the afternoon on 5/30/25. ADON stated, there was no evidence except this form that they requested the refill of the fentanyl patch for the scheduled dose of 9 AM on 5/30/25. ADON stated, there was no nursing documentation that they ordered refill or tried to receive the doctor's signature for the scheduled 9 AM dose of fentanyl patch before 5/30/25 when asked about evidence of requesting refill to the pharmacy. ADON acknowledged, the resident did not receive the patch on time at 9 AM on 5/30/25. During a concurrent interview and record review on 6/5/25 at 4:30 PM with ADON, the facility's policy and procedure (P&P) titled, PREPARATION AND GENERAL GUIDELINES dated October 2017 was reviewed. The P&P indicated, . MEDICATION ADMINISTRATION-GENERAL GUIDELINES . B. Administration . 2) Medications are administered in accordance with written orders of the attending physician . ADON acknowledged, they did not apply the scheduled 9 AM dose of fentanyl transdermal patch on time on 5/30/25 per the doctor's order. ADON stated, It can lead the patient to have a pain, when asked about the risk of not having the fentanyl patch on time. Review of the facility's P&P titled, Pain Management dated January 2025 indicated, . It is the policy of this center that residents receive care to attain and maintain the highest quality of care and life .

May 2025 4 deficiencies

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed review and revise the care plan to include pain manageme...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed review and revise the care plan to include pain management for Resident 525. This failure resulted in Resident 525 experiencing pain leading to discomfort. Findings: During a concurrent observation and interview on 05/20/25 at 1:27 PM with Resident 525 in Resident 525's room, Resident 525 reported pain of 9 out of 10 (based on the pain scale ranging from 0 to 10 with 0 being no pain and 10 being the highest level of pain) and noted that the last pain medication dose with Tylenol (pain medication also known as acetaminophen) was at 12:00 PM on 05/20/25 and it had been ineffective. During an observation on 05/22/25 at 8:58 AM in Resident 525's room, Resident 525 was observed awake, moving from lying flat on the back to using right hand and arm to pull self to lying on the left side (a position in which the left shoulder and left hip are touching the bed and the right side is facing up toward the ceiling). During a review of Resident 525's Medication Administration Record (MAR) on 05/22/25 at 9:09 AM using the facility's electronic health record (EHR) , a pain management order was identified for Monitor Pain every shift Indicate pain level and location if applicable Document Non-pharmacological pain interventions 1.Rest 2.Repositioning 3.None Document Y if nonpharmacological pain interventions were effective or N if not effective, NA for 0 pain -Start Date 05/09/2025 0700. Under the pain management order, pain levels were recorded from 05/09/25 to 05/21/25 for 3 shifts per day with a total of 39 pain levels recorded, and out of the 39 pain levels recorded, 92 percent of the pain levels recorded as 0. No pain level had been recorded for 05/22/25 during review of the MAR at the time of the review. Pain levels were also recorded under the order Tylenol Extra Strength Oral Tablet 500 mg (Acetaminophen) for 05/20/25 at 10:57 AM as 2 out of 10 pain and at 9:46 PM as 9 out of 10 pain. Under the same order for Tylenol, pain levels were recorded for 05/21/25 at 8:45 AM as 6 out of 10 pain and at 8:15 PM as 3 out of 10 pain. During a concurrent observation and interview on 05/22/25 at 9:25 AM with Resident 525 in Resident 525's room, Resident reported pain of 9 out of 10 and noted last given pain medication at about 9:00 AM on 05/22/25. Resident 525 was visibly uncomfortable lying on the left side and stated the pain medication was not working and pointed to the lower back as the location of pain. During concurrent observation and interview on 05/22/25 at 9:31 AM, Resident 525 stated getting help by pushing the call button when there is pain and then the lady comes in. Resident 525 stated having pain at the time of interveiw then requested for the nurse. During observation on 05/22/25 at 9:43 AM, Registered Nurse (RN) 4 entered Resident 525's room. RN 4 asked Resident 525 if something was needed and Resident 525 responded nothing. Shortly after, Resident 525 verbalized I have pain. RN 4 responded with I gave you Meloxicam (a type of medicine to relieve pain and reduce swelling in the body). Resident 525 reported pain level of 9 out of 10 to RN 4 and RN 4 responded but the medication is working and told Resident 525 that RN 4 will return to check on Resident 525 later. During an interview on 05/22/25 at 9:42 AM with RN 4, RN 4 confirmed Meloxicam 7.5 mg was and Tylenol 500 mg were recorded as last given at 8:40 AM on 05/22/25. RN 4 also noted a new pain medication order for Norco (a type of combined pain medication that includes acetaminophen, also know as Tylenol, and hydrocodone, a stronger pain reliever) that was ordered by Medical Doctor (MD) 2 on 05/22/25. RN 4 confirmed Norco was not available in medication cart for Resident 525. During a review of handwritten Physician Orders for Resident 525 dated 05/21/25, there are 2 orders that include: Celebrex 100 mg PO BID for pain x 14 days and Norco 5-325 PO q6hrs PRN pain give 1 hour before dressing changes signed by MD 1. During concurrent interview and record review on 05/22/25 at 9:59 AM with RN 7, RN 7 confirmed the EHR did not contain a progress note by MD 1 or MD 2 for the new medication orders for Celebrex 100 mg and Norco 5-325. RN 7 confirmed there was no documentation in the EHR or the Resident 525's paper chart describing the reasons why Resident 525 had new medication orders. During concurrent interview and record review on 05/22/25 at 10:11 AM with RN 4 and RN 7, RN 4 confirmed RN 4 did not document the 9 out of 10 pain for Resident 525. RN 4 confirmed Norco 5-325 was not given to Resident 525. RN 4 noted Norco 5-325 was for dressing changes only, but RN 7 confirmed the order for Norco 5-325 was to be given every 6 hours for pain and before dressing changes. RN 7 confirmed RN 4 had read the order for Norco 5-325 incorrectly. During concurrent interview and record review on 05/22/25 at 10:18 AM with RN 7, RN 7 provided an unsigned paper prescription order for hydrocodone-acetaminophen (also know as Norco) 5-325 mg. RN 7 confirmed this as the reason Norco 5-325 was not in medication cart for Resident 525. During a review of the MAR on 05/22/25 at 12:43 PM in PCC, pain level 9 out of 10 was not documented for the observation made on 05/22/25 at 9:43 AM by RN 4 for the order Monitor Pain every shift Indicate pain level and location if applicable Document Non-pharmacological pain interventions 1.Rest 2.Repositioning 3.None Document Y if nonpharmacological pain interventions were effective or N if not effective, NA for 0 pain -Start Date 05/09/2025 0700. During interview 05/22/25 at 1:42 PM with MD 1, MD 1 confirmed writing orders for Celebrex 100 mg and Norco 5-325 mg on 05/21/25 for Resident 525. MD 1 was uncertain if MD 1 had written a progress note for Resident 525 explaining reason for writing orders for Celebrex 100 mg and Norco 5-325 mg and Resident 525 did not have a change in condition. MD 1 notes MD 1's usual process is to type progress notes in a document program outside of PCC and later scans the progress note into PCC. MD 1 notes that orders or monitoring parameters for pain management are not entered by prescribers into PCC for monitoring a resident's pain for residents taking pain medication, but are instead common practice. MD 1 noted I don't put in orders for monitoring or how to monitor and then added nursing does that. During a review of Admission-readmission Nursing Evaluation - V 11 dated 05/09/25 section 2. NEUROLOGICAL item 6. PAIN Evaluation notes no answer for 1. Resident Conditions/Diagnosis contributing to pain; notes Yes for 2. Is resident interviewable?; notes No for 3. Does the resident have pain?; notes a. No Pain for 12. Pain Scale:; notes b. No for 14. Does the resident exhibit any physical signs and symptoms of pain; and the remaining questions within the 6. PAIN Evaluation are not answered. Section 10. INTEGUMENTARY/SKIN ISSUES notes Yes for 1.Skin Issues, A. Does resident have pressure ulcers, skin tears, bruises, abrasions, burns or other skin issues? and under Indicate Pressure Ulcers and/or other wound types the entry includes Site: 53) Sacrum, Type: Pressure, Length: 5.5, Width: 5.5, Depth: 0.2, and Stage: Unstageable. During a review of the Minimum Data Set (MDS) dated [DATE] for Resident 525, section Pain Assessment Interview was completed and noted pain or hurting at any time in the last 5 days; noted frequently experiencing pain or hurting over the last 5 days; noted occasionally having pain that med it hard to sleep at night; noted occasionally having limited participation in rehabilitation therapy sessions due to pain; noted frequently limiting day-to-day activities (excluding rehabilitation therapy sessions) because of pain; and noted a Pain Intensity of 9 on the Numeric Rating Scale (00-10). During review of CAA Worksheet with ARD of 05/13/2025 under Care Plan Considerations, a response of Yes is noted under the question Will Pain - Functional Status be addressed in the care plan? with the overall objective to Slow or minimize decline and minimize risks. During a review of the Care Plan Report with admission date of 05/09/25 for Resident 525, assessment, goals, and interventions/tasks related to pain was not include within the Care Plan Report.

CONCERN (D)

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

Deficiency F0740 (Tag F0740)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 30) received the necessary behavioral health care and services to attain or m...

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Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 30) received the necessary behavioral health care and services to attain or maintain the highest practicable mental and psychosocial well- being in accordance with the comprehensive assessment and plan of care. This failure resulted in Resident 30 having loud verbal outbursts, using foul language, inappropriate hand gestures when interacting with staff and other residents, including Resident 30 throwing urine at his roommate. Findings: A review of a Resident 30's Quarterly Minimum Data Set (MDS, a resident assessment tool). Dated 4/24/2025, indicated that Resident 30 has multiple diagnosis including Bipolar Disorder (a mental health condition characterized by intense mood swings), unspecified. During a concurrent interview and observation on 5/20/25 at 1:26 PM, Resident 30 was observed lying in bed with urinal, appearing to be a quarter filled, hanging on the left raised quarter siderail. Resident 30 reported he wants to go home. When asked about potential roommates, Resident 30 raised his middle finger and said I hate them (roommates). They (staff) do not care who they put in here. Resident 30 stated there used to be two other roommates and now there is only one. Resident 30 stated They moved the other motherfucker!. Resident 30 stated facility did not act on his concerns when he brought concerns to staff attention. During an observation on 5/20/2025 from 1:35 PM to 2:11 PM, there were multiple observations of Resident 30 yelling loudly and using profanity. On 5/20/2025 at 1:35 PM, Resident 30 was heard yelling Nurse! Nurse! repeatedly. The Licensed Vocational Nurse (LN1) and the Assistant Director of Nursing (ADON1) entered resident 30's room at 1:37PM and both came out at 1:41PM. However, Resident 30 continued to yell Fucking asshole! and other profanities in his room. Even with his door closed, Resident 30's volume was so loud that, his yelling could be heard from 2East hallway. On 5/20/2025 at 1:48 PM, Resident 30 continued yelling Where is my nurse! I need my water! ADON1 entered Resident 30's room at 1:48PM and exited room at 1:49PM. At 1:50PM, Resident 30 started yelling, Nurse! Nurse! Nurse!. At 1:50PM the Registered Nurse Supervisor (RN7) and ADON1 entered Resident 30's room. RN7 and ADON1 exited room at 1:54PM. Thirteen minutes later, on 5/20/2025 at 2:11PM, Resident 30 started yelling Nurse! Nurse!. The same pattern of yelling started again on 5/21/2025. During a subsequent observation on 5/21/2025 at 3:22PM in 2East Hallway, Resident 30 noted yelling Nurse!, Nurse! During an interview on 5/20/25 at 1:41 PM with LN 1, LN 1 stated facility staff was aware of Resident's 30 behaviors of throwing water on the floor or throwing meal trays across the room. LN 1 stated no roommate was assigned to bed B for safety reasons due to Resident 30 throwing urine on his last roommate. LN 1 stated there are days when Resident 30 can be angry and yelling non-stop. LN 1 stated while caring for Resident 30, she has observed Resident 30 having intermittent disagreements with his current roommate. These episodes sometimes escalated into Resident 30 yelling profanities and raising his middle finger at his roommate. In a concurrent interview and record review on 5/20/2025 at 1:42PM, with LN 1, LN 1 reviewed an electronic record titled admission Record and reported Resident 30 has been a patient in the facility since June 2022. LN 1 states, Resident 30 has documented behaviors of being disruptive, throwing urine on the floor, flipping furniture, and urinating on the floor dating back to 2024. LN 1 stated It's .mood changes and angry outbursts. During a concurrent interview and record review on 5/21/25 at 1:28 PM with the Case Manager (CM1) when reviewing policy titled Care Planning- Interdisciplinary Team last revised in March 2022, CM1 stated if the facility had concerns regarding a resident's behavioral needs, then the facility would refer them to outpatient/community services such as psychiatric, mental health, or relocation/discharge if the facility was unable to meet their needs. CM1 stated if a resident was unable to request services, the Social Services department would interview other facility staff, family members, Certified Nursing Assistants, Charge nurses (nursing manager), and monitor for changes in Resident's routine. When asked if the above interventions were carried out for Resident 30, CM1 verified they were not. A review of Resident 30's assessment titled Care Plan Report initiated on 3/11/2025 last revised on 3/11/2025 indicated a problem for Cognitive Loss due to: BIMS. BIMS =Brief Interview of Mental Status, a tool to assess memory, thinking, and reasoning. Resident 30 had a score of six out of fifteen. This indicated Resident 30 was severely impaired in his memory and reasoning. There was a documented intervention for staff to Anticipate resident needs. During a concurrent interview and record review on 5/21/2025 at 2:53PM with Licensed Vocational Nurse (LN2), LN2 stated Resident 30 was very unpredictable, had wild mood swings, will suddenly begin to scream and yell, and become very agitated. During a concurrent interview and observation on 5/21/2025 at 3:08PM with Certified Nurse Assistant (CNA2), CNA2 states Resident 30 is very moody with frequent changes in mood and behaviors, including the use of profanity. CNA2 stated the facility Nursing Supervisors were made aware of behaviors on several occasions. Durning a concurrent interview and record review on 5/22/25 at 11:00 AM with the Director of Nursing (DON), a review of Resident 30's assessment titled Care Plan Report initiated on 1/15/2025 last revised on 1/15/2025 indicated a problem for Lithium use due to: Bipolar Disorder [A mood disorder] with interventions to Monitor behaviors to assist and assure lowest possible therapeutic doses are given, Monitor changes in condition, and Monitor target behavior(s) via Point Click Care electronic medication administration record (E-MAR [An electronic health record]) initiated on 1/15/2025 as well. DON stated a change in condition assessment can be initiated due to abnormal behavior, any noted side effect form anti-psychotic medication use, or change in behavior that was noted in diagnosis. DON defined abnormal behavior as any behavior that resident does not usually display or if the resident becomes more erratic. A review of Resident 30's electronic medication administration record (E-MAR), indicated targeted behavior monitoring for Rapid nonstop talking was the only behavior log noted in record. DON verified the facility did not have any additional monitoring for behaviors outside of the targeted behavior noted in the E- MAR. During a concurrent interview and record review on 5/22/2025 at 11:17 AM with the DON, nursing progress notes dated 5/29/2023, 5/30/2023, 6/3/2023, 6/8/2024, and 6/15/2024 stated Resident 30 was noted urinating on the floor, throwing urinals against the trash can, and throwing furniture. DON verified that in 2023 there was a pattern of inappropriate behavior. Further review of a nursing progress note titled Episode of agitation on 2/12/25, indicated Resident 30 threw a cup of water at the door. DON stated the facility cannot monitor all behaviors, the nursing staff monitor for one off behaviors. DON stated the facility was unable to monitor every resident, and monitoring was initiated if the behavior was new. DON verified no documentation for monitoring Resident 30's behaviors of loud verbal outbursts, using profanity, throwing items was currently in place. A review of Resident 30's progress note dated 3/10/25 published by social services department, stated behaviors will be closely monitored for any changes in mood and behaviors. DON verified there is no documentation of monitoring of any changes in mood and behaviors in resident's record. During a concurrent interview and record review on 5/22/2025 at 3:01PM with ADON1, ADON1 stated the facility protocol for residents with new behaviors included informing the primary care physician or nurse practitioner to request for med review and behavioral monitoring, report to the facility social services department, and initiate behavior monitoring every shift if the resident was on psychotropic medication. ADON1 stated Resident 30 had a new behavior of throwing urine. ADON 1 verified the facility did not initiate behavioral monitoring for the new behavior identified. ADON 1 also verified Resident 30's assessment titled Care Plan Report initiated on 1/15/2025 last revised on 1/15/2025, stated facility staff will do interventions indefinitely.

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to maintain infection control program and practices designed to help prevent the development and transmission of diseases and in...

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Based on observation, interview, and record review, the facility failed to maintain infection control program and practices designed to help prevent the development and transmission of diseases and infections when the PICC (Peripherally Inserted Central Catheter: a long, thin, flexible tube inserted into a vein, usually in the arm, and advanced to a larger vein near the heart. It provides access to the bloodstream for delivering medications, fluids, and blood draws for a prolonged period, reducing the need for frequent needle insertions.) line dressing was overdue to change for one of 2 sampled residents (Resident 380). This failure had the potential to develop infection in Resident 380. Findings: Review of Resident 380's clinical record indicated, Resident 380 was admitted to the facility with diagnoses including diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), malnutrition (an imbalance between the nutrients your body needs to function and the nutrients it gets), and chronic kidney disease (a progressive condition where the kidneys gradually lose their ability to filter waste and excess fluid from the blood). During a concurrent observation and interview on 5/20/25 at 1:45 PM with Resident 380 in his room, Resident 380 had a PICC line dressing on his left upper arm. The PICC line dressing date was 5/11/25. Resident 380 stated, he had PICC line because he was a hard stick (a patient whose veins are difficult for medical professionals, such as phlebotomists or nurses, to access for blood draws or IV [Intravenous: Into your vein; into your blood stream, putting drugs or fluids directly into your blood] placement). During a concurrent observation and interview on 5/20/25 at 2:12 PM with Registered Nurse (RN) 3, Resident 380's PICC line dressing was observed. RN 3 stated, Resident 380 had the PICC line because they could not find a vein when he was getting IV fluid before. RN 3 stated, the PICC line dressing should be changed every night when asked. RN 3 acknowledged, the PICC line dressing was dated as 5/11/25. During an interview on 5/20/25 at 2:31 PM with RN 3, RN 3 stated, the PICC line dressing should be changed every 7 days. RN 3 stated, there is a risk of infection when asked if the dressing is not changed every 7 days. During an interview on 5/22/25 at 2:13 PM with Assistant Director of Nursing (ADON) 2, ADON 2 stated, It can develop infection, when asked about the risk of not changing the PICC line dressing timely. She stated, 7 days when asked how often it should be changed. During a concurrent interview and record review on 5/27/25 at 1:17 PM with ADON 1, Resident 380's doctor's orders were reviewed. ADON 1 verified there was no doctor's order for the PICC line dressing change. Review of the facility's policy and procedure (P&P) titled, PICC DRESSING CHANGE dated March 2023 indicated, I. To Be Performed By: RNs and IV Certified LVNs (Licensed Vocational Nurses) according to state law and facility policy . E. Change catheter securement device (a medical accessory used to securely hold a catheter in place) every 7 days . F. Change antimicrobial disc (a dressing used to reduce the risk of infection at the insertion site of a PICC line) every 7 days . Review of the facility's P&P titled, Infection Control Policies and Practices revised 3/19/25 indicated, . 2. The objectives of facility infection control policies, protocols, and practices are to: a. Support prevention, detection, investigation, and transmission of infections .

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary condition was met for food storage in the kitchen when there were expired strawberry topping and sli...

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Based on observation, interview, and record review, the facility failed to ensure safe and sanitary condition was met for food storage in the kitchen when there were expired strawberry topping and sliced turkey in the refrigerator. These failures had the potential to result in putting residents at risk for foodborne illness (a disease caused by consuming contaminated food or drink). Findings: During a concurrent observation and interview on 5/19/25 at 2:54 PM with Dietary Supervisor (DS) 1 and Dietary Manager (DM) in the kitchen, there was one container of strawberry topping in the refrigerator with the date 6/15/23 labeled on the lid. DS 1 removed the label with the date on it, then re-attached it when asked. A picture of the container of expired strawberry topping was taken. DM acknowledged, the labeled date meant use by date when asked. DM stated, It has to be expired, when asked if the strawberry topping was expired. During a concurrent observation and interview on 5/19/25 at 3:04 PM with DM in the kitchen, there was expired sliced turkey in a plastic bag in the refrigerator. The label on the bag indicated, Opened 05/13/25 . Discard 05/17/25 . DM acknowledged, the sliced turkey was expired when asked. A picture of the expired sliced turkey was taken. DM stated, Stomachache . There is a possibility of foodborne illness, when asked what the risks are of eating expired food. He stated, the facility's dietary staff might forget to discard the expired strawberry topping and sliced turkey. During an interview on 5/21/25 at 9:26 AM with Certified Dietary Manager (CDM), the pictures of the expired strawberry topping and sliced turkey were shown to her. CDM acknowledged, the strawberry topping and sliced turkey were expired and were not discarded timely when asked. She stated, the expired food can create food borne illness when asked if these items are used. Review of the facility's policy and procedure (P&P) titled, Food Storage updated in October 2017 indicated, . Food storage areas are maintained in a clean, safe, and sanitary environment . 10. Opened items have use by dates indicated on them . The Federal Food Code 2022 describes foodborne illness. The Food Code indicated, . Foodborne illness in the United States is a major cause of personal distress, preventable illness and death . Most foodborne illnesses occur in persons who are not part of recognized outbreaks. For many victims, foodborne illness results only in discomfort or lost time from the job. For some, especially . older adults in health care facilities, and those with impaired immune systems, foodborne illness is more serious and may be life threatening . Epidemiological (relating to the branch of medicine which deals with the incidence, distribution, and control of diseases) outbreak data repeatedly identify five major risk factors related to employee behaviors and preparation practices in . food service establishments as contributing to foodborne illness: o Improper holding temperatures, o Inadequate cooking, such as undercooking raw shell eggs, o Contaminated equipment, o Food from unsafe sources, and o Poor personal hygiene .

Mar 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

Based on interview and record review, the facility: 1. Did not ensure prescribed medication for Resident 1 was available on the scheduled administration time on 3/18/25 at 4:00 PM, and 3/19/25 at 12:...

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Based on interview and record review, the facility: 1. Did not ensure prescribed medication for Resident 1 was available on the scheduled administration time on 3/18/25 at 4:00 PM, and 3/19/25 at 12:00 AM and 8:00AM. 2. Did not properly account for the receipt of the controlled medication (drugs or substances that are regulated by the government due to their potential for abuse and addiction) (diazepam- a controlled substance to treat anxiety, muscle spasms, and seizures) for Resident 1. These failures resulted in the potential for reduced effectiveness to prevent a worsening of symptoms or flare-ups of muscle spasms or increased physical discomfort related to complex regional pain syndrome or potentially leading to anxiety or mood swings. Improper accounting practices during the receipt of this controlled medication compromises the facility's ability to maintain adequate medication availability and meet the resident's needs. Findings: 1. During a concurrent interview and record review on 3/19/25 at 1:35 PM with the Assistant Director of Nursing (ADON) and Licensed Vocational Nurse (LVN1) of Resident 1's medication administration record (MAR) dated March 1-31, 2025, was reviewed. MAR indicated , Valium (Diazepam) oral tablet 5mg give 1 tablet by mouth every 8 hours for muscle spasms related to complex regional pain syndrome, and the nursing/MAR notes dated 3/18/25 at 5:14 PM, 3/19/25 at 12:22 AM, 3/19/25 at 8:00AM, and 3/19/25 at 3:56 PM, were reviewed. Resident 1's March MAR and March 18-19, 2025 Nursing Notes indicated 3 doses (3/18/25 at 4:00 PM, 3/19/25 12:00 AM, and 3/19/25 at 8:00AM) of diazepam were not given. Both the ADON and LVN1 stated the resident's last dose of diazepam was given on 3/18/25 at 8:00 AM, and Resident 1 missed the next 3 doses due to no inventory. During an interview on 3/19/25 at 3:40 PM with LVN2, LVN2 stated the day nurse endorsed to him that there was no diazepam for Resident 1's 4:00 PM dose, and pharmacy had been called. LVN2 stated he notified the Family Nurse Practitioner (FNP) who was close by and he filled an order for 60 tabs which was faxed to pharmacy 3/18/25 at 3:50 PM. LVN2 stated he did not document a nursing note at the time he notified FNP of no supply, but when told by ADON to make a late entry of this, he complied. LVN2 admitted this was an error stating if it's not documented, it wasn't done, and I will do better next time. During an interview on 3/19/25 at 4:10 PM with Director of Nursing (DON), DON stated Resident 1 missed 3 doses of diazepam 5mg due to no supply. DON agreed facility did not ensure diazepam was available for this Resident and was not administered scheduled medication on time. DON agreed the facility Policy and Procedure (P/P) titled Administering Medications was not followed. During a review of Resident 1's Order Summary Report, dated 3/20/25, the Order Summary Report indicated diazepam oral tablet 5mg give 1 tablet by mouth every 8 hours for muscle spasms related to complex regional pain syndrome I. 2. During a concurrent interview and record review on 3/19/25 at 3:40 PM with LVN2, a faxed verification report dated 3/18/25 at 3:50 PM was reviewed. The verification report indicated that 60 tablets of diazepam 5mg were ordered for Resident 1 by the FNP. LVN2 stated FNP filled order for 60 tabs which was faxed to pharmacy 3/18/25 at 3:50 PM. During concurrent interview and record review on 3/19/25 at 4:00 PM with ADON, Manifest ID for rx#54009414 for Resident 1, dated 3/4/25 at 10:19 PM; Controlled Drug Record, dated 3/4/25, and LVN2's Nursing Note dated 3/19/25 at 8:53 PM were reviewed. The Manifest ID indicated that 90 tablets of diazepam 5mg for Resident 1 were delivered, and signed by LVN2. The Controlled Drug Record indicated 31 tabs of diazepam 5mg for Resident 1 was accepted on 3/8/25 at 8:00 AM. LVN2's Note indicated 42 tablets of diazepam were received from pharmacy today for the Resident. ADON stated there was a discrepancy of these documents. During a review of the facility's policy and procedure titled, Administering Medications, dated April 2019, indicated, medications are administered in a safe and timely manner, and as prescribed. The Controlled Medication Storage indicated under Procedures E (1 & 2)- any discrepancy in controlled substance medication counts is reported to the director of nursing immediately. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies

Jan 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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to thoroughly investigate a change in condition for one of three sampled resident (resident 1) when Resident 1 developed bruises...

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Based on observation, interview, and record review, the facility failed to thoroughly investigate a change in condition for one of three sampled resident (resident 1) when Resident 1 developed bruises to the left forearm and on top of the left hand with unknown origin. The facility failure has the potential for Resident 1 to not receive the necessary care and services. Findings: A review of the admission records indicated Resident 1 was admitted with diagnoses including end stage renal (kidney) failure (when the kidneys stopped working) and dementia (decline in memory or other thinking skills). A review of the nurses' notes dated 12/7/24, indicated, Resident 1 was noted with discoloration on the: left forearm measuring six (6) centimeters (cm, a unit of measurement) by (X) three (3) cm, top of left-hand site 1: 2.5 cm X two (2) cm, top of left-hand site 2: One (1) X one cm. A review of the physician order dated 12/7/24, indicated, to monitor discoloration on the left lower arm and to apply ice pack to the left wrist. A review of the care plan intervention dated 12/7/24, indicated, to keep area clean and dry, pat skin dry after bathing, report to Medical Doctor (MD) significant change in the skin. During an interview on 1/13/25, Registered Nurse 1 acknowledged that there was no investigation completed for the possible causes of the bruises found on Resident 1 LFA and top of the hand. During the interview on 1/13/25, Assistant Director of Nursing acknowledged there was no investigation completed for the possible causes of the bruises on Resident 1 LFA and top of left hand. A review of the Policy and Procedure titled, Abuse and Neglect - Clinical Protocol dated 3/2018, indicated, The nurse will assess the individual and document related findings. Assessment data will include: injury assessment (bleeding, bruising, deformity, swelling, etcetera [ect.]), pain assessment; current behavior; patients age and sex, all current medications, especially anticoagulants, non-steroidal anti-inflammatory drugs, salicylate, ; other platelet inhibitors; vital signs; behavior over last 24 hours (bruise could be related to movement disorder or aggressive behavior); history of any tendency towards bruising; all active diagnosis; and any recent labs .

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

Based on interview and record review the facility failed to develop a comprehensive plan of care for one of three residents (Resident 1) when osteopenia (bone density loss, weak bones) was not address...

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Based on interview and record review the facility failed to develop a comprehensive plan of care for one of three residents (Resident 1) when osteopenia (bone density loss, weak bones) was not addressed. The facility failure has the potential for Resident 1 to not receive necessary care and services. Findings: A review of the admission records indicated Resident 1 was admitted with diagnoses including end stage renal (kidney) failure (when the kidneys stopped working) and dementia (decline in memory or other thinking skills) and history of fractures (broken bones). A review of the Orthopedic notes dated 9/17/24, indicated, an Xray (a test that takes a pictures of the structures inside the body particularly the bones) result from 7/16/24 as followed: .Significant osteopenia evident along with degenerative changes about the wrist. During an interview on 1/10/25, at Assistant Director of Nursing reviewed the care plan for Resident 1 and stated that she did not see a care plan to address osteopenia. During an interview on 1/17/25, at 10:00 AM, the Director of Nursing stated that care plan is specific to the resident needs and guides the staff in providing care. The DON further stated that everyone is responsible in the development of the resident's care plan. They DON acknowledged a comprehensive care plan was not developed to address osteopenia. A review of the facility Policy and Procedure titled, Care Plan, Comprehensive Person Centered, dated 12/2016, indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetable to meet resident's physical, psychological and functional needs is developed and implemented for each resident . The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition change . A review of the Policy and Procedure titled, Care Planning - Interdisciplinary Team, dated 9/2013, indicated, .Our facility's Care Planning /Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident .

CONCERN (E) 📢 Someone Reported This

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

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure accurate assessment of the Minimum Data Set (MDS, a standard...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure accurate assessment of the Minimum Data Set (MDS, a standardized assessment tool) for one of three sampled residents (Resident 1) when the MDS did not document dementia (decline in memory or other thinking skills), fracture (broken bone) and osteopenia (bone density loss, weak bones) as active diagnoses. The facility failure resulted to inaccurate MDS to reflect Resident 1's current health status. Findings: During an observation on 1/105:02 PM, Resident 1 was awake, verbally responsive, sitting up in bed, with bandage to left forearm. Resident 1 was not able to relate how she sustained the fracture to the left forearm. During an interview on 1/3/25 @1:06 PM, MDS Nurse 1 reviewed the MDS dated [DATE], for Resident 1, acknowledged that dementia, osteopenia, and fracture was not entered in the MDS and stated that when completing the MDS, the residents clinical record is reviewed. MDS Nurse 1 also stated the physician order is not a source of information and dementia was care planned by the social services. MDS Nurse 1 further stated osteopenia could have been added if the nurses have communicated with the MDS Nurse. The MDS Nurse that completed Resident 1's MDS is no longer employed in the facility. During an interview on 1/13/24, at 1:41 PM, Social Services Designee 1 reviewed the care plan and stated that Resident 1 was admitted with diagnosis of dementia. During an interview on 1/16/25, at 4:00 PM, the Director of Nursing stated, MDS is an accurate assessment of resident's current status. The DON further stated that the MDS nurse dig through the chart and when the documentations does not match the facility take an additional step or redo the assessment. .Section I: Active Diagnoses .The items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death. One of the important functions of the MDS assessments is to generate an updated, accurate picture of the resident's status . Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) 3.0 Manual.

CONCERN (E) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to follow the physician (Medical Doctor, MD) order for one of three sampled resident (Resident 1) when the splint (a supportive ...

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Based on observation, interview, and record review, the facility failed to follow the physician (Medical Doctor, MD) order for one of three sampled resident (Resident 1) when the splint (a supportive device to immobilize [to stop or reduce movement] and protect a broken bone) was not applied to the fractured left forearm. The facility failure had the potential for Resident 1 to develop complication and further resident harm. Findings: A review of the admission records indicated Resident 1 was admitted with diagnoses including end stage renal (kidney) failure (when the kidneys stopped working) and dementia (decline in memory or other thinking skills) and history of fracture (broken bones). During an observation on 1/13/25, at 10 AM, Resident 1 was awake, verbally responsive, sitting up in bed. Resident 1 was not able to relate how she sustained the fracture to the left forearm. A review of Orthopedic note dated 9/17/24, indicated, Resident 1 has a minimally displaced left radial (one of the two bone in the forearm) shaft (makes up most of the bone length) fracture sustained around 4/14/24, with minimal healing at the area of the fracture site, no callus formation (soft tissue bridge that form at the site of the broken bone eventually hardening as the it heals) seen. The orthopedic notes further stated significant osteopenia was (bone density loss, weak bones) evident. A review of the physician order dated 7/18/24, indicated, .keep splint for most of the time, may remove once a day with arm fully supported with a pillow just to gently clean the skin around the arm . A review of the nurses' notes dated 12/1/24, indicated that the splint for the left forearm was missing. A review of the treatment administration record for 12/2024, indicated the splint was on hold on 12/2 to 12/9/24. A review of the orthopedic note dated 12/10/24, indicated resident was seen and that a splint was applied during the visit. During an interview on 1/10/25, at, 4:30 PM, the Director of Nursing reviewed the Treatment administration record, acknowledged the splint for the left arm fracture was on hold, and stated, It is on hold because we don't have them. During an interview on 1/13/25, at 11:35 AM, Registered Nurse 1 stated the Resident 1's son arranged the appointment and took the resident to the orthopedic clinic on 12/10/24. RN 1 also stated that they could have contacted the orthopedic department directly. RN 1 further stated they waited for when the splint becomes available

Oct 2024 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0947 (Tag F0947)

Could have caused harm · This affected multiple residents

Based on interview and record review, the facility failed to train and review the performance of three out of three sampled Certified Nursing Assistants (CNAs) when employee files of CNA 1, CNA 2, and...

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Based on interview and record review, the facility failed to train and review the performance of three out of three sampled Certified Nursing Assistants (CNAs) when employee files of CNA 1, CNA 2, and CNA 3 lacked documentation of initial training as well as a performance review required by facility policy and procedure. This failure has the potential to result in untrained CNAs providing unsafe care that could cause harm to Residents. Findings: A review of a documented titled New Hire Report dated 10/01/23 to 11/30/23 indicated that CNA 1, CNA 2, and CNA 3 were all hired in October of 2023. It further indicated that CNA 1 ended employment on April 2024; CNA 2 ended employment on March 2024; CNA 3 ended employment on February 2024. During a concurrent interview and record review on 10/02/24 at 10:35 AM with the Director of Staff Development (DSD), CNA 1 ' s employee file was reviewed. The DSD stated that after someone is hired, they will have two days of classroom orientation that includes topics about patient care. The DSD stated that this classroom instruction should be completed prior to staff starting to work on the unit. The DSD further stated that CNA 1 ' s employee file was missing the onboarding documents, and they would need to look for them. During a concurrent interview and record review on 10/02/24 at 2:30 PM with the DSD, CNA 2 and CNA 3 ' s employee files were reviewed. The DSD stated there was not a competency assessment done for CNA 2 or CNA 3. During a concurrent interview and record review on 10/03/24 2:19 PM with the DSD, CNA 1 ' s employee file was reviewed again. The employee file indicated that there was still no documentation of a performance or competency evaluation for CNA 1. When asked if the DSD was able to locate any documentation of a performance evaluation the DSD stated, no it doesn ' t seem like she ' s got one. During a concurrent interview and record review on 10/03/24 at 2:43 PM with the Assistant Director of Nursing (ADON), the facility document titled Certified Nursing Assistant Competency Assessment was reviewed. The document indicated that there were 67 different functions [skills] that a CNA had to demonstrate competency in. The ADON stated that this document should be done by the time you ' re done with orientation. The ADON further stated that CNA should not be independently working with residents until you are done with the competency assessment. During an interview with the ADON on 10/03/24 at 2:58 PM with the ADON, the ADON stated that the competency assessment and performance evaluation are important because, we have to be able to validate that someone is trained. A review of a facility policy and procedure (P&P) titled Performance Evaluations, last revised June 2010, indicated that A performance evaluation will be completed on each employee at the conclusion of his/her 90-day probationary period, and at least annually .The written performance evaluations will contain the director ' s and/or supervisor ' s remarks and suggestions, any action that should be taken (e.g., further training, etc.), and goals .The completed performance evaluation will be sent . to be placed in the employee ' s personal record. During a concurrent interview and record review on 10/03/24 at 3:32 PM with the Director of Nursing (DON), the employee files of CNA 1, CNA 2, and CNA 3 were reviewed. The employee files indicated that there was no initial competency evaluation during orientation or a performance evaluation after 90 days of hire for all three employees. The DON stated that the DSD will coordinate the orientation for CNAs. The DON further stated that the skills assessments are important so that CNAs can do the job properly . we can ' t have them on the floor not knowing how to do things.

Aug 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0557 (Tag F0557)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to retain personal possessions of Resident 1, one of two sampled resid...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to retain personal possessions of Resident 1, one of two sampled residents, when after return from hospitalization Resident 1's two head phones, one Blue Tooth speaker/microphone and two full Lysol disinfectant spray cans were missing from his closet. This failure resulted in depression, disappointment, and mental anguish to the resident. Findings: Resident 1 was admitted to the facility on [DATE], initial admission on [DATE], with diagnoses including osteomyelitis of vertebra, sacral region (bone infection of spine), pressure ulcer of sacral region (wound on lower back area), diabetes mellitus, heart failure, chronic pain syndrome, functional quadriplegia (complete immmobility of limbs), and history of pulmonary embolism (blocked artery in lungs). Review of resident''s MDS (Minimum Data Set) an assessment tool, indicated Resident 1 had good cognition (thinking ability), had clear speech and good hearing, required assistance to roll side to side, unable to sit, stand, or walk. Required staff sponge bath twice a week for hygiene. During an interview on 8/22/2024, at 4:20 PM, Resident 1 stated his personal property, two pairs of head phones, a Blue Tooth speaker/microphone and two spray cans of Lysol disinfectant went missing from his closet while he was at hospital. He appeared depressed and disappointed over the loss of his property. During an interview on 8/22/2024, at 4:50 PM, Social Services staff member, with Assistant Director of Nurses present (ADON), stated he would look for the missing personal property of Resident 1 and made note of the missing personal possessions. During a telephone interview on 8/26/2024 at 10:45 AM, Ombudsman stated she was aware of the missing personal possessions belonging to Resident 1 and would be following up on the outcome.

CONCERN (D) 📢 Someone Reported This

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

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from neglect when Resident ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from neglect when Resident 1, one of two sampled residents, was deprived of care and did not receive a sponge bath for one month. This failure resulted in discomfort, humiliation, and embarrassment to the resident. Findings: Resident 1 was admitted to the facility on [DATE], initial admission on [DATE], with diagnoses including osteomyelitis of vertebra, sacral region (bone infection of spine), stage 4 pressure ulcer of sacral region (wound on lower back area), diabetes mellitus, heart failure, chronic pain syndrome, functional quadriplegia (complete immobility of limbs), and history of pulmonary embolism (blocked artery in lungs). Review of resident's MDS (Minimum Data Set) an assessment tool, indicated Resident 1 had good cognition function (thinking ability), had clear speech and good hearing, required staff assistance to roll side to side, was unable to sit, stand, or walk. Required staff assistance for sponge bath twice a week for good hygiene. During an interview on 8/22/2024. 2:45 PM, Assistant Director of Nurses (ADON) was asked for policy on bathing residents and was informed that Resident had not been bathed for a month. During an interview on 8/22/2024, at 4:20 PM, Resident 1 stated on July 23, 2024, he had been asking for a sponge bath for a month and reported it to California Department of Public Health. Staff would reply to the resident they ran out of time or the next shift would do it. The next shift would say the previous shift (day shift) would do it. Resident asked staff many times to give him a sponge bath. He stated he felt dirty, grimy, slimy and embarrassed. He stated he did not get a sponge bath until he was hospitalized after the 7th of August. The facility deprived Resident 1 of physical care when they would not bathe him. His pressure ulcer had worsened upon admission to hospital and he became septic. Review of the facility policy on Bed Bath, revised March, 2021, indicated, Purpose: The purpose of this procedure are to promote cleanliness, provide comfort and to observe the condition of the residents skin.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide prn medication (as needed) on time to Resident 1, one of tw...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide prn medication (as needed) on time to Resident 1, one of two sampled residents, when the resident waited for pain relief caused by pressure ulcer (wound infection in lower back) and bone infection. This failure caused the resident unnecessary pain, discomfort, and anxiety. Findings: Resident 1 was admitted to the facility on [DATE], initial admission on [DATE], with diagnoses including osteomyelitis of vertebra, sacral region (bone infection of spine), pressure ulcer of sacral region (wound on lower back area), diabetes mellitus, heart failure, chronic pain syndrome, functional quadriplegia (complete immobility of limbs), and history of pulmonary embolism (blocked artery in lungs). Review of resident's MDS (Minimum Data Set) an assessment tool, indicated Resident 1 had good cognition function (thinking ability), had clear speech and good hearing, required assistance to roll side to side, unable to sit, stand, or walk. Required staff assistance for sponge bath twice a week for good hygiene. During an interview on 8/22/2024 at 4:20 PM, Resident 1 stated on 7/15/2024 at 5:44 PM, he waited 1-2 hours for his PRN pain medication. He stated he put his call light on and no one came. Later someone disconnected his call light and his call light was no longer usable. He tried to report it to a nurse manager and was told she was in a meeting. He reported it to the Ombudsman and the California Department of Public Health. He stated he was in great pain and discomfort and needed his pain medication. During an interview on 8/26/2024 at 2:45 PM, Assistant Director of Nurses (ADON) stated staff are told they are not to disconnect residents call light and are expected to provide care to the resident when they request it.

Jun 2024 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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an investigation, and results, related to abuse, neglect or ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an investigation, and results, related to abuse, neglect or mistreatment, when Resident 1, one of one sampled residents, was injured when she was dropped on the floor and her tooth was broken. For alleged violations of neglect or mistreatment that do not result in serious bodily injury the facility must report the allegation no later than 24 hours. The facility must provide in its report sufficient information to describe the alleged violation and indicate how residents are being protected. Within 5 working days of the incident, the facility must provide sufficient information to describe the results of the investigation and indicate any corrective actions taken. Any updates should be included. This failure showed no action was taken for the injury to the Residents tooth. Notice of violation was never made to the California Department of Public Health. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses including kidney disease, heart failure, diabetes, gait and mobility abnormalities, and glaucoma. Resident 1's Minimum Data Set, MDS, an assessment tool, indicated resident had no hearing difficulties, had cognitive impairment (thinking ability), required a two-person assist to move and reposition in bed, to transfer to chair/wheelchair and to dress. Resident 1 weighs 89 pounds, is 5 feet tall, [AGE] years old, and does not walk. During a telephone interview with the Assistant Director of Nurses (ADON) on 6/27/2024, at 12:33 PM, the ADON stated there was no incident report made for the residents injury resulting in the residents damaged tooth and the Department of Public Health was not notified of the fall and tooth injury. During a telephone interview on 7/11/2024, at 4:04 PM, son of Resident 1 stated in October, 2023 facility staff were transferring resident from wheelchair to bed during the day shift and they dropped her on the floor. She broke her tooth in the fall. The son stated he reported it to the facility. The resident did not see a dentist until 7/11/24, nine months after the fall, because the facility said she had no dental insurance and did not pay for her dental work. After a second visit to the dentist a root canal was required and performed after dental insurance was confirmed by the insurance company. A report by the facility to California Department of Public Health was never made for this incident. Review of the facility's policy on Unusual Occurrence Reporting, revised December, 2007, indicated, As required by federal or state regulations, our facility reports unusual occurrences or other reportable events which affect the health, safety, or welfare of our residents . 1. Our facility will report the following events to appropriate agencies . g. Allegations of abuse, neglect . 2. Unusual occurrences shall be reported via telephone to appropriate agencies as required by current law and/or regulations within (2) hours of such incident or as otherwise required by federal and state regulations. 3. A written report detailing the incident and actions taken by the facility after the event shall be sent or delivered to the state agency (and other appropriate agencies as required by law) within (48) hours of reporting the event or as required by federal and state regulations .

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Resident 1, one of one sampled resident, was assisted to obt...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure Resident 1, one of one sampled resident, was assisted to obtain or was reimbursed for eyeglasses after staff lost three pairs of residents prescription eyeglasses. Resident has glaucoma and vision difficulties. This failure resulted in creating depression and additional visual difficulties for the resident. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses including kidney disease, heart failure, diabetes, gait and mobility abnormalities, and glaucoma. Resident 1's Minimum Data Set, MDS, an assessment tool, indicated resident had no hearing difficulties, had cognitive impairment (thinking ability), required a two-person assist to move and reposition in bed, to transfer to chair/wheelchair and to dress. Resident 1 weighs 89 pounds, is 5 feet tall, [AGE] years old, and does not walk. During an interview on 7/11/2024, at 4:04 PM, resident 1's son stated the facility has lost the residents eyeglasses, at least, three times. Resident's son stated he has reported the loss of each of the eyeglasses to the facility and the social worker. Resident's son stated he filled out a report on 5/18/2024 the facility lost the last pair of eyeglasses. He states his mother is depressed over the loss of the last pair of eyeglasses. The facility has not replaced or reimbursed the resident for any of the eyeglasses. Review of Resident 1's Inventory of Personal Effects dated 9/30/2021 and 10/4/2021 indicated one pair of eyewear, Brown/Bronze, and one pair of Gold-colored eyeglasses were in her personal effects. The form was signed by the resident and resident's son. Review of facility Theft and Lost Report dated 6/14/2024 indicated, Prescription Glasses, lost. Were items noted on Inventory List: YES. Were items marked: YES. Resident will be referred to optometry/ophthalmology for review of new prescription. Residents son gave a copy of prescription. Signed by Social Services, and Director of Nursing. Review of the facility policy on Lost and Found, revised January, 2008, indicated, Our facility shall assist all personnel and residents in safe guarding their personal property .8. Reports of misappropriation or mistreatment of resident property are immediately investigated. The facility did not assist or refer the resident to optometry/ophthalmology to obtain appointment for new prescription eyeglasses. No investigation of lost prescription eyeglasses was made.

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 F0687 (Tag F0687)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure foot care (podiatrist service) was provided to Resident 1, o...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure foot care (podiatrist service) was provided to Resident 1, one of one sampled resident, when she did not receive any foot care service, e.g,, toe nail clipping, since admission, for 2 1/2 years, and has a condition that poses a risk to foot health (e.g., diabetes) this resulted in immobility, and overgrown, uncomfortable toe nails and feet. This failure resulted in neglect to the resident, caused pain, and loss of ability to walk. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses including kidney disease, heart failure, diabetes, gait and mobility abnormalities, and glaucoma. Resident 1's Minimum Data Set, MDS, an assessment tool, indicated resident had no hearing or vision difficulties, had cognitive impairment (thinking ability), required a two-person assist to move and reposition in bed, to transfer to chair/wheelchair and to dress. Resident 1 weighs 89 pounds, is 5 feet tall, [AGE] years old, and does not walk. Review of the facility policy on Abuse, Neglect, Exploitation, . revised April, 2021, indicated, Residents have the right to be free from abuse, neglect, exploitation . This includes but is not limited to freedom from corporal punishment, . physical abuse . Policy Interpretation and Implementation: The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect and exploitation .by anyone including but not necessarily limited to a. facility staff .2. Develop ad implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents; b. neglect of residents . 3. Ensure adequate staffing and oversight/support to prevent burnout, stressful working situations and high turnover rates. 4. Conduct employee background checks and not knowingly employ or otherwise engage any individual who has: a. been found guilty of abuse, neglect, exploitation . by a court of law; b. had a finding entered into the state nurse aide registry concerting abuse, neglect, exploitation .or c. a disciplinary action in effect against his/her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation . 5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive and emotional problems . 8. Identity and investigate all possible incidents of abuse, neglect, . 9. Investigate and report any allegations within time frames required by federal requirements . Record review of Resident 1's foot care treatment showed resident received foot care for the first time since being admitted to the facility, in May, 2024, and her toenails were clipped for the first time after 2 1/2 years. Pictures of clipped toe nails are included in records. During an interview on 6/24/2024 at 1:05 PM, the Assistant Director of Nurses, ADON, stated Resident received podiatry care on 5/15/2024. She could not provide evidence of any previous podiatry care performed since admission. Review of facility policy on Foot Care, revised March, 2018, indicated, Residents will receive appropriate care and treatment in order to maintain mobility and foot health. Policy Interpretation and Implementation: 1. Residents will be provided with foot care and treatment in accordance with professional standards of practice. 2. Overall foot care will include the care and treatment of medical conditions associated with foot complications (e.g., diabetes .) . 4. Trained staff may provide routine foot care (e.g., toenail clipping) within professional standards of practice for residents without complicating disease processes. Resident with foot disorders or medical conditions associated with foot complications will be referred to qualified professionals.

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

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assist Resident 1, one of one sampled resident, to obtain dental ca...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assist Resident 1, one of one sampled resident, to obtain dental care for a facility caused tooth injury, due to fall, for nine months. Facility must refer resident promptly, within 3 days, for dental services. This failure resulted in lack of care and services for nine months to resident. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses including kidney disease, heart failure, diabetes, gait and mobility abnormalities, and glaucoma. Resident 1's Minimum Data Set, MDS, an assessment tool, indicated resident had no hearing difficulties, had cognitive impairment (thinking ability), required a two-person assist to move and reposition in bed, to transfer to chair/wheelchair and to dress. Resident 1 weighs 89 pounds, 5 feet tall, [AGE] years old, and does not walk. During a telephone interview with Resident 1's son on 7/11/2024 at 4:04 PM, son stated in October, 2023, the facility staff dropped his mother on the floor and broke her front tooth. A report of the incident was not made by the facility. The facility said resident did not have dental coverage. And the facility did not pay for the dental care. The Administrator then, who is gone now stated the facility would pay for residents dental care. The residents second visit to the dentist determined a root canal was required and performed after dental insurance was confirmed. The residents son made all the appointments During a telephone interview the Assistant Director of Nurses, ADON, on 6/27/2024 at 12:33 PM, stated there was no incident report made for the residents injury and Department of Public Health was not notified. Review of the facility's policy on Accidents and Incidents-Investigating and Reporting, revised July, 2017, All accidents or incidents involving residents, . occurring on these premises shall be investigated and reported to the administrator. 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 2. 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 .; e. The name of witnesses and their accounts of the accident .f. The injured persons account; . 5. The nurse supervisor/charge nurse and/or department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the director of nursing services within 24 hours of the incident/accident .7. Incident/Accident reports will be reviewed by the Safety Committee for trends related to accident or safety hazards in the facility and analyze any individual resident vulnerabilities.

May 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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the result of its investigation of the abuse allegation invo...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the result of its investigation of the abuse allegation involving two residents (Resident 1 and Resident 2) on 1/29/24 was reported within five working days of the occurrence of the alleged incident to the State Survey Agency. This failure violated the federal mandated reporting time frame. Findings: Resident 1's admission Record indicated she was admitted on [DATE] and was discharged on 1/30/24. Review of Resident 1's Skilled Charting, dated 1/29/24 at 4:36 PM, indicated Pt (patient, also referred to a resident [referring to Resident 1]) called the police [NAME] (because) pt said she was verbally abused by roommate (referring to Resident 2) . Resident 2's admission Record indicated she was admitted on [DATE] and discharged on 3/11/24. Review of Resident 2's Skilled Charting, dated 1/29/24 at 4:10 PM, indicated Pt (Resident 2) had an argument with roommate (referring to Resident 1). (Resident 1) called the police for being verbally abused by the pt (Resident 2) in the hallway . During an interview on 5/16/24 at 2:10 PM, the Assistant Director of Nursing (ADON) stated the new Administrator was looking for the investigative report and will provide it to the surveyor as soon as possible. During a follow up interview on 5/16/24 at 2:48 PM, the ADON was unable to provide evidence that facility submitted an investigative report within five working days of the alleged incident to the State Survey Agency which is the California Department of Public Health. Review of the facility policy titled, Abuse Investigation and Reporting, last revised on 7/17, indicated Policy Statement - All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported . Reporting - 1. 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. State licensing/certification agency responsible for surveying/licensing the facility . 5. The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with the written report of the findings of the investigation within five (5) working days of the occurrence of the incident .

Apr 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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to treat Resident 1, one of one sampled resident, with dignity and res...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to treat Resident 1, one of one sampled resident, with dignity and respect when resident waited on the nurse call light over one hour for pain medications on two successive evenings and failed to provide pain management relief, in a timely manner when resident waited over an hour for pain medication for his leg wound on two occasions during the evening shift. This failure caused the resident pain and suffering, violation of his rights and decreased feelings of well-being. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, urinary tract infection, urinary catheter, gait and mobility abnormalities, colostomy status (an opening in the intestine through the abdominal wall), and chronic pain syndrome. Review of Resident 1 ' s MDS (Minimum Data Set) an assessment tool, showed resident has clear speech, hearing, and adequate vision. Resident has a cognition score (thinking ability) of 15. The highest score achievable. Resident has lower extremity impairment of both feet and cannot walk. During an interview, in the facility, on 4/4/2024, at 2:15 PM, Resident 1 stated he waited over one hour on the nurse call light for a nurse to give him pain medications for right foot pain for two nights, 3/28/2024 and 3/29/2024, during the evening shift. He said he was in great pain. Review of the Resident Council Meeting notes for January 2024, with the Administrator in attendance, indicated, In general, the call light response time has improved but there are still times when no one answers your light for 25-30 minutes . Review of the Resident Council Meeting notes for March 2024, with Administrator, Director of Nurses, Ombudsman, and others, in attendance, indicated, The resident said that sometimes her call light is unplugged by a CNA (Certified Nurses Assistance). Regarding response to call lights: When a (call) light is on, sometimes someone who is not your CNA will respond. After hearing what the resident needs, the person will turn off the call light and say, ' I ' ll let your CNA know, ' but sometimes the CNA doesn ' t ever show up and the call light is off now. A resident said that several times when he pushes his call light, someone answers the call but if he has his eyes closed or is dozing, the person will just turn off the light without finding out what he needs and leaves. Review of Resident Council Meeting notes for April 2024, with Administrator, Director of Nurses (DON), Infection Control Nurse, new Maintenance Manager, and Dietician, present indicated, Regarding CNA checking on patients, they are supposed to check them every two hours and answer call lights. CNAs are not supposed to all go on their breaks at the same time. They have a schedule and there should always be other CNA ' s covering for them. Residents replied that the ones covering don ' t do the two-hour checks of patients who aren ' t their assignment and even if they answer a call light, they won ' t necessarily do whatever the resident needs unless it ' s very easy like getting some ice. If it ' s a bigger request then they ' ll either say, ' You ' re CNA is on break, ' or ' your CNA is with another patient ' , or ' I ' ll let them know and then they turn off your call light. ' The Resident Council president said that she usually tells them not to turn off her call light until someone actually comes to assist her. In response the DON reminded everyone that the CNA can get in trouble if the light is not answered so, if it ' s not urgent, be willing to give them 10 minutes to get back to you. Review of facility ' s policy on Call System, Resident, revised 9/2022, Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation .3. The resident call system remains functional at all times .The resident call system is routinely maintained and tested by the maintenance department .6. Calls for assistance are answered as soon as possible but no later than 5 minutes. Urgent requests for assistance are addressed immediately .7. Call light response times are reviewed as part of the QAPI program.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pain management relief, in a timely manner, for Resident 1,...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pain management relief, in a timely manner, for Resident 1, one of one sampled resident, when resident waited over an hour for pain medication for his leg wound on two occasions during the evening shift. This failure resulted in unnecessary pain and suffering and decreased feelings of well-being for the resident. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, urinary tract infection, urinary catheter, gait and mobility abnormalities, colostomy status (opening in the intestine through the abdominal wall), Right leg wound with graft, and chronic pain syndrome. Review of Resident 1 ' s MDS (Minimum Data Set) an assessment tool, showed resident has clear speech, good hearing, and adequate vision. Resident has a cognition score (thinking ability) of 15. The highest score achievable. Resident has lower extremity impairment of both feet and cannot walk. During an interview, in the facility, on 4/4/2024 at 2:15 pm, Resident 1 stated he waited more than one hour on his call light for pain medication, on 3/28/2024 and 3/29/2024, during the evening shift. He stated he had right leg wound pain and was very uncomfortable. Review of residents Care Plan for Pain, dated 12/26/2023 indicated: Administer medications as ordered, assess pain every shift and as needed . Review of Residents Pain Evaluation form dated 4/4/2024 indicated, F. Relief of Pain: 1. 2 out of 10, 3. Current pain medication regimen: Lidocaine patch to back, Oxycodone PO (by mouth), Dilaudid PO, Lyrica PO. 4. Pain is relieved by b. medication 6. Time elapsed until pain relief after above interventions implemented: 5-10 minutes. G. Conclusion: 1. Is current pain management regimen effective: a. Yes. 2. Care Plan: Focus: Resident at risk for pain secondary to diagnoses-Urinary Tract Infection-Diabetes Mellitus2 with neuropathy-DM2 with Peripheral Vascular Disease, Left Renal Stone, Right Hydronephrosis (excess fluid in kidney due to backup of urine). Focus: Resident at risk for pain secondary to Goal: Resident will have adequate relief of pain or ability to cope with incompletely relieved pain through review date. Intervention: Administer medications as ordered. Intervention: Assess pain every shift and as needed. Intervention: Assist with positioning for comfort. Intervention: Notify MD/RR with signs/symptoms of unmanaged pain .

Apr 2024 8 deficiencies

CONCERN (D)

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

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to ensure confidential medical...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and facility policy review, the facility failed to ensure confidential medical information was kept private for 1 (Resident #185) of 4 sampled residents reviewed for dignity. Specifically, the facility failed to remove visible wristbands that identified medical information about the resident after Resident #185 was readmitted from the hospital. Findings included: A review of a facility policy titled, Resident Rights, revised in February 2021, revealed, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: privacy and confidentiality. The policy further specified, The unauthorized release, access, or disclosure of resident information is prohibited. A review of an admission Record revealed the facility admitted Resident #185 on 06/19/2023 and most recently readmitted the resident on 04/01/2024 with diagnoses that included abnormalities of gait and mobility and abnormal posture. The admission Record also reflected the resident had an allergy to latex. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/19/2024, revealed Resident #185 had a Brief Interview for Mental Status (BIMS) score of 12, indicating the resident had moderately impaired cognition. According to the MDS, the resident had not sustained any falls since their prior MDS assessment. A review of Resident #185's comprehensive care plan for their admission on [DATE] revealed there was no Focus area addressing fall risk. On 04/08/2024 at 11:25 AM, Resident #185 was observed wearing a yellow wristband with black letters that identified the resident as a fall risk and a green wristband that identified the resident had a latex allergy. During an observation and interview on 04/10/2024 at 2:53 PM, Resident #185 was observed wearing wristbands that identified they were at risk for falls and had a latex allergy. Resident #185 said the wristbands were applied while they were in the hospital. During an interview on 04/10/2024 at 3:37 PM, Licensed Vocational Nurse (LVN) #5 said that residents were sometimes admitted to the facility with wristbands in place. LVN #5 stated they were unaware that Resident #185 still had wristbands on and said they should have been removed. During an interview on 04/10/2024 at 3:51 PM, Registered Nurse (RN) #4 stated that sometimes residents were admitted to the facility with wristbands in place, and facility staff had to take them off. RN #4 said the facility only utilized name bands, and fall risk bands came from the hospital. RN #4 said the facility used a blue paper on the wall to identify residents that were at risk for falls. During an interview on 04/12/2024 at 11:08 AM, the Administrator stated the facility made sure resident information was maintained in a confidential manner. The Administrator said she expected the nurse who performed the initial assessment on a resident to remove any wristbands from the resident, if any were present.

CONCERN (D)

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on record review, interviews, and facility document and policy review, the facility failed to report an allegation of physical abuse involving 1 (Resident #197) of 4 sampled residents reviewed f...

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Based on record review, interviews, and facility document and policy review, the facility failed to report an allegation of physical abuse involving 1 (Resident #197) of 4 sampled residents reviewed for abuse to the California Department of Public Health (CDPH) within two hours. Findings included: A review of a facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised in September 2022, revealed, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The policy indicated, 1. If resident abuse, neglect, exploitation, misappropriate of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The policy further indicated, 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury. A review of an admission Record revealed the facility admitted Resident #197 on 09/20/2023. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease and severe dementia with other behavioral disturbance. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/25/2024, revealed Resident #197 had a Brief Interview for Mental Status (BIMS) score of 1, which indicated the resident had severe cognitive impairment. A review of Resident #197's Care Plan, revealed a Focus area, initiated on 03/21/2024, that indicated the resident hit another resident on the chest. An intervention dated 03/21/2024 indicated the facility initiated a Report of Suspected Dependent Adult/Elder Abuse (form SOC 341). A review of a Report of Suspected Dependent Adult/Elder Abuse (form SOC 341), dated 03/21/2024, revealed that on 03/21/2024 at 8:30 AM, a resident alleged they were suddenly hit on the chest by Resident #197. The report indicated CDPH was notified of the allegation on 03/21/2024 via facsimile. A review of a Transmission Verification Report revealed the facility faxed a copy of the Report of Suspected Dependent Adult/Elder Abuse to CDPH on 03/21/2024 at 1:01 PM, approximately four and a half hours after the allegation was made. During an interview on 04/12/2024 at 11:48 AM, the Administrator stated that her expectation was to report allegations of abuse to CDPH immediately but within two hours. She confirmed the facility had not reported the allegation of physical abuse involving Resident #197 within the required two-hour timeframe. The Administrator stated the allegation should have been reported to CDPH no later than 10:30 AM. During an interview on 04/12/2024 at 1:53 PM, the Assistant Director of Nursing (ADON) stated the allegation of abuse involving Resident #197 should have been reported to CDPH on 03/21/2024 by 10:30 AM.

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the use of an antipsychotic medication and physical behaviors directed towards others for 1 (Resident #197) of 2 sampled residents reviewed for behaviors and accurately reflected the discharge location for 1 (Resident #237) of 3 sampled residents reviewed for discharges. Findings included: A review of a facility policy titled, Certifying Accuracy of the Resident Assessment, revised in November 2019, revealed, Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. The policy further indicated, 3. The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. Different items on the MDS may have different observation periods. 1. A review of an admission Record revealed the facility admitted Resident #197 on 09/20/2023. According to the admission Record, the resident had a medical history that included diagnoses of Alzheimer's disease and severe dementia with other behavioral disturbance. A review of Resident #197's Order Summary Report, listing active orders as of 04/11/2024, revealed an order dated 09/20/2023 to monitor every shift for episodes of psychotic behavior and an order dated 11/18/2023 to monitor every shift for behaviors of biting, hitting, and entering other residents' rooms. The Order Summary Report also reflected an order dated 01/26/2024 for quetiapine fumarate (an antipsychotic medication) oral tablet 200 milligrams (mg), give one tablet by mouth in the evening for behavior manifestation of dementia illness manifested by physical aggression. A review of Resident #197's March 2024 Medication Administration Record (MAR) revealed documentation that indicated the resident received quetiapine fumarate daily as ordered. The MAR also reflected documentation that indicated the resident experienced one episode of psychotic behavior and exhibited a behavior of biting on 03/19/2024, exhibited a behavior of hitting on 03/23/2024, and exhibited behaviors of biting and hitting on 03/24/2024. A review of an IDT [interdisciplinary team] Note, dated 03/28/2024, revealed that on the morning of 03/21/2024, Resident #197 hit another resident on the chest. A review of a quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/25/2024, revealed Resident #197 had a Brief Interview for Mental Status (BIMS) score of 1, which indicated the resident had severe cognitive impairment. The MDS did not reflect the physical behaviors directed towards others displayed by the resident or the use of an antipsychotic medication during the seven-day look-back period. During an interview on 04/11/2024 at 3:11 PM, MDS Nurse #9 stated she was not aware Resident #197 had behaviors during the seven-day look-back period of their MDS. She stated she had been an MDS nurse for five months and was not used to the facility's electronic health record (EHR) system, so she did not know the various places she could look to identify if a resident exhibited behaviors. MDS Nurse #9 also stated she looked at the physician's orders to complete the medication section of the MDS, but she must have missed that Resident #197 was receiving an antipsychotic medication. During an interview on 04/12/2024 at 11:52 AM, the Administrator stated she expected the MDS team to use their best nursing judgement and to complete MDS assessments accurately. The Administrator confirmed that Resident #197's quarterly MDS should have been coded to reflect behaviors and antipsychotic medication use. 2. A review of an admission Record revealed the facility admitted Resident #237 on 01/10/2024 with diagnoses that included encounter for surgical aftercare following surgery on the digestive system, malignant neoplasm of colon, type two diabetes mellitus, hypokalemia (low potassium levels in the blood), colostomy status, hypertension, abnormal posture, abnormalities of gait and mobility, cognitive communication deficit, and oropharyngeal phase dysphagia. According to the admission Record, the facility discharged Resident #237 from the facility on 01/29/2024. A review of Resident #237's discharge Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/29/2024, revealed the resident's discharge date was 01/29/2024. According to the MDS, the facility discharged the resident to a Short-Term General Hospital, and their return to the facility was not anticipated. However, a review of Resident #237's Progress Notes revealed a Nursing Note, dated 01/29/2024, that indicated the resident was discharged from the facility at 12:30 PM, with all medications and personal belongings provided. According to the note, a family member picked the resident up. During an interview on 04/11/2024 at 3:16 PM, Minimum Data Set (MDS) Nurse #3 stated Resident #237 was discharged home. After reviewing the resident's discharge MDS dated [DATE], MDS Nurse #3 said the MDS was inaccurately coded to reflect the resident went to the hospital instead of home. MDS #3 said the inaccurate coding was an oversight. During an interview on 04/12/2024 at 1:54 PM, the Assistant Director of Nursing (ADON) stated she expected MDS assessments to be accurate. The ADON said Resident #237's discharge MDS should have been coded to reflect that the resident was discharged home. During an interview on 04/12/2024 at 11:52 AM, the Administrator stated said she expected the MDS team to use their best nursing judgement and to complete MDS assessments accurately.

CONCERN (D)

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

Based on interview, record review, and facility document and policy review, the facility failed to complete a new Level I Preadmission Screening and Resident Review (PASARR) after residents were diagn...

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Based on interview, record review, and facility document and policy review, the facility failed to complete a new Level I Preadmission Screening and Resident Review (PASARR) after residents were diagnosed with a new mental illness for 2 (Resident #41 and Resident #164) of 4 sampled residents reviewed for PASARR requirements. Findings included: A review of a facility policy titled, admission Criteria, revised in March 2019, revealed, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. A review of a facility policy titled, Change in a Resident's Condition or Status, revised in February 2021, revealed, 7. In addition to notifying the resident and/or representative, the state mental health agency or state intellectual disability agency will be notified within 24 hours of a significant change in the mental or physical condition of a resident with a mental disorder or intellectual disability. A review of Resident #41's admission Record revealed the facility admitted the resident on 09/23/2022 with a primary diagnosis of unspecified psychosis not due to a substance or known physiological condition. Per the admission Record, Resident #41 received a new diagnosis of schizoaffective disorder on 09/29/2022. A review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/30/2022, revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 5, indicating the resident had severe cognitive impairment. Per the MDS, the resident had active diagnoses that included psychotic disorder and schizophrenia and received an antipsychotic medication on four of seven days of the assessment look-back period. The MDS also indicted the resident had a serious mental illness A review of Resident #41's Care Plan revealed a Focus area, initiated on 09/23/2022, that indicated the resident was at risk for behavioral impairment and was receiving medication for schizoaffective disorder. A review of Resident #41's Level I PASARR Screening, dated 09/23/2022, revealed the screening reflected that the resident had a neurocognitive disorder with behavioral disturbance and microvascular cerebral ischemia psychosis and was prescribed psychotropic medications for mental illness. The Level I Screening did not reflect a diagnosis of schizoaffective disorder but was positive for Suspected MI [mental illness], and a Level II evaluation was required. A review of a letter from the State of California, Health and Human Services Agency, Department of Health Care Services to the facility, dated 09/27/2022, revealed a Level II Mental Health Evaluation was not scheduled due to Resident #41 not having a serious mental illness. The letter indicated, The case is now closed. To reopen, please submit a new Level I Screening. A review of Resident #164's admission Record revealed the facility admitted the resident on 12/30/2022. According to the admission Record, the resident was diagnosed with paranoid schizophrenia on 01/25/2024. A review of an annual MDS, with an ARD of 01/02/2024, revealed Resident #164 had a BIMS score of 13, indicating the resident was cognitively intact. According to the MDS, the resident had active diagnoses that included schizophrenia. A review of Resident #164's Care Plan revealed a Focus area, initiated on 03/11/2024, that indicated the resident was at risk for behavioral impairment and received psychotropic medication for a diagnosis of schizophrenia manifested by responding to hallucinations. On 04/09/2024 at 8:40 AM, a review of Resident #164's medical record revealed one Level I PASARR Screening that was completed in January 2023. There were no additional PASARRs contained within the resident's record, after the resident received a new diagnosis of schizophrenia. A review of Resident #164's Level I PASARR Screening, dated 01/01/2023, revealed the screening was Negative, the resident had No Serious Mental Illness, and a Level II evaluation was not required. During an interview on 04/12/2024 at 10:04 AM, the Assistant Director of Nursing (ADON) said PASARRs were completed at the hospital prior to admission and then reviewed to ensure they were accurate. The ADON said if a resident experienced a change in condition, staff should review to ensure their PASARR matched their current condition. The ADON said if a physician diagnosed a resident with a new diagnosis, their Level I PASARR Screening should be reviewed, and if needed, a MDS nurse completed a new PASARR. During an interview on 04/12/2024 at 12:39 PM, the Director of Nursing (DON) said PASARRs were completed prior to admission, and after admission, if a resident had a change in condition or new diagnosis, a MDS nurse completed another PASARR. During an interview on 04/12/2024 at 1:01 PM, the Administrator said she deferred to the nursing department on whether a new Level I Screening should be submitted when a resident was diagnosed with a new mental illness. The Administrator further stated she expected PASARRs to be accurate and for any inaccuracies to be corrected as soon as possible.

CONCERN (D)

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

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

Based on interviews, record review, facility policy review, and review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level I Assessment Guide,...

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Based on interviews, record review, facility policy review, and review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level I Assessment Guide, the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASARR) was accurately completed for 1 (Resident #139) of 4 sampled residents reviewed for PASARR requirements. Specifically, the facility failed to ensure Resident #139's Level I PASARR Screening reflected the presence of a serious diagnosed mental disorder. Findings included: A review of a facility policy titled, admission Criteria, revised in March 2019, revealed, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. A review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level I Assessment Guide, dated 01/12/2023, revealed, Section III-Serious Mental Illness Questions 10-12 This section helps determine if the individual may have a serious mental illness and benefit from specialized services. Question 10. Diagnosed Mental Illness *Does the individual have a serious diagnosed mental disorder such as Depressive Disorder, Anxiety Disorder, Panic Disorder, Schizophrenia/Schizoaffective Disorder, or symptoms of Psychosis, Delusions, and/or Mood Disturbance? *If yes, there will be a text box question [to] provide the type of mental illness. A review of Resident #139's admission Record revealed the facility admitted the resident on 09/19/2023 with diagnoses that included severe major depressive disorder with psychotic symptoms and schizoid personality disorder. A review of an admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/25/2023, revealed Resident #139 had a Brief Interview for Mental Status (BIMS) score of 10, indicating the resident had moderately impaired cognition. Per the MDS, at the time of the assessment, Resident #139 had active diagnoses that included depression and schizoid personality disorder. A review of Resident #139's Level I PASARR Screening, dated 11/02/2023, revealed Section III- Serious Mental Illness Screen, question #10 was answered No, and did not reflect the resident's diagnoses of major depressive disorder or schizoid personality disorder. This resulted in a Negative Level I Screening, and a Level II evaluation was not required. During an interview on 04/12/2024 at 10:03 AM, the Assistant Director of Nursing (ADON) said that when a resident was admitted from the hospital a Level I PASARR was completed before admission and then reviewed for accuracy. She said if a resident was admitted without having a Level I PASARR completed, a MDS nurse was responsible for completing one. The ADON said Resident #139's PASARR dated 11/02/2023 was inaccurate, and Question #10 should have been answered with a yes, which would have triggered the need for a Level II evaluation. The ADON said the Admissions Director or MDS nurses were responsible for PASARRS, and she expected them to make sure they were accurate. During an interview on 04/12/2024 at 12:26 PM, the Admissions Director said when a resident was admitted from the hospital, she asked the hospital to send a copy of their Level I PASARR Screening. She said she reviewed the PASARR, and if it was negative, she accepted the resident as a resident of the facility, and if it was positive, she notified the Director of Nursing (DON). During an interview on 04/12/2024 at 1:00 PM, the Administrator said she expected PASARRs to be accurate.

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

Based on record review, interviews, and facility policy review, the facility failed to ensure staff administered medication as ordered by the physician for 1 (Resident #180) of 1 sampled resident revi...

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Based on record review, interviews, and facility policy review, the facility failed to ensure staff administered medication as ordered by the physician for 1 (Resident #180) of 1 sampled resident reviewed for medication concerns. Findings included: A review of a facility policy titled, Administering Medications, revised in April 2019, revealed, Medications are administered in a safe and timely manner, and as prescribed. The policy specified, 4. Medication are administered in accordance with prescriber orders, including any required time frame. A review of Resident #180's admission Record revealed the facility admitted the resident on 05/18/2023 with diagnoses that included unspecified atrial fibrillation (an irregular, often rapid heart rate). A review of Resident #180's Care Plan revealed a Focus area, initiated on 05/18/2023, that indicated the resident had impaired cardiac and/or circulatory function with risk for complications related to a history of cerebrovascular accident (CVA, stroke), hypertension (high blood pressure), and atrial fibrillation. An intervention dated 05/19/2023 directed staff to administer medications as ordered by the physician. A review of Resident #180's Order Summary Report, listing active orders as of 04/11/2024, revealed an order dated 05/18/2023 for Pradaxa oral capsule 150 milligrams (mg), one capsule by mouth two times a day for atrial fibrillation. During an interview on 04/08/2024 at 1:54 PM, Registered Nurse (RN) #17 said Resident #180 had not received their Pradaxa since 04/05/2024. During an interview on 04/12/2024 at 1:00 PM, the Administrator said she expected staff to administer residents' medications within the timeframe ordered by the physician.

CONCERN (F)

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

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

Based on interviews and facility policy review, the facility failed to implement their Legionella (a pathogenic gram-negative bacteria) water management program. This had the potential to affect all 2...

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Based on interviews and facility policy review, the facility failed to implement their Legionella (a pathogenic gram-negative bacteria) water management program. This had the potential to affect all 229 residents residing in the facility. Findings included: A review of a facility policy titled, Legionella Water Management Program, revised in September 2022, revealed, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. Policy Interpretation and Implementation 1. As part of the infection prevention and control program, our facility has a water management program, which is overseen by the water management team. 2. The water management team consists of at least the following personnel: a. The infection preventionist; b. The administrator; c. The Medical Director (or designee); d. The director of maintenance; and e. The director of environmental services. 3. The purposes of the water management program are to identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaires' disease [a type of pneumonia caused by Legionella bacteria]. The policy specified, 5. The water management program includes the following elements: a. An interdisciplinary water management team (see above); b. A detailed description and diagram of the water system in the facility, including the following: (1) Receiving); (2) Cold water distribution; (3) Heating; (4) Hot water distribution; and (5) Waste. c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including the following: (1) Storage tanks; (2) Water heaters; (3) Filters; (4) Aerators; (5) Showerheads and hoses; (6) Misters, atomizers, air washers and humidifiers; (7) Fountains; and (8) Medical devices such as CPAP [continuous positive airway pressure] machines, hydrotherapy equipment, etc. [et cetera, other similar things]. The policy further indicated the water management program also included the following elements: e. Specific measures used to control the introduction and/or spread of Legionella (e.g. [exempli gratia, such as] temperature, disinfectants); f. The control limits or parameters that are acceptable and to be monitored; g. A diagram of where control measures are applied; h. A system to monitor control limits and the effectiveness of control measures; i. A plan for when control limits are not met and/or control measures are not effective; and j. Documentation of the program. During an interview on 04/11/2024 at 1:12 PM, Maintenance Assistant (MA) #1 stated he facility did not have a process for monitoring the facility for Legionella. During an interview on 04/11/2024 at 1:18 PM, MA #2 stated that he did not know anything about monitoring for Legionella. MA #2 said they had a floor plan, but he did not think that it included a diagram of the facility's water lines. MA #2 stated the facility was currently utilizing a Regional Maintenance staff member until a new Maintenance Director started work at the facility the following week. During an interview on 04/11/2024 at 1:22 PM, Regional Maintenance staff said he had been filling the Maintenance Director position since December 2023; however, he was not sure if the facility had a program or plan addressing Legionella. During a follow-up interview on 04/11/2024 at 1:39 PM, Regional Maintenance staff confirmed the facility had no documentation related to monitoring for Legionella. During an interview on 04/11/2024 at 2:53 PM, the [NAME] President of Clinical Operations (VPCO) said she was unable to locate any documentation related to water management or Legionella. During an interview on 04/12/2024 at 10:03 AM, the Assistant Director of Nursing (ADON) stated she expected maintenance staff to monitor for free-standing water and for the presence of Legionella. During an interview on 04/12/2024 at 1:00 PM, the Administrator said that she expected staff to monitor for Legionella and to maintain records of the monitoring.

MINOR (C)

Minor Issue - procedural, no safety impact

Staffing Information (Tag F0732)

Minor procedural issue · This affected most or all residents

Based on observations, record review, interviews, and facility policy review, the facility failed to ensure they posted the total number of and the actual hours worked for licensed and unlicensed nurs...

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Based on observations, record review, interviews, and facility policy review, the facility failed to ensure they posted the total number of and the actual hours worked for licensed and unlicensed nursing staff directly responsible for resident care per shift, which included registered nurses (RN), licensed practical nurses (LPN) or licensed vocational nurses (LVN), and certified nurse aides (CNA) and failed to post this information at the beginning of each shift in a prominent place readily accessible to residents and visitors. This had the potential to affect all 229 residents residing in the facility. Findings included: A review of a facility policy titled Posting Direct Care Daily Staffing Numbers, revised July 2016, revealed, Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for direct care of residents. The policy revealed, Policy Interpretation and Implementation 1. Within two (2) hours of the beginning of each shift, the number of licensed nurses (RNs, LPNs and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. 2. Directly responsible for resident care means that individuals are responsible for residents' care or some aspect of the residents' care including, but not limited to, assisting with activities of daily living (ADLs), performing gastrointestinal feeds, giving medications, supervising care given by CNAs, and performing nursing assessments to admit residents or notifying physicians of changes of condition. 3. Shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift. The information recorded on the form shall include the following: a. The name of the facility. b. The date for which the information is posted. c. The resident census at the beginning of the shift for which the information is posted. d. Twenty-four (24)-hour shift schedule operated by the facility. e. The shift for which the information is posted. f. Type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift. g. The actual time worked during that shift for each category and type of nursing staff. H. Total number of licensed and non-licensed nursing staff working for the posted shift. Further review revealed, 5. Within two (2) hours of the beginning of each shift, the shift supervisor shall compute the number of direct care staff and complete the Nursing Staff Directly Responsible for Resident Care form. The shift supervisor shall date the form, record the census and post the staffing information in the location(s) designated by the administrator. A review of a facility document titled Census and Direct Care Service Hours Per Patient Day (DHPPD) dated 04/08/2024 revealed the estimated scheduled total direct care service hours equaled 741.50 for all staff and scheduled total CNA direct care service hours equaled 517.50, with a census of 229 and did not include the total number of staff working per shift and the number of hours of each discipline per shift. Staff indicated the patient date start time as 12AM. A review of a facility document titled Census and Direct Care Service Hours Per Patient Day (DHPPD) dated 04/09/2024 revealed the estimated scheduled total direct care service hours equaled 833.50 for all staff and scheduled total CNA direct care service hours equaled 577.50, with a census of 229 and did not include the total number of staff working per shift and the number of hours of each discipline per shift. Staff indicated the patient date start time as 12AM. A review of a facility document titled Census and Direct Care Service Hours Per Patient Day (DHPPD) dated 04/10/2024 revealed the estimated scheduled total direct care service hours equaled 846.00 for all staff and scheduled total CNA direct care service hours equaled 606.00, with a census of 228 and did not include the total number of staff working per shift and the number of hours of each discipline per shift. Staff indicated the patient date start time as 12AM. A review of a facility document titled Census and Direct Care Service Hours Per Patient Day (DHPPD) dated 04/11/2024 revealed the estimated scheduled total direct care service hours equaled 846.00 for all staff and scheduled total CNA direct care service hours equaled 606.00, with a census of 228 and did not include the total number of staff working per shift and the number of hours of each discipline per shift. Staff indicated the patient date start time as 12 AM. A review of a facility document titled [Facility Name] Daily Staffing Sheet, dated 04/12/2024, revealed the form listed all the staff scheduled for this day and their assignments. The form listed the facility's staff schedules of 7:00 AM to 3:00 PM, 3:00 PM to 11:00 PM, and 11:00 PM to 7:00 AM. This form was maintained at each nurses' station in a binder not accessible to residents or visitors. This form did not include the number of staff broken out by discipline by shift or the facility's census. An observation on 04/09/2024 at 4:36 PM revealed the facility's staffing posting hung on the wall outside the conference room, not in a conspicuous area. The conference room was located across the large lobby and down a short hall towards the dining/activity room on the first floor of the facility. The posting was not visible when walking into the facility and going directly upstairs by accessing the elevator directly across the large lobby. When walking into the building and turning immediately to the right to head down 1 East Hall, the posting was not visible as it was located across the large lobby from the hallway. The posting was not visible when walking to access the 2nd floor via the stairwell. When entering the building and immediately turning to the left, the posting was not readily visible as it was located past the third door along the short hallway. An observation of the facility's staffing posting showed a census of 229 and did not include the breakdown of staff working in the facility by discipline or the total number of staff. An observation on 04/10/2024 at 8:55 AM revealed the staff posting had not yet been changed to reflect the 04/10/2024 date. During an interview on 04/11/2024 at 2:05 PM, the Assistant Administrator stated she thought the only staffing posting they had was the one right outside the door of the conference room. She stated someone told her they thought it was posted downstairs (the basement), but she did not know as she had not looked. An observation of the entire basement area on 04/11/2024 at 4:11 PM revealed no staff posting and no staff schedules posted. During an interview on 04/12/2024 at 9:30 AM, the Staffing Coordinator stated she only did the scheduling for nursing staff, including the CNAs and nurses, and then the nursing supervisors made the assignments. She stated she was responsible for posting the DHPPD form. She stated she posted the projected hours of the day and only posted the total number of hours for the nurses combined and the total number of hours for the CNAs for the day. She stated she would have to go through the schedule sheets to know how many RNs/LVNs they had individually. The Staffing Coordinator stated no one had ever told her she needed to post the total number of each discipline working; all she had ever been told was to post the form that was compliant with the State. She stated she updated the form on an hourly basis and gave the updated form to the Administrator for any changes to the census or because of staff callouts. The Staffing Coordinator stated all she had been instructed to do was post the projected hours; it was her responsibility, and she reported the hours to the Administrator. During an interview on 04/12/2024 at 12:25 PM, the Assistant Director of Nursing (ADON) stated her role was to go around to make sure staff were there, to make sure they had their projected PPD (Per Patient Day); if they did not, she would go back to the scheduler to see how they could shuffle staff around until they could call agency staff to get someone in to cover. The ADON stated they had their projected hours and had it broken down at each nurses' station. The ADON stated as far as she knew, it was the DHPPD that was posted for staff and visitors, and then the breakdown by discipline was located at each nurses' station. She stated she knew it was kept in a binder at each station but was not sure if it was posted so visitors and residents could see the breakdown. During an interview on 04/12/2024 at 1:47 PM, the Administrator stated she expected the daily staffing to include the census. The staff that were in the facility and the hours should be broken down by shift and with any changes in the census.

Jan 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised ba...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised based on the needs of the resident and in response to current interventions for one of five sampled residents (Resident 1). This deficient practice does not ensure plan of care was evaluated for effectiveness to prevent reoccurrence of physical aggression that could result to harm or serious injury to other residents and staff. Findings: Resident 1 was admitted on [DATE] with diagnoses including Alzheimer's disease (the most common type of dementia, a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment, involves parts of the brain that control thought, memory, and language). Review of Resident 1's Minimum Data Set (MDS - an assessment tool) dated 11/26/23 indicated, Resident 1 was cognitively impaired. Review of Resident 1's clnical record, admission H&P (History and Physical) dated 9/21/23 indicated, Resident 1 had advanced dementia with history of behavioral disturbances. Review of Resident 1's clinical record, Progress Notes dated 10/7/23, the nursing note indicated, .resident suddenly slap in the face and pinch the right arm of the roommate . Review of Resident 1's clinical record, Progress Notes dated 10/10/23, the nursing note indicated, .Resident continues to wander around going into other resident rooms and any attempt to redirect her by CNA (Certified Nursing Assistant) always resulting to kicking and biting the CNAs . Review of Resident 1's clinical record, Progress Notes dated 11/20/23, the IDT (Interdisciplinary Team) note indicated, Licensed Vocational Nurse (LVN) witnessed Resident 1 grabbing the foot and getting ready to punch another resident. Review of Resident 1's clinical record, Progress Notes dated 11/20/23, the Social Services Visit note indicated, as per charting of nurse on 11/19/23, resident had another physical aggression when Resident 1 was noted going inside another resident's room and hit resident's wife who was visiting at that time. Review of Resident 1's clinical record, Progress Notes dated 11/22/23, the Social Services Visit note indicated, that on 11/21/23, Resident lost her balance as she was trying to kick the staff on duty. Resident continues to have behavior episodes and often noted hitting staff who monitor her every shift. Review of Resident 1's clinical record, Long Term Care Psychiatry dated 11/28/23 indicated, .Multiple episodes last week of aggression towards staff and other residents .Kicks, bites, wanders into other residents' rooms, physically aggressive to other residents . Review of Resident 1's clinical record, undated Order Audit Report indicated, .Order date: 10/7/23 .Order Status: Active .Order Summary: May send to ER for further evaluation (unexplained physical aggression) . Review of Resident 1's care plan initiated on 11/20/23 indicated, Focus - Risk for Harm: Sefl Directed or Other-Directed Goal: Resident will not harm self or others .Resident will be free of physically aggressive behaviors . Interventions were: 1. Administer medications as prescribed 2. If resident poses a potential threat to injure self or others notify provider 3. If wandering or pacing, initiate visual supervision during acute episode 4. Maintain consistent schedule with daily routine 5. Monitor for cognitive, emotional or environmental factors that may contribute to violent behaviors 6. Provide clear, simple instructions 7. Utilize calming touch 8. Utilize diversion techniques as needed. The care plan did not reflect the physician's order May send to ER for further evaluation (unexplained physical aggression). During an interview on 1/22/24 at 10:12 AM, the CNA said that Resident 1 can walk fast and has to monitor resident's whereabouts constantly because she goes in other residents' rooms. CNA stated, Don't try to go against what she wants otherwise she'll get mad and will hit you. During an interview on 1/22/24 at 10:28 AM, the Registered Nurse (RN) said that Resident 1 is confused and has the tendency to walk around and go inside other residents' rooms. RN further said that there were incidents where Resident 1 was physically aggressive with other residents. RN stated, When she becomes combative, aggressive and a threat to others, we have to call the doctor and send to the hospital. During an interview on 1/22/24 at 12:39 PM, the Director of Nursing (DON) stated, We do an assessment. The MD (physician) order should reflect in the care plan. During an interview on 1/22/24 at 1:10 PM, the Social Services Director (SSD) stated, Care plan should have been revised to reflect the MD order. SSD verified that the order had a start date of 10/7/23. Review of facility policy titled, Care Plan, Comprehensive Person-Centered revised December 2016 indicated, .Policy Interpretation and Implementation .13. Assessments of residents are ongoing and care plans are revised as information about the residents and residents' condition change .

Jan 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews, the facility failed to provide goods and services such as the call lights to...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record reviews, the facility failed to provide goods and services such as the call lights to three residents to meet their needs by its staff when: 1) Resident 1, Resident 2 and Resident 3 were found to have their call lights not within reach and was found disconnected from the wall socket. 2) The facility did not ensure an orientation and training was implemented on general guidelines in answering the call light. These failures will result to an environment that promotes neglect. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) require but the facility fails to provide them to the resident(s) resulting in, or may result in, physical harm, pain, mental anguish, or emotional distress. FINDINGS: During a review of Resident 1's admission record dated 12/13/23, indicated the resident was admitted to the facility with diagnoses of: Hypertensive heart disease (a constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation), chronic kidney disease (CKD means your kidneys are damaged and can't filter blood the way they should), and type 2 diabetes (A chronic condition that affects the way the body processes blood sugar (glucose)), among others. During a review of Resident 1 minimum data set (MDS - an assessment tool for nursing home residents) her brief interview for mental status (BIMS - an evaluation tool to assess cognition) dated June 27, 2023, indicated her score was 10 indicating her cognition is moderately impaired. During a concurrent observation and interview with resident 1 on 12/13/23 at 1:58 PM, observed the resident looking sad and weepy. She was awake, alert, and responsive in bed watching TV. When asked how she calls for help she had a blank stare. When asked where her call light was, she continuous to have a blank stare. One surveyor looked for her call light. No call light was within her reach. The call light was found coiled on the floor below the head of her bed. The call light was observed to have been disconnected from the wall socket. During a concurrent interview and observation with Resident 1 on 12/13/23 at 2PM at her bedside, she stated her right elbow hurt when a restorative nurse assistant (RNA) hit her on her right arm. When asked if she can move her right arm and hand, observed she was able to move her right arm and hand. During an interview with a certified nurse assistant (CNA) CNA1 on 12/13/23 at 2:07 PM in the hall at the entrance to Resident 1's room, CNA1 stated, we don't give her the call light because she doesn't know how to use it. If you give her the call light she won't stop pressing it. Since I started working here in March, she (Resident 1) did not have the call light. They took it away. The three of them in this room are not capable of using the call light. No, I did not tell the nurse about the call light. During a concurrent observation and interview on 12/13/23 at 2:10 PM in Resident 1's room, observed all three of the residents in that room does not have a call light on their bed. Their call lights were detached from the wall socket. CNA1 stated Resident in bed B has dementia, so she does not know how to use the call light. Resident in bed C is alert. When asked how she knows when the residents needed help, CNA1 stated, they call for help. Resident 1 calls for help, help I always made my rounds to check on them. During a review of Resident 2 admission record, her diagnoses included: traumatic subdural hemorrhage without loss of consciousness (Impact a blow to the head [traumatic brain injury (TBI)], [Patients with TBI may have compromised cerebral blood flow (CBF) and are at risk for further ischemic insults due to hypoxia (low oxygen flow) and hypotension (low blood pressure)], hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (also known as ischemic stroke - occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), among others. During a review of Resident 2 MDS dated [DATE] her BIMS score was 2 indicating severe cognitive decline. During a review of Resident 3 admission record, her diagnoses included: sepsis (is a serious condition in which the body responds improperly to an infection) unspecified organism, urinary tract infection (UTI - is an infection in any part of the urinary system) unspecified, unspecified atrial fibrillation (the heart's upper chambers - called the atria - beat chaotically and irregularly) among others. During a review of Resident 3's MDS dated [DATE] her BIMS score was 3 indicating severe cognitive decline. During an interview with the charge nurse (CN) a registered nurse (RN) RN1 on 12/13/23 at 2:13 PM inside the residents' room where she was shown the coiled cord with the call light from the floor, the CN stated, I don't know that they disconnected her call light. Informed the CN that all three residents in that room had no access to call lights. The CN stated, I know the maintenance make their rounds every day to check the call lights. It was not care planned because I was not made aware that the residents have no call lights. During an interview with the Assistant Director of Nursing (ADON) ADON1 on 12/13/23 at 2:26 PM in the hallway, ADON1 stated, I don't know about that. I'm new here. During a concurrent observation and interview with the Director of Maintenance (DM) on 12/13/23 at 2:31 PM in the hall near the door of the residents' room, the DM was observed using his walkie talkie to speak with the maintenance assistant. The DM went inside the room and connected the call light to the wall socket and stated. It is working now Observed the light above the residents' door was on. During an interview with the director of staff development (DSD) a licensed vocational nurse (LVN), on 12/14/3 at 1:40 PM in the dining room, he stated I was made aware of this incident this morning. I give them in-services but not specifically on call light. The topics I teach are abuse and neglect; offering bedpan, not necessarily call lights. Yes, I have policy and procedure on call light. From now on I will start giving in-service on call light. During an interview with the Ombudsman on 12/14/23 at around 2:30 PM in the meeting room, the Ombudsman stated, I know about that incident (call light incident). The social worker (SW) told me earlier. During a review of the facility's policy and procedure (P&P) titled Abuse Prevention Program with revised date December 2016 with the policy statement: Our residents have the right to be free from abuse, neglect, This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse . Review of the facility's P&P titled, Abuse Prevention and Reporting with revised date July 2017, the policy statement indicated: All reports of resident abuse, neglect, . , mistreatment, .shall be promptly reported to the local state, and federal agencies, and thoroughly investigated by Facility management. Findings of abuse investigations will also be reported. During a review of the facility's P&P titled Resident Rights with revised date December 2016, the policy statement indicated: Employees shall treat all residents with kindness, respect, and dignity. During a review of the facility's P&P titled Answering the Call Light with revised date 2021, the purpose indicated: The purpose of this procedure is to ensure timely responses to the resident's requests and needs. General Guidelines: 1. Upon admission and periodically as needed, explain, and demonstrate use of the call light to the resident. 2. Ask the resident to return the demonstration. 3. Explain to the resident that a call system is also located in his/her bathroom. 4. Be sure that the call light is plugged in and functioning at all times. 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 6. Some residents may not be able to use their call light. Be sure you check these residents frequently. 7. Report all defective call lights to the nurse supervisor promptly. The P&P on answering call light included: steps in the procedure and documentation.

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop a comprehensive care plan for the two residents that include...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop a comprehensive care plan for the two residents that included measurable objectives and specific interventions when: Resident 1. The call light in Resident 1's room (all three beds) was found disconnected from the wall socket and was not within the residents' reach. Resident 2. Had a resident to resident altercation. Resident B was the abuser. No care plan was developed for this resident-to-resident abuse. This failure has the potential for not meeting the residents' goals of care to meet their highest practicable well-being. FINDINGS: 1. During a review of Resident 1's admission record dated 12/13/23, indicated the resident was admitted to the facility with diagnoses of: Hypertensive heart disease (a constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation), chronic kidney disease (CKD means your kidneys are damaged and can't filter blood the way they should), and type 2 diabetes (A chronic condition that affects the way the body processes blood sugar (glucose)), among others. During a review of Resident 1 minimum data set (MDS - an assessment tool for nursing home residents) her brief interview for mental status (BIMS - an evaluation tool to assess cognition) dated June 27, 2023, indicated her score was 10 indicating her cognition is moderately impaired. During a review of Resident 1 minimum data set (MDS - an assessment tool for nursing home residents) her brief interview for mental status (BIMS - an evaluation tool to assess cognition) dated June 27, 2023, indicated her score was 10 indicating her cognition is moderately impaired. During a concurrent observation and interview with resident 1 on 12/13/23 at 1:58 PM, observed the resident looking sad and weepy. She was awake, alert, and responsive in bed watching TV. When asked how she calls for help she had a blank stare. When asked where her call light was, she continuous to have a blank stare. One surveyor looked for her call light. No call light was within her reach. The call light was found coiled on the floor below the head of her bed. The call light was observed to have been disconnected from the wall socket. During a concurrent interview and observation with Resident 1 on 12/13/23 at 2PM at her bedside, she stated her right elbow hurt when a restorative nurse assistant (RNA) hit her on her right arm. When asked if she can move her right arm and hand, observed she was able to move her right arm and hand. During an interview with a certified nurse assistant (CNA) CNA1 on 12/13/23 at 2:07 PM in the hall at the entrance to Resident 1's room, CNA1 stated, we don't give her the call light because she doesn't know how to use it. If you give her the call light she won't stop pressing it. Since I started working here in March, she (Resident 1) did not have the call light. They took it away. The three of them in this room are not capable of using the call light. No, I did not tell the nurse about the call light. During a concurrent observation and interview on 12/13/23 at 2:10 PM in Resident 1's room, observed all three of the residents in that room does not have a call light on their bed. Their call lights were detached from the wall socket. CNA1 stated Resident in bed B has dementia, so she does not know how to use the call light. Resident in bed C is alert. When asked how she knows when the residents needed help, CNA1 stated, they call for help. Resident 1 calls for help, help I always made my rounds to check on them. During a review of Resident 2 admission record, her diagnoses included: traumatic subdural hemorrhage without loss of consciousness (Impact a blow to the head [traumatic brain injury (TBI)], [Patients with TBI may have compromised cerebral blood flow (CBF) and are at risk for further ischemic insults due to hypoxia (low oxygen flow) and hypotension (low blood pressure)], hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (also known as ischemic stroke - occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), among others. During a review of Resident 2 MDS dated [DATE] her BIMS score was 2 indicating severe cognitive decline. During a review of Resident 3 admission record, her diagnoses included: sepsis (is a serious condition in which the body responds improperly to an infection) unspecified organism, urinary tract infection (UTI - is an infection in any part of the urinary system) unspecified, unspecified atrial fibrillation (the heart's upper chambers - called the atria - beat chaotically and irregularly) among others. During a review of Resident 3's MDS dated [DATE] her BIMS score was 3 indicating severe cognitive decline. During an interview with the charge nurse (CN) a registered nurse (RN) RN1 on 12/13/23 at 2:13 PM inside the residents' room where she was shown the coiled cord with the call light from the floor, the CN stated, I don't know that they disconnected her call light. Informed the CN that all three residents in that room had no access to call lights. The CN stated, I know the maintenance make their rounds every day to check the call lights. It was not care planned because I was not made aware that the residents have no call lights. 2. During a review of Resident Review of 2's admission record, her diagnoses included: senile degeneration of brain (also known as Senile dementia is the mental deterioration (loss of intellectual. ability) that is associated with or the characteristics of old age), adult failure to thrive (a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments.), and dementia with behavioral disturbance among others. Review of Resident I MDS dated [DATE] indicated her BIMS score was 2 indicating severe cognitive decline. The facility was asked a couple times for an updated nursing care plan indicating the resident-to-resident abuse. The victim's nursing care plan was updated but not the abuser. During the exit conference with the Administrator and the Director of Nursing on 1/12/24 at 1:10 PM at the Administrator's office, both were informed that there was no care plan for Resident 2 on the abuse incident. Both acknowledged the deficiency. During a review of the facility's P&P titled: Care planning - interdisciplinary team with revised date, September 2013, indicated: Policy statement, our facility's care planning/ Interdisciplinary team is responsible for the development of an individualized care plan for each resident.

Jan 2024 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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on observation, interviews, and record reviews the facility failed to ensure the allegation of resident-to-resident abuse was promptly reported to the State Agency (SA, which is the California D...

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Based on observation, interviews, and record reviews the facility failed to ensure the allegation of resident-to-resident abuse was promptly reported to the State Agency (SA, which is the California Department of Public Health, CDPH) in accordance with the facility's policy and procedure for two of four sampled residents (Residents 2 and 3). Failure to promptly report allegation of abuse had the potential for further abuse to happen and thereby increasing the chances of harm to the residents. Findings: In an interview on 11/14/23, at 9:42 AM, Resident 2 was awake sitting up in her bed. Resident 2 stated, she remembered the day her roommate (Resident 3) hit on her head with her bare fist. It was lunch time when Resident 3 walked to her table, she was talking in non-English language. Resident 3 picked and messed with her food on her lunch tray, she told Resident 3 to stop and thought she (Resident 3) would go back to her bed. Resident 2 stated, she turned her head to the window and Resident 3 hit her on the right side with her (Resident 3) bare fist. Review of the Resident 3's Progress Notes dated 6/15/23, at 7:07 PM, it indicated, Nursing observations, evaluation, and recommendations are: At around 6:40 PM resident claimed that her roomate hit her head by her hand. Neuro (evaluating the patient's level of consciousness) vital signs and skin check was done and recorded. In an interview on 11/14/23, at 9:04 AM, with the Assistant Director of nursing (ADON), ADON stated, on 6/15/23 at 6:40 PM, Resident 2 reported that her roommate (Resident 3), without any provocation, hit her on the right side of her head using her (Resident 3) bare fist, it was unwitnessed. The DON 1 stated, the abuse allegation was not reported to the State Agency (SA, which is the California department of Public Health, CDPH) within 2 hours after the discovery of the incident. In an observation in the resident's room on 11/15/23, at 2:53 PM, Resident 3 was asleep in bed, lying on her left side. In an interview on 11/14/23, at 9:51 AM, with the ADON, ADON stated, after verifying with the License Nurse (LN, a Registry Staff) who took care of the resident at the time of the incident, the LN admitted she did not call CDPH. When asked what the facility time frame was to report allegation of abuse, ADON stated, within two (2) hours after the discovery of the incident. Review of the facility's Policy and Procedure titled Abuse Investigation and Reporting, with the last revised date of 7/17/ indicated, Reporting: . 2. An alleged violations of abuse . will be reported immediately, but no later than: a. two (2) hours if alleged violations involve abuse .

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record the facility failed to ensure the accuracy of assessment for one of four (4) sampled r...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record the facility failed to ensure the accuracy of assessment for one of four (4) sampled residents (Resident 1) when the Quarterly Minimum Data Set (MDS, as assessment tool) dated 9/27/23, did not reflect the Residents 1's on-going chronic pain. This deficient practice had the potential to delay the delivery of care and could result in the decline in resident's condition. Findings: Review of the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and was re-admitted on [DATE]. The History and Physical, dated 7/6/23 indicated, Resident 1 was initially 'admitted due to weakness, and now readmitted for UTI (Urinary tract infection, an infection in any part of the urinary system), and the other diagnoses included, chronic pain syndrome, abnormal gait and posture, urinary retention (inability to completely empty the bladder of urine), and right leg cellulitis (deep infection of the skin caused by bacteria). In an observation and interview on 11/17/23, at 9:37 AM, with Resident 1, Resident 1 was awake, alert in bed with the head of bed elevated about 30-degree angle. Resident 1 stated, the pain on his right leg was about 4/10 (a score of 0 means no pain, and 10 means the worst pain a person has ever felt) on the pain scale, and even if he received the pain medication (hydromorphone) the pain was present all the time, it never goes away. Review of the Quarterly Minimum Data Set, dated [DATE] indicated, Resident 1 had a clear speech, able to express ideas and wants, and had clear comprehension. The Brief Interview for Mental Status (BIMS) score was 14 (13-15 score indicate resident is cognitively intact) and the Pain Assessment Interview, Section J of the MDS, indicated, pain or hurting at any time in the last 5 days, it was marked as 0 (which means no pain). Review of the September 2023 Medication Administration Record (MAR), the 7-day look period of the MDS indicated, on 9/21/23 two (2) tablets of Hydromorphone (pain medication) were administered at 9:45 AM and 2:21 PM. On 9/22/23, two tablets of the pain medication were administered at 6:30 AM, at 3:59 PM, and at 8:49 PM. On 9/23/23 two tablets of the pain medication were administered at 12:59 AM, at 5:02 AM, 10:32 AM, and at 3:15 PM. On 9/24/23 two tablets of the pain medication were administered at 5:30 AM, at 10:29 AM, 3:15 PM, and 7:15 PM. On 9/25/23 two tablets of the pain medication were administered at 2:00 AM, 6:00 AM, 5:05 PM, and 9:11 PM. On 9/26/23 two tablets of the pain medication were administered at 7:42 AM, at 5:40 PM, and at 11:30 PM. On 9/27/23 two tablets of the pain medication were administered at 3:30 AM, at 9:28 AM, at 4:40 PM, and 9:39 PM. In concurrent record review and interview on 11/17/23, at 11:44 AM, with the MDS Coordinator 1, the Quarterly MDS dated [DATE] was reviewed. The MDS Coordinator 1 stated, pain was inaccurately coded, it should be coded as 1 (means yes) instead of 0 (means no), the resident had chronic pain and was administered pain medications during the 7 -day look back period of the MDS dated [DATE].

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the Medication Drug Regimen (also known as Drug...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the Medication Drug Regimen (also known as Drug Regimen Review [DDR], a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) for one of four (4) sampled residents (Resident 1), who received as needed doses of Hydromorphone (strong opioid-based pain medicine), were reviewed for drug irregularities when: 1. The facility consistently administered as needed doses of Hydromorphone for chronic muscular pain without conducting a thorough Drug Regimen Review (DRR). Without proper evaluation, there was a lack of oversight on the frequency and appropriateness of administering Hydromorphone. This failure to assess the necessity of each dose could lead to potential overuse and excessive dosing. 2. The Physician's order for Hydromorphone lacked a pain scale (a tool to measure pain intensity to improve communication and understanding about the pain a person may be experiencing), indicating a deficiency in providing clear indications for its use. Without a specified pain scale, the dosage may not have been appropriate for the level of pain experienced by the resident. 3. The facility failed to monitor and assess the effectiveness of the pain management regimen for Resident 1. Despite ongoing complaints of pain, there was no indication of adequate monitoring or adjustment to the medication regimen. This lack of monitoring resulted in the persistence of the resident's pain, indicating a failure in the overall management of the medication regimen. These deficient practices had resulted in inadequate pain control and/or pain management for the resident. Resident 1 felt pain was still staying even after the doses of the pain medication were administered, it was there all the time, it never goes away. Findings: 1. Review of the Face Sheet indicated Resident 1was originally admitted to the facility on [DATE] and was re-admitted on [DATE]. The History and Physical, dated 7/6/23 indicated, Resident 1 was initially admitted due to weakness, and now readmitted for UTI (Urinary tract infection, an infection in any part of the urinary system), and the other diagnoses included, chronic pain syndrome, abnormal gait and posture, urinary retention (inability to completely empty the bladder of urine), and right leg cellulitis (deep infection of the skin caused by bacteria). Review of the Care Plan on Resident at risk for pain, dated 7/7/23 indicated, the Goal was the Resident will have adequate relief of pain or ability to cope with incompletely relieved pain, and the Interventions/Tasks was Administer medications as ordered, Assess pain Q (every) shift and as needed, and notify MD (Physician)/RR (Responsible Party) with s/sx (signs and symptoms) of unmanaged pain. In an observation and interview on 11/17/23, at 9:37 AM, with Resident 1, Resident 1 was awake, alert in bed with the head of bed elevated about 30-degree angle. Resident 1 stated, the pain on his right leg was about 4/10 (a score of 0 means no pain, and 10 means the worst pain a person has ever felt) on the pain scale, and even if he received the pain medication (hydromorphone) the pain was present all the time, it never goes away. Review of the Order Listing Report with the last revision date of 7/21/23 indicated, Hydromorphone HCL Oral Tablet 2 (two) mg (milligrams) . Give 2 (two tablets by mouth every 4 (four) hours for chronic muscular pain. Review of the August 2023 Medication Administration Record (MAR) indicated, the as needed doses of Hydromorphone 2 mg dose were administered most of the time, once or twice every shift. Review of the September 2023 MAR indicated, the as needed doses of Hydromorphone 2 mg were administered most of the time, once or twice every shift. Review of the October 2023 MAR indicated, the as needed doses of Hydromorphone 2 mg were administered most of the time, once or twice every shift. Review of the November 2023 MAR indicated, from 11/1/23 to 11/17/23, the as needed doses of Hydromorphone 2 mg were administered most of the time, once or twice every shift. In a concurrent record review and interview on 11/17/23, at 10:25 AM, with the Assistant Director of Nursing (ADON) the August, September, October, and November 2023 MAR, were reviewed. The ADON stated, she expected the nursing staff to inform the physician about the frequency of the doses of Hydromorphone administered as needed and referral to the pain clinic maybe needed for better pain management. Record review of the facility's Policy and Procedure titled, Pain -Clinical Protocol with the last revised date of 3/18 indicated, Monitoring: 1. 2. The staff will evaluate and report . use of standing and PRN analgesics. a. b. if there are more than occasional analgesic requests, the physician will consider changing to regular administration of at least one analgesic with another medication for PRN use, . 2. In a concurrent record review and interview on 11/16/23, at 2:26 PM, with the Licensed Vocational Nurse (LVN 1), the August, September, October, and November 2023 Medication Administration Record (MAR) were reviewed. The LVN 1 stated, the order of Hydromorphone for chronic pain did not include the pain scale, it was incorrect, there was no mild, moderate and severe. The LVN 1 stated, the staff should have verified the order with the Physician because incorrect dosing due to not knowing the pain scale may affect the resident's liver, pain could not be managed, pain medication would not work, and consequently the pain medication would be ineffective. In an interview on 11/16/23, at 3:17 PM with the DON, DON stated, the staff should have clarified the Physician's order for the pain medication to indicate if the ordered dose was for mild, moderate, or severe pain because if the pain scale was not written on the order when the pain medication was administered, the resident's pain would not subside, it would not be controlled. In a concurrent record review and interview on 11/17/23, at 2:23 PM, with the Director of Nursing DON), the facility's 2023 Drug Regimen Review (DRR, also known as Medication Regimen review, MRR) binder for the months of August, September, and October were reviewed. The DON stated, she reviewed the 2023 DRR for August, September and October and there were no documented evaluation and recommendation from the Facility's Pharmacist (FP) regarding the PRN doses administered to the resident. In a phone interview on 11/17/23, at 3:13 PM, with the Facility Pharmacist (FP), FP stated, it was up to the Physician to start therapy or routine doses of medications. The resident had other therapy such as Lidocaine patches (a sticky fabric patch a person can apply to their skin at the site of pain), the Physician was aware of the therapy, he was aware of the pain management and from safety perspective it ' s adequate. The FP stated, in general, the physician was monitoring the pain management and the Physician approved the order. Record review of the facility' Policy and Procedure titled Pharmacy Services for Nursing Facilities with the last revised date of 4/08 indicated, IA2: Consultant Pharmacist Services Provider Requirements, with the last revised date of 10/17 indicated, Procedure: A. D. 2. Assisting the facility in evaluating the process of interpreting prescriber's orders . E. Activities that the consultant Pharmacist . performs includes, but not limited to: 1) Reviewing the medication regimen . for each resident . at least monthly or more frequently . incorporating federally mandated standards of care . The review will be documented in the resident medical record. 2. Communicating to the responsible prescriber and the facility leadership potential or actual problems detected and other findings relating to medication therapy orders as well as recommendations . 3. In an interview on 1/11/24 at 2:20 PM, with the Nursing Supervisor (NS 1), NS 1 stated, pain re-assessment should be done 30 minutes to one hour after the administration of pain medication per policy. In a concurrent record review and interview on 1/11/24, at 2:22 PM, with the Nursing Supervisor (NS 1), the MAR and Pain Level Summary (PLS) were reviewed. For the month of August 2023, the NS 1 stated, Hydromorphone 2 mg (milligrams) tablet was given on 8/7/23 at 12:38 AM, no pain re- assessment was done. NS verified, on 8/9/23 at 2:00 AM, Hydromorphone was given, no re-assessment done within 30 minutes to one hour. The next pain assessment was done at 8:00 AM (on 8/9/23, 6 hours after the dose of pain med was given. For the month of September 2023, NS 1 stated, on 9/21/23 at 9:45 AM and on 9/21/23 at 2:20 PM, Hydromorphone 2 mg tablets were given, pain re-assessment was not done. On 9/24/23 at 7:15 PM, Hydromorphone 2 mg tablet was given, the pain re-assessment was not done 30 minutes to one hour after the pain medication was given, as per policy. The next pain assessment was done at 9:41 PM (more than 2 hours after the dose was given). Continued record review of the 2023 October MAR and PLS and interview on 1/11/24, at 2:27 PM, with the NS 1, NS 1 stated, on 10/7/23 at 10:49 AM, Hydromorphone 2 mg tablet was given, pain re-assessment was done at 12:43 PM (close to 2 hours after the dose was given). On 10/7/23 at 4:20 PM, Hydromorphone 2 mg tablet was given, pain was re-assessed at 6:41 PM (more than 2 hours after the dose of the pain medication was given). On 10/20/23 at 6:00 AM, Hydromorphone 2 mg tablet was given, pain was re-assessed at 7:54 AM (close to 2 hours after the dose was given). On 10/20/23 at 3:10 PM, Hydromorphone 2 mg tablet was given, pain was re-reassessed at 6:31 PM (about 3 hours after the dose was given). On 10/20/23 at 6:33 PM, Hydromorphone was given and pain re-assessment was done at 10:18 AM (close to 4 hours after the dose was given). The NS 1 stated, pain re-assessment were done 2 to 4 hours after the dose of the pain medication was given, not after 30 minutes to one hour per policy. Continued record review of the 2023 November MAR and PLS and interview 1/11/24 at 2:33 PM with the NS 1, on 11/1/23 at 6:15 AM, Hydromorphone 2 mg tablet was given, pain was re-assessed at 8:18 AM (about 2 hours after the dose was last given). On 11/10/23 at 1:30 PM Hydromorphone 2 mg tablet was given, pain re-assessed at 6:03 PM (about 4 ½ hours after the dose of the pain medication was given). On 11/13/23 at 4:00 AM, Hydromorphone 2 mg tablet was given, pain was reassessed at 8:49 AM (more than 4 hours after the dose was given). Record review of the facility's Policy and Procedure (P&P) titled, Pain - Clinical Protocol, with the last revised date of 3/18 indicated, Assessment and Recognition. 2. The nursing staff will assess each individual for pain upon admission, . There was no mention of pain re-assessment following the administration of pain medication. In an interview on 1/11/24, at 3: 50 PM, with the Director of Nursing (DON), DON stated, there should be pain re-assessment after dose administration of pain medication and she (DON) would provide the policy. Review of the facility's P&P titled, Pain Assessment and Management, with the last revised date of 3/20 indicated, General Guidelines: . 5. Acute pain (or significant worsening of chronic pain) should be assessed every 30 minutes to 60 minutes after the onset and reassessed as indicated until relief is obtained. Documentation: 1. Document the resident's reported level of pain . 2. Upon completion of the pain assessment, the person conducting the assessment shall record the information . in the resident's medical record.

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

Based on interview and record review, the facility failed to prevent unnecessary use of medication for one of four (4) sampled residents (Resident 1) when: 1.The facility failed to monitor and assess...

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Based on interview and record review, the facility failed to prevent unnecessary use of medication for one of four (4) sampled residents (Resident 1) when: 1.The facility failed to monitor and assess the effectiveness of the pain management regimen for Resident 1. Despite ongoing complaints of pain, there was no indication of adequate monitoring or adjustment to the medication regimen. This lack of monitoring resulted in the persistence of the resident's pain, indicating a failure in the overall management of the medication regimen. Resident 1 felt pain was still staying even after the doses of the pain medication were administered, it was there all the time, it never goes away. 2. Doses of Hydromorphone (a strong opioid-based pain medicine) were administered for Pain Scale (PS, a tool to measure pain intensity to improve communication and understanding about the pain a person may be experiencing) of 0/10 (a score of 0 means no pain, and 10 means the worst pain a person have ever felt) on certain days for the months of August, September, October, and November 2023. This deficient practice had the potential to result in excessive drug use, overdose, and could place Resident at risk of harm and /or death. Findings: 1. In an interview on 1/11/24 at 2:20 PM, with the Nursing Supervisor (NS 1), NS 1 stated, pain re-assessment should be done 30 minutes to one hour after the administration of pain medication per policy. In a concurrent record review and interview on 1/11/24, at 2:22 PM, with the Nursing Supervisor (NS 1), the MAR and Pain Level Summary (PLS) were reviewed. For the month of August 2023, the NS 1 stated, Hydromorphone 2 mg (milligrams) tablet was given on 8/7/23 at 12:38 AM, no pain re- assessment was done. NS verified, on 8/9/23 at 2:00 AM, Hydromorphone was given, no re-assessment done within 30 minutes to one hour. The next pain assessment was done at 8:00 AM (on 8/9/23, 6 hours after the dose of pain med was given. For the month of September 2023, NS 1 stated, on 9/21/23 at 9:45 AM and on 9/21/23 at 2:20 PM, Hydromorphone 2 mg tablets were given, pain re-assessment was not done. On 9/24/23 at 7:15 PM, Hydromorphone 2 mg tablet was given, the pain re-assessment was not done 30 minutes to one hour after the pain medication was given, as per policy. The next pain assessment was done at 9:41 PM (more than 2 hours after the dose was given). Continued record review of the 2023 October MAR and PLS and interview on 1/11/24, at 2:27 PM, with the NS 1, NS 1 stated, on 10/7/23 at 10:49 AM, Hydromorphone 2 mg tablet was given, pain re-assessment was done at 12:43 PM (close to 2 hours after the dose was given). On 10/7/23 at 4:20 PM, Hydromorphone 2 mg tablet was given, pain was re-assessed at 6:41 PM (more than 2 hours after the dose of the pain medication was given). On 10/20/23 at 6:00 AM, Hydromorphone 2 mg tablet was given, pain was re-assessed at 7:54 AM (close to 2 hours after the dose was given). On 10/20/23 at 3:10 PM, Hydromorphone 2 mg tablet was given, pain was re-reassessed at 6:31 PM (about 3 hours after the dose was given). On 10/20/23 at 6:33 PM, Hydromorphone was given and pain re-assessment was done at 10:18 AM (close to 4 hours after the dose was given). The NS 1 stated, pain re-assessment were done 2 to 4 hours after the dose of the pain medication was given, not after 30 minutes to one hour per policy. Continued record review of the 2023 November MAR and PLS and interview 1/11/24 at 2:33 PM with the NS 1, on 11/1/23 at 6:15 AM, Hydromorphone 2 mg tablet was given, pain was re-assessed at 8:18 AM (about 2 hours after the dose was last given). On 11/10/23 at 1:30 PM Hydromorphone 2 mg tablet was given, pain re-assessed at 6:03 PM (about 4 ½ hours after the dose of the pain medication was given). On 11/13/23 at 4:00 AM, Hydromorphone 2 mg tablet was given, pain was reassessed at 8:49 AM (more than 4 hours after the dose was given). Record review of the facility's Policy and Procedure (P&P) titled, Pain - Clinical Protocol, with the last revised date of 3/18 indicated, Assessment and Recognition. 2. The nursing staff will assess each individual for pain upon admission, . There was no mention of pain re-assessment following the administration of pain medication. In an interview on 1/11/24, at 3: 50 PM, with the Director of Nursing (DON), DON stated, there should be pain re-assessment after dose administration of pain medication and she (DON) would provide the policy. Review of the facility's P&P titled, Pain Assessment and Management, with the last revised date of 3/20 indicated, General Guidelines: . 5. Acute pain (or significant worsening of chronic pain) should be assessed every 30 minutes to 60 minutes after the onset and reassessed as indicated until relief is obtained. Documentation: 1. Document the resident's reported level of pain . 2. Upon completion of the pain assessment, the person conducting the assessment shall record the information . in the resident's medical record. 2. In a concurrent record review and interview on 1/11/24 at 2:38 PM, with the Nursing Supervisor (NS 1), the 2023 August, September, and October Medication Administration (MAR) and the 2023 Pain Level Summary (PLS) were reviewed. The NS 1 stated, doses of Hydromorphone 2 mg (milligrams) tablet were administered for Pain Scale (PS) of 0/10 on 8/19/23 at 7:23 PM and on 8/20/23 at 11:45. For September 2023, doses of hydromorphone were given on 9/24/23 at 10:29 AM and on 9/26/23 at 11:30 PM for the PS of 0/10. Continued review and interview on 1/11/24, at 2:27 PM, with the NS 1, NS 1 stated, for October 2023, doses of hydromorphone were given on 10/28/23 at 11:52 AM and on 10/31/23 at 4:56 PM, for PS of 0/10. NS 1 stated, for November 2023, doses of hydromorphone were given on 11/2/23 at 1:20 PM and at 7:32 PM for PS of 0/10. On 11/6/23 at 10:21 PM for PS of 0/10, On 11/8/23 at 7:32 PM Hydromorphone 2 mg was given for PS of 0/10 and on 11/9/23 at 6:30 AM for PS 0/10. The NS 1 stated, Hydromorphone should not be administered for PS of 0/10, it was zero (means no pain), it can cause overdose. In an interview on 1/11/24 at 3:47 PM, with the Director of Nursing (DON), DON stated, for pain level of 0/10 the staff should not give the pain medication, there's no indication. DON stated, the Monthly DRR for the months of August, September, October, and November 2023 were not done for Resident 1. Record review of the facility's Policy and Procedure (P&P) titled, Pharmacy Services for Nursing Facilities, with the last revised date of 4/08 indicated. E. Activities that the consultant pharmacist .performs includes, . 1) Reviewing the medication regimen (medication regimen review) of each resident at least monthly, . The review will be documented in the resident's medical record. a. A resident drug regimen must be free of unnecessary drugs. An unnecessary drug is any drug when used in: . iii. Without adequate monitoring iv. Without adequate indication for its use.

Dec 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to notify the resident representative (RP) of one of three sampled re...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record reviews, the facility failed to notify the resident representative (RP) of one of three sampled residents (Resident 1) when Resident 1 had a fall incident and a discoloration on his left forearm. This deficient practice prevented Resident 1's representative in participating in the planning and decision-making of care and services rendered to the resident after the facility became aware of the incidents. Findings: Review of Resident 1's admission Record, indicated he was admitted on [DATE] with diagnoses that include unspecified fall, dementia (impairment in ability to remember, think, or make decisions that interferes with doing everyday activities), muscle weakness, and abnormalities of gait and mobility. Resident 1 was discharged on 11/25/23. During an interview on 12/13/23 at 1:53 PM, Registered Nurse (RN) 1 stated that after a resident fell, a new assessment is needed because of the change in the resident's condition. RN 1 stated, Yes, we should notify appropriate disciplines including the RP. During an interview on 12/15/23 at 8:36 AM, Licensed Vocational Nurse (LVN) 1 stated that a resident fall incident is a change of condition. LVN 1 stated, We notify RP, so that they know what is going on with their relative. During a concurrent interview and record review on 12/15/23 at 9:47 AM, with Assistant Director of Nursing (ADON) 1, Resident 1's clinical records were reviewed. Resident 1's Nursing Note, dated 9/24/23 at 3:15 AM indicated, Around 3:15 AM resident had unwitnessed fall. Resident 1's IDT (Interdisciplinary team) Post (after) Fall Meeting, dated 9/24/23 at 9 AM indicated Resident 1's fall incident on 9/24/23. ADON 1 verified that there was no documentation on both aforementioned Nursing Note and the IDT Meeting note that Resident 1's RP was notified. ADON 1 stated that there are no notes in resident's chart regarding notification of Resident 1's RP or family of the fall incident that occurred on 9/24/23. ADON 1 stated, It (fall incident) is a change of resident's condition. RP or family should be notified. During further review of Resident 1's clinical records with ADON 1, the Nursing Note, dated 11/4/23 at 2:33 PM indicated, This writer called by CNA and found resolving purplish discoloration noted on left forearm . Resident 1's Nursing Note, dated 11/5/23 at 7:25 PM indicated, Got a call from resident's granddaughter c/o (complaining of) bruise on resident's arm and that no report was made either to hospice or family . ADON 1 continued review of Resident 1's clinical records and was not able to provide evidence that Resident 1's family or RP was notified of the bruise on the left forearm. ADON 1 stated, We have to notify (RP) for any change of condition. When there's bruising, that's a change of condition. Review of the facility policy titled, Accidents and Incidents - Investigating and Reporting, revised on 07/17 indicated, Policy Interpretation and Implementation .The following data, as applicable, shall be included on the Report of Incident/Accident form . The date/time the injured person's family was notified and by whom . Review of the facility policy titled, Change in a Resident's Condition or Status, revised on 05/17 indicated, Policy Statement - Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). Policy Interpretation and Implementation . 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source . 5. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status .

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 F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to bathe or provide shower to one of four sampled residents (Resident ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to bathe or provide shower to one of four sampled residents (Resident 3) for 12 days from 10/5/23 to 10/17/23. This failure may lead to Resident 3's breakdown of skin integrity and accumulation of dirt and bacteria present on the skin's surface, increasing the risk of infection and can negatively impact Resident 3's sense of well-being. Findings: Review of Resident 3's admission Record, indicated Resident 3 was admitted on [DATE] with diagnoses that include ischemic colitis (occurs when blood flow to part of the large intestine is reduced), GI (gastro-intestinal) bleeding, hydronephrosis (swelling of one or both kidneys, and diabetes mellitus Type 2 (a disorder causing blood sugars to be abnormally high). Review of Resident 3's care plan titled, Resident at risk for ADL (activities of daily living) decline, dated 3/23/23 indicated, Interventions/Tasks . Shower/bad bath per schedule and as needed . Review of Resident 3's care plan titled, Resident at risk for skin breakdown, dated 3/23/23 indicated, Interventions/Tasks . Keep resident clean and dry, provide incontinence care as needed . During an interview on 12/13/23 at 1:31 PM, Certified Nursing Assistant (CNA) 2 stated, Showers are per schedule or per resident's preferences. Showers are recorded in shower sheets in binder and in PCC (Point-Click Care -a healthcare software) electronically. During a concurrent record review and interview with CNA 5 on 12/13/23 at 1:46 PM, CNA 5 stated regarding Resident 3's showers, Sometimes she refuses, but most of the time she agrees. She's twice a week, Monday and Thursday. CNA 5 further stated that showers are also given as needed, If they poop, might as well give shower even though not scheduled. During a follow up interview on 12/14/23 at 11 AM, CNA 5 stated that if staff provided showers/bath to a resident, It must be documented in the binder (referring to the facility binder containing Shower Check Skin Assessment (SCSA) forms) or PCC, if performed. That's the instructions. If blank (not documented), maybe it was not done. During a concurrent record review and interview with ADON 1 on 12/14/23 at 3:43 PM, ADON 1 reviewed the facility binder containing Shower Check Skin Assessment (SCSA) forms of Resident 3. ADON 1 was unable to find documentation of showers provided to Resident 3 from 10/6/23 to 10/17/23. During a concurrent record review and interview with Medical Record Staff (MRS) and ADON 2 on 12/15/23 at 10:45 AM, MRS provided photocopies of Resident 3's SCSA forms, dated 10/5/23 and 10/18/23. MRS stated, There's only October 5 (2023) and October 18 (2023). MRS confirmed that Resident 3 did not have completed SCSA forms from 10/6/23 to 10/17/23. ADON 2 reviewed Resident 3's Bed A: Bathing Scheduled (Every Monday, Thursday, and PRN [as needed]) for October 2023. ADON 2 verified that there was no documented evidence that showers or baths were provided to Resident 3 for 12 days, from 10/6/23 to 10/17/23. ADON 2 stated that bathing is important for hygiene and skin integrity and that lack of bathing increases risk for infection. Review of the facility policy and procedure (P&P) titled, Bath, Shower/Tub, revised on 2/18 indicated, Purpose - The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin .Documentation 1. The date and time the shower/tub bath was performed. 2. The name and title of the individual(s) who assisted the resident with the shower/tub bath .5. If the resident refused the shower/tub bath, the reason(s) .

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

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide one of 47 sampled residents (Resident 2) acce...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide one of 47 sampled residents (Resident 2) access to communication with staff and visitors in a language that is clear and understandable to the resident when a language translation service was not available for use by the resident. This deficient practice resulted in Resident 2 feeling frustrated for being unable to communicate with staff and relaying his needs and concerns and had the potential for the 47 residents with limited proficiency in English to not have access to communication with persons inside and outside the facility. Findings: Review of facility document, titled Languages List, dated 12/19/23 indicated that there are 47 residents whose primary language is not English and are listed as needing interpreter. Review of Resident 2's admission Record, indicated Resident 2 was admitted on [DATE] with diagnoses that include generalized anxiety disorder (persistent and excessive worry that interferes with daily activities) and hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing), affecting right dominant side. Review of Resident 2's Minimum Data Set (MDS - an assessment tool), dated 11/15/23, indicated that the resident's preferred language is Cantonese and needs or wants an interpreter to communicate with a doctor or a health care staff. Review of Resident 2's care plan titled, Resident continues to have preference for self-directed activities, dated 9/7/23, indicated Alteration in activity pursuits related to: Language Barrier (Cantonese) . During an interview on 12/13/23 at 11:07 AM, Certified Nursing Assistant (CNA) 1 stated, Most of my patients are Chinese. We do sign language or call my Chinese co-worker to translate, not here all the time. CNA 1 stated that using sign language with residents who need translation sometimes it works, sometimes not. Not sure about the translator line. During an interview on 12/13/23 at 2:31 PM, CNA 3 stated, I use sign posted in their room, not effective all the time, then I use google translate (a web-based free-to-user translation service). Sometimes google translate does not work, staff not always available to interpret. During an interview on 12/13/23 at 2:38 PM, CNA 4 stated, I use sign language, google translate. Sometimes it works, sometimes it doesn't. During an observation on 12/15/23 at 10:52 AM, Resident 2 was in his room, in bed, and was awake. When asked for permission to interview him, Resident 2 spoke in Chinese. When asked if he speaks and understands English, he continued to speak in Chinese, then shook his head and waved to this surveyor to go out of room. During an interview on 12/15/23 at 11:21 AM, Certified Nursing Assistant (CNA) 1 stated, He (Resident 2) cannot speak English. Sometimes there's a staff who speaks Chinese. CNA 1 stated, I would not know who to ask, if unable to find staff that can interpret for her and resident. During an interview on 12/15/23 at 11:28 AM, Registered Nurse (RN) 2 stated, There's no language service here, not here. I have worked in other facilities, they have it. Not here, I don't understand why they don't have it. RN 2 further stated, It's hard, if you want to ask him (Resident 2) about his day, what his needs are, he won't be able to answer, he won't understand, just basic one word communication with him and it's hard to understand what he is saying. During an interview on 12/15/23 at 11:32 AM, RN 3 stated regarding the facility's language translation service, There used to be a code that we're using, but they changed it. It's no longer working. During an interview on 12/15/23 at 1:21 PM, Resident 3's family member stated, I don't understand why they don't have one (language translation service). It's a problem because he gets mad, he gets frustrated when he wants to tell staff that he is hungry, or wants to do something, no one understands him. During a concurrent interview and record review on 12/19/23 at 1:26 PM, the Administrator confirmed that the facility currently does not have an interpreter service available for use by the residents and staff. The Administrator stated, Typically, we will reach out to family members, enlist their assistance, get them in facility to try to help us communicate (with the residents). The Administrator stated that she learned about the lack of interpreter service since you started looking into it. I think every facility could benefit from it. Review of the facility policy and procedure (P&P), titled Translation and/or Interpretation of Facility Services, revised 05/17 indicated, Policy Statement: This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. Policy Interpretation and Implementation . 13. Family members and friends shall not be relied upon to provide interpretation services for the resident, unless explicitly requested by the resident. If family or friends are used to interpret, the resident must provide written consent for disclosure of protected health information. 14. It is understood that providing meaningful access to services provided by this facility requires also that the LEP resident's needs and questions are accurately communicated to the staff. Oral interpretation services therefore include interpretation from the LEP resident's primary language back to English. 15. It is understood that in order to provide meaningful access to services provided by this facility, translation and/or interpretation must be provided in a way that is culturally relevant and appropriate to the LEP individual .

Dec 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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review the facility failed to develop a comprehensive care plan for a resident that included measurable objectives and specific interventions when: Resident ...

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Based on observation, interview and record review the facility failed to develop a comprehensive care plan for a resident that included measurable objectives and specific interventions when: Resident 1 's care plan was not updated when there were documentations of her having altercations with different residents in the facility. This failure has the potential for not meeting the resident's goals of care to meet her highest practicable well-being. FINDINGS: Resident 1 was admitted with the following diagnoses: Senile degeneration of brain (also known as Senile dementia is the mental deterioration (loss of intellectual ability) that is associated with or the characteristics of old age), adult failure to thrive (a state of decline that is multifactorial and may be caused by chronic concurrent diseases and functional impairments.), and dementia with behavioral disturbance among others. During a review of Resident 1 minimum data set (MDS- an assessment tool for nursing home residents) dated 10/1/2020 indicated her brief interview for mental status (BIMS - an assessment tool to assess the residents' cognitive status) score was 2 indicating severe cognitive decline. During a review of the clinical record of Resident 1, the progress notes indicated, on 10/21/23, at around 11 PM Resident 2 was heard by RN 1 yelling. RN1 found Resident 1 lying in bed with Resident 2. Both residents were separated immediately. During skin assessment, Resident 2 was found to have 0.1 cm scratch on her forehead and left hand. Resident 1 with no injury. Both resident's vital signs were within normal range. The doctor (MD), Administrators, families, CDPH were notified. During a review of Resident 2 admission record dated 12/14/23, indicated her diagnoses are metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), type 2 diabetes mellitus with hyperglycemia (occurs when a person's blood sugar elevates to potentially dangerous levels), Hemiplegia (paralysis of one side of the body) and hemiparesis (one sided muscle weakness) following cerebral infarction (or stroke occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) among others. During a review of Resident 2 MDS, her BIMS score was 5 indicating severe cognitive decline. During a review of the interdisciplinary (IDT) team note for Resident 3 dated 8/7/23 at 23:08, indicated, on the afternoon of 8/6/23, Resident 3 was kicked in the abdomen by Resident 1. Skin assessment to both residents with no injuries. No pain. Both residents with cognitive skills impairment. Daly city police came, MD was notified with order to follow facility protocol. Emotional support provided to the son of Resident 3. During a review of the clinical record for Resident 3 the admission record dated 12/14/23, her diagnoses include: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance and anxiety (ICD-10-CM code - A condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems. Dementia usually gets worse over time), spinal stenosis, lumbar region (a narrowing of the spinal canal in the lower part of your back), and essential primary hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition) among others. During a review of Resident 3 MDS, her BIMS score was 4 indicating severe cognitive impairment. During a concurrent observation and interview with Resident 1 on 12/14/23 at 11:10 AM, observed RN1 giving medication to Resident 1. Resident 1 was awake, sitting on the edge of her bed. Resident 1 took her medicine, drank water, and went back to lie down in bed and closed her eyes. Observed she opens and closed her eyes when she sees the surveyor. She was not responding when greeted and asked. During a review of Resident 1's clinical records, observed the nursing care plan for Resident 2, Resident 3 and Resident 4 were updated on abuse incidents involving Resident 1 as the perpetrator. Observed Resident 1's care plan was not updated on resident-to-resident abuse. During a review of Resident 1's clinical record the progress note dated 10/23/23 at15:59, the IDT note indicated Resident 1 had two resident-to-resident altercation: 1. 10/21/23 at 11 PM with Resident 2 2. 10/22/23 at 2:50 AM with another resident, (Resident 4) a male resident in another room. Resident 3's encounter with Resident 1 was on 8/6/23. During an exit interview with the Administrator and the Director of Nursing (DON) on 1/12/24 at 1:10 PM in the Administrator's office, both the Administrator and the DON were informed that Resident 1's nursing care plan was not updated on abuse. Both acknowledged their deficient practice. During an exit interview with the Administrator on 1/31/24 at 2:06 PM, the Administrator stated, I will look into that. Review of the facility's program with revised date December 2016 with the policy statement: Our residents have the right to be free from abuse, neglect, . The facility's policy and procedure (P&P) titled Abuse Investigation and Reporting with revised date July 2017, indicated: policy statement - All reports of resident abuse, neglect, . shall be promptly reported to local state, and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. The policy interpretation and implementation include the role of the administrator and the role of the investigator. During a review of the facility's P&P titled: Care planning - interdisciplinary team with revised date, September 2013, indicated: Policy statement, our facility's care planning/ Interdisciplinary team is responsible for the development of an individualized care plan for each resident.

Dec 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0637 (Tag F0637)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify and document, changes in Resident 1 ' s condition when: 1...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify and document, changes in Resident 1 ' s condition when: 1.Resident 1 ' s wound changed to Stage 4. 2.Resident 1 readmitted on [DATE], no skin assessment done. 3.The IDT (Interdisciplinary Team) did not address the changes in condition for Resident 1. These failures had the potential for resident ' s condition not assessed and needs not addressed could result to resident not getting the right treatment and care. Findings: During record review and concurrent interview on 12/6/23, with ADON, nurses progress notes on June 15,2022, indicated, Noc shift endorsed stage 4 on the back, wound nurse notified, gangrene on both heels, discoloration right leg. MD ordered, referral to wound doctor. Confirmed by ADON, No change of condition assessment found, no Skin Assessment found, no IDT meeting found in chart. Review of facility document Nutrition Note, dated 6/24/22, indicated, Weight Variance and Skin /Wound Nutrition Note: declined noted more significant after Covid +, has poor intake, wt loss x90 days is 18.7%, significant . No change of condition found in chart, no IDT meeting found in chart. Review of MDS (minimum Data Set) a tool for resident assessment and screening, dated 6/16/22, Quarterly review assessment; under K0300, Weight loss, 0 - No or Unknown.

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement comprehensive person-centered care plan for o...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement comprehensive person-centered care plan for one of three residents (Resident 1)when: There was no care plan on 6/10/22 addressing sacral discoloration. There was no care plan on 6/14/22 addressing mid -lower sacrum, coccyx, right and left heel wound . There was no care plan on 6/23/22 addressing the new order for Megesterol acetate (an appetite stimulant). There was no care plan on 7/3/22, when Resident 1 was re-admitted with new Antibiotic order for new Diagnosis of Cellulitis. These failures had the potential to prevent the resident from receiving appropriate and individualized care and services consistent with her needs. Findings: During a record review of facility document, admission Record, dated 7/5/22, indicated, admitted on [DATE] with diagnoses including: Asthma Exacerbation (condition which the airways are inflamed and produces extra mucus making it difficult to breathe), Atrial Fibrillation (irregular heartbeat) Congestive Heart Failure(a condition when the heart muscle doesn ' t pump blood as well as it should and Dementia ( loss of cognitive functioning, thinking, remembering and reasoning). Was discharged to acute on 8/22/22. During a review of nursing notes, dated 6/10/22, indicated, CNA reported discoloration to sacrum, measures 2x2 cm and left buttocks 1x1 cm. Not addressed in care plan. During a review of nursing notes dated, 6/14/22, indicated, CNA reported the presence of wound on patient ' s back. Unstageable wound on lower sacrum measuring 9.5cm x 4.5.cmc, coccyx 1.5 cm x 2.5 cm, right heel 1.5 cmx 2 cm, left heel 0.6cm x 1cm. Treatment as ordered, no care plan found. Review of Nutrition Note, dated , 6/24/22, indicated, Weight Variance and Skin/Wound Nutrition Note: conference with family, declined after Covid +, poor intake, leading to weight loss of 18.7% x 90 days. Weight loss due to muscle wasting, advanced age and wounds. RD visited to offer resource .intake better when family around .multiple wounds. Nutrition recommendation: Continue MVI with minerals, Vit C and resource 2.0 BID, and appetite stimulant, MD approved of Megesterol acetate 400mg BID to improve intake and weight maintenance and wound care. NO care plan found for new medication Megesterol. During a review of nursing note, dated 7/6/22, resident came back from acute hospital stay with new Diagnosis of Cellulitis and order for antibiotic. This condition was not addressed in care plan. During a concurrent chart review and interview on 12/6/23, at 2PM with RN, ADON 1(Assistant Director of Nursing), stated, new orders, medications and diagnosis should be care planned, new skin condition or changes in treatment should also be care planned. Reviewed document, confirmed, no care plan found for dates 6/10/22, 6/14/22, 6/23/22 and 7/3/22. Review of facility Policy and Procedure, Care Planning, Interdisciplinary Team, dated 9/2013, indicated, 8. The comprehensive, person centered careReview areReview of facility Policy and Procedure, Care Planning, Interdisciplinary Team, dated 9/2013, indicated, 8. The comprehensive, person centered care plan will: b. describe the services that are to be furnished to attain or maintain the resident ' s highest practicable, physical, mental, and psychosocial well -being: g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; k. Reflect treatment goals, timetables and objectives in measurable outcomes; l. Identify the professional services that are responsible for each element of care. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident ' s condition changes. 14. The IDT must review and update the care plan: a. When ther has been a significant change in the resident ' s condition; c. When the resident hs been readmitted to the facility from a hospital stay.

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician ' s order to obtain weight weekly on admission, an...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow physician ' s order to obtain weight weekly on admission, and failed to follow facility policy and procedure, as evidenced by no documented weight on day of admission, 3/11/22, week of 3/30/23 and 4/6/23. No Monthly weights for April and May 2022. This failure had the potential for changes in condition not being assessed and identified, resulting in Resident 1 weight loss. Findings: Review of facility document, Order Summary Report, Physician: MD1, dated 3/1/22-6/1/22, indicated, admission: Weekly Weight x 4 weeks, then reevaluate one time a day every Wed for 4 weeks. During an interview on 12/6/23 at 1:50 Pm with MO, ADON 2, stated, Weights are taken on day of admission, then one week after, then weekly x 4, taken on Sundays and Mondays, for the first month. Then every month and per MD ' s order. During a review of facility document, Weights and Vitals Summary, indicated, 3 /16/22 - 107.8. lbs (standing scale), 3/23/22 110 lbs (Standing), 6/20/22 -89.4 lbs (W/C scale), 7/20/22 - 98 lbs (lift with scale). Resident 1 was admitted [DATE], no admission weight taken. No weights taken on the third week 3/23/22 and fourth week 4/6/22. Weights are measured with different scales, no RNA available for interview. No Registered Dietician employed this time, unable to interview. Interview on 12/6/23 at 2 PM, with ADON 1, ADON 1 stated, the RNA take the weights of all patient in the facility, RD reviews and encodes the weight in the patient ' s chart. The patient refused weight to be taken on April and May of 2022. Review of facility Policy and Procedure, Weight Assessment and Intervention, dated 9/2008, indicated, The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our resident. Weight Assessment:1. The nursing staff will measure resident ' s weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measure monthly thereafter.

Nov 2023 6 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 F0565 (Tag F0565)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure prompt resolution of resident council grievances when two out of two sampled grievances lacked pertinent dates or conclusions/outcom...

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Based on interview and record review, the facility failed to ensure prompt resolution of resident council grievances when two out of two sampled grievances lacked pertinent dates or conclusions/outcomes necessary to demonstrate that grievances are processed effectively, and residents are apprised of progress towards resolution. This failure has the potential for resident council recommendations to not be considered or grievances to go unresolved. Findings: A review of the policy titled Resident Council, undated, indicated that A Resident Council Response Form will be utilized to track issues and their resolution. A review of the policy titled Grievances/Complaints, Filing (undated), provided on 11/27/23 at 10:51 AM, the policy indicated that all grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing including rationale for response. In addition, the policy indicated that upon receipt of a grievance and or complaint, the Grievance Officer will review and investigate the allegations and submit a written report of such finding to the Administrator within five (5) working days of receiving the grievance and/or complaint. During an interview on 11/17/23 at 11:06 AM with the Activities Director (AD), the AD stated that they are the recordkeeper and sometimes the presider for the resident council. The AD stated that they are responsible for routing resident council complaints to the appropriate departments and their timeline for resolution is as long as I have a response before the next resident council meeting takes place. A review of the resident council meeting minutes, dated July 21, 2023, at 1:30 PM, indicated, last month we brought up the issue of most of the departments not checking their voicemails and not responding to them . It seems that the situation has not changed for some departments because I ' m still not getting responses to my VMs [voice mails]. A review of the resident council meeting minutes dated October 20, 2023, at 1:30 PM, indicated, over many months, residents have repeatedly raised the issue of clothes being lost in the laundry or ruined. Each time, laundry ' s response to this is that residents or CNAs are not properly labeling the clothes with the person ' s name and room number . two residents have now started paying for and using an outside laundry service which they say does an excellent job. During a concurrent interview and record review on 11/27/23 at 3:25 PM with the AD, a form titled Resident Council Suggestion/Issue/Question/Concern, signed by a department head on 08/18/23 was reviewed. The form indicated that the issue was voice mail issues. The AD verified that there is no date filled out for when this issue was brought up or a narrative for what the specific issue is. The AD stated that if complaints aren ' t logged and information is missing, the issue won ' t be properly addressed and it [the complaint] will drag on. During a concurrent interview and record review on 11/27/23 at 3:30 PM with the AD, a form titled Resident Council Suggestion/Issue/Question/Concern, dated 08/17/23 was reviewed. The form indicated that the issue of concern as clothes getting mixed, clothes missing The AD verified that the issue was initially noted on June 23, 2023 and again on July 21, 2023. The AD verified that this was the most up to date information regarding this complaint. The AD verified that this same issue was brought up in the October 20, 2023, resident council meeting. Based on the timeline, the AD stated that their concerns were not really addressed, on this specific complaint. During an interview with the Administrator on 11/27/23 at 2:41 PM, the administrator stated that the AD is responsible for reporting resident council concerns to the appropriate department heads. During a concurrent interview and record review on 11/27/23 at 2:46 PM with the Administrator, a form titled Resident Council Suggestion/Issue/Question/ Concern, dated 08/17/23 was reviewed. The form indicated that the issue of concern as clothes getting mixed, clothes missing. The Administrator stated they were unable to discern a timeline for when the issue was brought up and the status of its resolution stating, I don ' t understand this one . it ' s all over the place. During a concurrent interview and record review on 11/27/23 at 2:49 PM with the Administrator, a form titled Resident Council/Suggestion/Issue/Question/ Concern, signed by a department head on 08/18/23 was reviewed. The administrator stated that unanswered voicemails is an ongoing issue stating, They just told me this month I ' m looking into it. The Administrator stated that they are doing some troubleshooting with their phone provider. The Administrator verified that they are unable to tell when the issue was brought up based on the reviewed form.

CONCERN (D) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to care for resident's need (Resident 2), by not reporting or notifyi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to care for resident's need (Resident 2), by not reporting or notifying the physician during change of condition when Resident 1 complained of chest pain and severe abdominal pain. This failure resulted in resident not properly assessed by the physician and not given the right medication and treatment. Findings: Resident 2 was admitted to the facility on [DATE] with diagnoses including Supraventricular Tachycardia (irregular fast heartbeat). The physician's progress note dated 4/15/23 indicated Resident 2 was a Full Code. During concurrent interview and record review on 11/16/23 at 4:22PM with LVN 2, RN 2, the Nursing Progress notes dated 4/14/2023 at 9:10PM, and the Medication Administration Record (MAR) dated 4/14/2023 at 9:11PM were reviewed. The Nursing Progress notes indicated patient c/o(complained of) chest pain, patient refusing to go to hospital, Pain medication administered. The MAR indicated Tramadol Hcl tablet 50mg give 1 tablet by mouth every 4 hours as needed for pain, was given at 9:11PM with a pain level of 4 and was effective at 10:49PM with a level of 0. LVN 2 stated that she remembered Resident 2 as a young lady in room [ROOM NUMBER], she likes rock music, refused two times to go to emergency room, she kept refusing. LVN 2 remembered that Resident 2 had chest pain, but she refused to go to the hospital, that she notified the Physician because she knows it ' s a serious issue, but Resident 2 refused to go to the hospital. Family Nurse Practitioner 1(FNP 1), said that we can ' t force resident if she does not want to go, so he ordered pain medication, but forgot to document it on the nurses notes that she notified the Physician. RN 2 stated If the resident refused to go to the hospital, we should have to document, if not documented, it means it is not done, and if there is chest pain they automatically go to the hospital if there is no Nitroglycerin ordered, and usually the physician will order transfer to the resident to the hospital if the patient or family permits, but all should be documented. During a review of nursing progress notes dated 4/27/2023 at 8:41AM indicated, patient complain of severe pain in abdomen due to cramping related to monthly menstrual cycle The Medication Administration Record (MAR) dated 4/27/2023 at 8:41AM was reviewed, and the MAR Indicated ' Tramadol HCl tablet 50mg 1 tablet by mouth every 4 hours as needed for pain was given with pain level of 8, with a follow up at 1:09PM and was effective. During a review of the facility ' s policy and procedure titled Acute Condition Changes-Clinical Protocol of the Nursing Services Policy and Procedure Manual for Long -Term Care revised March 2018, indicated In addition, the nurse shall assess and document/ report the following baseline information: a. Vital signs; b.Neurological status; c.Current level of pain and any recent changes in pain level .the Nursing staff will contact the physician based on the urgency of the situation, for emergencies, they will call or page the physician and require a prompt response (within approximate one- half hour or less), the nurse and physician will discuss and evaluate the situation, for example, vital signs, physical findings or detailed sequence of events and description of symptoms.

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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure prompt resolution of grievances when two out of two sampled resident grievances lacked pertinent dates or conclusions/outcomes neces...

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Based on interview and record review, the facility failed to ensure prompt resolution of grievances when two out of two sampled resident grievances lacked pertinent dates or conclusions/outcomes necessary to demonstrate that grievances are processed effectively, and residents are apprised of progress towards resolution. This failure has the potential to result in a residents ' voiced grievances not being heard or resolved. Findings: A review of the policy titled Grievances/Complaints, Filing (undated), provided on 11/27/23 at 10:51 AM, the policy indicated that all grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing including rationale for response. In addition, the policy indicated that upon receipt of a grievance and or complaint, the Grievance Officer will review and investigate the allegations and submit a written report of such finding to the Administrator within five (5) working days of receiving the grievance and/or complaint. During an interview on 11/17/23 at 11:06 AM with the Activities Director (AD), the AD stated that they are the recordkeeper and sometimes the presider for the resident council. The AD stated that they are responsible for routing resident council complaints to the appropriate departments and their timeline for resolution is as long as I have a response before the next resident council meeting takes place. A review of the resident council meeting minutes, dated July 21, 2023, at 1:30 PM, indicated, last month we brought up the issue of most of the departments not checking their voicemails and not responding to them . It seems that the situation has not changed for some departments because I ' m still not getting responses to my VMs [voice mails]. A review of the resident council meeting minutes dated October 20, 2023, at 1:30 PM, indicated, over many months, residents have repeatedly raised the issue of clothes being lost in the laundry or ruined. Each time, laundry ' s response to this is that residents or CNAs are not properly labeling the clothes with the person ' s name and room number . two residents have now started paying for and using an outside laundry service which they say does an excellent job. During a concurrent interview and record review on 11/27/23 at 3:25 PM with the AD, a form titled Resident Council Suggestion/Issue/Question/Concern, signed by a department head on 08/18/23 was reviewed. The form indicated that the issue was voice mail issues. The AD verified that there is no date filled out for when this issue was brought up or a narrative for what the specific issue is. The AD stated that if complaints aren ' t logged and information is missing, the issue won ' t be properly addressed and it [the complaint] will drag on. During a concurrent interview and record review on 11/27/23 at 3:30 PM with the AD, a form titled Resident Council Suggestion/Issue/Question/Concern, dated 08/17/23 was reviewed. The form indicated that the issue of concern as clothes getting mixed, clothes missing The AD verified that the issue was initially noted on June 23, 2023 and again on July 21, 2023. The AD verified that this was the most up to date information regarding this complaint. The AD verified that this same issue was brought up in the October 20, 2023, resident council meeting. Based on the timeline, the AD stated that their concerns were not really addressed, on this specific complaint. During an interview with the Administrator on 11/27/23 at 2:41 PM, the administrator stated that the AD is responsible for reporting resident council concerns to the appropriate department heads. During a concurrent interview and record review on 11/27/23 at 2:46 PM with the Administrator, a form titled Resident Council Suggestion/Issue/Question/ Concern, dated 08/17/23 was reviewed. The form indicated that the issue of concern as clothes getting mixed, clothes missing. The Administrator stated they were unable to discern a timeline for when the issue was brought up and the status of its resolution stating, I don ' t understand this one . it ' s all over the place. During a concurrent interview and record review on 11/27/23 at 2:49 PM with the Administrator, a form titled Resident Council/Suggestion/Issue/Question/ Concern, signed by a department head on 08/18/23 was reviewed. The administrator stated that unanswered voicemails is an ongoing issue stating, They just told me this month I ' m looking into it. The Administrator stated that they are doing some troubleshooting with their phone provider. The Administrator verified that they are unable to tell when the issue was brought up based on the reviewed form.

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

Based on interview and record review, the facility failed to ensure licensed nurses have the specific competencies and skills necessary to care for Residents needs (Resident 2) by not taking or report...

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Based on interview and record review, the facility failed to ensure licensed nurses have the specific competencies and skills necessary to care for Residents needs (Resident 2) by not taking or reportingto the physician the baseline vital signs during a change of resident's condition. This failure resulted to not meeting Resident 2's nursing needs and goals to attain the highest practicable well being. Findings: Record review indicated that on 4/14/2023 resident 2 complained of chest pain. There was no documented evidence that vital signs (Blood pressure, Temperature, Pulse, Respiration) were taken and reported to the physician. On 4/27/2023 Resident 2 complained of severe abdominal pain. There were no vital signs taken nor recorded. During a concurrent interview and record review on 11/16/2023 at 4:22PM, with LVN 2, staff claimed that on 4/14/2023, Resident 2 had chest pain and refused to go to the hospital. LVN 2 indicated that she notified FNP 1 but did not document, no assessment was made, no vital signs was taken. The Nursing Progress Notes 4/27/2023 at 8:41AM indicated , Resident 2 complained of severe pain in abdomen due to cramping related to monthly menstrual cycle. The Medication Administration Record (MAR) indicatedTramadol HCl tablet 50mg 1 tablet by mouth every 4 hours as needed for pain was given with a pain level of 8 (10 as the highest) with follow up 1:09PM and was effective, no documentation that FNP 1 was notified, no assessment was made and no vital signs was taken. The Blood pressure (BP) summary of Resident 2 dated April 2023, was reviewed: 4/01/2023, BP 125/84mmHg at 11:20AM; 4/5/2023, BP 100/66mmHg at 10:16PM; 4/9/2023, BP 105/66mmHg at 1:05PM; 4/20/2023, BP105/66mmHg at 10:15AM. During a review of the facility's policy and procedure titled Acute Condition Changes- Clinical Protocol of the nursing services policy and procedure Manual for Long Term Care revised 2018, indicated: In addition, the nurse shall assess and document/ report the following baseline information: a. Vital signs; b. Neurological status; c. Current level of pain and any recent changes in pain level , the nursing staff will contact the physician based on the urgency of the situation, for emergencies they will call or page the physician and require a prompt response (within approximately one-half hour or less), the nurse and physician will discuss and evaluate the situation, for example, vital signs, physical findings or detailed sequence of events and description of symptoms.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review, the facility failed to ensure that one out of three sampled residents (Resident 1) was free of any significant medication errors when Registered Nurs...

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Based on observation, interview and record review, the facility failed to ensure that one out of three sampled residents (Resident 1) was free of any significant medication errors when Registered Nurse (RN) 1 crushed an extended-release medication, Metoprolol (a blood pressure lowering medication made to release slowly over time). This failure had the potential to result in Resident 1 receiving a higher dose of a blood pressure medication at one time, increasing the risk for side effects or hypotensive symptoms (effects due to a quick drop in blood pressure). Findings: A review of Resident 1 ' s face sheet (summary of resident ' s demographic and admitting information), provided on 11/14/23 at 2:05 PM indicated, Resident 1 was admitted in the Fall of 2023 with multiple diagnoses, including: palliative care (specialized care to provide relief of symptoms from a serious illness), essential hypertension (high blood pressure of unknown cause), Alzheimer ' s (a brain disorder that slowly impairs memory and thinking skills), and atrial fibrillation (an irregular heart rhythm that begins in the upper part of the heart). A review of Resident 1 ' s active orders provided on 11/17/23 at 2:10 p.m. indicated the facility may crush medications unless contraindicated (a specific situation in which a medicine should not be used because it may be harmful to the person); this was ordered on 11/10/2023. In addition, there is a pharmacy order for Metoprolol Succinate ER Tablet Extended Release 24 Hour 50 MG (a blood pressure lowering medication made to release slowly over time) . Give 1 tablet by mouth once a day for HTN (hypertension, high blood pressure); this has an order start date of 11/11/2023. During an observation on 11/16/23 at 9:50 AM, RN 1 crushed two medications, losartan (a medication to lower blood pressure) and extended-release metoprolol, to administer to Resident 1. During an observation on 11/16/23 at 9:53 AM, RN 1 mixed crushed medications with apple sauce and placed spoon near resident ' s mouth and was committed to administering the medication when the surveyor intervened. During an interview on 11/16/23 at 9:55 AM with RN 1, RN 1 confirmed that they crushed only the tablets . losartan and metoprolol. When asked if extended-release medications are typically crushed, the nurse responded nope. RN 1 confirmed that if an extended-release medication is crushed and given to a resident, it is not going to work right due its modified rate of absorption. During a concurrent interview and record review on 11/16/23 at 10:05 AM with RN 1, Resident 1 ' s orders were reviewed. RN 1 read an order for Resident 1 stating, may crush medications unless contraindicated. RN 1 verified they should not have crushed the extended-release metoprolol. During an interview on 11/17/23 at 3:13 PM with Pharmacist 1, Pharmacist 1 stated that, generally crushing is not advised for extended-release medication. When asked specifically about crushing extended-release metoprolol, the pharmacist stated, it generally would not be advised. Pharmacist 1 verified the effects of crushing extended-release metoprolol stating, potentially there could be hypotensive effects and a larger drop in pulse (heart rate). During a concurrent interview and record review on 11/17/23 at 3:22 PM with Pharmacist 1, Resident 1 ' s medication orders were reviewed. Pharmacist 1 verified that crushing the metoprolol based on the current orders would be contraindicated stating, after reading that order I would not . this suggests that we should not be crushing that one, when referring to the extended-release metoprolol.

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 F0940 (Tag F0940)

Could have caused harm · This affected multiple residents

Based on interview and record review, the facility failed to demonstrate that they developed, maintained and implemented a training program for four out of four sampled clinical staff (registered nurs...

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Based on interview and record review, the facility failed to demonstrate that they developed, maintained and implemented a training program for four out of four sampled clinical staff (registered nurse [RN] 1, licensed vocational nurse [LVN] 1, certified nursing assistant [CNA] 1, and restorative nurse assistant [RNA] 1) when the facility could not produce documentation of orientation or competency documentation specific to the facility or resident care population for these four sampled staff. This failure has the potential to result in untrained staff that puts residents ' safety at risk. Findings: During an interview on 11/17/23 at 12:03 PM with the Director of Staff Development (DSD), a request was made for the employee files of RN 1, CNA 1, LVN 1, and RNA 1. A specific request for their licensure and documentation of orientation or competency training was made; the DSD verbalized understanding of the request. During an interview on 11/16/23 at 2:14 PM with CNA 1, CNA 1 states no when asked if the facility ever provided them with any type of orientation or on-boarding training. During concurrent interview and record review on 11/17/23 at 2:48 PM with DSD, RN 1 ' s employee file was reviewed. The employee file indicated a nursing license but no documentation on orientation or competency training. The DSD stated that RN 1 should have had an orientation. The DSD verified that they do not have any documentation of orientation or a competency training for RN 1 at that time, but they will attempt to find it. During concurrent interview and record review on 11/17/23 at 2:50 PM with DSD, LVN 1 ' s employee file was reviewed. The employee file indicated a vocational nursing license but no documentation on orientation or competency training. The DSD stated that LVN 1 should have had an orientation. The DSD verified that they do not have any documentation of orientation or a competency training for LVN 1 at that time, but they will attempt to find it. During concurrent interview and record review on 11/17/23 at 2:52 PM with DSD, CNA 1 ' s employee file was reviewed. The employee file indicated a nursing assistant certification but no documentation on orientation or competency training. The DSD stated that CNA 1 should have had an orientation. The DSD verified that they do not have any documentation of orientation or a competency training for the CNA 1 at that time, but they will attempt to find it. During concurrent interview and record review on 11/17/23 at 2:54 PM with DSD, RNA 1 ' s employee file was reviewed. The employee file indicated a nursing assistant certification but no documentation on orientation or competency training. The DSD stated that RNA 1 should have had an orientation and proof of an RNA certificate. The DSD verified that they do not have any documentation of orientation, competency training, or RNA certificate for the RNA 1 at that time, but they will attempt to find it. During an interview on 11/17/23 at 2:56 PM with the DSD, a request was made to provide any documentation of orientation or facility competency training for RN 1, LVN 1, CNA 1, and RNA 1. In addition, a request was made for the RNA certificate of RNA 1. The DSD stated that there is a policy for registry and staff onboarding. A request was made for that policy as well. The DSD verbalized understanding of the requests. During concurrent interview and record review on 11/17/23 at 3:35 PM with DSD, RNA 1 ' s certificate for RNA program was reviewed. The certificated indicated it was completed by RNA 1 in 2022. A request was made that all employee files originally requested be prepared for review on the next on-site visit to facility. DSD verbalized understanding. During a review of a policy title Competency of Nursing Staff (undated), provided on 11/21/23 at 2:34 PM via email from the Assistant Director of Nursing (ADON), the policy indicated, .licensed nurses and nursing assistants employed (or contracted) by the facility will: a. participate in a facility-specific, competency-based staff development and training program; and b. demonstrate specific competencies and skill sets deemed necessary to care for the needs of residents, as identified through resident assessments and described in plans of care. In addition, the policy indicated that, facility and resident-specific competency evaluations will be conducted upon hire, annually, and as deemed necessary based on the facility assessment. During an interview with the Director of Nursing (DON) on 11/27/23 at 9:42 AM, the DON verified that nursing staff are required to have an initial orientation prior to working directly with residents. During an interview with the DON on 11/27/23 at 10:47 AM, a request was made again for any documentation of orientation or facility competency training for RN 1, LVN 1, CNA 1, and RNA 1. The DON verbalized understanding of the requests. During an interview with the ADON on 11/27/23 at 12:36PM, a request was made again for any documentation of orientation or facility competency training for RN 1, LVN 1, CNA 1, and RNA 1. The ADON verbalized understanding of the requests. During an interview with ADON on 11/27/23 at 2:39 PM, the ADON stated that they are still looking for documentation of orientation or facility competency training for RN 1, LVN 1, CNA 1, and RNA 1. A request was made to furnish the documents for review by 5 PM on 11/27/23. The ADON verbalized understanding. During an interview with DON on 11/27/23 at 4:09 PM, the DON was reminded of requested documentation of orientation or facility competency training for RN 1, LVN 1, CNA 1, and RNA 1. During a concurrent interview and record review on 11/27/23 at 4:52 PM with the ADON, an elder abuse training for CNA 1 was reviewed. ADON verified that this is all the documentation they have so far as they are continuing to look for the other requested documents. During an interview on 11/27/23 at 4:59 PM with the ADON, the ADON verified that they currently do not have any documentation of orientation or facility competency training for RN 1, LVN 1, CNA 1, and RNA 1 at that time. ADON confirmed that RN 1 is a not a contracted staff member and that they should have a documented orientation stating, I know she has it, but I don ' t know why it wasn ' t shown.

Sept 2023 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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) was...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) was free from verbal abuse when Registered Nurse (RN) 3 told him Get out of my face twice. This failure resulted in Resident 2 stating I still don't feel safe here . during an observation and interview by the surveyor. Findings: Review of Resident 2's clinical record, Resident 2 was admitted on [DATE] with diagnoses including Obstructive Reflux Uropathy (flow of urine is blocked), Spinal Stenosis (narrowing of the spine), Functional Quadriplegia (complete inability to move). Review of Resident 2's Minimum Data Set (MDS, an assessment tool) dated 7/18/23, indicated a Brief Interview for Mental Status (BIMS, a cognitive assessment tool) score of 15. Which means intact cognitive response. Review of summary of investigation, dated 9/22/23 indicated RN 3 came into his room at the night of 09/12/2023 acting agitated and frustrated with him saying, what are you ratting on CNA 4 for? and You should apologize to CNA 4 when she comes back. As per the resident this went on for 15 minutes with the nurse's demeanor being confrontational, later that shift after this incident, he was asking for his pain medications and the shift nurse answered You know that medication you always ask for? You 're not getting any of it. This resident then brought up another incident earlier in the month about him asking to be brought back to bed in the nursing station and the same nurse saying, Get your ugly face out of my door, twice. During an observation and interview on 9/22/23 at 3:30 PM, Resident 2 was hesitant to talk and kept looking right and left to make sure that no facility staff could hear what he was telling surveyors. Resident 2 stated I don't feel safe with (RN3). I still don't feel safe here because he has friends here, this incident happened because RN 3 got upset because I ratted on CNA 4 about kicking my roommate, RN 3 told me to get out of my face, twice. Resident 2 added I don't want anybody to get in trouble. During an interview on 9/22/23 at 5:20 PM, the Director of Social Services (DSS) stated, the Interdisciplinary Team (IDT, a group of professionals who make treatment decisions for residents) should be done as soon as possible. DSS confirmed no IDT was found on Residents EMR. Review of Summary of Investigation, dated 9/22/23, indicated Alleged Nurse was interviewed and admitted he requested the resident to apologize to the CNA for reporting her and that his behavior is inappropriate. During Review of Policy and Procedure (P&P), dated December 2016, titled Abuse Prevention program indicated our residents have the right to be free from abuse .

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report the result of the abuse investigation to the California Department of Public Health (CDPH) within 5 working days in accordance with Federal requirements for one of three sampled residents (Resident 2). The alleged abuse incident for Resident 2 occurred on 9/12/23 and the result of facility investigation is not complete during the State Agency investigation visit on 9/21/23. The facility's failure to report abuse according to the required time frame had the potential to delay the identification and implementation of appropriate corrective actions and may place the residents at risk for abuse. Findings: Review of Resident 2's clinical record, Resident 2 was admitted on [DATE] with diagnoses including Obstructive Reflux Uropathy (Flow of urine is blocked), Spinal Stenosis (Narrowing of the spine), Functional Quadriplegia (complete inability to move). During an interview on 9/21/23, at 3:15 PM, the Administrator, stated we are in the process of completing the investigative summary. During an interview on 9/22/23, at 10:30 AM, Assistant Director of Nursing (ADON) 1 stated, the investigative summary was saved in her laptop and is at home that caused the delay, she confirmed that she will send it in 45 minutes. Review of email sent by Director of Social Services (DSS) dated 9/22/2 at 11:38 AM, indicated Will provide the summary of investigation for Resident 2 shortly. A Summary of Investigation dated 9/22/23 was received at CDPH on 9/22/23 at 2:50 PM. Eight (8) working days since the incident on 9/12/23. A review of P&P dated July 2017, titled Abuse Investigation and Reporting indicated, The Administrator, or his/her designee, will provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident.

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop care plans for two of three sampled residents ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop care plans for two of three sampled residents (Resident 1 and Resident 2) when: 1. There was no care plan developed to address alleged incident of staff verbal abuse to Resident 2 on 9/12/23. 2. There was no care plan developed to address the fall incident on 7/7/23 for Resident 1. This failure resulted to Resident 1's safety needs not being met and Resident 2's psychosocial needs not being met. Findings: Review of Resident 2's clinical record, Resident 2 was admitted on [DATE] with diagnoses including Obstructive Reflux Uropathy (flow of urine is blocked), Spinal Stenosis (narrowing of the spine), Functional Quadriplegia (complete inability to move). Review of Resident 2's clinical record was conducted on 9/22/23 at 4:50 PM with Registered Nurse 2 (RN 2). The records did not contain evidence that a care plan to address the staff verbal abuse on 9/12/23. During a concurrent interview with RN 2, RN 2 confirmed no care plan was developed and stated, No care plan was opened for risk for emotional distress. RN 2 added, There should be a care plan when a patient is abused. Review of Resident 1's clinical record indicated Resident 1 was admitted on [DATE] with diagnoses including end-stage renal disease with hemodialysis (kidney failure needing dialysis), Type II diabetes mellitus (high levels of sugar in the blood), and left-sided weakness related to cerebrovascular accident (stroke causing left sided weakness). Review of Resident 1's clinical record was conducted on 9/22/23 at 4:43 PM with RN 1. The records did not contain evidence that a care plan to address the fall on 7/7/23. During concurrent interview, RN 1 stated a new assessment, care plan and Interdisciplinary Team (IDT, grtoup of health care professionals who work for the client's goals) note should be done as soon as possible after a fall. RN 1 verified along with surveyor during record review that a post-fall care plan and IDT note were not completed. During a review of facility's policy titled The Care Plans, Comprehensive Centered revised December 2016 indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident receives adequate supervision to prevent accid...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident receives adequate supervision to prevent accidents, for one of three residents (Resident 1) when they failed to provide the appropriate level of assistance while transferring. This failure resulted in Resident 1 sustaining an injury to her left forehead, with bruising around her left eye area, from falling forward, while a Certified Nursing Assistant (CNA) was toileting the resident on 7/7/23. Findings: Review of Resident 1's clinical record indicated Resident 1 was admitted on [DATE] with diagnoses including end-stage renal disease with hemodialysis (kidney failure needing dialysis), Type II diabetes mellitus (high levels of sugar in the blood) and left-sided weakness related to cerebrovascular accident (stroke causing left sided weakness). A record review showed the admission assessment was done on 7/6/23. admission assessment lists Resident 1's Transferring status as 1-person assist. A record review of the 5-day Minimum Data Sheet (MDS, an assessment tool) for Resident 1 completed on 7/13/23 lists the Transfer status as Dependent, which is the assistance of 2 or more helpers is required for the resident to complete the activity. Review of Resident 1's record also indicated the date and time of the fall incident, which was 7/7/23 at 1:17 PM. Review of progress note written by LVN 1 dated 7/7/23 at 1:17 PM indicated, This writer responded to a call from inside the pt's room, pt fell face down while being cleaned up in the commode. (Patient noted with baseline left sided weakness from current diagnosis on admission), she loses balance leaning forward. Progress notes also indicated Neurochecks initiated, pt awake and alert, incident reported to Nurse Practitioner [NP 1] who happen to be in the building this afternoon, [family member] also notified about the incident. [NP 1] advised to send pt out for CT SCAN. Review of progress note by LVN 1 dated 7/7/23 at 1:17 PM indicated, Resident 1 was transferred to Hospital 1 (Hospital 1) on 7/7/23 at 3:15 PM. Progress note written by LVN 2 stated Resident back from [Hospital 1], via gurney at 0345 AM, no skin abrasion noted, discoloration on left side of face, VS WNL (within normal limits), as per [Hospital 1 Nurse] from [Hospital 1], resident has edema and hematoma on orbital region, CT inconclusive repeated 6 hr. after, no focal deficit, no changes on L side. During an interview with CNA 2 on 9/8/23 at 11:21 AM, CNA 2 stated if a person needs assistance and cannot ambulate on their own, then CNAs will use a mechanical lift, or gait belt and a 2 person assist for transferring residents from a bed to a wheelchair or to a commode. During a concurrent interview with CNA 3 on 9/8/23 at 11:21 AM, CNA 3 stated physical therapy (PT) tells the CNAs what level of assistance the residents need, i.e., 1-person assist, 2-person assist or max assist. During an interview with RN 1 on 9/21/23 4:43 PM, she stated Resident 1 should be checked more often than before and that resident should have been a 2-person assist during transfers. RN 1 also stated a new assessment, care plan and Interdisciplinary Team (IDT, a group of health care professionals who work together towards the goal of the client) note should be done as soon as possible after a fall. During an interview with RN 1, she reviewed Resident 1's clinical record, and did not find a post-fall care plan and IDT note completed after Resident 1 fell on 7/7/23. (Refer F656). Further interview with RN on 9/21/23 at 4:43 PM, RN 1 was asked about assist levels for residents (i.e., 1-person assist, 2-person assist, max care), she stated it is expected that the off-going CNA will let new shift know. For neurological checks post-fall, RN 1 stated they must be done every 15 minutes times 4, every 30 minutes times four, every hour times 4 and then every shift. RN 1 further stated if a resident is transferred to the hospital and returned after evaluation, then the neurological checks must resume at the last interval. During the interview on 9/21/23 at 4:43 PM with RN 1, she reviewed the clinical record of Resident 1 and did not find an interdisciplinary Note (IDT) note post-fall on 7/7/23, and there was no documentation of any listed interventions for Resident 1. During an interview with CNA 1 on 9/22/23 at 12:16 PM, CNA 1 said It's a guessing thing. I have to ask questions about what the resident needs, I don't get report, referring to resident level of assistance. CNA 1 also stated she took care of Resident 1 the day before the fall (7/6/23) and that she helped Resident 1 to the bathroom in a shower chair. CNA 1 stated she noticed Resident 1 did not hold her body up while on the toilet. Review of policy and procedure (P&P) titled Falls, and Fall Risk, Managing, last revised September 2023, states The IDT will review all falls, once a review is completed, Resident may be placed on the Fall Program. Review of same P&P also lists the following interventions but not limited to these interventions for the resident. Falling matt, 1:1, bed in lowest position, moving resident closer to nurse station, call lights in reach, toileting program, placing resident on the fall program or any other interventions that are resident centered. Review of P&P titled Safe Lifting and Movement of Residents, last revised July 2017, states Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Review of P&P titled Assessing Falls and Their Causes, last revised March 2018, states Observe for delayed complications of a fall for approximately forty-eight (48) hours after an observed or suspected fall and will document findings in the medical record.

Jul 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 F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of three residents` reviewed received servi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of three residents` reviewed received services according to professional standards of practice when: 1. Resident 5 had missed a regularly scheduled gluco-check (blood sugar check) 2. Resident 5 had missed Tamsulosin (a medication to treat the symptoms of enlarged prostate) and potassium ER (a medication to treat or prevent low pottasium level in the blood). 3. Facility staff did not empty Resident 5's urinary drainage bag. This failure had the potential to result to neglect resident's needs and not meet the professional standards of quality. Findings: 1. Resident 5 is a [AGE] year-old who was admitted on [DATE] with a diagnosis of cirrhosis (end-stage disease) of liver, morbid obesity, and type 2 diabetes (chronic, metabolic disease characterized by high blood sugar level). At the time of the abbreviated survey on 2/8/23 at 10:28 am, Resident 5 was awake, alert, oriented to person, place and time. He was conversant and sitting on the bed. During interview with Resident 5 on 2/8/23 at 10:28 am, Resident 5 stated, I get insulin twice a day. I get a blood sugar check at 6:00 am and 4:30 pm. Resident 5 continued, depending on how busy the nurses are, I get the blood sugar check between 4:00 pm to 6:00 pm. Sometimes, my dinner is cold already. 2. During record review, the monthly Medication Administration Record (MAR) for January 2023 showed: (i) a missed gluco-check and administration of Regular Insulin 100 unit/ml on 1/3/2023 at 6:30 am, 1/14/23 at 6:30 am, and 1/21/23 at 6:30 am; (ii)) Tamsuzolin HCL Capsule 0.4 mg. Give one capsule two times a day had one missed administration on 1/4/23 at 900 pm; (iii) Potassium Chloride ER 20MeQ give one tablet four times a day had one missed dose on 1/4/23 at 9:00 pm During record review, Resident 5 medication order reads: Potassium CL ER 20MEQ tablet. Give one tablet by mouth four times daily. On 2/6/23 and 2/7/23 there were no documented administration of Potassium Chloride and only one dose was administered on 2/5/23. 3. Resident 5 also showed a photo from his I-Phone of his foley catheter bag (urine collection bag) that is full. Resident 5 also stated, they don ' t empty it regularly. I have to ask them several times. During record review, the monthly Medication Administration Record (MAR) for January 2023 showed: Measurement of output on the indwelling foley catheter had a missed measurement on 1/21/23 at dayshift (7:00 am to 3:30 pm.).

CONCERN (D) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain an accurate record for one of three resident reviewed (Res...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain an accurate record for one of three resident reviewed (Resident 4), when the resident's bruise was not noted on the resident's clinical record This failure had the potential to result to delay in treatment or monitor further changes in condition. Findings: Resident 4 is a [AGE] year-old admitted on [DATE] with a diagnosis of idiopathic gout (build up of uric acid in smaller bones of the feet causing pain), chronic kidney disease and anemia (condition when there is not enough healthy red blood cells). At the time of the abbreviated survey, the resident was awake, alert, noted to be hard-of hearing and was opting to communicate via writing. During interview with clinical case manager (CCM) on 2/9/23 at 2:15 pm, CCM stated, resident 4 sent him a picture via text of a bruise on his leg. The text photo was date and stamped 1/16/23 at 12:47 pm. During review of Resident 4's record - the CCM wrote on 1/16/23, no further skin issues observed/noted to said area where resident claimed to be hit. LVN 1 wrote on 1/10/23, resident allowed (nurse) to check upper body and extremities. Skin is clear and intact. No open skin or bruises . and refused to let the nurse check lower extremities.

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that four of six residents (Resident 1, Residen...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that four of six residents (Resident 1, Resident 2, Resident 3, Resident 4) reviewed were free from abuse, when: 1. Resident 1 and Resident 2 had physical altercation on 1/25/23 which resulted in a laceration (a cut or tear on the skin) on Resident 1's head and a laceration on Resident 2's stomach. 2. Resident 2 touched Resident 3's external genitals inappropriately while Resident 3 was sleeping on 2/1/23 which had caused emotional trauma over a short period of time. 3. Registered Nurse (RN 2) struck Resident 4 on 1/10/23 which had resulted to bruise on Resident 4 ' s left lower leg Findings: 1. Resident 1 is a [AGE] year-old was admitted on [DATE] with diagnoses of end-stage renal disease (last stage of long term kidney disease), type 2 diabetes (chronic disease that occurs when blood sugar is too high), left-sided hemiplegia (paralysis) and hemiparesis (weakness). At the time of the abbreviated survey on 2/7/23, the patient was sitting on a wheelchair, alert, and oriented to person, place and time. Resident 2 is a [AGE] year-old admitted on [DATE] with diagnoses of diabetes (condition of high blood sugar), malignant neoplasm (cancer - abnormal cells divide uncontrollably and destroy body tissue) of the brain, and major depressive disorder (persistent feeling of sadness and loss of interest). At the time of the abbreviated survey on 2/7/23, the patient was lying in bed, awake, alert, conversant, and oriented to person, place and time. During interview with Resident 1 on 2/7/23 at 3:40 pm, Resident 1 stated, he (referring to Resident 2) hit me with a steel cane. Resident 1 proceeded to show the top of his head. The top of Resident 1 ' s head was observed to have a scar. During interview with Resident 2 on 2/7/23 at 2:48 pm, he stated, he (referring to Resident 1) hit me in the stomach twice. He hit me with what looked like a metal stick. I hit him. I tried to stop him. He called me a jackass. He is always making threats and tried to hit me. Resident 2 proceeded to show the right side of his abdomen. Resident 2 had a scar on right upper portion (quadrant) of his abdomen. During record review the Clinical Case Manager (CCM) wrote on 1/25/23 at 17:18, Resident 1 was noted with a cut in the left side of the head, and Resident 2 noted with cut on the right side of the abdomen. During record review, Resident 2 ' s progress note on 1/26/23 at 12:20 pm stated, resident transferred to another room r/t (related to) altercation with roommate. Resident unable to explain to nurse what caused altercation. 2. Resident 2 is a [AGE] year-old admitted on [DATE] with a diagnoses of type 2 diabetes (condition of high blood sugar), malignant neoplasm (cancer) of the brain and major depressive disorder. At the time of the abbreviated survey on 2/7/23, the patient was lying in bed, awake, alert, conversant, and oriented to person, place and time. Resident 3 is a [AGE] year-old admitted on [DATE] with a diagnosis of left-sided hemiplegia (paralysis) and hemiparesis (weakness), dysphagia (difficulty swallowing) following non-traumatic brain hemorrhage (bleeding), and kidney dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). At the time of the abbreviated survey on 2/7/23, the patient was lying on his back in bed, alert, conversant, oriented to person, place, and time. During an interview of Resident 3 on 2/7/23 at 10:50 am he stated, at 9 am on 2/1/23, bed B (Resident 2) came to me and touched my right thigh. Then moved his hand under my diaper. I pushed him with my right leg and he walked back to his bed. During an interview of CNA 3 on 2/7/23 at 11:12 am, she stated I am the regular CNA for Resident 3. He reported to me that his roommate touched his genitalia. CNA 3 further stated, I saw Resident 2 looking down on Resident 3. CNA 3 stated, Resident 2 was standing over on side of bed of Resident 3 while he slept. CNA 3 stated, (she) asked Resident 2 why are you staring at him (Resident 3)? Go back to your bed. During record review, CCM wrote on 2/1/23 at 16:30 CNA 3 asked CCM to immediately see Resident 3. Resident 3 reported to CCM .around 9: 00 am today while he was sleeping he was awakened by roommate (Resident 2) who at that time was touching his genitals. 3. Resident 4 is a [AGE] year-old admitted on [DATE] with a diagnosis of idiopathic gout (build up of uric acid in smaller bones of the feet causing pain), chronic kidney disease and anemia (condition when there is not enough healthy red blood cells). At the time of the abbreviated survey, the resident was awake, alert, noted to be hard-of hearing and was opting to communicate via writing. During the interview of Resident 4 on 2/6/23 at 12:37 pm, Resident 4 was noted to be hard-of hearing. Resident 4 showed a picture from his cell phone dated January 10, 2023 at 5:54 am. On observation, the photograph was that of a pinkish bruise approximately the size of a thumb located on what appeared to be the left lower leg above the ankle on the outside of the leg below the calf muscle. Resident 4 wrote on a piece of paper, the nurse did this. During an interview with the Clinical Case Manager (CCM) on 2/8/23 @4:16 pm, the CCM shared the same photograph that Resident 4 sent to him on 1/16/23 @12:47 pm via text message. Resident 4 ' s text message to the nurse stated, this is the result of the nurse physical strike against me. During record review, a written statement by RN 2 dated 1/12/23 was provided by the Director of Nursing (DON). RN 2 wrote , while passing meds, I entered Resident 4 ' s room to give . his meds. I called his name twice then gently touch his leg to try to wake him.

Jun 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0557 (Tag F0557)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure that one of four sampled residents' (Resident 2) personal belongings were inventoried upon admission and discharge. This failure had...

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Based on interview and record review, the facility failed to ensure that one of four sampled residents' (Resident 2) personal belongings were inventoried upon admission and discharge. This failure had compromised resident's right to determine adequate coverage of personal possessions. Findings: During review of Resident 2's clinical record, there was no personal inventory filled & signed by the resident. During interview with medical records assistant (MRA), on 5/31/23 at 4:15 pm, MRA acknowledged the lack of signed personal inventory. MRA stated that it should have been filled out and signed by the resident. The licensed nurse or certified nursing assistant or social worker should have filled up and asked the resident to sign.

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 F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure one (Resident 1) of three residents reviewed received shower bath during the course of his stay in the facility. This failure had th...

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Based on interview and record review, the facility failed to ensure one (Resident 1) of three residents reviewed received shower bath during the course of his stay in the facility. This failure had the potential to result for Resident 1 to develop various infections. Findings: During review of Resident 1's clinical record and shower monthly logs for April 2023, there was no record that Resident 1 took shower bath during the course of his stay in the facility. During interview with licensed vocational nurse (LVN) on 5/31/23 on 2:33 pm, LVN stated Resident 1 didn't take shower bath. He's supposed to take shower on 4/7/23.

May 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review, the facility failed to provide a policy that clearly define the mechanisms and procedures for assessing or identifying, monitoring and managing resid...

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Based on observation, interview and record review, the facility failed to provide a policy that clearly define the mechanisms and procedures for assessing or identifying, monitoring and managing residents at risk for elopement when: 1. Facility policy does not indicate procedure for assessment, identification, monitoring and managing resident at risk for wandering and elopement. 2. When Resident 1, left the faciity on 9/16/22, unauthorized and unsupervised. Findings: 1. During an interview on 9/16/22 at 5:30 PM with RN 1, RN stated, I reported the incident, resident is alert and oriented. Resident went to the bank, Chase Bank on 16th and Mission St SFO. We reported to police and was searching for him. We told the sister about him missing, he was not answering the phone. Sister called his cell phone and a guy answered not this resident. Per sister, the guy will give her the phone back. That ' s how the police was able to trace his location.The police brought him back at around 4 pm . patient came in calm and was upset about the money in his bank. He came home hungry and we gave him lunch. 2. During an interview with SS 1, SS 1 stated, I was at work last Friday, I'm aware of the incident.I ' m aware of the incident. We noticed by noon, that resident was missing, so we filed the SOC 341 form. I visited the patient today, patient able to recall the incident, did not mention about money, kept saying,I ' m okay don ' t want to talk about it.Asked for procedure or protocol for alert and oriented patient who wants to go out on pass? SS stated, the nurse will call the doctor, MD to evaluate the patient, will order OOP if able.Review of Physician ' s Orders, dated 4/11/22, indicates, May go out on Pass as part of therapeutic regimen.Review of eMAr dated 9/16/22, indicates, Dialysis days every Tuesday, Thursday and Saturday.Incident happened 9/16/22, a Friday. 3. During a review of facility Policy and Procedure for Missing Resident, no date, on 9/27/22, indicates, it is the policy of this facility that if a resident is determined missing to commence an immediate search for the resident.Review of facility Policy and Procedure for Wandering and Elopements, dated March 2019, indicates, the facility will identify residents who are at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environments for residents .if identified as risk for wandering, elopement , or other safety issues, the resident ' s care plan will include strategies and interventions to maintain the residents ' s safety . 4. During a review of the care plan dated 9/20/22,indicates, Actual incident of leaving building unaccompanied. At risk for injury due to episodes of wandering, patient tends to leave the building unaccompanied to go to the bank Interventions does not indicate supervision and safety when he goes out to the bank.Facility not able to provide care plan with interventions to maintain resident's safety. Therefore, the facility failed to follow Policies and Procedures provide a policy that clearly define the mechanisms and procedures for assessing or identifying, monitoring and managing residents at risk for elopement when: 1. Facility policy does not indicate procedure for assessment, identification, monitoring and managing resident at risk for wandering and elopement. 2. When Resident 1, left the faciity on 9/16/22, unauthorized and unsupervised.

May 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure Residents 1, 2, 3, and 4, four out of 32 sampled residents,...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure Residents 1, 2, 3, and 4, four out of 32 sampled residents, were protected from neglect. Family members of Residents 1, 3, and 4 reported: a pattern of waiting for long period of time for staff assistance with bowel and bladder care. Additionally, Residents 1 and 2's family members reported Residents 1 and 2 had to wait a long time for medications. The facility failed to ensure Residents 1, 2, 3, and 4 were free from neglect. This pattern of delayed staff response resulted in Residents 1, 3, and 4 not being cleaned in a timely manner and Residents 1 and 2 not receiving their medications in a timely manner. Findings: Resident 1 Review of Resident 1's records titled Minimum Data Set (MDS, a standardized resident assessment tool), dated 12/2/2022, indicated her BIM score was 15 out of 15 (BIM=Brief Interview for Mental status, a standardized test for memory and reasoning functions. A score of 13-15 indicates no impairment in memory and reasoning). According to her MDS: she required extensive assistance from one staff with: 1. Bed mobility 2. Transfers 3. Dressing 4. Toilet use and personal hygiene According to Resident 1's MDS, she was frequently incontinent of bladder and occasionally incontinent of bowel. Resident 1's MDS assessed her as displaying no episodes of hallucination (seeing, hearing, or sensing things that are not based on reality), no delusion (believing in something that is not based on reality), and no rejection of care. During an interview on 4/13/23 at 10:50 AM, Resident 1's family member stated .sometimes getting help, getting .(Resident 1) changed could be hours and hours. Sometimes it could be 1-2 hours before someone came to her room.when I was there, I saw how long it took them to help.Weekday or weekend it didn't matter. (Resident 1) told me on weekend it was worse.Waiting for medication just to get it, it took a lot of time. She said she could be waiting for an hour to two hours. Her roommate . experienced the same thing. They kept calling and calling the nurses for medication. Resident 1's family member stated when .I was there it was like an hour. She needed to be changed. I finally had to go find a nurse to help her. Resident 2 Review of Resident 2's MDS, dated [DATE], indicated he was independent in making consistent/ reasonable decision regarding tasks of daily life. Resident 2's MDS assessed him as displaying no episodes of hallucination, no delusion, and no rejection of care. According to Resident 2's MDS, he needed extensive assistance of one staff with: 1. Bed mobility 2. Dressing Review of Resident 2's MDS indicated he required supervision of one staff with: 1. Transfers 2. Walking in room and in corridor 3. Toilet use and personal hygiene Review of Resident 2's eMAR (electronic Medication Administration Records), for the month of March 2023, indicated he was taking medications for: 1. High cholesterol 2. Stroke prevention 3. Anti-depression 4. Reflux of gastric juices back into throat and mouth 5. High blood pressure 6. Irregular heartbeat 7. Lowering blood phosphorus due to kidney disease His eMAR also indicated he was getting vitamins and a nutritional supplement. During an interview on 4/13/23 at 12:02 PM, Resident 2's family member stated .for medication once he waited as long as an hour. Sometimes he has to go to his dialysis. He hasn't had his medication and we had to wait. They are taking too long to give him his medications. He goes to bathroom by himself. They are not supervising him. He might easily fall down. Resident 3 Review of Resident 3's MDS, dated [DATE], indicated his BIM score was 6 out of 15. A BIM score of 6 indicated Resident 3 had a drastic deterioration in memory and reasoning. Resident 3's MDS assessed him as displaying no episodes of hallucination, no delusion, and no rejection of care. According to Resident 3's MDS, he needed extensive assistance of one staff with: 1. Bed mobility 2. Transfers 3. Dressing 4. Toilet use and personal hygiene According to Resident 3's MDS, he was assessed as frequently incontinent of bowel and bladder. During an interview on 4/13/23 at 1:21 PM, Resident 3's family member stated .sometimes the facility is short staff. Resident 3's family member was asked how she knew the facility was short staffed. Resident 3's family member stated I visit my husband almost every afternoon, .Sometimes there's no nursing staff, we ring the call light, but no one come. I have to go look for them. Sometimes we have to wait 1/2 hour, sometimes longer. He needs to be changed. He doesn't speak English. I have go looking for them because he needs help . Resident 4 Review of Resident 4's MDS, dated [DATE], indicated her BIM score was 8 out of 15. A BIM score of 8 indicated Resident 4 had a mild deterioration in memory and reasoning. Resident 4's MDS assessed her as displaying no episodes of hallucination, no delusion, and no rejection of care. According to Resident 4's MDS, she needed extensive assistance of two staff with: 1. Bed mobility According to Resident 4's MDS, she needed extensive assistance of one staff with: 1. Dressing 2. Eating 3. Toilet use and personal hygiene According to Resident 4's MDS, she was assessed as always incontinent of bowel and bladder. During an interview on 4/13/23 1:02 PM, Resident 4's family member stated .Sometimes (Resident 4) was not cleaned. they didn't clean her. They told her they would be there and wouldn't come. Sometimes it would be over an hour. Sometimes she gets frustrated waiting and waiting for them. She would have to call me and then I would have to call them to go help her. Staff Interview During an interview, on 4/7/23 at 12:25 PM, LVN (Licensed Vocational Nurse) 1 stated .it seems like nobody wants to speak out about staffing. Certain people were covering up for each other.14 -20 patients for one CNA (Certified Nursing Assistant) it wasn't a really good experience. There's a high patient to CNA ratio. They just do the bare minimum. Like changing the diaper. I've seen and heard of long time for call lights to be answered and things to be done. I cannot manager the CNAs and care for my patients and answer the phone. One day it was really cold. The call light was probably on for at least 20 minutes. I would have to look for the CNA. It was another 20 minutes before the CNA could go help the patient. During an interview on 4/7/23 at 12:44 PM, LVN 2 stated .right now everywhere you go staffing is an issue. My first day over there I was left on my own and expected to care for my patients. That night no regular staff was there. No endorsement from staff going off shift. They just took off and expected me to pass medications. My experiences was if I'm scheduled five days a week, at least three of those day, we were usually short at least 1-2 staff. Longest they wait for call light, I would say ½ hour. Depends on the staff, some are never seen on the floor because they are with another patient. They are busy. Sometimes we find patients not clean when we come on shift .full of urine and BM (bowel movement). CNA complained that they cannot clean a patient. They just don't have enough staff. During an interview on 4/21/23 at 11:01 AM, the DON stated her expectation was that staff would answer a call light within 5-10 minutes if possible. The DON stated they have been educating staff that answering call lights is the responsibility of everyone, not just CNA and nurses. The DON stated she expects her staff to administer medications in a timely manner. The DON stated it is unacceptable for a dialysis appointment to be delayed for medication administration. Review of the facility's policy titled Answering the Call light, revised on October, 2020, indicated staff should .Answer the resident's call as soon as possible.If you have promised the resident you will return with an item or information, do so promptly.

Mar 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview & record review, the facility failed to follow physician's order for one (Resident 1) of three residents revi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview & record review, the facility failed to follow physician's order for one (Resident 1) of three residents reviewed, when licensed nurses did not re-evaluate Resident 1's pain status on evening shift of 3/14/22, night shift of 3/20/22 and day shift of 3/27/22. This failure had potential to result for Resident 1 to experience an increase in discomfort. Findings: During review of Resident 1's clinical record, Resident 1 was admitted on [DATE], with diagnosis included chronic obstructive pulmonary disease (COPD, lung disease that block airflow and make it difficult to breathe), spinal stenosis (narrowing of the spinal canal), and uropathy (blockage in your urinary tract). Review of Resident 1's medication administration record (MAR) dated 3/2022, indicated there was no licensed nurses' signature on evening shift of 3/14/22, night shift of 3/20/22 and day shift of 3/27/22 During interview with registered nurse (RN) on 11/16/22 at 3:24 pm, RN acknowledged that the licensed nurses did not re-evaluate Resident 1's pain on those dates as it was not documented on the MAR. During review of Resident 1's physician order dated 3/2022, indicated Pain monitoring using verbal/non-verbal 0-10 scale - 0 no pain, 1-3 mild pain, 4-7 moderate pain, 8-10 severe pain. Every shift for monitoring level of comfort.

Mar 2023 7 deficiencies 1 Harm

SERIOUS (H) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Deficiency F0692 (Tag F0692)

A resident was harmed · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a comprehensive systemic approach to ensure ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a comprehensive systemic approach to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status for four of eight sampled residents (Resident 1, 3, 4, and 6) when: 1. The facility failed to ensure a Registered Dietitian (RD) evaluated and reassessed Residents 1,3, 4, and 6's nutritional status to recommend nutritional interventions, after unplanned severe and continuous weight loss. a. Resident 1 experienced progressive weight loss from 11/2022 to 1/2023, with a total weight loss of 39.6 pounds (lbs.- a unit of measurement) (20 percent of body weight) with no implemented interventions to address the unplanned weight loss during this period. b. Resident 3 experienced a continuous and progressive weight decline from 9/2022 to 2/23, with a total loss of 44 lbs. (21 percent of body weight). There was a delay of care coordination with the RD, nursing, and physician to ensure weight loss was recognized and interventions were implemented during this period. c. Resident 4 experienced a 6.2 lbs. (six percent) weight loss within 3 months' time (12/22 to 2/23). There was no nutrition assessment and there was no plan of care during weight loss period. d. Resident 6 had continuous weight decline from 9/22 to 3/23, with a total loss of 26.8 lbs. or 10.9 %. There was no nutritional assessment and plan of care to address weight loss and prevent further weight loss. As a result, the facility's system was not effective at ensuring the Registered Dietitian (RD) and the Interdisciplinary team (IDT- a group of health professionals from the diverse fields who work in coordinated fashion toward a common goal for the resident) evaluated unplanned weight loss. The facility failed to ensure that nutrition interventions to address identified nutritional concerns were implemented. These failures resulted in weight loss for Residents 1, 3, 4 and 6. Findings: Resident 1 During a review of Resident 1's History and Physical (H&P) dated 11/15/22, indicated Resident 1 was admitted to the facility with diagnoses including cerebral infarction (also known as stroke- refers to damage to tissues in the brain due to loss of oxygen to the area), hypertension (high blood pressure), diabetes mellitus type II (a chronic condition that affects the way the body processes blood sugar in the body) Heart Failure (is a condition that occurs when the heart can't pump as well as it should) and dysphagia (difficulty swallowing). Resident 1's admission diet order was CCHO (consistent carbohydrate diet), SB6 (soft bite diet, level 6) texture and nectar thick fluids. Resident 1's medical record, indicated he weighed 200 pounds on his first admission on [DATE]. Resident 1 had multiple admissions including recent Covid - 19 diagnosis which resulted in poor appetite. Resident 1 was sent out and admitted to the hospital due to chest discomfort on 12/3/22 and re admitted back to the facility on [DATE]. Resident 1 was sent out and admitted to the hospital for altered level of consciousness on 1/9/23 and readmitted to the facility on [DATE]. On 2/18/23, Resident 1 expired. During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) assessment, dated 1/24/23 indicated Resident 1 weighed 160 pounds (lbs.) and had a Weight loss of 5 % or more in the last month or loss of 10% in the last 6 months and was not on physician prescribed weight -loss regimen [ a program that is supervised by a medical professional that specializes primarily in weight loss for individual that have a hard time losing weight despite their efforts] Resident 1's cognitive skills for daily decision making was cognitively intact. During a review of Resident 1's Weight Summary indicated the following weights: 11/16/22- 200.0 lbs. 1/20/23- 160.4 lbs. 1/25/23- 160.4 lbs. 2/3/23- 149.0 lbs. 2/15/23- 134.4 lbs. Resident admission weight on 11/16/22 was 200 lbs. There was no weight done by the staff in the month of 12/22. On 1/20/23 Resident 1's weight recorded was 160.4 lbs., a 19.8 percent loss in 3 months. On 2/3/23 Resident 1's weight went down to 149.0 lbs. (comparison weight 1/20/23, 160.4 lbs. 7 %- 11.4 lbs.). And on 2/15/23, weight was documented as 131.4 lbs. (comparison weight 1/20/23, 160 lbs.- 18.1%- 29 lbs.) (Total weight loss from 11/16/22 to 2/15/23 was approximately 34.3 % equivalent to 68.6 lbs. During a review of Resident 1's Nutrition Comprehensive Assessment dated 12/9/22, Registered Dietitian 1 (RD 1) documented Resident 1's weight was 200 lbs. (Weight was taken from Resident 1's admission weight record on 11/16/22). The RD 1 documented Inadequate intake r/t reduced appetite secondary to covid+ aeb [as evidence by] eating 0-50% of meals along w/ meal refusals. The nutritional intervention included was to order Glucerna every day between meals. Under Monitoring & Evaluation section, indicated to Monitor PO, wt [weight] trends, honor food preference as able and obtain wt. per facility protocol, and to follow up as needed. During a review of Resident 1's Order Recap Report (ORR) dated 12/01/22 to 1/31/23, it indicated Glucerna was ordered on 1/25/23 (a month and a half after it was recommended by the RD 1 on 12/9/22). It also indicated an order on 11/15/22, 12/5/22, and on 1/18/23 for weekly weights for 4 weeks, then reevaluate one time a day every Wednesday for four weeks. During a review of Resident 1's Nutrition Comprehensive Assessment dated 1/25/23, The Registered Dietitian 2 (RD 2) documented Resident 1's readmission weight 160.4 lbs. on 1/20/23 and had Weight loss 18 kg (20 % UBW [ Usual Body Weight) from 11/16/22 to 1/2023, it also indicated that it was unclear if its due to weight variances from previous admission. During a review of Resident 1's weight loss care plan, initiated on 1/25/23 and revised on 2/20/23 indicated the goal was to maintain weight, > 50 % of meals, nourishments and supplements and will be free from signs and symptoms of dehydration. Interventions listed included obtain weight as ordered, monitor for signs and symptoms of dehydration, and encourage fluids while awake in addition with meals. There was no indication the care plan was implemented as interventions such as weekly weight monitoring. During a review of the physician's Progress Notes dated 11/17/22 to 1/31/23, there was no documentation the physician was aware and or addressed Resident 1's severe weight loss until 2/8/2023. The physician progress notes dated 2/8/23 indicated under the Chief Complaint/ Nature of Presenting Problem was, weight loss, poor appetite and covid follow up. It also indicated; Resident 1 had been losing weight with over 10 lbs. in less than 2 weeks. Under the Plan for weight loss and poor appetite was RD consult, encourage to eat and to continue Remeron (for depression manifested by poor oral intake). During a concurrent interview and record review on 3/7/23 at 11:15 AM with the Restorative Nursing Assistant 1 (RNA 1) (2 East unit) and RNA 2 (2 [NAME] unit), Resident 1's electronic weight record (EWR) summary and 2 East and 2 [NAME] unit's weight binders were reviewed. Resident 1's EWR summary indicated on 11/16/22 Resident 1's weight was 200 lbs. (admission weight). There was no recorded weight for the month of December 2022. The following weight recorded was on 1/25/23, Resident 1's weight documented was 160.4 lbs. (Re admission weight). 2 [NAME] unit weight binder indicated Resident 1's weight was 200 lbs. taken on 11/2022. RNA 2 stated that was the only weight record of Resident 1 in 2 [NAME] unit before Resident 1 transferred to 2 East unit. There was no documented weight of Resident 1 in 2 East unit record binder. RNA 1 stated, Resident 1 was transferred from 2 [NAME] to 2 East unit on the first week of 12/22. RNA 1 stated Resident 1's weight was never taken while he was in 2 East unit. During a concurrent interview and record review on 3/8/23 at 10 AM with the Director of Nursing (DON), Resident 1's medical electronic record was reviewed. In the nutrition comprehensive assessment dated [DATE], the RD 1 did not document the actual re -admission weight (re-admission [DATE]) but rather documented the previous weight of Resident 1 taken on 11/15/22 (Initial admission.) The nutrition intervention recommendation of Glucerna every day in between meals and to obtain weight per facility protocol, and to follow up as needed were not implemented. There was no nutrition and weight loss care plan to address the nutritional status of Resident 1 on time. (Weight loss care plan was initiated on 1/25/23). There was no documentation of the license nurses informing the RD and or the physician about Resident 1's severe weight loss. There was no documentation of the physician was aware and addressed the severe weight loss during the period when Resident 1 lost his appetite and had poor intake. The DON verified and acknowledged the findings. The DON stated the facility missed taking Resident 1's weights as ordered and as per facility's policy. The DON reviewed the RD1's comprehensive assessment dated [DATE], and stated, Resident 1's weight should have been taken when he was re - admitted to the facility on [DATE]. The DON further stated that the RD 1 could have documented the actual weight of Resident 1 when he was readmitted on [DATE], and it could have addressed and monitored the progressive weight loss on time. The DON stated when a Resident had a weight loss, the information was given to the nurses and the nurse was responsible for notifying the physician and the RD. The DON stated physician notification should have been documented in Resident 1's clinical record. The DON confirmed physician notification was not documented in the electronic medical record. The DON stated there was a gap in communication with the previous RD (RD 1), she stated her expectation from the RD was to attend every weight meeting in the facility, provide recommendations and interventions regarding nutrition issues and to talk to the management directly regarding the weight and nutrition issues. The DON stated the RD 1 transitioned from full time to part time and to on call during the period of 11/2022 through 1/2023. The DON added, the RD 1 is no longer working in the facility. During a concurrent interview and record review on 3/8/23, at 11:40 AM, with RD 2, Resident 1's weight summary, nutrition assessment and nutrition notes from 11/22 through 2/23 were reviewed. The RD 2 stated she started to work at the facility on the last week of 1/2023 as a part time basis and sometimes remotely. The RD 2 stated her job duties included completing nutritional evaluations on all new admissions and focusing on the residents with weight loss issues. The RD 2 also indicated she was not sure how the facility conducts their IDT meeting for weight loss issues. The RD 2 stated she communicated with the Dietary manager (DM), if there was a new admission in the facility or if there were weight loss issues. She stated Resident 1 was re admitted to the facility on [DATE], and that was the reason why she did Resident 1's nutrition comprehensive assessment on 1/25/23. It indicated Resident 1's weight was 160.4 lbs. and had Significant weight change of 5 lbs. % or more in the last month or weigh change 10 % or more in the last 6 months. The RD 2 documented that there was a Wt. loss 18 kg (20 % UBW [Usual Body Weight] from 11/16/22 to 1/20/23, unclear if d/t [due to] wt. scale from previous admit The RD 2 stated the previous RD (RD1) did not specify if it was a planned weight loss, and if it was planned, it should have been coordinated with the resident and the physician such as what was the expectations and what was the weight to achieve. During an interview on 3/15/22 at 11:25 AM, with Registered Nurse 1 (RN 1), RN 1 stated License nurses were responsible in documenting a resident's weight in their medical electronic record. RN 1 stated she obtains resident weight list from the Restorative Nurse Assistant (RNA). If a resident triggered an alert for significant weight change, she would notify the physician and would document the physician notification in the electronic medical record, under progress notes and update the care plan. Resident 3 During a review of Resident 3's Resident Dashboard indicated Resident 3's initial admission was on 5/14/22 with diagnoses including acute embolism (a block in an artery caused by blood clots or other substances) and thrombosis (is the formation of a blood clot inside of blood vessels) of deep veins or right upper extremity, type 2 diabetes mellitus (characterized by high level of sugar in the blood), rheumatoid arthritis (causes joint inflammation and pain) and effusion (an abnormal collection of fluid in hollow spaces or between tissues of the body). admission Diet was Consistent Carb diet, Regular texture. Thin liquid consistency. During a review of Resident 3's Weights and Vitals Summary indicated as follows: Resident 3's admission weight was 208 lbs.; Resident 3 experienced a continuous and progressive weight decline from 9/5/2022 to 2/21/22. Monthly weights taken as follows: 5/16/22 - 208 lbs. (admission weight) 9/5/22 - 210 lbs. 10/6//22 - 198 lbs. 11/6/22 - 200 lbs. 11/30/22- 200 lbs. 12/4/22 -202.2 lbs. 1/25/23- 181.4 lbs. 2/3/2023- 166 lbs. 2/21/23- 166 lbs. In the months of 9/22 to 10/22, Resident 3 lost 12 lbs. (5.7 % weight loss). In the months of 12/22 to 1/23 Resident 3 lost 20.8 lbs. (10%) in a month, In the months of 1/23 to 2/3/23, Resident 3 loss additional 15.4 lbs. (8%). Resident 3 experienced a total weight loss 44 lbs. or 21% of her body weight over 6 months, which was considered severe. During a review of Resident 3's Nutrition Comprehensive Assessment dated 12/6/22, it indicated RD 1 documented Resident 3's admission weight was 202.2 lbs. and that there was no significant weight change of 5 lbs./5% or more in the last month or weight change of 10% or more in the last 6 months. RD 1 indicated in the summary notes that Resident 3's weight had been stable for 180 days. RD 1 indicated the nutritional goal for Resident 3 included no significant weight changes, intake 50 % or more of most meals and maintain skin integrity. There was no follow up Nutrition Comprehensive Assessment after 12/6/22. During a review of Resident 3's Nutrition Quarterly Review dated 3/7/23, indicated Resident weight 30 days (one month) ago was 200 lbs. and 208 lbs. 180 days (six months) ago. The RD 1 indicated that Resident 3 had a significant weight loss (Considered significant loss-5 % weight loss in a month, 7.5 % in 3 months and 10 % weight loss in six month) of 34 lbs. rather than severe weight loss (Considered severe weight loss- greater than 5% in one month, greater than 7.5% in 3 months and greater than 10 % in six months) During a review of NSG [nursing]: Skilled Charting progress notes from 1/25/23 to 2/1/23 indicated Resident 3 was stable, no significant change, and to continue current plan of care. There was no documentation of resident 3's weight loss was reported to the RD and physician. During a review of Resident 3's physician's Visit dated 12/19/22 through 2/13/23, under Nursing Home Progress Note indicated History Comments 2: Patient is awake, alert, good mood, no reports of shortness of breath, chest pain abdominal pain, headaches, TIA's [ Transient Ischemic Attack- a temporary blockage of blood flow to the brain] or decrease oral intake There was no indication of Resident 3's weight loss was recognized by the physician. During a review of Resident 3's Unspecified: Dietary care plan dated 12/1/22 indicated Resident 3 was at risk for altered status, one of the interventions was to Assess and report to MD ARNP [Advance Registered Nurse Practitioner]: any significant weight loss or gain. There was no care plan to address the severe weight loss for Resident 3. During a concurrent interview and record review on 3/8/23 at 11:20 AM with the RD 2 and the Dietary Manager (DM), Resident 3's weight record summary and nutrition assessments were reviewed. The RD 2 stated she was not familiar with Resident 3's weight and nutrition issues, and it was being handled by the other RD consultant in the facility that had just started recently as a part time consultant. The DM stated she was not aware of Resident 3's nutrition and weight issues before because during that time, it was The RD 1 was the one involved in taking care of weight and nutrition issues. During a concurrent interview and record review on 3/16/23 at 11:40 AM with the DON, Resident 3's medical electronic record was reviewed. The DON was asked why the severe weight loss of Resident 3 was not identified or interventions provided on time. The DON acknowledged that there was a gap in communication with the RD 1, and the nursing staff. The DON stated the facility was a big facility and there was only one RD during that time. Resident 4 During a review of Resident 4's face sheet (document containing personal and medical information) dated 3/15/23, indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including, Traumatic subdural hemorrhage (Buildup of blood on the surface of the brain) without loss of consciousness and Dementia (loss of cognitive functioning, remembering). On 3/28/22, Resident 4's documented weight was 109.0 lbs. Resident 4's diet was Regular diet with minced and moist texture and nectar thick liquids. During a review of Resident 4's Weight Summary indicated as follows: 3/28/22- 109 lbs. 4/13/22- 109 lbs. 5/5/22- 115.8 lbs. 6/17/22- 116 lbs. 7/13/22- 120 lbs. 8/5/22- 119 lbs. 9/6/22- 120 lbs. 10/7/22- 123 lbs. 11/3/22- 122 lbs. 12/8/22- 122 lbs. 1/5/23- 118 lbs. 2/3/23- 113 lbs. 2/21/23-115.8 lbs. 3/10/23- 115 lbs. Resident 4 weights was from 109 lbs. to 123 lbs. within seven months. The weight was stable for two months and began declining from 12/22 through 2/23, Resident 4 lost 6.2 lbs. in three months' time (6 % weight loss). There was no Nutrition Assessment done during the weight loss period. During a review of Resident 4's Care Plan There was no care plan /intervention documentation to address the weight loss. During a concurrent observation and interview on 3/15/23 at 12:20 PM with Resident 4 in his room. Resident 4 was observed sitting on his bed with his meal tray on top of his bedside table. Resident 4 stated he was done eating his lunch. Resident 4's meal tray was observed with untouched pudding, thicken fruit juice, thicken milk, and untouched mashed potatoes still on his plate. Resident 4 stated, I don't like this food, that is the reason probably why I'm losing weight During a review of Resident 4's Amount Eaten with Meals dated 3/15/23 indicated the amount Resident 4's had eaten for lunch was documented as 3 equivalent of 50 to 75 %. During a concurrent interview and record review on 3/15/23 at 1 PM with Certified Nurse Assistant 1 (CNA1), Resident 4's Amount Eaten with Meals documentation was reviewed. CNA1 stated he document the meal intake percentages based on his own calculation only. During a concurrent interview and record review on 3/17/23 at 10:50 AM with the DM, Resident 4's latest History and Food Preferences dated 11/21/22 was reviewed. It indicated special request for lunch was puree fruit and pudding. The DM stated there was no updated food preference for Resident 4, and Resident 4 was on her to do list. Resident 6 During a review of Resident 6's face sheet (Document containing personal and medical information) dated 3/14/23 indicated Resident 1 admitted to the facility on [DATE] with diagnoses included type 2 diabetes mellitus, hypertension, gout (a form of arthritis- joint inflammation) and acute cystitis (bladder infection). Resident 6's admission weight was documented as 215.6 lbs. During a review of Resident 6's Weight Summary indicated as follows: 9/29/22- 215.6 lbs. 12/4/22- 212.3 lbs. 1/25/23 191.2 lbs. 2/3/23- 192.0 lbs. 3/9/23- 188.8 lbs. The weight summary indicated, Resident 6's admission weight on 9/29/22 was 215.6 lbs. There was no weight documented on the month of 10/22-11/22. On 12/4/22, Resident 6's weight recorded was 212.3 lbs., and on 1/25/23 resident weight declined to 191.2 lbs. (9.7%) loss in one month. 3/9/23, resident weight continued to decline to 188.8 lbs. (Total weight loss from 9/29/22 to 3/9/23 was 26.8 lbs. (12% loss in six months). There was no nutritional assessment and care plan documentation during the weight loss period. During a review of Nursing progress note dated 12/22 through 3/23, there was no documentation that Resident 6's weight loss was reported to the RD and MD. During a concurrent interview and record review on 3/16/23, at 2:22 PM with the DON, Resident 6's weight summary, nutritional assessment and nursing progress notes were reviewed. The DON acknowledged that there was no documentation the nursing staff reported the weight loss to the RD and to the primary physician. The DON stated that there should be a nutritional assessment and care plan done to address Resident 6's weight issue. The DON stated, there was a communication gap with the previous RD (RD1). During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, revised 09/2008, the P& P indicated Weight Assessment 1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. 2. Weights will be recorded in each unit's weight record chart or notebook and in the individual's medical record. 3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing. 4. The Dietitian will respond within 24 hours of receipt of written notification. 5. The dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends overtime. Negative trends will be evaluated by the treatment team whether the criteria for significant weight change have been met. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria . 1 month 5% weight loss is significant; greater than 5 % is severe. 3 months- 7.5 % weight loss is significant; greater than 7.5 is severe. 6 months- 10 % weight loss is significant; greater than 10 % is severe. 7. If the weight change is desirable, this will be documented and no change in the care plan will be necessary . Care Planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the physician, nursing staff, the Dietitian, the Consultant Pharmacist, and the resident or resident's legal surrogate. 2. Individualized care plan shall address to the extent possible: a. The identified causes of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment .Interventions for undesirable weight loss shall be based on careful consideration of the following .Interventions for undesirable weight loss shall be based on careful consideration of the following . Nutrition and hydration needs of the resident . During a review of the facility's P&P titled Nutritional Assessment, revised 10/2017, the P& P indicated, .As part of the comprehensive assessment, the nutritional assessment will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition .Individualized care plans shall address , to the extent possible: .goals and benchmarks for improvement; and d. timeframes and parameters for monitoring and reassessment . During a review of the facility P&P titled, Nutrition (impaired) Unplanned Weight loss- Clinical Protocol revised 9/17, indicated Assessment and Recognition .The nursing staff will monitor and document the weight and dietary intake of residents in format which permits comparison overtime . The staff will report to the physician's significant weight gains or losses or any abrupt or persistent change from baseline appetite or food intake . The facility document titled Dietitian undated, indicated .Duties and Responsibilities . Care plan and Assessment Functions . Develop a written dietary plan of care (preliminary and comprehensive) that identifies the dietary problems/needs of the resident and the goals to be accomplished for each dietary problem/need identified .Review nurses notes to determine if the care plan is being followed. Discuss problem areas with the director of Nursing Services . Review and revise the care plans and assessments as necessary, but at least quarterly .

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

Based on observation and interview, the facility failed to protect the privacy of personal information for 16 residents when Registered Nurse 2 (RN 2) left the protected health information (PHI) expos...

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Based on observation and interview, the facility failed to protect the privacy of personal information for 16 residents when Registered Nurse 2 (RN 2) left the protected health information (PHI) exposed for public view. This failure had the potential for unauthorized access to personal information and violated residents' rights for privacy and confidentiality. Findings: During a concurrent observation and interview with the Nurse Supervisor 1 (NS 1) on 3/6/23 at 9:40 AM, the medication cart (MC) was observed parked at 1 East Nurse Station unit's hallway. The MC screen monitor was observed on, unattended and visible to everyone who passed by the MC in the hallway. In the screen monitor, displayed 16 resident's identifiable personal information and pictures. It was observed there were several residents and staff passing by the hallway. The NS 1 acknowledged that computer screen should be off and not left unattended and accessible to unauthorized individuals to see. The NS 1 stated leaving the computer screen on and easily accessible to unauthorized individual to see residents personal and medical information was a violation resident's rights for privacy and confidentiality During a review of facility Policy & Procedure titled Charting and Documentation with the last revised date of 7/2017 indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record . Information documented in the resident's clinical record is confidential and may only be released in accordance with state law, the Health Insurance Portability and Accountability Act (HIPAA) and facility policy .

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure accuracy of assessment for one of two closed records reviewed...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure accuracy of assessment for one of two closed records reviewed (Resident 1) when: a. The Minimum Date Set (MDS-an assessment tool) dated [DATE] indicated weight for Resident 1 was 200 pounds (lbs, a unit of measure). (Resident was not weighed for the month of 12/22) b. Resident 1's added weight information on [DATE] for [DATE] weight was documented as 186.6 lbs. by the Director of Nursing (DON) Findings: During a review of Resident 1's History and Physical (H&P) dated [DATE], it indicated Resident 1 was admitted to the facility with diagnoses including cerebral infarction (also known as stroke- refers to damage to tissues in the brain due to loss of oxygen to the area), hypertension (high blood pressure), diabetes mellitus type II (a chronic condition that affects the way the body processes blood sugar in the body) Heart Failure (a condition that occurs when the heart can't pump as well as it should) and dysphagia (difficulty swallowing). Resident 1's admission diet order was CCHO (consistent carbohydrate diet), SB6 (soft bite diet, level 6) texture and nectar thick fluids. Resident 1's medical record, indicated he weighed 200 pounds on his first admission on [DATE]. Resident 1 had multiple admissions including recent Covid - 19 diagnosis which resulted in poor appetite. Resident 1 was sent out and admitted to the hospital due to chest discomfort on [DATE] and re admitted back to the facility on [DATE]. Resident 1 was sent out and admitted to the hospital for altered level of consciousness on [DATE] and readmitted to the facility on [DATE]. On [DATE], Resident 1 expired. During a review of Resident 1's MDS assessment, dated [DATE] indicated Resident 1 weighed was 200 lbs. and there was no Weight loss of 5 % or more in the last month or loss of 10% in the last 6 months On [DATE], a review of Resident 1's Weight Summary indicated the following weights: [DATE]- 200.0 lbs. [DATE]- 160.4 lbs. [DATE]- 160.4 lbs. [DATE]- 149.0 lbs. [DATE]- 134.4 lbs. Resident admission weight on [DATE] was 200 lbs. There was no weight done by the staff in the month of 12/22 (Resident 1 was readmitted to the facility on [DATE]). On [DATE] at 9 AM, the surveyor reviewed the Resident 1's Weight Summary [WS], at this time, it indicated an added weight documentation for Resident 1. The added documented weight information was dated on [DATE], the weight was documented as 186.6 lbs. During a concurrent interview and record review on [DATE] at 11:00 AM with Restorative Nurse Assistant 1 (RNA 1) (2 East unit) and RNA 2 (2 [NAME] unit), Resident 1's electronic weight record (EWR) summary and 2 East and 2West unit's weight binders were reviewed. In the Resident 1's EWR summary indicated on [DATE] Resident 1's weight was 200 lbs. (admission weight). There was no recorded weight for the month of [DATE]. The following weight recorded was on [DATE] and [DATE], Resident 1's weight documented was 160.4 lbs. (Re admission weight). 2 [NAME] unit weight binder indicated Resident 1's weight was 200 lbs. taken on 11/2022. RNA 2 stated that was the only weight record of Resident 1 in 2 [NAME] unit before Resident 1 transferred to 2 East unit. There was no documented weight of Resident 1 in 2 East unit record binder. RNA 1 stated, Resident 1 was transferred from 2 [NAME] to 2 East unit on the first week of 12/22. RNA 1 stated Resident 1's weight was never taken while he was in 2 East unit. During a concurrent interview and record review on [DATE], at 11:10 AM with the Nurse Supervisor 1 (NS 1), the Resident 1's WS was reviewed. The NS 1 stated she was not sure why there was an additional weight information added in the closed record of Resident 1. The NS 1 stated the added information dated [DATE] was appeared done by the DON. During a concurrent interview and record review on [DATE]. At 11:45 AM with the DON, the WS and the MDS assessment dated [DATE] were reviewed. The DON acknowledged that she added weight information dated [DATE] on Resident 1's closed records and stated, I should not have done that. The DON stated Resident 1 was not weigh when he was re admitted to the facility on [DATE] and for the month of [DATE]. The DON stated the facility's MDS coordinator who did the assessment on [DATE] was currently on a medical leave. During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, revised 09/2008, the P& P indicated Weight Assessment 1. The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. 2. Weights will be recorded in each unit's weight record chart or notebook and in the individual's medical record. 3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing. 4. The Dietitian will respond within 24 hours of receipt of written notification. 5. The dietitian will review the unit Weight Record by the 15 th of the month to follow individual weight trends overtime. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. 7. The threshold for significant unplanned and undesired weight loss will be based on the following criteria . 1 month 5% weight loss is significant; greater than 5 % is severe. 3 months- 7.5 % weight loss is significant; greater than 7.5 is severe. 6 months- 10 % weight loss is significant; greater than 10 % is severe .

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure nursing services met professional standards when Resident 2's...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure nursing services met professional standards when Resident 2's (R2); a) Physician's order to obtain weight everyday was not implemented b) Unwitnessed fall incident was not investigated to identify the possible cause of the fall and put in place effective interventions to minimize fall risks. c) Neurological assessment (neurological exam- is done to assess for any abnormalities in the nervous system that can cause problems with daily functioning) was not completed after resident's unwitnessed fall on [DATE]. These failures had the potential to decrease the facility's ability to ensure the resident received proper care and evaluation to meet his needs. Findings: R2 was admitted to the facility on [DATE] with diagnoses included fracture of unspecified part of neck of right femur (thigh bone), subsequent encounter for closed fracture, congestive heart failure (CHF- a weakened heart condition that causes fluid buildup in the feet, lungs, and other organs. Symptoms include shortness of breath, fatigue, and edema.), type 2 diabetes mellitus (A chronic disease, characterized by high level of sugar in the blood), anemia (a condition in which the body does not have enough healthy red blood cells) and gout (a common form of inflammatory arthritis that is very painful). Resident 2 expired on [DATE]. a) During a review of R2's Order Summary Report indicated an active order dated [DATE] of Daily Weights due to CHF pls. [please] notify MD [Doctor of Medicine] on business hrs. if wt. [weight] changes of 2 lbs. (pounds) or more in one day one time a day. During a review of R2's Weight Summary indicated Resident 2's weight on [DATE] was 121.4 lbs. There was no other weight documented. During a review of nursing progress notes dated [DATE] through [DATE], there was no indication and documentation that Resident 3's daily weight order was implemented. During a review of R2's nursing Progress Notes dated [DATE] AT 5:08 AM indicated Resident 2 was found on the floor in his room. Resident 2 was on his back, with laceration to the right side of the scalp and a lump on the back of his head. On the same date at 10 PM, R2's progress notes indicated , he was sent to hospital in the morning for Computed Tomography (CT- X-ray imaging procedure) scan with negative result and came back to the facility at 6:30 PM. During a review of physical therapy Treatment Encounter Note(s) dated [DATE] at 3:58 PM, indicated: while R2 was doing his therapy session, there was a reported slight increased on rt leg internal rotation. It also indicated; the physician ordered to send R2 to emergency room (ER). b) During a review of R2's Pavilion Fall Risk Evaluation dated [DATE], it indicated Resident 2 had a score of 27, categorized as High Risk. During a review of R2's clinical records, there was no evidence the facility investigated to identify the possible causes of R2's unwitnessed fall. c) During a review of R2's NSG: Neurocheck for Falls/Facility Protocol (Neurocheck assessment- a systematic evaluation of important clinical signs that provide evidence to help determine further management and investigation of the patient's condition), dated [DATE], it indicated a time schedule for neuro check as follows: Neurological checks every 15 minutes (four times for first one hour), every 30 minutes (four times for next two hours), every one hour (4 times for the next four hours), every shift (shift x 8 - total sixty-four hours). The assessments for every one hour and every shift were not completed, the last assessment for every one hour was done on [DATE], at 07:15 AM (1st hour), there was no assessments done on 2nd, 3rd, and 4th hour. The last assessment done for every shift was done on [DATE], at 11:21 PM (1st shift), the 2nd shift assessment indicated the same date and time as indicated in the 1st shift assessment. There was no assessment done on 3rd, 4th, 5th, 6th, 7th, and 8th shifts. During a concurrent interview and record review with the DON on [DATE], at 10:40 AM. R2's clinical record was reviewed. The DON acknowledged that Resident 2's weight was not done daily as ordered by the physician. The DON stated weighing the resident everyday was important because R2 had a CHF diagnosis. The DON added she was not sure why it was not done. The DON verified and acknowledged that the R2's neurological assessment/evaluation was not completed after the fall. The DON stated her expectation for the neurological assessment/ evaluation was to be continued and completed by the staff. The DON confirmed there was no post fall investigation done by the facility. The DON acknowledged the unwitnessed fall incident was not reported to the California Department of Public Health (CDPH). During a review of the facility policy and procedure (P&P) titled Falls-Clinical Protocol revised date 3/18, indicated . For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall . While many falls are isolated individual incidents, a few individuals fall repeatedly. Those individuals often have an identifiable underlying cause .delayed complications such as late fractures and major bruising may occur hours or days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall .The staff and physician will monitor and document the individual response to interventions intended to reduce falling or consequences of falling .Frail elderly individuals are often at greater risk for serious adverse consequences of falls .Risk of serious adverse consequences can sometimes be minimized even falls cannot be prevented . During a review of the facility P&P titled Neurological Assessment revised date 4/23, indicated Assessment of the neurological system should be completed whenever there is suspected head injury or impaired neurological responses .

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

Based on observation and interview, the facility failed to ensure a safe environment when a sharp object (pair of scissors) was found on top of the medication cart at 1 East Nurse Station, in an open ...

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Based on observation and interview, the facility failed to ensure a safe environment when a sharp object (pair of scissors) was found on top of the medication cart at 1 East Nurse Station, in an open space, unattended. This deficient practice had the potential to cause accident and harm when accessed by other residents. Findings: During an observation and concurrent interview with the Nurse Supervisor 1 (NS 1) on 3/6/23 at 9:40 AM, at 1 East Nursing Unit, a pair of pointed tip scissors was observed in an open space, on top of an unattended medication cart. The NS 1 acknowledged and stated the scissors should be in a locked medication cart for safety.

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 F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review the facility failed to safely store medications when, the Medication Cart (MC) at 1 East Nurse Station, was left unlocked, unattended, and observed t...

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Based on observation, interview, and record review the facility failed to safely store medications when, the Medication Cart (MC) at 1 East Nurse Station, was left unlocked, unattended, and observed to have pre poured medications stored on the first drawer of the cart. These deficient practices had the potential for unauthorized access to the medications and may place the residents at risk of harm or death due to associated adverse effects from the unauthorized use of the medications. And it can increase the potential for medication errors. Findings: During an observation and concurrent interview with the Nurse Supervisor 1 (NS 1) on 3/6/23 at 9:40 AM, at the 1 East Nursing Unit, the MC was parked against the wall, near the Nurse's Station. The MC was left unlocked and unattended. There were several residents and staff walking around the Nurse's station. The MC first drawer was observed with pre poured medications in a medication cup. NS 1 verified the MC was unlocked and unattended. NS 1 stated the MC was supposed to be locked if its unattended because unauthorized people including the residents who were confused might get into the MC and get something. The NS 1 stated, the Registered Nurse 2 (RN 2) was the staff assigned to the MC in 1 East. During an interview on 3/6/23 at 9:45 AM, with the RN 2 and the NS 1 present, RN 2 was asked if he was supposed to leave the MC unlocked and unattended, RN 2 did not answer the question but stated Are you trying to put me in trouble?' RN 2 stated, the pre poured medications were for a resident who was not in the room. The NS 1 acknowledged pre-pouring medications was not a good practice when passing medications. The NS 1 stated RN 2 should have checked the resident first if he/she in the room or where abouts before preparing the mediations. Review of the facility's Policy and Procedure (P&P) titled, Storage of Medications, with the last revised date of 11/20 indicated, Policy Interpretation and Implementation: . 6. Unlocked medication carts are not left unattended. Review of the facility's P&P titled, Security of Medication Cart, with the last revised date of 4/07 indicated, Policy Interpretation and Implementation: . 4. Medication Carts must be securely locked at all times when out of the nurse's view.

CONCERN (E) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Based on observations, interviews, and record reviews, the facility failed to implement its infection control program in accordance with internal policies and procedures, nationally recognized infecti...

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Based on observations, interviews, and record reviews, the facility failed to implement its infection control program in accordance with internal policies and procedures, nationally recognized infection control guidelines and regulations when: a. Two residents (Resident 9 and Resident 10) who were tested COVID positive (a highly contagious respiratory disease) were cohorted with Resident 11, who was tested negative for COVID. b. A visitor was not provided with infection control restrictions and practices before visiting Resident 9, a COVID positive resident. Failure to implement infection prevention practices may contributed to the cross contamination of infection that can jeopardize the health of residents, staff, and visitors. Findings: During an interview on 3/15/23, at 10:40 AM, the Director of Nursing (DON) stated that there were three residents tested positive for COVID. The three residents were, Resident 9, Resident 10 and Resident 12. The DON added, Resident 9 and 10 were in the same room and Resident 12 was alone because her room mate was transferred to the hospital. Review of Resident 9's Progress Notes, dated 3/14/23, at 10:42 PM, indicated, .resident tested positive from covid .Nurse supervisor made aware. Review of Resident 10's Progress Notes, dated 3/14/23, at 11:22 PM, indicated, Rapid test done due to room mate being tested positive, result came positive . Review of Resident 11's Progress Notes, dated 3/14/23, at 11:26 PM, indicated, Rapid test done due to room mate being tested positive, result came negative, pt (patient) is asymptomatic (no symptoms) . During observation on 3/15/23, at 11:20 AM, an isolation precaution instruction was posted outside the room shared by Resident 9, 10, and 11. During an interview on 3/15/23, at 11:30 AM, the Certified Nursing Assistant 2 (CNA 2) stated that Resident 9, Resident 10, and Resident 11 were sharing the room. CNA 2 confirmed that Resident 9 and Resident 10 were tested positive of COVID but not Resident 11. CNA 2 added, Isolation is for Bed A (Resident 9) and B (Resident 10) only, not for Bed C (Resident 11). During an interview on 3/15/23, at 11:57 AM, Nurse Supervisor 2 (NS 2) stated, Resident 9 and 10 were tested COVID positive and Resident 11 remains COVID negative. NS 2 explained that the three residents were cohorted (in the same room) in one room because It is not a good move to move Resident 11 because he's already been exposed (to COVID). That's always been our practice, not to move exposed residents. During an interview on 3/15/23, at 12:06 PM, CNA 2 stated, Resident 9 and 10 stays on their bed most of the time. Resident 11 more independent, gets up, goes around the room, and uses his walker to go to the restroom. When asked why Resident 11 was in the same room as with COVID positive residents, CNA 2 replied, I know huh. They should not be in the same room. That's my question too. During an interview on 3/15/23, at 2:30 PM, the Assistant Director of Nursing (ADON) stated that she is also the acting Infection Preventionist (IP) of the facility. The ADON confirmed that Resident 9 and Resident 10 were both tested COVID positive and was kept in the room with Resident 11 who was tested negative for COVID. The ADON further stated, That's what we've been doing. We don't move exposed residents. Review of facility COVID-19 Mitigation Plan revised on 01/2023, under Response to Test Results and Cohorting Residents indicated, Based on test results, actions taken by the facility may vary depending upon how many residents are affected and where they are located within the facility. Resident will be cohorted in one of three distict areas (isolation, quarantine and COVID-19 free or COVID-19 recovered area) of the facility based on COVID-19 test results . The quarantine area is for exposed residents and newly symptomatic residents pending results .Isolation is only for residents who have laboratory confirmed COVID-19 with or without symptoms-regardless of vaccination status . According to the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes updated on 9/23/22, under Patient Placement, Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom. If cohorting, only patients with the same respiratory pathogen should be housed in the same room. MDRO colonization status and/or presence of other communicable disease should also be taken into consideration during the cohorting process . b. During an observation on 3/15/23, at 11:32 AM, Visitor 1 was waiting outside the room of Resident 9 as the door of the room was closed. During an interview, Visitor 1 stated, he is a neighbor of Resident 9 and he came in to visit Resident 9. Visitor 1 was wearing a surgical mask and stated, This is what I wore from outside (referring to the mask that he is wearing). He explained that he signed in the log located in the front desk and stated, The staff didn't tell me anything that he has COVID. The lady didn't ask who I am visiting. No instruction. I should go home. During an interview on 3/15/23, at 11:35 AM, the Front Desk Staff (FDS) explained that she was relieving the Receptionist for lunch break. FDS stated she was not aware that Visitor 1 was visiting Resident 9 and also not aware that Resident 9 on isolation. During an interview on 3/15/23, at 2:37 PM, the ADON stated, for visitors, We (staff) have to make sure to explain the infection control precaution and offer PPE (Personal Protective Equipment such as gown, gloves, and masks). Review of facility COVID-19 Mitigation Plan revised on 01/2023, under VISITATION GUIDANCE indicated, .Passive screening of visitor's self screen for fever, COVID-19 symptoms and or exposure with an individual with COVID-19 infection in the prior 14 days is required .The facility will post informational material at the entrance of the facility restricting visitation if the if the visitor has a positive COVID-19 viral test, has symptoms of COVID-19 or they had a close contact with someone with COVID-19 infection, the required masking protocol, the correct PPE, hand hygiene and cough etiquette requirements . Under General Visitation Measures indicated, .Residents who are COVID-19 positive on transmission-based precautions should preferably receive virtual visits or through closed windows .Visitors will sign in on the visitors log and asked to leave information to facilitate contact tracing . Under Indoor, In-Room Visitation indicated, If a resident is in quarantine or isolation, the visitor will be advised of the risks of visitation and physical contact prior to the visit . According to the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes updated on 9/23/22, .Educate Residents, Healthcare Personnel, and Visitors about SARS-CoV-2, Current Precautions Being Taken in the Facility, and Actions They Should Take to Protect Themselves .Educate and train HCP, including facility-based and consultant personnel (e.g., rehabilitation therapy, wound care, podiatry, barber), ombudsman, and volunteers who provide care or services in the facility. Including consultants is important since they commonly provide care in multiple facilities where they can be exposed to and serve as a source of SARS-CoV-2. Educate HCP about any new policies or procedures .Reinforce adherence to standard IPC measures including hand hygiene and selection and correct use of PPE. Have HCP demonstrate competency with putting on and removing PPE and monitor adherence by observing their resident care activities .

Jan 2023 4 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Deficiency F0740 (Tag F0740)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to address suicidal ideation (thinking about wanting to end one's own ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to address suicidal ideation (thinking about wanting to end one's own life) when the facility did not re-assess Resident 2's verbalization I no longer wish to be here on 9/8/22, and the facility did not create and implement a care plan for suicidal ideation for one of three residents reviewed. This failure resulted in Resident 2's suicide attempt on 9/21/22, by using scissors to cut his neck. Findings: 1. During review of Resident 2's clinical record, Resident 2 was admitted on [DATE] with diagnoses including generalized anxiety (persistent worry and fear) disorder, depression (elevation or lowering of a person's mood), and paraplegia (paralysis of the lower body), and previous suicide attempt. Review of Resident 2's minimum data set (MDS, resident assessment tool) dated 8/26/22, indicated Resident 2 was cognitively intact and required extensive assistance to perform activities of daily living (ADLs, things like bathing, eating, and toileting). Resident 2 had mood symptoms present of feeling down or depressed and was moving more slowly or was increasingly fidgety. Review of Resident 2' pre-admission screening and resident review (PASRR, is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) dated 5/13/22, indicated positive for Level 1 screening which prompted a PASSR Level II (A Level II is necessary to confirm the indicated diagnosis noted in the Level I Screening and to determine whether placement or continued stay in a Nursing Facility is appropriate) evaluation. However, PASSR II evaluation was not completed. During an interview with Administrator (ADM)and Director of Nursing (DON) on 9/30/22 at 1:30 PM, both of them stated PASRR II evaluation was never completed for Resident 2. Review of Resident 2's physician order dated 9/2022, indicated Escitalopram oxalate 5 milligram (mg, measurement unit of mass) 1 tablet a day for depression; Diazepam 5 mg. Give 1 tablet by mouth every 8 hours as needed for anxiety/restlessness . During review of the physician's note dated 9/8/22 indicated that Resident 2 stated I no longer wish to be here and agreed to speak to the psychiatry team. During an interview with the DON on 10/28/22 at 10:40 AM, DON stated that no documentation was present in Resident 2's clinical record between care providers (doctors, NP, nurses, staff, etc.) regarding the assessment or lack of assessment of suicidal ideation in Resident 2. DON also stated that the referral on 9/8/22 from the doctor to Psych NP was the only referral/ communication between staff regarding Resident 2's suicidal ideation. Review of the psychiatry nurse practitioner's (NP) note dated 9/9/22 indicated that Resident 2 has had suicidal thoughts, but the NP was unable to evaluate the resident . Will visit again next time I am in the building. Plan: no changes currently . During an interview with the ADM on 10/20/22 at 11:55 AM, ADM stated that Resident 2 had verbalized to the physician on 9/08/22 that he did not wish to be here. The ADM viewed the sentence was in the context of the heatwave at the time, as Resident 2 was sitting in front of the fan. The ADM stated that if they knew Resident 2 had any suicidal ideation then they would have searched Resident 2 for hazardous objects, provided safe cutlery, and performed safety checks on Resident 2 every 15 minutes. During an interview with the Director of Nursing (DON) on 10/28/22 at 10:40 AM, the DON stated the NP did not come back to the facility to re-evaluate Resident 2. DON acknowledged the NP should have re-evaluated Resident 2 to assess his suicidal thoughts. Review of Resident 2's care plan titled at risk for psychosocial well-being due to adjustment to skilled nursing facility created and initiated on 5/21/22, indicates the facility will refer to mental health team as needed and contact social services for follow up if exhibiting behaviors of depression, anxiety, anger, delusions, or adjustment concerns . Interview with the Social Worker (SW) and Case Manager (CM) on 9/30/22 at 3:20 PM, the SW and CM stated no referral was made or visit/s made by the SW or CM to address suicide. Review of facility's policy and procedure titled, Behavior Assessment, Intervention and Monitoring revised March 2019, states that the Facility will provide, and residents will receive behavioral-health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment . The policy also stated the Resident will have minimal complication associated with the management of altered or impaired behavior. Per this policy, the facility will thoroughly evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors . Under the section of Monitoring , the policy states that If the resident is being treated for altered behavior or mood, the interdisciplinary team (team treating the Resident that consist of the Physician, Nurses, social worker, and administration) will seek and document any improvement or worsening in the individual's behavior, mood, and function . 2. Review of Resident 2's clinical record, indicated there was no care plan to address his suicidal ideation. During an interview with the DON on 10/28/22 at 3:56 PM, she stated that there was no care plan for addressing Resident 2's suicidal ideation, because the facility staff did not re-assess Resident 2 when he stated he no longer wish to be here. During an interview on 10/04/22 at 11:34 AM with Licensed Vocational Nurse (LVN 2) for Resident 2 on the night of 9/21/22, LVN 2 stated that they did not do safety checks on Resident 2 at the time of the incident because she was unaware of Resident 2's suicide ideations. LVN 2 also stated that had she known about Resident 2's suicidal thoughts, LVN 2 would have done periodic safety check on him. During an interview with the Certified Nurse Assistant (CNA 1) on 10/10/22 at 2:33 PM, CNA 1 stated she did not do a safety check for Resident 2 prior to the incident because she too was unaware Resident 2 had suicidal ideations. During an interview with the social worker (SW) on 10/27/22 at 11:11 AM, SW stated that her department was never notified that Resident 2 had suicidal thoughts. The SW stated if the department was made aware, then they would have formulated a plan with the care team to keep Resident 2 safe. Review of Resident 2's progress notes dated 9/21/22 indicated At 12:36 a.m., while charting at the nursing station, writer heard resident yell out, I'm going to slit my neck. This writer immediately ran into resident's room and saw resident with small amount of blood flowing down his neck. Applied pressure to wound, initiated code blue (Emergency Code for immediate medical attention) and dialed 911 for suicide attempt. Asked resident what item he used; resident stated scissors. Asked resident where the scissors are, resident refused to give information .Resident turned to his side table and pulled out green pair of scissors. Nurse standing on right side of resident able to confiscate scissors out of resident's hands safely. Resident refused to state where he obtained the scissors from. Review of Resident 2's history of present illness (HPI) from acute hospital dated 9/21/22, indicated At SNF (skilled nursing facility) where he resides, Resident 2 attempted suicide by using trauma shears to neck. He reports 2 other suicide attempts. He says he does not see life worth due to his paraplegia and chronic pain and wants a cocktail (mixture of medications) to die but says he cannot find a doctor to give him anything. He emphasizes he does not want to return to that hell (SNF) .Resident 2 confirmed attempting suicide two other times in addition to the one he was admitted for , while at the skilled nursing facility. Resident 2 stated that he does not see life worth of living due to his paraplegia, and wants a cocktail to die, but can't find a doctor to help him. Resident 2 stated that he feels likes he can no longer be mobile with his wheelchair and his activity has declined during his skilled nursing stay . Resident 2 verified causing an open wound to the throat was an attempt to suicide, and his intent to die is 100% and that he will try any means possible . Review of the policy titled suicide threats revised December 2007 indicated All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in residents' behavior immediately. As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present .

CONCERN (D) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to notify the physician when Resident 1's suprapubic catheter (SPC, a catheter or flexible tube placed through the abdomen into the bladder to...

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Based on interview and record review, the facility failed to notify the physician when Resident 1's suprapubic catheter (SPC, a catheter or flexible tube placed through the abdomen into the bladder to drain urine) was dislodged on the morning of 9/28/22, for one of three residents reviewed. This failure had the potential to result to worsen resident's condition. Findings. Review of Resident 1's progress notes dated 9/28/22 (at 09:36) indicated at around 8:00 am, certified nurses assistant (CNA) called licensed nurse to inform Resident 1's SPC was pulled out. During interview with Resident 1 on 10/20/22 at 11:16 am, Resident 1 stated that she was not given a choice to go the emergency room, and was told by staff that the resident will see her doctor in the morning. Resident 1 verbalized that she did not know if she needed to go to the emergency room when her SPC came out and was only told that she should have gone to the emergency room. During interview with the licensed vocational nurse (LVN 1) on 10/20/22 at 3:48 PM, LVN 1 stated she did not notify the physician nor the supervisor when the SPC was dislodged. Interview with the DON on 9/30/22 at 1:30 PM, DON stated that facility staff was unaware that Resident 1's SPC was no longer in place. DON stated that if not replaced promptly, the suprapubic track may close, necessitating a further procedure to reintroduce the catheter, usually at a later date. Review of the facility's policy titled Suprapubic Catheter Care dated on October 2010 indicates Notify your supervisor immediately in the event of hemorrhage(bleeding) or if the catheter is pulled out. Notify the physician of any abnormalities in the skin assessment. Review of the policy titled, Change in a Resident's Condition or Status dated February 2021 reads The nurse will notify the resident's attending physician or physician on call when there has been a(an); (a)Accident or incident involving the resident. (b) Discovery of injuries of an unknown source.(c)Adverse reaction to medication. (d)Significant change in the resident's physical/emotional/mental conditions.(e)Need to alter the resident's medical treatment significantly. (f) Refusal of treatment. (g) Need to transfer the resident to a hospital/treatment center. A significant change' of condition is a major decline or improvement in the resident's status that; (a) Will not normally resolve itself without intervention by staff or clinical interventions (b)Impacts more than one area of the resident's health status .

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 F0558 (Tag F0558)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to answer the call lights in a reasonable timeframe and in accordance with their own standard of practice for nine of 27 residen...

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Based on observation, interview, and record review, the facility failed to answer the call lights in a reasonable timeframe and in accordance with their own standard of practice for nine of 27 residents (Residents' 1,2,3,6,7,8,9, 10 and 12) reviewed. This failure had the potential to neglect the residents' needs. Findings: During random observation on 9/30/22 at 2:00 PM to 5:00 PM, the call light tracking monitor showed the following: 1. Resident 8's call light was on for six minutes(min), and 33 seconds(sec). 2. Resident 7's call light was on for nine min and 46 sec 3. Resident 10's call light was on for ten min and 40 sec 4. Resident 9's call light was on for 21 min and 38sec During observation on 9/30/22 at 2:15 PM, call light for Resident 6 was on for longer than 45min. During interview with Resident 6 at 3:00PM, Resident 6 stated she would like the dressing on their hand changed as it is hard to eat lunch. During an interview with the director of nursing (DON) on 9/30/22 at 1:30 PM, DON stated that the standard of practice is to answer call lights immediately. During concurrent observation and interview, while rounding with assistant director of nursing (ADON) on 9/30/22 at 3:04 pm, Resident 7 was yelling for help from the hallway. Resident 7's call light was on the floor and not within resident's reach. Resident 7 had to use the bathroom. The ADON picked up the call light and turned it on for the Resident 7. The resident awaited help but verbalized urgency in needing to use the bathroom. During interview with Resident 12 on 9/30/22 at 3:15 PM, Resident 12 stated call lights always take long to answer. This happened in all shifts. During an interview on 9/30/22 at 3:15 PM with the ADON, the ADON stated that the call light must be answered immediately and that call lights should be within resident's reach. During an interview with the ombudsman (legal representative who mediates fair settlement) 9/27/22 at 11:15 AM, the ombudsman stated that Residents' 1, 2 and 3 called to notify him of the lack of staff and long wait for call lights to be answered. During an interview with the Resident 3 on 9/27/22 at 2:15 PM, Resident 3 stated that she filed multiple complaints with the administration at the facility and the ombudsman, regarding long wait times for call lights to be answered and the facility being short staffed. Resident 3 stated there have been times where there is no certified nurse's assistant (CNA) for her wing which has 58 Residents and sometimes only one CNA. During an interview with CNA 1 on 10/10/22 at 2:33 PM, CNA stated call lights should be answered immediately. CNA also stated that if one CNA was with another resident, that CNA would not be aware of other call lights then usually, other CNA's or nurses would help. CNA 1 stated that at times she can get assigned to 14 to 17 patients, sometimes more if the census was high. The facility's standard workflow was that anyone that is close to the room where the call light is on should answer the call light during shift change. Review of the facility's policy titled Answering the call light date revised 3/2021 indicated The purpose of this procedure is to ensure timely responses to the resident's request and needs and When the resident is in bed or confined to a chair be sure the call light is within reach of the resident Review of the care plans for Residents 6, 7, and 10, interventions indicated keep call light within reach at bedside. Encourage Resident to ask for ADL (activities of daily living) assistance. Residents 8 and 9 have interventions that state to have call light within reach and answered promptly .

CONCERN (E) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a safe environment for six of 30 residents rev...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a safe environment for six of 30 residents reviewed, when: 1. Razors were seen in the bedside cabinets for Residents 13,14, and 15. 2. An electric tea kettle was seen plugged into an outlet in Resident 16's room. 3. There were two unapproved electrical extension cords with six plugged-in devices in a crowded area in Resident 12's room. These failures had the potential to endanger resident safety and cause unanticipated event/s that can lead to accidental or intentional injury. 4.Resident 2 was able to obtain scissors, which resulted to Resident 2 cut off his neck to carry out a suicide attempt, and was admitted to an acute care hospital. Findings: 1. During observation on 9/30/22 at 2:30 PM, razors were seen in the bedside cabinets for Residents 13,14, and 15. During an interview with the Assistant Director of Nursing (ADON) on 9/30/22 at 2:31 pm, the ADON stated that razors should be disposed of into a biohazard bin because it poses a safety or injury risk. 2. During an observation on 9/30/22, at 2:00 PM, an electric water kettle was seen plugged into an outlet at the bedside for Resident 16. Interview with the maintenance supervisor (MS) on 10/20/22 at 11:03 AM, MS stated that appliance that have heating elements are not permitted in the facility. The MS stated the electric kettle was not safe to use at the bedside, and posed a burn or fire hazard. The MS stated that they did not have prior knowledge of the electric kettle presence in the facility and has been removed. 3. Review of Resident 12's minimum data set (MDS, an assessment tool) on 7/28/22 indicated Resident 12 had diagnoses included infections, chronic obstructive pulmonary disease (COPD, long term respiratory disease), anxiety and depression. Resident 12 was cognitively intact and independent of activities of daily living (ADLs). During observation on 9/30/22 at 3:15PM, the following items were seen at Resident 12's bedside: (a) Two [NAME] lamps, (b)Two air purifier- one on the floor and one on the bedside table. (c) Two extension cords plugged into the outlet with six other appliances attached to it, with the cords tangled around bedside table. (d) A pitcher of water on the bedside table directly above cords and the air purifier. (e) Multiple pens, markers, papers, pizza boxes, and personal care items scattered on the floor, underneath the bedside table and surrounding the bed. (f) Resident 12's headboard and left side of the bed was against a wall, leaving the right side and foot of bed open. Both the right side and foot of bed was blocked with multiple belongings, electrical cords, and equipment preventing the bedside table to be moved. Wheelchairs and large boxes with belongings were surrounding the bed and took all the floor space allotted for Resident 12. During interview with the ADON on 9/30/22 at 3:20 PM, ADON acknowledged the accumulation of belongings, the extensions cords, and electrical appliances were a fire and trip hazards. During interview with MS on 10/20/22 at 11:03 AM, MS stated that all electric equipment needs to be checked for safety prior to bringing in the facility. MS stated that the electric kettle, air purifiers, extension cords, and [NAME] lamp were not approved by maintenance staff to use in the facility. He stated these items are not permissible in the facility as safe electrical equipment and are safety hazards. He also stated no liquids should be kept near electrical equipment. These tangled cords and clutter were a trip and fire hazard. The facility's policy and procedure ( P&P) titled Electrical Safety for Residents revised date January 2011, states Inspect electrical outlets, extension cords, power strips, and electrical devices as part of routine fire safety and maintenance inspections, Extension cords shall not be used as a substitute for adequate wiring in the facility Review of the facility P&P titled Personal property dated October 2017 reads that Resident are permitted to bring room furnishings if; the room is large enough to accommodate the furniture, the furniture does not infringe upon the rights of others, and the furniture does not violate current life safety code requirements . This policy also indicated the residents personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished. Subsequent items brought into or removed from the facility shall be added to or deleted from the personal property inventory by the facility at the written request of the resident or an authorized resident representative . 4. During review of Resident 2's clinical record, Resident 2 was admitted on [DATE] with diagnoses included generalized anxiety (persistent worry & fear) disorder, depression (elevation or lowering of a person's mood), and paraplegia (leg paralysis). Review of Resident 2's MDS dated [DATE], indicated Resident 2 was cognitively intact, and required extensive assistance to perform activities for daily living (ADLs). Resident 2 had mood symptoms present of feeling down or depressed and was moving more slowly or was increasingly fidgety. Verbal behavior of screaming and yelling were documented. Behavior in refusal of care and wondering (moving around in or out of the facility where it was not permitted) were present during this assessment. Review of Resident 2's nurses' progress notes dated 9/21/22, indicated At 12:36 AM, while charting at the nursing station, heard resident yell out, I'm going to slit my neck. LVN immediately ran into resident's room and saw resident with small amount of blood flowing down his neck. Applied pressure to wound, initiated code blue and dialed 911 for suicide attempt. When asked what item Resident 2 used to slit his throat, Resident 2 then turned to his side table and pulled out green pair of scissors. Nurse standing on right side of resident confiscated the scissors out of resident's hands safely . During interview with licensed vocational nurse (LVN 2) on 10/04/22 at 11:34 AM, LVN 2 stated it is unknown how Resident 2 acquired scissors on 9/21/22. LVN 2 had asked the resident where he took it from, but the resident did not answer. LVN 2 also stated she did not do a purposeful round check on resident safety on the start of her shift. LVN 2 stated that it's uncommon for them to do a purposeful round safety check on every resident they're assigned on start or during their shift. During interview with certified nursing assistant (CNA 2) on 10/10/22, at 2:33 pm, CNA 2 stated that she did not do a purposeful round safety check on Resident 2. During interview with social service worker (SSW) dated 10/27/22 at 11:11 AM, the SSW stated Resident 2 was leaving the facility for several hours without informing the staff and returning to the facility. During an interview with the SSW and case manager (CM) on 9/30/22 at 3:20 p.m., CM and the SSW stated the facility staff should check on Resident 2's environment regularly, for any dangerous objects, when he returns in the building from out on pass to ensure resident safety. Review of the physician's note dated 9/8/22 indicated that Resident 2 stated I no longer wish to be here and agreed to speak to the Psychiatry team. Review of the psychiatry nurse practitioner (NP) note dated 9/9/22 indicated that Resident 2 has had passive suicidal thoughts, but the NP was unable to evaluate the resident and stated Not able to complete visit due to lack of cooperation. Not possible to do a real assessment today due to uncooperativeness. Will visit again next time I am in the building. Plan: no changes currently . Review of Resident 2's progress notes for 9/09/22 at 9:55 AM (created on 09/23/22 at 09:57), indicated a room search was done, and no hazardous items were found. No other room searches were performed after 09/09/22. During interview with the Administrator (ADM) on 10/20/22 at 11:50 AM, the ADM stated that if there was knowledge of a resident wanting to harm himself, the process is to search the resident for harmful objects, provide safe cutlery and safe objects for daily living, and check on the resident every 15 minutes. Review of Resident 2's history of present illness (HPI) from acute hospital dated 9/21/22, indicated At SNF (skilled nursing facility) where he resides, Resident 2 attempted suicide by using trauma shears to neck. He reports 2 other suicide attempts. He says he does not see life worth due to his paraplegia and chronic pain and wants a cocktail (mixture of medications) to die but says he cannot find a doctor to give him anything. He emphasizes he does not want to return to that hell (SNF) . Review of the policy titled suicide threats revised December 2007 indicated All nursing personnel and other staff involved in caring for the resident shall be informed of the suicide threat and instructed to report changes in residents' behavior immediately. As indicated, a psychiatric consultation or transfer for emergency psychiatric evaluation may be initiated. If the resident remains in the facility, staff will monitor the resident's mood and behavior and update care plans accordingly, until a physician has determined that a risk of suicide does not appear to be present .

Jan 2023 6 deficiencies

CONCERN (E) 📢 Someone Reported This

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

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

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review the facility failed to ensure effective communication when the staff, residents and their families were not notified of the facility's COVID -19 infe...

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Based on observation, interview, and record review the facility failed to ensure effective communication when the staff, residents and their families were not notified of the facility's COVID -19 infection status and the facility's interventions to lessen the severity of the situation. This facility failure has the potential to the spread of infection to staff, residents, and their families due to lack of knowledge of COVID 19 infection status in the facility. Findings: During observation and concurrent interview on 6/6/22 at 6:45 PM, Resident 71, who was a resident in the yellow zone (a designated area in the facility occupied by residents under observation and/or investigation for COVID 19 infection), was ambulating in the lobby accompanied by his son. Resident 71 and the son was on their way to enter the 2 [NAME] unit hallway, which was a designated green zone (designated area in the facility occupied by residents without COVID-19 infection). Resident 71's son stated, I do not know what the yellow zone means. We have been walking my dad in these hallways (yellow zone hallway and the green zone hallway). No one had talked to us about it. During an interview on 6/6/22, at 7:30 PM, Licensed Vocational Nurse 1 stated, The COVID unit are rooms 110,111, 112, 113, 114, 115, 116, 117, 118, 119, and 120. We have 11 residents, and we have a new admission, total of 12. During an interview on 6/21/22, at 12 PM, the Administrator stated. The designated person to do notification is me and the social worker. We notify the family through phone calls and emails. We communicate to the staff through group messaging. When a resident turned up positive with COVID (COVID-19 infection), the family and the physician (attending medical doctor) were notified, and the resident is transferred to the COVID-19 unit (designated area of the facility occupied by residents with COVID -19 infection). The staff at (name of the facility) do the notifications if it is their resident who turned up with COVID-19 and was transferred to our COVID unit. We don't notify the families if the resident was admitted with COVID. They were admitted from the hospital. They know. During a review of facility census, the facility COVID unit was occupied as follows: 6/22/22 has 17 residents; 6/16/22 has 22 residents; 6/15/22 has 20 residents; 6/14/22 has 16 residents; 6/7/22 has 12 residents; 6/6/22 has 11 residents; 5/28/22 has 20 residents; 5/26/22 has 22 residents; 4/13/22 has 6 residents. A review of the following results as confirmed through a laboratory testing indicated the following: Resident 71, a resident in 2 [NAME] unit, tested positive with COVID 19 infection on 5/30/22; Resident 59, a resident in 2 East unit, tested positive with COVID 19 infection on 5/26/22; Resident 6, a resident in 2 East unit, tested positive with COVID 19 infection on 5/26/22; Resident 60, a resident in 1 East unit, tested positive with COVID 19 infection on 5/26/22; Resident 31, a resident in 1 East unit, tested positive with COVID 19 infection on 5/26/22; Resident 5, a resident in 2 [NAME] unit, tested positive with COVID 19 infection on 5/24/22, and Resident 4, a resident in 2 East unit, tested positive with COVID 19 infection on 5/24/22. The facility was unable to provide proof of documentation of communication of the facility's COVID -19 status, it's impact to the facility provision of care, and mitigating actions to prevent transmission of infection to the staff, residents, and their families. During an interview on 6/22/22, at 4:35 PM, Registered Nurse stated, Communication is by mouth. You must be in the facility. There used to be a group messaging but it's for the few of them. I don't know who's really included in that group messaging. I am not included there. If I am not here, I will not know the COVID -19 status of the facility.

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 F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to ensure sufficient number of licensed nurses to meet the resident needs when: a. Two (2) of the four units had one LN on duty ...

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Based on observation, interview, and record review, the facility failed to ensure sufficient number of licensed nurses to meet the resident needs when: a. Two (2) of the four units had one LN on duty instead of two LN ' s. b. There was no LN on duty in the COVID unit. This facility failure resulted in the postponement in the medication administration to 66 residents. Findings: During an observation and concurrent interview on 6/6/22, at 7:25 PM, in the COVID-19 Unit, Licensed Vocational Nurse (LVN) 2 stated, There was no endorsement. There was no nurse during the day shift. We have 11 residents. A review of the facility census dated 6/6/21, 2 [NAME] unit was occupied by 53 residents and 2 East unit was occupied by 50 residents. During an interview on 6/7/22, at 1:40 PM, LVN 2 stated, I did the medpass (medication administration) yesterday (6/6/22) in three different units. The first one is in 2 [NAME] Unit Team 2. There was supposed to be two nurses but there's only one nurse. I passed the medications in 2 [NAME] unit from 8:30 AM to 10:30 AM. When I finished, I went to 2 East unit where there was only one nurse too. I passed the medication for three hours, from 10:30 AM to 1:30 PM. Then, I went to take my lunch. There was no nurse in the COVID unit so, I went there last. I went there after my lunch break. It was around 2 PM when I started passing the 9 AM medications. It was hard. I passed the medications in 3 different units. A lot of the medications were given very late. Residents may have difficulties if they do not get the medications on time. We were short of nurses yesterday (6/6/22). The nurses from the registry did not show up. If you see me and the registered nurse administering medications, that's a clear indication that we are short staff. That means there's nobody else. During an interview on 6/7/22, at 2:25 PM, the Director of Nursing stated that she was not aware of the short staffing on 6/6/22. During an interview on 6/7/22, at 3:35 PM, the Administrator acknowledged two of the four units had one LN on duty instead of two LN's, and there was no LN on duty in the COVID unit.

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 F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure safe medication administration for 14 of 147 sampled residen...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure safe medication administration for 14 of 147 sampled resident (Resident 8, 15, 17, 20, 31, 33, 35, 36, 38, 59, 61, 64, 66, and 80) when: a. Fingerstick blood sugar check was not performed and medication was not administered before meals; b. Medications were administered in multiple doses at one time, and c. Medications were not administered as scheduled. This failure has the potential for the residents to have adverse and or untoward effects from overdose, inaccurate doses of medication administered, and not receiving prescribed medications as scheduled. Findings: a1. Resident 36 was admitted with diagnoses including diabetes mellitus (DM, abnormally high blood sugar). A review of medication administration audit dated 6/6/22, indicated .order summary admelog solostar solution (insulin lispro, used to lower blood sugar) . inject per sliding scale (blood sugar was checked and the dose of the medication is based on the blood sugar level before meals) . scheduled at 06:30 (6:30 AM), was performed and medication was administered at 8:10 AM. a2. A review of the facesheet indicated Resident 31 was admitted with diagnoses including DM. A review of the medication audit report dated 6/6/22, indicated Humulin R solution (used to lower blood sugar) as per sliding scale, was scheduled at 21:00 (9 PM). The medication audit report indicated, the blood sugar check was performed and the medication was administered at 00:38 (12:38 AM). The medication audit report has no proof of documentation the blood sugar level was checked and medication administered at 06:30 (6:30 AM). During an interview on 6/22/22, at 4:35 PM, Registered Nurse (RN) 1 acknowledged the blood sugar check was not performed and the medication was not administered. RN 1 stated, Blood sugar should be checked before meals, before the resident eat and before administering the insulin. The blood sugar is higher after meals. You have to give more insulin. b1. A review of the face sheet indicated Resident 15 was admitted with diagnoses including chronic obstructive pulmonary disease (COPD, a lung disease that makes it hard to breathe). During a review of medication administration audit report for 5/28/22, indicated: Medication Combivent respimat (used to prevent and treat shortness of breath) aerosol solution scheduled for 00:00 (12 AM) was administered at 06:53 (6:53 AM) Medication combivent respimat scheduled for 06:00 (6 AM), was administered at 06:53. b2. A review of the face sheet indicated Resident 17 was admitted with diagnoses including cancer of the lung. A review of the medication administration audit report for 5/28/22 indicated: Medication oxycodone HCl (used to treat moderate to severe pain) scheduled for 00:00 (12 AM) was administered at 06:48 (6:48 AM). Medication oxycodone HCL scheduled for 06:00, was administered at 06:47 (6:47 AM) Medication lorazepam (used to treat anxiety [severe nervousness and restlessness) schedule at 00:00 was administered at 06:48; Medication lorazepam scheduled at 04:00, administered at 06:47. b3. A review of face sheet indicated Resident 33 was admitted with diagnoses including COPD. During a review of medication administration audit report for Resident 33 indicated the following medications were administered at one time at 20:39 (8:39 PM). 1.Ipratropium-albuterol solution scheduled at 17:00, 2. Ipratropium-albuterol solution scheduled at 21:00. b4. During a review of the face sheet indicated Resident 8 was admitted with diagnoses including asthma. During a review of medication administration history for Resident 8 indicated, the following medications were administered at one time at 23:57 (11:57 PM). Medication combivent respimat aerosol solution scheduled for 17:00. Medication combivent respimat aerosol solution scheduled for 21:00. During a review of medication administration audit for Resident 15 and Resident 17, and concurrent interview on 6/16/22, at 4 PM, Director of Nursing (DON) acknowledged two medication doses was administered at the same time as indicated in the medication administration audit. The DON stated, I am going to review them. I have to give inservice. A review of the Policy and Procedure titled Administering medicationsdated 4/2019, indicated,Policy statement, Medications are administered in a safe and timely manner, and as prescribed .Policy interpretations and Implementation .4. Medications are administered in accordance with prescribers orders, including any required time frame. 5. Medication administration times are determined by the resident need and benefit, not staff convenience . 7. Medications are adminitered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meals) . b5. Resident 20 was admitted on [DATE] with diagnoses including chronic pain syndrome, diabetes mellitus (a metabolic disease that causes high blood sugar), hypokalemia (lower than normal potassium level in the bloodstream), and venous insufficiency (a condition in which the veins have problems sending blood from the legs back to the heart). During a concurrent record review and interview with LVN 3, on 6/16/22 at 4:56 PM, Resident 20's Medication Administration Audit Report (MAAR), dated 6/6/22 indicated: 1. Oxycodone HCL capsule 5 mg, scheduled at 8 AM, was administered at 11:53 AM. 2. Oxycodone HCL capsule 5 mg, scheduled at 12 PM, was administered at 11:59 AM. These medications were administered with a six (6) minute interval, instead of the prescribed four (4) hour interval. LVN 3 stated, The 8 AM schedule (Oxycodone 5 mg) was given late (for Resident 20). It was almost time for (Resident 20's) 12 PM medications. I placed the medication (Oxycodone tablet 5 mg) in a medication cup, left the medication in his (Resident 20) room. I should not have left the medication with him. If he (Resident 20) took them [sic] (Oxycodone) at 12 (PM), it may cause an adverse reaction, can affect the level of consciousness, may cause respiratory distress. c1.During a review of Resident 20's MAAR, dated 4/11/22, with RN 1, on 6/16/22 at 1:35 PM, the Administration Time for Oxycodone HCL 5 mg, scheduled at 12 PM and Oxycontin 20 mg, scheduled at 2 PM were blank. In a concurrent interview, RN 1 stated that if the Administration Time in the MAAR is blank, That means it was not given. Nurses document after giving it (referring to medication). If it's not documented, then it's not given. A review of Resident 20's MAAR, dated 5/20/22 indicated Oxycontin 20 mg, scheduled at 6 AM, was not administered. A review of Resident 20's physician's orders for April 2022 to June 2022, indicated an order of Oxycodone HCL 5 mg, one tablet by mouth every four hours for chronic pain, and Oxycontin tablet ER 12-hour abuse-deterrent 20 mg, one table by mouth every eight hours for chronic pain. A review of Resident 20's care plan for pain medication therapy, dated 8/11/21, indicated a goal for Resident 20 to be free of discomfort or adverse side effects from pain medication. The care plan interventions include, but not limited to, administer analgesic (pain reliever) medication as ordered by physician. c2. Resident 12 was admitted [DATE] with diagnoses including atrial fibrillation (an irregular heart rhythm), asthma (a condition that makes breathing difficult), dementia with behavioral disturbance (loss of cognitive functioning), chronic kidney disease (gradual loss of kidney function), and osteoarthritis (condition where the joints in your body become inflamed and damaged). A review of Resident 12's MAAR, dated 4/11/22 indicated the following medications were not administered: 1. Furosemide (used to treat fluid build-up and swelling) 20 mg, scheduled at 9 AM. 2. Esomeprazole Magnesium Delayed Release (used to treat certain stomach and esophagus problems, such as acid reflux, ulcers) 40mg, scheduled at 9 AM. 3. Raloxifene HCL (medication used by women to prevent and treat bone loss after menopause) 60 mg, scheduled at 9 AM. 4. Combivent Respimat 20-100 mcg/actuation solution, scheduled at 9 AM. 5. Apixaban (a medicine to help prevent blood clots) 2.5 mg, scheduled at 9 AM. 6. Digoxin (used to treat atrial fibrillation and heart failure) 125 mcg, scheduled at 9 AM. 7. Risperdal (used to treat certain mental/mood disorders) 0.25 mg, scheduled at 9 AM. 8. Docusate sodium (a laxative) 100 mg, scheduled at 9 AM. 9. Med pass 2.0 (dietary supplement) 120 ml (milliliter), scheduled at 9 AM. 10. Creon 24000-76000 units (contains digestive enzymes and is used to improve food digestion in people who cannot digest food properly), scheduled at 9 AM. 11. Combivent Respimat 20-100 mcg/actuation solution, scheduled at 1 PM. 12. Creon 24000-76000 units, scheduled at 1 PM. 13. Med pass 2.0 120 ml, scheduled at 1 PM. c3. Resident 31 was admitted on [DATE] with diagnoses including lung cancer and COPD. A review of Resident 31's MAR, dated 4/13/22 indicated, 1. Oxycodone HCL 5 mg, scheduled at 6 AM, was not administered. c4. Resident 38 was admitted on [DATE] with diagnoses including DM, peripheral neuropathy (nerve damage causing pain, numbness, tingling, swelling, or muscle weakness in different parts of the body), gastro-esophageal reflux disease (GERD - a condition in which acid from the stomach comes up into the esophagus), and chronic pain syndrome. A review of Resident 38's MAR, dated 4/13/22 indicated the following medications were not administered: 1. Hydrocodone-Acetaminophen (used to relieve severe pain) 10-325 mg, scheduled at 6 AM, was not administered. 2. Gabapentin (used to relieve nerve pain) 600 mg, scheduled at 6 AM, was not administered. 3. Omeprazole (used to treat heartburn and indigestion) 20 mg, scheduled at 6:30 AM, was not administered. 4. Humulin N Suspension (used to lower blood sugar levels) 23 units, scheduled at 6:30 AM, was not administered. c5. Resident 61 was admitted 0n 12/15/21 with diagnoses including left lower ankle fracture. A review of Resident 61's MAR, dated 4/13/22 indicated Hydrocodone-Acetaminophen 5-326 mg, scheduled at 6 AM, was not administered. c6. Resident 66 was admitted on [DATE] with diagnoses including diabetes mellitus. A review of Resident 66's MAR, dated 4/13/22 indicated the following medications were not administered: 1. Glipizide (used to lower blood sugar levels) 10 mg, scheduled at 6:30 AM. 2. Pantoprazole Sodium (used to treat certain stomach and esophagus problems, such as acid reflux) 40 mg, scheduled at 6:30 AM. c7. Resident 59 was admitted on [DATE] with diagnoses including hypothyroidism (a common condition where the thyroid doesn't create and release enough thyroid hormone into the bloodstream). A review of Resident 59's MAAR, dated 4/13/22 indicated Levothyroxine Sodium (medication used to treat an underactive thyroid gland) 150 mg, scheduled at 6:30 AM, was not administered. Resident 59's MAAR, dated 5/3/22 indicated Levothyroxine Sodium 150 mg, scheduled at 6:30 AM, was not administered. c8. Resident 64 was admitted [DATE] with diagnoses including GERD. A review of Resident 64's MAR, dated 5/3/22 indicated Omeprazole 20 mg, scheduled at 6:30 AM, was not administered. c9. Resident 80 was admitted on [DATE] with diagnoses including DM. A review of Resident 80's MAR, dated 4/13/22 indicated Novolog Solution (usedto lower blood sugar levels) 100 unit/ml, scheduled at 6:30 AM, was not administered. A review of the Policy and Procedure titled Administering medicationsdated 4/19, indicated,Policy Statement, Medications are administered in a safe and timely manner, and as prescribed .Policy interpretations and Implementation .4. Medications are administered in accordance with prescribers orders, including any required time frame. 5. Medication administration times are determined by the resident need and benefit, not staff convenience . 7. Medications are adminitered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meals) .

CONCERN (F) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to administer medications in accordance with professional...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to administer medications in accordance with professional standards to 44 of 147 sampled residents ( Residents 1, 2, 3, 4, 5, 6, 7 ,8 , 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 27, 28, 29, 30, 31, 32, 33, 34, 35, 37, 38, 39, 46, 55, 64, 72, 74, 75, 76, 77, 79, 80, 81, and 82) when medications were not administered timely as prescribed by the physician. This facility failure has the potential for residents to experience symptoms including chest pain, breathing difficulty, hyperglycemia/hypoglycemia that might lead to a medical emergency. Findings: During an observation and concurrent interview on 6/6/22, at 7:25 PM, in the COVID-19 Unit, Licensed Vocational Nurse (LVN) 2 stated, There was no endorsement. There was no nurse during the day shift. During an interview on 6/7/22, at 1:40 PM, LVN 2 stated, I did the medpass (medication administration) yesterday (6/6/22) in three different units. The first one is in 2 [NAME] Unit Team 2. There was supposed to be two nurses but there's only one nurse. I passed the medications in 2 [NAME] unit from 8:30 AM to 10:30 AM. When I finished, I went to 2 East unit where there was only one nurse too. I passed the medication for three hours, from 10:30 AM to 1:30 PM. Then, I went to take my lunch. There was no nurse in the COVID unit so, I went there last. I went there after my lunch break. It was around 2 PM when I started passing the 9 AM medications. It was hard. I passed the medications in 3 different units. A lot of the medications were given very late. Residents may have difficulties if they do not get the medications on time. We were short of nurses yesterday (6/6/22). The nurses from the registry did not show up. If you see me and (name of a Registered Nurse) passing meds (administering medications) that a clear indication that we are short staff. That means there's nobody else. 1. During review of Resident 1's clinical record, indicated Resident 1 was admitted with diagnoses including atrial fibrillation (irregular heartbeat) and cerebral infarction (stroke). A review of the physician order for month of 6/22, indicated the following medications were scheduled to be given at 9:00 AM and was administered at 2:42 PM: a. Digoxin (used to control irregular heartbeat); b. Fludrocortisone Acetate (to help some types of low blood pressure) tablet; c. Midodrine HCl (used by residents whose low blood pressure severely limits their ability to perform daily activities); d. Potassium Bicarb-Citric Acid ( to treat low potassium in the blood]) tablet. 2. During a review of the face sheet indicated Resident 2 was admitted with diagnoses including cerebral infarction (CVA, stroke) and acute cystitis (urinary tract infection, UTI) and dementia (decline in memory and other thinking skills). During a review of the physician order month of 6/2022, indicated, .aspirin tablet chewable 81 mg. Give 1 (one) tablet for by mouth one a day for CVA. Take with breakfast .Macrobid capsule 100 mg .Give one capsule by mouth two times a day for urinary tract infection (UTI). During a review of medication administration history for Resident 2 indicated, the following medications scheduled for 9:00 AM, was administered by LVN 2 at 2:18 PM.: a. Aspirin b. Macrobid capsule. 3. During a review of the face sheet indicated Resident 3 was admitted with diagnoses including heart failure (when the heart muscle does not pump as strong as it should). During review of medication administration history for Resident 3, indicated, the following medications such as amlodipine, spironolactone and losartan potassium ( medications used to treat abnormally high blood pressure). scheduled for 9:00 AM, was administered by LVN 2 at 2:23 PM. 4. During a review of the admisiion record indicated Resident 4 was admitted with diagnoses including parkinson's disease (movement disorder) CVA, and diabetes mellitus high blood sugar). During a review of medication administration history for Resident 4 indicated the following medications such as carbidopa-levodopa (used to treat symptoms of parkinson's disease, such as stiffness or tremors), aspirin, levemir solution insulin (used to control high blood sugar) and novolog solution insulin (lower mealtime blood sugar spikes). scheduled for 9:00 AM, was administered by LVN 2 at 2:27 PM. 5. During a review of the face sheet indicated Resident 5 was admitted with diagnoses including chronic gout (repeated episodes of pain and inflammation that often affects the joint). During a review of medication administration history for Resident 5 indicated allupurinol which was scheduled for 9:00 AM, was administered by LVN 2 at 2:55 pm. 6. During a review of the face sheet indicated Resident 6 was admitted with diagnoses including asthma (a condition in which your airways narrow and swell and make breathing difficult). During a review of medication administration history for Resident 6 indicated albuterol sulfate HFA aerosol solution (to relieve difficulty of breathing) scheduled for 9:00 AM, was administered by LVN 2 at 2:40 PM. 7. During review of the admission record indicated Resident 7 was admitted with diagnoses including intracerebral hemorrhage (bleeding inside the brain), diabetes mellitus, and retention of urine (difficulty urinating and completely emptying the bladder). During a review of medication administration audit report for Resident 7 indicated the following medications such as plavix (used to prevent blood clot formation) and amlodipine which was scheduled at 9:00 am were administered at 12:04 PM. Also, the medications such as tamsulosin HCL (used to treat the symptoms of an enlarged prostate that cause difficulty in passing urine) and aricept (used to treat dementia) scheduled at 9:00 PM was administered at 11:56 PM. 8. During a review of the face sheet indicated Resident 8 was admitted with diagnoses including heart failure, asthma, and aortic stenosis (narrowing of the valve [passage that folds or closes to prevent the return flow of the body fluid passing through it] in the large blood vessel branching off the heart). During a review of medication administration audit report for Resident 8 indicated the following medications: a. Furosemide (used to treat fluid retention and swelling caused heart failure). b. Esomeprazole (used to treat conditions where there is too much acid in the stomach).c. Apixaban (used to treat and prevent blood clots) d. Combivent Respimat aerosol solution (provides relief from an asthma attack by relaxing the smooth muscles in your airways). e. Digoxin (used to treat heart failure and irregular heart beats) were scheduled to give at 9:00 AM was then administered 12: 05 PM. Also, the medications such as apixaban and combivent respimat aerosol solution were scheduled at 5:00 PM was then administered 11:57 PM. 9. During a review of the face sheet indicated Resident 9 was admitted with diagnoses including myocardial infarction (heart attack), and paroxysmal atrial fibrillation. During a review of medication administration audit report for Resident 9 indicated the following medications scheduled at 09:00 was administered at 12:26 PM: a.Cardizem LA treat high blood pressure and chest pain) b. Metoprolol Succinate (used to treat chest pain, heart failure, and high blood pressure).The medication brimonidine Tartrate solution (for treatment of glaucoma[eye condition that can cause blindness) scheduled at 08:00 AM was then administered at 12:26 PM. The following medications scheduled for 09:00 am was administered at 12:27 PM: a. Eliquiz b. Furosemide c. Potassium chloride d. Famotidine. The medication Brimonidine Tartrate solution scheduled at 4:00 PM was administered at 12:13 AM. The medication Famotidine tablet scheduled at 5:00 PM was administered at 12:13 am. The medication metoprolol succinate scheduled at 9:00 pm was then administered at 12:13 am 10. During a review of the face sheet indicated Resident 10 was admitted with diagnoses including tachycardia (a heart rate that is more than 100 beats per minute). During a review of medication administration audit report for Resident 10 indicated: a. Diltiazem CD (treat high blood pressure and chest pain) scheduled at 09:00 (9 AM) was administered at 12:10 PM. b. Duloxitine HCL (used to treat major depressive disorder [mental health disorder characterized by persistent loss of interest in activities, causing significant impairment in daily life) scheduled at 09:00 was administered at 12:26 PM. 11. During a review of the face sheet indicated Resident 11 was admitted with diagnoses including heart failure. During a review of medication administration audit report for Resident 11 indicated the following medications such as eliquiz and furosemide were scheduled at 09:00 am was administered at 12:15 pm. 12. During a review of the face sheet indicated Resident 12 was admitted with diagnoses including cerebral infarction, failure to thrive (unexplained weight loss, malnutrition and disability), and dementia. During a review of medication administration audit report for Resident 12 indicated the following medications scheduled at 09:00 was administered at 13:18 (1:18 PM): a. Lidocaine patch (used to relieve pain); b. Megestrol Acetate (used to treat the symptoms of loss of appetite); c. Clopidogrel Bisulfate; d. Memantine HCL (used to treat moderate to severe confusion) 13. During a review of the face sheet indicated Resident 13 was admitted with diagnoses including gout, hypertension (high blood pressure). During a review of medication administration audit report for Resident 13 indicated the following medications - colchicine and clonidine were scheduled at 09:00 was administered at 11:31 AM. The following medications scheduled at 21:00 was administered at 00:25 (12:25 AM) a. Losartan potassium; b. Clonidine HCL The medication Protonix tablet scheduled at 5:00 PM was administered at 12:25 am. 14. During a review of the face sheet indicated Resident 14 was admitted with diagnoses including diabetes, hypertension, and osteoarthritis (pain and swelling of the joints). During a review of medication administration audit report for Resident 14 indicated the following medications scheduled at 09:00 was administered after 12 PM: a.Metformin HCL; b. Amlodipine besylate; c. Aspirin tablet The medication Atorvastatin scheduled at 9:00 pm was administered after 12:00 am. 15. During a review of the face sheet indicated Resident 15 was admitted with diagnoses including osteoarthritis, cancer of the lungs, and hypertension. During a review of medication administration audit report on 6/2022, for Resident 15 indicated the following medications scheduled at 09:00 was administered at 13:21 (1:21 PM).:a. Carvedilol (used to treat high blood pressure) ; b. Prednisone. The medication diclofenac sodium gel scheduled at 1:00 PM was administered at 7:33 PM. The medication carvedilol scheduled 5:00 PM was administered at 12:26 AM. 16. During a review of the face sheet indicated Resident 16 was admitted with diagnoses including cerebral infarction and left femur (thigh bone) fracture (broken bone). During a review of medication administration audit report month of 6/2022, for Resident 16 indicated the following: a.The medications such as xarelto and baclofen were scheduled at 09:00 am was administered after 1:00 PM.The medication Pantoprazole sodium scheduled at 16:30 (4:30 PM) was administered at 12:27 AM. The following medications - atorvastatin and baclofen were scheduled at 5:00 PM was administered at 12:27 AM. 17. During a review of the face sheet indicated Resident 17 was admitted with diagnoses included lung cancer. During a review of medication administration audit report for Resident 17 indicated: The medication Lorazapem (used to treat anxiety [a mental health disorder characterized by feelings of worry, anxiety, or fear) tablet scheduled at 08:00 (8 AM) was administered at 12:29 PM. The following medications scheduled at 9:00 AM was administered from 12:29 - 12:32 PM: a. Tamsulosin HCL; b. Fluticasone propionate HFA aerosol ; c. Gabapentin ; d. Atorvastatin tablet scheduled at 09:00 (9 AM) was administered at 12:29 PM. The medications scheduled at 8:00 PM and 9:00 PM was administered at 12:30 AM: a. Mirtazapine (used to treat depression [a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life]); b. Trazodone (used to treat depression) 18. During a review of the face sheet indicated Resident 18 was admitted with diagnoses including cerebrovascular accident, dementia, diabetes, heart failure and epilepsy. During a review of medication administration audit report month of 6/2022, for Resident 18 indicated the following medications scheduled at 08:00 and 09:00 was administered at 13:03 (1:03 PM).: a.Glimepiride (used to lower blood sugar); b. Finasteride (used to treat enlarged prostate); c. Lacosamide (used to treat seizure) ; d. Fluoxetine (used to treat depression); e. Trajenta (used to lower blood sugar); f. Carvedilol (used to treat high blood pressure); g. Pantoprazole (used to treat certain conditions where there is too much acid in the stomach). The medication Novolog insulin scheduled at 11:30 AM was administered at 1:03 pm. The medication Carvedilol tablet scheduled at 5:00 PM was administered at 12:32 am. The following medications scheduled at 9:00 pm was administered at 12:32 AM: a. Lacosamide; b. Mirtazapine; c. Novolog insulin scheduled at 4:30 PM was administered at 12:31 AM; d. Novolog insulin scheduled at 9:00 PM was administered at 11:31 PM. 19. During a review of the face sheet indicated Resident 19 was admitted with diagnoses including subarachnoid hemorrhage (stroke), chronic obstructive pulmonary disease (a lung disease that causes difficulty to breathe) prostatic hyperplasia (enlargement of the prostate) and depression (excessive sadness and hopelessness). During a review of medication administration audit report month of 6/2022, for Resident 19 indicated scheduled at 09:00 was administered at 13:40 (1:40 PM): a.Venlafaxine HCL (used to treat depression) b. Flomax (tamsulosin) c. Tiotropium bromide (used to treat asthma). The following medications scheduled at 21:00 was administered at 12:33 AM: a. Tiopiramate (anti-seizures); b. Trazodone; c. Melatonin (sleep aid) 20. During a review of the face sheet indicated Resident 27 was admitted with diagnoses including gout and hypertension. During a review of medication administration audit report for Resident 27 indicated the following medications scheduled at 09:00 am was administered at 1:44 PM: a. Amlodipine b. Allupurinol ; c. Finasteride d. Hydralazine (used to treat high blood pressure)e. Tamsulosin. The following medications was administered at 12:33 AM: a. Allupurinol scheduled at 5:00 pm; b. Hydralazine scheduled at 5:00 pm; c. Melatonin scheduled at 9:00 pm 21. During a review of the face sheet indicated Resident 28 was admitted with diagnoses including diabetes, heart failure, atrial fibrillation, and osteoarthritis. During a review of medication administration audit report month of 6/2022, for Resident 28 indicated the following medications scheduled at 09:00 am was administered at 1:50 PM. a.Spironolactone (used to lower blood pressure); b. Eliquiz (used to prevent blood clot); c. Diclofenac gel (used to relieve pain); d. Januvia (used to lower blood sugar); e. Metoprolol succinate. The following medications schedules at 9:00 pm was administered at 12:34 AM.a. Diclofenac gel, and b. Insulin Glargine 22. During a review of the face sheet indicated Resident 29 was admitted with diagnoses including heart failure, gout, and depression. During a review of medication administration audit report month of 6/2022, for Resident 29 indicated the following medications scheduled at 09:00 was administered from 11:10 to 11:12 AM: a. Finasteride b. Amlodipine c. Colchicine d. Gabapentin (used to relieve pain) e. Tegretol (used to treat seizures). The medication Tegretol tablet scheduled at 9:00 PM was administered at 12:28 AM. 23. During a review of the face sheet indicated Resident 30 was admitted with diagnoses including cerebral vascular disease, hypertension, and hyperlipidimia. During a review of medication administration audit report month of 6/2022 for Resident 30 indicated scheduled at 9:00 AM was administered at 1:51 PM: a. Memantine HCl b. Valsartan tablet (used to treat high blood pressure). The following medications was administered at 12:35 AM: a. Memantine HCL scheduled at 5:00 pm; b. Pravastatin sodium (used to lower bad cholesterol [waxy substance found in the blood) scheduled at 5:00 pm ; c. Donezepil (used to treat confusion) scheduled at 9:00 pm; d. Lorazepam scheduled at 9:00 pm. 23. During a review of the face sheet indicated Resident 31 was admitted with diagnoses including diabetes, sleep apnea (a potentially serious sleep disorder in which breathing repeatedly stops and starts), hypertension. During a review of medication administration audit report month of 6/2022, for Resident 31 indicated the following medications scheduled at 09:00 was administered at 11:04 AM: a.Pregabalin (used to control seizures and pain); b. Atenolol; c. Glipizide; d. Advair discus. The following medications were administered between 12:37 AM and 12:38 AM: a. Diclofenac gel scheduled at 5:00 pm; b. Morphine sulfate ER (used to treat moderate to severe pain) scheduled at 9:00 pm; c. Atorvastatin tablet scheduled at 9:00 pm; d. Pregabalin tablet scheduled at 9:00 pm. 24. During a review of the face sheet indicated Resident 32 was admitted with diagnoses including head injury, hypertensive heart disease with heart failure, and atrial fibrillation. During a review of medication administration audit report month of 6/2022, for Resident 32 indicated medications scheduled at 09:00 (9 AM) was administered at between 12:46 and 12:49 PM: a. Losartan b. Carvedilol c. Potassium chloride d. Furosemide . The following medications scheduled at 5:00 pm, was administered at 12:41 AM. a. Furosemide; b. Carvedilol ; c. Potassium chloride. Medication heparin sodium (used to prevent blood clot) scheduled at 10:00 PM, was administered at 12:41 am. 25. During a review of the face sheet indicated Resident 33 was admitted with diagnoses including chronic obstructive pulmonary disease, gastro esophageal reflux disease, and dementia. During a review of medication administration audit report for Resident 33 indicated the following medications scheduled at 09:00 was administered between 1:52 to 1:53 PM: a. Prednisone ; b. Ipratropium-albuterol solution ; c. Symbicort aerosol (used to treat asthma); d. Amlodipine ; e. Metoprolol tartrate ; f. Protonix (used to treat certain conditions where there is too much acid in the stomach). The following medications were administered at 8:39 PM. a. Ipratropium-albuterol solution scheduled at 5:00 pm, b. Ipratropium-albuterol solution scheduled at 9:00 PM. 26. During a review of the face sheet indicated Resident 34 was admitted with diagnoses including cerebral infarction, diabetes, and hypertension. During a review of medication administration audit report for Resident 34 indicated, scheduled at 0900 was administered at 1:04 PM: a. Insulin detemir b. Lasix c. Eliquiz d. Clopidogrel e. Metoprolol. The medication Novolog insulin scheduled at 11:39am was administered at 1:04 pm.The mediation Novolog insulin scheduled at 16:30 (4:30 PM, before meal) was administered at 20:43 (8:43 PM).The medication Metoprolol tartrate scheduled at 21:00 (9 PM) was administered at 00:43 (12:43 AM). 27. During a review of the face sheet indicated Resident 35 was admitted with diagnoses including During a review of medication administration audit report for Resident 35 indicated the following medications was administered at 12:23 AM: a. Eliquiz tablet scheduled at 5:00 pm; b. Perphenazine tablet scheduled at 9:00 pm c. Lovastatin tablet scheduled at 9:00 pm. 28. During a review of the face sheet indicated Resident 37 was admitted with diagnoses including asthma. A review of medication administration audit report dated 5/20/22, indicated medication stiolto respimat aerosol solution (used to treat and prevent shortness of breath) scheduled for 09:00, was administered at 12:45. 29. During a review of the face sheet indicated Resident 39 was admitted with diagnoses including hip fracture (broken bone). A review of medication administration audit report dated 6/6/22, indicated: Medication tramadol scheduled at 12:00 (12 PM), was administered at 15:04 (3:04 PM).Medication tramadol schedules at 00:00 (12 AM), was administered at 02.09 (2:09 AM). During an interview on 6/16/22 at 2:25 PM, the Director of Nursing stated she took a day off on 6/6/22 and was not aware that there were staffing shortage. During an interview on 6/21/22, at 3:20 PM, Registered Nurse 1 stated, The facility's medication administration schedule are 9 AM for once a day or daily, 9 AM and 5 PM for twice a day,9 AM, 1 PM, 5 PM for three times a day, 9 AM, 1 PM, 5 PM, 9 PM for four times a day, 6 AM, 12 PM, 6 PM, 12 AM, for every six hours, 6 AM, 2 PM, 10 PM for every eight hours but it depends when the medication was started. We have to adjust the time. For every 12 hours, it's 9 AM, 9 PM. 30. Resident 20 was admitted on [DATE] with diagnoses including chronic pain syndrome, diabetes mellitus (a metabolic disease that causes high blood sugar), hypokalemia (lower than normal potassium level in the bloodstream), and venous insufficiency (a condition in which the veins have problems sending blood from the legs back to the heart). During an observation and concurrent interview on 6/16/22, at 2:30 PM, Resident 20 was lying in bed and awake. Resident 20 stated, We didn't have a nurse in the morning (on 6/6/22). I did not get medications until 1:30 PM. Most of the medications I take were late. Other dates (medication administration) were late, too. Resident 20 also stated that he did not receive Oxycodone (used to treat severe pain) 5 mg that was scheduled at 8 AM until after 12 PM on 6/6/22. During an interview on 6/16/22 at 3:51 PM, the Director of Nursing (DON) stated that prescribed medications may be administered one hour before, and one hour after the scheduled administration time. The DON stated that a medication is given late if it was administered more than one hour after the scheduled administration time. During a concurrent record review and interview on 6/16/22 at 4:56 PM, LVN 2 stated that the unit where Resident 20 resides was short of one licensed nurse during the day shift on 6/6/22 and the residents' medications were not administered as scheduled. LVN 2 stated, The 8 AM (medication) schedule was given late (for Resident 20). Almost time for 12 PM meds (medications). LVN 2 also stated that the medications scheduled for 9 AM were also administered late. A review of Resident 20's physician's orders for 6/22 indicated the following medications were prescribed and review of Resident 20's MAAR dated 6/6/22 indicated a. Oxycodone Hydrochloride (HCl) capsule 5 mg, scheduled at 8 AM, was administered at 11:53 AM; b. Potassium Chloride (a supplement used to prevent and to treat low potassium) ER (extended release) 20 MEQ (milliequivalents), scheduled at 9 AM, was administered at 11:56 AM; c. Eliquis 5 mg, scheduled at 9 AM, was administered at 11:55 AM; d. Glipizide 5 mg, scheduled at 9 AM, was administered at 11:55 AM; e. Oxycodone HCL 5 mg, scheduled at 4 PM, was administered at 11:58 PM; f. Eliquis 5 mg, scheduled at 5 PM, was administered at 11:58 PM; g. Glipizide 5 mg, scheduled at 5 PM, was administered at 11:59 PM; h. Insulin Regular Human Solution 5 units, scheduled at 4:30 PM, was administered at 11:58 PM; i. Potassium Chloride ER, scheduled at 5 PM, was administered at 11:59 PM. A review of Resident 20's physician's orders and MAR dated 4/11/22 indicated the following medications: a. Oxycodone HCL 5 mg, scheduled at 4 PM, was administered at 10:47 PM; b. Insulin Regular 5 units, scheduled at 4:30 PM, was administered at 6:14 PM; c. Oxycodone HCL 5 mg, scheduled at 8 PM, was administered at 10:45 PM; d. Oxycodone HCL 5 mg, scheduled at 12 MN, was administered at 1:32 PM; e. Oxycodone HCL 5 mg, scheduled at 4 AM, was administered at 7:58 PM; f. Oxycontin ER 20 mg, scheduled at 6 AM, was administered at 7:58 AM. A review of Resident 20's MAR dated 4/13/22 indicated, a. Oxycodone HCL 5 mg, scheduled at 8 AM, was administered at 12:04 PM. b. Potassium Chloride ER, scheduled at 9 AM, was administered at 12:04 PM c. Eliquis 5 mg, scheduled at 9 AM, was administered at 12:04 PM.d. Oxycodone HCL 5 mg, scheduled at 12 PM, was administered at 4:06 PM; e. Potassium Chloride ER, scheduled at 1 PM, was administered at 4:06 PM; f. Oxycontin ER 20 mg, scheduled at 2 PM, was administered at 4:06 PM; g. Oxycodone HCL 5 mg, scheduled at 4 PM, was administered at 7:32 PM; h. Insulin Regular 5 units, was scheduled at 4:30 PM, was administered at 7:32 PM; i. Eliquis 5mg, was scheduled at 5 PM, was administered at 7:32 PM; j. Glipizide 5 mg, scheduled at 5 PM, was administered at 7:32 PM; k. Potassium Chloride ER, scheduled at 5 PM, was administered at 7:32 PM. A review of Resident 20's MAAR dated 4/29/22 indicated, a. Oxycodone HCL 5 mg, scheduled at 8 AM, was administered at 10:31 AM; b. Oxycodone HCL 5 mg, scheduled at 12 PM, was administered 2:02 PM; c. Oxycodone HCL 5 mg, scheduled at 12 AM, was administered at 2:21 AM; d. Oxycodone HCL 5 mg, scheduled at 4 AM, was administered at 7 AM. Additionally, on 4/30/22 indicated, a. Oxycodone HCL 5 mg, scheduled at 8 AM, was administered at 11:49 AM; b. Potassium Chloride 20 MEQ, scheduled at 9 AM, was administered at 11:49 AM; c. Insulin Regular 5 units, scheduled at 4:30 PM, was administered at 7:17 PM; d. Oxycodone HCL 5 mg, scheduled at 4 AM, was administered at 7:20 AM. A review of Resident 20's MAAR, dated 5/1/22 indicated, a. Oxycodone HCL 5 mg, scheduled at 8 AM, was administered at 10:34 AM; b. Insulin Regular 5 units, scheduled at 4:30 PM, was administered at 7:37 PM. The MAAR, dated 5/2/22 indicated, a. Oxycodone HCL 5 mg, scheduled at 12 PM, was administered at 2 PM; b. Oxycodone HCL 5 mg, scheduled at 4 AM, was administered at 5:33 AM. A review of Resident 20's MAAR, dated 5/3/22 indicated, Oxycodone HCL 5 mg, scheduled at 12 AM, was administered at 3:39 AM. A review of Resident 20's MAAR, dated 5/18/22 indicated, a. Oxycodone HCL 5 mg, scheduled at 8 AM, was administered at 10:06 AM; b. Oxycodone HCL 5 mg, scheduled at 8 PM, was administered at 12:55 AM; c. Oxycontin 20 mg, scheduled at 10 PM, was administered at 12:55 AM. A review of Resident 20's MAAR, dated 5/20/22 indicated Oxycodone HCL 5 mg, scheduled at 12 AM, was administered at 3:04 AM. A review of Resident 20's MAAR, dated 5/22/22 indicated, a. Oxycodone HCL 5 mg, scheduled at 8 AM, was administered at 10:58 AM. b. Oxycodone HCL 5 mg, scheduled at 4 PM, was administered at 6:49 PM. c. Oxycodone HCL 5 mg, scheduled at 12 AM, was administered at 4:01 AM. 31. A review of Resident 12's MAAR, dated 4/11/22 indicated, a. Apixaban 2.5 mg, scheduled at 5 PM, was administered at 10:49 PM; b. Creon (used to improve food digestion in people who cannot digest food properly) 24000-76000 units, scheduled at 5 PM, was administered at 10:50 PM; c. Combivent Respimat 20-100 mcg/actuation solution 1 puff, scheduled at 5 PM, was administered at 10:50 PM 32. A review of Resident 10's MAAR, dated 4/13/22 indicated the following medications scheduled at 9 AM were administered at 12:03 PM: a. Amlodipine Besylate 5 mg; b. Calcium Carbonate (used to prevent or treat a calcium deficiency, heartburn, or indigestion) 1250 mg; c. Plavix 75 mg d. Metformin HCl (used to lower blood sugar levels) 500 mg e. Docusate Sodium (laxative) 250 mg f. Cholecalciferol (dietary supplement used to treat Vitamin D deficiency) 25 mcg (microgram) 33. A review of Resident 31's MAAR, dated 4/13/22 indicated, a. Gabapentin 100 mg, scheduled at 9 AM, was administered at 12:09 PM; b. Oxycodone HCL 5 mg, scheduled at 12 PM, was administered at 4:06 PM; c. Gabapentin 100 mg, scheduled at 1 PM, was administered at 4:06 PM. 34. Resident 38 was admitted on [DATE] with diagnoses including DM, hypertension (high blood pressure), depression (a mood disorder causing persistent feeling of sadness and loss of interest), peripheral neuropathy (nerve damage causing pain, numbness, tingling, swelling, or muscle weakness in different parts of the body), gastro-esophageal reflux disease (GERD - a condition in which acid from the stomach comes up into the esophagus), and chronic pain syndrome. A review of Resident 38's MAR, dated 4/13/22 indicated the following medications scheduled at 9 AM were administered at 12:16 PM: a. Oyster Shell Calcium 500 mg; b. Atenolol 25 mg; c. Fluticasone-salmeterol (used to treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by asthma) 100-50 mcg/dose; d. Metformin 500 mg; e. Duloxetine HCL (used to treat depression and anxiety) 30 mg; f. Lidocaine Patch 4% (used to reduce itching and pain); g. Liraglutide Solution Pen-Injector (used to control blood sugar levels) 18 mg/3ml (milliliter) 35. A review of Resident 33's MAR, dated 4/13/22 indicated Tiotropium Bromide Monohydrate (bronchodilator - a medication that relaxes and opens the airways, or bronchi, in the lungs) 18 mcg, scheduled at 9 AM, was administered at 12:13 PM. 36. Resident 80 was admitted on [DATE] with diagnoses that include dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), DM, and hypertension. A review of Resident 80's MAR, dated 4/13/22 indicated the following medications scheduled at 9 AM were administered at 12:48 PM: a. Exelon Patch (used to treat dementia) 4.6 mg/24hr ; b. Glipizide 5mg; c. Amlodipine Besylate (used to treat hypertension) 2.5 mg 37. A review of Resident 35's MAAR, dated 5/3/22 indicated the following medications scheduled at 9 AM were administered at 4:43 PM: a. Januvia (used to lower blood sugar levels for people with type 2 DM [when the body is unable to effectively use insulin) 25 mg; b. Metoprolol Succinate ER 0.5 mg; c. Apixaban 2.5 mg; d. Spironolactone 25 mg; e. Diclofenac Sodium Gel (used to treat mild to moderate pain) 1%; f. Spironolactone 25 mg; g. Multivitamin-Minerals tablet, and h. Acetaminophen (used to treat mild to moderate pain) 650 mg, scheduled at 8 AM, was administered at 4:43 PM 38. Resident 64 was admitted on [DATE] with diagnoses including urinary tract infection, neuromuscular dysfunction of the bladder, paraplegia (paralysis of lower legs and body), multiple sclerosis (a disabling disease of the brain and spinal cord), and fibromyalgia (disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues.) A review of Resident 64's MAAR, dated 5/3/22 indicated the following medications scheduled at 9 AM were administered at 11:34 AM: a. Cranberry (used to reduce risk of bladder infections)tablet 450 mg; b. Vitamin C 500 mg; c. Miralax Powder (used to treat constipation) 17 gram; d. Baclofen 20 mg; e. Cytra-2 solution (used to make the urine less acidic) 500-334 mg/5ml; f. Multivitamin-Mineral tablet; g. Docusate Sodium 250 mg; h. Culturelle capsule (used to improve digestive and immune health); i. Amitiza (used to treat constipation) 24 mcg A review of the Policy and Procedure titled Administering medicationsdated 4/2019, indicated,Policy statement, Medications are administered in a safe and timely manner, and as prescribed .Policy interpretations and Implementation .4. Medications are administered in accordance with prescribers orders, including any required time frame. 5. Medication administration times are determined by the resident[TRUNCATED]

CONCERN (F) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

Based on observation, interview and record review the facility failed to implement their infection control and prevention program when: a. N95 mask was inappropriately used by eight (8) staff; b. Annu...

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Based on observation, interview and record review the facility failed to implement their infection control and prevention program when: a. N95 mask was inappropriately used by eight (8) staff; b. Annual fit testing was not performed. c. Hand sanitizers were used to disinfect care equipment ' s and high touched areas; d. There was no proof of documentation of health examination for nine (9) employees and no proof of documentation of tuberculosis screening (This test checks to see if you have been infected with tuberculosis, commonly known as TB. TB is a serious bacterial infection that mainly affects the lungs. TB spreads through the air when a person with TB coughs, sneezes, or talks) for three (3) employees. e. Facility has no proof of documentation of antibiotic surveillance. f. Resident from different units tested positive with COVID-19 infection. This facility failure has the potential for the spread of infection to the residents and staff. Findings: a. During observation and concurrent interview on 6/6/22, at 6:35 PM, the Certified Nurse Assistant (CNA, caregiver) 1 placed paper towel on the table in front of where she's going to sit to eat. CNA 1 then removed her face shield and place it on the paper towel laid on the table. CNA 1 stated that she slid her N95 mask down under her chin when she eats. CNA 1 also stated, I take my N95 mask home and pour boiling water on it. I dry it and get it ready for the next use. I also keep an extra mask in my pocket. CNA 1 then pull out an unsealed and unwrap N95 mask from her pocket. During observation and concurrent interview on 6/23/22, at 7:35 AM, CNA 6 and CNA 7, had the straps of their N95 mask cut, tied the straps to make a loop and placed them behind the ears. CNA 6 stated, The mask it too tight. It is uncomfortable. CNA 7 stated, I had the strap cut because it is more comfortable when I put it behind the ears. A review of the manufacturer's instructions indicated, .Use instructions .Do not wash. Store in a cool, dry place, away from fire and contamination .Wearing instructions .Place elastic bands around the neck and head respectively . b. During a review of employee fit testing results, the last employee fit testing was performed in 1/2021. A review of fit testing dated 10/1/20, indicated, CNA 8 .failed . A review of fit testing dated 12/31/20, indicated, CNA 9 .failed . During an interview on 6/22/22, at 11:35 AM, staffing personnel stated CNA 8 and CNA 9, are regularly scheduled to work. During an interview on 6/22/22, at 12:05 PM, Central supply staff stated, We order one type of N95 mask (used to help provide respiratory protection). All employees wear the same type of mask. The facility provides all employees with N95 (name of brand) particulate respirator. c. During observation and concurrent interviews on 6/6/22, at 7:05 PM, CNA 1 and LVN 1 presented the hand sanitizer as the disinfectants used. LVN 3 stated, It is used to clean the tabletops. CNA 3 and LVN 3 was not able to locate disinfectants in the unit. CNA 3 while pointing to the hand sanitizers stated, We use it to disinfect the counters and doorknobs. This is all we have. d. During a review of employee files on 6/22/22, at 3:30 PM, indicated no proof of documentation of health examination (a requirement to ensure the safety and well-being of the patients and coworkers, and that the employee is capable of performing the job) for Registered Nurse (RN) 2, RN 3, LVN 6, LVN 7, LVN 8, and LVN 9. There was no proof of documentation of tuberculosis screening for RN 2, LVN 8, and LVN 9. e. The facility was unable to provide proof of documentation of antibiotic surveillance in the facility. f. A review of the following results as confirmed through a laboratory testing indicated COVID-19 infection: Resident 71, resident in 2 West, tested positive with COVID 19 infection on 5/30/22. Resident 59, a resident in 2 East unit, tested positive with COVID 19 infection on 5/26/22. Resident 6, a resident in 2 East unit, tested positive with COVID 19 infection on 5/26/22. Resident 60, a resident in 1 East unit, tested positive with COVID 19 infection on 5/26/22. Resident 31, a resident in 1 East unit, tested positive with COVID 19 infection on 5/26/22. Resident 5, a resident in 2 [NAME] unit, tested positive with COVID 19 infection on 5/24/22. Resident 4, a resident in 2 East unit, tested positive with COVID 19 infection on 5/24/22. During observation and concurrent interview on 6/6/22, at 7 PM, CNA 2 stated, The yellow zone is where the residents from the COVID unit were transferred to continue to recover. When a resident is finished with their stay in the COVID unit we were asked to pick up the resident from the COVID unit and transferred here (yellow zone). During an interview on 6/7/22, at 4:10 PM, CNA 4 stated, I do not remember the last time we had an Inservice on infection control. CNA 5 stated , We do not have an infection control nurse and no Director of Staff Development (DSD, Educator). During an interview on 6/7/22, at 2:25 PM, the Director of Nursing (DON, Director of Nursing Services) stated, There is no Infection Preventionist (IP). I have no training in infection prevention and control. During an interview on 6/21/22, at 12 PM, the Administrator acknowledged the facility has no full time Infection Preventionist.

CONCERN (F) 📢 Someone Reported This

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

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

Deficiency F0882 (Tag F0882)

Could have caused harm · This affected most or all residents

Based on observation, interview and record review, the facility failed to have a designated Infection Preventionist (IP). This facility failure resulted to lack of oversight to the infection preventio...

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Based on observation, interview and record review, the facility failed to have a designated Infection Preventionist (IP). This facility failure resulted to lack of oversight to the infection prevention and control program in the facility. Findings: During observation on 6/3/22, at 7:30 PM, the facility has a covid unit occupied by 12 residents with COVID-19 infections. During an interview on 6/7/22, at 2:25 PM, the Director of Nursing stated that there is no IP. The previous IP's last day at work was May 5, 2022. I do the IP role 2 to 3 hours a day. I cannot account my activities on those hours. I do not have a training in infection control and prevention. I do not have time to get the training because I am also the DSD, and I am also the DON. During an interview on 6/21/22, at 12:00 PM, the Administrator acknowledged the facility has no full time IP.

Dec 2022 2 deficiencies

CONCERN (E) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

Based on observation, interview and record review, the facility failed to consistently implement infection control precautions necessary to deter the spread of Covid-19 virus in the facility, when: 1....

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Based on observation, interview and record review, the facility failed to consistently implement infection control precautions necessary to deter the spread of Covid-19 virus in the facility, when: 1. Facility staffs did not store their PPEs (personal protective equipments) properly while on break. 2. Some staff did not know what type of isolation precautions to follow prior to entering residents' room due to lack of signages on the front door. 3. Facility staffs were not wearing face shields while in the nursing station. 4. There were no zoning sections in the facility at this time. Residents with Covid19+ were isolated in their rooms, and identified with signages on the door as to droplet/contact precaution. 5. There was a mop soaked in the water bucket for a long period of time in the emergency area. These failures had placed residents in the increased risk of likely spread of COVID-19 that may potentially cause serious illness, hospitalization and/or death. Findings: 1. During observation on 12/1/22 at 12:00 PM, CNA 1 was in the break room and while drinking, her faceshield was on the table, ID badge and N95 mask were on top of the face shield. In an interview with CNA1, she stated, I don't know, where should I put it? During interview with Infection Control Preventionist (ICP), on 12/1/22 at 2:00 PM, ICP stated, staff on break should remove N95 and face shield and store in brown bag or in between paper towel. The last in service on PPE use was couple weeks ago, and one on Monday, it's an ongoing in service on PPE. ICP acknowledged the wrong practices of storing PPE while on break. 2. During an observation on the second floor, on 12/5/22 at 2:00 PM, the isolation cart set up was outside of the room. There was no signage for Transmission Based Precaution (TBP), No Personal Protective Equipment ( PPE) signage. During interview with CNA 1 who was next door, she stated, I don't know if they are positive. During interview with Licensed Vocational Nurse (LVN) on 12/5/22 at 2:00 PM, LVN 1 stated, All three residents are Covid positive in that room. The DON and Administrator and Infection Control Nurse take care of those signage. I know who of my patients are positive, they tell me during start of shift. 3. During observation on 11/30/22 at 10:00 AM, LVN 2 was preparing medications. LVN 2 had no face shield. Interview with LVN 2, LVN 2 stated, I have no idea I have to wear face shield. During interview with Staff Development Department ( DSD), on 12/1/22 at 11:00 AM, DSD stated, We have registry staff (an individual licensed or certified by a regulatory agency who receives compensation from a third party to work at a healthcare institution). We use 4 different registries to complete our staffing. We have contracts with each one. Orientation of the registry staff were on computer mode which included tour of the facility, crash cart location, emergency expectation, abuse reporting, PPE use .keep records of registry staff that includes vaccination, license. The registry were the ones screening their employees. Review of facility's mitigation plan, 3. Personal Protective Equipment (PPE), indicated, Staff has been trained on selecting, donning and doffing appropriate PPE and demonstrate competency of such skills during resident care. 3. Signs are posted immediately outside of resident's room indicating appropriate infection control and precautions and required PPE in accordance with CDC/CDPH guidance. 4. During observation on 11/30/22 at 11:30 AM, there were no zoning sections in the facility at this time. Residents with Covid19 positive are isolated in their rooms, and identified with signages on the door as to droplet/contact precaution. Interview with administrator on 12/5/22 at 2:30 PM, ADM stated they had not updated their mitigation plan to reflect the current practice of isolating residents in their respective rooms while residents with confirmed Covid-19 positive are on quarantine. 5. During observation on 11/30/22, at 11:25 AM, there was a mop soaked in the water bucket, next to staircase for a long period of time in the red marking area with a signage indicated, Do not block, keep clear at all times. Interview with maintenance supervisor on 11/30/22 at 11:35 AM, MS stated that the mop should be cleaned after every use. The mop should not be soaked in the water bucket for a long period of time because germs may thrive in there.

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 F0885 (Tag F0885)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide timely information to residents/representatives, and famili...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide timely information to residents/representatives, and families of confirmed cases of COVID-19 infections in their area for 4 of 10 residents and one of two family interviewed. (Residents 1, 2, 3 and 4). Findings: 1. On 11/30/22 at 11:12 a.m., Resident 2 was interviewed. She stated she thinks she was not getting the whole story about the COVID positive cases in the facility. 2. On 11/30/22 at 11:20 a.m., Resident 3 was interviewed. He indicated he didn't know of COVID-19 positive cases unless he asked, and he asks once a day. He wasn't being told much of anything. On 11/30/22 at 11:25 a.m, the family member designated at Resident 2 and 3 was interviewed. He indicated the facility doesn't let him know anything. He checks on Resident 2 and 3 a whole lot, but it had been a while. No information had been provided for how to obtain COVID-19 status of the facility. 3. On 11/30/22 at 12:00 p.m., Resident 4 stated the facility was not letting her know of any new cases of COVID-19. No one had informed her of any staff positive cases. On 11/30/22 at 11:45 p.m., the DON (Director of Nursing) stated all they have done was talk to the residents, making sure they understand if they have tested positive or not. DON also stated that Social Worker (SW) had called the family members over the phone, to try to inform them about COVID-19 status in the facility but some of them did not pick up their phones. Interview with Infection Preventionist (IP) on 12/05/22, IP stated that on 11/22/22, residents were tested thru PCR for Covid-19. However, the samples were rejected and she had contacted MHOAC (Medical Health Operational Area Coordination, represents the single point of contact responsible for monitoring and ensuring adequate medical & health resources are in place during a local emergency) inadvertently to ask for PPE supplies to about 169 unconfirmed Covid-19 residents/staffs on 11/25/22. 600 regular masks were then dropped to the facility on [DATE]. IP stated that this information was not communicated to the residents/representatives and family members. Interview with ADM on 12/05/22, at 2:00 pm, ADM stated they had implemented No visitation policy on 11/28/22 to 12/01/22. ADM acknowledged there was no facility process in place to ensure residents, their representatives and families were notified by 5 p.m. the next calendar day. 4. During interview with Resident 1's responsible party (RP), on 12/5/22 at 2:25 PM, RP stated, I got a call this morning around 8:00 AM, that my family member (Resident 1) passed away. I live in another county so I called a relative family member who lives around the facility. I called the mortuary to have his body picked up from the facility. About two hours later, I got a call from facility staff that it was a mistake and that my family member (Resident 1) is alive. I'm happy my family member is alive but that was not right. I took him to the administrator 's office to express this frustration about this miscommunication . RP also stated about rules on visitation, We came on thanksgiving day, we were not allowed to visit because of lockdown. No one called and there was no email nor notification. It was thanksgiving and so we have to see our family member (Resident 1). Resident 1 can 't speak and no one has seen him for more than 10 days now. I was told that the responsible people to do the email are off due to holiday. We were very upset about that. I came today and we still did not get any email or call that we can visit, but we came anyway. I did not know if our family member is Covid positive or not.

Jun 2021 9 deficiencies 1 Harm

SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Pressure Ulcer Prevention (Tag F0686)

A resident was harmed · This affected 1 resident

Based on observation, interview, and record review, the facility failed to prevent the development of an avoidable pressure injury for Resident 277, one of three sampled residents with pressure injuri...

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Based on observation, interview, and record review, the facility failed to prevent the development of an avoidable pressure injury for Resident 277, one of three sampled residents with pressure injuries. The facility assessed Resident 277 as high risk for developing pressure injuries (localized damage to the skin and/or underlying soft tissue usually over a bony prominence. A pressure injury may present as intact skin and may be painful). However, the facility failed to implement interventions to off load pressure to Resident 277's heels. As a result of this failure, Resident 277 developed a pressure injury to her left heel on 6/24/21. Findings: A review of Resident 277's admission record dated 6/17/21 indicated, she had end stage renal disease (ESRD, when the kidney failed to function normally), dementia (decline in memory or cognition), and diabetes (abnormally high sugar level in the blood). During initial tour and concurrent interview with Certified Nurse Assistant (CNA) 3, on 6/22/21, at 10:15 AM, Resident 277 was lying on her back, head of bed elevated, and both her heels were touching the mattress. There were no devices implemented to elevate her heels or to off load pressure to her heels. CNA 3 stated, She (Resident 277) cannot do anything for herself. She is totally dependent and has a pressure ulcer (pressure injury) on the buttock. During an observation and concurrent interview with the CNA 3, on 6/23/21, at 9 AM, Resident 277 was lying on her back with head of bed elevated, both her heels were touching the mattress. There were no devices implemented to elevate her heels or to off load pressure to her heels. CNA 3 stated she was waiting for help to clean the resident. During wound care observation and concurrent interview with the Treatment Nurse (TN), on 6/24/21, at 9 AM, TN explained that she will do wound treatment to the left buttock. Resident 277 moaned and stated, My left foot hurts. Resident 277's heel was observed to have a dark purple patch. The TN stated, I just learned about it (left foot pressure injury) this morning. It measures 3.5 centimeters by 4 centimeters. The pressure injury is new. A review of Resident Data Collection dated 6/17/21, indicated Resident 277 has no pressure injury on the left heel on the day of admission. A review of Resident 277's care plan dated 6/19/21, indicated the following: .Focus: High risk for pressure injury related to (RT) diagnosis (DX): End stage renal disease (ESRD), Peripheral vascular disease (PVD) Morbid obesity . Goal: Will not have pressure injury through review date .target date: 9/16/21. Interventions/Tasks: Assist and turning and repositioning every (q) shift; Pressure relieving device in bed and wheelchair; Provide good nutrition and hydration; Assist with meals; Offer fluids as ordered; Provide good skin care after incontinent episode; Assess for skin breakdown Q shift and notify MD (doctor)/Responsible Person (RP) . A review of Nursing Notes dated 6/18/21, 6/19/21, 6/20/21, 6/21/21, 6/22/21, and 6/24/21 did not indicate that Resident 277 has left foot pressure injury. A review of the facility policy and procedure titled, Pressure Injury Risk Assessment dated 3/2020, identified ESRD, diabetes and cognitive impairment as risk factors for the development of pressure injuries. The policy indicated . General guidelines .2. Risks factors that increases a resident's susceptibility to develop .pressure injury (PI) .b. impaired/decreased mobility . h.circulation deficits . i.end stage renal disease .diabetes .m cognitive impairment . A review of the facility policy and procedure titled, Prevention of Pressure Injuries dated 4/2020, indicated .Skin assessment 3. Inspect the skin .when performing or assisting with personal care or activity of daily living (ADLs) . The cause of pressure injuries is prolonged pressure to a bony area of the body. Uninterrupted pressure is the main cause of pressure injuries, impaired mobility is probably the most common reason residents are exposed to unrelieved pressure. Immobility if prolonged, leads to muscle and soft tissue atrophy (decrease in size), decreasing the bulk over which bony prominence's are supported, further increasing the risk of developing pressure ulcer. The Journal of Legal Nurse Consulting, Spring 2012, recommends that care givers off load bony areas of the body to prevent pressure injuries. The Journal of Legal Nursing Consulting stated Pressure can be lessened by establishing a patient turning schedule that is documented. The standard of care for turning and repositioning is every 2 hours in the recumbent individual and every 15 minutes in a seated person .Off load the heels with a pillow, heel protection device, or wedge .

CONCERN (D)

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

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete a Baseline Care Plan (BCP) for one of 42 samp...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete a Baseline Care Plan (BCP) for one of 42 sampled residents (Resident 276) when there was no evidence of documentation of a completed BCP. A BCP includes minimum healthcare information necessary to properly care for each resident immediately upon their admission, which would address resident-specific health and safety concerns to prevent decline, injury, such as elopement or fall risk, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. This deficient practice had the potential to result in inadequate care and services rendered to the resident. Findings: Resident 276 was admitted on [DATE], with diagnoses including osteoarthritis (pain and swelling on the joints) and pneumonitis (inflammation [swelling] of the lungs). During the initial tour on 6/22/21, at 9:40 AM, Resident 276 was observed grimacing while repositioning himself in the wheelchair. Resident 276 pointed to his swollen right knee and stated too much pain. Resident 276 clinical record did not indicate that a BCP was developed. During an interview with Registered Nurse (RN) 1 on 6/24/21, at 10:45 AM, RN 1 acknowledged that the BCP was not developed and a copy was not provided to the responsible person (RP). RN 1 stated, The responsible party should have signed the baseline care plan. The baseline care plan is completed by the admission nurse. During a review of facility document titled Initial Care Plan Summary, the Initial Care Plan Summary indicated, This summary is to be completed within 48 hours by the admission nurse. Review by the RN Supervisor. All problems, goals and interventions will be reviewed and replaced by a comprehensive care plan within 21 days. Review of facility Care Plans - Baseline Policy and Procedure dated 4/2020, indicated, The facility will develop a baseline care plan within 48 hours of admission which provide instructions for the provision of effective and person-centered care to each resident. 1. Our facility's Care planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops a baseline care plan for each resident beginning on admission that attempts to strike a balance between conditions and risks affecting the resident's health and safety, and what is important to him or her, within the limitations of the baseline care plan timeframe. 2. The baseline care plan will include the minimum healthcare information necessary to properly care for each resident immediately upon their admission . Each resident's baseline care plan will include a minimum of the following: Initial goals based on admission orders. Dietary orders. Therapy services. Social services . 3. The resident's baseline care plan is begun on admission and implemented within 48 hours of admission. 4. The facility will provide the resident and the representative if applicable, with a written summary of the baseline care plan by completion of the comprehensive care plan. The summary will include at the minimum, of following: initial goals for the resident, a list of medications and dietary instructions, services and treatments to be administered by the facility and personnel acting on behalf of the facility. 5. A representative will obtain signature, or verification, that the summary was given to the resident or resident representative if applicable.

CONCERN (D)

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

Deficiency F0836 (Tag F0836)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to submit an application for Change of Ownership (CHOW) to the department. This facility failed to meet the state law (Title 22, 72201 (2)) r...

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Based on interview and record review, the facility failed to submit an application for Change of Ownership (CHOW) to the department. This facility failed to meet the state law (Title 22, 72201 (2)) requirement. Findings: During an interview with the Administrator on 6/22/21, at 9:45 AM, he explained that they took over the facility on 4/8/21. The name of new owner is (name redacted). He acknowledged there is no application filed for the CHOW. During an interview with the Administrator on 6/22/21, at 12 PM, he stated that the company lawyer is calling the Department regarding the CHOW application. During an observation on 6/24/21, the license posted in the facility consumer board indicated license under the name of the previous owner. The California Code of Regulations (CCR) Title 22: Social Security , Division 5, Chapter 3, Article 2, indicated Application required .(2) Change of Ownership .

CONCERN (D)

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

Deficiency F0849 (Tag F0849)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility has no valid contract to provide onsite hospice care. This facility failure ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility has no valid contract to provide onsite hospice care. This facility failure has the potential to negatively impact the provision of care for Resident 30. Definition: Hospice care means a comprehensive set of services . identified and coordinated by an interdisciplinary group (IDG) to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill patient and/or family members, as delineated in a specific patient plan of care .these services are provided by a Medicare-certified hospice . Findings: Resident 30 was admitted on [DATE] under the care of (Hospice Care agency), diagnoses include heart failure (when the heart does not pump as strong as it should), chronic obstructive pulmonary disease (COPD,a group of lung diseases that block airflow and make it difficult to breathe), and cerebral infarction (stroke). During an interview with the Administrator on 6/23/21, at 9 AM, he stated, It should be in one of these binders. I will bring it to you. During a review of the facility document titled Hospice-Skilled Nursing Facility Agreement, dated 6/22/21, and concurrent interview with the Administrator and the Director of Nursing (DON) on 6/28/21, at 11 AM, Administrator stated, This agreement is executed as of June 22, 2021.The ADM1 acknowledged the document was dated June 22, 2021, and Resident 30 was admitted under (name of Hospice Care Agency) on 4/3/21. The DON stated, (name of previous company) took a lot of documents with them. Review of Hospice -Skilled Nursing Facility Agreement indicated, This agreement is executed as of June 22, 2021 and effective as of Effective Date .Article I Definitions .1.3 Effective date shall mean June 22, 2021 .

CONCERN (D)

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

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review, the facility failed to ensure a safe, functional, and clean environment for residents. 1. Beauty salon door was not kept clean. 2. Uncleaned equipme...

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Based on observation, interview and record review, the facility failed to ensure a safe, functional, and clean environment for residents. 1. Beauty salon door was not kept clean. 2. Uncleaned equipment and residents' personal items were stored in the residents' shower room. 3. The eye wash station located in the laundry room was not cleaned. These failures had the potential to not provide a clean and safe living conditions for the residents. 1. During an initial tour observation on 6/22/21 at 8:53 AM, the beauty salon located at the first floor had a sign at the door indicating, In Use, and the entrance door was closed. The door had fixed horizontal slats on the lower panel that had significant accumulation of dust and gray-like fuzzy material. During an interview on 6/22/21 at 8:54 AM, with Housekeeping Aide (HKA) 1, HKA 1 acknowledged the observations and stated, .it's dirty . should be dusted off and cleaned . HKA 1 stated his responsibility were to clean residents' room, and called in another staff who was in the hallway. During an interview on 6/22/21 at 8:55 AM, with HKA 2, HKA 2 stated, he was responsible for cleaning the beauty salon/room. HKA 2 stated the door slats were dusty and dirty and said, forgot to clean. During an interview on 6/23/21 at 10:20 AM, with the Infection Preventionist (IP), IP stated the Housekeeping Department is responsible for cleaning the door vent/grilles. IP stated, the dust collected had the potential risk to cause allergies and other respiratory issues on residents. 2. During an observation on 6/22/21 at 10:50 AM with Certified Nursing Assistant (CNA) 5 present, the following were noted in the residents' shower room located at the west section of the second floor: several wheelchairs, two commodes stacked on top of the other, unlabeled clear plastic bag with articles of clothing inside, opened plastic bag that contained articles of clothing, and a white soiled linen bin with a bag of trash inside. The black-cushion cover of the bench next to a shower stalls had dispersed white-colored smudges. CNA 5 stated, only one shower stall was available for use. The unused shower stall had a wheelchair inside. CNA 5 acknowledged the observations and stated, the wheelchairs, commodes and clothing inside the plastic bags were dirty. CNA 5 stated, the equipment and items had been stuck here for a while, and should not be stored in the residents' shower room. CNA 5 stated, the wheelchairs were supposed to be stored in the Rehabilitation department. During an interview on 6/22/21 at 11:35 AM, with the Director of Rehabilitation (DOR), DOR stated, facility-owned wheelchairs were cleaned and stored in a designated space in the garage, with a few kept in their department. DOR stated, rehabilitation staff also used a storage room for wheelchairs located at the east-section of the second floor. DOR stated, he was not aware the nursing staff or certified nursing assistants kept wheelchairs in the shower room located on the second floor west-section. DOR stated, it's [resident shower room] for shower not storage . DOR stated, he had to ask the Administrator on who had oversight of the wheelchair storage and cleaning process. During an interview on 6/23/21 at 10:40 AM, with the Infection Preventionist (IP), and Director of Staff Development (DSD), IP stated wheelchairs were supposed to be stored down in the basement storage area. IP stated, we don't want them [wheelchairs] there [in the shower room]. DSD stated, the plastic bags that contained residents' clothing found in the shower room should be labeled . endorsed to the laundry department and washed . given to the Social Services Department if the residents were discharged from the facility . The IP stated, the equipment and items found in the shower room were infection control concern because if it were not clean .it could harbor pathogens, bacteria . During a review of the facility's Maintenance Advisory document, dated 10/7/16, the document indicated, STORAGE, SAFEKEEPING AND DELIVERY OF HEALTHCARE EQUIPMENT AND SUPPLIES TO RESIDENT'S ROOM . Healthcare equipment for residents like . commodes, wheelchairs . are required to be clean and disinfected according to infection control policy. For this reason, we are hereby advised and reminded to maintain the cleanliness and sanitation of these healthcare equipment from the storage, during safekeeping and before delivery to the resident's room. Healthcare equipment to be stored shall be organized and maintain cleanliness . During a review of the facility's policy and procedure (P&P), posted in the laundry room titled, LAUNDRY AND LINEN - GENERAL POLICY AND GUIDELINES, undated, the P&P indicated, .Soiled linen is stored in separate, well ventilated areas and is not permitted to accumulate in the facility. Soiled linen and clothing are stored separately in suitable containers. Soiled linen is not sorted, laundered, rinsed or stored in bathrooms, resident's rooms, kitchens or food storage areas . 3. During a concurrent observation and interview on 6/23/21 at 9:09 AM with Housekeeping Supervisor (HKS), the hand-washing sink connected to wall-mounted orange - colored eye wash fountain, located near the entrance of the laundry room had significant accumulation of dust and lint. The two spray heads were uncovered. Both spray heads and flip top dust covers had notable white-colored spots. HKS acknowledged the findings. HKS also stated the spray heads should be covered to prevent accumulation of dirt and dust.

CONCERN (E)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility failed to ensure psychotropic medication is used to treat a specifi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, facility failed to ensure psychotropic medication is used to treat a specific diagnosis and documented condition for one of three sampled residents, (Resident 102) when: a. Risperdal (an antipsychotic) was indicated for dementia (decline in memory or other thinking skills); b. Consent was not obtained for use of Risperdal; c. There is no specific target behavior monitoring for use of Risperdal. Failure to obtain consent, identify and monitor specific behavior manifestation for the use of psychotropic medication had the potential to put the residents at risk of receiving unnecessary medications that could result in serious harm. Definition: Antipsychotic are drugs used to control the symptoms (a physical or mental feature indicating a disease condition) of schizophrenia (a severe mental illness that may change the way a person think, speak, and behave). Findings: Resident 102 was admitted on [DATE], with diagnoses including dementia (decline in memory or other decision making ability) and heart failure (when the heart does not pump as strong as it should). Minimum Data Set (an assessment tool) dated 6/20/21 brief score of mental status (a brief memory test to help determine cognitive function) score of 3 indicates severe cognitive impairment. During tour of the facility on 6/22/21, at 9:50 AM, Resident 102 was observed sitting up in the wheelchair, alert and verbally responsive. Resident 102 stated, I do not know how am I and where I am. During an interview with Licensed Vocational Nurse (LVN) 3 on 6/24/21, at 10:20 AM, she stated, Resident 102 tried to get up from bed without assistance and when he is a wheelchair, he tries to stand up and walk. During a review of Resident 102's Medication Administration Record for June 2021, indicated Risperdal 0.5 mg was tablet administered on 6/16, 6/17, 6/18, 6/19, 6/20, 6/21, 6/22, 6/23, and 6/24. During a review of Resident 102's physician (medical doctor) order dated 6/15/21, indicated Risperdal give 0.5 mg by mouth at bedtime for dementia. During an interview on 6/25/21, at 11:40 AM, with Resident 102's Responsible Person (RP, family, relative) stated, I do not know he is taking Risperdal. I did not talk to any one about that medicine. The last time I talk to a doctor was when he was still in the hospital and they told me he is ready to go back to the facility. No one from the facility talk to me about giving the medication. He was not taking that kind of medication at home. During a review of Resident 102's Informed Consent for Psychotherapeutic Antipsychotic and concurrent interview with LVN 3 on 6/25/21, at 11 AM, she acknowledged the consent was not completed and stated, The consent should say what behavior to monitor and it has to be signed by the doctor. LVN 3 checked the electronic Medication Administration Record and stated, Risperdal is indicated for dementia and is given since 6/16/21. There is no behavior monitoring. During an interview with the Director of Nursing (DON) on 5/25/21, at 3:30 PM, she stated that the consent should indicate the behavior that needs to be monitored and acknowledged the consent was not completed. During a review of facility Policy and Procedure(P&P), dated 12/16, titled Antipsychotic Medication Use, P&P indicated, .Policy Interpretation and Implementation 1. The residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. 2. The attending physician and other staff will gather and document information to clarify resident's behavior, mood, . and risks to the resident and others . 7. Antipsychotic medications shall generally be used only for the following condition .a. schizophrenia (severe mental illness), b. schizoaffective disorder (severe mental disorder) . 8. a. The behavioral symptoms present a danger to the resident and others .11 . Antipsychotic medications will not be used if the only symptoms are . d. Impaired Memory .

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.c During an observation on 6/22/21, at 10:15 AM, by the door of room [ROOM NUMBER], CNA 3 tied the dirty linen plastic bag, pl...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.c During an observation on 6/22/21, at 10:15 AM, by the door of room [ROOM NUMBER], CNA 3 tied the dirty linen plastic bag, placed it in the dirty linen barrel in the hallway. CNA 3 did not perform hand hygiene, CNA 3 went to room [ROOM NUMBER], moved Resident 111's table, then proceeded to Resident 103, touched the bed control by the head of Resident 103, adjusted the height of the bed. CNA 3 came out of the room did not perform hand hygiene. During an interview on 6/22/21, at 10:25 AM, with CNA 3, in the hallway of unit 2 West, CNA 3 stated, I'm sorry, I forgot . I did not wash my hands or use the hand sanitizer . During an interview on 6/23/21, at 10:05 AM, with the Infection Prevention and Control (IP) Nurse and Director of Staff Development (DSD), IP Nurse stated, staff was supposed to follow standard precautions [the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where health care is delivered] before and after giving resident's care. The DSD also stated, staff was supposed to wash hands or use hand sanitizer after picking up and dumping the dirty linen in the barrel, before proceeding to do another task or another room and in between resident care. During a review of the facility's policy and procedure (P & P), titled, Handwashing/Hand Hygiene, dated August 2019, the P & P indicated, .Use an alcohol-based hand rub containing at least 62% alcohol; or alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: a) Before and after direct contact with residents; i) After contact with objects (e.g. medical equipment) in the immediate vicinity of the resident; After removing gloves . During a review of the facility's policy and procedure (P&P) titled, Standard Precautions, dated October 2018, the P & P indicated, .Hand hygiene is performed with ABHR or soap and water: b. (1) before and after contact with the resident; .(3) after contact with items in the resident's room . 3. During an observation on 6/23/21 at 9:30 AM in the laundry room, with Assistant Housekeeping Supervisor (AHKS) and Housekeeping Supervisor (HKS), two open shelving units were next to laundered items that hung from a rack. AHKS stated, the laundered clothing and linens were clean and belonged to residents. The open shelving units next to the rack were stacked mostly with uncovered pillows. One of the two shelving units had an unlabeled shoe, a black rubber cushion and a used, unlabeled disposable face shield hanging in one corner of the shelving unit pole. The items found in the shelving units had accumulated significant amounts of dust and lint. HKS acknowledged the observations and said, .the area is dirty . will start organizing and bring to the garage . we are going to clear the spot . HSK stated the area noted had to be kept clean for infection control. During a review of the facility's policy and procedure (P&P), posted in the laundry room titled, LAUNDRY AND LINEN - GENERAL POLICY AND GUIDELINES, undated, the P&P indicated, .Linens are handled, stored and processed so as to control the spread of infection. Clean linen and clothing are stored in clean, dry, dust-free areas accessible to the nursing staff . Based on observation, interview and record review, the facility failed to implement infection control and prevention program when: 1.a Registered Nurse (RN) 3 brought out a cup from Resident 375's room which was on contact precautions (infection control and prevention measures used for diseases caused by microorganisms that may be spread easily by contact with the patient's intact skin or with contaminated environmental surfaces). 1.b. Physical Therapy Assistant (PTA) did not: (a) wear appropropriate personal protective equipment (PPE) prior to entering Resident 375's room (b) did not perform hand hygiene after exiting Resident 375's room. 2.a. Licensed Vocational Nurse (LVN) 4 did not perform hand hygiene during dressing changes on 1 of twenty-eight sampled resident (Resident 79). 2.b Certified Nurse Assistant (CNA)3 did not perform hand hygiene [wash hands with soap and water or use an alcohol based hand rub (ABHR)] after handing dirty linen, in between, and after the care of two residents (Resident 111 and Resident 103). 3. Clean clothing and linens were stored next to dirty items in the laundry room. These deficient practices had the potential to promote development and spread of communicable diseases and infections in the facility. Findings: 1.a During a review of Resident 375's Physician's order dated 6/23/21, the document indicated, MRSA Precautions (Contact Precautions) . Order Date - 6/13/21 . End Date - [blank] . During an initial tour observation on 6/22/21 at 9:53 AM, Resident 375's room had a sign posted next to the entry door that indicated, CONTACT PRECAUTIONS Bed# A . STOP . Staff - Required: Gown & Gloves - Point-Of-Care Risk Assessment - When there is a risk of splash or spray, wear face and eye protection . During an observation on 6/22/21 at 9:56 AM, Resident 375 was in the room with Certified Nursing Assistant (CNA) 4. CNA 4 had a gown, face mask and gloves. At 9:57 AM, CNA 4 handed a brown-colored plastic cup to Registered Nurse (RN) 3 who was at the hallway outside the room. RN 3 had a face mask and no gloves on. RN 3 warmed the cup in the microwave located in a dining hall outside the Resident 375's room. During an interview on 6/22/21 at 10:03 AM, with RN 3, RN 3 stated Resident 375 was on contact precautions due to MRSA (Methicillin-Resistant Staphylococcus Aureus, a type of bacteria that causes infections in different parts of the body and is resistant to several antibiotics). RN 3 confirmed she did not wear gloves and said, I should have worn gloves when handling the contaminated cup . I should have prepared another coffee for her [Resident 375] . I should have cleaned the microwave [after use] . RN 3 stated contact precautions had to be followed to prevent transmission of infection to others. 1.b During an observation on 6/22/21 at 10:01 AM, a PTA went inside Resident 375's room without gown and gloves on. When the PTA exited Resident 375's room, no hand hygiene observed. During an interview on 6/22/21 at 11:20 AM, with PTA, PTA stated he went inside Resident 375's room because the call light was on. PTA acknowledged he did not wear the appropriate PPE and said, did not put the gown on . PTA stated he was supposed to wear the appropriate PPE because the resident was on contact precautions. PTA acknowledged he did not do hand hygiene after he exited the resident's room and said, I should do it [hand hygiene] . I should know better . we don't want to create infection in the building . During an interview on 6/23/21 at 10:49 AM, with the Infection Preventionist (IP) and Director of Staff Development (DSD), the DSD stated the facility followed the Centers for Disease Control and Prevention (CDC) and Association for Professionals in Infection Control and Epidemiology (APIC) guidelines on Infection Control and Prevention. The IP stated staff were expected to follow contact precautions including appropriate use of personal protective equipment (PPE). During a review of the facility's policy and procedure (P&P) titled, Isolation - Initiating Transmission-Based Precautions, dated 8/2019, the P&P indicated, Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Transmission-based precautions may include contact precautions . 3. When transmission-based precautions are implemented, the infection preventionist (or designee): a. clearly identifies the type of precautions, the anticipated duration, and the personal protective equipment (PPE) that must be used . d. determines the appropriate notification on the room entrance door and on the front of the resident's chart so that personnel and visitors are aware of the need for and type of precautions . 4. Transmission-based precautions remain in effect until the attending physician or infection preventionist discontinues them, which occurs after criteria for discontinuation are met . During a review of the CDC's Guideline on Transmission-Based Precautions, dated 1/7/16, retrieved on 7/6/21 https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html#anchor_1564057963 the guidance indicated, . Contact Precautions - Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission . Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens . Prioritize cleaning and disinfection of the rooms of patients on contact precautions ensuring rooms are frequently cleaned and disinfected . focusing on frequently-touched surfaces and equipment in the immediate vicinity of the patient . 2.a During an observation on 6/25/21 at 10:20, LVN 4 entered the Resident 79's room, and donned gloves. LVN 4 pulled up the Resident 79's clothing and began to remove the existing dressing. LVN 4 was called out of the room to answer a phone call. LVN 4 returned to the room and performed hand hygiene and donned gloves. LVN 4 pulled up Resident 79's gown and removed the old dressing. LVN 4 then opened the clean gauzes without changing gloves and touched the clean gauze dressing. LVN 4 sprayed normal saline (clear solution to rinse wounds) at the gastrostomy tube site, cleaned the area with the gauzes and applied clean gauzes to site. LVN 4 taped the site and labeled it with date and time of dressing change. LVN 4 removed his gloves and performed hand hygiene. LVN 4 stated he would degerm the bottle of normal saline spray before he returned it to the cart. During a review of the Policy and Procedure(P&P), Handwashing/Hand Hygiene, dated August 2019, the P&P indicated, .hand hygiene should be performed before handling clean or soiled dressings, gauze pads . before moving from a contaminated body site to a clean body site during resident care . after contact with a resident's intact skin .

CONCERN (F)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected most or all residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure safe medication storage and distribution practi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure safe medication storage and distribution practice when: 1. Three of four medication carts (2 [NAME] Team 1, 1 [NAME] Team 2, 2 East Team 1) had loose tablets in the drawers. 2. One of two medication room refrigerators (1 East) had unlabeled medications stored. 3. Four of four medication carts (1 [NAME] Team 1, 2 [NAME] Team 1, 2 East Team 1, 1 [NAME] Team 2), had out of date medications stored. 4. Two of four medication carts (1 [NAME] Team 1, 2 East Team 1) had medications with unreadable label stored. 5. One of four medication carts (1 [NAME] Team 1) had medication labeled refrigerate stored. This failure had the potential for resident to receive wrong medications, contaminated medication, and/or ineffective medication. Findings: During a concurrent observation and interview, on 6/22/21 at 4:00 pm with RN 2, to review 1 [NAME] Team 1 Medication Cart, observed Resident 67's Xalatan (prescription medication for the treatment of high eye pressure) eye drop bottle had use by date 3/04/21 and Latanoprost (a medication used to treat increased eye pressure) box labeled refrigerate in the medication cart. Latanoprost bottle had an opened date 4/2/21. RN 2 stated, I think she was discharged .we keep medication in the cart for seven days until they are readmitted . Observed a bottle of Lactulose (a medication prescribed to treat or prevent complications of liver disease) had unreadable label stored in the cart. During a concurrent observation and interview on 6/23/21, at 10:10am with LVN 4, to review 1 [NAME] Team 2 Medication Cart, observed multiple loose medication tablets at the bottom of second drawer. LVN 4 stated, .we clean the drawers at the end of every shift . Observed a vial of Insulin Lispro (rapid acting medication to treat high blood sugar), had a hand written open date 5/20/21 and the box had a hand written open date 5/20/21 also. LVN 4 further stated, . we are supposed to replace insulin every 28 days after opening .I will order a new one now . During a concurrent observation and interview in 1 East Medication room, on 6/23/21 at 4:26 pm with SSD, observed one unopened vial of Cyanocobalamin (a man-made form of vitamin B12) 1000 mcg/ml, vial had no resident identifying label. SSD stated, .I'm not sure why the unlabeled vial is stored there . During a concurrent observation and interview on 6/24/21 at 10:27am, with LVN 3, to review 2 [NAME] Team 1 medication cart, observed four loose medications tablets in 2nd drawer. Observed Resident 91's Insulin Lispro had a handwritten open date 5/20/21. LVN 3 stated, .we try to clean but we are so short staffed lately . During a concurrent observation and interview on 6/24/21 at 3:00 pm, with RN 5, to review 2 East Team 1 medication cart, observed seven loose medication tablets in the second drawer and a bottle cap in the narcotics drawer. RN 5 stated, .we try to clean up right away . Observed Resident 23 Lantus ( long acting medication to treat high blood sugar) bottle dated 5/25/21, a Novolog vial (medication to treat high blood sugar) dated 5/24/21 and Resident 90's Prednisone (a medication to treat inflamation) eye drops bottle with date opened and resident name faded and unreadable. RN 5 stated .insulin is good for 28 days these need to be replaced . Observed Resident 90's Oxycodone- Acetaminophen 5mg/325mg (a medication to treat pain) medication packet, had 7/15/2020 expiration date . RN 5 Stated .she really hasn't been taking any pain meds During a review of the facility's policy and procedure (P&P) titled Storage of Medications, dated 11/20, the P&P indicated, .Facility stores all drugs and biologicals in a safe, secure and orderly manner .Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are recieved .Nursing staff is responsible for maintiaing storage and preperation areas in a clean, safe , and sanitary manner . During a review of the facility's policy and procedure (P&P) titled Labeling of Medication Containers, dated 4/19, the P&P indicated, All medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations. Medication labels must be legible at all times .Any medication packaging or containers that are inadequately or improperly labeled are returned to the issuing pharmacy. During a review of the facility's policy and procedure (P&P) titled Discarding and Destroying Medications, dated 4/19, the P&P indicated, Medications will be destoyed with accordance with federal, state and local regulations governing management of non-hazardous phamaceuticals, hazardous waste and controlled substances .All unused controlled substances shall be retained in a securely locked area with restricted access until disposed of During Review of https://online.[NAME].com/lco/action/search?q=Novolog&t=name&va=Novolog (a nationally recognized drug reference) accessed on 6/28/21 indicated NovoLOG: Once punctured (in use), vials may be stored under refrigeration or at room temperature and use; within 28 days. During Review of https://online.[NAME].com/lco/action/search?q=LAntus&t=name&va=LAntus accessed on 6/28/21 indicated Once punctured (in use), store vials refrigerated or at room temperature; use within 28 days. During Review of https://online.[NAME].com/lco/action/search?q=lispro%20insulin&t=name&va=lispro%20insulin accessed on 6/28/21 indicated . Once punctured (in use), vials may be stored under refrigeration or at room temperature; use within 28 days. During Review of https://online.[NAME].com/lco/action/search?q=Latanoprost&t=name&va=Latanoprost accessed on 6/28/21 indicated Solution: Store intact bottles under refrigeration at 2°C to 8°C (36°F to 46°F). Protect from light. Once opened, the container may be stored at room temperature for 6 weeks. During Review of https://online.[NAME].com/lco/action/search?q=Xalatan&t=name&va=Xalatan (accessed on 6/28/21 indicated Solution: Store intact bottles under refrigeration at 2°C to 8°C (36°F to 46°F). Protect from light. Once opened, the container may be stored at room temperature for 6 weeks.

CONCERN (F)

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

QAPI Program (Tag F0867)

Could have caused harm · This affected most or all residents

Based on interview and record review the facility failed to implement its plan of action to correct the identified deficiencies when: 1. Result of the audit logs for baseline care plan (BCP), wound su...

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Based on interview and record review the facility failed to implement its plan of action to correct the identified deficiencies when: 1. Result of the audit logs for baseline care plan (BCP), wound summary, psychotropic medication were not reviewed as indicated in the plan of correction (POC) dated 9/20/21. 2. In-services were not completed as indicated in the POC dated 9/20/21. The facility failure may result in a repeated regulatory noncompliance which had the potential for residents not receive necessary care and services. Findings: 1a. During an interview on 9/23/21, at 3:05 PM, the Medical Record Director (MRD)stated, I do the audit for the baseline care plan daily and bring them to the Director of Nursing (DON). During an interview on 9/23/21, at 3:10 PM, DON stated, I do not have a documented weekly audit. I didn't know I have to do that. Review of the facility F655 BCP POC, dated 9/20/21 indicated, .3 .Medical Records (MR) will complete a weekly audit of admission and readmissions BCP and review it with the DON . b. During an interview on 9/23/21, at 2:20 PM, DON stated that the wound summary was not reviewed with the Interdisciplinary Team weekly. During an interview on 9/23/21, at 3:05 PM, the MRD Director stated, I review them daily and take them to the DON. Review of the facility F686 Treatment/Services to Prevent/Heal Pressure Ulcer POC, dated 9/20/21 indicated, .2. A skin sweep was conducted by LN's [Licensed Nurse] on current residents by 8/3/21. An audit was developed from the findings to ensure that residents had the necessary interventions to decrease the risk of pressure injury .DON or designee will review the wound summary with IDT weekly . c. During concurrent record review and an interview on 9/22/21, at 3:10 PM, the facility was not able to provide evidence of documentation of Weekly Psychotropic Audit. The DON stated, I did not know I have to write them down. Review of the facility F 758 Fre from Unnecessary Psychotropic Medications POC, dated 9/20/21 indicated, .2. A report was run for residents taking psychotropic medications. DON and MR audited for order, consents, objective behaviors, diagnosis, care plans .3 .MR will conduct weekly audits and review results with DON and Social Services (SS) . 2. During an interview on 9/22/21, at 10:20 AM, the Director of Staff Development (DSD) stated, There is no lesson plan for the in-services on BCP, Pressure ulcer prevention, and psychotropic medication management given to staff. DON stated, There is no lesson plan. A lesson plan serves as a guide that an instructor or trainer uses to determine what the students will learn, how the lesson will be taught as well as how learning will be evaluated. During an interview on 9/22/21, at 4:45 PM, the DON acknowledged that she provided the staff in-service but did not have a references and stated I am new and had no idea. 2b.

GOLDEN PAVILION HEALTHCARE

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