What is GORDON LANE CARE CENTER's CMS rating?

GORDON LANE CARE CENTER has a two-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

How many inspection deficiencies does GORDON LANE CARE CENTER have?

GORDON LANE CARE CENTER has 99 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at GORDON LANE CARE CENTER?

GORDON LANE CARE CENTER has a two-star staffing rating from CMS with 0.32 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 GORDON LANE CARE CENTER located?

GORDON LANE CARE CENTER is located in FULLERTON, CA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does GORDON LANE CARE CENTER have?

GORDON LANE CARE CENTER has 99 certified beds.

Who owns GORDON LANE CARE CENTER?

GORDON LANE CARE CENTER is a for profit - limited liability company facility and is part of the DAVID & FRANK JOHNSON chain.

Is GORDON LANE CARE CENTER safe?

GORDON LANE CARE CENTER 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 GORDON LANE CARE CENTER stick around?

GORDON LANE CARE CENTER has average staff turnover at 36%, which is typical for the nursing home industry.

Was GORDON LANE CARE CENTER ever fined?

No, GORDON LANE CARE CENTER has no federal fines on record, indicating a clean compliance history with Medicare and Medicaid requirements.

Is GORDON LANE CARE CENTER on any federal watch list?

No, GORDON LANE CARE CENTER 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 GORDON LANE CARE CENTER?

Medicare inspectors have found 99 deficiencies at GORDON LANE CARE CENTER: 87 moderate, 12 minor. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting GORDON LANE CARE CENTER?

Families visiting GORDON LANE CARE CENTER should ask about daily routines, communication with families, how they handle medical emergencies. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does GORDON LANE CARE CENTER compare to other nursing homes?

GORDON LANE CARE CENTER has a 2-star overall rating, which is below average compared to other nursing homes in CA. Families should carefully review inspection findings and consider alternatives.

GORDON LANE CARE CENTER

Name: GORDON LANE CARE CENTER
Address: 1821 E CHAPMAN AVE, FULLERTON, CA, 92831, US
Telephone: (714) 879-7301
Rating: 2.0

1821 E CHAPMAN AVE, FULLERTON, CA 92831 · (714) 879-7301

For profit - Limited Liability company 99 Beds DAVID & FRANK JOHNSON Data: November 2025

Trust Grade

50/100

#808 of 1155 in CA

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Last Inspection: April 2024

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

Overview

Gordon Lane Care Center in Fullerton, California has a Trust Grade of C, indicating that it is average compared to other nursing homes. It ranks #808 out of 1155 facilities in California and #58 out of 72 in Orange County, placing it in the bottom half of options available. The facility is improving, with issues decreasing from 38 in 2024 to just 6 in 2025. Staffing is a relative strength, as the turnover rate is 36%, which is below the state average, but the RN coverage is concerning, being less than 82% of other facilities. There have been no fines, which is positive, but recent inspections highlighted several issues, including improper food safety practices in the kitchen and inadequate medication storage, which could pose health risks to residents. Overall, while there are positive aspects, families should weigh these concerns when considering this facility.

Trust Score: C
In California: #808/1155
Safety Record: Low Risk
Inspections: Getting Better
Staff Stability: 36% turnover. Near California's 48% average. Typical for the industry.
Penalties: No fines on record. Clean compliance history, better than most California facilities.
Skilled Nurses: Each resident gets only 19 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 99 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★☆☆☆

2.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★★★★☆

4.0

Care Quality

★★☆☆☆

2.0

Inspection Score

↔

Stable

2024: 38 issues

2025: 6 issues

The Good

4-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover below average (36%)
12 points below California average of 48%

Facility shows strength in quality measures, fire safety.

The Bad

2-Star Overall Rating

Below California average (3.1)

Below average - review inspection findings carefully

Staff Turnover: 36%

Near California avg (46%)

Typical for the industry

Chain: DAVID & FRANK JOHNSON

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 99 deficiencies on record

Aug 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to maintain proper infection control practices. * The facility failed to ensure one laundry rolling rack with clean residents' clothing was appropriately covered when it was transported through the hallways and was left unattended. * The facility failed to ensure the local public health department was informed of Resident 63's unresolved scabies. Additionally, the facility failed to place Resident 63 on proper contact isolation for the unresolved scabies. * The facility failed to ensure CNA 7 did not use the same pair of gloves and gown when providing care to Resident 48 on EBP and then to Resident 105 who was not on EBP. This posed the risk of cross-contamination and spread of infection. * The facility failed to ensure Resident 36's indwelling urinary drainage bag was not touching the floor. This failure had the potential to put the resident at risk for urinary infection. * The facility failed to ensure Resident 1's tubing of negative pressure wound therapy (a therapeutic technique that uses controlled negative pressure to promote wound healing) was not touching the floor.Findings: 1. Review of the facility’s P&P titled Handling Clean Linen revised 12/2022 showed it is the policy of the facility to handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection. The P&P further showed linen can become contaminated with pathogens from contact with intact skin or body substances or form environmental contaminants or contaminated hands. Moreover, the P&P showed clean linen shall be delivered to resident care units on covered linen carts with covers down. Nothing shall be kept on top of linen carts. On 7/31/25 at 1320 hours, during an observation, one laundry rolling rack with the clean residents’ clothing was transported down the hallway from room [ROOM NUMBER] to room [ROOM NUMBER]. The laundry rolling rack was uncovered and passed by several residents and staff. Further observation showed the laundry rolling rack was left unattended and uncovered in between rooms [ROOM NUMBERS]. On 7/31/25 at 1323 hours, an observation and concurrent interview was conducted with Janitor 1. Janitor 1 returned to the laundry rolling rack and verified the findings. Janitor 1 stated the clean residents' clothes should not be left unattended and uncovered for infection control. On 8/1/25 at 1021 hours, an interview with the DON was conducted. The DON acknowledged the findings and stated the residents’ clean linen cart should be covered when transporting down the hallway and when left unattended to maintain infection control. On 8/4/25 at 1406 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings. 2. Review of the facility’s P&P titled Head Lice and Scabies Exposure and Treatment revised 12/2022 showed the facility ensures the residents who contract scabies or head lice are treated according to current standards of practice to eradicate the infestation and prevent further exposure and transmission. Human scabies are caused by the human itch mite. It is contagious and can be transmitted by direct, prolonged skin to skin contact with an affected person. The P&P further showed proper treatment and infection control measures should be utilized to prevent outbreaks within the facility. The infested resident will be placed in a single occupancy room away from other residents to avoid transmission. Review of the facility's document obtained from The Public Health Nurse titled Prevention and Control of Scabies in California Healthcare Settings, California Department of Public Health Division of Communicable Disease Control in Consultation with Center for Health Care Quality Healthcare-Associated Infections Program dated 8/2020 showed the residents with atypical or crusted scabies often require several scabicides to completely kill all the mites. The document further showed for all optional treatment plans, at least three skin scrapings performed at least one week after the completion of the selected treatment should be negative before scabies is declared cured. Medical record review for Resident 63 was initiated on 7/29/25. Resident 63 was admitted to the facility on [DATE], and readmitted back on 1/19/25. Review of Resident 63’s Quarterly MDS assessment dated [DATE], showed resident had a BIMS score of 3, indicating severe cognitive impairment. Review of Resident 63’s Order Summary Report for August 2025 showed the following physician’s orders: - order dated 6/16/25, for Elimite External Cream 5% apply to the neck, foot, abdominal folds topically for one day and may rinse off after eight hours. - order dated 6/23/25, for Elimite External Cream 5% (medication to treat parasites) apply to the neck, foot, abdominal folds topically for one day and may rinse off after eight hours. - order dated 7/3/25, for Ivermectin (medication to treat parasites) 6 mg give two tablets by mouth one time a day every Friday for scabies until 8/1/25. Review of Resident 63’s Lab Results Report dated 6/18/25, showed the resident was with Sarcoptes scabiei (a parasitic mite that burrows into the skin causes scabies). Further review of Resident 63’s medical record failed to show documented evidence a follow up labs or a skin test were completed after 6/18/25, and prior to the physician’s order for the Ivermectin medication on 7/4/25. On 7/30/25 at 1530 hours, an interview and concurrent medical record review was conducted with LVN 6. LVN 6 verified the above findings. LVN 6 stated although Resident 63 received the Elimite cream as ordered on 6/16 and 6/23/25, the resident’s skin condition did not improve. LVN 6 stated the Medical Director was notified of Resident 63’s unresolved rash and increase itchiness. LVN 6 stated the Medical Director ordered Ivermectin medication on 7/4/25 until 8/1/25. LVN 6 further verified Resident 63 was not on the contact isolation after the Ivermectin medication was ordered, and the resident has been outside her room multiple times. On 7/31/25 at 1446 hours, a telephone interview was conducted with the Public Health Nurse. The Public Health Nurse stated the recommendations for the residents with scabies were to be treated with Elimite cream and can be taken off contact isolation after the treatment; however, the Public Health Nurse stated, if the resident has atypical rashes (crusty rashes), then the resident should be placed on the contact isolation and re-tested for scabies. On 8/4/25 at 0924 hours, an interview and concurrent medical record review was conducted with the IP. The IP verified the above findings. The IP stated Resident 63 was treated with the Elimite cream; however, the resident’s rash was not healing and described the rash as “generalized,” “pimple-like with whiteheads,” “crusty on the edge,” “clustered,” and “skin redness” due to the increased itchiness. The IP verified Resident 63 was last seen by the wound physician on 6/19/25, and was not seen by the wound physician or a dermatologist after the resident still presented with unresolved rashes and itchiness. The IP verified the facility did not do another skin test after the initial lab result dated 6/18/25 was done. The IP stated another testing of the skin would have allowed information of whether Resident 63’s unresolved skin concern was related to a positive scabies result. Moreover, the IP verified the facility did not inform the Public Health Nurse of Resident 63’s unresolved skin rash and increased itchiness. The IP stated the facility should have informed the Public Health Nurse to obtain further recommendations and instructions on the care of Resident 63 and to reduce the potential exposure of scabies to other residents, visitors, and staff. On 8/4/25 at 1024 hours, a telephone interview with the Medical Director was conducted. The Medical Director verified he ordered the Ivermectin medication for Resident 63. When the Medical Director was informed the facility did not inform the Public Health Nurse of Resident 63’s unresolved rashes and increased itchiness, the Medical Director stated he was not aware of that. The Medical Director also stated the type of strain the resident had would indicate if the resident would need to be placed on the contact isolation. However, the Medical Director was informed there were no other skin scrape tests or dermatologist follow up to determine what type of strain the resident had. The Medical Director was informed and acknowledged the findings. On 8/4/25 at 1406 hours, an interview was conducted with the Administrator, DON, and Nurse Consultant. The Administrator, DON, and Nurse Consultant were informed and acknowledged the above findings. Cross Reference with F684. 3. According to CDC’s The Basics of Standards Precautions (undated), wear a gown when contact between clothing or skin with resident blood or body substances is expected, and to not wear the same gown between residents. Review of the facility’s EBP sign showed everyone must clean hands, including before entering and when leaving the room, and the providers and staff also wear gloves and gown for the high contact resident care activities: ADLs care, caring for the devices, toileting and changing incontinence briefs, wound care, mobility assistance, transferring and preparing to leave room, and cleaning environment. On 8/1/25 at 0607 hours, an EBP sign was observed posted outside Room A, and a number “6” was observed by Resident 48’s name by the door. The following was observed: - CNA 7 was observed inside the room with gloves and gown on. Resident 48 was awake and in bed. When asked about Resident 48’s call light, CNA 7 looked for the call light. CNA 7 placed the call light within Resident 48’s reach, repositioned Resident 48 by touching his head, back and arms, and then repositioned Resident 47’s pillow. - Without removing the gown and gloves used for Resident 48, CNA 7 untangled Resident 105’s call light cord and placed the call light button on Resident 105’s stomach area. CNA 7 then offered water to Resident 105 and touched the resident’s water pitcher and cup. CNA 7 emptied Resident 105’s urinal. On 8/1/25 at 0620 hours, an interview was conducted with CNA 7. CNA 7 verified the above findings. CNA 7 acknowledged she used the same gown and gloves to reposition Resident 48 and then assisted Resident 105. On 8/4/25 at 0912 hours, an interview was conducted with the IP. The IP stated the number “6” by the resident’s name meant the resident in the room was on EBP. The IP stated the staff cannot wear the same gown and gloves in caring for different residents. 4. According to the CDC guidelines for the Prevention of Catheter-Associated Urinary Tract Infection dated 2009 under the Proper Techniques for Urinary Catheter Maintenance section showed to keep the collecting bag below the level of the bladder at all times and do not rest on the floor. Medical record review for Resident 36 was initiated on 7/29/25. Resident 36 was admitted to the facility on [DATE]. Review of Resident 36's H&P examination dated 4/1/25, showed Resident 36 had the capacity to understand and make decisions. Review of Resident’s 36 MDS quarterly assessment dated [DATE], showed the resident had a BIMS score of 13 (meaning cognitively intact) and had an indwelling urinary catheter. Review of Resident 36's Physician Order Summary showed a physician's order dated 7/30/25, for indwelling urinary foley catheter size French 16/5 ml for obstructive uropathy (a urinary tract disorder that occurs when urine flow is obstructed). On 7/29/25 at 0935 hours, during the initial tour of the facility, an observation was conducted in Resident's 36 room. Resident 36 was lying in bed with an indwelling urinary catheter, with the tubing attached to a drainage bag. The drainage bag was observed touching the floor. On 7/29/25 at 1002 hours, an observation and concurrent interview for Resident 36 was conducted with CNA 1. CNA 1 verified Resident 36's indwelling urinary catheter drainage bag was touching the floor. On 7/29/25 at 1005 hours, an observation and concurrent interview for Resident 36 was conducted with LVN 4. LVN 4 verified the above findings. On 8/4/25 at 0834 hours, an interview was conducted with the DON. The DON acknowledged the above findings and stated the indwelling urinary catheter drainage bag should not be touching the floor to prevent infection. Cross reference to F550 5. Review of the facility’s P&P titled Negative Pressure Wound Therapy dated 12/19/22, showed to promote wound healing of various types of wounds, it is the policy of the facility to provide evidence- based treatment in accordance with current standards of practice and physician wounds. Further review of the P&P showed clean technique shall be utilized unless otherwise specified by the physician. Medical record review for Resident 1 was initiated on 7/29/25. Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 1’s Order Summary Report showed an order dated 7/8/25, for negative pressure wound therapy, wound location sacrum, continuous intensity, low pressure 125 mm/Hg, and to change dressing on every day shift, Monday, Wednesday, and Friday. Further review of the physician's order showed to cleanse the wound with normal saline, pat dry, apply foam, and cover with transparent dressing. On 7/29/25 at 1120 hours, Resident 1 was observed in bed and the negative pressure wound therapy was connected to Resident 1's wound. The tubing of Resident 1’s negative wound pressure therapy was touching the floor. On 7/29/25 at 1249 hours, an observation and concurrent interview was conducted with LVN 4. LVN 4 verified the observation and stated the negative pressure wound therapy tubing should not be touching the floor. On 7/30/25 at 1452 hours, Resident 1 was observed in bed and the negative pressure wound therapy was connected to Resident 1’s wound. The tubing of Resident 1’s negative wound pressure therapy was observed touching the floor. On 7/30/25 at 1332 hours, an observation and interview was conducted with LVN 6. LVN 6 stated he provided wound care treatment to the residents in the facility. LVN 6 verified the tubing of Resident 1’s negative wound pressure therapy was observed touching the floor. LVN 6 stated the negative wound pressure therapy tubing should not touch the floor to prevent contamination and wound infection. On 8/1/25 at 1243 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

CONCERN (D) 📢 Someone Reported This

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

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

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, facility document review, and facility P&P review, the facility failed to monitor and address the use of the antibiotics when the resident's condition did not meet McGeer's criteria for two of five residents (Residents 4 and 53) reviewed for antibiotic stewardship. This failure had the potential for the antibiotics to be used when it was not indicated and the development of antibiotic-resistant bacteria.Findings: Review of the facility's P&P titled Antibiotic Stewardship Program revised 12/19/22, showed it is the policy of the facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. The program included antibiotic use protocols as a system to monitor antibiotic use.the facility uses the (CDC's NHSN Surveillance Definition, updated McGeer's criteria, or other surveillance tool) to define infection. The Loeb Minimum Criteria may be used to determine whether to treat an infection with antibiotics. 1. Medical record review for Resident 4 was initiated on 7/29/25. Resident 4 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of the facility's untitled document showed Resident 4 had wound infection and was prescribed piperacillin sodium tazobactam (an antibiotics) intravenous solution 4.5 gm. Further review of the document did not show if Resident 4's infection met the McGeer's criteria for a true infection or Loeb's minimum criteria to treat the infection with antibiotics. Review of Resident 4's Infection Screening Evaluation dated 7/9/25, showed Resident 4 had a repeated temperature more than 99 degree Fahrenheit. Further review of the Infection Screening Evaluation failed to show if the symptoms experienced by Resident 4 met the McGeer's criteria for true infection or Loeb's minimum criteria to treat the infection with antibiotics. Review of Resident 4's Antibiotic Time Out dated 7/12/25, showed Resident 4 was prescribed with piperacillin sodium tazobactam intravenous solution 4.5 gm, intravenously every eight hours. The presenting symptoms showed fever, abdominal pain or tenderness, and diarrhea. Under the section for the Narrative note showed the criteria was met, reviewed antibiotic stewardship program and clinical status of the resident with the medical doctor, and as per medical doctor, to continue with the antibiotic treatment as ordered from the acute care hospital. Further review of Resident 4's medical records failed to show if Resident 4 had fever, abdominal pain tenderness, and diarrhea in the facility. On 7/31/25 at 1412 hours, an interview and concurrent medical record review for Resident 4 was conducted with the IP. The IP stated the facility used the McGeer's criteria. The IP stated if a resident did not meet the criteria for a true infection using the McGeer's criteria, the physician would be notified. The IP verified Resident 4 did not have a fever, abdominal pain or tenderness, and diarrhea in the facility. The IP further stated Resident 4's infection did not meet the McGeer criteria for infection. The IP stated she should have accurately notified the physician regarding Resident 4's symptoms that did not meet the McGeer's Criteria for a true infection when the IV antibiotic was ordered. 2. Medical record review for Resident 53 was initiated on 7/31/25. Resident 53 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of the facility's untitled document showed Resident 53 had a pneumonia and was prescribed with doxycycline hyclate (an antibiotic) 100 mg. Further review of the document did not show if Resident 53's infection met the McGeer's criteria for a true infection or Loeb's minimum criteria to treat the infection with the antibiotic. Review of the Resident 53's Infection Screening Evaluation dated 7/25/25, showed Resident 53 had new or changed lung exam abnormalities and unproductive cough. Further review of the Infection Screening Evaluation did not show if the above symptoms met the McGeer's criteria for a true infection or Loeb's minimum criteria to treat the infection with antibiotics. Review of the Resident 53's Antibiotic Time Out dated 7/28/25, showed Resident 53 was receiving doxycycline hyclate oral tablet 100 mg medication, by mouth two times a day. Further review of the Antibiotic Time Out showed Resident 53 had presenting symptoms of chest x-ray with pneumonia (a lung infection) or a new infiltrate (the abnormal presence of substances within tissues or cells, often in a way that is not normal), new or changed lung exam abnormalities, and acute functional decline. Under the section for the Narrative note showed the criteria met per McGeer's, reviewed antibiotic stewardship program and clinical status of the resident with the medical doctor, per the medical doctor, to continue with the antibiotic as ordered. Review of Resident 53's chest x-ray dated 7/25/25, showed mild parabronchial thickening, suggestive of respiratory bronchiolitis (an inflammation of the small airways in the lungs), and no focal infiltrates. Further review of Resident 53's medical records failed to show if Resident 53 had a chest X-ray result showing pneumonia or a new infiltrate, and if Resident 53 had an acute functional decline. On 7/31/25 at 1412 hours, an interview and concurrent medical record review for Resident 53 was conducted with the IP. The IP verified Resident 53's chest x-ray did not show pneumonia or a new infiltrate, and Resident 53 did not have an acute functional decline. The IP verified Resident 53's symptoms did not meet the McGeer's criteria for infection. The IP stated she should have accurately notified the physician regarding Resident 53's symptoms that did not meet the McGeer's criteria for a true infection when the antibiotic was ordered. On 8/1/25 at 1243 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to maintain the infection prevention and control practices to help prevent the transmission of communicable diseases and infections for one of three sampled residents (Resident 1) placed on contact precautions. * The facility failed to ensure the staff donned an isolation gown before contacting with Resident 1 and/or his environment. Additionally, the staff did not properly discard the isolation gown after wearing it in Resident 1's room. * The facility failed to handle the clean linens so as to prevent the spread of infection. These failures posed the risk for transmission of infection and the development of disease-causing microorganisms. Findings: 1. Review of the facility's P&P titled Head Lice and Scabies Exposure and Treatment dated 12/19/22,showed the staff will follow appropriate transmission-based precautions, including PPE use, when providing care to the affected resident/s. Review of Resident 1's medical record was initiated on 6/17/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Order Summary Report dated 6/17/25, showed a physician's order dated 6/11/25, for contact precautions for scabies until further orders. On 6/17/25 at 0740 hours, an observation and concurrent interview was conducted with CNA 4. CNA 4 was inside Resident 1's room feeding Resident 1. CNA 4 was not wearing an isolation gown while in the room. There was a contact precautions sign posted outside of Resident 1's room, to don PPE before entering the room. CNA 4 was asked why he did not don an isolation gown. CNA 4 stated there was no isolation gown by the designated supply area. CNA 4 verified he should have worn a gown before going inside Resident 1's room. CNA 4 then donned an isolation gown continued with Resident 1's feeding. When finished, CNA 4 removed his isolation gown and discarded the used gown in a regular trash bin which was overflowing with used gowns in Resident 1's room bathroom. CNA 4 stated there was no black trash bin available, so he discarded the used gown in the regular trash bin. CNA 4 further stated, if there was a black trash bin, he would have discarded the used gown in there and not in the regular trash bin. On 6/17/25 at 0742 hours, an interview was conducted with the IP. The IP verified CNA 4 did not don an isolation gown and discarded the used isolation gown in a regular garbage container. The IP stated a gown must be donned when getting inside the isolation rooms and discarded in the appropriate designated garbage bin. On 6/17/25 at 1330 hours, an interview was conducted with the DON. The DON verified the above findings and stated an in-service was initiated regarding the importance of huddle, environmental rounds and to ensure the residents' plan of care are followed. On 6/18/25 at 0740 hours, an interview with the Environmental Services Director was conducted regarding the unavailability of trash bin designated for used PPE for Resident 7's room. The Environmental Services Director stated, I don't know what happened. The Environmental Services Director further stated designated trash bins were provided yesterday and physically checked all rooms to ensure the proper garbage bins were provided. 2. Review of the facility's P&P titled Handling Clean Linen revised 12/2022 showed it is the policy of this facility to handle, store, process, and transport clean linen in a safe and sanitary method to prevent contamination of the linen, which can lead to infection. On 6/18/25 at 0827 hours, a facility tour was conducted with the Environmental Services Director in Resident 1's room. CNA 5 was observed placing clean linen on top of the dirty hamper in front of Resident 1's room. CNA 5 acknowledged and verified the clean linen was on top of the dirty hamper and stated, I'm sorry. The Environmental Services Director and CNA 5 acknowledged and verified the findings. On 6/18/25 at 830 hours, during an interview, the IP verified the clean linens were on top of the hamper and were now contaminated. On 6/18/25 at 1620 hours, an interview was conducted with the Administrator, DON, IP, and DSD. The Administrator, DON, IP, and DSD verified the above findin

Jun 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the allegation of abuse was reported within the required time frame, the resident's responsible party was notified of the allegation, the investigation was initiated after the abuse allegation was identified, and the staff were provided an in-service regarding the code of conduct and sexual abuse prevention for one of five sampled residents (Resident 4). * CNA 11 witnessed CNA 10 in Resident 4's room. CNA 10's top scrub was lifted in front of Resident 4. This failure posed the risk for Resident 4 to not be protected against the alleged abuse and placed other vulnerable residents at risk for abuse. Findings: Review of the facility's P&P titled Abuse, Neglect and Exploitation dated 12/19/22, showed the facility will have written procedures that include reporting of all alleged violations to the Administrator, state agency, adult protective services, and to all other required agencies within specified time frame. The P&P further showed reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involves abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. On 5/30/25, the CDPH, L&C program received a complaint alleging CNA 10 was topless and braless in Resident 4's room. The complaint further showed there was no police report, nor was the ombudsman notified. Additionally, there were two staff members who were present during the incident. Medical record review for Resident 4 was initiated on 6/2/25. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's H&P examination dated 2/4/25, showed the resident was not able to make decisions. Review of Resident 4's MDS dated [DATE], showed the resident was rarely/ never understood thus BIMS was not conducted. Review of Resident 4's medical record failed to show documented evidence the abuse allegation was reported within the required time frame, the resident's responsible party was notified of the allegation, an abuse investigation was initiated, the resident was monitored for the clinical/psychosocial status after the alleged incident occurred from 5/25 to 6/1/25. Additionally, there was no care plan initiated for the alleged incident. On 5/30/25 at 1540 hours, an interview was conducted with the SSD. The SSD stated she was not aware of the incident until now. The SSD verified Resident 4's responsible party was not notified of the incident. On 5/30/25 at 1614 hours, a telephone interview was conducted with CNA 10. CNA 10 stated while she was walking down the hall, her bra came undone. CNA 10 went into Resident 4's room to fix it. CNA 10 stated CNA 11 walked in the room and saw her scrub top was lifted. CNA 10 stated she jokingly told CNA 11 she was flashing the resident. CNA 10 further stated she knew she made a huge mistake and was being childish about the joke. CNA 10 verified her scrub top was up, and her bra was down by her waist. CNA 10 verified her breasts were exposed. CNA 10 verified Resident 4 was awake. On 5/30/25 at 1647 hours, an interview was conducted with the Administrator. The Administrator verified there was no report made to CDPH, ombudsman, law enforcement or the physician. The Administrator stated for an allegation to be deemed sexual, there had to be contact. On 6/2/25 at 0750 hours, an interview was conducted with the Administrator. The Administratorstated the alleged incident was reported to her right after it occurred. The Administrator stated on 5/24/25, the alleged CNA (CNA 10) had a wardrobe malfunction and went inside Resident 4's room. The alleged CNA was sent home immediately pending an investigation. The Administratorstated the alleged incident was not reported to CDPH because it was considered a code of conduct issue rather than an abuse allegation. On 6/2/25 at 1000 hours, an interview was conducted with the DSD. The DSD stated the alleged incident occurred on 5/24/25, during the evening shift. The DSD was asked why was not reported. The DSD responded, it was just a report of an employee, and it was just a rumor. The DSD verified there was no in-service given to facility staff regarding the code of conduct or sexual abuse prevention, after the allegation was reported. On 6/2/25 at 1200 hours, a phone interview was conducted with CNA 12. CNA 12 stated she saw CNAs 10 and 11 talking right by Resident 4's room. CNA 12 stated she observed CNA 11's facial expression and noted something was wrong. CNA 12 further stated CNA 11 informed her CNA 10's scrub top was up when CNA 11 opened the door. CNA 11 informed CNA 12, CNA 10 stated she wanted to give Resident 4 something special because it was his birthday, seeing the balloons, she flashed her breasts. On 6/2/25 at 1340 hours, a telephone interview was conducted with CNA 11. CNA 11 stated on 5/24/25, she had finished providing care to her assigned residents. CNA 11 stated she wondered why Resident 4's door was closed. CNA 11 stated she knocked on the door and saw CNA 10 lifting her scrub top in front of Resident 4. CNA 11 stated she got scared and closed the door. CNA 10 immediately followed CNA 11 and stated it was Resident 4's birthday so she flashed her breast. CNA 11 stated CNA 10 told her she did not know what was on her mind at that moment. CNA 11 further stated CNA 10 apologized to her and immediately reported the incident to the supervisor on duty. When asked if she had witnessed this incident before, CNA 11 stated no but CNA 10 told her she had exposed her breasts to Resident 4 before. On 6/2/25 at 1449 hours, a telephone interview was conducted with CNA 10. CNA 10 stated as she was walking down the hallway, she felt the clip of her bra was off and quickly went inside Resident 4's room to fix it. CNA 10 stated CNA 11 walked in the room and saw her scrub top was lifted up. CNA 10 stated she jokingly told CNA 11 she was flashing the resident. CNA 10 further stated she was not even in the room for 2-3 minutes, and she was not sure what she thought CNA 11 thought she was doing. CNA 10 further stated she should have gone to the bathroom and denied exposing her breasts to the resident. CNA 10 stated she was sent home immediately after 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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility document review, the facility failed to ensure the medications were administered as ordered for one of five sampled residents (Resident 2). * Resident 2 did not receive the prescribed medications upon admission as ordered by the physician. This failure had the potential to negatively impact Resident 2's medical condition. Findings: Medical record review for Resident 2 was initiated on 5/28/35. Resident 2 was readmitted to the facility on [DATE]. Review of Resident 2's Order Summary Report dated 5/27/25 showed the following physician orders: - dated 5/14/25, omeprazole (medication to treat heart burn) DR (delayed release) 20 mg capsule to give one capsule by mouth one time a day - dated 5/14/25, venlafaxine HCL (antidepressant medication) ER (extended release) 150 mg capsule, two capsules by mouth one time a day - dated 5/12/25, lamotrigine (antiseizure medication) oral tablet 150 mg, one tablet by mouth two times a day - dated 5/12/25, lisinopril (antihypertensive medication) oral tablet 10 mg, one tablet by mouth one time a day - dated 5/12/25, metformin (medication to treat diabetes) HCL oral tablet 500 mg, one tablet by mouth two times a day - dated 5/12/25, metoprolol tartrate oral tablet 25 mg, one tablet by mouth two times a day - dated 5/13/25, vitamin C (supplement) oral tablet 500 mg, one tablet by mouth one time a day - dated 5/12/25, acetaminophen (pain reliever) oral tablet 325 mg, two tablets by mouth every four hours as needed for mild pain - dated 5/12/25, magnesium hydroxide (laxative medication) oral suspension, 30 ml by mouth as needed for constipation for 60 Days - dated 5/12/25, gabapentin (nerve pain medication) oral capsule 300 mg, one capsule by mouth one time a day - dated 5/12/25, vitamin B-12 (supplement) oral tablet 1000 mcg, one tablet by mouth one time a day - dated 5/12/25, clonidine HCl (antihypertensive medication) oral tablet 0.1 mg, one tablet by mouth every eight hours as needed for HTN for 60 Days SBP greater than 160 mmHg - dated 5/12/25, dextromethorphan-guaifenesin (medication for cough) oral syrup 10-100 mg/5ml, 10 ml by mouth every six hours as needed for cough and congestion On 5/28/25 at 0908 hours, an interview was conducted with LVN 1. LVN 1 stated on 5/13/25, as he was giving medications, LVN 1 noted Resident 2's medications were not delivered except for one (gabapentin medication). LVN 1 stated he contacted the pharmacy and refaxed the orders to the pharmacy. LVN 1 stated the nursing supervisor, and the physician were notified the resident's medications were not delivered upon readmission. LVN 1 stated the resident's medications were still not delivered on the following day. LVN 1 called the pharmacy, refaxed the orders and notified the DON. LVN 1 verified the medications were not available from 5/13 until he came to work on 5/15/25. On 5/29/25 at 1414 hours, an interview and concurrent facility document review was conducted with the Pharmacy Manager. The Pharmacy Manager stated Resident 4's orders were electronically misfiled to an unknown folder instead of filing it to the admission file. The Pharmacy Manager further stated Resident 4's readmission orders, were not reviewed and medications were not processed. Review of the pharmacy's tracking log showed the following: - 5/12/25 at 1910 hours, received fax - 5/13/25 at 2125 hours, received fax for Ascorbic Acid (Vitamin C) - 5/13/25 at 1700 hours, guaifenesin, clonidine, Vitamin B-12, gabapentin, magnesium, Tylenol (acetaminophen) orders received - 5/13/25 at 0650 hours, clonidine and gabapentin were sent to the facility. - 5/14/25 at 1323 hours, phone call received from the DON, medications not received; - Medications were delivered on the evening of 5/14/25 at 1746 hours. The Pharmacy Manager verified the above findings. On 6/2/25 at 1635 hours, an interview was conducted with the DON and Administrator. The DON and Administrator were informed and verified the above findings.

Feb 2025 1 deficiency

MINOR (B) 📢 Someone Reported This

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

Minor Issue - procedural, no safety impact

Deficiency F0761 (Tag F0761)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to ensure the medications were stored in a safe and secure manner as evidence by: * Resident 7 had a bottle of One a Day Multivitamin/Multimineral (supplement) on the top of the bedside table. * A Hibiclens (antiseptic skin cleanser) was observed on top of the grab bars unattended inside Shower room [ROOM NUMBER]. These failuresposed the risk for non-licensed staff and visitors to have access to the medications. Findings: Review of the facility's P&P titled Resident Self Administration of Medication revised 12/2022 showed it is the policy of this facility to support each resident's right to self-administer the medication. A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the other resident's rooms or to confused roommates of the resident who self-administers medication. The following conditions are met for bedside storage to occur: a. The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if locked storage is ineffective. b. The medications provided to the resident for bedside storage are kept in the containers dispensed by the provider pharmacy. Review of the facility's P&P titled Resident Showers revised 12/2022 showed help the resident back to their room and return personal hygiene products to their designated spot. 1. Medical record review for Resident 7 was initiated on 1/29/25. Resident 7 was admitted to the facility on [DATE], and readmitted on [DATE]. On 1/29/25 at 1044 hours, an observation was conducted in Resident 7's room. A bottle of One a Day Multivitamin/Multimineral was observed on the top of the bedside table. On 1/29/25 at 1558 hours, an observation conducted inResident 7's room. A bottle of One a Day Multivitamin/Multimineral was observed on the top of the bedside table. Another resident was observed self-propelling in a wheelchair inside the room. Review of Resident 7's medical record failed to show a Self-Administration of Medication assessment was completed. On 1/29/25 at 1637 hours, an interview and concurrent observation was conducted with RN 1. RN 1 verified Resident 7 had a bottle of One a Day Multivitamin/Multimineral on the top of the bedside table. RN 1 discussed with Resident 7 regarding having the medications at the bedside and proceeded to remove the bottle of the multivitamin from Resident 7's room. RN 1 stated the medications were not kept at bedside and stored in the medication cart. RN 1 stated the process to have any medications at the resident's bedside would include a notification to the physician, a resident assessment for self-administration of medications, and implement the orders recommended by the physician. RN 1 verified the assessment to self-administer the medications was not completed for Resident 7. 2. On 1/30/25 at 0931 hours, an interview and concurrent observation of Shower room [ROOM NUMBER] was conducted with CNA 1. A bottle of Hibiclens antiseptic skin cleanser was observed on top of the grab bars. CNA 1 stated the cleanser was not supposed to be left in the shower room. The bottle of the Hibiclens antiseptic skin cleanser showed an active ingredient of chlorhexidine gluconate solution (a substance that slows or stops the growth of microorganism). On 2/5/25 at 1253 hours, an interview with the DON was conducted. The DON stated the Hibiclens should not be left unattended in the shower room. On 2/5/25 at 1640 hours, the Administrator and the DON wasmade aware and acknowledged the findings.

Nov 2024 2 deficiencies

MINOR (B) 📢 Someone Reported This

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

Minor Issue - procedural, no safety impact

Deficiency F0657 (Tag F0657)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the comprehensive plan of care was revised to reflect the resident's current wound care treatment and interventions as ordered for one of three sampled residents (Resident 2). * Resident 2's care plan was not revised to address the use of wound vac for the pressure ulcer of the sacrococcyx area. This failure posed the risk of not providing the resident with individualized and person-centered care. Findings: Closed medical record review for Resident 2 was initiated on 11/21/24. Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident 2's physician's order dated 6/8/22 to 9/15/22, showed to perform the following wound care to the pressure ulcer of the sacrococcyx site: clean with normal saline, pat dry, apply a granulating foam on wound bed, seal with a transparent dressing, and connect to wound vac at 150 mmHg setting every day shift on Mondays, Wednesdays, and Fridays for 30 days. Review of Resident 2's plan of care dated 7/8/22, showed the wound management goal and interventions for the pressure ulcer of the sacrococcyx site to include the following wound care: apply the skin protectant as ordered, elevate the lower extremities when in bed, handle gently during care, keep clean and dry, perform the laboratory tests as ordered, medicate as ordered, monitor for any signs and symptoms of infection, and reposition every two hours. However, the care plan failed to include the use of wound vac every Monday, Wednesday, and Friday on the day shifts for 30 days as ordered. On 11/15/24 at 1620 hours, a concurrent interview and closed medical record review for Resident 2 was conducted with RN 1. RN 1 stated the care plan should be individualized and updated to reflect the current treatment and interventions for the pressure ulcer of the sacrococcyx site. On 11/21/24 at 1615 hours, the DON acknowledged the findings.

MINOR (B) 📢 Someone Reported This

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

Minor Issue - procedural, no safety impact

Infection Control (Tag F0880)

Minor procedural issue · This affected multiple residents

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Oct 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their P&P for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when the facility failed to report in a timely manner an allegation of staff-to-resident abuse to the CDPH, L&C Program for one of two sampled residents (Resident 1). This failure had the potential for the abuse allegation going unreported and uninvestigated. Findings: Review of the facility's P&P titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation revised 12/19/22, showed it is the policy of the facility to report the allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources and misappropriation of resident property are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. Closed medical record review for Resident 1 was initiated on 10/1/24. Resident 1 was admitted to the facility on [DATE], and discharged on 9/18/24. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 had a BIMS score of 14, indicating Resident 1's cognition was intact. Review of Resident 1's Progress Notes showed an entry dated 9/17/24, by the SSD. The SSD documented the police came to the facility regarding a call made by Resident 1 alleging CNA 1 was rough with Resident 1 during brief change. On 10/1/24 at 1549 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were both aware Resident 1 called 911 (emergency call number) regarding an allegation of abuse. The Administrator and DON both acknowledged no report regarding the incident was sent to CDPH, L&C Program. On 10/2/24 at 1033 hours, a telephone interview was conducted with CNA 1. CNA 1 stated he was accused of rough handling by Resident 1. CNA 1 further stated he reported the incident to the charge nurse. On 10/2/24 at 1339 hours, an interview was conducted with the SSD. The SSD stated the police came to the facility on 9/17/24, at around noontime regarding a 911 call from Resident 1. The SSD stated Resident 1 alleged CNA 1 was rough during care. The SSD verified no report was sent to CDPH, L&C Program on 9/17/24.

CONCERN (D) 📢 Someone Reported This

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

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to implement their abuse P&P related to the investigation of the physical abuse for one of two sampled residents (Resident 1). * The facility failed to remove the alleged employee from resident care areas while the facility was investigating the abuse allegation. * The facility failed to send the result of the abuse investigation to the CDPH L&C Program. These failures posed the risk of Residents 1 to not be protected against the alleged abuse and placed other vulnerable residents at risk for abuse. Findings: Review of the facility's P&P titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation revised 12/19/22, showed when the suspicion of abuse/neglect/exploitation or reports of abuse/neglect/exploitation occur, the licensed nurse will remove the accused employee from resident care areas. The Administrator or designee will obtain statements from direct care staff, suspend the accused employee pending completion of the investigation and within five working days of the incident, report sufficient information to describe the results of the investigation. Closed medical record review for Resident 1 was initiated on 10/1/24. Resident 1 was admitted to the facility on [DATE], and discharged on 9/18/24. Review of Resident 1's MDS assessment dated [DATE], showed Resident 1 had a BIMS score of 14, indicating Resident 1's cognition was intact. Review of Resident 1's Progress Notes showed an entry dated 9/17/24, by the SSD. The SSD documented the police department came to the facility regarding a call made by Resident 1 alleging CNA 1 was rough with Resident 1 during brief change. a. Review of CNA 1's Timesheet dated 9/17/24, showed CNA 1 worked from 0655 to 1103 hours, 1135 to 1600 hours, and 1630 to 2330 hours. CNA 1 had a meal break from 1103 to 1135 hours and 1600 to 1630 hours. Review of Resident 1's Behavior Monitoring & Interventions for September 2024 showed a documentation entry of NB (no behavior observed) by the CNA 1 on 9/17/24 at 1442 hours. On 10/1/24 at 1549 hours, an interview was conducted with the Administrator and DON. The Administrator and DON were both aware that Resident 1 called 911 (emergency call number) regarding an allegation of abuse. The Administrator and DON was asked if an investigation was done, the Administrator and DON stated the internal investigation was done while the police were in the facility. b. Review of the facility's Investigation Summary dated 9/17/24, showed the facility conducted and concluded the internal investigation of Resident 1's abuse allegation against CNA 1. However, there was no documented evidence the Investigative Summary was sent to CDPH L&C Program. On 10/2/24 at 1504 hours, a concurrent interview and facility document review was conducted with the Administrator. When asked regarding Resident 1's abuse allegation, the Administrator stated the DSD started to investigate on 9/17/24. The DSD interviewed CNAs 1 and 2. The SSD interviewed Resident 2 and another resident. The Administrator was asked when the investigation was concluded, the Administrator stated she signed and dated the Investigation Summary on 9/17/24. The Administrator was asked if CNA 1 was suspended from work, the Administrator stated CNA 1 was not suspended because the police stated the allegation was unsubstantiated. The Administrator stated the DSD only changed the CNA assigned to the Resident 1. Cross reference to F609.

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) was free from the unnecessary psychotropic medications (any drug that affects brain activity). * The facility failed to obtain the informed consent from Resident 1 or surrogate for the use of Seroquel (brand name for quetiapine fumarate, a drug to treat bipolar disorder) * The facility failed to ensure Resident 1's behavior was monitored for the use of citalopram (to treat depression), quetiapine fumarate, divalproex sodium (to treat the manic phase of bipolar disorder) and lorazepam (to treat anxiety disorder) medications. * The facility failed to ensure Resident 1 was monitored for side effects and/or adverse effects related to the use of citalopram, quetiapine fumarate, divalproex sodium and lorazepam medications. * The facility failed to ensure Resident 1 was provided with the non-pharmacologic intervention for the use of the citalopram, quetiapine fumarate, divalproex sodium and lorazepam medications. These failures have the potential to negatively affect Resident 1's well-being. Findings: Review of the facility's P&P titled Use of Psychotropic Medication revised 12/19/22, showed the residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/non-pharmacological interventions. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics. Closed medical record review for Resident 1 was initiated on 10/1/24. Resident was admitted to the facility on [DATE], and discharged on 9/18/24. Review of Resident 1's Order Summary Report showed a physician's order dated 9/17/24, to administer the following medications: - citalopram 20 mg tablet one time a day for bipolar disorder manifested by constant yelling out. - divalproex sodium 250 mg tablet two times a day for bipolar disorder manifested by false accusations. Review of Resident 1's MAR for September 2024 showed Resident 1 had a physician's order and was administered the following medications: - citalopram 20 mg tablet one time a day for bipolar disorder on 9/10, 9/11, 9/12, 9/14, 9/15, 9/16, and 9/17/24; - divalproex sodium delayed release 250 mg tablets two times a day for bipolar disorder on 9/10, 9/11, 9/12, 9/14, 9/15, and 9/17/24; - quetiapine fumarate 50 mg tablet by mouth at bedtime for bipolar disorder on 9/10, 9/12, 9/13, 9/14, 9/15, and 9/17/24; and - lorazepam 0.5 mg every six hours as needed for anxiety manifested by verbalization of feeling anxious on 9/12/24 at 1700 hours, 9/13/24 at 1900 hours, 9/14/24 at 0800 and 1700 hours, 9/15/24 at 1700 and 2346 hours, and 9/17/24 at 0800 hours. a. Review of Resident 1's Physician Documentation of Informed Consent showed an informed consent was obtained from the surrogate for the following medications: - citalopram 20 mg for bipolar disorder manifested by constant yelling; - divalproex 250 mg for bipolar disorder manifested by false accusation; and - lorazepam 0.5 mg as needed for anxiety manifested by verbalization of feeling anxious. However, there was no documentation of an informed consent obtained from Resident 1 or surrogate for quetiapine medication use. b. Review of Resident 1's Behavior Monitoring & Interventions for September 2024 showed to monitor Resident 1 for bipolar disorder manifested by constant yelling out and false accusations and anxiety manifested by verbalization of feeling anxious. The monitoring sheet showed Resident 1's behavior was monitored on 9/17 - 9/19/24. However, Resident 1's medical record showed no behavior monitoring and interventions for 9/9/24 to 9/16/24. c. Review of the facility's P&P titled Use of Psychotropic Medication revised 12/19/22, showed the resident's response to the medication(s), including progress towards goals and presence/absence of adverse consequences, shall be documented in the resident's medical record. Review of Resident 1's Plan of Care initiated on 9/11/24, showed a care plan problem addressing Resident 1's use of the following: - psychotropic medication related to bipolar disorder. The interventions included to monitor for side effects and monitor/document/report PRN any adverse reaction of psychotropic medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking) dry mouth, constipation, blurred vision, disorientation, confusion, difficulty urination, hypertension, dark urine, yellow skin, nausea and vomiting, lethargy, and drooling; and - antianxiety medication due to anxiety disorder. The interventions included to monitor for side effects and monitor/document/report PRN any adverse reactions to anti-anxiety therapy of drowsiness, slurred speech, dizziness, nausea, and aggressive or impulsive behavior. Review of Resident 1's medical record failed to show documented evidence Resident 1 was monitored for the side effects and/or adverse effects of psychotropic and antianxiety medications. d. Review of the facility's P&P titled Use of Psychotropic Medication revised 12/19/22, showed the residents who use psychotropic drugs shall also receive non-pharmacologic interventions to facilitate reduction or discontinuation of the psychotropic drugs. Review of Resident 1's MAR for September 2024 showed Resident 1 was administered the following medications: - citalopram 20 mg tablet one time a day for bipolar disorder on 9/10, 9/11, 9/12, 9/14, 9/15, 9/16, and 9/17/24; - divalproex sodium delayed release 250 mg tablets two times a day for bipolar disorder on 9/10, 9/11, 9/12, 9/14, 9/15, and 9/17/24; - quetiapine fumarate 50 mg tablet by mouth at bedtime for bipolar disorder on 9/10, 9/12, 9/13, 9/14, 9/15, and 9/17/24 ; and - lorazepam 0.5 mg every six hours as needed for anxiety manifested by verbalization of feeling anxious on 9/12/24 at 1700 hours, 9/13/24 at 1900 hours, 9/14/24 at 0800 and 1700 hours, 9/15/24 at 1700 and 2346 hours, and 9/17/24 at 0800 hours. Review of Resident 1's medical record failed to show documented evidence Resident 1 was provided with the non-pharmacologic interventions for the psychotropic medication use. On 10/2/24 at 0930 hours, a concurrent interview and medical record review was conducted with LVNs 1 and 2. LVN 1 stated Resident 1 was calm on admission; however, following the day of admission, Resident 1 started to be aggressive and calling out names. LVN 1 stated Resident 1 was on divalproex, Seroquel, and citalopram. LVN 1 was asked if there was any non-pharmacological intervention provided to Resident 1, LVN 1 was unable to provide documentation. LVN 2 was asked if there was any psychotropic medications monitoring, LVN 2 confirmed there was no physician's order for the monitoring of the psychotropic medications. LVN 2 further confirmed there was no monitoring record for the psychotropic medications in the MAR for September 2024. On 10/2/24 at 1523 hours, a concurrent interview and medical record review was conducted with RN 1. RN 1 verified there was no informed consent obtained from Resident 1 for the use of Seroquel medication. RN 1 also verified there was no physician's order for the monitoring of the side effects, and no documentation of the non-pharmacological interventions provided to Resident 1 for the use of the psychotropic medications. Furthermore, RN 1 stated the monitoring of the side effects of the psychotropic medications should be in the MAR to keep in track on the documentation. On 10/2/24 at 1531 hours, an interview was conducted with the Administrator. The Administrator was made aware and acknowledged the above findings.

Sept 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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to protect the resident's rights to be free from the verbal abuse by a staff for one of 10 sampled residents (Resident 1). * Resident 1 was asking for help and CNA 3 answered Resident 1 in a foul language in Spanish. This failure had the potential to negatively impact Resident 1's well-being. Findings: Review of the facility's P&P titled Abuse, Neglect and Exploitation revised on 12/19/22, showed it is the policy of the facility to provide protections for the health, welfare and rights of each resident. Review of the facility's SOC 341 form dated 8/30/24, showed a student nurse witnessed CNA 3 using a foul language in Spanish to Resident 1. Review of the facility's conclusion letter dated 9/3/24, showed the facility substantiated the incident as verbal abuse. Medical record review for Resident 1 was initiated on 9/3/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's MDS dated [DATE], showed Resident 1 was severely cognitively impaired. On 9/3/24 at 1415 hours, an interview was conducted with Resident 1. Resident 1 was unable to remember the incident. Review of the facility's investigation conclusion report showed the facility had substantiated the incident as verbal abuse. On 9/3/24 at 1503 hours, a telephone interview was conducted with the student nurse. The student nurse and CNA 3 were changing the resident next to Resident 1 when Resident 1 started to ask for help. CNA 3 answered in Hispanic ya callate pinche perro which translated to a foul language in English. The student nurse immediately reported the incident to the clinical instructor. On 9/3/24 at 1541 hours, an interview was conducted with the Administrator. The Administrator stated other residents assigned to CNA 3 were interviewed and stated CNA 3 was not verbally abusive to the residents. The student nurse was interviewed and stated together with CNA 3, they were changing the resident next to Resident 1. Resident 1 started to ask for help and CNA 3 answered in a foul language in Spanish. CNA 3 was immediately suspended.

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to maintain the infection control practices designed to provide the safe and sanitary environment and help prevent the development and transmission of diseases and infections. * Resident 8 who was positive for COVID-19 and required isolation precautions, was cohorted with Resident 9 who was negative for COVID-19. This failure posed the risk of infection and transmission of COVID-19 and other disease-causing microorganisms. Findings: According to the CDC's Infection Control Guidance: SARS-CoV-2, under section 2, Recommended infection prevention and control practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection, showed to place a patient with confirmed SARS-CoV-2 infection in a single person room .if cohorting, only patients with the same respiratory pathogen should be housed in the same room. Review of the facility document titled [NAME] Lane Care Center dated 8/12/24, showed the census admissions. Under the admissions showed Resident 8 was admitted to the facility at 1723 hours, and Resident 9 was admitted to the facility at 2148 hours. Both residents were admitted to Room A. Medical record review for Resident 8 was initiated on 9/3/24. Resident 8 was readmitted to the facility on [DATE], to Room A. Review of Resident 8's COVID-19 Rapid Test dated 8/6/24 at 0612 hours, showed Resident 8 was positive for COVID-19. Review of Resident 8's Change in Condition Evaluation dated 8/6/24, showed Resident 8's physician ordered for Resident 8 to be transferred to the acute care hospital for positive COVID, shortness of breath, and congestion. Review of Resident 8's ADV Clinical admission dated 8/12/24, showed Resident 8 was currently on azithromycin (antibiotic) for diagnosis of COVID-19 positive. Review of Resident 8's Order Summary Report dated 9/3/24, showed a physician's ordered dated 8/12/24, for contract droplet precautions every shift for COVID positive for 5 days starting 8/12/24, and ending on 8/16/24. Review of Resident 8's Notification of Room/Bed/Roommate Change dated 8/12/24 at 1954 hours, showed Resident 8's room was changed from Room B to Room A due to a medical necessity. Review of Resident 8's Notification of Room/Bed/Roommate Change dated 8/13/24, showed Resident 8's room was changed from Room A to Room C due to a medical necessity. Medical record review for Resident 9 was initiated on 9/3/24. Resident 9 was readmitted to the facility on [DATE], to Room A. Review of Resident 9's COVID-19 Rapid Test dated 8/12/24 at 2143 hours, showed Resident 9 was negative for COVID-19. On 9/3/24 at 1355 hours, an interview and concurrent medical record review was conducted with the IP. The IP verified the above findings. The IP verified Resident 9 tested negative for COVID-19 and was placed in a room with Resident 8 who was tested positive for COVID-19 and required isolation precautions. The IP verified it was not the facility's policy to cohort the positive tested COVID-19 residents with negative tested COVID-19 residents. The IP stated she found out Residents 8 and 9 were cohorting together the next day on 8/13/24, and moved Resident 8 once she saw Resident 8 was taking medications for COVID-19. The IP stated there was a miscommunication with admissions and they were unaware that Resident 8 was COVID positive. The IP verified Resident 9 was at high risk for developing a respiratory infection.

MINOR (B) 📢 Someone Reported This

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

Minor Issue - procedural, no safety impact

Deficiency F0557 (Tag F0557)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the resident personal belongings were properly recorded for two of 10 sampled residents (Residents 2 and 6). This failure had the potential for the residents' personal belongings being lost or stolen. Findings: Review of the facility's P&P titled Resident Personal Belongings revised 12/2022 showed all residents personal items will be inventoried at the time of admission by the social services designee, or another designated staff member and documentation shall be retained in the medical record. Additional possessions brought in during the duration of the individual's stay shall be added to the existing personal belongings inventory listing. Following the discharge or death of a resident, all personal clothing and items of a customized personal nature are to be given to the designated resident representative. Review of the facility's P&P titled Theft and Loss Program revised 12/2022 showed the following under policy interpretation and implementation: upon admission, residents/responsible parties will be informed of the facility's theft and loss program policies and procedures. A resident property inventory will be completed to identify personal property the resident brought with him/her to the facility. The items will be listed on a two part form; Resident's Clothing and Possessions. After completing the admission section of the Resident's Clothing and Possessions form, the resident/surrogate will sign the form. The yellow copy of the form is then given to the resident/surrogate and the white copy becomes part of the resident's medical record. 1. Medical record review for Resident 2 was initiated on 8/29/24. Resident 2 was readmitted to the facility on [DATE]. Review of Resident 2's Clothing and Possessions form failed to show a date and signature from the resident or responsible party. There were personal belongings listed on the form. On 8/29/24 at 1017 hours, a concurrent interview and facility document review was conducted with LVN 1. LVN 1 stated the resident's inventory list was done upon the resident's admission. LVN 1 stated Resident 2 was readmitted to the facility on [DATE]. LVN 1 verified Resident 2's Clothing and Possessions form was incomplete and there was no documented evidence a Resident 2's Clothing and Possessions form was completed on 8/19/24, upon Resident 2's readmission. 2. Medical record review for Resident 6 was initiated on 8/29/24. Resident 6 was admitted to the facility on [DATE]. On 8/29/24 at 0925 hours, a concurrent observation and interview was conducted with Resident 6. Resident 6 stated she had all her personal belongings on her nightstand and one dress in her closet. When asked if the staff inventoried her personal belongings upon admission, Resident 6 stated she did not know and they kept her bag with her. On 8/29/24 at 0951 hours, a concurrent observation, interview, and medical record review was conducted with LVN 2. LVN 2 stated on admission, a CNA will do the inventory for the resident and the resident or family will sign the form. LVN 2 reviewed Resident 6's Resident's Clothing and Possessions form. The form showed there was no signature from the resident or responsible party. LVN 2 verified Resident 6's Clothing and Possessions form was incomplete. An inventory check of Resident 6's personal belongings was performed. Upon the inventory check, LVN 2 verified there were personal belongings not listed on the form and Resident 6's clothing was unlabeled. On 9/3/24 at 0959 hours, the DON acknowledged the above findings.

Jun 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of seven sampled residents (Resident 1) attended the scheduled neurology consultation appointment for * Resident 1 had a telemedicine neurology consultation for dementia. Resident 1's appointment was scheduled to take place at the facility utilizing Resident 1's telephone. However, at the time of Resident 1's appointment, no staff were present to assist Resident 1 with her appointment via telephone. As a result, Resident 1 did not attend her scheduled neurology appointment. This failure had the potential to delay Resident 1's plan of care. Findings: Review of the facility's P&P titled Accommodation of Needs dated 12/19/22, showed the facility will treat each resident with respect and dignity and will evaluate and make reasonable accommodations for the individual needs and preferences of a resident. Based on individual needs and preferences, the facility will assist the resident as much as possible in maintaining and/or achieving independent functioning, dignity, and well being to the extend possible. Medical record review for Resident 1 was initiated on 6/6/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's physician's progress note dated 4/23/24, showed Resident 1's primary issues included mild cognitive impairment likely vascular dementia. Resident 1's secondary issues included frailty syndrome. With Resident 1's age and comorbidities, Resident 1 was vulnerable to cognitive decline including periods of delirium, in the setting of cognitive impairment and/or dementia. Review of Resident 1's Order Summary Report showed an order dated 4/24/24, for a follow-up appointment with Physician 1 for a neurology consult for dementia. Review of Resident 1's Case Management Progress Note dated 4/26/24 at 1603 hours, showed Resident 1's neurology consult was scheduled for 5/21/24 at 0815 hours,via telemedicine. Further review of Resident 1's medical record show no documented evidence Resident 1 had attended her scheduled neurology consult scheduled for 5/21/24 at 0815 hours. On 6/24/24 at 1317 hours, an interview and concurrent medical record review was conducted with the Case Manager. The Case Manager verified Resident 1 had a scheduled neurology consult appointment for dementia, scheduled for 5/21/24 at 0815 hours. The Case Manager stated on the morning of 5/21/24, before Resident 1's scheduled neurology appointment, the Case Manager went to Resident 1's room and reminded Resident 1 that she had a scheduled telephone neurology appointment scheduled for 0815 hours. The Case Manager stated she was not available at the actual time (0815 hours) of Resident 1's scheduled appointment and was unable to be present in Resident 1's room at 0815 hours, nor did she delegate this task to another staff member, to ensure Resident 1 attended her neurology consult appointment for dementia. The Case Manager was then asked if Resident 1 had attended her neurology consult appointment for dementia. The Case Manager stated Resident 1 had not attended her appointment. The Case Manager stated her normal practice would to be present in Resident 1's room, at the time of Resident 1's telemedicine neurology appointment, to ensure Resident 1 received the necessary assistance to attend her appointment. The Case Manager stated she was unable to be present in Resident 1's room at the time of her neurology appointment as she was with other residents. The Case Manager stated she subsequently rescheduled Resident 1's neurology appointment for 6/18/24. On 6/25/24 at 1145 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 1's physician's progress note dated 4/23/24, showed Resident 1's primary issues included mild cognitive impairment likely vascular dementia. Resident 1's secondary issues included frailty syndrome and with Resident 1's age and comorbidities, Resident 1 was vulnerable to cognitive decline, including periods of delirium in the setting of cognitive impairment and/or dementia. The DON stated her expectation was for a staff member to be present in Resident 1's room at the time of her neurology consult appointment for dementia, to provide Resident 1 with any assistance she may have needed to attend her scheduled appointment. Cross reference to F656.

MINOR (B) 📢 Someone Reported This

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

Minor Issue - procedural, no safety impact

Comprehensive Care Plan (Tag F0656)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to develop the plan of care to reflect the individual care needs for one of seven final sampled residents (Resident 1). * The facility failed to develop a care plan to address Resident 1's risk for impaired cognition. This failure posed the risk for not providing appropriate and individualized care to the resident. Findings: Review of the facility's P&P titled Comprehensive Care Plans dated 12/19/22, showed it is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The care planning process will include an assessment of the resident's strengths and needs. Medical record review for Resident 1 was initiated on 6/6/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's physician's progress note dated 4/23/24, showed Resident 1's primary issues include mild cognitive impairment likely vascular dementia. Resident 1's secondary issues included frailty syndrome. With Resident 1's age and comorbidities, Resident 1 was vulnerable to cognitive decline including periods of delirium, in the setting of cognitive impairment and/or dementia. Review of Resident 1's Order Summary Report showed an order dated 4/24/24, for a follow-up appointment with Physician 1 for a neurology consult for dementia. Further review of Resident 1's plan of care failed to show a comprehensive and individualized care plan problem to address Resident 1's mild cognitive impairment likely due to vascular dementia and vulnerability to cognitive decline. On 6/25/24 at 1145 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 1's plan of care failed to show a comprehensive and individualized care plan specific to Resident 1's mild cognitive impairment likely due to vascular dementia and vulnerability to cognitive decline.

MINOR (B) 📢 Someone Reported This

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

Minor Issue - procedural, no safety impact

Medical Records (Tag F0842)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to maintain an accurate medical record for one of seven sampled residents (Resident 1). * The facility failed to ensure the licensed nurse documented her initials on Resident 1's TAR (indicating the treatment was provided) as per the facility's P&P. This failure had the potential for the resident's needs not being met as the medical information was incomplete. Findings: Review of the facility's P&P titled Documentation in Medical Record dated 12/19/22, showed the licensed staff shall document all services provided in the resident's medical record in accordance with state law and facility policy. Medical record review for Resident 1 was initiated on 6/6/24. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Order Summary Report showed an order dated 5/20/24, to apply a warm compress to Resident 1's right groin area for 20 minutes four times a day for five days. Review of Resident 1's TAR for May 2024 showed the licensed nurse failed to document her initials on the TAR for the application of Resident 1's warm compress to the right groin area for 20 minutes on 5/21/24 at 0900 and 1300 hours. On 6/25/24 at 1035 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 verified she was assigned to care for Resident 1 on 5/21/24, duringthe morning shift (0700 to 1500 hours). LVN 4 verified Resident 1's TAR failed to show documentation (licensed nurse's initials) Resident 1's warm compress to the right groin was applied on 5/21/24 at 0900 and 1300 hours. LVN 4 stated the treatment nurse who administered Resident 1's warm compress was responsible for documenting (on the TAR) the warm compress was applied. LVN 4 stated the purpose of documenting the licensed nurse's initials on the resident's TARwas to indicate the resident's treatment was provided as ordered by the physician and applied at the time the treatment was ordered by the physician. On 6/25/24 at 1145 hours, an interview was conducted with the DON. The DON was asked about the facility's policy specific to documentation of the resident'streatments. The DON stated after a licensed nurse administered a treatment, the licensed nurse was required to document on the resident's TAR to show the treatment was administered in accordance with the physician's order.

Apr 2024 27 deficiencies

CONCERN (D)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of six sampled residents (Resident 26) reviewed for psychotropic use was informed of the use of the psychotropic medication (medication affecting brain activities associated with mental processes and behavior). * The facility failed to ensure the informed consent was obtained prior to administering the Seroquel (an antipsychotic medication that treats several kinds of mental health conditions including schizophrenia) and paroxetine (a medication used to treat depression) for Resident 26. This failure had the potential for Resident 26 to not be informed of the medication and potential effects of Seroquel and paroxetine. Findings: Review of the facility's P&P titled Informed Consent revised on 12/2022 showed it is the policy of this facility to uphold the rights of residents to participate in the panning and decision-making process concerning their care and treatment. When situations arise that involve complex decisions, the facility will verify the informed consent has been obtained prior to any medical intervention or treatment is initiated, including but not limited to, administration of psychotherapeutic medications. Review of the facility's P&P titled Use of Psychotropic Medication revised on 9/2022 showed the residents and or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments or non- pharmacological interventions. Medical record review for Resident 26 was initiated on 4/9/24. Resident 26 was admitted to the facility on [DATE]. Review of Resident 26's MDS 5-day assessment dated [DATE], showed Resident 26 was able to make self-understood and able to understand others. Review of Resident 26's Order Summary Report as of 4/10/24, showed the following orders: - Seroquel XR 300 mg one tablet by mouth one time a day for Schizophrenia manifested by frequent mood swings - paroxetine hcl 40 mg one tablet by mouth one time a day for depression manifested by verbalization of feeling depressed. Review of Resident 26's MAR for April 2024 showed Resident 26 received Seroquel XR 300 mg one tablet one time a day since 2/16/24, and paroxetine hcl 40 mg one tablet one time a day since 2/17/24. Review of Resident 26's Physician Documentation of Informed Consent for Seroquel 300 mg, undated, failed to show a physician signature on the form. Review of Resident 26's Physician Documentation of Informed Consent for paroxetine 40 mg, undated, failed to show a physician signature on the form. Review of the Facility Verification of Informed Consent form was incomplete and failed to show verification of informed consent was obtained from and by the facility staff for Seroquel 300 mg for Schizophrenia and paroxetine 40 mg for depression. On 4/11/24 at 0840 hours, a concurrent interview and medical record review was conducted with LVN 3. LVN 3 verified Resident 26 was currently receiving Seroquel XR 300 mg one tablet one time a day since 2/16/24, and paroxetine hcl 40 mg one tablet one time a day since 2/17/24. LVN 3 verified the informed consents for Seroquel XR 300 mg and paroxetine hcl 40 mg were not signed by the MD and the facility verification form failed to show verification of informed consent obtained from and by the facility staff for Seroquel and paroxetine. On 4/11/24 at 1338 hours, a concurrent interview and medical record review was conducted with the DON. The DON stated the informed consents should have been signed by the MD and the facility verification of informed consents should have been completely filled out.

CONCERN (D)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review for Resident 67 was initiated on 4/12/24. Resident 67 was admitted to the facility on [DATE], and was readmitted [DATE]. Review of Resident 67's MDS Section C dated 1/27/24, showed Resident 67 had a BIMS Summary Score of 14. Review of Resident 67's H&P examination dated 10/19/23, showed Resident 67 was oriented to date, time, and place; and able to make decisions. On 4/11/24 at 1608 hours, an interview was conducted with Resident 67. Resident 67 stated CNA 8 came 4/10/24 at 1030 hours, and said she would periodically check throughout the course of the day but she never came back. Resident 67 further stated he pushed the call light button, but she never showed up. On 4/12 /24 at 1440 hours, an interview was conducted with DON and Administrator. They were informed of the above finding and acknowledged the CNA and other staff should have attended to Resident 67's needs. Based on observation, interview, and P&P review, the facility failed to ensure the accomodations of needs were met for one of 19 final sampled resident (Resident 67) and two of nonsampled residents (Residents 83 and 84). * The call lights were not within reach for Residents 83 and 84. * The call light was not answered promptly for Resident 67. These failures had the potential for the residents not getting their needs met timely. Findings: Review of the facility's P&P titled Call Lights: Accessibility and Timely Response revised 9/2/22, showed the purpose of this policy is to assure the facility is adequately equipped with a call light. Staff will ensure the call light is within reach of resident and secure as needed. Medical Record review for Resident 83 was initiated on 4/9/24. Resident 83 was admitted to the facility on [DATE]. Review of Resident 83's 5-day admission Assessment MDS dated [DATE], showed under Section B, the resident was able to make needs known, understood, and understand. Section C showed BIMS 9 and section GG showed no limitation in range of motion of both upper and lower extremities. On 4/9/24 at 0815 hours, during initial tour, Resident 83 was observed laying in bed. The call light was observed behind the head board of Resident 83's bed. On 4/9/24 at 0817 hours, an interview was conducted with CNA 3. CNA 3 stated Resident 83 was able to use the call light and make needs known. CNA 3 verified the call light was behind Resident 83's headboard and should be placed within easy reach. 2. Medical record review for Resident 84 was initiated on 4/9/24. Resident 84 was admitted to the facility on [DATE]. Review of Resident 84's 5-day Assessment MDS dated [DATE], showed under Section B, the resident was able to make needs known, understood, and understand. Section C showed BIMS 12 and section GG showed no limitation in range of motion of both upper and lower extremities. On 4/9/24 at 0851 hours during the initial tour, Resident 84 was observed laying in bed. The call light was clipped to the call light panel on the wall. On 4/9/24 at 0900 hours, an interview was conducted with the customer relations staff. The customer relations staff stated Resident 84 was able to use call light and able to make needs known. Customer Relations further stated the call light should be kept within Resident 84's reach. On 4/11/24 at 1438 hours, an interview was conducted with the DON. The DON stated the call lights were expected to be within the resident's reach. The DON was informed and acknowledged the above findings.

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to implement the comprehensive care plan to address the individual care needs for one of one sampled resident (Resident 7) reviewed for IV antibiotic use. * The facility failed to develop a plan of care addressing Resident 7's Vancomycin (antibiotic used to treat and prevent various bacterial infections) treatment given intravenously (giving medicines through a needle or tube inserted into a vein). This failure had the potential for not providing appropriate, consistent, and individualized care. Findings: According to the facility's P&P titled Comprehensive Care Plans revised 12/19/22, showed the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident comprehensive assessment. Medical record review for Resident 7 was conducted on 4/10/24. Resident 7 was readmitted to the facility on [DATE]. Review of Resident 7's comprehensive care plan initiated on 4/10/22, and revised on 4/10/24, showed a care plan problem addressing the IV therapy of Rocephin (antibiotic used to treat many kinds of bacterial infection) related to UTI (urinary tract infection). The intervention included when on Vancomycin, to monitor the input and output and check for signs of nephrotoxicity which was initiated on 4/10/24. Review of Resident 7's Order Summary Report for the order dates between 11/1/23 to 4/30/24, showed an initial order for Vancomycin IV solution dated 3/26/24, to use 1.25 gram intravenously one time a day for UTI/sepsis until 4/28/24. The order summary repport showed the Vancomycin trough level (to check inadequacy and an increased risk of developing bacterial resistance) on 3/30/24 at 0830 hours. Review of Resident 7's IV Administration Report for March 2024 showed Vancomycin 1.25 grams was intravenously started on 3/28/24. On 4/10/24 at 1439 hours, an interview and concurrent medical record review was conducted with RN 2. RN 2 reviewed Resident 7's plan of care and was not able to see a care plan for Vancomycin IV therapy. The last care plan for IV therapy was resolved on 3/1/23. Furthermore, RN 2 stated no care plan was developed. On 4/11/24 at 1305 hours, an interview and concurrent medical record review was conducted with RN 3. RN 3 stated a care plan should be initiated as soon as the physician had new orders. RN 3 verified the daily Vancomycin IV was started on 3/27/24, until 4/28/24, and the care plan interventions for the use of Vancomycin was only initiated on 4/10/24. Furthermore, RN 3 verified Vancomycin was in the intervention and not as a focused problem. On 4/12/24 at 1015 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified a care plan for IV Vancomycin was only initiated on 4/10/24.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care was revised to reflect the resident's care needs for one of 19 final sampled residents (Resident 84). * The facility failed to ensure Resident 84's care plan was revised to reflect the treatment for both lower extremities for maintenance of skin integrity from the cellulitis related to venous insufficiency (a condition in which the veins fail to return blood efficiently to the heart). This failure placed Resident 84 at risk for the specific care needs not being addressed. Findings: Review of the facility's P&P titled Comprehensive Care Plan revised 12/19/22, showed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident's rights, that includes measurable objectives and time frames to meet resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Review of Resident 74's medical record was initiated on 4/9/24. Resident 74 was admitted on [DATE], and readmitted on [DATE]. Resident 74's H&P examination dated 1/17/24, showed Resident 74 had the capacity to understand and make decisions. Review of Resident 74's Order Summary Report dated 4/10/24 showed the following physician's orders: - for the left lower leg swelling, to clean with soap and water, apply vitamin A and D ointment daily and wrap with Kerlix (roll gauze), then cohesive bandage every day shift for 14 days. - for the right lower leg swelling, to clean with soap and water, apply vitamin A and D ointment daily and wrap with Kerlix, then cohesive bandage every day shift for 14 days. Review of Resident 74's care plan failed to show the care plan was revised to show the interventions for the treatments to the left and right lower legs for skin maintenance. On 4/10/24 at 0835 hours, an interview and medical record review were conducted with LVN 2. LVN 2 verified the above physician's treatment orders and care plan were not updated for the left and right lower legs. On 4/10/24 at 1237 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the development of a wound for one of three sampled residents observed for wound care (Resident 74). * The facility failed to provide skin treatment to Resident 74's right lower leg swelling as ordered by the physician. This failure had the potential for Resident 74 to develop or worsening of skin breakdown. Findings: Review of the facility's P&P titled Clean Dressing Change revised on 12/19/22 showed to provide wound care in a manner to decrease potential for infection and or cross contamination. The physician's order will specify type of dressing and frequency of changes. The policy showed place a barrier cloth or pad next to the resident, under the wound to protect the linen and other body sites; and apply topical ointments or creams and dress the wound as ordered. Review of Resident 74's Order Summary Report dated 4/10/24, showed the following physician's orders: - for the left lower leg swelling, to clean with soap and water, apply vitamin A and D ointment daily and wrap with Kerlix (antimicrobial large roll dressing to provide an antimicrobial barrier to prevent microbial penetration and microbial growth within the dressing) then cohesive bandage every day shift for 14 days ordered on 4/9/24. - for the right lower leg swelling, to clean with soap and water, apply vitamin A and D ointment daily and wrap with Kerlix then cohesive bandage every day shift for 14 days ordered on 4/9/24. On 4/10/24 at 0828 hours, a wound care observation for the resident's right leg was conducted with LVN 2. LVN 2 had completed the dressing change to the left leg prior to the observation of the wound care treatment. LVN 2 was observed having the Derma Klenz (a wound cleanser with zinc that contains no detergents and facilitates the removal of wound debris) wound cleanser on Resident 74's bed, and Kerlix dressing and latex flexible cohesive bandage on a metal plate on Resident 74's bedside table. LVN 2 was observed to spray Derma Klenz on a gauze, cleanse the right leg, applied vitamin A and D ointment, and wrap with Kerlix dressing then put the cohesive bandage. On 4/10/24 at 0835 hours, an interview and medical record review was conducted with LVN 2. LVN 2 verified the physician's order was to use soap and water. LVN 2 verified he used Derma Klenz to the right leg during the wound care observation instead of cleansing the area with soap and water. LVN 2 verified he failed to provide a cloth barrier or protective drape under Resident 74's foot during the wound care. On 4/10/24 at 1237 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services were provided to prevent the worsening of a pressure ulcer for one of the three sampled residents observed wound care (Resident 26). * The facility failed to provide wound treatment to Resident 26's right hip and right lateral malleolus pressure injuries as ordered by the physician. This failure had the potential for Resident 26's worsening of existing pressure ulcer. Findings: Review of the facility's P&P titled Clean Dressing Change revised on 12/19/22, showed the facility to provide wound care in a manner to decrease potential for infection and or cross contamination. Physician's order will specify type of dressing and frequency of changes. Policy explanation and compliance guidelines showed place a barrier cloth or pad next to the resident, under the wound to protect the linen and other body sites. Apply topical ointments or creams and dress the wound as ordered. Review of Resident 26's Order Summary Report dated 4/10/24, showed the following physician's orders: - an order dated 3/22/24, for the right lateral malleolus (a bony projection on either side of the ankle) pressure injury, to cleanse with Dakin (a mixture of sodium hypochlorite and boric acid diluted in water) solution ¼ (quarter) strength pat dry, apply Santyl (used to remove damaged tissue from chronic skin ulcers and severely burned areas) ointment daily, and cover with a dry dressing, then secure with Kerlix (antimicrobial large roll dressing to provide an antimicrobial barrier to prevent microbial penetration and microbial growth within the dressing) for 30 days. - an order dated 4/9/24, for the right hip pressure injury, to cleanse with normal saline (a nontoxic, isotonic solution that does not damage healing tissues), pat dry, soak a dry gauze on Dakin solution ¼ strength daily, and cover with a dry dressing for 30 days. On 4/10/24 at 0905 hours, a wound care observation was conducted with LVN 2. LVN 2 was observed during the wound care of Resident 26's right lateral malleolus and right hip pressure injuries. LVN 2 was observed to set up a bedside table covered with the protective drape with the following supplies: Derma Klenz (a wound cleanser with zinc that contains no detergents and facilitates the removal of wound debris) spray, a bottle of ¼ strength Dakin solution, dry gauze dressings and Kerlix dressing; and took the bedside table to Resident 26's bedside. LVN 2 washed hands, donned gloves, and removed the old dressing of the right malleolus. LVN 2 supported Resident 26's right foot on top of the pillow. LVN 2 washed hands, then proceeded to spray Derma Klenz on the gauze, and cleansed the right lateral malleolus pressure injury. LVN 2 washed hands, donned gloves then soaked the dry gauze with ¼ strength Dakin solution, applied to the right lateral malleolus pressure injury, then wrapped with Kerlix dressing. However, LVN 2 did not apply Santyl ointment to the right lateral malleolus pressure injury as ordered. LVN 2 proceeded to perform the right hip pressure injury wound care. LVN 2 washed hands, donned gloves, rolled up Resident 26's diaper and rolled down the resident's pants then removed the dressing of the right hip. LVN 2 washed hands, donned gloves, sprayed Derma Klenz to a gauze and cleansed the right hip pressure injury, LVN 2 washed hands, donned gloves, then soaked a dry gauze with ¼ strength Dakin solution; and the diaper was observed to flipped back to the wound bed and the pants rolled back up to the pressure injury site. LVN 2 proceeded to put the gauze dressing soaked with Dakin solution to the right hip pressure injury and covered with a dry dressing. However, LVN 2 used Derma Klenz instead of normal saline as ordered. On 4/10/24 at 0935 hours, a concurrent interview and medical record review were conducted with LVN 2. LVN 2 verified Derma Klenz was used to cleanse the right lateral malleolus and the dressing soaked with Dakin solution applied to the right lateral malleolus pressure injury, and covered with Kerlix dressing. LVN 2 verified Santyl ointment was not applied to the right lateral malleolus wound as ordered by the physician. LVN 2 also verified right hip pressure injury was cleansed with Derma Klenz instead of normal saline as ordered. LVN 2 verified he failed to open the diaper to prevent it from flipping back to the wound bed. LVN 2 verified he did not put any protective pads under the pressure injury sites to protect the body sites. LVN 2 further stated he did not get the wound care treatment supply this morning from the central supply and used what he had in the treatment cart. Cross reference to F684.

CONCERN (D)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the necessary GT care and services for one of two sampled residents reviewed for GT care. * The facility failed to ensure Resident 53 was positioned safely at 30 to 45 degrees during the enteral feeding via GT. This failure posed the risk for developing complications related to GT. Findings: According to Taylor's Fundamentals of Nursing seventh edition, Nursing Considerations with Tube Feeding, to make sure the resident is as upright as possible during feeding. If the resident is in bed during feedings, elevate the head of the bed at least 30 degrees during feeding and for one hour afterward to prevent reflux (occurs when stomach acid repeatedly flows back into the esophagus or the tube connecting your mouth and stomach) and aspiration. Medical record review for Resident 53 was initiated on 4/9/24. Resident 53 was readmitted to the facility on [DATE]. Review of Resident 53's Order Summary Report showed a physician's order dated 3/21/24, to administer Diabetisource AC 1.2 (a tube feeding formula made with a unique blend of carbohydrates that includes pureed fruits and vegetables) at 65 ml per hour for 20 hours to provide 1300 ml per day. On 4/11/24 at 0816 hours, Resident 53 was observed slouched in bed. Resident 53's GT Diabetisource AC 1.2 was observed infusing via a feeding pump at 65 ml per hour. On 4/11/24 at 0820 hours, an observation for Resident 53 and concurrent interview was conducted with LVN 1. Resident 53 was observed slouched in bed with the GT feeding pump turned on. LVN 1 verified the above findings. LVN 1 stated Resident 53 usually slides down the bed, and she would ask the CNAs for assistance to pull him up, and there should be a pillow on his legs to prevent Resident 53 from sliding down. On 4/12/24 at 1410 hours, Resident 53 was observed slouched in bed. Resident 53's GT Diabetisource AC 1.2 was observed infusing via a feeding pump at 65 ml per hour. On 4/12/24 at 1417 hours, an observation for Resident 53 and concurrent interview was conducted with LVN 1. Resident 53 was observed slouched in bed with the GT feeding pump turned on. LVN 1 verified the above findings. LVN 1 stated Resident 53's family members just came out of the room, and they could have repositioned the resident. LVN 1 could not provide documentation when asked if an education or a training was provided to Resident 53's family members regarding repositioning the resident while the resident was receiving a GT feeding. On 4/12/24 at 1426 hours, an interview and concurrent medical record review for Resident 53 was conducted with the DON. The DON stated the head of the bed of the resident receiving feeding via GT should be at least 45 degrees. The DON stated she was not aware if Resident 53 sliding down the bed. The DON stated if Resident 53's family members repositioned the resident, they should be educated to keep Resident 53's head of the bed elevated while the GT feeding was on.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of one sampled resident (Resident 74) reviewed for the use of BiPAP (Bilevel positive airway pressure, a form of noninvasive ventilation that providers use to help with breathing) was provided with the appropriate respiratory care. * The facility failed to ensure the BiPAP mask was cleaned according to the facility's P&P. This failure had the potential to negatively impact Resident 74's medical condition. Findings: Review of the facility's P&P titled CPAP (continuous positive airway pressure) /BiPAP Cleaning revised on 12/19/22, showed to clean the CPAP/BiPAP equipment in accordance with the current CDC guidelines and manufacturer recommendations in order to prevent the occurrence or spread of infection. The P&P also showed clean mask frame daily after use with CPAP cleaning wipe or soap and water. Dry well. Cover with plastic bag or completely enclosed in machine storage when not in use. Weekly cleaning activities: a. wash headgear/ straps in warm, soapy water and air dry; b. wash tubing with warm, soapy water and air dry. Review of Resident 74's medical record was initiated on 4/9/24. Resident was admitted on [DATE], and readmitted on [DATE]. Resident 74's H&P examination dated 1/17/24, showed Resident 74 had the capacity to understand and make decisions. Review of Resident 74's MDS Quarterly assessment dated [DATE], under Section C, showed BIMS of 14 (cognitively intact). Review of the Order Summary Report for April 2024 showed an order for BiPAP as follows: - Type of mask: Full Mask, - Humidifier, oxygen at 2 liters/minute - Pressure settings IPAP (inspiratory positive airway pressure, pressure delivered while the patient is inhaling): cmH18 EPAP (expiratory positive airway pressure, pressure delivered while the patient is exhaling): 5 cmH20 every evening and night shift shortness of breath monitoring of mask placement. On 4/9/24 at 0825 hours, an interview with Resident 74 was conducted. Resident 74 stated her BiPAP mask was never cleaned since she was admitted to the facility. On 4/9/24 at 0942 hours, an interview was conducted with LVN 3. LVN 3 verified the resident used BiPAP at night and had no treatment order for the cleaning of the BiPAP mask. On 4/10/24 at 1238 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings. The DON further stated a treatment order was placed yesterday to clean the BiPAP mask.

CONCERN (D)

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

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the pain management was provided to two of two sampled residents (Residents 7 and 23). * The facility failed to notify the physician of Resident 7's pain to obtain a pain medication to manage the resident's pain. * The facility failed to ensure Resident 23 was administed the pain medications as ordered. These failure had the potentitial for not providing the necessary care and services and effectively managing the residents' pain. Findings: 1. According to the facility's P&P titled Pain Management revised 12/19/22, showed the facility must ensure the pain management is provided to the residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The P&P also showed the following: - Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated; - Evaluate the resident for pain and the cause(s) upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs. - Manage or prevent pain, consistent with the comprehensive assessment and plan of care; - Facility staff will observe for nonverbal indicators which may indicate the presence of pain. These indicators include but are not limited to negative vocalizations (e.g. groaning, crying, whimpering, screaming); The pain management and treatment section in the P&P showed the following: - Based upon the evaluation, the facility in collaboration with the attending physician/prescriber, other health care professionals and the resident and/or the resident's representative will develop, implement, monitor, and revise as necessary interventions to prevent or manage each individual resident's pain. - The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain or may be included as a specific pain management need or goal. Medical record review for Resident 7 was initiated on 4/10/24. Resident 7 was readmitted to the facility on [DATE]. Review of Resident 7's MDS dated [DATE], showed Resident 7 was moderately cognitively impaired. Review of Resident 7's Order Summary Report showed an order dated 3/26/24, for the pain evaluation (on a pain scale of 0 to 10 with 0 = no pain, 1-4 = mild pain, 5-7 = moderate pain, 8-9 = severe pain, 10 = very severe pain) every shift Review of Resident 7's plan of care showed a care plan problem initiated on 12/1/23, addressing the resident's pain related to diabetic neuropathy (nerve damage), medical procedure, and wound. The care plan interventions included to administer analgesia medication as ordered and give half an hour before treatments or care. Review of the Progress Notes for skin evaluation dated 3/27 and 4/4/24, showed Resident 7 had constant pain and painful skin tissue. There was no documented evidence of the physician notification of the resident's constant pain. There was no pian medication prescribed for the resident. On 4/11/24 at 0820 hours, an observation and concurrent interview regarding Resident 7's coccyx (a small triangular bone at the base of the spinal column) pressure ulcer was conducted with LVN 2. CNA 4 was also present to assist with repositioning Resident 7. Resident 7 was observed smiling before the start of the wound treatment. When the bandaged of the coccyx wound was removed by LVN 2, Resident 7 started to cry. Resident 7 continued to cry and stated it hurt. When LVN 2 was asked if a pain medication was given prior to wound care treatment, LVN 2 stated no. The wound treatment for Resident 7 was not completed because Resident 7 continued to cry. Further review of the medical record showed the physician's order dated 4/11/24, to administer tramadol 50 mg one tablet every 12 hours as needed for moderate to severe pain (pain score of 5-9) for 60 days; and Tylenol 325 (over-the-counter analgesic) two tablets every six hours as needed for mild to moderate pain (pain score of 4-6) for 60 days. On 4/11/24 at 1013 hours, an observation and concurrent interview regarding Resident 7's coccyx area pressure ulcer was conducted with LVN 2. CNA 5 was also present to assist with repositioning Resident 7. According to LVN 2, Resident 7 was administered tramadol (medication for pain) at 0920 hours. LVN 2 applied zinc oxide (used to treat or prevent minor skin irritations) around the wound area and packed the pressure ulcer with dakin solution (used to kill germs and prevent germ growth in wounds). Wound treatment for Resident 7 was completed. LVN 2 stated Resident 7's physician was not notified regarding the resident's increased pain, and did not request for an order for pain medication. On 4/11/24 at 1243 hours, an interview was conducted with CNA 6. CNA 6 stated Resident 7 was always complaining of pain. Resident 7 was crying and complaining of pain at the legs and back. CNA 6 stated the CNA reported to the nurse if Resident 7 was in pain. On 4/11/24 at 1305 hours, an interview and concurrent medical review was conducted with RN 3. RN 3 verified a pain medication was not initiated on admission and the care plan for pain was not followed for Resident 7. On 4/12/24 at 0826 hours, an interview and concurrent medical review was conducted with LVN 4. LVN 4 stated the orders for Tylenol and Tramadol were recently renewed on 4/11/24, for Resident 7. LVN 4 confirmed no pain medication was given to Resident 7 during the medication administration. On 4/12/24 at 1032 hours, an interview and concurrent medical review was conducted with the DON. The DON did not see any pain medication ordered before 4/11/24, for Resident 7. The DON verified the care plan for Resident 7 showed to medicate the resident 30 minutes prior to wound care. On 4/12/24 at 1244 hours, an interview was conducted with LVN 2. LVN 2 described Resident 7's moaning came and went when the wound treatment was provided. Resident 7 would moan when the bandaged was removed and when the wound was cleaned and packed. When asked if the physician was notified of Resident 7's pain during the wound treatment, LVN 2 stated no. 2. On 4/9/24 at 0912 hours, during the initial facility tour, Resident 23 was observed sitting in the wheelchair in the room. Resident 23 stated she was on her wheelchair so she can get the nurse to give her pain medication for her back pain. Medical record review for Resident 23 was initiated on 4/9/24. Resident 23 was readmitted to the facility on [DATE]. Review of Resident 23's MDS (Minimum Data Set, a standardized assessment tool) dated 3/22/24, showed Resident 23 was cognitively intact. Review of Resident 23's Order Summary Report showed the following physician's orders: - On 3/28/24, for the pain evaluation (on the pain scale of 0 to 10 with 0 = no pain, 1-4 = mild pain, 5-7 = moderate pain, 8-9 = severe pain, and 10 = very severe pain) every shift; - On 3/22/24, methadone (opioid analgesic) 15 mg by mouth two times a day for moderate to severe pain; - On 3/28/24, Tylenol 325 mg two tablets by mouth every six hours as needed for mild pain; and -On 3/28/24, to administer hydromorphone (opioid analgesic) 4 mg one tablet by mouth every four hours as needed for moderate pain for 60 days; Review of Resident 23's MAR for March and April 2024 showed Resident 23 was given pain medication not corresponding to the pain level as per the physician's orders. For example: - Resident 23 had a mild pain level of 3-4 and was given the methadone medication on 3/24/24 at 0900 hours, and 4/1, 4/2, 4/4, 4/5, 4/8, 4/9, and 4/10/24 at 1700 hours; and - Resident 23 had a severe pain level of 8 and was given the hydromorphone medication on 3/28/24 at 1902 hours, 3/30/24 at 1000 hours, 4/5/24 at 1400 hours, 4/6/24 at 0620 and 2100 hours, and 4/9/24 at 0230 hours. Further review of Resident 23's medical record did not show Resident 23's severe pain level was addressed. On 4/12/24 at 1250 hours, an interview and concurrent medical record review for Resident 23 was conducted with RN 1. RN 1 verified the above findings. RN 1 stated Resident 23 was always complaining of pain, and the resident would come to the nursing station to ask for pain medication. RN 1 verified the pain medications were not administered to Resident 23 per the physician's orders.

CONCERN (D)

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure two of two sampled residents (Residents 59 and 61) reviewed for dialysis services were monitored for fluid restriction as ordered. This failure posed the risk of the residents' not receiving appropriate care. Findings: 1. On 4/10/24, medical record review was initiated for Resident 59. Resident 59 was readmitted to the facility on [DATE], and discharged to the acute care hospital on 4/11/24. Review of Resident 59's physician's progress note dated 12/8/23, showed Resident 59's diagnoses included end stage renal disease with dialysis. Review of Resident 59's nutritional assessment dated [DATE], showed Resident 59's albumin level was trending downward. Review of Resident 59's April 2024 Order Summary Report showed an order dated 12/22/23, for Novasource 275 ml (nutritional supplement) three times daily; and an order dated 12/5/23, for a breakdown of Resident 59's daily fluid restrictions provided by nursing: a daily total of 780 ml. Review of Resident 59's April 2024 intake and output record completed by the nursing staff showed Resident 59's total daily fluid intake was ranging between 920 to 1260 ml, exceeding the 780 ml daily fluid restriction provided by the nursing. On 4/11/24 at 1552 hours, a concurrent interview and medical record review of Resident 59's Intake and Output Record for April 2024 was conducted with LVN 5. When asked about documenting the specific amount consumed by Resident 59 for his Novasource, LVN 5 stated the amounts documented on Resident 59's Intake and Output Record were just the total fluids intake, and LVN 5 was not sure of any specific fluid total amount or how much of the documented amounts were water or the resident's Novasource, or other liquid. LVN 5 stated the nursing staff gave the resident the nutritional supplement and documented as given, but not how much of the supplement was consumed by the resident. LVN 5 stated the daily total tallied on the document could be from the dietary or nursing. On 4/12/24 at 1033 hours, a concurrent interview and medical record review was conducted with the RD. When asked about the order of the daily fluid intake for Resident 59's (780 ml daily fluid restriction provided by nursing and 720 ml daily fluid restriction provided by the dietary) and the amounts documented on Resident 59's April Intake and Output Record, the RD stated she did not audit the total of fluid intake provided by the nursing staff. According to the RD, the nursing staff was in charge of tallying the amounts of liquids consumed by Resident 59. When asked about Resident 59's Novasource, the RD stated the nursing staff would verbally inform her if Resident 59 drank his Novasource or not. 2. On 4/10/24, medical record review was initiated for Resident 61. Resident 61 was admitted to the facility on [DATE], with diagnoses including end stage renal disease with dialysis. Review of Resident 61's nutritional assessment dated [DATE] showed Resident 61 was on fluid restriction per the dialysis center. Review of Resident 61's April 2024 Order Summary Report showed an order dated 4/9/24, for Boost 275 ml (nutritional supplement) twice daily, and an order dated 4/10/24, for a breakdown of Resident 61's daily fluid restrictions provided by the nursing staff: a daily total of 600 ml. Review of Resident 61's April 2024 Intake and Output Record completed by the nursing staff showed Resident 61's total daily fluid intake was more than 600 ml daily fluid restriction on 4/1, 4/2, 4/4, 4/5, 4/6, 4/7, 4/8, 4/9, and 4/10/24. On 4/11/24 at 1552 hours, an interview was conducted with LVN 5. When asked about Resident 61's intake and output record, LVN 5 stated he could not locate it. When asked about documenting the specific amount consumed by Resident 61 for her Boost, LVN 5 stated the amounts documented on Resident 61's Intake and Output Record were just the documentation of the total fluids. LVN 5 was not sure of any specific fluid total amount or how much of the documented amounts were water or the resident's Boost, or other liquid. LVN 5 stated the nursing staff gave the resident the nutritional supplement and documented as given, but not how much of the supplement was consumed by the resident. LVN 5 stated the daily total tallied on the document could be from the dietary or nursing. On 04/12/24 at 1033 hours, a concurrent interview and medical record review was conducted with the RD. When asked about the order for daily fluid intake for Resident 61 (600 ml nursing daily fluid restriction and 600 ml dietary daily fluid restriction) and the amounts documented on Resident 61's April Intake & Output Record, the RD stated she did not audit the total fluid intake provided by the nursing. Per the RD, the nursing staff was in charge of tallying amounts of liquids consumed by Resident 61. When asked about Resident 61's Boost, the RD stated the nursing staff would verbally inform her if Resident 61 drank her Boost or not.

CONCERN (D)

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the CMS QSO-24-08-NH dated 3/20/24, for Enhanced Barrier Precautions in Nursing Homes to Prevent Spread of MDROs, showed MDRO transmission is common in long-term care facilities such as nursing homes, contributing to substantial resident morbidity and mortality and increased healthcare costs. Many residents in nursing homes are at increased risk of becoming colonized and developing infections with MDROs. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of MDROs that employs targeted gown and glove use during high-contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. On 4/10/24 at 0927 hours, an Enhanced Barrier Precautions sign was observed posted outside Resident 35's room alerting anyone to perform hand hygiene before entering and when leaving the room. The sign also alerted the providers and staff to wear gloves and a gown for high-contact resident care activities. A number 6 was observed beside Resident 35's name by the door. A cart containing gowns was observed inside the room. CNAs 1 and 2 were observed assisting Resident 35 transfer from bed to wheelchair. CNAs 1 and 2 were wearing gloves but not wearing gowns. On 4/10/24 at 0941 hours, an observation for Resident 35 and concurrent interview was conducted with CNA 1. CNA 1 verified the above findings. CNA 1 verified the Enhanced Barrier Precaution sign placed outside Resident 35's room, with a number 6 besides Resident 35's name by the door. CNA 1 verified she transferred Resident 35 from bed to wheelchair, with CNA 2. CNA 1 verified they were only wearing gloves, and not gown while transferring Resident 35. When asked if they had received any inservice training on EBP, CNA 1 answered yes, but did not remember when the last training was. On 4/11/24 at 1539 hours, an interview and concurrent facility document review was conducted with the IP. The IP stated when an Enhanced Barrier Precaution sign was placed by the door and the resident's name was marked with a number 6, the staff who provided the high-contact care activities should wear gloves and a gown, in addition to hand hygiene. The IP stated high-contact resident care activities included transferring, or mobility assistance and preparing the resident to leave the room. When asked if she had provided inservice training to the facility staff regarding EBP, the IP stated she had provided an inservice training to all the staff, including the CNAs, licensed nurses, therapists, and students, to which she showed the inservice training records. Review of the Inservice Training Report dated 4/1/24, for the Implementation of ESP (Enhanced Standard Precaution)/ EBP for all staff did not show CNAs 1 and 2 were provided an inservice training on ESP/ EBP. The IP verified the above findings. Cross reference to F880, example #6. Based on observation, interview, and facility document review, the facility failed to ensure the nursing services were provided by the appropriate staff (four of four CNAs) as evidenced by: * Two CNAs (CNAs 9 and 10) applied the oxygen tubing and set the residents' oxygen rate. * The facility failed to ensure CNAs 1 and 2 were provided training on the implementation of the enhanced barrier precautions. CNAs 1 and 2 were observed not wearing a gown while transferring Resident 35 on enhanced barrier precautions. These failures posed the risk of the residents not receiving appropriate care. Findings: 1. On 4/9/24 at 1220 hours, CNA 9 was observed grabbing Resident 61's oxygen tubing and placing it into Resident 61's nostrils. CNA 9 was observed asking Resident 61's sitter whether Resident 61 was on two liters of oxygen. CNA 9 was then observed setting the dial on Resident 61's oxygen tank. On 4/9/24 at 1227 hours, an interview was conducted with CNA 9. When asked about setting the dial on Resident 61's oxygen tank, CNA 9 verified he set Resident 61's oxygen to two liters per minute. CNA 9 verbalized he was taught by a nurse as to how to set the number on the resident's oxygen tank and cylinder. Review of Resident 61's April 2024 Order Summary Report showed Resident 61 was admitted to the facility on [DATE], with diagnoses, including acute respiratory failure with hypoxia, asthma, and anxiety disorder. Further review the orders showed Resident 61 had an order dated 3/9/24, for oxygen via nasal cannula at two liters per minute, may titrate oxygen to maintain oxygen saturation level greater or equal to 92%. 2. On 4/10/24, medical record review for Resident 49 was initiated. Resident 49 was readmitted to the facility on [DATE], with diagnoses including COPD exacerbation and acute hypoxic respiratory failure. Review of Resident 49's physician's orders showed an order dated 3/21/24, for oxygen via nasal cannula three liters per minute, may titrate to keep oxygen saturation level at 92% or higher. On 4/10/24 at 1512 hours, an interview was conducted with CNA 10. When asked about caring for the residents on oxygen, CNA 10 verbalized he would put the resident's oxygen tubing on, would sometimes put on the oxygen humidifier on the resident's oxygen concentrator, and would set the oxygen levels. When asked about setting the resident's oxygen rate, CNA 10 verbalized most residents were on two to three liters of oxygen. When asked how he knew what number to set the oxygen setting for Resident 61, CNA 10 stated he would check with the nurse. On 04/10/24 at 1606 hours, the DSD verified the CNAs were not to touch the residents' oxygen.

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the needs of the residents when: * The facility failed to ensure all controlled medications were accurately documented for one of 19 final sampled residents (Resident 61) and one nonsampled resident (Resident 46). * The facility failed to ensure the oral and IV E-Kit(s) for Nursing Station A were refilled/replaced by pharmacy within 72 hours of opening the E-Kit(s). These failures posed the risk for diversion of the controlled medications and medication administration errors; and timely replacement of medication for emergency use. Findings: Review of the facility's P&P titled Controlled Substance Administration and Accountability revised 6/5/23, showed it is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure. All controlled substances (Schedule II, III, IV, V) are accounted for in one of the following ways: All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided. Review of the facility's P&P titled Preparation and General Guidelines IIA7: Controlled Substance revised 10/2019, showed when a controlled substance is administered, the license nurse administering the medication immediately enters the following on the accountability record and/or medication administration records (MAR): - Date and time of administration (MAR, Accountability record) - Amount administered (Accountability record) - Remaining quantity (Accountability record) - Signature of the nurse administering the dose on the accountability record at the time the medication is removed from supply. - Initials of the nurse administering the dose. 1. On 4/11/24 at 1230 hours, an interview and concurrent medication cart inspection of Medication Cart C was conducted with LVN 3. During the inspection of Medication Cart C, the Controlled Medication Count sheets were reviewed with LVN 3. The form titled Antibiotic Or Controlled Drug Record showed a count of eight tablets remaining for lorazepam (medication to relieve anxiety) 0.5 mg for Resident 61. The form showed the last written entry for Count #9 with the month of 4 (April), untimed, and with staff signature. However, review of Resident 61's medication bubble pack/card containing lorazepam 0.5 mg tablet showed nine tablets remaining. LVN 3 verified the controlled count sheet and the medication supply on hand did not match. LVN 3 stated he popped the medication out of the bubble pack; however, the lorazepam was not due; and he signed it but left it in the bubble pack. LVN 3 further stated Resident 61 were to receive the lorazepam every Monday, Wednesday, and Friday; and he had signed it by mistake. When asked for the facility's process when an error occurred pertaining to controlled medications, LVN 3 stated he should have crossed out the entry right away in the Controlled Drug Record to correct the error he made. 2. On 4/11/24 at 1232 hours, an interview and concurrent medication cart inspection of Medication Cart C was conducted with LVN 3. During the inspection of Medication Cart C, the Controlled Medication Count sheets were reviewed with LVN 3. The form titled Antibiotic Or Controlled Drug Record showed a count of six tablets for clonazepam (medication to relieve anxiety or control seizures) 2 mg for Resident 46. The form showed a last written entry for Count #7 on 4/11/24 at 0900 hours, with staff signature. However, review of Resident 46's medication bubble pack/card containing clonazepam 2 mg showed seven tablets remaining. LVN 3 verified the Controlled Medication Count sheet and the medication supply on hand did not match. When LVN 3 was asked if he performed a count today with the previous shift for the controlled medications, LVN 3 stated yes. LVN 3 further verified he signed the clonazepam out for 4/11/24 at 0900 hours; however, he did not take the medication out of the bubble pack and did not administer the medication to Resident 46 because the resident had been sleeping since 0900 hours. 3. Review of the facility's P&P titled Medication Ordering and Receiving from Pharmacy IC5: Emergency Pharmacy Service and Emergency Kits dated 8/2014, showed if exchanging kits, the used sealed kits are replaced with the new sealed kits within 72 hours of opening. On 4/9/24 at 1023 hours, an inspection of Medication Room A and concurrent interview was conducted with the DSD. The oral E-kit showed a fill date of 4/4/24, and the IV E-kit showed a pack date of 4/8/24. The DSD verified the fill date/pack date for the oral and IV E-Kit(s). Review of the oral E-kit log showed showed oxycodone (controlled pain medication) 5 mg was taken out on 3/27/24 at 1130 hours. Review of the IV E-Kit Pharmacy Log showed Flagyl (an antibiotic to treat infection) 500 mg was taken out of the E-kit on 3/31/24. On 4/10/24 1156 hours, an interview and concurrent facility document review was conducted with the DON. When asked about the process of removing a medication from the E kit, the DON stated the facility must first obtain authorization from the pharmacy to open the E-kit before opening the E-Kit and the nurses were supposed to log each time a medication was pulled from the E-Kit. The DON verified the oral and IV E-Kit(s) were not replaced within 72 hours. The DON further stated either the medications removed from the E-Kit(s) were not being logged accordingly on the E-Kit log or the E-Kit replacement was not ordered on time.

CONCERN (D)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the Pharmacy Consultant's recommendations were acted upon for one of five unnecessary medication sampled residents (Resident 23). * The facility failed to follow-up on the Pharmacy Consultant recommendation to monitor for CNS (central nervous system) and respiratory depression for Resident 23 who was taking routine gabapentin (nerve pain medication), methadone (opioid narcotic analgesic), and Dilaudid (opioid narcotic analgesic) medications. In addition, the facility failed to follow-up on the Pharmacy Consultant recommendation to place hold parameters for gabapentin medication for Resident 23. These failures had the potential to put the resident at risk for adverse consequences related to the medications. Findings: Review of the facility's P&P titled Medication Regimen Review revised date 12/19/22, showed medication regimen review (MRR) or drug regimen review, is a thorough evaluation of the mediation regimen of a resident, with a goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with the medication. The facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities. Medical record review for Resident 23 was initiated on 4/9/24. Resident 23 was readmitted to the facility on [DATE]. Review of Resident 23's Order Summary Report showed the following physician's orders dated: - On 3/22/24, to administer methadone 15 mg by mouth two times a day for moderate to severe pain; - On 3/28/24, to administer gabapentin 800 mg one tablet by mouth three times a day neuropathy (a condition that affects the nerves outside the brain or spinal cord); and - On 3/28/24, to administer hydromorphone (Dilaudid) four mg one tablet by mouth as needed for moderate pain for 60 days. Review of the Consultant Pharmacist's Medication Regimen Review for Resident 19 dated 3/26/24, showed to monitor for CNS and respiratory depression, and to clarify order for the gabapentin medication to hold if the respiratory rate less than 10 breaths per minute. Resident 23 was receiving routine gabapentin, methadone, and Dilaudid. This combination can potentiate the effects of the opiate on respiration, CNS depression, sedation, and hypotension. Under the Follow-Through section showed a handwritten note showing as per resident, she was taking before, doesn't want to change. On 2/8/24 at 1001 hours, an interview and concurrent medical record review for Resident 23 was conducted with RN 2. RN 2 verified the above findings. RN 2 stated she was responsible for following up on the pharmacy consultant's recommendations. When asked about the pharmacy consultant's recommendations for Resident 23, RN 2 stated she wrote on the follow-through section that Resident 23 did not want any changes to her medications. When asked to elaborate, RN 2 stated Resident 23 did not want the gabapentin, Dilaudid, and methadone medications combined. When asked about the pharmacy consultant's recommendation to monitor Resident 23 for CNS and respiratory depression, RN 2 could not provide documented evidence to show Resident 23 was being monitored for CNS and respiratory depression. When asked about the pharmacy consultant's recommendation to place the hold parameters for the gabapentin medication, RN 2 could not provide documented evidence she clarified the order for the hold parameter with the attending physician.

CONCERN (D)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 24%. Two licensed nurses (LVNs 1 and 4) who were observed during the medication administration were found to have made errors. * LVN 1 failed to check Resident 53's heart rate prior to administering metoprolol (blood pressure medication) per the physician's orders. In addition, Resident 53 received partial dose for one medicaiton when residual of the medication was left in the medication cup. * Resident 72 received partial doses for three medications when residual of the medications were left in the medication cups. These failures had the potential to negatively impact the residents' health status and well-being. Findings: Review of the facility's P&P titled Medication Administration- General Guidelines dated October 2017 showed the medications are administered as prescribed in accordance with good nursing principles and practices. 1.a. On 4/10/24 at 0915 hours, a medication administration observation for Resident 53 was conducted with LVN 1. LVN 1 prepared and administered Resident 53's medications which included the following: - one tablet of apixaban 5 mg (medication to treat and prevent blood clots) - one tablet of aspirin 81 mg (medication use to treat pain, headache, inflammation and reduce the risk of a heart attack) - 35 units of Basaglar insulin (medication use to treat diabetes) - one tablet of metoprolol tartate 100 mg (medication use to treat high blood pressure) - five ml of multivitamin with mineral (supplement) - one tablet of vitamin C (supplement). LVN 1 was observed pouring water into the medication cup containing the crushed metoprolol tablet. LVN 1 was then observed reaching for the GT syringe, however, LVN 1 was immediately instructed to stop and step away from the resident. When LVN 1 was asked if she knew why she was instructed to stop the medication administration, LVN 1 stated she did not know. LVN 1 stated she needed to check Resident 53's pulse rate first prior to administering the metoprolol medication but forgot. LVN 1 was then observed checking Resident 53's pulse rate and administering the metoprolol via GT. Review of Resident 53's Order Summary Report dated 4/11/24 showed a physician's order to administer metoprolol tartate 100 mg one tablet via GT two times a day for HTN (hypertension), hold if SBP (systolic blood pressure) less than 110 mmHg or HR (heart rate) less than 60 beats per minute. b. LVN 1 was observed crushing the vitamin C, mixing it with water in a separate medication cup. After administering the medication, the medication cup was observed with medication residue. On 4/10/24 at 0933 hours, an interview was conducted with LVN 1. LVN 1 verified there was medication residue in the medication cup for vitamin C. LVN 1 stated she should have added more water into the medication cup to fully dissolve the medication. 2. On 4/11/24 at 0850 hours, a medication administration observation for Resident 72 was conducted with LVN 4. LVN 4 prepared and administered Resident 72's medications which included the following: - one tablet of famotidine 20 mg (medication use to prevent and treat heartburn) - one tablet of finasteride 5 mg (medication use to shrink enlarged prostates in men) - one tablet of quetiapine 25 mg (medication use to treat schizophrenia and bipolar disorder) - one tablet of metoprolol 50 mg (medication use to treat high blood pressure) - five ml of levetiracetam (medication use to treat seizures) - one table of multivitamin with mineral (supplement) - 10 units of Lantus Solostar insulin (medication use to treat diabetes). LVN 4 was observed crushing the multivitamin with mineral, metoprolol and famotidine and mixing it with water in three separate medication cups. After administering the medications, the three medication cups were each observed with medication residue. On 4/11/24 at 0915 hours, an interview was conducted with LVN 4. LVN 4 verified there were medication residue in the medication cups for multivitamin with mineral, metoprolol and famotidine. LVN 4 verified Resident 72 did not receive the complete dose for the multivitamin with mineral, metoprolol and famotidine. On 4/11/24 at 1445 hours, an interview was conducted with the DON. The DON was informed and acknowledged the above findings.

CONCERN (D)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of two LVNs observed for medication administration administered the medications without significant medication errors. * LVN 1 failed to check Resident 53's heart rate prior to administering metoprolol per the physician's orders. This failure placed Resident 53 at risk for medical complications. Findings: Review of the facility's P&P titled Medication Administration- General Guidelines dated October 2017 showed the medications are administered as prescribed in accordance with good nursing principles and practices. On 4/10/24 at 0915 hours, a medication administration observation for Resident 53 was conducted with LVN 1. LVN 1 prepared and administered Resident 53's medications which included the following: - one tablet of apixaban 5 mg - one tablet of aspirin 81 mg - 35 units of Basaglar insulin - one tablet of metoprolol tartate 100 mg - five ml of multivitamin with mineral - one tablet of vitamin C. LVN 1 was observed pouring water into the medication cup containing the crushed metoprolol tablet. LVN 1 was then observed reaching for the GT syringe, however, LVN 1 was immediately instructed to stop and step away from the resident. When LVN 1 was asked if she knew why she was instructed to stop the medication administration, LVN 1 stated she did not know. LVN 1 then stated she needed to check Resident 53's pulse rate first prior to administering the metoprolol medication but forgot. LVN 1 was then observed checking Resident 53's pulse rate and administering the metoprolol via GT. Review of Resident 53's Order Summary Report dated 4/11/24, showed a physician's order to administer metoprolol tartate 100 mg one tablet via GT two times a day for HTN, hold if SBP (systolic blood pressure) less than 110 mmHg or HR (heart rate) less than 60 beat per minute. On at 04/11/24 at 952 hours, a medical record review and concurrent interview was conducted with the DON and LVN 1. The DON and LVN 1 verified Resident 53's physician's order for the metoprolol included the parameter when to hold the medication based on the resident's blood pressure or heart rate. The DON was informed and acknowledged the above finding. The DON stated she made sure to teach the license nurses when she observed them during medication administration. Cross reference to F759, example #1.

CONCERN (D)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected 1 resident

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4. Review of Resident 4's physician's order dated 2/12/22, showed an order for the regular diet, regular texture, thin consistency, add fortified foods with all meals. On 4/9/24 at 1200 hours, during the dining observation, Resident 4 stated, I don't know why I received two desserts, I didn't ask for it. Resident 4 was observed seated at a dining table with another male resident. Next to Resident 4's lunch plate entree were two small bowls of fudge brownie with coconut topping desserts covered with plastic wrap. When asked if Resident 4 asked for two desserts, Resident 4 stated, I didn't ask for that. I can't eat all that. I don't eat sweets and I don't know why I got two desserts. The DSD and LVN 6 verified Resident 4 received two desserts. LVN 6 stated she checked Resident 4's lunch meal tray today and stated, I checked the meal tray, I checked it against the diet slip, the list. Resident 4's meal ticket on her lunch tray showed regular, regular portion, independent with feed ability; devices - none; allergies- none; beverages - whole milk; dislikes - none; prefers - no preferences; regular TID (three times a day) (Fortified Food, fortified cream soup). When asked what the purpose of the diet slip and list were, LVN 6 stated to make sure the resident was served the right meal. LVN 6 stated, I gave her, Resident 4, two desserts because she wanted two. LVN 6 was observed approaching and asking Resident 4 if Resident 4 wanted two desserts and Resident 4 stated, no, I did not. I don't even eat one. I didn't ask for that. LVN 6 verified Resident 4 should not have received two desserts. Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the menus were followed as evidenced by: * The facility failed to ensure the spreadsheet was followed for the liberal house renal diet and renal diet. The facility failed to provide 10 pieces of cheese ravioli for Residents 13 and 34 as per the menu. *The facility failed to ensure the menu for the pureed breadstick and butter was followed when the wrong scoop size was used to serve the pureed bread for Residents 16 and 78. * The facility failed to provide butter or margarine, and milk to Resident 78 as per the menu. In addition, the facility failed to provide coffee to Resident 78 as per the resident's lunch tray ticket. * The facility failed to provide the appropriate dessert portion to one nonsampled resident (Resident 4). Two desserts instead of one dessert were given to Resident 4 during lunch. These failures had the potential for the residents to not receive adequate nutrition and appropriate servings to meet their individual needs. Findings: Review of the facility's P&P titled Menu Planning Criteria revised 5/20/20, showed the food and nutritional needs of the residents shall be planned to meet the U.S. Dietary Guidelines and Dietary Reference Intakes, in order to provide menus that include safe and adequate intake of essential nutrients. 1. Review of the facility's Daily Spreadsheet for Wednesday dated 4/10/24, for lunch showed to serve 10 each cheese ravioli (no sauce) for liberal house renal and renal diets. On 4/10/24 at 1130 hours, during the tray line observation, Resident 13 was noted to have been served with nine cheese raviolis and Resident 34 was served with seven cheese raviolis, instead of the 10 cheese raviolis per the day's menu spreadsheet. On 4/10/24 at 1410 hours, an interview was conducted with the DSS, with the RD and DSS in Training present. According to the DSS, the facility was using the jumbo ravioli five pounds 80 ounces bag. The menu indicated cheese ravioli, frozen .57 ounces with portion size of ten each. The RD, DSS and DSS in Training all confirmed the number of raviolis to be served using the five pounds 80 ounces bag had not been changed in the menu. 2. Review of the facility's Daily Spreadsheet Wednesday dated 4/10/24, for lunch, showed puree#12/1 each for the breadstick and butter. On 4/10/24 at 1130 hours, during the trayline observation, the [NAME] was noted to be using #16 scoop (colored royal blue = ¼ cup) to serve pureed breadstick and butter instead of the #12 scoop (colored green = 1/3 cup) as per the facility's menu spreadsheet. On 4/10/24 at 1130 hours, an observation, interview, and concurrent trayline inspection was conducted with the DSS and Cook. When asked about the scoop used for the pureed breadstick and butter, the [NAME] showed the royal blue scooper. The tray cart was stopped prior to tray distribution to the residents. The DSS was asked to show the items to be served for the residents on pureed diet. The DSS showed Residents 16 and 78 were on a regular pureed diet and both were served with pureed breadstick and butter. The DSS verified the findings. 3. Review of the facility's menu titled Week at a Glance, Spring 2024 for Regular diet showed the lunch menu for 4/9/24, was roast beef au jus, oven roasted potatoes, savory peas, dinner roll and butter or margarine, fudge brownie with coconut topping, and whole mil On 4/9/24 at 1212 hours, during the dining observation, Resident 78 was observed being assisted with her meals by Resident 78's Family Member. Resident 78 was served with beef, dinner roll, peas, potatoes, a slice of fudge brownie, and juice. Resident 78's Family Member stated Resident 78 was not served with butter or margarine, which was needed since the dinner roll was dry. Resident 78's Family Member also stated Resident 78 was not served with milk per the weekly menu, nor served with coffee per the tray ticket. Review of Resident 78's lunch tray ticket dated 4/9/24, showed coffee and juice were to be served for Resident 78. On 4/9/24 at 1231 hours, an observation for Resident 78 and concurrent interview as conducted with the DSS, with Resident 78's Family Member present. The DSS verified Resident 78 was not served with butter or margarine with the dinner roll. In addition, the DSS verified Resident 78 was not served with whole milk as per the weekly menu. The DSS also verified Resident 78 was also not served with coffee as per the tray ticket.

CONCERN (D)

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and facility document review, the facility failed to ensure the food served was palatable. * The facility failed to ensure the roast beef served to Residents 78, 27, and 392 was not tough and not hard to cut or chew. This failure had the potential for the residents to not eat the food served and could affect their nutritional status. Findings: Review of the facility's menu titled Week at a Glance, Spring 2024 for regular diet showed the lunch menu for 4/9/24, including roast beef au jus, oven roasted potatoes, savory peas, dinner roll and butter or margarine, fudgy brownie with coconut topping, and whole milk. 1. On 4/9/24 at 1212 hours, during the dining observation, Resident 78 was observed being assisted with her meals by Resident 78's Family Member. Resident 78's Family Member stated the roast beef served to Resident 78 was very hard to cut and chew. Resident 78's Family Member was observed trying to cut the roast beef several times with a knife but could not cut the roast beef. Review of Resident 78's tray ticket dated 4/9/24, showed Resident 78 was on NAS (no added salt) - regular diet. 2. On 4/9/24 at 1220 hours, during the dining observation, Resident 392 was observed sitting in the wheelchair inside her room. A lunch tray was observed in front of her. When asked about the roast beef, Resident 392 stated, very hard. Resident 392 was observed trying to cut the roast beef several times with a knife and could not cut the roast beef. Review of Resident 392's tray ticket dated 4/9/24, showed Resident 392 was on a regular diet. 3. On 4/9/24 at 1222 hours, during the dining observation, Resident 27 was observed sitting in bed. A lunch tray was observed in front of him. When asked about the roast beef, Resident 27 stated the roast beef was not edible. Resident 27 was observed trying to cut the roast beef several times with a knife and could not cut the roast beef. Review of Resident 27's tray ticket dated 4/9/24, showed Resident 27 was on a regular diet. On 4/9/24 at 1231 hours, an observation for Residents 27, 78, and 392, and concurrent interview was conducted with the DSS. The DSS verified the above findings. The DSS verified the roast beef served to Residents 27, 78 and 392 was tough and hard to cut.

CONCERN (D)

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

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected 1 resident

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Based on observation, interview, facility document review, and facility P&P, the facility failed to ensure the residents on pureed diet were provided with food prepared in a form to meet the residents' individual needs. This failure risk posed the risk for residents on pureed diet to develop complications like aspiration (accidental breathing in food or fluid into the lungs) and choking. Findings: Review of the facility's titled Texture-Modified and Thickened Liquids revised 9/27/21, showed texture-modified diets are prepared and served as prescribed by the physician or appropriate personnel at the community when a resident has difficulty chewing and/or swallowing. For pureed: designed for people who have severe chewing and/or swallowing problems. Properly pureed foods eliminate the chewing phase. Smooth with no lumps. Review of the Diet Type Report completed by the facility on 4/12/24, showed 10 residents on pureed diet texture. On 4/10/24 at 1030 hours, a pureed food preparation was observed with the Dietary Cook. The DSS and RD were present during the observation. A food processor was used to puree the vegetable lasagna. The pureed vegetable lasagna showed tiny carrot bits after preparation. This was verified by the DSS. The RD verified the above findings and stated the tiny carrot bits from the pureed vegetable lasagna could cause choking.

CONCERN (D)

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

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility document review, the facility failed to ensure the food preferences was honored for one nonsampled resident (Resident 543). * Resident 543's tray card showed puree regular with dislikes all dairy products; however, he was served pureed breadstick and butter with milk. This failure had the potential to negatively impact the resident's well-being. Findings: Medical record review for Resident 543 was initiated on 4/10/24. Resident 543 was admitted to the facility on [DATE]. Review of the Diet Type Report for pureed diet completed by the facility on 4/12/24, did not show any additional directions for Resident 543. Review of Resident 543's lunch tray ticket showed dislikes all dairy products. On 4/10/24 at 1030 hours, a pureed food preparation was observed with the Cook. The DSS and RD were present during the observation. During the pureed food preparation observation for the breadstick and butter, the Dietary [NAME] was observed to add milk to softened the breadstick and butter. When asked what was added to the breadstick and butter, the Dietary [NAME] stated milk. On 4/10/24 at 1130 hours, during trayline observation, the Dietary [NAME] was observed to serve pureed breadstick and butter for the residents with pureed diet. The tray cart was stopped prior to tray distribution to the residents. The DSS was asked to show the items to be served for the residents on pureed diet. The DSS showed Resident 543's lunch tray ticket showed dislike all dairy products and was served with pureed breadstick and butter added with milk. The RD had interviewed Resident 543's family member, Resident 543 did not have allergies to dairy products. The facility could serve yogurt and cottage cheese, however, Resident 543's family member did not want milk or milk products on Resident 543's meal.

CONCERN (D)

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to maintain the complete and accurate medical records for two of 19 final sampled residents (Residents 23 and 31). * The facility failed to ensure the complete documentation for Resident 31's ADL- Bed Mobility Intervention/Task. * The facility failed to ensure the informed consents obtained from Resident 23 were signed by the physician. These failures had the potential for the resident care needs not being met as the medical information was incomplete and inaccurate. Findings: 1. Review of the facility's P&P titled Documentation in Medical Record revised 12/19/22, showed documentation should be timely, accurate, relevant and complete, containing sufficient details about resident's care and responses to care for. Medical record review for Resident 31 was initiated on 4/10/24. Resident 31 was admitted to the facility on [DATE]. Review of Resident 31's Care Plan dated 2/3/24, showed the resident had an ADL self-care performance deficit related to Disease Process Diagnosis: Generalized body weakness, post status fall, Urinary Tract Infection, C-Diff, Cerebrovascular Accident with Right side Weakness, Diabetes Mellitus, hypokalemia, dysphagia, Hypertension, Hyperlipidemia, Acute Kidney Failure. The interventions included requires extensive assistance by (1) one staff to turn and reposition in bed. Review of the ADL- Bed Mobility Intervention/Task Documentation Survey Report for the months of March and April 2024 showed missing documentation for the ADL Bed Mobility on the following dates: - 3/2, 3/8, 3/9, 3/10, 3/11, 3/15, 3/16, 3/17, 3/20, 3/21, 3/22, 3/27, 3/29, 4/1, and 4/4/24, for the night shift; and - 3/16, 3/21, and 3/24/24, for the day shift On 4/12/24 at 1335 hours, an interview was conducted with the Medical Records Director. The Medical Records Director verified the missing documentations on the mentioned dates and stated the assigned staff should have documented care they had provided. On 4/12/24 at 1440 hours, an interview was conducted with the DON. The DON acknowledged the missing documentation.2. Medical record review for Resident 23 was initiated on 4/9/24. Resident 23 was readmitted to the facility on [DATE]. Review of Resident 23's MDS dated [DATE], showed Resident 23 was cognitively intact. Review of Resident 23's Order Summary Report showed the following physician's orders dated 3/18/24: - To administer buspirone (antidepressant medication) 10 mg one table by mouth two times a day for anxiety manifested by verbalization of feeling anxious; and - To administer citalopram (antidepressant medication) 20 mg one tablet by mouth at bedtime for depression manifested by verbalization of feeling of sadness. Review of Resident 23's MAR for March and April 2024 showed Resident 23 received the buspirone medication from 3/19 to 4/10/24 at 0900 and 1700 hours, and on 4/11/24 at 0900 hours; and received the citalopram medication from 3/19 to 4/10/24 at 2100 hours. Review of the Physician Documentation of Informed Consent (undated) for buspirone medication did not show the consent was signed by the physician who obtained the informed consent. Review of the Physician Documentation of Informed Consent (undated) for citalopram medication did not show the consent was signed by the physician who obtained the informed consent. On 4/11/24 at 1359 hours, a concurrent interview and record review was conducted with RN 1. RN 1 verified the above findings. RN 1 stated the charge nurses or the social services department usually asked the physician who obtained the informed consents from Resident 23 to sign the informed consents for the citalopram and buspirone medications. On 4/12/24 at 1419 hours, a concurrent interview and record review was conducted with the DON. The DON verified the above findings. The DON stated she would ask the medical records to ask the physician who obtained the informed consents from Resident 23 to sign the informed consents for the citalopram and buspirone medications.

CONCERN (D)

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

Room Equipment (Tag F0908)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and facility document review, the facility failed to ensure one glucometer (Glucometer C) from one of five medication carts (Medication Cart C) was maintained in safe operating condition. This failure had the potential for residents requiring glucose checks to have inaccurate readings. Findings: Review of the Assure Platinum Blood Glucose Monitoring System Instruction Manual, under Quality Checks, showed to use Assure Dose Control Solutions to check if the meter and test strips are working correctly as a system, and if the test is correct. A control solution test is performed when a new bottle of test strips is opened. On 4/11/24 at 1245 hours, Medication Cart C inspection was conducted with LVN 3. One glucometer (Glucometer C) was observed inside the top drawer of Medication Cart C. The bottle of Assure Platinum Blood Glucose Test Strips was observed with an open date of 4/11/24, and Lot No. 012523B. A bottle of control solution was observed with the control solution range for Level 1 was 84-105 mg/dl, and the control solution range for Level 2 was 203-253 mg/dl. On 4/11/24 at 1246 hours, an interview and concurrent review of the Assure 3 Blood Glucose Monitoring System: Daily Quality Control Record for Glucometer C was conducted with LVN 3. The Daily Quality Control Record for April 2024 showed the quality control checks for the glucometer was checked every day. However, the information on the log for Glucometer C with the date of 4/11/24, did not match the test strips Lot No. and the control solution ranges on the control solution bottle. The log for Glucometer C dated 4/11/24, showed the test strips Lot No. was 120623A, Level 1 control range was 84-104 mg/dl, and Level 2 control range was 201-251 mg/dl. LVN 3 verified the findings and also verified there was no other bottle of the glucose test strips inside Medication Cart C to match the documentation dated 4/11/24, in the Assure 3 Blood Glucose Monitoring System: Daily Quality Control Record for Glucometer C. LVN 3 stated the glucometer quality control was done by the night shift (2300-0700 hours) licensed nurse. LVN 3 verified and acknowledged the findings. LVN 3 further stated the quality control checks must be done whenever a new bottle of test strips was opened.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to ensure the medications were stored and labeled properly and failed to ensure the drugs and biologicals were stored in a safe manner when: * One of two medication rooms (Medication Room A) had one opened, unsealed package of IV Statlock PICC Plus (a device to secure an IV catheter from kinking which could lead to blockage of fluids going through the vein). * The facility's Central Supply Room was observed to contain artificial tears, earwax softener drops, dry eye relief, muscle rub cream, and enema bottles stored on the same shelf next to the oral medications such as calcium, omeprazole, sodium chloride, and fish oil. * The facility's treatment cart was observed to contain the expired dressings, topical creams with labels not readable; and the treatment supplies and cart were not maintained in a sanitary condition. * Two of three medication carts (Medication Carts A and C) contained the medication bottles with sticky residue, and Medication Cart A had an expired medication inside the medication cart. * The facility failed to ensure zinc oxide ointment medication was safely stored in the Treatment Cart. The zinc oxide was observed on top of the Treatment Cart unattended by a licensed staff. These failures had the potential to negatively impact the residents' well-being and unauthorized persons having access to the medications. Findings: Review of the facility's P&P titled Medication Storage in the Facility ID1: Storage of Medications dated 4/08, under the section Procedures, showed the following: - Orally administered medications are kept separate from the externally used medications such as suppositories, liquids, and lotions. - Eye medications are kept separately from ear medications. - Orally administered medications are kept seprate from externally used medications, such as suppositories, liquids, and lotions. - Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from the stock, disposed of acccording to the procedures for medication disposal, and reordered from the pharmacy if a current order exists. - Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures. - Medication storage conditions are monitored on a routine basis and corrective action taken if problems are identified. 1. On [DATE] at 1101 hours, an inspection of Medication Room A and concurrent interview was conducted with the DSD. During the inspection, an unseald tray of Statloc PICC Plus was observed inside Medication Room A, stored with the rest of the IV supplies in a plastic container. The DSD acknowledged and verified the findings. 2. On [DATE] at 1131 hours, an inspection of the facility's Central Supply Room and concurrent interview was conducted with CNA 3. CNA 3 verified she was in charge of stocking the Central Supply Room. During the Central Supply Room inspection, several over the counter medications (non-prescription medications) such as bottles of artificial tears, dry eye relief, earwax softener drops, enema (helps to relieve constipation) bottles and containers of muscle pain relief rub cream were stored alongside with multiple bottles of oral over the counter medications such as calcium (supplement to prevent weak or brittle bones), sodium chloride (essential nutrient to help prevent residents from becoming dehydrated), fish oil (supplement to reduce pain, improve morning stiffness and relieve joint tenderness) capsules , and omeprazole (medication to relieve heartburn, difficulty swallowing, and cough) tablets on the same shelf. When asked if she should have stored the medications such as enema, muscle rub, artificial tears next to oral medications, CNA 3 stated no, and would not have done how the medications were stores together; however, the medications were already stored that way and just followed what was already there. CNA 3 verified the findings and stated the identified medications should not have been stored together. 3. On [DATE] at 1435 hours, a Treatment Cart inspection and concurrent interview was conducted with LVN 1. During the Treatment Cart inspection, the following was identified: - A 4 x 4 gauze was observed laid directly on the surface of the inside of the treatment cart - A tube of Traimicinolone Acetonide Cream 0.1% (topical medication to treat skin conditions resulting from allergies or immune system disorders) label was not clear and readable - A tube of Fluocinonide Cream 0.1% (topical medication to treat skin conditions resulting from allergies) label was not clear and readable - Procure Hydrocortisone Acetate 1% Cream (topical medication to relieve itching associated with minor skin irritation or inflammation) was stored inside a box of bandaids - 10 packets of Medifill Collagen Particles (collagen which promotes wound healing and formation of new tissues), 1 g, had an expiration date of 2/2024 - DermaFilm X-Thin Clear Hydrocolloid Wound Dressing (a dressing which helps maintain a moist wound environment to support moist wound healing; also provides insulation and protection) with Grid, 6 x 6, box was wet. -The bottom drawer of the treatment cart was observed with reddish, yellowish stain -A bottle of Nystatin (treats fungal or yeast infection) topic powder had no cover, and no open date. -A bottle of Providone Iodine Prep Solution (a solution to disinfecting skin, cleans abrasions, cuts, or lacerations) was observed with brown, dried solution on the outside of the container. -A Derma Klenz Wound cleaner container was observed with brown stain on the outside of the container LVN 1 acknowledged and verified all the findings. 4. On [DATE] at 0852 hours, a medication pass observation was conducted with LVN 1. During the observation, Medication Cart A was observed with a bottle of ProStat liquid (liquid protein) with an expiration date of [DATE]. Furthermore, the bottle of ProStat liquid was noted with sticky residue on the outside of the bottle. LVN 1 acknowledged and verified the findings. On [DATE] at 1317 hours, an inspection of Medication Cart C and concurrent interview was conducted with LVN 3. During the inspection, a bottle of Milk of Magnesia (laxative) was observed with white dried dripping residue from the top to bottom of the bottle. In addition, a bottle of Geri Tussin (cough medicine) was observed with dried red dripping residue from the top to bottom of the bottle. LVN 3 acknowledged and verified the findings. 5. Review of the facility's P&P titled Medication Storage in the Facility dated 4/2008 showed to ensure medications are stored safely, securely and properly, only licensed nurses, pharmacy personnel and those lawfully authorized are allowed to access to medications. On [DATE] at 0848 hours, during an observation in the hallway near Station 2, a zinc oxide ointment was placed on top of the Treatment Cart, unattended by the licensed nurse. On [DATE] at 0849 hours, an interview was conducted with RN 3. RN 3 stated the zinc oxide ointment medication should be stored inside the Treatment Cart and not left unattended. On [DATE] at 1307 hours, an interview was with LVN 2. LVN 2 stated it was his honest mistake. The licensed nurses should not leave any medication on top of treatment cart and that some residents may be confused , might take it and use it in different way. On [DATE] at 1440 hours, an interview was conducted with the DON. The DON stated the zinc oxide ointment should not be left unattended on top of the Treatment Cart and should be stored properly in the Treatment Cart.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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7. On 4/11/24 at 1310 hours, an inspection of Medication Cart C was conducted with LVN 3, the following was observed: - One container of chocolate pudding with a printed sticker date of 4/10/24, on the lid and a printed sticker date of 4/11/24, on the outside of the container. - One container of apple sauce with a printed sticker date of 4/10/24, on the lid and a printed sticker date of 4/11/24, on the outside of the container. LVN 3 verified the above finding. On 4/11/24 at 1313 hours, an interview was conducted with the DSS and DSS in Training. The DSS and DSS in Training verified the dates printed on the lids and the containers of the above items did not match. The DSS in Training stated the dietary staff were responsible to check these containers for the proper preparation dates. In addition, The DSS and DSS in Training stated both dates on the lid and on the container should match. Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the food preparation, storage, and sanitary requirements were met in the kitchen. * The facility failed to ensure the proper disposal, labeling and dating of foods in the kitchen. * The facility failed to ensure the cutting board was in sanitary condition. * The facility failed to ensure the countertop can opener was free from brownish, whitish, and grayish discoloration. * The facility failed to ensure the stainless mixing bowls, knives, and water pitchers were rinsed prior to use. * The facility failed to ensure one knife and blender were air dried prior to use. * The facility failed to ensure a clean spatula was placed on top of an unsanitized preparation area. These failures had the potential to cause foodborne illnesses to a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: Review of the Dietary Order Listing Report completed by the facility on 4/12/24, showed 84 of 88 residents in the facility received food prepared in the kitchen. 1. Review of the facility's P&P titled Food Storage revised 8/29/23 showed the food items should be stored, thawed, and prepared in accordance with good sanitary practice. Any expired or outdated food products should be discarded. Review of the facility's POL 154b - Refrigerated Storage Chart with revised date 12/28/20, recommended storage time at 35-41 degrees Fahrenheit or less for unopened beets, carrots, radishes, turnips were one to two weeks. During the initial kitchen tour with the DSS on 4/9/24 at 0745 hours, the following items were observed: - one pack of opened hamburger buns with received date of 4/4/24, and used by 4/4/24; - Several pieces of carrots in a plastic bin with received date of 3/25/24, and used by 4/7/24. Carrots were not in the original plastic bag; - Grape jelly in plastic container measuring more than two liters with no received and used by date; - Few pieces of ham with incorrect label, with the prepared date of 5/6/24, and used by 5/14/24. The DSS verified the findings. 2. According to the USDA Food Code 2022 4-501.12 Cutting Surfaces, cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These may be transferred to foods that are prepared on such surfaces. During the initial kitchen tour on 4/9/24 at 0745 hours, with the DSS, one brown chopping board was observed heavily marred and scratched. The DSS verified the finding and stated the bacteria could get into the cracks. 3. According to USDA Food Code 2022 4-202.15 Can Openers, once the can openers become pitted or the surface in any way becomes uncleanable, they must be replaced because they can no longer be adequately cleaned and sanitized. Can openers must be designed to facilitate replacement. During an initial kitchen tour on 4/9/24 at 0745 hours, with the DSS, a brownish, whitish, and grayish discoloration were observed on the countertop can opener. The DSS confirmed the findings. 4. According to USDA Food Code 2022 4-101.11, Inability to effectively wash, rinse and sanitize the surfaces of food equipment may lead to the buildup of pathogenic organisms transmissible through food. During an initial kitchen tour on 4/9/24 at 0745 hours, with the DSS, the following items were observed: - One stainless steel mixing bowl with hard water marks - Four knives with hard water marks on the tip The DSS verified the findings. 5. According to the USDA Food Code 2022, Section 4-901.11, Equipment and Utensils, Air-Drying Required, after cleaning and sanitizing, equipment and utensils shall be air-dried or used after adequate draining. Wet equipment may allow an environment where microorganism can begin to grow. During the initial kitchen tour on 4/9/24 at 0745 hours, with the DSS, one knife observed with remaining water residue. The DSS verified this finding. On 4/10/24 at 1030 hours, an observation and concurrent interview was conducted during the pureed food preparation. The Dietary [NAME] was handed a blender still with remaining drops of water inside. The DSS verified the blender still had water inside and had it air dried. Furthermore, the DSS stated water remnants could contain bacteria. Utensils prior to use should be completely dry. 6. According to the USDA Food Code 2022, Section 4-602.11, Equipment Food-Contact Surfaces and Utensils, equipment food-contact surfaces and utensils shall be cleaned at any time during the operation when contamination may have occurred. On 4/10/24 hours, an observation was conducted during the pureed food preparation. The Assistance Dietary [NAME] placed a clean spatula on top of an unsanitized preparation area. The observation was verified by the DSS.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the infection control practices designed to provide a safe and sanitary environment were followed. * LVN 1 used Sanicloth disinfectant wipes with an unreadable expiration date. * LVN 1 placed the spoons directly on the bedside table and used the spoons to stir the medications prior to administering medications. * LVN 1 placed the piston syringe and plunger used for G-tube medication administration directly on the bedside table surface without a barrier. * LVN 4 failed to follow the Enhanced Barrier Precautions when she did not wear a gown during medication administration via G-tube for Resident 72. * LVN 4 did not perform hand hygiene and did not change gloves prior to administering oral, enteral, and subcutaneous medications. LVN 4 wore the same pair of gloves during the entire medication pass. In addition, LVN 4 used the bottom of the spoons to stir the medications and placed directly on the bedside table. LVN 4 also placed the piston syringe plunger directly on the bedside table for Resident 72 * The facility failed to ensure Derma Klenz (is a superior wound cleanser with zinc that contains no detergents and facilitates the removal of wound debris) spray was sanitized after used with two of 3 sampled residents (Residents 26 and 74) observed with wound care prior returning to treatment cart. * CNA 8 failed to perform hand hygiene prior to getting clean towels from storage room, entering Room F, getting personal item from bedside drawer of Resident 3, before donning new set of gloves, and before repositioning Resident 3 to clean up soiled diaper. * CNA 8 failed to label basin found on top of toilet tank in the Room E's restroom. Room E occupied with three residents (Resident 24, 38, and 77). *CNA 1 failed to follow the Enhanced Standard Precautions when caring for Resident 35. These failures placed the residents and staff at increased risk for infections. Findings: Review of the facility's P&P titled Infection Prevention and Control Program, revised 9/2/22, showed the facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmissions of the communicable diseases and infections as per accepted national standards and guidelines. Review of the facility's document titled Enhanced Standard Precautions (undated) showed everyone must perform hand hygiene before entering the room. The document also showed anyone who participate in any of the six moments must also don gown, and gloves. The six moments included morning and evening care, toileting and changing incontinence briefs, caring for devices and giving medical treatment, cleaning the environment, wound care, and mobility assistance and preparing to leave the room. 1. On 4/10/24 at 0837 hours, a medication pass observation was conducted with LVN 1 for Resident 53. Prior to medication administration, LVN 1 cleaned the bedside table, sanitized the bulb of the sphygmomanometer, wiped the top of the medication cart, and sanitized the stethoscope using the Sanicloth wipes. The Sanicloth wipes container showed a non-readable expiration date. On 4/10/24 at 0949 hours, a medication pass observation was conducted with LVN 1 for Resident 54. LVN 1 wiped Resident 54's bedside table, blood pressure cuff, stethoscope, and top of the medication cart with Sanicloth wipes. The Sanicloth wipes that LVN 1 used for Resident 54 was obtained from the same container of Sanicloth wipes with non-readable expiration date. On 4/10/24 at 1045 hours, an interview and concurrent review of the expiration date of Sanicloth wipes was conducted with LVN 1. LVN 1 was asked to verify the expiration date on the container of the Sanicloth wipes that she had used for Residents 53 and 54. LVN 1 verified she could not read it and it was not legible. 2. On 4/10/24 at 0837 hours, a medication pass observation was conducted with LVN 1 for Resident 53. Prior to the medication administration, LVN 1 wiped the bedside table with Sanicloth wipes, with unknown expiration date due to the expiration date was not readable. On 4/10/24 at 0904 hours, LVN 1 placed 6 spoons directly on Resident 53's bedside table. On 4/10/24 at 0911 hours, LVN 1 placed the piston syringe directly on Resident 53's bedside table which LVN 3 used to check for residual, flush the G-tube with water, and administer the medications via G-tube. On 4/10/24 at 1045 hours, an interview was conducted with LVN 1. When asked why she placed the spoons directly on Resident 53's bedside table, LVN 1 acknowledged and reasoned she wiped the bedside table first. LVN 1 verified the Sanicloth wipes did not have a readable label for expiration date. LVN 1 further stated she should have brought out a tray to use during the medication pass. 3. On 04/11/24 at 820 hours, during observation of medication administration with LVN 4, LVN 4 did not don a gown prior to administering medications via G-tube for Resident 72. LVN 4 read out loud the signage/posting outside of ENHANCED BARRIER PRECAUTION to prevent the spread of infections for specific care activities such as: Morning and Evening care, Toileting and Changing Incontinence briefs, Caring for devices and giving Medical treatments, Wound care, Mobility Assistance and preparing to leave the Room and Cleaning and Disinfecting the Environment. When asked if LVN 4 should have worn a gown prior to administering Resident 72's medications she stated yes, for the G-tube, for infection control. LVN 4 read out loud the Enhanced Barrier Precaution posted outside of Resident 72's room. When asked why LVN 4 did not put a gown on prior to medication administration, perform hand hygiene, change gloves during the entire medication pass, LVN 4 stated I forgot. LVN 4 was observed using the bottom end of each spoon to stir each of Resident 72's medications in separate medication cups. LVN 4 was also observed placing these 6 used spoons and a piston syringe plunger used for G-tube medication administration, directly on to the surface of a tray table without a barrier. On 4/11/24 at 916 hours, LVN 4 verified the 6 used spoons and piston syringe were directly on the surface of the tray table and LVN 4 stated, I should have put these (spoons and piston syringe) in a separate cup for infection control. Reviewed signage/posting outside of Resident 72's room which showed ENHANCED BARRIER PRECAUTION to prevent the spread of infections for specific care activities such as: Morning and Evening care, Toileting and Changing Incontinence briefs, Caring for devices and giving Medical treatments, Wound care, Mobility Assistance and preparing to leave the Room and Cleaning and Disinfecting the Environment. 4. Review of the facility's P&P titled Hand Hygiene revised 9/2/22, showed all staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors, the use of gloves does not replace hand hygiene, if task requires gloves, perform hand hygiene prior donning gloves. Hand Hygiene Table showed hand hygiene should be performed before and after handling clean or soiled dressings, linens etc, before performing resident care procedures. On 4/9/24 at 0950 hours, during the initial tour, CNA 8 was observed in Station 1 hallway, went directly to the storage room, took clean towels without performing hand hygiene. CNA 8 proceeded to enter Room F, without observing proper hand hygiene, laid clean towels on Resident 3's bed then opened the bedside table drawer, and took the personal item of Resident 3. CNA 8 was observed to not perform hand hygiene as she wore a new set of gloves, then repositioned Resident 3 to clean up the soiled diaper. On 4/9/24 at 1045 hours, an interview was conducted with CNA 8. CNA 8 verified she should have performed hand hygiene before getting clean towels, before entering room [ROOM NUMBER], before getting personal items from the bedside drawer of Resident 3, before donning new set of gloves, and before repositioning Resident 3. On 4/10/24 at 1417 hours, an interview was conducted with RN 2. RN 2 verified CNA 8 should have always performed hand hygiene before getting towels, before entering residents' room, before touching residents' items in their drawers, before donning gloves and before providing direct contact with the residents. On 4/12/24 at 1440 hours, an interview was conducted with the DON. The DON acknowledged the above findings. 5. Review of the facility's P&P titled Resident Personal Belongings revised 12/19/22, showed the facility will ensure the resident's belongings are kept in a neat and orderly fashion and maintained in resident's room. On 4/9/24 at 0825 hours, during the initial tour, an unlabeled basin was observed on top of the toilet tank in Room E's restroom occupied by three residents (Residents 24, 38, and 77). On 4/10/24 at 0912 hours, an observation and concurrent interview with CNA 2 in Room E was conducted. The unlabeled basin remained on top of the toilet tank. CNA 2 stated it was used for the bed bath for Resident 38. CNA 2 further stated she should have labeled the basin to prevent cross contamination and should have not left it on top of the toilet tank. On 4/10/24 at 1208 hours, an interview was conducted with the MDS LVN. The MDS LVN acknowledged CNA 2 should have labeled the basin to prevent cross contamination, properly and neatly stored the resident's basin. On 4/12/24 at 1440 hours, an interview was conducted with the DON. The DON acknowledged the resident's basin should have been labeled, ensured that it was kept clean, and neatly maintained.2. On 4/10/24 at 0828 hours, a wound care observation for Resident 74 was conducted with LVN 2. LVN 2 was observed having the Derma Klenz wound cleanser on Resident 74's bed. LVN 2 used Derma Klenz spray to cleanse the resident's right leg. The Derma Klenz spray was not labeled with the resident's name. After the wound care was completed, LVN 2 was observed returning the Derma Klenz to the treatment cart. On 4/10/24 at 0835 hours, a concurrent interview and medical record review were conducted with LVN 2. LVN 2 verified he did not clean the Derma Klenz spray prior to retuning to the treatment cart. LVN 2 further stated the Derma Klenz spray was being used as community supply. On 4/12/24 at 1029 hours, an interview with the IP was conducted. The IP stated LVN 2 should have cleaned the Derma Klenz spray prior to returning to the cart to prevent the spread of infection. 3. On 4/10/24 at 0905 hours, a wound care observation for Resident 26 was conducted with LVN 2. LVN 2 was observed provided treatment to the resident's right lateral malleolus and right hip pressure injuries. LVN 2 was observed using the Derma Klenz spray to Resident 26's pressure injuries. The Derma Klenz spray was not labeled with the resident's name. After wound care was completed, LVN 2 was observed returning the Derma Klenz spray to the treatment cart. On 4/10/24 at 0935 hours, a concurrent interview and medical record review were conducted with LVN 2. LVN 2 verified Resident 26 was on enhanced based precaution. LVN 2 verified the Derma Klenz was used to cleanse the right lateral malleolus and right hip pressure injuries, and LVN 2 stated he did not clean the Derma Klenz spray prior to retuning to the treatment cart. LVN 2 further stated the Derma Klenz spray was being used as community supply. On 4/12/24 at 1029 hours, an interview with the IP was conducted. The IP stated LVN 2 should have cleaned the Derma Klenz spray prior to returning to the cart to prevent the spread of infection. 6. Review of the facility's document titled Enhanced Standard Precautions (undated) showed everyone must perform hand hygiene before entering the room. The document also showed anyone who participate in any of the six moments must also don gown, and gloves. The six moments included morning and evening care, toileting and changing incontinence briefs, caring for devices and giving medical treatment, cleaning the environment, wound care, and mobility assistance and preparing to leave the room. Review of the CMS QSO-24-08-NH dated 3/20/24, for Enhanced Barrier Precautions in Nursing Homes to Prevent Spread of MDROs, showed MDRO transmission is common in long-term care facilities such as nursing homes, contributing to substantial resident morbidity and mortality and increased healthcare costs. Many residents in nursing homes are at increased risk of becoming colonized and developing infections with MDROs. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of MDROs that employs targeted gown and glove use during high-contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. On 4/10/24 at 0927 hours, an Enhanced Barrier Precautions sign was observed posted outside Resident 35's room alerting anyone to perform hand hygiene before entering and when leaving the room. The sign also alerted the providers and staff to wear gloves and a gown for high-contact resident care activities. A number 6 was observed beside Resident 35's name by the door. A cart containing gowns was observed inside the room. CNAs 1 and 2 were observed assisting Resident 35 transfer from bed to wheelchair. CNAs 1 and 2 were wearing gloves but were not observed wearing gowns. On 4/10/24 at 0941 hours, an observation for Resident 35 and concurrent interview was conducted with CNA 1. CNA 1 verified the above findings. CNA 1 verified the Enhanced Barrier Precaution sign placed outside Resident 35's room, with a number 6 besides Resident 35's name by the door. CNA 1 verified she transferred Resident 35 from the bed to wheelchair with CNA 2. CNA 1 verified they were only wearing gloves, and not gown while transferring Resident 35. Medical record review for Resident 35 was initiated on 4/9/24. Resident 35 was readmitted to the facility 11/12/19. Review of Resident 35's Order Summary Report showed a physician's order dated 4/3/24, for enhanced barrier precaution to prevent the spread of infections for specific care activities such as morning and evening care, toileting and changing incontinent briefs, caring for devices and giving medical treatments, wound care, mobility assistance and preparing to leave the room, and cleaning and disinfecting the environment every shift for indwelling medical device. On 4/11/24 at 1539 hours, an interview and concurrent medical record review for Resident 35 was conducted with the IP. The IP verified the above findings. The IP stated when an Enhanced Barrier Precaution sign was placed by the door and the resident's name was marked with a number 6, the staff who provided the high-contact care activities should wear gloves and a gown, in addition to hand hygiene. The IP stated high-contact resident care activities included transferring, or mobility assistance and preparing the resident to leave the room. Cross reference to F726, example #2.

CONCERN (E)

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

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to ensure the residents' call light system was fully functional as evidenced by: * The call light system for two of two nursing stations were not audible. * Resident 67's call light was not answered promptly. These failures posed the risk of staff not responding promptly to residents in need of immediate assistance. Findings: Review of the facility's P&P titled Call Lights: Accessibility and Timely Response revised 9/2/22, showed the staff members who see or hear an activated call light were responsible for responding. If the staff member could not provide what the resident desired, the appropriate personnel should be notified. 1. On 4/9/24 at 1408 hours, Resident 61's call light was observed on but not audible. On 4/10/24 at 1041 hours, Resident 61's call light was observed on but not audible. On 4/10/24, medical record review for Resident 61 was initiated. Resident 61 was admitted to the facility on [DATE]. Resident 61 was observed to have a sitter inside her room due to being at risk for and having a history of falls. On 4/11/24 at 1525 hours, the call lights for Resident Rooms C and D were observed on but not audible. Concurrent observation and interview of Resident Rooms A and B (rooms not visible and located the farthest away from the nurses station) was conducted with the Maintenance Director. The Maintenance Director verified the call lights for Resident Rooms A and B were not audible. When asked about the call lights system, the Maintenance Director verbalized the facility received recommendations from the technicians to replace the entire facility's call light system due to the problem with the facility's call lights system not being fully functional. On 4/11/24 at 1646 hours, the survey team and facility staff checked the call light system of the whole facility, and the call lights were observed turned on showing the lights at the door and the panel but there was no audible sounds for Nursing Stations 1, 2, and 3. On 4/11/24 at 1629 hours, the survey team had a meeting with the Administrator, AIT and DON. They were informed of the call light system concerns. The Administrator stated the call light system stopped working last week, either Thursday or Friday. The Administrator stated the call lights turned on in the call light panel, but there was no audible sound in Nursing Station A; and the call light panel completely stopped working in Nursing Station B. The Administrator stated they called the vendor on 4/5/24 (Friday), and the technician came to check the call light system on 4/9/24. Review of the emailed report sent by the vendor dated 4/11/24, showed the vendor would send quote for a new system for a facility with 22 rooms with three beds, and 15 rooms with two beds. When asked for the actual quote and work order, the Administrator stated it was verbal conversation with the vendor and would ask the vendor for documentation. Per the Administrator, the interventions for the call light system not being fully functional included providing residents with manual bells. However, the staff were observed providing bells to the residents after the meeting with the facility's management team. Review of the Guardian Angel Daily Inspections for 4/12/24, for Resident Rooms A and B showed some of the residents inside these rooms verbalized their call light response time was 30 minutes. On 4/12/24 at 1700 hours, the survey team conducted an inspection of the facility's call lights. There was audible sounds heard from the call light panel but some were still not working. Rooms 8, 5, 36, 19, 21, 23, 24, 31, and 27's call lights were still not working, operate in the room but did not annunciate at the nursing station 2. On 4/11/24 at 1608 hours, an interview was conducted with Resident 67. Resident 67 stated CNA 8 came to the resident's room on 4/10/24 at 1030 hours, but the CNA never came back. Resident 67 further stated he pushed the call light button but the CNA never showed up. Medical record review for Resident 67 was initiated on 4/12/24. Resident 67 was admitted to the facility on [DATE], and was readmitted [DATE]. Review of Resident 67's H&P examination dated 10/19/23, showed Resident 67 was able to make decisions. On 4/11/24 at 1440 hours, during an interview with the DON and Administrator, they were made aware of the above findings. The DON and Administrator acknowledged that CNA and other staff should have attended to Resident 67's needs.

MINOR (B)

Minor Issue - procedural, no safety impact

Resident Rights (Tag F0550)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and interview, the facility failed to promote the dignity and respect for one nonsampled resident (Resident 65). * CNA 7 was observed standing over Resident 65 while assisting and feeding the resident with lunch. This failure posed the risk of not treating the resident with dignity and respect. Findings: Medical record review for Resident 65 was initiated on 4/10/24. Resident 65 was admitted to the facility on [DATE]. Review of Resident 65's H&P examination dated 3/28/24, showed Resident 65 had capacity to understand and make decisions. On 4/9/24 at 0847 hours, a concurrent observation and interview was conducted with Resident 65 in the dining room. Resident 65 stated he needed assistance when eating during meal times. On 4/9/24 at 1221 hours, a lunch meal observation for Resident 65 and concurrent interview was conducted with CNA 7. CNA 7 was observed standing over Resident 65 while assisting and feeding him. CNA 7 acknowledged he should not have stood over while feeding Resident 65. On 4/10/24 at 1417 hours, an interview was conducted with RN 2. RN 2 acknowledged CNA 7 should be at eye level with Resident 65 while assisting in feeding during meal times. On 4/12/24 at 1440 hours, an interview was conducted with the DON. The DON stated CNA 7 should have been seated and be at eye level when feeding the residents.

MINOR (B)

Minor Issue - procedural, no safety impact

Grievances (Tag F0585)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to thoroughly investigate a grievance for one of 19 sampled residents (Resident 87). This failure posed the risk of not taking all appropriate corrective action. Findings: Medical record review for Resident 87 was initiated on 4/10/24. Resident 87 was admitted to the facility on [DATE]. Review of Resident 87's H&P examination dated 3/21/24, showed Resident 87 had diagnoses included post status multiple falls, episodes of delirium, anxiety, and generalized muscle weakness. Further review showed Resident 87 did not have the capacity to understand and make decisions. Review of Resident 87's progress note dated 4/1/24, showed Resident 87's RP verbalizing that she observed many times where the staff did not answer the call lights and the residents almost falling. The RP further stated she had to go find a staff. Further review of the medical record showed no documented evidence the resident's RP concerns was addressed. On 4/12/24 at 1046 hours, a concurrent interview and medical record review was conducted with the DON. When asked if any investigation was completed for the reason for call lights not being answered or for the residents almost falling, the DON did not have any documented investigation follow up for the resident's RP concern. Cross reference to F919.

Dec 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 F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, document review, and facility P&P review, the facility failed to provide the written information regarding the rights to accept or refuse medical or surgical treatments and formulate the advance directives for two of the fivesampled resident (Residents 2 and 3). This failure had the potential for the residents ' decision regarding their healthcare and treatment options not being honored. Findings: According to the Code of Federal Regulations, Section § 483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident ' s option, formulate an advance directive. Review of the facility P&P titled Resident ' s Right Regarding Treatment and Advance Directives revised 12/9/22, showed it is the policy of this facility to support and facilitates a resident right to request, refuse and/or discontinue medical or surgical treatment and to formulate and advance directive. The section Policy Explanation and Compliance Guidelines showed on admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident, if cognitively able to, would like to formulate an advance directive and the facility will provide the resident or resident representative information in a manner that is easy to understand, about the right to refuse medical and surgical treatment and formulate an advance directive. In the event the resident is unable to formulate and advance directive to cognitive impairment or deemed by the medical doctor that the resident in incapable of making decisions on his or her own, the facility will provide information and education to the resident representative. 1. Medical record review for Resident 2 was initiated on 11/23/23. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2 ' s History and Physical evaluation dated 2/15/23, showed Resident 2 had the capacity to understand and make decisions. Review of Resident 2 ' medical record failed to show an advance directive on file or if the advance directive information was provided to Resident 2. Review of Resident 2 ' s Social Service assessment dated [DATE], showed Resident 2 was asked if he wanted to initiate an advance directive. However, the documentation failed to show Resident 2 was provided with the advance directive information and education. On 12/13/23 at 1157 hours, an interview and concurrent record review was conducted with the SSD. The SSD verified Resident 2 did not have an advanced directive in the medical record. On 12/13/23 at 1550 hours, a follow-up interview and concurrent medical record review was conducted with the SSD. The SSD verified and acknowledged there was no documented evidence Resident 2 received the advance directive information and education. 2. Medical record review for Resident 3 was initiated on 11/22/23. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3 ' s History and Physical evaluation dated 11/17/23, showed Resident 3 was able to make decisions. Review of Resident 3 ' s Social Services admission Assessment completed by the SSD Assistant dated 11/20/23, showed the staff indicated no for the section for advance directive to be offered/reviewed,. On 12/13/23 at 1550 hours, an interview and concurrent interview was conducted with the SSD. The SSD verified the above findings. On 12/13/23 at 1059 hours, a telephone interview was conducted with the SSD. The SSD verified and acknowledged there were no documented evidence Resident 3 received the advance directive information and education.

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to assess one of the five sampled residents (Resident 4) for their risk for falls. This failure had the potential for the resident not receiving appropriate interventionsbased on the resident ' s fall risk assessment. Findings: Review of the facility ' s P&P titled Fall Prevention Program revised 12/19/22, showed each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. The section for Policy Explanation and Compliance Guidelines showed the following: - The facility utilizes a standard risk assessment for determining a resident ' s fall risk. - The nurse and/or interdisciplinary team will initiate interventions on the resident ' s care plan in accordance with the resident ' s level of risk. - Fall interventions include, but not limited to complete fall risk assessment every 90 days and as indicated when resident ' s condition changes. - At risk protocols showed to provided interventions that address unique risk factors measured by the risk assessment tool: medications, psychological, cognitive status, or recent change in functional status. Medical record review for Resident 4 was initiated on 12/6/23. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4 ' s Change of Condition Evaluation dated 12/1/23, showed Resident 4 had an unwitnessed fall. Review of Resident 4 ' s SNF/NF to Hospital Transfer Form dated 12/1/23, showed Resident 4 was discharged to the acute care hospital due to a laceration on the left side of the forehead and deformity to the back of the right hand. Review of Resident 4 ' s Fall Risk assessment dated [DATE], showed Resident 4 was at risk for falls. Further review of Resident 4 ' s Fall Risk assessment record failed to show a fall risk re-assessment was completed after 11/25/22, every 90 days and when the resident ' s condition changed as per the facility ' s P&P. On 12/12/23 at 1608 hours, and interview and concurrent medical record review was conducted with RN 2. RN 2 verified the above findings and acknowledged Resident 4 should have been assessed for their risk for falls as per the facility ' s policy.

Oct 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to notify the resident and their representative of the transfer/discharge and reasons for the transfer in writing for one of six sampled residents (Resident 1). This failure had the potential for the resident and their representative not knowing about the appeal process should the resident and their representative believe the transfer or discharge was inappropriate or involuntary. Findings: On 10/10/23 at 1347 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated Resident 1 was transferred to the acute care hospital on [DATE]. Family Member 1 stated the facility did not provide Resident 1 or his responsible party with a written Notice of Transfer/Discharge. Family Member 1 stated she believed the transfer was inappropriate. Closed medical record review for Resident 1 was initiated on 10/10/2023. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's History and Physical examination dated 5/11/23, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1's Order Summary Report, showed a physician's order dated 10/5/23, to transfer Resident 1 to the acute care hospital for a 5150 hold due to angry outbursts, throwing objects at staff, foul language, unable to calm himself, and for further evaluation. Review of Resident 1's Progress Notes dated 10/5/23 at 1330 hours, showed Resident 1 was transferred out to the acute care hospital. Review of the Notice of Transfer/discharge date d 10/5/2023, showed no signature in the section for the resident/resident representative's signature. The Notice of Transfer/Discharge showed, If you believe that the proposed transfer/discharge is inappropriate in your case, and is involuntary, you have the right to appeal. The appeal can be filed in writing to, or by calling the following: DHCS Office of Administrative Hearing and Appeals, State Long-Term Care Ombudsman Office, State Agency for the Developmentally Disabled, and/or the State Agency for the Mentally Ill. The notice further showed if the resident or their representative intended to appeal, it was important to do so within 10 calendar days of being notified. The ability of the Department of Health to render a decision on the appeal, may be jeopardized if the appeal is not submitted within (10) ten calendar days. Review of the Resident 1's Progress Notes dated 10/5 to 10/12/23,failed to show documentation Resident 1's responsible party was notified of the transfer or discharge and reasons for the transferin writing. On 10/11/23 at 1427 hours, an interview and concurrent closed medical record review was conducted with the DON. The DON verified the above findings and stated there was no documented evidence a written Notice of Transfer/Discharge was provided to Resident 1's responsible party.

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 F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of six sampled residents (Resident 1) and/or their representative were provided with the written information regarding the facility's bed-hold policy when the resident was transferredto the acute care hospital. This failure had the potential for Resident 1 or their representative to be unaware of their rights to request a bed hold and return to the first available bed should the resident's hospital stay exceed the seven-day bed-hold period. Findings: Review of the facility's P&P titled Bed-Hold Notice Upon Transfer revised 12/19/2022, showed at the time of the transfer or therapeutic leave, the residents or resident representatives will be informed in writing of the bed-hold and return policy. On 10/10/2023 at 1347 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated Resident 1 was transferred to the acute care hospital on [DATE]. Family Member 1 stated the facility did not provide Resident 1 and/or his responsible party with written information regarding the facility's bed-hold policy when the resident was transferred to the acute care hospital. Closed medical record review for Resident 1 was initiated on 10/10/2023. Resident 1 was admitted to the facility on [DATE], and transferred to acute care hospital on [DATE]. Review of Resident 1's History and Physical examination dated 5/11/23, showed Resident 1 had the capacity to understand and make decisions. Review of Resident 1's Order Summary Report showed a physician's order dated 10/5/23, to transfer Resident 1 to the acute care hospital for a 5150 hold due to angry outbursts, throwing objects at staff, foul language, unable to calm himself and for further evaluation. Review of Resident 1' s Progress Notes dated 10/5/23 at 1330 hours, showed Resident 1 was transferred out to the acute care hospital. Review of the Resident 1's medical record failed to show documented evidence of a written bed hold information was provided to the Resident 1 and/or resident representative. On 10/11/2023 at 1427 hours, an interview and a concurrent closed medical record review for Resident 1 was conducted with the DON. The DON verified the above findings and stated there was no documented evidence of a written bed-hold information was provided to the Resident 1 and/or their representative.

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to provide the necessary care and services for one of six sampled residents (Resident 5) to ensure the resident maintained their highest physical well-being. * The facility did not notify the primary physician when Resident 5 refused her meals (breakfast and lunch) and was given sixunits of insulin as per the sliding scale as ordered by the physician. This failure had the potential for not providing necessary care and services to Resident 5. Findings: Lexicomp Online (a pharmacy resource used by healthcare professionals) showed Insulin Lispro is administered subcutaneously (injection given in the fatty tissue, just under the skin) within 15 minutes before or immediately after a meal. Identified under warning/precaution concerns related to adverse effects, the most common adverse effect of insulin is hypoglycemia (low blood sugar). Hypoglycemia may result from changes in meal patterns (e.g., timing of meals, changes in level of activity, increased work, or exercise without eating). Patients with kidney or liver impairment may be at a higher risk. Further review of the document showed, under the section monitoring parameters in hospitalized patients who are eating, monitor blood glucose before meal and at bedtime; in patients who are not eating or are receiving continues enteral feeds, monitor blood sugar every 4 to 6 hours. More frequent monitoring may be required in some cases (e.g., recurrent hypoglycemia, changes in nutrition, medication changes affecting glycemic (blood sugar) control). Closed medical record review for Resident 5 was initiated on 10/24/23. Resident 5 was admitted to the facility on [DATE], and transferred to the acute care hospital on 6/22/23. Review of Resident 5's History and Physical examination dated 3/9/23, showed Resident 5 had a diagnosis of DM. Review of the Resident 5's Care Plan dated 3/8/23, showed a care plan problem addressing DM. The goal was for the resident to be free of signs and symptoms of hypoglycemia with the interventions to monitor/document/report as needed for compliance with the diet and document any problems. Review of Resident 5 ' s Progress Notes dated 6/22/23 at 1830 hours, showed Resident 5 did not respond to her name. Resident 5's blood sugar was 20 mg/dl (a critically low blood sugar level). Further review of the document showed the emergency services were called by Resident 5's family member. Resident 5 was then transferred to the acute care hospital. Review of Resident 5's Order Summary Report dated 6/22/23, showed an order dated 5/25/23, to administer Insulin Lispro Injection Solution 100 unit/ml (Insulin Lispro) subcutaneously before meals and at bedtimes as per the following sliding scale (dose of insulin based on blood sugar level): - For blood sugar level 70-200 mg/dl, give 0 unit; - For blood sugar level 201-250 mg/dl, give 6 units; - For blood sugar level 251-300 mg/dl, give 8 units; - For blood sugar level 301-350 mg/dl, give 10 units; - For blood sugar level 351-400 mg/dl, give 12 units; and, - For blood sugar level 401 +, give 15 units. Further review of the Order Summary Report showed the following: - if Resident 5's blood sugar level greater than 401 mg/dl,to give 15 units of insulin, recheck after three hours and if blood sugar levelgreater than 400 mg/dl, to call MD; - If blood sugar level less than 70 mg/dl,to give cookie, soda or orange juice, recheck blood sugar after 15 minutes and call MD; if resident was unresponsive or there was change in level of consciousness, to give Glucagon (sugar agent) 1 mg IM (intramuscular), then call MD. Review of Resident 5's Medication Administration Record for June 2023 showed the Insulin Lispro as per the sliding scale was scheduled to be administered at 0630, 1130, 1630, and 2100 hours. Resident 5 was administered insulin lispro on 6/22/23, during the following times and corresponding blood sugar levels: - at 0630 hours, blood sugar level was 120 mg/dl, no insulin was administered; - at 1130 hours, blood sugar level was 226 mg/dl, six units of insulin were administered; - at 1630 hours, no record of blood sugar level, 3 was documented (3=hospitalization). Review of Resident 5's ADL flowsheet dated 10/24/23, under the sections for Intervention/Task, Nutrition-Amount Eaten showed the following on 6/22/23: - at 0700 hours, RR (Resident 5 Refused); - at 1200 hours, RR (Resident 5 Refused); and, - at 1700 hours –no entry Review of Resident 5's closed medical record did not show documented evidence Resident 5's physician was notified of Resident 5's refusal to eat breakfast and lunch, still with six units of insulin administered at 1130 hours. On 10/24/23 at 1143 hours, a telephone interview was conducted with LVN 4 who worked in the evening shift. LVN 4 stated on 6/22/23 at around 1830 hours, Resident 5's family member reported to her their concern regarding Resident 5 being unresponsive. LVN 4 stated she checked Resident 5's blood sugar level and it was 20 mg/dl. LVN 4 stated Resident 5's family called emergency services even before she could administer glucagon to Resident 5. LVN 4 stated she was aware Resident 5 received six units of insulin as per sliding scale parameters on 6/22/23 at 1130 hours. LVN 4 was asked if she was aware Resident 5 refused breakfast and lunch that day. LVN 4 stated the morning shift nurse did not report to her regarding Resident 5 refusing the breakfast and lunch that day. On 10/24/23 at 1416 hours, an interview and concurrent closed record review was conducted with RN 1. RN 1 verified the above findings. RN 1 stated Resident 5 was on a high dose of insulin sliding scale. RN 1 stated the LVN administering insulin should have made sure the resident ate their meal; if the resident refused their meal, then the facility staff should offer alternatives; if the resident still refused the alternative food, then the facility staff should notify the physician. RN 1 stated the LVN should have notified the physician when Resident 5 refused two consecutivemeals and the six unit of insulin was administered as per the sliding scale. On 10/24/23 at 1514 hours, an interview and concurrent closedrecord review was conducted with the DSD. The DSD verified the above findings. When the DSD was asked if there wereany documented evidence Resident 5 was offered food alternatives when Resident 5 refused breakfast and lunch. The DSD stated she was not able to find any documentation. The DSD stated if a resident refused any meals, alternatives should be offered and if theresident still refuses the food, then the doctor should be notified, especially when the resident was receiving a high dose of insulin. The DSD verified theMD was not notified when Resident 5 refused breakfast and lunch on 6/22/23. The DSD verified on 6/22/23 at 1830 hours, Resident 5'sblood sugar level dropped to 20 mg/dl. The DSD stated Resident 5 refusing two consecutive meals was a change of condition, and the physician should have been notified. On 10/24/23 at 1533 hours, an interview was conducted with CNA 4. CNA 4 verified they took care of Resident 5 on 6/22/23, during themorning shift. CNA 4 stated on 6/22/23, Resident 5 refused breakfast, lunch, and any alternatives offered. CNA 4 stated he saw Resident 5's family offering food to the Resident 5, but he could not verify if Resident 5 ate the food offered by the family. CNA 4 stated he notified the LVN assigned to Resident 5 and documented the refusal of the meals.

Oct 2023 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the controlled medications signed out of the controlled drug records were administered and documented on the MAR for four of six sampled residents (Residents 1, 2, 3, and 4). In addition, Resident 2's pain medication was signed out on the controlled drug record two hours apart on 9/12/23 at 1400 and 1600 hours, instead of every four hours as ordered by the physician. These failures had the potential to result in controlled medications abuse or diversion and poor health outcomes to the residents. Findings: Review of the facility's P&P titled Medication Administration dated 12/2022 showed the medications are administered by the licensed nurses or other staff who are legally authorized to do so in this state as ordered by the physician and in accordance with the professional standards of practice in a manner to prevent contamination or infection, and to sign the MAR after administering the medications. 1. Medical record review for Resident 1 was initiated on 9/27/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's Order Summary Report showed a physician's order dated 8/04/23, for hydrocodone-acetaminophen 5-325 mg (a combination opioid medication used to manage pain when non-opioid medications are not working well enough) one tablet by mouth every six hours as needed for pain management. Review of Resident 1's Antibiotic or Controlled Drug Record showed hydrocodone- acetaminophen 5/325 mg tablets were removed from the bubble pack on the following dates and times: - 8/26/23 at 1630 hours; - 8/27/23 at 0000, 0900, 1630 hours; - 8/28/23 at 0200 and 2100 hours; - 8/29/23 at 1107 and 1700 hours; - 8/30/23 at 0000, 1600 and 2300 hours; - 8/31/23 at 1200 and 2100 hours; - 9/1/23 at 0817 and 2230 hours; - 9/2/23 at 0800 and 2100 hours; - 9/3/23 at 1900 hours; - 9/4/23 at 2000 hours; - 9/5/23 at 0800 and 1700 hours; - 9/6/23 at 2000 hours; - 9/7/23 at 1900 hours; - 9/8/23 at 1648 hours; - 9/12/23 at 2100 hours; - 9/14/23 at 0800, 1600 and 2200 hours; and, - 9/15/23 at 1000 hours. However, review of Resident 1's MAR from 8/26/23 to 9/15/23, showed the above hydrocodone-acetaminophen 5/325 mg tablets removed from the controlled drug record were not documented as administered on the following dates and times: - 8/26/23 at 1630 hours; - 8/27/23 at 1630 hours; - 8/30/23 at 1600 hours; - 8/31/23 at 2100 hours; - 9/14/23 at 2200 hours; and, - 9/15/23 at 1000 hours. During an interview on 10/2/23 at 1233 hours, the DON acknowledged the missing documentation. 2. Medical record review for Resident 2 was initiated on 9/27/23. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE],with fibromyalgia (a chronic disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping). Review of Resident 2's Order Summary Report showed the physician's orders dated 8/1 and 9/16/23, to administer hydrocodone-acetaminophen 10-325 mg onetablet by mouth every four hours as needed for severe pain. Review of Resident 2's Antibiotic or Controlled Drug Record showed hydrocodone-acetaminophen 10-325 mg tablets were removed from the bubble pack on the following dates and times: - 8/22/23 at 0500, 1100, 1600, and 2100 hours; - 8/23/23 at 0600, 1100, 1800, and 2200 hours; - 8/25/23 at 0600, 1000, 1600, and 2200 hours; - 8/26/23 at 0600, 1000, 1600, and 2100 hours; - 8/27/23 at 0600, 1100, 1600, and 2100 hours; - 8/29/23 at 0500, 1100, 1600, and 2100 hours; - 8/30/23 at 0600, 1100, 1600, and 2100 hours; - 8/31/23 at 0600, 1600, and 2100 hours; - 9/1/23 at 0600, 1000, 1600, and 2100 hours; - 9/7/23 at 0600, 1100, 1700, and 2200 hours; - 9/8/23 at 0600, 1000, 1600, and 2100 hours; - 9/9/23 at 0600, 1000, 1600, and 2100 hours ; - 9/10/23 at 0600, 1100, 1600, and 2100 hours; - 9/12/23 at 0400, 0800, 1400, 1600, and 2100 hours; - 9/15/23 at 0600, 1400, and 1830 hours; - 9/16/23 at 0800, 1200, 1640, and 2100 hours; - 9/21/23 at 0600, 1100, 1630, and 2031 hours; - 9/24/23 at 0600, 1000, 1600, and 2100 hours; and, - 9/26/23 at 0500, 1100, 1600, and 2030 hours. However, review of Resident 2's MARs for August and September 2023 for the dates corresponding to the controlled medication removal records showed the above hydrocodone-acetaminophen 10-325 mg tablets removed from the controlled drug record were not documented as administered on the following dates and times: - 8/22/23 at 0500 and 1100 hours; - 8/23/23 at 2200 hours; - 8/25/23 at 2200 hours; - 8/26/23 at 1000, 1600, and 2100 hours; - 8/27/23 at 1600 and 2100 hours; - 8/29/23 at 2100 hours; - 8/30/23 at 1100, 1600, and 2100 hours; - 8/31/23 at 0600 hours; - 9/1/23 at 1000 hours; - 9/7/23 at 1100 and 2200 hours; - 9/8/23 at 0600 hours; - 9/9/23 at 0600 and 2100 hours; - 9/10/23 at 0600 and 2100 hours; - 9/12/23 at 0800 and 1400 hours; - 9/15/23 at 1400 and 1830 hours; - 9/16/23 at 0800 and 1200 hours; - 9/21/23 at 1100 hours; - 9/24/23 at 0600 hours; and, - 9/26/23 at 1100 hours. Further review of the MAR September 2023 showed on 9/12/23, hydrocodone-acetaminophen 10-325 mg tablet was signed out two hours earlier (at 1600 hours) after the last dose (at 1400 hours) was signed out instead of every four hours as ordered by the physician. During an interview on 10/2/23 at 1233 hours, the DON acknowledged the missing documentation. The DON stated the nursing staff must have documented removal of the hydrocodone-acetaminophen 10-325 mg tablet from the controlled medication record at the wrong time. 3. Medical record review for Resident 3 was initiated on 9/27/23. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's Order Summary Report showed a physician's order dated 9/13/23, to administer hydrocodone-acetaminophen 5-325 mg one tablet by mouth every six hours as needed for severe pain. Review of Resident 3's Antibiotic or Controlled Drug Record showed hydrocodone- acetaminophen 5/325 mg tablets were removed from the controlled medication record on the following dates and times: - 9/19/23 at 0000, 1200, and 2100 hours; and, - 9/21/23 at 1300 and 1900 hours. However, review of Resident 3's MAR for September 2023 showed the above hydrocodone-acetaminophen 5-325 mg tablets removed were not documented as administered on 9/19/23 at 0000 hour, and 9/21/23 at 1300 hours. During an interview on 10/2/23 at 1233 hours, the DON acknowledged the missing documentation. 4. Medical record review for Resident 4 was initiated on 10/2/23. Resident 4 was admitted for cellulitis (a common bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin). Review of Resident 4's Order Summary Report showed a physician's order dated 9/6/23, to administer hydrocodone-acetaminophen 5-325 mg one tablet by mouth every sixhours as needed for moderate pain (for the pain level of 5-7 on a 0-10 pain scale with 0 = no pain and 10 = worst pain). Review of Resident 4's Antibiotic or Controlled Drug Record showed hydrocodone- acetaminophen 5/325 mg tablet was removed from the controlled medication record on 9/24/23, but was not documented on the September 2023 MAR. During an interview on 10/2/23 at 1233 hours, the DON acknowledged the missing documentation.

Aug 2023 13 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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the family member for one of the five sampled residents (Resident 4) was notified of the resident's transfer to the acute care hospital. This failure had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled Notification of Changes revised 12/19/22, showed the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is change requiring such notification. Circumstances requiring notification included Accidents potential to require physician intervention and a transfer or discharge of resident from the facility. Under additional considerations, showed contact information of resident's legal representative or family member must be recorded and periodically updated. On 7/27/23 at 1710 hours, an interview was conducted with Resident 4's family member. Resident 4's family member stated she was not notified of Resident 4's transfer to the acute care hospital on 7/25/23. Resident 4's family member further stated she was told by the facility staff that her number on file was incorrect and the facility corrected the contact number when she was at the facility on 7/25/23. Medical record review for Resident 4 was initiated on 7/28/23. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's hospital Facesheet undated and the facility Facesheet printed on 7/28/23 at 1513 hours, showed the correct contact number for Resident 4's family member. However, the facility Facesheet printed on 7/6/23 at 1457 hours, showed an incorrect number for Resident 4's family member. On 8/4/23 at 1439 hours, an interview and concurrent medical record review was conducted with the admission Coordinator. Resident 4's acute care hospital and facility Facesheets were reviewed with the admission Coordinator. The admission Coordinator acknowledged the contact number of Resident 4's family member was incorrect in the Facesheet the day Resident 4 was admitted on [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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the necessary care and services to ensure six of 21 sampled residents (Residents 4, 9, 18, 19, 20, and 21) maintained their highest practicable physical well-being. * The facility failed to notify the physician when Resident 4's pulse rate less than 60 bpm and DBP was below 60 mmHg as ordered by the physician. * The facility failed to monitor Resident 20 for signs and symptoms of pacemaker malfunction as ordered by the physician. * The facility failed to correctly apply the lidocaine patch 5% (pain reliever) to Resident 19 as ordered by the physician. * The facility failed to provide the Culturelle (probiotics) and the calcium carbonate-vitamin D and minerals (supplement) to Resident 18 as ordered by the physician. * Resident 9 was sent to the dialysis center without waiting for the resident's physician recommendations post status change in condition and the dialysis center was not notified of Resident 9's change in condition. * The facility failed to ensure Resident 21's amiodarone and digoxin (medication to prevent and treat fast or irregular heartbeat) were administered based on the physician's ordered parameter. In addition, Resident 21 was not administered her potassium chloride (supplement) medication as ordered by the physician due to the medication being unavailable. These failures had the potential to negatively impact Residents 4, 9, 18, 19, 20 and 21's health and well-being. Findings: Review of the facility's P&P titled Provision of Physician Ordered Services revised 5/15/23, showed documentation of consultations, diagnostic tests, the results, and date/time of physician notification will be maintained in the resident's clinical record. Under the section medication administration and therapeutic treatments showed, qualified nursing personnel will administer medications ad ordered by the physician, physician assistant, nurse practitioner, or clinical nurse specialist. Medications will be administered following protocols, dosage guidelines, and documentation procedures. Review of the facility's P&P titled Medication Administration General Guidelines dated 10/2017, showed medications are administered in accordance with the written orders of the attending physician. 1. Medical record review for Resident 4 was initiated on 7/28/23. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's Order Summary Report showed a physician's order dated 7/6/23, to monitor apical pulse and BP every shift daily for pacemaker use. Review of Resident 4's Order Summary Report further showed a physician's order dated 7/6/23, to observe/report signs and symptoms of pacemaker malfunction i.e. (that is) pulse less than 60 bpm, SBP less than 90 mmHg, DBP less than 60 mmHg, and/or resident becomes symptomatic: SOB (short of breath), chest pain, dizziness, ALOC (altered level of consciousness), and hypotension every shift. If symptomatic indicate (+/plus) if asymptomatic indicate (-/negative). Review of Resident 4's July 2023 Monitor Record showed the following: - pulse of 58 bpm on 7/13/23, the morning shift, - pulse of 56 bmp on 7/14/23, the morning shift, - pulse of 58 bmp on 7/17/23, the morning shift, - pulse of 58 bmp and DBP of 56 mmHg on 7/23/23, the afternoon shift, and - pulse of 58 bmp on 7/24/23, the morning and afternoon shifts. On 8/23/23 at 1040 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 verified the above pulse rates and DBP readings. When asked if Resident 4's physician was notified, LVN 5 was unable to show the documentation if the physician was notified of Resident 4's pulse rate less than 60 bmp and DBP less than 60 mmHg. On 8/23/23 at 1625 hours, an interview and concurrent record review was conducted with the DON. The DON was made aware of the above findings and acknowledged Resident 4's physician should have been notified of Resident 4's pulse rate less than 60 bmp and DBP less than 60 mmHg. Cross reference to F842, example #1. 2. Medical record review for Resident 20 was initiated on 8/23/23. Resident 20 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 20's Order Summary Report showed a physician's order dated 7/8/22, to observe/report signs and symptoms of pacemaker malfunction i.e. (that is) pulse less than 60 bpm, SBP less than 90 mmHg, DBP less than 60 mmHg, and/or resident becomes symptomatic: SOB (short of breath), chest pain, dizziness, ALOC (altered level of consciousness), and hypotension every shift. If symptomatic indicate (+) if asymptomatic indicate (-). Review of Resident 20's July 2023 Monitor Record failed to show documented evidence Resident 20 was monitored for signs and symptoms of pacemaker malfunction as ordered by the physician. Review of Resident 20's August 2023 Monitor Record failed to show documented evidence Resident 20 was monitored for signs and symptoms of pacemaker malfunction as ordered by the physician. On 8/23/23 at 1152 hours, an interview and concurrent medical record review was conducted with LVN 12. LVN 12 verified Resident 20 was not monitored for signs and symptoms of pacemaker malfunction as ordered by the physician. On 8/23/23 at 1625 hours, an interview and concurrent medical record review was conducted with the DON. The DON was made aware Resident 20's medical record failed to show the monitoring of signs and symptoms of pacemaker malfunction for Resident 20. The DON acknowledged Resident 20 should have been monitored for the signs and symptoms of pacemaker malfunction as ordered by the physician. 3. Medical record review for Resident 19 was initiated on 8/23/23. Resident was admitted to the facility on [DATE]. On 8/23/23 at 0844 hours, a medication administration observation was conducted with LVN 5. LVN 5 was observed preparing and administered the following medications: - Pro Stat (protein supplement) 30 ml, - hydralazine (medication to treat high blood pressure) 100 mg one tablet, - metformin (medication to treat diabetes) 1,000 mg one tablet, - losartan (medication to treat high blood pressure) 100 mg one tablet, - escitalopram (medication to treat depression) 10 mg one tablet, - heparin (blood thinner) 5,000 units/ml one ml, - multivitamins with minerals (supplement) one tablet, and - lidocaine patch 5%, one patch. During the medication administration observation with LVN 5, LVN 5 was observed removing a white patch from Resident 19's left knee, then applied the lidocaine 5% patch over Resident 19's left knee. Review of Resident 19's Order Summary Report showed a physician's order dated 6/25/23, to apply lidocaine patch 5% to the right knee topically every 12 hours, to apply in AM and remove at bedtime. On 8/23/23 at 1040 hours, an interview and concurrent medical record review was conducted with LVN 5. When asked regarding the patch removed from Resident 19's left knee, LVN 5 verified the old lidocaine patch on Resident 19's left knee should have been removed on 8/22/23 at 2100 hours. When asked regarding the lidocaine patch applied to Resident 19's left knee, LVN 5 acknowledged the lidocaine patch was not administered to Resident 19 as ordered by the physician. On 8/23/23 at 1625 hours, an interview and concurrent record review was conducted with the DON. The DON was made aware Resident 19's old lidocaine patch was on the left knee, and the new lidocaine patch was applied to Resident 19's left knee. The DON acknowledged the lidocaine patch was not administered to Resident 19 as ordered by the physician. 4. Medical Record review for Resident 18 was initiated on 8/23/23. Resident 18 was admitted to the facility on [DATE]. On 8/23/23 at 1433 hours, a medication administration observation was conducted with LVN 9. LVN 9 was observed preparing and administered the following medications: - acetaminophen (pain reliever) 325 mg two tablets, - oyster shell calcium 250 mg plus Vitamin D 3.1 mcg (supplement) one tablet, - Optinex (Lactobacillus Acidophilus and Bulgaris probiotic) one tablet, - docusate sodium (stool softener) 100 mg one tablet, and - Eliquis 5mg (anticoagulant) one tablet. Review of Resident 18's Order Summary Report showed a physician's order dated 8/4/23, to administer Culturelle (Lactobacillus Rhamnosus probiotic) one capsule by mouth two times a day and calcium carbonate-Vitamin D with minerals (supplement) one tablet by mouth two times a day. On 8/22/23 at 1722 hours, an interview and concurrent medical record review was conducted with LVN 9. LVN 9 verified the physician's order for Resident 18's Culturelle and calcium carbonate-vitamin D with minerals and the supplements were administered to Resident 18. LVN 9 acknowledged Resident 18 was not provided with supplements as ordered by the physician. LVN 9 verified the Medication Cart B did not contain the supplies for Resident 18's Culturelle and calcium carbonate-Vitamin D with minerals supplement. On 8/22/23 at 1745 hours, an interview was conducted with LVN 2. When asked if the Medication Cart A had supplies for Culturelle and calcium carbonate-Vitamin D with minerals, LVN 2 verified Medication Cart A did not contain supplies of Culturelle and calcium carbonate-Vitamin D with minerals supplement. On 8/23/23 at 1152 hours, an interview and concurrent medical record review was conducted with LVN 12. LVN 12 verified the calcium carbonate-Vitamin D with minerals and Culturelle supplements were administered to Resident 18 at 0900 hours. When asked what supplements were provided to Resident 18, LVN 12 showed a bottle for Optinex probiotic, calcium carbonate 500 mg, and Vitamin D 25 mcg. LVN 12 was made aware of Resident 18's supplements orders and acknowledged Resident 18 was not provided with supplements as ordered by the physician. LVN 12 verified Medication Cart B did not contain the supplies for Resident 18's Culturelle and calcium carbonate-Vitamin D with minerals supplement. On 8/23/23 at 1429 hours, an interview was conducted with the Central Supply Manager. The Central Supply Manager did not recall ordering Culturelle and calcium carbonate-Vitamin D with minerals supplements. On 8/23/23 at 1625 hours, an interview was conducted with the DON. The DON was made aware of Resident 18's physician order for Culturelle and calcium carbonate-vitamin D with minerals dated 8/4/23. The DON verified Resident 18's Culturelle and calcium carbonate-Vitamin D with minerals supplements were not ordered from the pharmacy. The DON acknowledged Resident 18's Culturelle and calcium carbonate-Vitamin D with minerals supplies should have been ordered and administered as ordered by the physician. Cross reference to F755. 5. On 8/4/23 at 1340 hours, an interview with Resident 9's RP was conducted. The RP stated on 7/28/23 at around 0600 hours, Resident 9 requested a staff to check her disposable underwear because she thought she might be soiled. Resident 9's RP stated Resident 9 requested to be sent to the hospital because Resident 9 felt she was having a lot of blood loss coming from her perineal area. Resident 9's RP further stated Resident 9 was transported to her dialysis center with a towel across her lap. The RP stated on arrival to the dialysis center, Resident 9 was observed with her disposable underwear soaked with blood. Resident 9 was then transferred to the acute care hospital for evaluation. Resident 9's RP stated Resident 9 suffered blood loss requiring a blood transfusion, and was diagnosed with hemorrhoids. On 8/4/23, closed medical record review for Resident 9 was initiated. Resident 9 was readmitted to the facility on [DATE], and discharged on 7/28/23. Resident 9's diagnoses included chronic anemia, end stage kidney disease, and on hemodialysis. Review of Resident 9's progress notes showed an SBAR dated 7/28/23 at 0730 hours, showed Resident 9 was observed with bright red blood coming from her vaginal area. Further review of the SBAR failed to show any physician's recommendations for this change in condition. Review of Resident 9's progress notes showed a note dated 7/28/23, 0828 hours, the dialysis center had contacted the facility to report Resident 9 was transferred to the acute care hospital for evaluation of Resident 9's vaginal bleeding. Review of Resident 9's dialysis note dated 7/28/23, showed Resident 9 was transferred to the acute care hospital for evaluation of Resident 9's diaper soaked with blood. On 8/16/23 at 0821 hours, an interview was conducted with Dialysis Center RN 1. When asked about Resident 9's condition on 7/28/23, RN 1 stated the resident requested a staff to check her disposable diaper for blood. RN 1 stated Resident 9's disposable underwear was observed soaked with blood and was transferred to the acute care hospital for further evaluation due to Resident 9 could not receive dialysis treatment in her present condition. On 8/16/23 at 1504 hours, an interview was conducted with LVN 7. When asked about Resident 9 on 7/28/23, LVN 7 stated Resident 9's assigned CNA reported that Resident 9 had blood on her disposable diaper. LVN 7 stated a change in condition was completed for Resident 9's vaginal bleeding. When asked if she received any physician's order for Resident 9's change in condition, LVN 7 verified she did not receive any physician's order. When asked about Resident 9 going to the dialysis without any physician's order related to Resident 9's change in condition, LVN 7 could not explain. When asked if she (LVN 7) notified Resident 9's dialysis center of Resident 9's vaginal bleeding, LVN 7 stated she did not notify the dialysis center about Resident 9's change in condition. 6. Review of the facility's P&P titled Medication Administration dated October 2017 showed medications are administered in accordance with written orders of the attending physician. Review of the facility's P&P titled Medication Administration dated October 2017 showed medications are administered in accordance with written orders of the attending physician. Medical record review for Resident 21 was initiated on 8/23/23. Resident 21 was admitted to the facility on [DATE], and readmitted on [DATE]. Resident 21 was admitted with a diagnosis of congestive heart failure (a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply) and atrial fibrillation (abnormal heartbeat). Review of Resident 21's History and Physical Examination dated 5/18/23, showed Resident 21 had no capacity to understand and make decisions. a. On 8/23/23 at 0839 hours, a medication administration observation and concurrent interview was conducted with LVN 1. During the medication administration observation, LVN 1 was asked if Resident 21 would be receiving her potassium chloride medication, LVN 1 stated Resident 21's potassium chloride bubble pack was empty, and she needed to call the pharmacy after medication administration. LVN 1 added she worked yesterday, 8/22/23, and she recalled not giving Resident 21 her potassium chloride since the potassium chloride bubble pack was empty. Review of Resident 21's empty potassium chloride bubble pack showed a fill date of 7/7/23, with the quantity of 30 tablets. Review of Resident 21's Order Audit Report for potassium chloride showed the bubble pack was dispensed on 7/8/23. Review of Resident 21's Order Summary Report for August 2023 showed an order dated 3/23/22, to administer potassium chloride extended release 10 meq two tablet by mouth. Review of the Medication Administration Record for August 2023 showed LVN 1 gave Resident 21 potassium chloride extended release 10 meq two tablet by mouth on 8/22/23. Review of the facility's Emergency Kit Pharmacy Log for August 2023 failed to show LVN 1 obtained potassium chloride from the emergency kit for Resident 21 on 8/22/23. On 8/23/23 at 1035 hours, a follow-up interview and medical record review was conducted with LVN 1. LVN 1 acknowledged and verified she was not able to give Resident 21's potassium chloride on 8/22/23; however, she signed Resident 21's MAR indicating she administered the medication. LVN 1 also stated it was a mistake on her behalf and she shouldn't have documented as administered when it was not given to the resident. On 8/23/23 at 1615 hours, an interview and concurrent facility document review was conducted with the DON. The DON reviewed Resident 21's Order Audit Report and empty potassium chloride bubble pack. The DON acknowledged the nurses should have reordered the potassium chloride medication on 8/7/23, 30 days after it was reordered on 7/7/23, and dispensed on 7/8/23, with 30 tablets. When asked where the nurses got the medication to administer to Resident 21 if the current potassium chloride bubble pack was dispensed last 7/8/23, with 30 tablets and should have been exhausted since 8/7/23, the DON stated she needed to investigate further and interview the staff. On 8/24/23 at 1400 hours, a follow-up interview and concurrent facility record review was conducted with the DON. The DON was unable to provide documentation to show Resident 21's potassium chloride was reordered after the medication bubble pack was exhausted on 8/7/23, or any documentation to show the nurses had obtained Resident 21's potassium chloride from the emergency kit. Cross reference to F842, example #3. b. On 8/23/23 at 0839 hours, a medication administration observation and concurrent interview was conducted with LVN 1. LVN 1 was observed putting aside Resident 21's digoxin and amiodarone medications without removing the medication tablet from the bubble pack. LVN 1 stated Resident 21's heart rate was 60 bmp so she will held and not give both digoxin and amiodarone. Review of Resident 21's Order Summary Report for August 2023 showed the following physician's orders: - an order dated 3/23/22, to administer amiodarone hydrochloride (antiarrhythmics) 200 mg one tablet by mouth. Hold if heart rate less than 60 bpm; - an order dated 3/28/22, to administer digoxin (antiarrhythmics) 125 mcg one tablet by mouth every Monday, Wednesday, Friday. Hold if apical pulse (a pulse point on your chest at the bottom tip of your heart) below 60 bpm; Review of Resident 21's MAR dated August 2023 showed the following: - on 8/23/23, digoxin 125 mcg was withheld when the pulse was 60 bpm. - on 8/23/23, amiodarone hydrochloride 200 mg was withheld when the pulse was 60 bpm. Resident 21's digoxin and amiodarone hydrochloride were not administered as ordered. On 8/23/23 at 1035 hours, an interview and concurrent medical record review was conducted with LVN 1. When asked if LVN 1 should have given Resident 21 her digoxin and amiodarone medications, LVN 1 stated no, since Resident 21's heart rate was 60 bpm and the order was not to give if below 60 bpm, so she did not give the medications. LVN 1 was asked to read the parameters for both the digoxin and amiodarone orders. When asked again if 60 beats per minute was below 60, LVN 1 did not answer. On 8/23/23 at 1615 hours, an interview and concurrent medical record review was conducted with the DON. The DON acknowledged the above findings and stated the nurse should still have given the medications and to hold the medications only if the resident's heart rate was 59 bpm and below.

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services to two of five sampled residents (Resident 4 and 6). * The facility failed to document the assessment of Resident 4 after the fall. This failure had the potential for resident care not met as the resident documentation of assessment and immediate intervention was incomplete. * The facility failed to complete the neurological assessment following an unwitnessed fall for Resident 6. This failure had the potential to delay the detection and response to changes in resident's neurological status post fall. Findings: Review of the facility's P&P titled Fall Prevention Program revised 12/19/22, showed the following: - fall interventions include but not limited to monitor for changes in resident's cognition, gait, ability to rise/sit, and balance and monitor vital signs in accordance with facility policy. - when any resident experiences a fall, the facility will assess the resident, complete a post-fall assessment, and document all assessment and actions. 1. Medical record review for Resident 4 was initiated on 7/28/23. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's Order Summary Report showed a physician's order dated 7/25/23, to transfer Resident 4 via 911 for further evaluation and treatment due to status post unwitnessed fall. Review of Resident 4's medical record failed to show the documentation of post fall assessment and the immediate interventions provided to Resident 4 after fall. On 8/9/23 at 1420 hours, an interview and concurrent record review was conducted with LVN 5. When asked if Resident 4 was assessed and immediate interventions were provided to Resident 4 post fall, LVN 5 was unable to show the documentation of assessment and immediate intervention provided to Resident 4 prior to sending Resident 4 to the acute care hospital. On 8/22/23 at 1506 hours, an interview was conducted with the DON. The DON was made aware of no documentation of an assessment and immediate interventions post fall in Resident 4's medical record. The DON acknowledged Resident 4's post fall assessment and immediate interventions should have been documented in Resident 4's medical record. 2. Medical record review for Resident 6 was initiated on 7/28/23. Resident was admitted to the facility on [DATE]. Review of Resident 6's Change of Condition Evaluation dated 5/18/23, showed Resident 6 had a fall. Review of Resident 6's Interdisciplinary Care Conference dated 5/18/23, showed Resident 6 had an unwitnessed fall and the IDT (Interdisciplinary Team) recommended neurologic monitoring. Review of Resident 6's Neurological Flowsheet initiated on 5/18/23, failed to show the complete documentation of Resident 6's neurological status. On 8/3/23 at 1428 hours, and interview and concurrent record review was conducted with LVN 1. LVN 1 verified Resident 6's Neurological Flowsheet post fall was incomplete. On 8/22/23 at 1506 hours, an interview was conducted with the DON. The DON was made aware Resident 6's Neurological Flowsheet post fall was incomplete. The DON acknowledged Resident 6's neurologic monitoring post fall should have been completed.

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the pharmaceutical services to meet the needs of three of 21 sampled residents (Residents 16, 18, and 21). * The facility failed to ensure Residents 16 and 21 was administered the correct dosage of medication as prescribed by the physician. * The facility failed to administer the Culturelle (probiotic supplement) and calcium carbonate-vitamin D with minerals (supplement) to Resident 18 as ordered by the physician. These failures had the potential to negatively affect the residents' health conditions. Findings: According to the facility's P&P titled Medication Administration dated October 2017 under the section Preparation showed prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in direction or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. The Administration section showed, medications are administered in accordance with written orders of the attending physician. 1. Medical record review for Resident 16 was initiated on 8/22/23. Resident 15 was admitted to the facility on [DATE], and readmitted on [DATE]. On 8/22/23 at 1613 hours, a medication administration observation was conducted with LVN 2. During the medication administration observation, LVN 2 administered the following medications due at 1700 hours to Resident 16: - sucralfate (medication to treat and prevent duodenal ulcers) one gram by mouth; - senna plus: docusate sodium 50 mg with sennoside 8.6 mg (stool softener) one tablet by mouth; - milk of magnesia (medication to treat constipation) 15 ml by mouth. Review of Resident 16's Order Summary Report for August 2023 showed an order dated 8/1/23, to administer senna 8.6 mg one tablet by mouth two times a day. On 8/22/23 at 1703 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 verified she administered a combination of docusate sodium and senna instead of senna 8.6 mg. On 8/23/23 at 1615 hours, the DON was informed and acknowledged the above findings. 2. Medical record review for Resident 21 was initiated on 8/23/23. Resident 21 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 21's History and Physical Examination dated 5/18/23, showed Resident 21 had no capacity to understand and make decisions. On 8/23/23 at 0839 hours, a medication administration observation was conducted with LVN 1. During the medication administration observation, LVN 1 administered the following medications due at 0900 hours to Resident 21: - sertraline hydrochloride (antidepressant) 25 mg one tablet by mouth; - apixaban (blood thinner) 5 mg one tablet by mouth; - furosemide 40 mg one tablet by mouth; - aspirin chewable (medication to help lower risk of a heart attack, stroke or blood clot) 81 mg one tablet by mouth; - cyanocobalamin (supplement) 500 mcg two tablets by mouth; - docusate sodium (stool softener) 100 mg one tablet by mouth; - ferrous sulfate (medication to treat or prevent low levels of iron in the blood) 325 mg one tablet by mouth; - multivitamin with minerals (supplement) one tablet by mouth; - acetaminophen (pain reliever and fever reducer) 325 mg two tablets by mouth; - ascorbic acid oral tablet (supplement) 250 mg two tablets by mouth; - levetiracetam sodium 100 mg/ml (medication to treat seizures) 7.5 ml by mouth; - lactulose (medication to treat constipation or treat high ammonia levels) solution 10 gm/15 ml, 30 ml by mouth; - calcium 600 mg with cholecalciferol 400 iu (supplement) two tablets by mouth; - pro-stat liquid (protein supplement) 30 ml by mouth; - digoxin was held and not given - amiodarone was held and not given - potassium chloride extended release not given due to the medication being unavailable Review of Resident 21's Order Summary Report for August 2023 showed the following physician's order: - an order dated 5/7/22, to administer calcium-cholecalciferol 250-125 mg two tablets by mouth. - an order dated 8/17/23, to administer furosemide 40 mg 0.5 tablet by mouth. On 8/23/23 at 1035 hours, a follow-up interview and concurrent medication cart inspection and medical record review was conducted with LVN 1. LVN 1 verified and acknowledged she gave Resident 21 calcium 600 mg with cholecalciferol 400 international units instead of calcium 250 with cholecalciferol 25 iu and furosemide 40 mg instead of 20 mg. On 8/24/23 at 1400 hours, the DON was informed and verified the above findings. Cross reference to F761. 3. Medical Record review for Resident 18 was initiated on 8/23/23. Resident 18 was admitted to the facility on [DATE]. On 8/23/23 at 1433 hours, a medication administration observation was conducted with LVN 9. LVN 9 was observed preparing and administered the following medications: - acetaminophen (pain reliever) 325 mg two tablets, - oyster shell calcium 250 mg plus Vitamin D 3.1 mcg (supplement) one tablet, - Optinex (Lactobacillus Acidophilus and Bulgaris probiotic) one tablet, - docusate sodium (stool softener) 100 mg one tablet, and - Eliquis 5 mg (anticoagulant) one tablet. Review of Resident 18's Order Summary Report showed a physician's order dated 8/4/23, to administer Culturelle (Lactobacillus Rhamnosus probiotic) one capsule by mouth two times a day and calcium carbonate-Vitamin D with minerals (supplement) one tablet by mouth two times a day. On 8/22/23 at 1722 hours, an interview and concurrent medical record review was conducted with LVN 9. LVN 9 verified the physician's order for Resident 18's Culturelle and calcium carbonate-vitamin D with minerals and the supplements administered to Resident 18. LVN 9 acknowledged Resident 18 was not provided with the supplements as ordered by the physician. On 8/23/23 at 1152 hours, an interview and concurrent review of medical records was conducted with LVN 12. LVN 12 verified the calcium carbonate-Vitamin D with minerals and Culturelle supplements were administered to Resident 18 at 0900 hours. When asked what supplements were provided to Resident 18, LVN 12 showed the bottles for Optinex probiotic, calcium carbonate 500 mg, and Vitamin D 25 mcg. LVN 12 was made aware of Resident 18's supplements orders and LVN 12 acknowledged Resident 18 was not provided with supplements as ordered by the physician. On 8/23/23 at 1625 hours, an interview was conducted with the DON. The DON was made aware of the Culturelle and calcium carbonate-Vitamin D with minerals provided to Resident 18. The DON acknowledged Resident 18's Culturelle and calcium carbonate-Vitamin D with minerals should have been administered as ordered by the physician. Cross reference to F684, example #4.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure two of five sampled residents (Resident 4 and 7) were free from unnecessary drugs. * The facility failed to ensure Resident 4's midodrine HCL (medication to treat low blood pressure) was administered as per the physician's order parameter. * The facility failed to ensure Resident 7's Cardizem (medication to treat high blood pressure) and carvedilol (medication to treat high blood pressure) was administered as per the physician's order parameter. These failures had the potential for the residents to receive unnecessary medication and develop significant side effects from errors in medication administration. Findings: 1. Medical record review for Resident 4 was initiated on 7/28/23. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's Order Summary Report showed a physician's order dated 7/6/23, to administer midodrine HCL 2.5 mg one tablet by mouth three times a day hold for SBP greater than 110 mmHg. Review of Resident 4's August 2023 MAR showed Resident 4 received midodrine medication with the SBP above 110 mmHg as follows: - SBP of 127 mmHg at 0900 hours and 1300 hours on 7/7/23, - SBP of 124 mmHg at 1300 hours on 7/9/23, - SBP of 122 mmHg at 1300 hours on 7/10/23, - SBP of 128 mmHg at 1300 hours on 7/11/23, and - SBP of 126 mmHg at 1700 hours on 7/19/23. In addition, the midodrine medication was not administered on 7/20/23 at 1700 hours, when the resident's SBP was 101 mmHg. On 8/10/23 at 1500 hours, an interview and concurrent medical record review was conducted with LVN 5. LVN 5 verified Resident 4's physician order and July 2023 MAR for midodrine HCL and acknowledged Resident 4's midodrine HCL was not administered as per the physician's order parameter. ON 8/22/23 at 1506 hours, an interview and concurrent record review was conducted with the DON. The DON was made aware of Resident 4's midodrine HCL medication administration and acknowledge Resident 4's midodrine HCL medication should be administered based on the physician's order parameter. 2. Medical record review for Resident 7 was initiated on 8/9/23. Resident 7 was admitted to the facility on [DATE]. Review of Resident 7's Order Summary Report showed a physician's order dated 5/10/23, to administer Cardizem 60 mg one tablet via GT every eight hours hold if SBP less than 110 mmHg or pulse less than 65 bpm and carvedilol 25 mg one tablet via GT two times a day hold if SBP less than 110 mmHg or pulse less than 65 bpm. Review of Resident 7's May 2023 MAR showed Resident 7's Cardizem medication was administered with the following SBP less than 110 mmHg: - SBP of 99 mmHg at 1700 hours on 5/11/23; - SBP of 106 mmHg at 0600 hours on 5/13/23; - SBP of 105 mmHg at 0600 hours and SBP of 100 at 1400 hours on 5/19/23; - SBP of 100 at 0900 hours, 100 mmHg at 1400 hours, and 102 mmHg at 1700 hours on 5/20/23; - SBP of 101 mmHg at 0600 hours on 5/26/23; - SBP of 99 mmHg at 0600 hours and 109 mmHg at 1700 hours on 5/27/23; - SBP of 107 mmHg at 2200 hours on 5/28/23; - SBP of 102 mmHg at 1700 hours on 5/29/23; and - SBP of 98 mmHg at 0600 hours on 5/31/23. In addition, the Cardizem medication was not administered as follows: - on 5/16/23 at 1400 hours, with SBP of 115 mmHg - on 5/17/23 at 0900 hours, with SBP of 116 mmHg - on 5/29/23 at 2200 hours, with SBP of 135 mmHg On 8/22/23 at 0949 hours, an interview and concurrent medical record review was conducted with LVN 10. LVN 10 verified Resident 7's physician order and May 2023 MAR for Cardizem and carvedilol and acknowledged Resident 7's Cardizem and Carvedilol were not administered based on the physician's order parameter. ON 8/22/23 at 1506 hours, an interview and concurrent record review was conducted with the DON. The DON was made aware of Resident 7's Cardizem and carvedilol medication administration and acknowledged Resident 7's Cardizem and carvedilol medication should be administered based on the physician's order parameter.

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of five sampled residents (Resident 4) was free from significant medication errors. * The facility failed to ensure Resident 4's metolazone (water pill) was ordered based on Resident 4's discharge instruction from the hospital. This failure had the potential to negatively impact the resident's well-being. Findings: Review of the facility's P&P titled admission of a Resident revised 12/19/22, showed residents are admitted to the facility under orders of the attending physician. Medical record review for Resident 4 was initiated on 7/28/23. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's Order Summary Report showed a physician's order dated 7/6/23, to administer metolazone 5 mg one tablet by mouth every Wednesday and Saturday. Review of Resident 4's Skilled Nursing Facility Transfer Orders from the hospital printed on 7/6/23 at 1438 hours, showed an order for metolazone 5 mg one tablet by mouth twice a week on Wednesday and Saturday. However, review of Resident 4's July 2023 MAR showed Resident 4's metolazone 5mg one tablet was scheduled to be administered twice a day at 0900 and 1700 hours on Wednesdays and Saturdays. Resident 4's July 2023 MAR further showed metolazone was administered twice a day as follows: - at 0900 and 1700 hours on 7/8/23 (Saturday), - at 0900 hours, and refused at 1700 hours on 7/12/23 (Wednesday), - at 0900 and 1700 hours on 7/15/23 (Saturday), - at 0900 and 1700 hours on 7/19/23 (Wednesday), and - at 0900 and 1700 hours on 7/22/23 (Saturday). Review of Resident 4's Order Administration Note dated 7/12/23, showed a documentation for Resident 4's metolazone 5 mg as follows: offered three times, explained the risks and benefits, the resident stated already taking medication in the morning; and Resident 4 refused three times. On 8/4/23 at 1536 hours, an interview was conducted with LVN 4. When asked regarding Resident 4's metolazone medication, LVN 4 verified the attempt to administer Resident 4's metolazone medication on 7/12/23 at 1700 hours, but Resident 4 refused. On 8/9/23 at 1528 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 verified Resident 4's hospital discharge order for metolazone 5 mg one tablet by mouth twice a week on Wednesday and Saturday. LVN 2 acknowledged Resident 4's metolazone medication was administered twice a day on Wednesdays and Saturdays as documented in Resident 4's July 2023 MAR. When asked if metolazone was supposed to be given twice a day on Wednesday and Saturday based on Resident 4's acute care hospital discharge order, LVN 2 stated no. On 8/24/23 at 1346 hours, an interview and concurrent facility document review was conducted with the DON. The DON verified discrepancies in Resident 4's metolazone documentation but acknowledged Resident 4 received the metolazone medication twice a day which resulted in significant medication error.

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

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Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure Residents 21's furosemide (a diuretic medication to help reduce the amount of excess fluid in the body by increasing the amount of urine produced) medication was removed from the medication cart and disposed of when the furosemide medication order was discontinued and changed by the physician. This failure resulted in LVN 1 administering twice the dose of furosemide, which had the potential to negatively affect Resident 21's health condition. Findings: According to the facility's Policy and Procedure titled Medication Storage revised 12/19/22, under the section Policy, showed it is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. The Policy Explanation and Compliance Guidelines section showed for unused medications, the pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn, illegible, or missing labels. These medications are destroyed in accordance with facility policy. On 8/23/23 at 0839 hours, a medication administration observation was conducted with LVN 1. During the medication administration observation, LVN 1 administered the following medications due at 0900 hours to Resident 21: - sertraline hydrochloride (antidepressant) 25 mg one tablet by mouth; - apixaban (blood thinner) 5 mg one tablet by mouth; - furosemide 40 mg one tablet by mouth; - aspirin chewable (medication to help lower risk of a heart attack, stroke or blood clot) 81 mg one tablet by mouth; - cyanocobalamin (supplement) 500 mcg two tablets by mouth; - docusate sodium (stool softener) 100 mg one tablet by mouth; - ferrous sulfate (medication to treat or prevent low levels of iron in the blood) 325 mg one tablet by mouth; - multivitamin with minerals (supplement) one tablet by mouth; - acetaminophen (pain reliever and fever reducer) 325 mg two tablets by mouth; - ascorbic acid oral tablet (supplement) 250 mg two tablets by mouth; - levetiracetam sodium 100 mg/ml (medication to treat seizures) 7.5 ml by mouth; - lactulose (medication to treat constipation or treat high ammonia levels) solution 10 gm/15 ml, give 30 ml by mouth; - calcium 600 mg with cholecalciferol 400 international units (supplement) two tablets by mouth; - pro-stat liquid (protein supplement) 30 ml by mouth; - digoxin was held and not given - amiodarone was held and not given - potassium chloride extended release not given due to the medication being unavailable Review of Resident 21's Order Summary Report for the month of August 2023 showed an order dated 8/17/23, to administer furosemide 40 mg give 0.5 tablet by mouth two times a day. Review of Resident 21's Medication Administration Record (MAR) for August 2023 showed the following: - a discontinued date on 8/17/23, for furosemide 40 mg give 1 tablet by mouth two times a day; - a start date on 8/17/23, for furosemide 40 mg give 0.5 tablet (20 mg) by mouth two times a day. On 8/23/23 at 1035 hours, a follow-up interview and concurrent medication cart inspection and medical record review was conducted with LVN 1. When LVN 1 was asked to read Resident 21's furosemide order and MAR, then inspect Resident 21's furosemide medication bubble pack (a package used to dispense medications), LVN 1 verified Resident 21's furosemide medication order and MAR did not match Resident 21's furosemide medication bubble pack. LVN 1 also stated the order was changed from 40 mg to 20 mg on 8/17/23; however, the fill date on the furosemide medication bubble pack showed 8/15/23. LVN 1 verified and acknowledged she gave Resident 21 furosemide 40 mg instead of 20 mg. On 8/24/23 at 1400 hours, when asked what the process was for change in order and discontinued medications, the DON acknowledged the above findings and stated the pharmacy should have delivered a new bubble pack reflecting the new orders, the nurses should have applied a change of direction sticker on the bubble pack, or the bubble pack should have been pulled out from the medication cart and discontinued. Cross reference to F755, example #2.

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

Laboratory Services (Tag F0770)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the laboratory test for one of the five sampled residents (Resident 4) was ordered. * The facility failed to clarify the order for BMP test as per Resident 4's hospital discharge order with the admitting physician. This failure posed a risk for undetected blood test abnormality that could significantly impact the resident's well-being. Findings: Review of the facility's P&P titled Laboratory Services and Reporting revised 12/19/22, showed the facility must provide or obtain laboratory services to meet the needs of its residents. Medical record review for Resident 4 was initiated on 7/28/23. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's Skilled Nursing Facility Transfer Orders from the hospital printed 7/6/23 at 1438 hours, showed a laboratory order for BMP every other day for diagnosis of CKD (Chronic Kidney Disease). Review of Resident 4's medical record failed to show the physician's order and/or laboratory test result for the BMP test for Resident 4 while residing at the facility. On 8/9/23 at 1528 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 verified the laboratory order for BMP to be done every other day for Resident 4 in the hospital's discharge order. LVN 2 verified Resident 4's medical record failed to show the physician's order and/or laboratory test result of BMP for Resident 4. On 8/9/23 at 1610 hours, an interview and concurrent record review was conducted with RN 1. RN 1 verified the laboratory order for BMP to be done every other day for Resident 4 in the hospital's discharge order. When asked if the admitting physician gave an order for the BMP test to be done on Resident 4, RN 1 acknowledged she failed to verify the hospital's discharge order for BMP with Resident 4's admitting physician.

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 F0836 (Tag F0836)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure compliance with state laws for one of 11 sampled residents (Resident 8) as evidenced by: * Resident 8's death certificate was not signed within the required time frame. This failure resulted in a delay in obtaining Resident 8's death certificate and a delay in arranging for funeral services. Findings: The Health and Safety Code Div. 102, Chapter 6, Article 1, section 102800, a death certificate shall be completed and submitted to the deceased 's funeral home within 15 hours after death. On [DATE] at 0917 hours, an interview with Resident 8's RP was conducted. The RP stated the facility delayed in providing Resident 8's death certificate to the funeral home. Resident 8's RP stated it took about one week to obtain the signed death certificate from the facility that resulted in Resident 8's burial being delayed. On [DATE], closed medical record review was initiated for Resident 8. Resident 8 had expired at the facility on [DATE]. Review of Resident 8's death certificate showed the certificate was signed by Resident 8's physician on [DATE]. On [DATE] at 1417 hours, an interview was conducted with Resident 8's funeral home Family Counselor 1. Family Counselor 1 stated he electronically faxed Resident 8's death certificate to the facility for Resident 8's physician to sign. Per the Family Counselor, he faxed the request to the facility on 7/24, 7/25, 7/26, and [DATE]. On [DATE] at 1507 hours, an interview was conducted with the Administrator. The Administrator stated all electronic faxes were deleted daily once read. When asked about the faxes received from Resident 8's funeral home, the Administrator stated the facility received a fax from Resident 8's funeral home on either [DATE] or [DATE]. On [DATE], at 1145 hours, concurrent interview and closed medical record review was conducted with the DON. The DON verified Resident 8's funeral home successfully electronically faxed Resident 8's death certificate paperwork to be signed by Resident 8's physician on 7/24 and [DATE]. The DON was unable to explain what happened to these electronic faxes that were successfully sent to the facility on 7/24 and [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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review the facility failed to ensure the medical record accuracy for two of 21 sampled residents (Residents 4 and 21). * The facility failed to ensure the documentation of Resident 4's pacemaker malfunction monitoring was accurate. In addition, the facility failed to ensure the documentation of Resident 4's Covid-19 rapid test results was timely and accurate. * Resident 21's MAR showed one medication was inaccurately documented as administered on 8/22/23 at 0900 hours. These failures had the potential for the residents' care needs not being met as Residents 4 and 21's medical information were inaccurate. Findings: Review of the facility's P&P titled Documentation in Medical Record revised 12/19/22, showed documentation should be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. 1. Medical record review for Resident 4 was initiated on 7/28/23. Resident 4 was admitted to the facility on [DATE]. a. Review of Resident 4's Order Summary Report showed a physician's order dated 7/6/23, to monitor the apical pulse and BP every shift daily for the pacemaker use. Review of Resident 4's Order Summary Report further showed a physician's order dated 7/6/23, to observe/report signs and symptoms of pacemaker malfunction i.e. (that is) pulse less than 60 bpm, SBP less than 90 mmHg, DBP less than 60 mmHg, and/or resident becomes symptomatic: SOB (short of breath), chest pain, dizziness, ALOC (altered level of consciousness), and hypotension every shift. If symptomatic indicate plus sign (+/plus) if asymptomatic indicate (-/negative). Review of Resident 4's July 2023 Monitor Record showed the following: - pulse of 58 bpm on 7/13/23, the morning shift, - pulse of 56 bmp on 7/14/23, the morning shift, - pulse of 58 bmp on 7/17/23, the morning shift, - pulse of 58 bmp and DBP of 56 mmHg on 7/23/23, the afternoon shift, and - pulse of 58 bpm on 7/24/23, the morning and afternoon shifts. Review of Resident 4's Monitor Record for July 2023 further showed under observe/report signs and symptoms of pacemaker malfunction documentation, it indicated asymptomatic (-) on 7/13, 7/14, 7/17, 7/23, and 7/24/23 for pulse less then 60 bpm and DBP less than 60 mmHg. On 8/23/23 at 1040 hours, an interview and concurrent record review was conducted with LVN 5. LVN 5 verified the documentation of Resident 4's pulse less then 60 bpm and DBP less than 60 mmHg, and the (-) documentation in Resident 4's signs and symptoms of pacemaker malfunction monitoring. LVN 5 acknowledged the documentation of Resident 4's monitoring for the signs and symptoms of pacemaker malfunction was not accurate. b. Review of the facility's P&P titled Coronavirus Prevention and Response revised 3/14/23, under section 22. Managing admissions and residents who leave the facility showed admission in counties where community transmission level is high should be tested upon admission; admission testing at lower levels of community transmission will be at the discretion of the facility. Testing is recommended at admission, and if negative, again at 48 hours after the first negative test, and if negative, again at 48 hours after the second negative test. Review of Resident 4's medical record failed to show Resident 4 was tested for Covid-19 virus. On 8/10/23 at 1357 hours, an interview and concurrent medical record review was conducted with the IP nurse. When asked if the facility had tested the residents for Covid-19 virus, the IP stated the facility performed a Covid-19 rapid test on the new residents upon admission (day one), day three, and day five. When asked to show Resident 4's documentation of Covid-19 rapid test, the IP nurse was unable to find the documentation of Resident 4's Covid-19 rapid test and the IP nurse further stated she would follow-up with the Medical Record Department. On 8/16/23 at 1415 hours, an interview and concurrent medical record review was conducted with the IP nurse. The IP nurse showed the documentation of Resident 4's negative results for Covid-19 Rapid Tests done on 7/6, 7/9, and 7/11/23. Further review of Resident 4's Progress Notes for Covid-19 Rapid Test dated 7/6, 7/9, and 7/11/23, showed a late entry documentation created on 8/16/23. On 8/24/23 at 1055 hours, a follow-up interview and record review was conducted with the IP nurse. When asked regarding Resident 4's Covid-19 Rapid Test results late entry created on 8/16/23, the IP nurse acknowledged making the late entry after the interview and concurrent record review conducted on 8/10/23. The IP nurse further stated she based Resident 4's negative results on the report provided by the nurses. When asked to show the report for Resident 4's Covid-19 Rapid Tests, the IP was not able to provide the document. 2. According to the facility's P&P titled Documentation in Medical Record revised 12/19/22, under the section Policy, showed each resident's medical record shall contain a representation of the experiences of the resident and include enough information to provide a picture of the resident's progress. The Policy Explanation and Compliance Guidelines section showed, documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care. Medical record review for Resident 21 was initiated on 8/23/23. Resident 21 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 21's History and Physical Examination dated 5/18/23, showed Resident 21 had no capacity to understand and make decisions. On 8/23/23 at 0839 hours, a medication administration observation and concurrent interview was conducted with LVN 1. During the medication administration observation, LVN 1 was asked if Resident 21 would be receiving her potassium chloride medication, LVN 1 stated Resident 21's potassium chloride bubble pack was empty, and she needed to call the pharmacy after medication administration. LVN 1 added she worked yesterday, 8/22/23, and she recalled not giving Resident 21 her potassium chloride since the potassium chloride bubble pack was empty. Review of Resident 21's empty potassium chloride bubble pack showing a fill date of 7/7/23, with the quantity of 30 tablets. Review of Resident 21's Order Audit Report for potassium chloride showed the bubble pack was dispensed on 7/8/23. Review of Resident 21's Order Summary Report for August 2023 showed an order dated 3/23/22, to administer potassium chloride extended release 10 meq two tablet by mouth. Review of the Medication Administration Record for August 2023 showed LVN 1 gave Resident 21 potassium chloride extended release 10 meq two tablet by mouth on 8/22/23. Review of the facility's Emergency Kit Pharmacy Log for August 2023 failed to show LVN 1 obtained potassium chloride from the emergency kit for Resident 21 on 8/22/23. On 8/23/23 at 1035 hours, a follow-up interview and medical record review was conducted with LVN 1. LVN 1 acknowledged and verified she was not able to give Resident 21's potassium chloride on 8/22/23; however, she signed Resident 21's MAR indicating she administered the medication. LVN 1 also stated it was a mistake on her behalf and she should not have documented as administered when it was not given to the resident. On 8/23/23 at 1615 hours, the DON was informed and verified the above findings. Cross reference to F684, example #6.

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and facility P&P review, the facility failed to maintain the effective infection control practices. * LVNs 1 and 2 failed to perform hand hygiene before donning and after doffing gloves during medication administration. This failure placed the residents and the staff at increased risk for infections. Findings: According to the facility's P&P titled Hand Hygiene revised 12/19/22 showed staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. Hand hygiene is indicated and will be performed under the conditions listed, but not limited to, after handling contaminated objects, before preparing or handling medications, before and after handling clean or soiled linens, before performing resident care procedures, and when in doubt. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. a. On 8/22/23 at 1619 hours, a medication administration observation was conducted with LVN 2. LVN 2 prepared Resident 16's medication then proceeded to Resident 16's room, performed hand hygiene, wore gloves, touched Resident 16's privacy curtain with gloved hands, closed Resident' 16's door with gloved hands, then went back to Resident 16 to administer Resident 16's medications wearing the same gloves. On 8/22/23 at 1632 hours, LVN 2 acknowledged the above findings and stated she should have changed her gloves and performed hand hygiene after touching Resident 16's privacy curtain and closing the door. b. On 8/23/23 at 0839 hours, a medication administration observation and concurrent interview was conducted with LVN 1. LVN 1 was observed checking Resident 21's blood pressure and heart rate. LVN 1 performed hand hygiene, wore gloves to clean the digital wrist blood pressure monitor, removed her gloves, and proceeded to open Medication Cart A and pick up Resident 21's medication bubble packs. After preparing Resident 16's medications in medication cups, LVN 1 proceeded to pick up the medication cups, went in Resident 16's room, put on gloves without performing hand hygiene. LVN 1 acknowledged the above findings and stated she should have performed hand hygiene before putting on gloves and after removing her gloves. On 8/23/23 at 1615 hours, the DON was informed and verified the above findings.

MINOR (B) 📢 Someone Reported This

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

Minor Issue - procedural, no safety impact

Deficiency F0583 (Tag F0583)

Minor procedural issue · This affected multiple residents

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Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the personal privacy for one of four nonsampled residents (Resident B). Resident B's PHI was left unattended on a computer screen showing the resident identifier information. This failure had the potential to negatively affect the dignity of the resident and violate Resident B's privacy. Findings: Review of the facility's P&P titled Confidentiality of Personal and Medical Records revised 12/19/22, showed this facility honors the resident's right to secure and confidential personal and medical records. This includes the right to confidentiality of all information contained in a resident's records, regardless of the form of storage or location of the record. Under section Policy Explanation and Compliance Guidelines showed, keep confidential is defined as safeguarding the content of information including written documentation, video, audio, or other computer stored information from unauthorized disclosure without the consent of the individual and/or the individual's surrogate or representative. During an observation on 8/22/22 at 1610 hours, a laptop computer on the medication cart was left open in front of Room A. The laptop computer screen faced the hallway where two other residents were observed, and displayed Resident B's personal information including diagnoses, allergy information, medication list, and picture. On 8/22/22 at 1612 hours, a concurrent observation and interview was conducted with LVN 2. LVN 2 verified the laptop computer was left unattended and showed Resident B's information. LVN 2 acknowledged the laptop computer should not be left unattended showing the resident identifier information because it was a privacy concern. On 8/23/23 at 1615 hours, the DON was informed and verified the above findings.

MINOR (B) 📢 Someone Reported This

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

Minor Issue - procedural, no safety impact

Comprehensive Care Plan (Tag F0656)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the care plan was implemented for one of five sampled residents (Resident 4). * The facility failed to implement the Covid-19 signs and symptoms monitoring interventions for Resident 4. This failure had the potential for the resident to not receive the necessary care and services. Findings: Review of the facility's P&P titled Comprehensive Care Plans revised 12/19/22, showed it is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and timeframes to meet a resident medical, nursing, and mental and psychological needs that are identified in the resident's comprehensive assessment and qualified staff responsible for carrying out interventions will be notified of their roles and responsibilities for carrying out the intervention, initially and when changes are made. Review of the facility's P&P titled Coronavirus Prevention and Response revised 3/14/23, showed the facility will respond promptly upon suspicion of illness associated with a SARS-CoV-2 infection in efforts to identify, treat, and prevent the spread of the virus and staff shall be alert to signs of Covid-19 and notify resident's physician if evident: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headaches, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea. Medical record review for Resident 4 was initiated on 7/28/23. Resident 4 was admitted to the facility on [DATE]. Review of Resident 4's Care Plan showed a care plan problem initiated on 7/7/23, addressing the risk of getting Covid-19 infection with the interventions included to monitor the resident for the following Covid-19 signs and symptoms: fever or chills, cough, shortness of breath, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea. Review of Resident 4's medical record failed to show Resident 4 was monitored for the above signs and symptoms of Covid-19. On 8/10/23 at 1357 hours, an interview and concurrent medical record review was conducted with the IP nurse. Resident 4's care plan interventions to monitor Resident 4 for the signs and symptoms of Covid-19 were reviewed with the IP nurse. When asked if Resident 4 was monitored, the IP nurse was unable to verify if Resident 4 was monitored for the signs and symptoms of Covid-19. The IP nurse stated Resident 4's medical record did not show a complete documentation of Covid-19 signs and symptoms monitoring. On 8/22/23 at 1506 hours, an interview and medical concurrent record review was conducted with the DON. The DON was made aware of Resident 4's care plan interventions to monitor Resident 4 for signs and symptoms Covid-19. The DON acknowledged Resident 4 should have been monitored for the signs and symptoms of Covid-19 as shown in the resident person-centered care plan interventions.

Aug 2023 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the pharmaceutical services were provided to meet the resident needs as evidenced by: * Resident 1 had been getting his as needed pain medication four to six times a day for over a month. Resident 1 ran out of his pain medication on 7/17/23. As a result, Resident 1 did not receive pain medication for three days. * Controlled medications signed out of the Controlled Drug Records that were administered and documented on the MAR were not consistent for three of three sampled residents (Residents 1, 2, and 3). * The discontinued non-controlled medications were destroyed by two licensed nurses as specified by the facility's P&P. These failures had the potential to result in the medication diversion, medication administration errors, and poor health outcomes to the residents. Findings: 1. Medical record review for Resident 1 was initiated on 8/1/23. Resident 1 was admitted to the facility on [DATE], and readmitted on [DATE]. Review of Resident 1's Order Summary Report showed a physician's order dated 7/12/23, to administer hydrocodone-acetaminophen 10-325 mg tablet (a combination opioid medication used to relieve moderate to severe pain), one tablet by mouth every four hours as needed for moderate to severe pain (pain level of 7-10) for 60 days. Review of Resident 1's MARs showed Resident 1 had been receiving hydrocodone-acetaminophen 10-325 mg for over three months. Review of the Controlled Drug Records showed hydrocodone-acetaminophen 10-325 mg had been signed out five to six times a day for Resident 1 since 6/30/23. Review of the Controlled Drug Record showed Resident 1 ran out of hydrocodone-acetaminophen 10-325 mg tablets on 7/17/23 at 0800 hours. Review of the resident's MAR for July 20223 showed Resident 1 did not receive hydrocodone-acetaminophen 10-325 mg tablet or any other pain medications for three days until 7/20/23 at 16645 hours, when hydrocodone-acetaminophen 10-325 mg tablets were delivered and signed out of the CDR. Review of Resident 1's pain assessment monitoring record showed no pain was documented every shift (three shifts a day) except for five shifts for the month of July 2023. Review of Resident 1's pain assessment monitoring record showed on 7/18/23, the resident's pain level was documented as 9 which was severe on the pain scale of 0 to 10 with 0 = no pain and 10 = severe pain. On 8/1/23 at 1533 hours, an interview was conducted with Resident 1. Resident 1 stated he had no problem receiving his medications. Resident 1 did not recall instances when he did not receive the pain medications when needed. During an interview on 8/1/23 at 1455 hours, LN 1 stated when a resident ran out of pain medication, the LNs called the pharmacy to get approval for the use of medications in the emergency kit. During an interview on 8/2/23 at 1003 hours, LN 1 did not recall anything about 7/18/23, including Resident 1's pain level and his pain medication. During an interview on 8/2/23 at 1012 hours, LN 2 stated Resident 1 regularly asked for hydrocodone-acetaminophen 10-325 mg every four hours. LN 2 stated they tried not to allow Resident 1's pain medication to run out. LN 2 could not recall Resident 1's hydrocodone-acetaminophen 10-325 mg tablet running out on 7/17/23, during her shift. If Resident 1 ran out of the pain medication, LN 2 would let the resident know and try to get the medication filled by the pharmacy. If the pain medication was running low, LN 2 would call the pharmacy for refill. If there was no refill, the LN would call the MD for order. During a concurrent interview and medical record review on 8/2/23 at 1245 hours, the DON verified Resident 1 did not have hydrocodone-acetaminophen 10-325 mg tablets for 3 days. 2. Review of the facility's P&P titled Medication Administration-General Guidelines dated 10/2017 showed the staff who administers the medication dose records the administration on the resident's MAR directly after the medication is given. At the end of each medication pass, the staff administering the medications will review the MAR to ensure the necessary doses were administered and documented. In no case should the staff who has administered the medication reports off-duty without first recording the administration of any medications. a. Medical record review for Resident 1 was initiated on 8/1/23. The resident was admitted to facility on 8/23/18, and readmitted on [DATE]. Review of Resident 1's Order Summary Report showed a physician's order dated 7/12/23, to administer hydrocodone-acetaminophen 10-325 mg tablet, one tablet by mouth every four hours as needed for moderate to severe pain (pain level of 7-10) for 60 days. Review of Resident 1's Controlled Drug Record for July 2023 showed hydrocodone-acetaminophen 10/325 mg tablets were removed from the bubble packs (the bubble package is a packaged container with 31 single-use dose compartments [i.e., bubbles] that can contain medications) on the following dates and times: - 7/1/23 at 0000, 0400, 0800, 1200, 1600, and 2000 hours, - 7/2/23 at 0000, 0400, 0800, 1200, 1600, and 2000 hours, - 7/3/23 at 0000, 0400, 0800, 1200, 1600, and 2000 hours, - 7/4/23 at 0000, 0800, 1200, 1600, and 2000 hours, - 7/5/23 at 0000, 0400, 0800, 1200, 1600, and 2000 hours, - 7/6/23 at 0000, 0400, 0800, 1200, 1600, and 2000 hours, - 7/7/23 at 0000, 0400, 0800, 1200, 1600, and 2000 hours, - 7/8/23 at 0000, 0400, 0800, 1200, 1600, and 2000 hours, - 7/9/23 at 0000, 0400, 0800, 1200, 1600, and 2000 hours, - 7/10/23 at 0000, 0400, 0800, 1200, 1600, and 2000 hours, - 7/11/23 at 0000, 0400, 0800, 1200, 1600, and 2000 hours, - 7/12/23 at 0000, 0400, 0800, 1200, 1600, and 2000 hours, - 7/13/23 at 0000, 0400, 0800, 1200, 1600, and 2000 hours, - 7/14/23 at 0000, 0400, 0800, 1200, 1600, and 2000 hours, - 7/15/23 at 0000, 0400, 0800, 1200, 1600, and 2000 hours, - 7/16/23 at 0000, 0400, 0800, 1200, and 2000 hours, - 7/17/23 at 0000, 0400, and 0800 hours, - 7/18/23, none was documented, - 7/19/23, none was documented, - 7/20/23 at 1645 and 2110 hours, - 7/21/23 at 0000, 0400, 0800, 1200, 1600, and 2000 hours, - 7/22/23 at 0000, 0400, 0800, 1200, 1600, and 2000 hours, - 7/23/23 at 0000, 0400, 0800, 1200, 1600, and 2000 hours, - 7/24/23 at 0000, 0400, 0800, 1200, 1600, and 2000 hours, - 7/25/23 at 0000, 0400, 0800, 1200, 1600, and 2000 hours, - 7/26/23 at 0000, 0400, 0800, 1200, 1600, and 2000 hours, - 7/27/23 at 0000, 0400, 0800, 1200, 1600, and 2000 hours, - 7/28/23 at 0000, 0400, 0800, 1200, 1600, and 2000 hours, - 7/29/23 at 0000, 0400, 1000, 1400, 1600, and 2000 hours, - 7/30/23 at 0000, 0400, 0800, 1200, 1600, and 2000 hours, and - 7/31/23 at 0000, 0400, 0800, 1200, 1600, and 2000 hours. However, review of Resident 1's MAR for July 2023 showed hydrocodone-acetaminophen 10/325 mg tablets were documented as administered only on the following dates and times: - 7/2/23 at 0800 hours, - 7/3/23 at 0800 and 1200 hours, - 7/4/23 at 0401 hours, - 7/5/23 to 7/11/23, none was documented, - 7/12/23 at 1600 and 2000 hours, - 7/13/23 at 1600 and 2000 hours, - 7/14/23 at 1600 and 2000 hours, - 7/15/23 at 1600 and 2005 hours, - 7/21/23 at 0800 and 1200 hours, - 7/24/23 at 1609 and 2040 hours, - 7/25/23 at 1609 and 2045 hours, - 7/26/23 at 1600 and 2000 hours, - 7/27/23 at 1600 and 2000 hours, - 7/28/23 at 1200, 1600, and 2014 hours, - 7/30/23 at 0800, 1600, and 2100 hours, and - 7/31/23 at 1559 hours. Review of the MAR and Controlled Drug Record for July 2023 showed hydrocodone-acetaminophen 10/325 mg tablets were removed 165 times from the Controlled Drug Records in July 2023; however, the administration was documented only 29 times. This may have resulted in a medication error on 7/29/23, when hydrocodone-acetaminophen 10/325 mg tablets were signed out of the Controlled Drug Record at 1400 and 1600 hours, two hours apart instead of every four hours as ordered by the physician. There was no documentation the two doses were administered. On 8/1/23 at 1615 hours, a concurrent interview and medical record review was conducted with the DON. The DON verified several hydrocodone-acetaminophen 10/325 mg tablets were signed out of Resident 1 controlled drug record but were not documented as administered on the MAR. b. Medical record review for Resident 2 was initiated on 8/1/23. Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's Order Summary Report showed a physician's order dated 7/20/23, to administer oxycodone hydrochloride tablet 20 mg (a semi-synthetic opioid analgesic used to treat moderate to severe pain), one tablet orally every four hours as needed for moderate to severe pain. Review of Resident 2's Controlled Drug Record for July 2023 showed oxycodone hydrochloride tablet 20 mg tablets were removed from the bubble packs on the following dates and times: - 7/21/23 at 0500, 0900, 1300, and 2100 hours, - 7/22/23 at 1030, 1440, and 2049 hours, - 7/23/23 at 1000, 1400, and 2100 hours, - 7/24/23 at 0100, 0500, 1000, and 2100 hours, - 7/25/23 at 0100, 1100, and 2100 hours, - 7/26/23 at 0500, 1045, and 2000 hours, - 7/27/23 at 0530, 1100, and 2100 hours, - 7/28/23 at 0400, 1030, 1430, and 2100 hours, - 7/29/23 at 0500, 0900, and 2000 hours, - 7/30/23 at 0500, and 1000 hours, and - 7/31/23 at 0100 and 1230 hours. However, review of Resident 2's MAR for July 2023 showed oxycodone hydrochloride 20 mg tablets were documented as administered only on the following dates and times: - 7/21/23 at 0500 hours, - 7/22/23 at 2049 hours, - 7/23/23, none was documented, - 7/24/23 at 2100 hours, - 7/25/23, none was documented, - 7/26/23, none was documented, - 7/27/23 at 0530 hours, - 7/28/23 at 0400 hours, - 7/29/23, none was documented, - 7/30/23 at 0500 hours, and - 7/31/23, none was documented. Review of the MAR and Controlled Drug Record for July 2023 showed oxycodone hydrochloride 20 mg tablets were removed from the bubble packs 34 times but was only documented as administered only six times. During an interview on 8/1/23 at 1524 hours, Resident 2 stated she has been receiving medications timely most of the time, but there had been problems with medications running out and not being refilled timely. Resident 2 stated it had been better lately and had been getting her pain medications regularly. On 8/1/23 at 1615 hours, a concurrent interview and medical record review was conducted with the DON. The DON verified several oxycodone hydrochloride 20 mg tablets were signed out of controlled drug record but were not documented as administered on Resident 2's Medication Administration. c. Medical record review for Resident 3 was initiated on 8/1/23. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's Order Summary Report showed a physician's order dated 6/4/23, to administer hydrocodone-acetaminophen oral tablet 10-325 mg, one tablet by mouth every six hours as needed for pain management. Review of Resident 3's Controlled Drug Record showed hydrocodone-acetaminophen 10/325 mg tablets were removed from the bubble packs on the following dates and times: - 7/17/23 at 1200 hours, - 7/18/23 at 0700 hours, and - 7/19/23 at 0600 hours. However, review of Resident 3's MAR for July 2023 showed no documented evidence oxycodone hydrochloride 20 mg tablets were administered on 7/17 to 7/19, 2023. During an interview on 8/1/23 at 1550 hours, Resident 3 stated she did not like hydrocodone-acetaminophen 10/325 mg tablets and refused to take the medications. Resident 3 stated she had not asked for any pain medication. On 8/1/23 at 1615 hours, a concurrent interview and medical record review was conducted with the DON. The DON verified three hydrocodone-acetaminophen 10/325 mg tablets were signed out of the Controlled Drug Record but were not documented as administered on Resident 3's MAR. The DON also verified Resident 3 stated she did not receive any hydrocodone-acetaminophen 10/325 mg tablet. During an interview on 8/2/23 at 1003 hours, LN 1 confirmed the signature on Resident 3 Controlled Drug Record on 7/18/23 at 0700 hours was her signature but did not remember anything about that day. LN 1 acknowledged not documenting on 7/18/23, for Resident 3's hydrocodone-acetaminophen 10/325 mg tablet administration on the MAR. During an interview on 8/2/23 at 1003 hours, LN 2 confirmed her signature on Resident 3 Controlled Drug Record on 7/17/23 at 1200 hours. She stated she usually would sign out the controlled medications only if the resident asked for it. Resident 3 must have asked for hydrocodone-acetaminophen 10/325 mg tablets. LN 2 acknowledged not documenting Resident 3's hydrocodone-acetaminophen 10/325 mg tablet administration on the MAR on 7/18/23. 3. Review of the facility's P&P titled Medication Destruction dated 10/2017 showed non- controlled medication destruction occurs in the presence of two licensed nurses. Review of the facility's medication disposition record showed only one licensed nurse disposed of multiple medications on 3/12, 3/18, 3/19, 3/26, 4/1, 7/3, 7/7, and 7/20/23. During an interview on 8/1/23 at 1244 hours, LN 3 stated she did the disposal at the nurses' station in the presence of other nurses. She assumed if other nurses were around during the disposal, it was okay. She was not aware the witnesses had to be docume

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. * The facility failed to provide Resident 1's prescribed medication as ordered by the physician. This posed the risk of a negative impact on Resident 1's medical condition. Findings: Review of the facility's P&P titled Medication Administration dated 10/2017 showed the medications are administered as prescribed in accordance with good nursing principles and practices. Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after). Closed medical record review for Resident 1 was initiated on 5/17/23. Resident 1 was admitted to the facility on [DATE], in the evening and discharged to the acute care hospital on 5/5/23 around 1320 hours. Review of the Medication Administration Records (MAR) for May 2023 showed Resident 1 was not given the following medications on 5/5/23: - Levothyroxine sodium oral tablet 200 mcg by mouth one time a day for Hypothyroidism at 0730 hours. - Famotidine tablet 20 mg one tablet by mouth two times a day for GERD at 0730 hours. - Enoxaparin sodium injection solution (blood clot) Inject 0.4 ml subcutaneously one time a day at 0900 hours. - Metformin HCl tablet 500 mg one tablet by mouth every 12 hours for diabetes at 0900 hours. - Insulin Aspart (short acting insulin), inject before meal at 0730 and 1100 hours as per the following sliding scale: if BS level: 70 – 150 mg/dl = 0; BS level: 151 - 200 mg/dl = 2 units; BS level: 201 - 250mg/dl = 2 units; BS level: 251 - 300 mg/dl = 3 units; BS level: 301 - 350 mg/dl = 4 units; BS level: 351 - 400mg/dl = 5 units; and BS level: 401 - 402mg/dl = 6 units; and call MD if BS level >401 mg/dl. On 5/17/23 at 0920 hours, an interview and concurrent closed medical record review was conducted with LVN 1. LVN 1acknowledged she did not administer the abovefive medications prescribed to Resident 1. LVN 1 stated the medications were not available. LVN 1 was asked how long the medications should be delivered to the facility, LVN 1 stated she did not know. On 5/17/23 at 1140 hours, an interview and concurrent closed medical record was conducted with the DON. The DON was asked how long the medications should be deliveredto the facility, the DON stated after the staff faxed the orders to the pharmacy, the pharmacy staff should deliver within four to sixhours. The DON verified and acknowledged the medications were not administered. When asked what would happen if the resident did not take his medications, the DON stated Resident 1 could develop medical complications. On 5/17/23 at 1216 hours, an interview and concurrent closed medical record review was conducted with LVN 2. LVN 2 stated she was thedesk nurse on 5/5/23 at 0730 hours, she called the pharmacy and was told they would deliver Resident 1's medications within four to six hours. LVN 2 stated at noon, the medications had not yet delivered.

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility document review, the facility failed to follow the physician's medication order for one of two sampled residents (Resident 1). This had the potential to cause harm or adverse effects from the medication. Findings: Review of the facility's P&P titled Medication Administration dated 9/2022 showed the medications will be administered as ordered by the physician. While administering the medication, the nurse will compare the medication with the MAR to verify the correct time. Closed medical record review for Resident 1 was initiated on 3/8/23. Resident 1 was admitted to the facility on [DATE], and discharged on 10/24/22. Review of Resident 1's physician'sorders showed an order dated 10/12/22, for cyclobenzaprine hydrochloride (HCl) 5 mg as needed for muscle spasms at bedtime. Review of Resident 1's MAR for October 2022 showed on 10/14/22 at 0909 hours, cyclobenzaprine HCl 5 mg was administered to the resident. On 3/8/23 at 1232 hours, an interview and concurrent closed medical record review was conducted with the DON. The DON reviewed Resident 1's MAR and verified the cyclobenzaprine HCl was administered at 0909 hours (morning time), and not at bedtime as ordered by the physician.

Mar 2022 14 deficiencies

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, fundamental nursing skills review, and facility P&P review, the facility failed to meet the professional standards of care for one of the 20 final sampled residents (Resident 71). * LVN 5 failed to follow the standard nursing procedures for the administration of eye drops to Resident 71. This failure posed the risk for developing complications related to inappropriate technique in eye medication administration. Findings: According to the 7th edition of Fundamentals of Nursing by [NAME] et al, the chapter of Medications-Instilling Eyedrops showed the following steps: - clean the eyelids and eyelashes for debris, - tilt the patients head back , - remove the cap from the medication bottle , - invert the plastic medication container, - have the patient look up , - place the thumb or two fingers near the margin of the lower eyelid immediately below the eyelashes, and exert pressure downward over the body prominence of the check. The lower conjunctival sac is exposed as the low lid is pulled down. - instill the dropper close to the eye but avoid touching the eyelids or lashes, - squeeze the container and allow the prescribed medication to fall in the lower conjunctival sac, - release the lower eyelid and ask the patient to close the eyes gently, - apply gentle pressure with your gloved finger over the inner canthus to prevent the Eyedrops from flowing into the tear duct. This minimizes the risk of systemic effects from the medication, - instruct the patient not the rub the affect eye, - remove gloves, perform hand hygiene, - chart the administration of medication in the MAR, and - evaluate the patient's response to the medication. According to the facility's P&P titled Specific Medication Administration Procedures IIB: Eye Drop Administration revised October 2019, the facility will ensure to administer the ophthalmic solution/suspension into the eye in a safe, accurate, and effective manner. Under the section for Procedures, it showed with a gloved finger, gently pull down lower eyelid to form pouch while instructing the resident to look up. Hold inverted bottle between the thumb and index finger, and press gently to instill prescribe number of drops into pouch near the outer corner of eye . Instruct resident to close eyes slowly to allow for even distribution over surface of the eye. The resident should refrain from blinking or squeezing eyes shut . While the eye is closed, use one finger to compress the tear duct in the inner corner of the eye for 1-2 minutes. This reduces the systemic absorption of the medication. Alternatively, the resident may keep his/her eyes closed for approximately three minutes. On 3/16/22 at 0816 hours, a medication administration observation was conducted with LVN 5 for Resident 71. LVN 5 administered the following eye medications to Resident 71: - difluprednate (medication use to treat eye irritation and inflammation), 0.05% two drops to the inner corner of left eye, - gatifloxacin (medication use to treat pink eye) 0.5% one drop to the inner corner of left eye, - Prolensa (medication use to treat eye pain and swelling after cataract surgery) 0.07% one drop to the inner corner of left eye, and - Simbrinza (medication use to treat high pressure in the eye due to glaucoma) 1%-0.2% one drop to the inner corner of left eye. LVN 5 did not provide the instructions for Resident 71 to close his eyes and/or compress the tear duct in the inner corner of left eye after the eye drops were administered. Resident 71 kept his left eye open after each eye drop administration. On 3/16/22 at 1044 hours, an interview was conducted with LVN 5. When asked on how the eye drops were administered, LVN 5 stated the eye drops had to be administered in the inner corner of the eye. LVN 5 stated the eye drop should enter the tear duct (opening of the tears ducts located in the inner corner of the eye). LVN 5 stated after administering the eye drop medication, she had to provide instruction for the resident to blink the eye. When asked when last reviewed the nursing skills for eye drop administration, LVN 5 stated she was not evaluated for it. LVN 5 stated she was evaluated on administering other forms of medication except for the eye drop medication. LVN 5 acknowledged the four eye drops medications for Resident 71 were administered into the inner corner of Resident 71's left eye where the tear duct was located. LVN 5 acknowledged that she did not compress the tear duct in the inner corner of the eye after she administered the medication but instead had instructed Resident 71 to blink his eyes. LVN 5 acknowledged she needed to review the nursing procedure on the eye drop administration.

CONCERN (D)

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 20 final sampled residents (Resident 75) was provided restorative nursing care as ordered by the physician. * Resident 75 had a physician's order to provide a rolled washcloth for the right hand contracture. The facility failed to ensure a rolled washcloth was applied to Resident 75's right hand to prevent further decline in the contracture. This failure had the potential to decrease Resident 75's optimal physical functioning. Findings: Review of the facility's P&P titled Restorative Nursing Care (undated) showed the restorative nursing care is performed as ordered and care planned for those residents who require such services. Such programs include assisting residents to adjust to their disabilities, to use their orthotic devices such as hand rolls. On 3/15/22 at approximately 0728 hours, during an initial tour of the facility, an observation was conducted for Resident 75. Resident 75 was seen in bed, awake. Resident 75 made eye contact but did not respond to any questions. Resident 75's right hand and fingers were observed to be contracted (one or more fingers involuntarily contracts and pulls inward towards the palm of the hand; hand involuntarily pulls inward toward the arm). There were no splints or rolled washcloths applied to Resident 75's right hand. Medical record review for Resident 75 was initiated on 3/15/22. Resident 75 was readmitted to the facility on [DATE]. Review of Resident 75's History and Physical examination dated 3/3/21, showed Resident 75 did not have the capacity to understand and make decisions. Review of the MDS assessment dated [DATE], showed Resident 75 was severely cognitively impaired. The document also showed Resident 75 had an impairment to both sides of her lower and upper extremities. Review of Resident 75's Order Summary Report dated 3/18/22, showed a physician's order dated 7/30/20, to place a rolled washcloth in Resident 75's right hand at all times. Review of the plan of care showed a care plan problem addressing Resident 75's potential decline in range of motion with a revision date of 12/16/21. One of the interventions specified for this problem was to place a rolled washcloth in Resident 75's right hand at all times. Further review of the medical record failed to show documentation the rolled washcloth was applied to Resident 75's right hand. On 3/17/22 at 1052 hours, an observation and concurrent interview was conducted with CNA 3. Resident 75 was observed in bed, awake. Resident 75's right hand was observed with no rolled washcloth in place. CNA 3 acknowledged there was no rolled washcloth in Resident 75's right hand. On 3/17/22 at 1627 hours, an observation and concurrent interview was conducted with CNA 4. Resident 75's right hand was observed with no rolled washcloth in place. CNA 4 acknowledged there was no rolled washcloth in Resident 's right hand. On 3/18/22 at 0719 hours, an observation and concurrent interview was conducted with CNA 5. Resident 75's right hand was observed with no rolled washcloths in place. CNA 5 acknowledged there was no rolled washcloth in Resident 75's right hand. On 3/18/22 at 0721 hours, an observation and concurrent interview was conducted with LVN 2. LVN 2 verified the findings and stated Resident 75 needed a rolled washcloth on her right hand. On 3/18/22 at 0926 hours, an interview was conducted with the DOR. The DOR stated the hand rolls helped with mobility of the hand and to an extent, it would prevent decline in the contracture of the hand.

CONCERN (D)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility document review, the facility failed to provide the necessary care and services to address the nutritional needs for one of 20 final sampled residents (Resident 76). * The facility failed to ensure Resident 76's weight was monitored as ordered by the physician. Resident 76 was experiencing weight loss and had a physician's order to be weighed every 48 hours for 10 days. This failure had the potential to contribute to Resident 76's unmonitored weight loss and delayed intervention. Findings: On 3/17/22 at 0736 hours, an observation and concurrent interview was conducted with Resident 76. Resident 76 was observed in bed, independently eating her breakfast. Resident 76 stated she had lost weight but was not sure of how much she had lost. Medical record review for Resident 76 was initiated on 3/15/22. Resident 76 was readmitted to the facility on [DATE]. Review of Resident 76's History and Physician examination dated 2/24/22, showed Resident 76 had the capacity to understand and make decisions. Review of Resident 76's Order Summary Report dated 3/18/22, showed a physician's order dated 2/22/22, to check Resident 76's weight every 48 hours for 10 days and call the physician if the weight was above the baseline weight. Review of Resident 76's Weights and Vitals Summary dated 3/17/22, showed Resident 76's weights on the following dates, which showed Resident 76 was experiencing the weight loss: - 2/23/22, 115 lbs - 3/2/22, 118 lbs - 3/7/22, 116 lbs - 3/14/22, 112 lbs Further review of the medical record failed to show Resident 76's weights were monitored every 48 hours for 10 days as ordered by the physician. Review of Resident 76's Nutritional assessment dated [DATE], showed Resident 76 had a recent weight loss of 10 lbs in two months. On 3/17/22 at 0834 hours, an interview and facility document review was conducted with RNA 1. RNA 1 stated the RNAs were responsible for checking the weight of resident in the facility. RNA 1 added the licensed nurses communicated whether the resident needed their weights checked more frequently than once a month for the long-term residents and more than weekly for four weeks for the newly admitted residents. When asked, RNA 1 stated RNAs would report the residents' weights to the licensed nurses right after the weights were checked. RNA 1 stated and verified Resident 76's weights were monitored weekly due to being readmitted from the acute care hospital, and there was no documentation showing Resident 76's weights were checked every 48 hours. On 3/17/22 at 1108 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the above findings and stated the physician's order should have been followed.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and manufacturer's instructions, the facility failed to provide safe respiratory care for one of 20 final sampled residents (Residents 48). * The facility failed to ensure Resident 48's nebulizer mask kit was stored in accordance with the manufacturer's instructions. This had the potential for increased risks of infection. Findings: Review of the manufacturer's instructions titled Vixone Nebulizer Mask Kit (includes a tubing, bowl and mask) under cleaning instructions showed the following: - The VixOne nebulizer must be assembled and disinfected periodically in order to operate correctly. The manufacturer recommends full disassembly and disinfection of all components at the end of each treatment day, - Place all parts on a clean surface (fresh paper towel) to dry, - After parts are dry, reassemble and store kit until next use. Review of Resident 48's medical record was initiated on 3/16/22. Resident 48 was readmitted to the facility on [DATE]. Review of Resident 48's Order Summary Report dated 3/17/22, showed the following: - an order dated on 3/13/22, to transfer to acute hospital via 911 due to chest pain, - an order dated on 3/16/21, to administer Combivent Respimat Aerosol Solution (medications used to treat and prevent symptoms of wheezing and shortness of breath) 20 to 100 micrograms per actuation (the action of causing a device to operate) one inhalation inhale orally every four hours as needed for shortness of breath. On 3/16/22 at 0728 and 0915 hours, a nebulizer machine (a small machine that turns liquid medicine into mist) was observed on top of Resident 48's bedside drawer. Resident 48's nebulizer tubing was observed to be attached to the nebulizer machine. Resident 48's nebulizer bowl (where the medication solution is poured) and the nebulizer mask were observed to be placed inside Resident 48's top drawer. The nebulizer bowl still had some remaining liquid inside and was undated. Resident 48's top drawer was observed to also contain the bottle of shampoo, bottle of lotion, unopened bag of chips, and sealable bag containing a kidney basin, toothbrush, and toothpaste. On 3/16/22 at 0919 hours, an observation and concurrent interview was conducted with the IP. When asked about the process for storing the nebulizer kit, the IP stated and demonstrated it should be stored in a plastic bag with the date when it was initially used. The IP also acknowledged and verified Resident 48's nebulizer kit had no date. On 3/17/22 at 1415 hours, an interview was conducted with the DON. The DON stated Resident 48 was sent to the acute hospital on 3/13/22, and he required a one time use of the nebulizer, which was not given since the paramedics arrived to transport Resident 48 to the hospital. The DON verified and acknowledged the findings and stated the nurses should have either disposed the nebulizer kit or cleaned it according to the manufacturer's instruction, dated it, and placed it in a labeled plastic bag.

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services for two of 20 final sampled residents (Residents 71 and 72) and one nonsampled resident (Resident 4). * The number of tablets for Resident 4's tramadol documented in the Controlled Medication Count Sheet did not match the number of tablets remaining in the medication bubble pack. * Resident 72's Controlled Medication Count Sheet for buprenorphine (narcotic medication) did not match the entry in the MAR. * Resident 72's buprenorphine was not administered as ordered by the physician. Resident 72's buprenorphine was not available. * The facility failed to ensure Resident 71's Trajenta (medication for blood glucose control) was administered as ordered by the physician. Resident 71's Trajenta was not available. * The Q Shift Controlled Drug Reconciliation had missing nurses' signatures. These failures posed the risk for diversion of controlled medications and possible complications related to residents not receiving the prescribed medications. Findings: Review of the facility's P&P titled Preparation and General Guidelines IIA7: Controlled Substance revised October 2019, under the section Procedures, showed when a controlled substance is administered, the license nurse administering the medication immediately enters the following on the accountability record and/or medication administration records (MAR): - Date and time of administration (MAR, Accountability record) - Amount administered (Accountability record) - Remaining quantity (Accountability record) - Signature of the nurse administering the dose on the accountability record at the time the medication is removed from supply. - Initials of the nurse administering the dose. 1. On 3/16/22 at 1103 hours, during the inspection of Medication Cart 3, the Controlled Medication Count sheets were reviewed with LVN 5. The Controlled Medication Count sheet showed a pharmacy label for Resident 4's tramadol 50 mg one table by mouth daily on weekdays (Monday through Friday). The Controlled Medication Count sheet for tramadol showed 5 remaining tablets were not yet administered to Resident 4. However, review of Resident 4's tramadol 50 mg medication bubble pack showed only four tablets were left. The Controlled Medication Count sheet for Resident 4's tramadol did not match the remaining number of tablets in the medication bubble pack. LVN 5 verified the findings. LVN 5 stated she administered Resident 4's tramadol in the morning but forgot to document it in the Controlled Medication Count Sheet. When asked about the process of removing the narcotics from the medication bubble pack, LVN 5 stated it should have been documented as soon as a medication tablet was removed. 2. On 3/16/22 1150 hours, a narcotic inspection was conducted with the DON. When asked how the nurses would document in the Controlled Medication Count Sheet, the DON stated once a tablet was removed from the medication bubble pack, the staff had to sign the sheet. When asked about the process for disposing the narcotic medications, the DON stated all discontinued narcotics were given to her by the staff. The DON stated she disposed the narcotics in the presence of the pharmacist and they both signed the Controlled Medication Count Sheet. A random review of the Controlled Medication Count sheets showed Resident 72's buprenorphine count sheet was included in the disposed narcotic file. The DON stated the medications from the file were disposed with the pharmacist. Medical record review for Resident 72 initiated on 3/18/22. Resident 72 was initially admitted to the facility 3/11/21, and readmitted on [DATE]. Review of the Order Summary Report showed a physician order dated 12/30/21, to administer buprenorphine HCL 2 mg one tablet sublingually (under the tongue) every 6 hours for pain management. a. Review of the MAR for March 2022 showed Resident 72 received buprenorphine 2 mg one tablet on 3/15/22 at 1200 hours and 1800 hours. Review of the Controlled Medication Count sheet for Resident 72's Buprenophrine 2 mg (medication to treat pain) tablet #2 was given 3/15/22 at 1200 hours, and the entry for tablet #1 had no date and signature. The area for tablet #1 was covered with pharmacy sticker label. The Controlled Medication Count sheet for Resident 72's buprenorphine did not match Resident 72's MAR. On 3/16/22 at 1500 hours, a concurrent interview and medical record review was conducted with the DON. The DON stated she disposed all narcotic medications with the pharmacist and had no medication left. When asked about Resident 72's buprenorphine 2 mg tablets, the DON verified the Controlled Medication Count sheet for Resident 72's buprenorphine 2 mg showed the entry for tablet#1 was left blank with no date and signature. The DON stated she was not sure what happened and would find it out. On 3/16/22 at 1633 hours, further interview was conducted with the DON. The DON stated the buprenorphine 2 mg tablet #1 was administered to Resident 72. The DON showed Resident 72's MAR and stated the buprenorphine tablet #1 was given on 3/15/22 at 1800 hours. The DON acknowledged Resident 72's MAR did not match the Controlled Medication Count Sheet. b. Review of the MAR for March 2022 showed Resident 72 reported a pain level of 8 (on a 0-10 pain scale with 0= no pain and 10 = worst pain) on 3/16/22 at 0000 hours (12 midnight). Review of the Orders-Administration note dated 3/16/22 at 0037 hours, showed Resident 72's buprenorphine was not administered due to unavailability. 03/18/22 at 1541 hours, an interview was conducted with the DON. The DON verified Resident 72's buprenorphine dose on 3/16/22 at 1200 am was not given because he ran out of the medication. 3. On 3/16/22 0816 hours, a medication administration observation for Resident 71 was conducted with LVN 5. LVN 5 prepared and administered Resident 71's medications. LVN 5 withheld Resident 71's Trajenta (medication for blood sugar control) 5 mg medication. When asked why she did not administer Resident 71's Trajenta, LVN 5 stated the medication was not available and was reordered. Medical record review for Resident 71 was initiated on 3/16/22. Resident 71 was readmitted to the facility on [DATE]. Review of Resident 71's MAR dated March 2022 showed a physician's order for Trajenta 5 mg one tablet by mouth one time a day. There was a code 6 on 3/16/22 at 0900 hours. Record review of the Progress Notes- Orders Administration Note dated 3/16/22 at 0822 hour, showed Resident 71's Trajenta medication was not available and was reordered. On 3/16/22 at 1026 hours, an interview was conducted with LVN 5. LVN verified Resident 71's Trajenta was not administered because it was not available. 4. Review of the facility's P&P titled Medication Ordering and Receiving from Pharmacy IC4: Receiving controlled substances revised September 2019. Under the section Procedures showed two nurses witness placement of the controlled substances in a secured compartment of the medicine cart; Controlled substance inventory sheets are completed, if necessary, and filed appropriately. Review of the Q Shift Controlled Drug Reconciliation form showed missing nurse's signatures on the following dates and shifts: - on 2/22/22, 0700-1500 hours on-coming shift and 1500-2300 hours for both off-going and on-coming shift. - on 2/23/22, 2300-0700 hours off going shift, and 1500-2300 hours on-coming shift. - on 2/26/22, 2300-0700 hours on-coming shift and off-going shift; 0700-1500 hours off-going shift; and 1500-2300 hours on-coming shift. On 3/16/22 at 1500 hours, a concurrent interview and medical record review was conducted with the DON. The DON verified the findings. The DON stated the nurses had to sign the Controlled Drug Reconciliation form every shift before they left and when they came to work to ensure accurate narcotic count.

CONCERN (D)

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure one of five unnecessary medication sampled residents (Residents 12) was free from unnecessary drugs. * The facility failed to ensure Resident 12's midodrine hydrochloride (medication used to treat low blood pressure) was administered based on the physician's ordered parameter. This failure had the potential for Resident 12 to receive unnecessary medication and develop significant side effects arising from errors in administration. Findings: Medical record review for Resident 12 was initiated on 3/17/22. Resident 12 was admitted on [DATE], and readmitted to the facility on [DATE]. Resident 12 had a diagnosis of hypotension (abnormally low blood pressure). Review of Resident 12's Medication Review Report showed an order dated 11/5/21, to administer midodrine hydrochloride 10 mg give one tablet by mouth one time a day every Tuesday, Thursday, and Saturday for hypotension; to hold if systolic blood pressure (SBP, the top number of the blood pressure) > (more than) 120 mmHg, one hour before dialysis. Review of Resident 12's MAR dated March 2022 showed the following: - on 3/10/22, midodrine hydrochloride 10 mg was administered to Resident 12 when her SBP was 130 mmHg. - on 3/17/22, midodrine hydrochloride 10 mg was withheld when the SBP was 114 mmHg. Resident 12's midodrine was not administered as ordered. On 3/17/22 at 1452 hours, an interview and concurrent medical record review was conducted with LVN 1. When LVN 1 was asked to read the parameters for the midodrine hydrochloride order, LVN 1 stated to hold if SBP less than 120 mmHg. When asked again what the > symbol meant, LVN 1 stated the symbol meant greater than. LVN 1 verified the above findings and stated the nurse should have held Resident 12's midodrine hydrochloride on 3/10/22, when Resident 12's SBP was 130 mmHg. LVN 1 added Resident 1 should have been given midodrine hydrochloride on 3/17/22, when Resident 12's SBP was 114 mmHg. On 3/17/22 at 1540 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified Resident 12 was administered midodrine hydrochloride when Resident 12's SBP was above the parameters prescribed by the physician, and the medication was held when Resident 12's SBP was less than 120 mmHg.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled General Guidelines for the Use of Psychoactive Medications revised October 2017 under section Unnecessary Drugs showed each resident's drug regimen must be free from unnecessary drugs. Unnecessary drugs are any drugs when used without adequate monitoring. Review of Resident 58's medical record was initiated on 3/17/22. Resident 58 was admitted to the facility on [DATE]. Review of Resident 58's Order Summary Report showed the following physician's order dated 12/12/20: - Zoloft Tablet 25 mg one tablet by mouth one time a day for depression manifested by feeling sadness - anti-depressant medication - monitor for dry mouth, constipation, blurred vision, disorientation, confusion, difficulty urinating, hypertension, dark urine, yellow skin, nausea and vomiting, lethargy, drooling. Enter Y if side effect is observed for Zoloft use - monitor for: feeling sadness and record the number of times the behavior was manifested. Review of the Psychiatric Evaluation Notes dated 10/4/20 and 1/11/22, showed to continue Zoloft and monitoring. The pharmacy recommendation to attempt GDR (gradual dose reduction) if medically warranted dated 9/13/21, showed the physician disagreed with the pharmacy recommendation for GDR, benefit outweighs the risk. Review of the MARs and Monitoring Records for January 2022 and March 2022 showed missing documentation for monitoring of side effects and behavior of feeling sadness for Resident 58's use of Zoloft on the following dates: - on 1/3/22, for the 7-3 shift - on 1/5/22, for the 11-7 shift - on 1/8/22, for the 7-3 shift - on 1/13/22, for the 11-7 shift - on 1/17/22, for the 11-7 shift - on 1/18/22, for the 11-7 shift -on 3/12/22, for the 7-3 shift - on 3/16/22, for the 3-11 shift 03/17/22 at 1352 hours, interview and concurrent medical record review was conducted with RN 1. RN 1 stated the medication side effects and behavior manifestation monitoring should be done every shift. RN 1 verified the missing documentation for the Zoloft's side effects and behavior monitoring in the MARs for March and January 2022. Based on observation, interview, medical record review and facility P&P review, the facility failed to ensure two of 20 final sampled residents (Residents 41 and 58) were free from unnecessary psychotropic medications. * The facility failed to ensure to monitor for a specific behavior manifestation related to Resident 41's use of mirtazapine (anti-depression medication). This had the potential for inaccurate behavior monitoring and Resident 41's physician not having the necessary information to determine the effectiveness of the medication. * The facility failed to monitor the side effects and behavior manifestation for Resident 58's use of Zoloft (anti-depression medication). This had the potential for inaccurate side effects and behavior monitoring and for Resident 58's physician not having the necessary information to determine effectiveness of medication and if Resident 58 had side effects from medication. Findings: 1. Review of the facility's P&P titled General Guidelines for the Use of Psychoactive Medications revised 10/17 showed the antipsychotic medications should not be used if poor self-care is the only indication for its use. Medical record review for Resident 41 was initiated on 3/14/22. Resident 41 was readmitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 41 was severely cognitively impaired and required extensive assistance and total dependence on the facility staff for his ADL care. Review of Resident 41's Order Summary Report dated 3/17/22, showed a physician's order dated 2/22/22 to administer one tablet of mirtazapine 15 mg by mouth at bedtime for depression manifested by poor motivation during ADL care. Review if Resident 41's MAR for March 2022 showed Resident 41 was administered mirtazapine 15 mg at bedtime as ordered by the physician. Further review of the medical record failed to show documentation of the specific behavior manifestation to justify Resident 41's use of mirtazapine. On 3/17/22 at 1413 hours, an interview was conducted with CNA 1. CNA 1 verified she knew the care of Resident 41. CNA 1 stated Resident 41 could not verbalize any of his needs and required total assistance from the facility staff for all his care. When asked, CNA 1 stated Resident 41 could not physically perform any form of ADL care. On 3/17/22 at 1430 hours, an interview and concurrent medical record review was conducted with LVN 1. LVN 1 stated Resident 41 responded to verbal and tactile stimuli. LVN 1 stated Resident 1 was totally dependent on the staff for his daily care and could not independently perform any of his ADL care. LVN 1 verified Resident 41 had an active physician's order to be administered mirtazapine 15 mg at bedtime for depression manifested by poor motivation during ADL care. When asked how the licensed nurses monitored poor motivation with ADL care when Resident 41 could not physically perform any ADL care independently. LVN 1 answered she could not describe how the behavior would look like for Resident 41 due to his inability to perform his own ADL care. On 3/17/22 at 1519 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified the findings. RN 1 stated Resident 41 could not perform ADL care by himself and the behavior manifestation for mirtazapine 25 mg should be clarified with the physician.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to store the drugs and biologicals in a safe manner for three of the 20 sampled residents (Residents 23, 53, and 57). * Topical, suppository, liquid and tablet forms of medications were observed to be stored together in a drawer in Medication Cart 3. The failure post the risk for contamination of medications. * Multiple expired medications and insulin pen with no open date were observed in Medication Cart 3. This failure had the potential for the administration of expired or deteriorated medications or biologicals. *A bottle nasal spray was observed on top of Resident 57's bedside table. This failure had the potential for residents, staff and visitors to have access to the medication. * The keys to the medication cabinets and medication refrigerator for Medication room [ROOM NUMBER] left in an unsecured drawer drawer in the nurse's station. This failure had the potential for unlicensed staff to have access to medications. Findings: Review of the facility's P&P titled Medication Storage in the Facility ID1: Storage of Medications revised August 2019, under the section Procedures, showed the medication room, carts, and medication supplies are locked or attended by persons with authorized access . Orally administered medications are kept separate from externally used medication, such as suppositories, liquids, and lotions . Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication, and reorder from pharmacy, if a current order exist. 1. On 3/16/22 at 1103 hours, an inspection of Medication Cart 3 was conducted with LVN 5. The following medications were observed in the left bottom drawer: - an open box of loperamide HCL (anti-diarrhea medication) 2 mg tablets, - an open box of famotidine (medication for heartburn ) 10 mg tablets, - an open box of Benadryl 25 mg tablets (medication to treat allergy), - a box of microdot Glucose Gel containing 3 tubes (used to treat low blood sugar), - an open Vicks vaporub container (topical medication used to suppress cough and breath easily), - un-opened bottle of aspirin 325 mg tablets (medication to reduce fever and relieve mild to moderate pain), - an open bottle of Derma Klenz liquid (a wound cleanser), - an open package of cough drops (used to suppress cough), - an open box of bisacodyl suppositories 10 mg tablets (stool softener). LVN 5 verified the findings and acknowledged the topical, tablets, and suppositories medications should not be mixed together. 2. Review of Humalog (insulin lispro injection) Prescribing Information revised 03/2013 was initiated on 3/16/22. Under the section Storage and Handling, it showed in-use Humalog vials, cartridges, pens, and Humalog KwikPen should be stored at room temperature, below 86 degrees fahrenheit (30 degrees Celsius) and must be used within 28 days or be discarded, even if they still contain Humalog. On 3/16/22 at 1103 hours, an inspection of Medication Cart 3 was conducted with LVN 5. The following expired medications were identified: - insulin lispro 100 U/ml (units/milliliters) pen for Resident 23 was observed with an open date of 2/8/22 - an open package of cough drops with an expiration date of 2/2022 The following medications were not labeled with the resident name or had no open dates: - a used Levemir flextouch pen of Resident 53 had no open date. - an open Vicks vaporub container was labeled as 35C with no resident name. LVN 5 verified the findings and acknowledged those medications were expired and had to be disposed. LVN 5 was stated she did not know when the Levemir pen was opened and who the Vicks Vaporub was for. 3. Review of the facility's P&P titled Medication Storage in the Facility ID1: Storage of Medications revised August 2019, under section Policy showed, medication and biologicals are stored, securely, and properly, following manufacturer's recommendation or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. a. On 3/14/22 at 0922 hours, during the initial tour, a bottle of Walgreens wal-four nasal spray (a medication to treat nasal decongestion) was observed on top of Resident 57's bedside table. Resident 57 stated she used the nasal spray 4 times per day. On 3/14/22 1535 hours, Resident 57 was observed asleep. A bottle of wal-four nasal spray was still on top of Resident 57's bedside table. Review of Resident 57's medical record was initiated on 3/14/22. Resident 57 was admitted to the facility on [DATE]. Review of the Order Summary Report did not show an order for the use of a nasal spray. Review of the Progress Notes-Self Administration of Medication, showed Resident 57 was not capable of storing medications in a secure location. Resident 57 was not capable of opening/closing the medication containers. Resident 58 was not capable of administering the medication via various routes. Resident 57 was not able to dispense the proper dosage of medications. Resident 57 was not capable of safe self-administration of medications. On 3/14/22 at 1544 hours, a concurrent observation and interview was conducted with LVN 6. LVN 6 verified the nasal spray on top of Resident 57's bedside table and stated the resident was not supposed to have medications at bedside. LVN 6 verified there was no physician's order for the use of nasal spray. LVN 6 verified Resident 57 was not able to self-administer medications based on the Self Administration of medication assessment. b. On 3/16/22 at 0750 hours, after the inspection of Medication room [ROOM NUMBER] with RN 1, RN 1 left a bunch of keys in an unsecured drawer in Nurse's Station A. RN 1 left the station. Non licensed facility staff were observed by the copier in Nurse's Station A. On 3/16/22 at 0803 hours, a concurrent observation and interview was conducted with RN 1. A bunch of keys were observed in an unsecured drawer in Nurse's Station A. When asked what the keys were for, RN 1 stated the keys were used to open the medication drawers and the medication refrigerator in the medication room. RN 1 acknowledged she should have not left the keys to Medication room [ROOM NUMBER] in the nurse's station drawer which was accessible to the unlicensed staff.

CONCERN (D)

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

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observation, interview, and medical record review, the facility failed to provide one of the 20 final sampled residents (Resident 58) the appropriate diet to meet individual needs. * The facility failed to ensure Resident 58 was provided the appropriate meal substitute. Resident 58 had a physician's order of puree diet and was provided a whole uncut cheese quesadilla at lunch. This failure posed the risk for the resident to develop complications like aspiration and choking. Findings: 1. On 3/14/22 at 1232 hours, during dining observation, Resident 58's puree meal was observed to be untouched. Resident 58 was observed dipping a rolled tortilla (looks like a burrito) in a cup of hot cocoa. When asked what Resident 58 was eating, RNA 1 stated Resident 58 did not like the puree food and had requested for cheese quesadilla as her lunch meal substitute. RNA 1 stated she had been requesting for the quesadilla since she was placed on puree diet. Review of the meal ticket showed Resident 58 was on regular-pureed diet (eating plan where all the foods have a soft, pudding-like consistency for patient with swallowing problems) for Monday lunch, 3/14/22. On 3/14/22 at 1239 hours, a concurrent observation and interview was conducted with DON. The DON stated Resident 58 was on a puree diet and had to be provided with a pureed food. The DON stated Resident 58 used to be on a mechanical soft diet (pureed, finely chopped, blended, or ground to make them smaller, softer, and easier to chew), but was changed to a puree diet while awaiting for her dentures. Medical record review for Resident 58 initiated on 3/14/22. Resident 58 was admitted to the facility on [DATE]. Review of the Physician's Order dated 1/25/22, showed to discontinue Resident 58's mechanical soft texture diet and change to puree texture diet. Review of the MDS dated [DATE], showed Resident 58 had severe cognitive impairment. Resident 58 had swallowing problems and was on mechanically altered diet. Review of the Progress Notes-Nutritional assessment dated [DATE], showed Resident 58 was on a regular pureed diet texture. Resident 58's nutritional risk factor included swallowing difficulty. The RD's nutritional recommendation showed the current diet was adequate and appropriate for resident needs. Review of the plan of care showed a care plan problem addressing Resident 58's risk for nutritional problem showed an intervention to provide regular pureed diet. On 3/17/22 at 1536 hours, an interview was conducted with the DOR. The DOR stated Resident 58 used to be on a mechanical soft diet but was changed to puree diet while awaiting for tooth extraction. The DOR provided Resident 58 the whole burrito (not pureed) was not an appropriate diet for Resident 58 who was on a puree diet. On 3/18/22 at 0904 hours, interview was conducted with the SLP. The SLP stated she assessed Resident 58 on 11/17/21, when Resident 58 had a diet of mechanical soft, thin liquid. The SLP stated Resident 58's diet was changed from mechanical soft to puree because of dental extraction. The SLP verified giving Resident 58 a whole uncut burrito or cheese quesadilla was not an appropriate food for puree diet.

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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2. Review of the facility's P&P titled Specific Medication Administration Procedures IIB5: Eye Drop Administration revised October 2019, showed to administer eye ophthalmic solution/suspension into the eye in a safe, accurate and effective manner. Wash ands before and after procedure, put on examination gloves. Change gloves after each administration of drops .Remove and dispose of gloves. Wash hands thoroughly with antimicrobial soap and water or facility- approved hand sanitizer. On 3/16/22 at 0816 hours, a medication administration observation was conducted with LVN 5. LVN 5 prepared four eye medications for Resident 71. LVN 5 did following: - After the administration of Resident 71's first eye drop medication, LVN 5 took off her gloves, carried the medication tray to the medication cart located just outside the room and sanitized her hands using an alcohol based hand rub. LVN 5 was observed carrying the medication tray which contained Resident 71's eye drop medications and placed it at bedside table. Without performing hand hygiene, LVN 5 donned on a new pair of gloves and administered Resident 71's second eye drop medication. - After the administration of Resident 71's third eye drop medication, LVN 5 remained at bedside and was observed still wearing the same gloves used when she administered Resident 71's third eye drop medication. LVN 5 touched Resident 71's medication tray and bedside table. After five minutes, LVN 5 while still using the same gloves administered Resident 71's eye drops. LVN 5 did not perform hand hygiene and change her gloves prior to administering the fourth eye drop medication. On 3/16/22 at 1044 hours, an interview was conducted with LVN 5. LVN 5 verified the findings and stated she should have performed hand hygiene when administering the eye drop medications. Based on observation, interview, and facility P&P review, the facility failed to maintain the effective infection control practices. * LVNs 3 and 4 failed to perform hand hygiene before donning and after doffing gloves during resident care. * LVN 5 failed to perform hand hygiene when she administered the eye drops medication to Resident 71 These failures placed the residents and the staff at increased risk for infections. Findings: 1. Review of the facility's P&P titled Handwashing/Hand Hygiene revised January 2021, under the section When to Wash Hands, showed the employees must wash their hands for at least twenty seconds using soap and water under the following conditions: before and after performing any invasive procedure (for example, finger stick blood sampling) and after removing gloves or aprons. To use alcohol-based hand rub: after removing gloves. Under section When to use Alcohol-Based Hand Rub it showed in most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use an alcohol-based hand rub containing 60-95% ethanol or isopropanol for all of the following situations: before and after direct contact with residents, before preparing or handling medications, and after removing gloves. a. On 3/14/22 at 1525 hours, LVN 3 was observed going inside Room B, wearing gloves, and carrying a glucometer (a machine used to measure and display the amount of sugar in the blood) with blood sugar strips and lancet (a small, needle-like medical supplies that is used to make a very small prick in your skin to collect a few drops of blood for testing in a diabetic monitor) placed inside a transparent cup. LVN 3 was observed exiting Room B still wearing the same gloves. On 3/14/22 at 1527 hours, LVN 3 acknowledged she did not perform hand hygiene prior to donning and doffing gloves. b. On 3/17/22 at 0817 hours, LVN 4 was observed exiting Room F, doffed the gloves and donned new pair of gloves and took alcohol wipes from the medication cart. LVN 4 did not perform hand hygiene after removing and before donning new gloves. On 3/17/22 at 0820 hours, LVN 4 acknowledged she did not perform hand hygiene before and after removing her gloves.

CONCERN (D)

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

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected 1 resident

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Based on interview and facility document review, the facility failed to establish the infection control program designed to provide a safe and sanitary environment. * The facility failed to ensure Resident 29 was accurately assessed for the presence of sings and symptoms of infection based other Mc Geer's criteria. Resident 29 who present with manifestations of a wound infection was erroneously classified as not a true infection even if the Mc Geer's criteria was met. This failure posed the risk for the development of complications when the resident's infection was not properly addressed and the documentation of inaccurate data within the antibiotic surveillance program. Findings: Review of the facility's P&P for Infection Control Surveillance Program revised on January 2018 showed the Infection Preventionist, .shall be responsible to implement the surveillance program. The infection Control Surveillance Process will include: - Collection of sings and symptom date, lab date and comparing to standard written definition (criteria) for infections, - Review of antibiotic orders - Mc Geer's criteria (a set of criteria used in long term care facilities to determine if signs and symptoms constitute a true infection) will be utilized to define infection surveillance activities. Loeb's Criteria will be the minimal criteria for ordering antibiotics. Review of Resident 29's Surveillance Data Collection Form for Skin, Soft Tissue and Mucosal Infection dated 1/30/22, showed the following: -Resident 29's onset of symptoms of wound infection on 1/28/22. -Loeb's Minimum Criteria for Initiating Antibiotic for Cellulitis, Soft Tissue or Wound Infection showed any one of the criteria had to be present to initiate antibiotic therapy for Resident 29: * Resident 29 had a new or increasing purulent drainage and had tenderness and warmth on the area. * Resident 29 had achieved the two criteria to be placed on antibiotic therapy based on the Loeb's criteria. -The McGeer Criteria for Cellulitis, Soft Tissue or Wound Infection showed at least one of the following criteria must be present for Resident 29 to be classified as having a true infection: * Pus present at a wound, skin, or soft tissue site, which was marked as present. * New or increasing presence of at least four of the following sign or symptom sub-criteria: redness and tenderness or pain at the affected site were present. Resident 29 had achieved the criteria for a true skin infection based on the Mc Geer's Criteria. - Resident 29 was prescribed linezolid (antibiotic) 600 mg every day. - The IP classified the infection as not meeting Mc Geer's criteria. On 3/17/22 at 0832 hours, an interview and concurrent facility record review was conducted with the IP. When asked about the facility's process on antibiotic stewardship, the IP stated surveillance of antibiotic use was reviewed to ensure appropriate antibiotic usage. The IP stated the resident's on antibiotics were reviewed for signs and symptoms based on the McGeer's criteria to ensure it was a true infection which warrants antibiotic therapy. The IP stated the Loeb's criteria was used as the minimum criteria for initiating antibiotic therapy. When asked about Resident 29's symptoms for wound infection, the IP stated for Resident 29 to meet the criteria for a true wound infection, he needed to have at least one the two criteria. The IP stated Resident 29 had met at least one of the criteria. The IP verified Resident 29's infection was mistakenly not classified as a true infection. The IP acknowledged Resident 29's Surveillance Data Collection Form was not accurate.

CONCERN (D)

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

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and facility P&P review, the facility failed to maintain a safe and homelike environment. * Rooms A, B, C, and D were observed with torn floor mats at the resident's bedside. This lack of maintenance placed the living conditions of residents in an unkempt environment. Findings: Review of the facility's P&P titled Interior Maintenace Resident Room and Equipmnet effective 3/1/16, showed the facility to maintain in good repair, all interior surfaces, fixtures, equipment, appliances, and furnishings to provide a safe, clean, comfortable environment for residents and employees. On 3/14/22 at 1115 hours, during an initial tour of the facility, a torn floor mat was observed by a resident's bed in Room D. The floor mat was torn at the left top corner and bottom right corner. On 3/14/22 at 1130 hours, a floor mat with torn corners was observed at a resident's bedside in Room C. On 3/14/22 at 1517 hours, a floor mat with torn corners was observed at a resident's bedside in Room B. On 3/14/22 at 1531 hours, a floor mat with torn corners and exposed foam was observed at a resident's bedside in Room A. On 3/15/22 at 1048 hours, a concurrent observation and interview was conducted with the House Keeping Supervisor. The Housekeeping Supervisor verified the above findings and stated the floormats had to be replaced.

CONCERN (E)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

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Based on observation, interview, facility document review, and facility P&P review, the facility failed to follow the menu for 13 of 13 residents (Residents 8, 11, 16, 27, 28, 38, 41, 49, 50, 70, 86, 535, and 536) who were on the pureed textured diets. This failure posed the risk of the residents' nutritional needs not being met and/or residents' food preferences not being honored. Findings: Review of the facility's P&P titled Menu Planning showed all daily menu changes, with the reason for the change, are to be noted on the back of the kitchen spreadsheet. The Dietitian has to approve permanent changes on the menu and should sign and date spreadsheets when changes are made. Menu changes should also be noted on menus on the consumers board and any other menus which may be posted. Review of the facility's Spring Cycle Menu -Week 2 Wednesday dated 3/16/22, showed the following food items were to be served for lunch service: simmered Chinese chicken with one ounce sauce, brown rice, stir fry vegetables, parsley sprig, Mandarin Asian salad, lemon snow bar. On 3/16/22 at 0902 hours, an observation of the puree preparation and concurrent interview was conducted with [NAME] 1. [NAME] 1 was observed preparing pureed simmered Chinese chicken and pureed corn. [NAME] 1 stated he already prepared the rice using a powdered form with added water. [NAME] 1 stated he did not have any other pureed food to prepare. On 3/16/22 at 1140 hours, an observation of tray line was conducted with [NAME] 1. A cream-colored pureed food was observed in one of the serving trays. [NAME] 1 stated they were mashed potatoes and he used powdered kind to make them. The facility had 13 residents (Residents 8, 11, 16, 27, 28, 38, 41, 49, 50, 70, 86, 535, and 536) who were on the pureed textured diets. The following examples were some of the residents (Residents 28, 49, and 50) who had physician's orders for pureed diets. 1. On 3/16/22 at 1205 hours, an observation and concurrent facility document review was conducted for Resident 28. Resident 28's meal ticket dated 3/16/22, showed he was on a regular-puree textured diet and should receive pureed brown rice, pureed simmered chicken, pureed stir fry vegetables, pureed mandarin Asian salad, pureed lemon snow bars, milk, apple juice, and water. However, observation of Resident 28's lunch tray showed the following items: mashed potatoes, pureed corn, pureed simmered chicken, pureed lemon snow bar, apple juice, milk and water. Resident 28 was not served the Mandarin Asian salad and pureed parsley flakes. On 3/17/22 at 1207 hours, an observation and concurrent interview was conducted with CNA 6. CNA 6 verified the above findings. 2. On 3/16/22 at 1208 hours, an observation and concurrent facility document review were conducted for Resident 49. Resident 49's meal ticket dated 3/16/22, showed she was on a CCHO (carbohydrate controlled)-puree textured diet and should receive pureed brown rice, pureed simmered chicken, pureed stir fry vegetables, pureed mandarin Asian salad, pureed lemon snow bars, milk, and assorted juice. However, observation of Resident 49's lunch tray showed the following items: mashed potatoes, pureed corn, pureed simmered chicken, pureed lemon snow bar, apple juice, milk, and water. Resident 49 was not served Mandarin Asian salad and pureed parsley flakes. On 3/16/22 at 1209 hours, an observation and concurrent interview was conducted with CNA 2. CNA 2 verified the above findings. CNA 2 stated whatever was on the meal ticket should be served to Resident 49. 3. On 3/16/22 at 1210 hours, an observation and facility document review were conducted for Resident 50. Resident 50's meal ticket dated 3/16/22, showed she was on a CCHO-puree textured diet and should receive pureed brown rice, pureed simmered chicken, pureed stir fry vegetables, pureed mandarin Asian salad, pureed lemon snow bars, milk, and cranberry juice. However, observation of Resident 50's lunch tray showed the following items: mashed potatoes, pureed corn, pureed simmered chicken, pureed lemon snow bar, cranberry juice, and milk. Resident 49 was not served Mandarin Asian salad and pureed parsley flakes. On 3/16/22 at 1214 hours, an observation and concurrent interview was conducted with the DSD. The DSD verified the above findings. On 3/16/22 at 1221 hours, a telephone interview was conducted with the RD. The RD stated all substitutions or changes in the menu should be approved by the dietician prior to serving the meal. When asked if she approved any substitutions or changes in the menu for 3/16/22, the RD stated no. On 3/16/22 at 1314 hours, an interview was conducted with the Dietary Manager and [NAME] 1. When asked why food posted in the menu was not the same as the food served to the residents, the Dietary Manager stated he was not aware of the changes made. When asked why the residents on puree diet were served mashed potatoes instead of pureed brown rice as written in the menu, the Dietary Manager stated the cream of rice was served and not mashed potatoes. The Dietary Manager was informed that during tray line observation, [NAME] 1 verified he was serving mashed potatoes for the resident with puree-textured diets. The Dietary Manager was asked why pureed corn was served instead of the posted pureed stir fry vegetables, the Dietary Manager started questioning [NAME] 1. [NAME] 1 verified he served pureed corn and added a few pieces of cauliflower. The Dietary Manager was asked if pureed stir fry vegetables were the same as pureed corn with a few pieces of cauliflower. The Dietary Manager stated no. The Dietary Manager was asked why the facility did not serve pureed Mandarin Asian salad. The Dietary Manager verified they did not have the pureed salad. On 3/18/22 at 0940 hours, an interview was conducted with the RD. The RD stated the meal trays should be served with all items reflected on the residents' meal tickets.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview, facility document review, and facility P&P review, the facility failed to follow proper sanitation and food storage practices. * There were multiple expired food items in the kitchen. * The facility failed to ensure the low-temp dishwasher was checked for chlorine concentration properly and the chlorine test paper was not expired. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen. Findings: 1. Review of the CMS 672 completed by the DON dated 3/14/22, showed 85 of 94 residents residing in the facility received food prepared in the kitchen. On 3/14/22 at 0723 hours, an initial tour of the kitchen was conducted with the [NAME] 1. The following observations were made: - 12 cartons of Lyon's Ready Care Thickened Apple Juice labeled best if used by March 7, 2022. - multiple food seasoning with handwritten dates, use by date 2/8/22, 2/18/22, 2/23/22, 3/1/22, and 3/3/22. No manufactured date on the bottles noted. On 3/14/22 at 0750 hours, an observation and concurrent interview was conducted with the Dietary Manager (DM). The DM stated, best by date meant to discard the food items. The DM and verified the findings. 2. Review of the facility's P&P titled Dish Washing dated 2018 showed a temperature log (and chlorine log for low-temperature machines) will be kept and maintained by the dishwashers to assure that the dish machine is working correctly. This log will be completed each meal prior to any dishwashing. The chlorine should read 50 to 100 parts per million on dish surface in final rinse. a. On 3/16/22 at 0758 hours, an observation of dish washing was conducted with Dietary Aide 1. Dietary Aide 1 was observed in the clean side of the dishwasher. Dietary Aide 1 stated the dishwasher was a low-temperature dishwasher and used chlorine for sanitation. Dietary Aide 1 was asked to check the concentration of chlorine being used. Dietary Aide 1 took a chlorine test paper vial stored on top of the dishwasher and dipped the test strip paper unto the solution inside the dishwasher. Dietary Aide 1 compared the color of the strip to the color chart on the vial. and determined the chlorine concentration was 50 ppm (parts per million). When asked to show the chlorine test paper vial, the vial had an expiration date read February 1, 201_. The last digit of the expiration year was not readable. Dietary Aide 1 stated she could not read the last number. Dietary Aide 1 called in the Dietary Manager, and he verified using another vial of chlorine test strips that the date on the vial was in fact the expiration date. When asked how they would know if the strips were expired or not, the Dietary Manager stated the expired chlorine test paper should not be used. b. Review of the facility's Dish Machine Log for March 2022 showed the log was completed every meal. The document had three columns for each meal labeled as wash, rinse and initials. All the results entered for the wash column had a value of 110. Review of the chart used as a guide in the chlorine test paper bottle showed the following values: 10 PPM, 50 PPM, 100 PPM, and 200 PPM. On 3/18/22 at 1324 hours, an interview and concurrent facility document review was conducted with the Dietary Manager. When asked to explain what numbers in the Dish Machine Log meant, the Dietary Manager stated the wash column would show the chlorine test results and the rinse column was the dishwasher temperature. When asked how the dietary staff tested a chlorine concentration of 110 ppm if the chart in the chlorine test paper vial would only show 10-50-100-200 ppm, the Dietary Manager stated the first dietary staff that entered a value of 110 made a mistake and everyone else copied the one above. When asked who was responsible in checking the logs for accuracy, the Dietary Manager did not respond. On 3/18/22 at 1135 hours, a follow-up interview was conducted with the RD. The RD stated the dietary staff should use the unexpired chlorine test strips and should be checked daily.

Jan 2020 19 deficiencies

CONCERN (D)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and facility document review, the facility failed to accommodate the needs of two of 23 sampled residents (Residents 72 and 81) and four nonsampled residents (Residents 6, 17, 20, and 87). * Residents 6, 17, 20, 72, 81, and 87 stated they had to wait 30 minutes or longer to get their call lights answered. Failure to respond to call lights in a reasonable amount of time had the potential to impair the residents' abilities to receive timely care/treatment/services and had the potential to negatively impact the residents' dignity. Findings: On 1/23/2020 at 1312 hours, a resident group interview was conducted. Residents 6, 17, 20, 72, 81, and 87 stated They had to wait 30 minutes or longer to get assistance for toileting or make requests for pain medication. a. Resident 17 stated It took an hour and a half on the evening shift for someone to respond when he wanted to request pain medication. Resident 17 stated this upset him. b. Resident 81 stated she felt angry when she pressed the call light and needed to go out to find a CNA to get help to the restroom. Resident 81 stated the CNAs did not come right away and, when they did respond, they turned off the call light without attending to her needs. c. Resident 72 stated she had a lot of pain from getting to the wheelchair and finding the staff to give her pain medication took a long time. Resident 72 stated sometimes they never came and sometimes she had to wait a half hour. Resident 72 stated it made her angry to have to wait so long for assistance. d. Resident 87 stated three days ago she pressed the call light for medication and experienced right leg pain at a level of 8/10 (on a scale of 0 - 10, 0 being no pain and 10 the worst pain). Resident 87 stated she waited a long time and the call light was turned off by the staff and and she had to press the call light again. e. Resident 6 stated she had to wait approximate 30 minutes to be cleaned. Someone came to help after she had to press the call light a second time. Resident 6 stated she was lying in bed and needed to be cleaned. Resident 6 stated she felt uncomfortable and was not able to move in the bed. f. Resident 20 stated sometimes during the second and third shifts, the staff members did not introduce themselves. Resident 20 stated she needed help to go to the restroom and waited two hours. Resident 20 stated the CNAs turned off the call light without attending to her needs. Review of the Guardian Angel Weekly Inspection form for January 2020 showed a question, how many minutes for staff to respond to call lights? Three residents responded it took longer on the evening shift, two responded it took longer than 20 minutes, and one responded the staff never came. On 1/23/2020 at 1544 hours, a concurrent interview and facility document review was conducted with the Administrator. The Administrator was asked if he was aware of the call light issue. The Administrator stated he was aware of the concern regarding the call lights from last January's resident council meeting. The Administrator stated they have call light monitoring rounds, online survey at admission and discharge, room rounds, tools filled out by the Department Manager. The Department Manager pushed the call light to see how many minutes it took for staff to respond to the call light. The Administrator was asked to show documentation. After reviewing the Guardian Angel Weekly Inspection report, the Administrator verified the finding.

CONCERN (D)

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

Deficiency F0661 (Tag F0661)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure one of three closed record sampled residents (Residents 90) was discharged with complete medical information and an accurate medication list in the discharge summary. * The facility failed to ensure an accurate medication list for Resident 90. The Discharge Instruction form did not show the amount of each medication given by the facility to Resident 90. These failures posed the risk of exposing the resident to associated complications related to the use of an unnecessary medication and the diversion of medications. Findings: Closed medical record review for Resident 90 was initiated on 1/27/2020. Resident 90 was admitted to the facility on [DATE], and was discharged on 11/4/19. Review of Resident 90's Physician Orders from 11/1 through 11/30/19, showed orders dated 10/27/19, for Colace (stool softener) 100 mg, one capsule by mouth twice a day, hold if more than two stools, enoxaparin sodium (anticoagulant to stop the formation of blood clots) 40 mg/0.4 ml subcutaneous daily for DVT (deep vein thrombosis) prophylaxis, amlodipine besylate (blood pressure medication) 10 mg by mouth daily; hold if systolic blood pressure less than 105, Senna 8.6 mg by mouth daily as needed for constipation, give with Miralax (laxative), tramadol hydrochloride 50 mg, one tablet by mouth every six hours as needed for moderate pain, tramadol hydrochloride 50 mg, two tablets by mouth every six hours as needed for severe pain, GlycoLax powder (laxative, same as Miralax) 17 grams by mouth daily as needed for constipation, mix with 8 ounces of juice or water, give with Senna (laxative), bisacodyl suppository 10 mg, one per rectum daily for constipation, and alprazolam (antianxiety) 0.25 mg by mouth for anxiety as needed at bedtime manifested by episodes of verbalization of feeling anxious and Tylenol 650 mg as needed for a temperature over 100.5 degrees Fahrenheit. Review of Resident 90's Discharge Instruction form dated 11/4/19, showed Senna 8.6 mg by mouth daily as needed for constipation, tramadol 50 mg, one tablet by mouth up to 4 times as needed moderate pain, Colace 100 mg, one capsule by mouth twice a day, alprazolam 0.25 mg by mouth for anxiety as needed for anxiety, and amlodipine besylate 10 mg by mouth daily. Under Amount Released failed to show how many doses of each medication were sent home with the resident. On 1/27/2020 at 1531 hours, an interview and concurrent closed medical record review was conducted with LVN 4. LVN 4 was asked about the medications Senna, tramadol, Colace, alprazolam, GlycoLax, bisacodyl, and enoxaparin. LVN 4 stated the discharge instructions should have included the Tylenol, enoxaparin, hydrazaline, and GlycoLax. LVN 4 acknowledged the alprazolam had no time, the tramadol did not follow administration times and the indication the physician ordered, there was no parameter for the administration of amlodipine, there was no instruction how to take the senna, and no parameter for the Colace. LVN 4 verified there were no orders to discontinue the Tylenol, enoxaparin, hydrazaline, and GlycoLax. LVN 4 verified the above findings.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the environment remained free from accident hazards for one of 23 final sampled residents (Resident 37). * Resident 37 had a physician's order to suction the resident as necessary for excessive secretions. However, the staff failed to maintain the suction equipment at the resident's bedside. This posed the risk of medical complications if the resident required suctioning but had no suction equipment readily available. Findings: Medical record review for Resident 37 was initiated on 1/22/2020. Resident 37 was readmitted to the facility on [DATE]. Review of Resident 37's Order Summary Report showed a physician's order dated 11/5/18, may suction as needed for excessive secretions. On 1/28/2020 at 0914 hours, an observation of resident 37 was conducted. Resident 37 was observed coughing. Loose phlegm was heard as the resident coughed. The resident began to grimace by clenching her teeth together. No suction equipment was observed at the bedside. On 1/28/2020 at 0916 hours, an observation of Resident 37 was conducted with CNA 2. CNA 2 observed Resident 37's expression described above. When asked about Resident 37's expression, CNA 2 stated it was the expression Resident 37 made when she was in pain or discomfort. Resident 37 continued coughing with loose phlegm heard as the resident coughed. The resident continued to grimace by clenching her teeth together. On 1/28/2020 at 0923 hours and 0925 hours, Resident 37 was observed coughing with loose phlegm heard as the resident coughed while the resident continued to grimace and clench her teeth together. On 1/28/2020 at 0927 hours, Resident 37 was observed coughing. MDS Coordinator 2 was observed walking into Resident 37's room and observed Resident 37 coughing. Loose phlegm was heard as the resident coughed. On 1/28/2020 at 0932 hours, MDS Coordinator 2 walked back into Resident 37's room and advised Resident 37 she was going to suction her. On 1/28/2020 at 0940 hours, LVN 2 was observed entering Resident 37's room with a wrapped suction canister, wrapped canister lid, wrapped suction tubing, and wrapped suction tip. On 1/28/2020 at 0958 hours, an interview was conducted with LVN 2. LVN 2 stated she usually needed to suction Resident 37 twice during her shift. LVN 2 stated Resident 37 usually got really congested. When asked about the lack of suction equipment at the bedside, LVN 2 verified the suction equipment should have been available at the bedside and was not.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 1/23/2020 at 1519 hours, Resident 240 was observed in bed, receiving oxygen at 5 liters per minute through a nasal cannula. Medical record review for Resident 240 was initiated on 1/23/2020. Resident 240 was admitted to the facility on [DATE]. Review of Resident 240's Physician Orders dated 1/1 - 1/31/2020, failed to show a physician's order for oxygen. On 1/23/2020 at 1529 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 stated Resident 240 was on continuous 2 liters of oxygen and was to be titrated up to 5 liters of oxygen PRN (as needed) to keep the oxygen saturation above 90%. LVN 2 reviewed Resident 240's medical record and verified it failed to show a physician's order for oxygen. LVN 2 verified Resident 240 was currently on 5 liters of oxygen and stated she did not realize it. LVN 2 stated she should have verified there was a physician's order written on 1/22/2020, for Resident 240 to be placed on continuous oxygen. LVN 2 verified the resident was administered oxygen throughout the night without a written physician's orders. LVN 2 reviewed Resident 240's Medication Record dated 1/1 - 1/31/2020, and verified the order to monitor oxygen saturation every shift dated 11/6/19, showed only initials were placed instead of the resident's oxygen saturation on approximately half of the entries for the month of January. LVN 2 stated the percentage of Resident 240's oxygen saturation should have been recorded. On 1/24/2020 at 0914 hours, Resident 240 was observed in bed, receiving oxygen at 5 liters per minute. Resident 240 stated he was not currently feeling short of breath. On 1/24/2020 at 1243 hours, Resident 240 was observed in bed, receiving oxygen at 5 liters per minute. LVN 2 obtained Resident 240's oxygen saturation and showing it was at 86%. LVN 2 stated on 1/23/2020, the resident was also having episodes of low oxygen saturation in the 80% range. On 1/28/2020 at 0845 hours, Resident 240 was observed asleep in bed, receiving oxygen at 5 liters per minute. On 1/28/2020 at 1100 hours, an observation of Resident 240 and concurrent interview was conducted with LVN 2. Resident 240 was observed in bed receiving oxygen at 5 liters per minute. LVN 2 obtained Resident 240's oxygen saturation and it was at 95%. Review of Resident 240's Medication Sheet (undated) showed an order dated 1/23/2020 to titrate oxygen to 5 liters per minute via nasal cannula continuous PRN. Only one entry on 1/23/2020, showed the resident received 5 liters of oxygen PRN. Resident 240's oxygen saturation obtained every shift on 1/24 -1/28/2020 ranged from 92 to 98%. Review of Resident 240's Licensed Nurses' Daily Skilled Charting notes showed: - An entry dated 1/23/2020 at 1805 hours, showed Resident 240's oxygen saturation was 93% on 2 liters via nasal cannula. - An entry dated 1/24/2020 for the 2300 - 0700 shift, showed Resident 240's oxygen saturation was 95% on 2 liters via nasal cannula. - An entry dated 1/25/2020 at 1400 hours, showed Resident 240's oxygen saturation was 95% on 2 liters via nasal cannula. - An entry dated 1/26/2020 for the 1500 - 2300 shift, showed Resident 240's oxygen saturation was 96% on 2 liters via nasal cannula. - An entry dated 1/27/2020 at 0620 hours, showed Resident 240's oxygen saturation was 97% on room air. On 1/28/2020 at 1522 hours, a follow-up interview and concurrent medical record review was conducted with LVN 2. LVN 2 verified the Medication Sheet (undated) showed there was only one entry on 1/23/2020, showing Resident 240 was administered the PRN oxygen. LVN 2 stated each time the resident was administered 5 liters of oxygen, it should have been documented. LVN 2 stated this was a concern to her because the medical record from 1/24 - 1/28/2020, failed to show Resident 240 was administered 5 liters of oxygen and show the resident's oxygen saturations were between 92 to 98%. On 1/28/2020 at 1528 hours, an interview was conducted with the DON. The DON stated if a resident was placed on PRN oxygen, it had to be documented each time on the Medication Sheet. The DON stated if Resident 240 was administered the PRN oxygen of 5 liters, the physician should have been contacted. The DON also verified the order to monitor oxygen saturations on the Medication Sheet should reflect the resident's oxygen saturation number, not the nurses' initials. Based on observation, interview, and medical record review, the facility failed to provide the necessary care and treatment for one of 23 final sampled residents (Resident 6) and two nonsampled residents (Residents 42 and 240) receiving respiratory therapy as ordered by the physician. * The facility failed to administer oxygen therapy to Residents 6 and 42 as ordered by their physicians. This posed the risk of the residents developing complications as a result of inadequate oxygen therapy. * The facility administered oxygen therapy to Resident 240 without a physician's order. In addition, the facility failed to document Resident 240's oxygen saturation as ordered by the physician. These failures had the potential for the resident to develop complications from unnecessary use of supplemental oxygen and a delay in identifying Resident 240's status change. Findings: 1. Medical record review for Resident 42 was initiated on 1/22/2020. Resident 42 was readmitted to the facility on [DATE]. Review of Resident 42's History and Physical Examination dated 11/15/19, showed Resident 42 had a past medical history of hypoxemia (low oxygen level). Review of Resident 42's Order Summary Report showed a physician's order dated 11/13/19, for oxygen at 3 liters per minute via nasal canal (oxygen tubing with two prongs to deliver oxygen into each nostril) routinely to keep the oxygen saturation level (amount of oxygen in the blood) above 92%. Review of Resident 42's plan of care showed a care plan problem dated 11/13 titled impaired respiratory function. The interventions included oxygen inhalation if ordered. Monitor oxygen saturation as ordered. On 1/22/2020 at 1104 hours, Resident 42 was observed with a nasal cannula wrapped around her right ear. On 1/23/2020 at 1027 hours, Resident 42 was observed in the dining room participating in activates. The oxygen tank dial was observed to be set on two liters per minute. On 1/23/2020 at 1059 hours, a concurrent observation, medical record review and interview was conducted with LVN 2 regarding Resident. Resident 42 was observed in the dining room. Resident 42's oxygen tank dial was observed set to 2 liters per minute. LVN 2 verified the above finding. LVN 2 reviewed Resident 42's medical record. The Physicians Order Summary dated 1/1/20 - 1/31/20, showed Resident 42 had a physician's order dated 11/13/19, for oxygen at 3 liters per minute via nasal canal to keep the oxygen saturation above 92%. LVN 2 verified the above findings and stated Resident 42's oxygen dial should have been set to 3 liters per minutes as ordered by the physician. On 1/23/2020 at 1134 hours, a concurrent observation and interview was conducted with LVN 2 regarding Resident 42. Resident 42 was observed with the dial on her oxygen tank set to 2 liters per minute. LVN 2 verified the above finding and stated Resident 42 should have been on 3 liters of oxygen. 2. On 1/23/2020 at 1456 hours, a concurrent observation and interview was conducted of Resident 6 with LVN 8. Resident 6 was observed wearing a nasal cannula. Resident 6's oxygen tank was observed to be turned off. LVN 8 verified the above finding and stated the oxygen tank should have been turned on. LVN 8 checked Resident 6's oxygen saturation level. Resident 6's oxygen saturation level was 90%. Medical record review for Resident 6 was initiated on 1/23/2020. Resident 6 was readmitted to the facility on [DATE]. Review of Resident 6's Physician Orders dated 1/1 - 1/31/2020, showed a physician's order dated 7/14/19, for oxygen at 2 liters per minute via nasal canal continuously for shortness of breath.

CONCERN (D)

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

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide treatment and care in accordance with professional standards of practice for adequate pain management for one of 23 final sampled residents (Resident 81) and one nonsampled resident (Resident 82). * Resident 81 was administered pain medication outside of the physician's ordered pain parameters. The resident had two physician's orders for moderate pain, and no physician's orders for mild, severe and very severe pain. * Resident 82 was administered discontinued pain medication. These failures resulted in the residents' pain not being treated effectively and lack of an individualized resident centered pain management plan to meet the specific needs of the residents. Findings: 1. Medical record review for Resident 81 was initiated on 1/22/2020. Resident 81 was readmitted to the facility on [DATE]. On 1/24/2020 at 0756 hours, a medication pass observation was conducted with LVN 3 for Resident 81. LVN 3 assessed resident 81 for pain, and Resident 81 stated they had a pain rating of 8/10 on the pain scale (on a scale of 0 - 10, 0 being no pain to 10 being the worst pain). LVN 3 prepared and administered Percocet 10/325 mg to Resident 81. Review of Resident 81's Physician Orders dated 1/1 - 1/31/2020, showed the following physician's orders for as needed pain medication: - An order dated 10/18/19, for Percocet 10/325 mg every six hours as needed for moderate pain. - An order dated 12/6/18, for Tylenol 750 mg every four hours as needed for moderate pain. Review of the facility's Pain Assessment Flow Sheet showed the following pain levels based on a word description pain scale of 0 through 10: - mild pain: pain level described as 1 through 4; - moderate pain: pain level described as 5 through 7; - severe pain: pain level described as 8 through 9; and - very severe: pain level described as 10. On 1/24/2020 at 0938 hours, a concurrent interview and medical record review was conducted with LVN 3. LVN 3 stated the pain scale severity levels as moderate pain for a pain level of 5-7, severe for a pain level of 8-9, and very severe for a pain level of 10. LVN 3 verified the resident had a pain level of 8 and was administered Percocet because she did not have an order for anything stronger. LVN 3 stated Resident 81 had an order for Tylenol for mild pain. When asked to locate the order, LVN 3 reviewed the orders and stated the Tylenol was ordered for moderate pain. LVN 3 verified Resident 81 did not have orders for mild, severe or very severe pain. When LVN 3 asked how they determined which pain medication to administer as needed, LVN 3 stated Resident 81 usually wanted the Percocet, so she administered the Percocet. 2. Medical record review for resident 82 was initiated on 1/23/2020. Resident 82 was admitted to the facility on [DATE]. Review of Resident 82's Physician Orders showed the following: -An order dated 1/2/2020, for Norco 5/325 mg, one tablet as needed for moderate pain for 14 days, with a discontinue date of 1/16/2020. -An order dated 1/2/2020, for Norco 5/325 mg, two tablets as needed for severe pain, for 14 days, with a discontinue date of 1/16/2020. Review of Resident 82's Medication Record for 1/2 - 1/31/2020, showed the area to document the administration of Norco 5/325 mg, one tablet as needed for moderate pain contained initials documenting the administration of Norco 13 of the 15 days between 1/2 - 1/16/2020. Two initials were documented for 1/17/2020, and 1/18/2020, showing Resident 82 was administered Norco. The remainder of the dates for January 2020 were blocked out with asterisks. The Medication Record to document the Norco 5/325 mg, two tablets as needed for moderate pain showed the resident received one dose between 1/2 - 1/16/2020. The remaining dates from 1/17 -1/31/2020, were blocked out with asterisks. On 1/23/2020 at 1033 hours, an interview and inspection of the medication cart on Station 2 was conducted with LVN 2. During the inspection, LVN 2 stated she had administered Norco to Resident 82 earlier in the morning. Review of the Medication Record for January 2020 showed the medication had asterisks for 1/17 through 1/31/2020. LVN 2 stated the asterisks meant the medication was discontinued. LVN 2 verified the order was discontinued when she administered the medication earlier in her shift. However, on the back of the Medication Record where the nurses were to document the administration of the Norco with the reason, the time, their initials, and the result, two nurses documented the administration of Norco one tablet on 1/17/2020, at 1050 hours and 1/20/2020, at 1620 hours. On 1/29/2020 at 1133 hours, a follow up interview and medical record review was conducted with LVN 2. LVN 2 verified the crossed out initials on 1/17/20 and 1/18/20, were hers and stated she administered the Norco on those dates as well as on 1/23/20. When asked why the initials were lined through with error written above them, LVN 2 stated because the order was discontinued and needed to be clarified to continue the order.

CONCERN (D)

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure one nonsampled resident (Resident 640) was free from unnecessary drugs. * The facility failed to discontinue the hydralazine (blood pressure medication) PRN order after five days if Resident 640's systolic blood pressure was stable, as prescribed by the physician. This had the potential for the resident to receive an unnecessary medication, and develop significant side effects such as hypotension (low blood pressure) and tachycardia (abnormally fast heart rate). Findings: Review of Lexicomp, an online reference for healthcare professionals showed adverse effects of hydralazine include hypotension and tachycardia. Medical record review for Resident 640 showed Resident 640 was admitted to the facility on [DATE]. Review of Resident 640's Physician Orders dated 12/31/19, to 1/31/2020, showed a physician's order dated 12/31/19, to administer hydralazine 10 mg via NGT every eight hours as needed for SBP greater than 160, okay to discontinue after five days if the SBP was stable. Another order showed to monitor the blood pressure every eight hours for hydralazine use. Review of Resident 640's Medication Record dated 1/1 to 1/31/2020, showed the order for hydralazine 10 mg via NGT every eight hours as needed for SBP greater than 160, okay to discontinue after five days if SBP is stable. Monitor blood pressure every eight hours for hydralazine use. The Medication Record showed initials of licensed nurses for 0600, 1400, and 2200 hours; however, the record did not show blood pressure measurements. On 1/24/20 1230 hours, a concurrent interview and medical record review was conducted with LVN 4. LVN 4 verified the above findings. LVN 4 was asked where the licensed nurses documented the measurements for Resident 640's blood pressure. LVN 4 stated if there was an order to monitor Resident 640's blood pressure, the measurements should be documented on the medication record. LVN 4 verified there were no documented blood pressure measurements on Resident 640's Medication Record, and the record showed signed initials of licensed nurses only. Review of Resident 640's Nurses Notes showed from 1/1/2020 to 1/4/2020, Resident 640's SBP remained between 128 to 135. Review of Resident 640's Licensed Nurses' Daily Skilled Charting, showed from 1/2/2020, to 1/6/2020, Resident 640's SBP remained between 126 to 132. The above blood pressure measurements did not show a SBP measurement greater than 160. On 1/24/2020 at 1445 hours, a concurrent interview and medical record review was conducted with the DON. The DON verified the hydralazine PRN order for Resident 640, okay to discontinue after five days if systolic blood pressure was stable. The DON verified Resident 640's blood pressure had been stable. The DON verified the order for hydralazine was not discontinued when Resident 640's BP had been stable for five days.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure one nonsampled resident (Resident 640) was free from unnecessary psychotropic drugs (any drug that affects brain activities associated with mental processes and behavior). * The facility failed to ensure the PRN order for lorazepam (antianxiety medication) for Resident 640 was limited to 14 days. This had the potential for the resident to experience adverse effects from the drug. Findings: Medical record review for Resident 640 showed Resident 640 was admitted to the facility on [DATE]. Review of Resident 640's Physician Orders dated 12/31/19 to 1/31/2020, showed an order dated 12/31/19, to administer lorazepam 0.5 mg every six hours PRN for anxiety manifested by hands shaking. The order did not show an end date for administration. Review of Resident 640's Medication Record dated 1/1-1/31/2020, showed to administer lorazepam 0.5 mg via NGT every six hours as needed for anxiety manifested by hands shaking. The medication was signed out from the record on 1/6 and 1/19/2020. On 1/24/2020 at 1230 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 verified the above findings. LVN 4 was asked if Resident 640's lorazepam PRN order was clarified with the physician. LVN 4 stated Resident 640's lorazepam PRN order was not clarified with the physician. Further review of Resident 640's Note to Attending Physician and Prescriber form dated 1/14/2020, showed to evaluate a stop date for Ativan (brand name for lorazepam) 0.5 mg every six hours PRN for anxiety; however, the form did not show a response from the physician to address the stop date for the medication. Cross reference to F867.

CONCERN (D)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 1/24/20 at 0756 hours, a medication pass observation was conducted with LVN 3. LVN 2 was observed preparing and B12 1000 mcg with 30 mg Calcium one tablet, to Resident 81 by mouth. Medical record review for Resident 81 was initiated on 1/23/20. Resident 81 was readmitted to the facility on [DATE]. Review of Resident 81's physician's orders showed an order dated 9/17/18, for B12 1000 mcg one tablet by mouth daily. On 1/24/20 at 0938 hours, an interview and concurrent observation was conducted with LVN 3. LVN verified the bottle of B12 1000 mcg contained 30 mg of calcium. When asked if there was an order for B12 1000 mcg with Calcium 30 mg, LVN 2 stated that's how the B12 was supplied. On 1/29/20 at 0848 hours, a telephone interview was conducted with the Pharmacy Consultant. The Pharmacy Consultant stated for residents with orders for B12, if the supply on hand does not match the physician's orders, the orders needs to be clarified. Cross reference to F755, example #3. Based on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The facility's medication error rate was 7.4%. Two licensed nurses (LVNs 1 and 3) who administered medications were found to have errors. * LVN 1 failed to administer the correct dose of enoxaparin sodium (a blood thinner delivered via injection) to Resident 640. This posed the risk of the resident for bleeding. * LVN 3 failed to administer one medication as ordered. This posed the risk of the resident receiving the unprescribed medications. Findings: 1. On 1/24/20 at 0816 hours, a medication pass observation was conducted with LVN 1. LVN 1 was observed preparing medications for Resident 640 including enoxaparin sodium injection. The label on the Resident 640's enoxaparin sodium box showed 80mg (0.8 ml) syringe, and to inject 0.7 ml (70mg) subcutaneosuly (area under the skin and above the muscle layer) every 12 hours. During the administration of the enoxaparin injection to Resident 640, LVN 1 was asked if he would administer the entire amount of the medication in the syringe. LVN 1 stated yes. The surveyor asked LVN 1 to review the directions shown on the label of the enoxaparin box. The LVN 1 reviewed the directions shown on the label of the enoxaparin box and the medication administration record, and the LVN verified he should not had administered the entire amount of the medication to Resident 640. LVN 1 explained he should only administer 0.7 ml (70 mg) to the resident. LVN 1 verified the syringe contained 0.8 ml of enoxparin. LVN 1 was asked how did he know there was 0.8 ml in the syringe. LVN 1 stated the syringe barrel had measurement indicator which corresponded to the amount of solution in the syringe. Medical record review for Resident 81 was initiated on 1/24/20. Resident 640 was admitted to the facility on [DATE]. Review of Resident 640's Medication Sheet dated 1/20/20, showed Lovenox 70 mg subcutaneously every 12 hours for deep vein thrombosis (blood clot) prophylaxis (preventative measure) until the INR was greater or equal to 2. The medication sheet showed the Lovenox was signed out by the licensed nurses showing the medication was administered to Resident 640. Cross reference to F760.

CONCERN (D)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure one nonsampled resident (Resident 640) was free from significant medication error. Resident 640 was repeatedly administered the wrong dose of a blood thinner, enoxaparin (same as Lovenox). This failure placed Resident 640 at increased risk for bleeding. Findings: Medical record review for Resident 640 was initiated on 1/24/2020. Resident was admitted to the facility on [DATE]. Record review of Resident 640's Physician's Telephone Orders dated 1/20/2020, showed an order to administer Lovenox 70 mg subcutaneously every 12 hours until the INR was greater or equal to 2. Review of the label on Resident 640's enoxaparin label dated 1/20/2020, showed enoxaparin 80 mg in 0.8 ml single dose syringes were supplied for Resident 640. The label also showed to inject 70 mg (0.7 ml) subcutaneously every 12 hours. Review of Resident 640's Medication Sheet dated 1/20/2020, showed Lovenox 70 mg subcutaneously every 12 hours for deep vein thrombosis (blood clot) prophylaxis (prevention) until the INR was greater or equal to 2. The medication sheet showed the Lovenox was signed by the licensed nurses showing the medication was administered to Resident 640. On 1/24/2020 at 0816 hours, an observation of medication administration and concurrent interview and medical record review was conducted with LVN 1. LVN 1 was about to administer enoxaparin 80 mg. LVN 1 was asked to stop and verify the order. LVN 1 verified the medication label showed a directive to administer enoxaparin 70 mg every 12 hours. LVN 1 stated he did not know there was 0.8 ml (80 mg) in the syringe. LVN 1 stated he had administered 80 mg of enoxaparin twice before, on 1/22 an 1/23/2020. On 1/24/2020 at 1207 hours, a follow-up interview and concurrent medical record review was conducted with LVN 1. During the review of the Resident 640's Medication Sheet with LVN 1, LVN 1 verified he signed the Lovenox on the Medication Sheet and administered 80 mg to Resident 640 on 1/22, 1/23, and 1/24/2020 at 0900 hours. LVN 1 verified the Lovenox order was to administer 70 mg, not 80 mg. Cross reference to F759, example #1.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to ensure the medications were properly stored and labeled. * Discontinued Norco (a narcotic pain medication) 5/325 mg was found in Station 2' s medication cart. * Two containers of nitroglycerin (a medication used to treat chest pain) were left unattended, stored inside the medication administration record binder located on top of Station 2's medication cart. * One opened and undated single-use vial of Epogen (an injectable medication used to treat anemia) was found in the medication refrigerator. * One opened and undated bottle of lubricating eye drops was observed in Station 2's medication cart. * One loose unidentified tablet was found in an box containing an opened bottle of artificial tears located in the medication cart for Station 2. * Multiple loose unidentified tablets were found in two drawers of the medication cart for Station 1. Failure to properly label medications and dispose of expired medications had the potential to compromise the efficacy of the medications, allowed unlicensed staff and residents access to unsecured medications and access to discontinued medications. Findings: 1. On 1/23/2020 at 1033 hours, inspection of the medication cart for Station 2 was conducted with LVN 2. The following was identified: a. Two containers of nitroglycerin were observed inside the medication administration binder located on top of the medication cart. LVN 2 stated she needed to put them away. During the cart inspection, LVN 2 walked away from the cart and went into another room down the hallway. While the LVN was away, a Medical Records staff member opened the binder where the two containers were left unattended and unsecured. When LVN 2 returned, she verified she forgot to store the medication. b. A bubble pack with 23 tablets of Norco 5/325 mg for Resident 82 was observed. When the medication was compared to Resident 82's medication administration record, LVN 2 stated the medication had been discontinued. Medical record review for Resident 82 was initiated on 1/23/2020. Resident 82 was admitted to the facility on [DATE]. Review of Resident 82's Physician Orders showed an order dated 1/2/2020, for Norco 5/325 mg, one tablet as needed for moderate pain for 14 days, with a discontinue date of 1/16/2020. Another order dated 1/2/2020, showed to administer Norco 5/325 mg, two tablets as needed for severe pain, for 14 days, with a discontinue date of 1/16/2020. On 1/24/2020 at 1032 hours, an interview was conducted with the DON. The DON stated discontinued controlled medications should be given to the DON to be stored until they could be destroyed with the pharmacist. c. An opened and undated bottle of Artificial Tears was observed in the top drawer. LVN 2 stated the bottle should be dated to show when it was opened. d. A loose, unidentified tablet was observed inside a box of Artificial Tears along with the bottle of Artificial Tears. LVN 2 stated she could not identify the tablet and verified it should not have been there. 2. On 1/23/2020 at 1024 hours, an interview and observation was conducted with RN 1. An inspection of the medication refrigerator for Stations 1 and 2 was inspected. An opened, undated vial of Resident 339's Epogen was observed inside the refrigerator. RN 1 stated the resident had been discharged from the facility and the medication vial should be removed. Closed medical record review for Resident 339 was initiated on 1/23/20. Resident 339 was discharged from the facility on 12/28/19. The National Drug Code listing, a system used to identify drug products, showed the Epogen vial was a single use vial. Lexicomp, an online resource for healthcare professionals, showed the Epogen single-dose vial contained no preservatives and unused portions must be discarded. 3. On 1/23/2020 at 1411 hours, inspection of the medication cart for Station 1 was conducted with LVN 3. During the inspection of the medication cart, there were multiple loose tablets observed on the bottom section of the two drawers which contained bubble packs of medications. These findings were verified by LVN 3.

CONCERN (D)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected 1 resident

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Based on observation, interview, facility P&P review, and facility document review, the facility failed to ensure the menu was followed for one of 23 final sampled residents (Resident 39). This failure had the potential to affect the nutritional intake of the resident. Findings: Review of the facility's P&P titled Meal Distribution dated 5/14 showed nursing staff shall be responsible for verifying meal accuracy. Review of the facility's document titled Diet Guide Sheet, under Lunch, Day 11, dated Week 2, Wednesday, showed a mechanical soft diet included whipped sweet potatoes, herbed green beans, pumpkin cheesecake bar, milk, coffee, dinner roll/bread, and ground turkey with cranberry glaze. Medical record review for Resident 39 was initiated 1/22/2020. Resident 39 was on a cardiac mechanical soft diet. On 1/22/2020 at 1304 hours, an observation of lunch service and concurrent interview was conducted with Resident 39. Resident 39's meal tray did not include a dinner roll or bread. Resident 39 stated she did not always receive what was written on the menu. Resident 39 added she would have liked to receive all the items listed on the menu. On 1/22/2020 at 1312 hours, an interview was conducted with the RD. The RD verified Resident 39 was not served a dinner roll or bread. The RD stated Resident 39 should have received items listed on the menu.

CONCERN (D)

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

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

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Based on observation, interview and medical record review, the facility failed to provide food that accommodated resident allergies, intolerance, and preferences for one nonsampled resident (Resident 139), and one of 23 final sampled residents (Resident 39). * Resident 139 stated she was allergic to green beans and was lactose-intolerant; however, she was served green beans and regular milk on her lunch tray. * Resident 39 was not served food listed on her list of preferences. These failures had the potential to negatively impact the residents' well-being. Findings: 1. Review of the Physician Orders for Resident 139, showed an order dated 1/21/2020, for a mechanical soft carbohydrate controlled diet. On 1/22/2020 at 1315 hours, a concurrent observation and interview was conducted with Resident 139. Resident 139 was observed eating lunch brought by her family member while waiting for the lunch tray from the kitchen. Resident 139 stated she could not eat bean products and soy milk or regular milk which caused her to have diarrhea and a rash. On 1/22/2020 at 1330 hours, a concurrent observation and interview was conducted with the RD in Resident 139's room. The lunch tray from the kitchen was delivered to Resident 139's bedside table. Whipped sweet potatoes, cooked green beans and regular milk were observed on Resident 139's lunch tray. Resident 139 stated she could not have the green beans and the regular milk. Review of the meal ticket on Resident 139's tray with the RD, showed Resident 139's lunch menu on 1/22/2020 was whipped sweet potatoes, seasoned spinach and Lactaid milk. the RD verified the findings. The RD stated the green beans and regular milk should not been on Resident 139's tray. The RD stated the food should have been checked for accuracy and accommodated Resident 139's allergies, intolerance, and preferences. 2. Review of Resident 39's lunch meal ticket dated 1/22/2020, showed the resident's tray should include mashed potatoes, herbed green beans, skim milk, pumpkin cheesecake bar, ground chicken noodle soup, dinner roll or bread, ground smothered turkey patty, and mechanical soft cottage cheese. On 1/22/2020 at 1304 hours, a concurrent observation of lunch service and an interview was conducted with Resident 39. Resident 39's meal tray did not include cottage cheese and soup. Resident 39 stated she liked cottage cheese and she wanted to eat it with each meal. On 1/22/2020 at 1312 hours, an interview was conducted with the RD. The RD verified Resident 39 did not receive cottage cheese and soup. The RD verified those two items to be Resident 39's preferences. The RD stated Resident 39 should have been served items on her preference list.

CONCERN (D)

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

QAPI Program (Tag F0867)

Could have caused harm · This affected 1 resident

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Based on interview and facility document review, the facility failed to implement their QAPI plan of action. There was no documentation to show the facility had monitored the effects of the corrective action plans to identify if they had achieved and sustained improvement for one repeated deficient practice cited at F758 in accordance with their plan of correction (POC) from the last recertification survey completed on 3/19/19. This had the potential to affect the quality of care for all residents in the facility with orders for as needed psychotropic medications. Findings: On 1/29/2020 at 1057 hours, an interview and concurrent facility document review was conducted with the Administrator and the DON. Review of the POC submitted by the facility to the California Department of Public Health, Licensing and Certification Program for F758 cited from the last recertification survey completed on 3/19/19, showed the licensed nurses would monitor for compliance during the daily 24-hour chart check. Any findings would be corrected and reported to the DON. While reviewing the facility's POC, the DON stated she would locate the daily monitoring tool utilized by the staff. On 1/29/2020 at 1154 hours, a follow-up interview was conducted with the Administrator and the DON. The Administrator and the DON stated they were unable to locate the monitoring tool to show their POC was implemented.

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 1/22/2020 at 1031 hours, an concurrent observation and interview was conducted with LVN 1. Resident 65's syringe for the GT was observed undated. LVN 1 verified the finding. Medical record review for Resident 65 was initiated on 1/22/2020. Resident 65 was admitted to the facility on [DATE]. Review of the Physician Orders for Resident 65 showed an order dated on 12/10/19, to flush the GT with a minimum of 50 ml of water before and after medication administration and change the syringe daily on the 2300 to 0700 hours shift. Review of Resident 65's plan of care showed a care plan problem dated 12/10/19, addressing the GT. The interventions included to change the syringe daily. On 1/29/2020 at 0840 hours, a concurrent observation and interview was conducted with RN 1. The syringe used for Resident 65's GT was observed dated 1/28/2020 at 0600 hours. RN 1 stated the night shift should have changed the syringe before 0730 hours every day due to the risk of infection. On 1/29/2020 at 1030 hours, an interview was conducted with the DSD. The DSD verified the above findings and stated there was a risk of infection if the nurse did not change the syringe daily as ordered. 3. On 1/22/2020 at 1031 hours, a concurrent observation of Resident 141's GT syringe and interview was conducted with LVN 1. Resident 141's GT syringe was observed hanging next to the feeding bag. The GT syringe was undated. LVN 1 verified the finding. Medical record review for Resident 141 was initiated on 1/22/2020. Resident 141 was admitted to the facility on [DATE]. Review of the Physician Orders for Resident 141 showed an order dated 1/20/2020, to flush the feeding tube with a minimum of 50 ml of water before and after medication administration and change the syringe daily on the 2300 to 0700 hours shift. Review of Resident 141's plan of care showed a care plan problem dated 1/20/2020, to address the GT feeding. The interventions included to change the syringe daily. On 1/29/2020 at 0840 hours, a concurrent observation and interview was conducted with RN 1. The syringe used for Resident 141's GT was observed dated 1/28/2020 at 0600 hours. RN 1 stated the night shift should have changed the syringe before 0730 hours every day due to the risk of infection. On 1/29/2020 at 1030 hours, an interview was conducted with the DSD. The DSD verified the above findings and stated there was a risk of infection if the nurse did not change the syringe daily as ordered. Based on observation, interview, and medical record review, the facility failed to maintain infection control practices to help prevent the development and transmission of diseases and infections. * The facility failed to ensure staff practiced contact precautions when entering the room of residents who were on transmission-based precautions. * The facility failed to ensure Resident 65's and 141's GT syringes were changed daily according to the physician's order for one nonsampled resident. These failures posed the risk of infection and the transmission of disease causing microorganisms. Findings: 1. According to the CDC, for contact precautions, everyone should wear a gown and gloves for all interactions that may involve contact with the resident or the resident's environment. On 1/24/2020 at 1037 hours, Room A was observed with a precaution sign warning people to perform hand hygiene, don a gown and don gloves before entering the room. CNA 1 was observed inside Room A removing bed linen without wearing a gown. On 1/24/2020 at 1038 hours, an interview was conducted with CNA 1. CNA 1 verified she was not wearing a gown inside Room A. CNA 1 stated she was taking out Room A's bed linens to be cleaned. On 1/24/2020 at 1055 hours, an interview was conducted with LVN 4. LVN 4 stated Residents 192 and 189 residing in Room A were currently on transmission-based contact precautions for MRSA (methicillin resistant staphylococcus aureus, bacteria resistant to common antibiotics) of their wounds. On 1/24/2020 at 1221 hours, an interview was conducted with LVN 4. LVN 4 stated everyone who entered Room A should have been wearing PPE (personal protective equipment) no matter what they were doing in the room.

CONCERN (E)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Medical record review for Resident 239 was initiated on 1/28/2020. Resident 239 was admitted to the facility on [DATE]. Review of Resident 239's Physician Orders for Infusion Therapy showed a physician's order dated 1/18/2020, for Invanz (ertapenem) 1 gram every 24 hours for 11 days. Review of Resident 239's Intravenous Therapy Medication Record (undated) failed to show ertapenem was administered on 1/20/2020. Medication administration entries on 1/18 and 1/19/2020, showed ertapenem was administered at 2000 hours. From 1/21-1/28/2020 ertapenem was administered at 1300 hours. On 1/28/2020 at 0910 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 stated he did not work on 1/20/2020, and stated Resident 239's ertapenem was normally delivered each day but was not delivered on 1/20/2020, due to insurance reasons. RN 1 verified Resident 239's Intravenous Therapy Medication Record showed the resident was administered ertapenem at 2000 hours for the first two days and was not administered ertapenem on 1/20/2020. On 1/28/2020 at 1435 hours, an interview and medical record review was conducted with RN 2. RN 2 stated RN 1 was working on 1/20/2020, and administered the ertapenem to Resident 239 at 1300 hours instead of at 2000 hours as ordered. RN 2 stated the physician was not contacted. When asked why, RN 2 did not respond. RN 2 stated the physician should have been contacted. RN 2 stated she notified the resident on 1/20/2020 about what occurred but did not document it. RN 2 stated she also notified the DON. On 1/28/2020 at 1446 hours, an interview was conducted with the DON. The DON stated RN 3 administered the ertapenem to Resident 239 on 1/20/2020, at 1300 hours instead of 2000 hours as ordered. The DON stated RN 3 did not notify anyone when this occurred. The DON stated the incident was brought to the facility's attention by Resident 239 to RN 2 because the resident knew it was not the correct time for the medication to be administered. The DON stated she notified the physician but did not document it. The DON stated RN 3 did not sign the Intravenous Therapy Medication Record sheet because he ran out of time. On 1/28/2020 at 1508 hours, an interview was conducted with Resident 239. Resident 239 stated on 1/20/2020, an RN gave him his antibiotic at 1330 hours. Resident 239 stated he questioned the RN about why he was receiving his ertapenem dose early. Resident 239 stated the RN did not respond to his question. Resident 239 stated he notified another staff member that he was given the ertapenem dose incorrectly. Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide pharmacy services for three of 23 final sampled residents (Residents 18, 37, and 81) and 13 nonsampled residents (Residents 6, 20, 28, 32, 40, 41, 44, 56, 67, 82, 83, 239, and 640). * Resident 18 had Norco (an opioid medication for pain) and mobic (nonsteroidal anti-inflammatory medication for pain) at their bedside. This had the potential for the resident not being provided with appropriate care and treatment and the possibility of medical complications. * Resident 37's lisinopril (blood pressure medication) was not administered as ordered by the physician. This posed the risk of the resident's blood pressure not being controlled. * Three of 3 medication carts were stocked with vitamin B-12 with calcium instead of B-12. This affected 11 of 11 residents (Residents 6, 20, 28, 32, 40, 41, 44, 56, 67, 81, 83) with physicians' orders for vitamin B-12. This had the potential for the residents to receive unnecessary medication, and develop significant side effects. * The Controlled Medication Count Sheets did not match the medication administration records for Residents 82 and 239, resulting in controlled medications being unaccounted for. * The facility failed to ensure Resident 239's IV ertapenem (antibiotic medication) was administered as ordered. This had the potential for the resident to develop unwanted adverse reactions. * The facility failed to ensure Resident 640's vital signs were appropriately monitored when administering lisinopril. This posed the risk of medical complications. Findings: 1. Review of the facility's P&P titled Medication Administration-General Guidelines revised October 2019 showed the resident is always observed after medication administration to ensure the dose was completely ingested. On 1/22/2020 at 1019 hours, an observation and concurrent interview was conducted with Resident 18. A clear plastic medication cup was observed on the resident's overbed table. Two tablets were observed in the medication cup. Resident 18 stated one of the tablets was Norco and she could not remember what the other tablet was. Resident 18 stated the nurse gave them to her earlier with her other medications, but she didn't take the two tablets yet, and would take them when she needed them. Review of Resident 18's medical record showed two physician's orders dated 1/8/2020, one for Norco 5/325 mg, one tablet every eight hours as needed for pain and another for mobic 15 mg every 12 hours as needed for pain. On 1/22/2020 at 1112 hours, the two tablets were observed on Resident 18's overbed table. On 1/22/20 at 1116 hours, an interview and concurrent observation was conducted with LVN 5. LVN 5 observed the tablets and identified one tablet as Norco and the other tablet as mobic. LVN 5 stated he passed Resident 18's medications at approximately 0900 hours that morning and didn't realize Resident 18 did not take all of them. LVN 5 reviewed Resident 18's medical record and verified Resident 18 did not have orders to leave medications at the bedside. 2. Medical record review for Resident 37 was initiated on 1/23/2020. Review of the Physician Orders showed a physician's order dated 11/4/18, for lisinopril 2.5 mg, one tablet daily for hypertension with instructions to hold the mediation for a SBP less than 110. Review of Resident 37's Medication Records for October and November 2019 showed the lisinopril order with the ordered SBP parameters. Handwritten next to the SBP parameter was a parameter to hold the lisinopril for a heart rate less than 60. Review of the October Medication Record showed on 10/4/19, for the 0900 hours lisinopril dose, Resident 37's heart rate was 54. On 10/26/19, for the 0900 hours dose, Resident 37's heart rate was 59. On 10/29/19, for the 0900 hours dose, the resident ' s heart rate was 54. All three doses were documented as held. Review of Resident 37's Medication Record for November showed on 11/5/19, for the 0900 hours dose of lisinopril, Resident 37's heart rate was 55. On 11/26/19, for the 0900 hours dose, the resident's heart rate was 54. Both doses of lisinopril were documented as held. On 1/29/2020 at 0912 hours, an interview and concurrent medical record review was conducted with LVN 6. LVN 6 stated he spoke to one of the RN Supervisors regarding Resident 37's heart rate and the RN told him to add to hold the resident's lisinopril for a heart rate less than 60 to the Medication Record. LVN 6 reviewed the Medication Records for the above dates and verified those were his initials and the doses were held due to Resident 37's heart rate being below 60. When asked if a physician's order was obtained prior to adding the heart rate parameter to the Medication Record, LVN 6 stated there was no new order obtained. LVN 6 verified there should have been a physician's order obtained. 3. On 1/24/2020 at 0756 hours, a medication administration observation for Resident 81 was conducted with LVN 3. LVN 3 was observed preparing and administering vitamin B-12 with 30 mg of calcium to the resident. Review of Resident 81's Physician Orders showed a physician's order dated 9/17/19, for vitamin B-12, 1000 mcg daily. On 1/24/2020 at 0938 hours, an interview and concurrent observation was conducted with LVN 3. LVN 3 retrieved the vitamin B-12 from the medication cart Station 1 and stated the vitamin B-12 1000 mcg was what she administered to the resident. LVN 3 verified the label showed vitamin B-12 1000 mcg and calcium 30 mg. LVN 3 was asked if there were any other bottles of vitamin B-12 in the cart. LVN 3 removed a bottle of vitamin B-12 100 mcg. The label showed vitamin B-12 100 mcg and calcium 100 mg. When asked if there were any bottles with only vitamin B-12, LVN 3 stated no, and verified the two vitamin B-12 bottles containing calcium were the only vitamin B-12 supply available in the cart. On 1/28/2020 at 0753 hours, an inspection of the medication cart on Station 2 was conducted with LVN 2. LVN 2 removed one bottle of vitamin B-12 1000 mcg from the cart. The bottle was labeled vitamin B-12 1000 mcg and calcium 30 mg. LVN 2 verified no other bottles of vitamin B-12 were located in the cart. On 1/28/2020 at 0758 hours, an inspection of the medication cart on Station 3 was conducted with LVN 7. LVN 7 removed one bottle of vitamin B-12 1000 mcg from the cart. The bottle was labeled vitamin B-12 1000 mcg and calcium 30 mg. On 1/28/2020 at 0815 hours, an interview and concurrent observation was conducted with the Central Supply staff member. The Central Supply staff member stated she was responsible for ordering and stocking the OTC (over-the-counter) floor stock medications. Inspection of the OTC medications showed five bottles of vitamin B-12 1000 mcg and 5 bottles of vitamin B-12 100 mcg. The Central Supply staff member stated she reordered the OTCs when the supply got low. The Central Supply staff member observed the labeling on the vitamin B-12 bottles and verified the label for vitamin B-12 1000 mcg also showed calcium 30 mg, and the label for vitamin B-12 100 mcg also showed calcium 100 mg. The Central Supply staff member stated when she reorders the OTCs, sometimes the company supplies a different brand, but it should be the same active ingredients. The Central Supply staff member stated she was not aware the vitamin B-12 contained calcium. On 1/28/2020 at 1527 hours, a Medical Records staff member provided a report and stated it was all the residents in the facility with active orders for vitamin B-12. The report, titled Order Text Search dated 1/28/2020, listed 11 residents (Residents 6, 20, 28, 32, 40, 41, 44, 56, 67, 81, and 83). The report showed Resident 83 had an active order for vitamin B-12 2500 mg daily. On 1/28/20 at 1531 hours, an interview was conducted with LVN 5. LVN 5 stated they used the floor stock vitamin B-12 1000 mcg tablets for Resident 83 and used 2.5 tablets to provide the 2500 mcg. On 1/29/20 at 0848 hours, a telephone interview was conducted with the Pharmacy Consultant. The Pharmacy Consultant stated for residents with orders for B 12, if the supply on hand does not match the physician's orders, the orders needs to be clarified. Cross reference to F759, example #2. 4. On 1/23/2020 at 1033 hours, an interview, medical record review and concurrent medication cart inspection was conducted with LVN 2. During the inspection, a controlled medication reconciliation was conducted. a. Medical record review for Resident 82 was initiated on 1/23/2020. Resident 82 was admitted to the facility on [DATE]. Review of Resident 82's Controlled Medication Count Sheet for Norco 5/325 mg and Resident 82's Medication Record failed to show documentation the removed Norco was administered to the resident for eleven instances on the following dates and times: - 1/4/2020 at 2100 hours, - 1/6/2020 at 2200 hours, - 1/12/2020 at 0700 hours, - 1/13/2020 at 2200 hours, - 1/15/2020 at 1445 hours, - 1/17/2020 at 1621 hours, - 1/18/2020 at 1800 hours, - 1/19/2020 at 1900 hours, - 1/20/2020 at 1630 hours, - 1/21/2020 at 2100 hours, and - 1/22/2020 at 2000 hours. In addition, Resident 82's Controlled Medication Count Sheet showed Norco 5/325 mg was removed on 1/11/2020 at 1700 hours and at 2200 hours. Resident 82's Medication Record only showed one of the doses was administered to the resident, leaving one tablet of Norco 5/325 mg unaccounted for, for a total of 12 Norco 5/325 mg tablets unaccounted for. LVN 2 verified Resident 82's Medication Record did not account for all the Norco tablets signed for on the Controlled Medication Count Sheet. b. Medical record review for Resident 239 was initiated on 1/23/2020. Resident 239 was admitted to the facility on [DATE]. Review of Resident 239's Controlled Medication Count Sheet for Percocet (an opioid medication for pain) 5/325 mg tablets showed Percocet was removed from the supply on 1/20/2020. Review of Resident 239's Medication Record for 1/28 through 1/31/2020, failed to show documentation the Percocet was administered to the resident. LVN 2 verified the Controlled Medication Count Sheet did not correlate with the Medication Record. 5. Review of Lexicomp, an online reference for clinical drug information, showed adverse effects of lisinopril include hypotension (low blood pressure) and dizziness, and to monitor the blood pressure and heart rate. On 1/24/20 at 0816 hours, a concurrent medication administration observation and medical record review was conducted with LVN 1. LVN 1 was observed preparing medications for Resident 640, including a lisinopril tablet. LVN 1 was not observed checking Resident 640's vital signs, including the blood pressure and heart rate during to the administration process of the medication. Review of Resident 640's Physician's Telephone Orders showed to administer lisinopril 10 mg via GT daily for hypertension (high blood pressure). Review of Resident 640's Current Medication, a form from an external facility, with a prescribed date of 12/6/19, showed lisinopril 10 mg, one tablet by mouth for hypertension, hold the medication if the SBP was less than 105 or the heart rate was less than 60 beats per minute. Review of Resident 640's SNF Initial H&P (history and physical) dated 1/1/2020, showed under Impression/Plan section; hypertension, previously hypotensive (low blood pressure), hold blood pressure medications if the SBP less than 110. Review of Resident 640's Medication Sheet dated 1/7/2020, showed lisinopril 10 mg via NGT every day for hypertension. The record showed the lisinopril was signed by the licensed nurses showing the medication was administered to Resident 640. On 1/24/2020 at 1207 hours, a concurrent interview and medical record review was conducted with LVN 1. LVN 1 acknowledged he did not check Resident 640's vital signs when he administered the lisinopril. During review of Resident 640's Current Medication form from an external facility with LVN 1, the LVN acknowledged the form showed the lisinopril medication had a directive to hold if the resident's SBP was less than 105 or the heart rate was less than 60. LVN 1 was asked if the directives, as described above, were clarified with the physician. LVN 1 stated no. LVN 1 verified the directives for the lisinopril should had been clarified with the physician. On 1/24/202019 at 1445 hours, a concurrent interview and medical record review was conducted with the DON. The DON stated it was a best practice of the facility to check the vital signs of a resident who was on anti-hypertensive medications. The DON acknowledged there was no physician's order to check Resident 640's BP and heart rate prior to the lisinopril administration.

CONCERN (E)

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

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 1/23/2020 at 0821 hours, Room B's call light indicator, above the door, was observed illuminated from the hallway. A light indicator on Station A's call light system was observed illuminated, showing Room B needed assistance. However, Station A's call light system had no audible alarm alerting staff a resident was calling for assistance. A staff member was observed sitting at the nurses' station with her back against the call light system. On 1/23/2020 at 0826 hours, Room C's call light indicator, above the door, was observed illuminated from the hallway. While Room B's call light indicator above the door remained illuminated, two light indicators on the call light system were observed illuminated, showing Rooms B and C needed assistance. However, the call light system still had no audible alarm alerting staff residents were calling for assistance. Two staff members were observed walking in the hallways and another staff member was observed sitting at the nurses' station with her back against the call light system. Rooms B and C were not assisted by the staff at this time. On 1/23/2020 at 0945 hours, an interview was conducted with LVN 4. LVN 4 was asked how the call light system worked. LVN 4 stated the call light system had an audible bell to alert staff a resident was calling for assistance. LVN 4 verified the audible bell was not working and had not been working for a couple of days. On 1/23/2020 at 0950 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor verified the audible sound from the call light system was not working and the issue had not been reported to him. The Maintenance Supervisor stated there should have been an audible bell to alert the nurses when the residents called. The Maintenance Supervisor stated he needed to call an outside company to fix the system. The Maintenance Supervisor stated Station A' s call light system serviced 20 of the 37 rooms in the facility. Based on observation, interview, and facility document review, the facility failed to ensure the call light system was in working order for one of 23 final sampled residents (Resident 69) and for one of two nurses' stations (Station A). * The facility failed to ensure the call light for Resident 69 was in working order. * The facility failed to ensure one of two call light systems in the facility was in good working condition. Station A's call light system, which serviced 20 of 37 rooms in the facility, had a broken audible alarm. These failures had the potential for the residents to not receive timely care when calling the staff for assistance. Findings: 1a. Medical record review for Resident 69 was initiated on 1/22/2020. Resident 69 was admitted to the facility on [DATE]. On 1/23/2020 at 0824 hours, CNA 4 was observed pressing Resident 69's bedside call light. The call light failed to trigger the indicator over Resident 69's door to light up. On 1/23/2020 at 0826 hours, an observation of Resident 69's call light was conducted with CNAs 2 and 4. CNA 4 was observed pressing Resident 69 ' s call light 15 times before CNA 2 observed the indicator over Resident 69's door light up. CNAs 2 and 4 verified the above findings. On 1/23/2020 at 0907 hours, an observation and interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor was observed pressing Resident 69's call light six times. The indicator over Resident 69 ' s door did not light up. When asked about the malfunctioning call light, the Maintenance Supervisor stated no one had made him aware the call light was not functioning properly. b. Review of an untitled and undated facility document printed on the facility's letterhead showed Resident 69's bed was previously occupied by two other residents from 11/12 to 12/12/19, at different times. On 1/23/2020 at 0917 hours, an interview and concurrent facility document review was conducted with the Maintenance Supervisor. Review of the Maintenance Log for Station A showed the call light for Resident 69's bed was last reported as not working on 11/13/19, and was not repaired until 12/12/19. The Maintenance Supervisor verified the above. When asked if this meant the two residents who previously occupied Resident 69's room did not have a working call light from 11/13 to 12/12/19, the Maintenance Supervisor answered yes.

CONCERN (F)

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

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

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Based on observation, interview, and facility document review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen. * The food items were stored beyond the use by date. * The unlabeled open glass container of liquid was observed in a toaster. * The kitchen equipment was not clean and properly stored. * The dishes were not properly sanitized. * The food temperatures were recorded before the food was cooked. * The microwave in the dining room was not clean. These failures posed the risk for food borne illnesses in a highly susceptible population of residents who consumed food prepared in the facility. Findings: Review of the CMS 672 Resident Census and Conditions of Residents form completed by the facility dated 1/22/2020, showed 85 of 96 residents residing in the facility received food prepared in the kitchen. 1. During an initial tour of the kitchen on 1/22/2020 at 0945 hours, a concurrent observation and interview was conducted with the Dietary Manager. The following were identified: - A bottle of milk with an expiration date of 1/18/20; - An opened bottle of fat free milk without an opened date; - A can of green chili with an expiration date of 8/9/19; and - An open liquid glass container without a label was observed in a toaster. The Dietary Manager verified the findings. The Dietary Manager stated the items above should have been discarded. 2. Review of the facility's P&P titled Food Preparation revised 9/2017 showed all utensils, food contact equipment, and food contact surfaces will be cleaned and sanitized after every use. During initial tour of the kitchen on 1/22/2020 at 0945 hours, a concurrent observation and interview was conducted with the Dietary Manager. A storage rack was observed with sticky dust. A scoop for dry goods was sitting on top of the rack. Another scoop used for dry goods was observed covered in a dusty substance. The Dietary Manager verified the findings. The Dietary manager stated they should have cleaned the equipment. On 1/23/2020 at 1345 hours, an observation was conducted in the kitchen. The Dietary Aid was observed hand washing dishes in the two-compartment sink. The sanitizing compartment sink was observed filling with approximately four to five inches of sanitizer solution. The Dietary Aide was observed placing the washed and rinsed metal food bins upside down with approximately four inches of the bins sticking out of the sanitizer solution. After eight minutes, the Dietary Aide was observed removing the bins without submerging all sides of the bins and placing them to air dry above the sink. On 1/23/2020 at 1358 hours, an interview was conducted with the Dietary Aide. When asked about the process of sanitizing the metal bins, the Dietary Aide stated he dipped the metal bins into the sanitizing sink then air dried them. When asked how he made sure all sides of the metal bins were completely dipped in the sanitizer solution, the Dietary Aide was not sure. On 1/23/2020 at 1403 hours, an interview was conducted with the Dietary Manager. The Dietary Manager verified the findings and stated the dishes should not have been air dried, they should have been placed through the dish washing machine. 3. Review of the facility's P&P titled Food Preparation revised 7/2017 showed the temperature for Time/Temperature Control for Safety (TCS) foods will be recorded at the time of service. On 1/22/2020 at 1020 hours, a concurrent observation and interview was conducted with the Dietary Manager. The food temperatures for lunch trays were observed recorded before the food was cooked. The Dietary Manager verified the findings. The Dietary Manager stated the [NAME] should have taken the food temperatures after he cooked the food. On 1/23/2020 at 1040 hours, an interview was conducted with the Cook. When asked about the food temperatures recorded on 1/22/2020 at 1020 hours, the [NAME] stated he should have done it correctly by taking the temperatures at the steam table. 4. On 1/23/2020 at 1102 hours, a concurrent observation and interview was conducted with CNA 2. A microwave in the dining room was observed with a paper towel and orange residue in it. The bottom corner of the microwave appeared burned. The top of the microwave was observed with food residue on it. CNA 2 verified the findings. CNA 2 stated the alert residents microwaved their own food, and the housekeeping staff was in charge of cleaning the microwave. On 1/23/2020 at 1124 hours, an interview was conducted with the housekeeping staff. The housekeeping staff stated she usually cleaned the microwave in the dining room every day after lunch. However, the housekeeping staff stated it was everybody's responsibility to clean it. On 1/23/2020 at 1143 hours, an interview was conducted with the RD. The RD stated it was everyone's responsibility to clean the microwave. The RD stated the residents should not be microwaving their own food, the CNAs and LVNs should microwave the food for the residents.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0582 (Tag F0582)

Minor procedural issue · This affected multiple residents

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Based on interview and facility document review, the facility failed to provide two nonsampled residents (Residents 20 and 59) with the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055. The SNF ABN Form CMS-10055 is used to inform residents of their potential financial liability and appeal rights and protections should they wish to receive care and services that may not be covered by Medicare. Failure to provide this information to the residents posed the risk of the residents not being allowed to make an informed decision regarding their Medicare services. Findings: On 1/28/2020 at 1145 hours, an interview and concurrent facility document review was conducted with the Administrator regarding Residents 20 and 59. The Administrator stated Resident 20's Medicare Part A skilled services episode start date was 10/28/2020, the last covered day of Part A service was 12/18/2020, and Resident 20 continued residing in the facility after their Medicare Part A services ended. The Administrator stated Resident 59's Medicare Part A skilled services episode start date was 7/12/19, last covered day of Part A services was 9/29/19, and Resident 59 continued residing in the facility after their Medicare Part A services ended. The Administrator was asked to provide the original notice or documentation Residents 20 and 59 were provided the SNF ABN Form CMS-10055. The Administrator stated Residents 20 and 59 were not provided the SNF ABN Form CMS-10055.

MINOR (B)

Minor Issue - procedural, no safety impact

Medical Records (Tag F0842)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to maintain complete and accurate medical records for one of 23 final sampled residents (Resident 11). The facility failed to document Resident 11's hearing assessment accurately. This posed the risk of the interdisciplinary team staff having inaccurate information when providing care to the resident. Findings: Medical record review for Resident 11 was initiated on 1/22/20. Resident 11 was admitted to the facility on [DATE]. Review of Resident 11's History and Physical dated 9/13/19, did not show an assessment addressing the resident's hearing. Review of Resident 11's Otolaryngology and Ear, Nose, Throat Consults dated 12/6/18, and 5/24/19, did not show assessments addressing the resident's hearing loss. Review of Resident 11's Ophthalmology Exam, Consult and Report dated 10/24/19, showed hard of hearing per son. Review of Resident 11's MDSs dated 4/29/19, and 10/28/19, showed the resident's hearing was highly impaired. Review of Resident 11's Weekly Summary showed the resident was assessed multiple times with adequate hearing function. For example, from 1/20 through 1/26/2020, from 10/6 through 10/13/19, and from 9/29 to 10/6/19. Review of Resident 11's Social Service Assessments dated 1/29, 4/29, 7/29, and 10/28/19, showed the resident was deaf. Review of Resident 11's Activity Progress Notes dated 1/29, 4/29, and 7/30/19, showed the resident had adequate hearing function. On 1/23/2020 at 1348 hours, a concurrent interview and medical review was conducted with the Social Services Director. The Social Services Director was asked to describe the hearing function of Resident 11. The Social Services Director stated Resident 11 was deaf. The Social Services Director explained she obtained the hearing status of the Resident 11 from the resident's family. On 1/28/2020 at 1427 hours, a concurrent interview and medical record review was conducted with MDS Coordinator 1. The MDS Nurse was asked to describe Resident 11's hearing assessment. MDS Coordinator 1 stated Resident 11's hearing function was highly impaired. MDS Coordinator 1 was asked to explain what highly impaired meant. MDS Coordinator 1 stated highly impaired meant Resident 11 had an absence of useful hearing. MDS Coordinator 1 explained Resident 11 could not hear, including conversations and music. MDS Coordinator 1 was asked to describe how she performed hearing assessment on Resident 11. MDS Coordinator 1 stated she performed the hearing assessment for Resident 11 by interviewing the resident's family member. MDS Coordinator 1 verified there were inconsistencies of Resident 11's hearing assessment within the interdisciplinary team staff.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

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

Our Honest Assessment

Strengths

• No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
• No fines on record. Clean compliance history, better than most California facilities.
• 36% turnover. Below California's 48% average. Good staff retention means consistent care.

Concerns

• 99 deficiencies on record. Higher than average. Multiple issues found across inspections.
• Grade C (50/100). Below average facility with significant concerns.

Bottom line: Mixed indicators with Trust Score of 50/100. Visit in person and ask pointed questions.

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About This Facility

What is Gordon Lane's CMS Rating?

CMS assigns GORDON LANE CARE CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within California, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Gordon Lane Staffed?

CMS rates GORDON LANE CARE CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 36%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Gordon Lane?

State health inspectors documented 99 deficiencies at GORDON LANE CARE CENTER during 2020 to 2025. These included: 87 with potential for harm and 12 minor or isolated issues. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.

Who Owns and Operates Gordon Lane?

GORDON LANE CARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by DAVID & FRANK JOHNSON, a chain that manages multiple nursing homes. With 99 certified beds and approximately 92 residents (about 93% occupancy), it is a smaller facility located in FULLERTON, California.

How Does Gordon Lane Compare to Other California Nursing Homes?

Compared to the 100 nursing homes in California, GORDON LANE CARE CENTER's overall rating (2 stars) is below the state average of 3.1, staff turnover (36%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Gordon Lane?

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

Is Gordon Lane Safe?

Based on CMS inspection data, GORDON LANE CARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in California. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Gordon Lane Stick Around?

GORDON LANE CARE CENTER has a staff turnover rate of 36%, which is about average for California nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Gordon Lane Ever Fined?

GORDON LANE CARE CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Gordon Lane on Any Federal Watch List?

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

Facility Details

Beds: 99
Avg. Residents: 92
Occupancy: 93.6%
Ownership: For profit - Limited Liability company
Chain: DAVID & FRANK JOHNSON
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
2-Star Rating: +10
99 Deficiencies: -10
Final Score: 50/100

Nearby Alternatives

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Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 555797