WEST GARDENA POST ACUTE
For profit - Limited Liability company
50 Beds
ABRAHAM BAK & MENACHEM GASTWIRTH
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
43/100
#505 of 1155 in CA
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
West Gardena Post Acute has a Trust Grade of D, indicating below-average performance with some concerning issues. It ranks #505 out of 1155 facilities in California, placing it in the top half, and #81 out of 369 in Los Angeles County, meaning only 80 local options are better. The facility is showing improvement, reducing its number of issues from 12 in 2024 to just 1 in 2025. Staffing is average, with a rating of 3 out of 5 stars and a turnover rate of 40%, which is similar to the state average. However, it has concerning fines totaling $40,870, which is higher than 88% of California facilities, indicating potential compliance problems. On a positive note, RN coverage is better than 90% of California facilities, which can help catch issues that other staff might miss. However, there have been serious incidents, such as a resident not receiving timely medical attention for a change in condition, leading to an emergency surgery, and a resident falling while being turned by a single staff member when they required two for safety. These incidents highlight both the strengths and weaknesses of the facility, making it important for families to weigh their options carefully.
- Trust Score
- D
- In California
- #505/1155
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 40% turnover. Near California's 48% average. Typical for the industry.
- Penalties ○ Average
- $40,870 in fines. Higher than 74% of California facilities. Some compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 18 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 35 deficiencies on record. Higher than average. Multiple issues found across inspections.
43/100
Top 43%
Review needed
12 → 1 violations
★★★★☆
4.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 12 issues
2025: 1 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (40%)
8 points below California average of 48%
Facility shows strength in fire safety.
The Bad
Staff Turnover: 40%
Near California avg (46%)
Typical for the industry
Federal Fines: $40,870
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: ABRAHAM BAK & MENACHEM GASTWIRTH
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 35 deficiencies on record
1 life-threatening 2 actual harm
Jul 2025
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained when cockr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained when cockroaches were observed in the kitchen. This deficient practice resulted in the facility's kitchen being closed for use to the residents and had the potential to spread bacteria and viruses that cause illness, affecting the population of residents in the facility (44) who resided in there and who received food from the facility's kitchen by consuming potentially contaminated food.Findings: During an observation on 7/11/2025, at 2:19 p.m., of the facility's dry food storage area in their kitchen, in the presence of the Dietary Services Supervisor (DSS), a medium sized dark brown cockroach was seen running out of a box of white powdered thickener that was inside an open plastic bag. During an observation on 7/11/2025, at 2:26 p.m., of the facility's dry food storage area in their kitchen, in the presence of the Dietary Services Supervisor (DSS), a medium sized dark brown cockroach was seen running out of a box of individually packaged crackers. During a review of the facility pest control invoice dated 5/12/2025, the invoice indicated the facility treated Resident 1's room for roaches. During a review of facility pest control invoice dated 5/20/2025, the invoice indicated the facility treated Resident 1's room for American roaches (water bugs). During a review of facility pest control invoice dated 5/28/2025, the invoice indicated the facility treated Resident 1's room for American roaches. During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis of heart failure ([CHF] a heart disorder which causes the heart to not pump blood efficiently, sometimes resulting in leg swelling). During a review of Resident 1's History and Physical (H&P), dated 6/4/2025, the H&P indicated Resident 1 had capacity to understand and make decisions. During an interview on 7/11/2025 at 2:38 p.m., the Dietary Supervisor (DS) stated the thicker plastic bag should have been closed as part of their infection control practices and so bugs do not get inside. During an interview on 7/11/2025 at 2:40 p.m., the Dietary Aide (DA) 1 stated approximately one month ago, she noticed a few small roaches on a few different occasions in the dry storage area and informed the DS to tell pest control. DA 1 stated pest control came twice in the past month to treat the area. During an interview on 7/11/2025 at 2:44 p.m., the DS stated she had not been informed by anyone that cockroaches were seen in the kitchen, and she had not seen any herself. During an interview on 7/15/2025 at 10:02 a.m., Resident 1 stated approximately one month ago he saw two big roaches in his room but stated he has not seen any since then. During an interview on 7/11/2025 at 12 p.m., the Director of Nursing (DON) stated she had worked at the facility for three years and was not aware there were roaches in the building. The DON stated she found out today (7/11/2025) there were roaches found in the kitchen when the environmental health department came to the facility at approximately 12 p.m. and pointed them out to the DSS. The DON stated the environmental health department staff used a flash light, tapped firmly on a wood shelf in the kitchen and two roaches measuring about one and a half inches came out During review of facility's Policy and Procedure (P/P) titled Pest Control dated 5/2008, the P/P indicated the facility maintains an on-going pest control program to ensure that the building is kept free from insects and rodents.
Oct 2024
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an interview and record review the facility failed to ensure one of 12 sampled resident (Resident 25) advance directive (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an interview and record review the facility failed to ensure one of 12 sampled resident (Resident 25) advance directive (a legal document that specifies what actions should be taken for your health if you are no longer able to make decisions for yourself) had a signature of a witness when it was signed by Resident 25.
This failure had the potential to cause conflict with the residents' wishes regarding health care in the event residents became incapacitated (unable to participate in a meaningful way in medical decisions) or unable to make medical decisions that would not be identified and/or carried out by the facility staff.
Findings:
During a review of Resident 25's admission Record. the admission Record indicated, Resident 25 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including chronic kidney disease (a condition where the kidneys are damaged and cannot filter the blood properly), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control ).
During a review of Resident 25's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/2/2024, the MDS indicated Resident 25 had the ability to make self understood and the ability to express ideas and wants. The MDS indicated Resident 25 had the ability to understand others. The MDS indicated Resident 25 needed partial to moderate assistance with eating. The MDS indicated Resident 25 was dependent on nursing staff for oral hygiene, toileting, showering, bathing, dressing, putting on and taking off shoes, personal hygiene, repositioning and transferring. The MDS indicated Resident 25 had an advance directive available and reviewed.
During a review of Resident 25's History and Physical (H&P), dated 8/11/2024, the H&P indicated Resident 25 had the capacity to understand and make medical decisions.
During a review of Resident 25's Care Plan, dated 8/21/2024, the Care Plan indicated Resident 25 had an advance directive done on 2/5/2023. The Care Plan indicated to review Resident 25's advance directive/ Physician Orders for Life-Sustaining Treatment (POLST- a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) with resident, family, and IDT (Interdisciplinary Team-a group of professionals from different healthcare disciplines who work together to coordinate and deliver personalized care to patients) at least quarterly to ensure they are current and provide education as needed.
During a review of Resident 25's 10/02/24 POLST dated 7/22/2024, the POLST indicated Resident 25 had an advance directive dated 2/5/2023 available and reviewed.
During a concurrent interview and record review on 10/2/2024 at 3:41 p.m., with Social Services Director (SSD), reviewed Resident 25's advance directive. The advance directive indicated on 2/5/2023 there was no signature for a witness. The advance directive indicated it was not valid without two signatures for a witness. The SSD stated an advance directive was when the Resident assigns somebody to make medical decisions when they lose the mental capacity. The SSD stated the Resident must have the mental capacity to initiate an advance directive. The SSD stated the advance directive needs to have at least one witness or it was not valid, and we cannot honor the residents' wishes.
During a review of Resident 25's Progress Notes by the SSD, dated 10/3/2024 at 9:27 a.m., the Progress Notes indicated, a call was placed to Resident 25's Power of Attorney (a legal authorization for a designated person to make decisions about another person's property, finances, or medical care) to inform them that the advance directive that was done on 2/5/2023 was not complete and needs to be notarized and had to have at least one witness.
During an interview on 10/03/2024 at 1:39 p.m., with the Director of Nursing (DON) the DON stated if an advance directive was not valid the residents' health care decision may not be honored.
During a review of the facility's policy and procedure (P&P) titled, Advance Directives, revised 12/2016, the P&P indicated Advance directives will be respected in accordance with state law and facility policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate safety precautions to residents a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate safety precautions to residents at risk for fall and seizures (involuntary muscle movement) for two of three sampled residents (Resident 246, 4). Facility failed to ensure:
a. Resident 246, who was on fall risk precaution with one floor mat placed on the left corner of the bed had no foot metal bedside table on top of the floor mat.
b. Resident 4, who was placed on fall precautions and seizure precaution with a floor mat by the left corner of the bed had no big sized wheelchair placed on top of the floor mat.
This deficient practice had the potential for injury when Residents 246 and 4 would fall out of bed and hit their head on the metal equipment placed on top of the floor mat.
Findings:
During a review of Resident 246's admission Record, the admission Record indicated Resident 246 was admitted to the facility on [DATE], with diagnosed including muscle weakness, lack of coordination (impairment in movement), fracture (broken bone) of other part of pelvis (hip bones).
During a review of Resident 246's Minimum Data Set (MDS, ([MDS] a federally mandated resident assessment tool) dated 9/23/24, indicated Resident 246 had severe cognitive (ability to think and memorize) impairment.
During a review of Resident 246's care plan titled Resident at high risk for falls and injuries related to advancing age, cognitive impairment, visual impairment, communication impairment, limitation of mobility, . dated 9/17/24, indicated interventions including, resident may have floor mat on left side of bed. Educate the resident/family/caregivers about safety reminders, causative risks/factors and what to do if a fall occurs.
During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including cardiomyopathy (diseases of the heart muscle, where the walls of the heart chambers have become stretched, thickened, or stiff), depression (a common mental health condition that causes a persistent feeling of sadness and changes in how you think, sleep, eat and act),atrial fibrillation (an irregular or abnormal heart beat and often very rapid heart rhythm) and epilepsy (disorder in which nerve cell activity in the brain is disturbed, causing seizures [involuntary muscle movements]).
During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 had severe cognitive (ability to learn, understand, and make decisions) impairment and requires assistance for all activities of daily living.
During a concurrent observation and interview on 9/30/2024 at 12:32 p.m., with Licensed Vocational Nurse (LVN) 1 in Resident 246's room, observed Resident 246 lying in a low bed with two grab bars up on both side, floor mat (a cushioning pad designed to help prevent injuries from falls by absorbing the force of impact ) by the left side of the bed with an iron bedside table placed on top of the floor mat LVN 1, stated the bedside table was not supposed to be placed on the floor mat as the floor mat was used for safety precaution because resident was a fall risk. LVN 1 stated if Resident 246 fall out of bed, Resident 246 could hit her head on the heavy iron bedside table that was placed on top of the floor mat. LVN 1 stated it was better to move bedside table away from the floor mat when not in use.
b. During a concurrent observation and interview on 10/01/24 at 1:30 p.m., observed Resident 4 bed side rails was padded, and floor mat, with a wheelchair placed on top of the floor mat. LVN 1 stated the wheelchair should not be placed on top of the floor mat because Resident 4 was a fall risk and on seizure precaution. LVN 1 stated if Resident 4 falls out of bed he could hit his head on the big sized wheelchair placed on top of the floor mat. LVN 1 stated the wheelchair should be removed on top of the floor mat when not in use.
During an interview on 10/02/24 at 10:53 a.m., with LVN 1, LVN 1 stated the floor mat was for fall risk precaution. LVN 1 stated the floor mat can prevent injury in case resident falls from the bed. LVN 1 stated having a side table on top of the floor mat can cause injury to the resident when resident falls out of bed.
During an interview on 10/02/24 at 11:15 a.m., with Certified Nursing Assistant (CNA) 1 stated floor mat keeps the resident safe in the vent resident falls out of bed. CNA 1 stated the floor mat serves a cushion to prevent injury. CNA 1 stated there should not be anything placed on top of the floor mat because resident (in general) can hit their head from the bedside table and wheelchair when they fall out of bed.
During a review of facility's policy and procedure (P&P) titled Falls -clinical protocol dated 3/2018, the P&P indicated The staff and practitioner will review each resident's factors for falling and document in the medical record.
a. Examples of risk factors for falling include lightheadedness, dizziness, multiple medications, musculoskeletal abnormalities, peripheral neuropathy, gait and balance disorders, hypotension, cognitive impairment, weakness, environmental hazards, confusion, visual impairment. Fall risk factors include environmental factors that contribute to the risk of falls include obstacle in the foot path.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess for pain before wound care treatment on one of ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess for pain before wound care treatment on one of three sampled residents (Resident 246) who had a skin tear on right upper knee.
This failure had the potential for Resident 246 to experience unrelieved pain during wound care treatment.
Findings:
During a review of Resident 246's admission Record, the admission Record indicated Resident 246 was admitted to the facility on [DATE], with diagnoses including muscle weakness, lack of coordination (impairment in movement), fracture (broken bone) of other part of pelvis (hip bones).
During a review of Resident 246's Minimum Data Set (MDS, ([MDS] a federally mandated resident assessment tool) dated 9/23/24, indicated Resident 246 had severe cognitive (ability to think, understand, learn, and remember) impairment.
During a review of Resident 246's Physician Order dated 9/16/24, the Physician Order indicated to clean the wound with normal saline (NS-cleaning solution for the wound), pat dry, apply Xeroform (type of dressing), wrap with kerlix (type of dressing) daily for self-inflicted skin tear on right knee. Monitor right knee skin tear for signs and symptoms of infection, pain, or any other complications.
During a review of Resident 246 Physician Order dated 10/2/24, the Physician Order indicated to monitor for pain during, before, and after treatment of right upper knee skin tear every shift.
During a concurrent observation and interview on 10/2/24 at 10:27 a.m., with Licensed Vocational Nurse (LVN) 3, observed Resident 246 complained of pain during wound care treatment. LVN 3 stated Resident 246 had no physician order for pain medication to be given prior to wound care treatment.
During an interview on 10/2/24 at 11: 43 a.m., with LVN 3 stated prior to starting wound care treatment she should have assess Resident 246 pain level. LVN 3 stated she was not aware that Resident 246 did not have an order for pain medication. LVN 3 stated she should assess Resident 246 pain prior to wound treatment and during wound treatment. LVN 3 stated Resident 246 does not have an order for pain medication and had to call the physician to get a physician order.
Review of facility policy and procedure (P&P) titled Treatment Nurse Competency dated 11/15/23, indicated Pain assessed/ observed before, during, and after treatment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to:
1. Clarify physician order for Combivent (generic na...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to:
1. Clarify physician order for Combivent (generic name - ipratropium bromide and albuterol sulfate Inhalation Aerosol [a medication in form of inhalation spray to treat chronic obstructive pulmonary disease {COPD} - a chronic lung disease causing difficulty in breathing) in accordance with manufacturer's specifications for one of ten sampled residents (Resident 14) during medication administration.
2. Ensure availability of Combivent as ordered by the prescriber for one of ten residents (Resident 14).
These failures had the potential to cause duplication of therapy and/or result in worsening of COPD symptoms such as difficulty breathing, and hospitalization.
Findings:
During a review of Resident 14's admission Record, dated [DATE], the admission Record indicated, Resident 14 was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including COPD and sleep apnea (a sleep disorder that causes people to repeatedly stop breathing or breathe shallowly while they sleep).
During a review of Resident 14's History and Physical (H&P), dated [DATE], the document indicated Resident 14 had the capacity to understand and make decisions.
During a review of Resident 14's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated [DATE], the MDS indicated the Resident 14 had intact cognition (ability to think, understand, learn, and remember). The MDS indicated the resident required partial/moderate assistance to maximal assistance from facility staff for activities of daily living (tasks of everyday life that include personal hygiene, dressing, getting in and out of bed or chair, bathing, and toileting.)
During a review of Resident 14's Physician Order Summary Report, dated [DATE], the Physician Order Summary Report indicated the following orders:
Combivent Aerosol 18-103 microgram (mcg - a unit of measurement) / actuation (act - spray of dose) (ipratropium-albuterol) 2 puffs inhale orally as needed for shortness of breath (SOB), order date [DATE], start date [DATE].
Ipratropium-Albuterol Inhalation Solution (the inhalation solution administered via jet nebulizer [small machine that turns liquid medicine into a mist that can be inhaled to treat respiratory illnesses] connected to an air compressor with an adequate air flow, equipped with a mouthpiece or suitable face mask) 0.5-2.5 (3) milligram (mg - a unit of measurement for mass) / 3 milliliter (mL - a unit of measurement for volume) 3 mg/ml inhale orally every 4 hours as needed for shortness of breath or wheezing (high-pitched, whistling sound that can occur during breathing when the airways in the lungs become narrowed or blocked) , order date [DATE], start date [DATE].
During an observation on [DATE] at 12:35 p.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 prepared one medication including Humalog ( medication to treat DM) 100 units (a unit of measurement for insulin)/mL insulin 6 units to be administered subcutaneously as directed per sliding scale.
During a review of Resident 14's active orders as part of medication reconciliation method on [DATE] at 9:53 a.m., the following order was identified with instructions not in accordance with manufacturer specifications:
Combivent Aerosol 18-103 mcg/act 2 puffs inhale orally as needed for shortness of breath (SOB), order date [DATE], start date [DATE].
According to manufacturer's package instructions, the instructions for Combivent Inhalation Aerosol are two inhalations four times a day. May take additional inhalations as required; however, the total number of inhalations should not exceed 12 in 24 hours. Safety and efficacy of additional doses of Combivent Inhalation Aerosol beyond 12 puffs/24 hours have not been studied.
According to manufacturer's package instructions, the instructions for Combivent Respimat (generic name - ipratropium bromide and albuterol inhalation spray) are one inhalation four times a day, not to exceed six inhalations in 24 hours.
During a concurrent interview and record review on [DATE] at 12:03 p.m. with LVN 4, the physician order summary document for Combivent Aerosol 18-103 mcg/act, dated [DATE] was reviewed. The physician order summary indicated Combivent Aerosol 18-103 mcg/act (ipratropium-albuterol) with instructions as two (2) puffs inhale orally as needed for SOB. LVN 4 stated, the frequency for Combivent was not indicated on the order. LVN 4 stated there would be a risk for medication to be overdosed or underdosed because the instructions did not indicate how many times could the medication be used and/or what would be the maximum dosage. LVN 4 stated she should have checked on Resident 14's Combivent's appropriate dosing frequency and if the facility had the medication in stock for Resident 14. LVN 4 stated there would be a high risk of side effects such as shortness of breath if Combivent was underdosed because it would not be effective and may lead to hospitalization. LVN 4 stated if Combivent was overdosed, there would be a risk for chest pain, dry throat, and upper respiratory infections. LVN 4 stated that Combivent was prescribed as needed and Resident 14 had not requested the medication. LVN 4 stated she could not confirm or remember if she had Combivent Inhalation Aerosol in stock in the medication cart because it was as needed. LVN 4 stated Combivent was not administered at all although there was an active physician order since [DATE]. LVN 4 stated Resident 14 was also on ipratropium-albuterol inhalation solution for shortness of breath and wheezing. LVN 4 stated the resident was receiving continuous positive airway pressure (CPAP - a breathing machine designed to increase air pressure, keeping the airway open when the person breathes in) for sleep apnea but did not know if it helped with COPD and did not want to say something that she was not sure about.
During an interview on [DATE] at 4:09 p.m., with the Director of Nurses (DON), the DON stated, Combivent usually prescribed four times a day, not to exceed six times a day for shortness of breath and could be an as needed order. The DON stated Resident 14's physician order for Combivent was missing dose frequency. The DON stated the licensed nurse failed to clarify the medication order with the physician. The DON stated, the resident was usually vocal and will ask for medication, but she has not requested the Combivent to be given. The DON stated it was the nurses' responsibility to clarify the Combivent order and ensure that it was available. The DON stated failure to clarify the order with Resident 14's physician could have resulted in administering more than the manufacturer recommended dose and/or less than the manufacturer recommended dose. The DON stated, Resident 14 was not treated pharmacologically (a term used to describe treatment with a medication) for COPD. The DON stated Resident 14 could have experienced adverse effects such as shortness of breath, tachycardia (a faster heart rate than normal), and hospitalization.
During an interview on [DATE] at 1:17 p.m., with Resident 14, Resident 14 stated she did not remember receiving Combivent Inhalation Aerosol treatment. Resident 14 stated she only used the CPAP machine and would tell the nurse when she needed the breathing treatment.
During a review of Resident 14's Medication Administration Record (MAR) for [DATE] ([DATE] to [DATE]) and [DATE] ([DATE] to [DATE]), the MAR indicated there were no doses of Combivent documented as administered.
During a review of Resident 14's MAR for [DATE] ([DATE] to [DATE]), [DATE] ([DATE] to [DATE]) and [DATE] ([DATE] to [DATE]), the MAR indicated there were no doses of ipratropium-albuterol inhalation solution 0.5-2.5 (3) mg / 3 mL documented as administered.
During a review of Resident 14's pharmacy deliveries for [DATE], dated [DATE], [DATE], [DATE], [DATE],[DATE], [DATE] there was no delivery receipt for Combivent Inhalation Aerosol.
During a review of the facility's policy and procedure (P&P) titled, Medication Orders, dated 11/2014, the P&P indicated, When recording PRN medication orders, specify the type, route, dosage, frequency, strength and the reason for administration.
During a review of the facility's P&P titled, Administering Medications, dated 12/2012, the P&P indicated, Medications shall be administered in a safe and timely manner, and as prescribed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two of three sampled residents (Resident 4 and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two of three sampled residents (Resident 4 and 19) was provided their activities of choice (preference).
This failure had the potential for Resident 4 and 19 to have no mental and emotional interaction that could negatively impact their quality of life.
Findings:
During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including cardiomyopathy (diseases of the heart muscle, where the walls of the heart chambers have become stretched, thickened, or stiff), depression (a common mental health condition that causes a persistent feeling of sadness and changes in how you think, sleep, eat and act), and atrial fibrillation (an irregular or abnormal heart beat and often very rapid heart rhythm).
During a review of Resident 4's Minimum Data Set ([MDS] MDS - a federally mandated resident assessment tool) dated 9/13/2024, the MDS indicated Resident 4 had severe cognitive (ability to learn, understand, and make decisions) impairment and requires assistance for all activities of daily living.
During a review of Resident 4's care plan titled Resident 4 likes to do independent activities such as watching television, listening to music, going outside for fresh air when weather is nice and doing some group activities like playing dominos sometimes and socializing with residents dated 05/21/2024, the care plan interventions including activities will continue to encourage resident to participate in activities of choice, will remind resident of activities of choice, will do one on one activities as needed.
During an observation on 9/30/2024 at 8:41 a.m., and 11:02 a.m., observed Resident 4 in bed sleeping.
During an observation on 10/1/2024 at 10:35 a.m., and 2:03 p.m., observed Resident 4 in bed sleeping.
During a review of Resident 19's admission Record, the admission Record indicated Resident 19 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing), major depressive disorder (a serious mood disorder that can cause a range of symptoms that affect a person's daily life), and chronic kidney disease ([CKD] a condition where the kidneys are damaged and cannot filter blood properly).
During a review of Resident 19's MDS dated [DATE], the MDS indicated Resident 19 had moderate cognitive impairment and requires assistance for all activities of daily living.
During a review of Resident 4's care plan titled Resident 19 prefers independent activities and Resident 19 likes listening to the television in the lobby with other residents from time to time dated 10/02/2024, the care plan interventions including aid with daily care to meet accommodation request and needs and incorporate preferences to daily care and schedule of resident while in the facility.
During an observation on 9/30/2024 at 11:14 a.m., and 2:57 p.m., observed Resident 19 in bed sleeping.
During an observation on 10/1/2024 at 9:03 a.m., and 11:31 a.m., observed Resident 19 in bed sleeping.
During an interview on 10/1/2024 at 2:52 p.m., Resident 19 stated that he would like to go to the activity room and socialize with other residents and was not offered to the resident in the last couple of days.
During a concurrent interview and record review on 10/2/2024 at 3:15 p.m., the licensed vocational nurse (LVN 2) stated that if the activity documentation was empty, it means that activity was not provided. Reviewed Resident 19 activity documentation for 9/25/2024 through 9/30/2024 indicated no documentation of activities were rendered and was not signed.
During a concurrent interview and record review on 10/2/2024 at 4:07 p.m., with the Activity Director (AD), reviewed activity documentation for Resident 4 and 19. The activity documentation for 9/25/2024 through 9/30/2024 indicated no documentation of activities were rendered and was not signed. The AD stated that those dates mentioned above are had no documentation activities were given. The AD stated if a resident (in general) was not getting the activities according to plan it affects the resident psychosocial wellbeing including their mental health.
During the review of facility's policy and procedure (P&P) titled Activity Programs revised 6/2018, indicated: Activity programs are designed to meet the interests of and support the physical, mental, and psychosocial wellbeing of each resident. The activities program is provided to support the well-being of residents and to encourage both independence and community interaction. All activities are documented in the resident's medical record.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 21 of 25 residents rooms met of 80 square feet ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 21 of 25 residents rooms met of 80 square feet ([sq. ft] a unit of area measurement) per residents in multi-bed resident rooms. Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 15, 16, 17, 18, 20, 21, 22, 23, 25, and 26 were occupied with two residents and room [ROOM NUMBER] was occupied with three residents per room, and room [ROOM NUMBER] was occupied with four residents per room.
This deficient practice had the potential to result in an inadequate provision of safe nursing care, and privacy for the residents.
Findings:
On 10/01/24 at 1:57 p.m., during the initial tour of the facility, residents' rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 18, 17, 18, 19, 20, 21, 22, 23, 25, and 26, did not meet the requirement of 80 sq. ft per resident.
A review of Client Accommodations Analysis form, provided by the facility Maintenance Supervisor (MS) rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,12 ,14,15, 16, 17, 18, 19,20,21,22,23, 25, and 26 were occupied by two residents each and total square feet measurement ranged between 139.43 square feet to 148.19 square feet.
During an interview on 10/01/24 at 2:23 p.m., with the Director of Nursing (DON), the DON stated all the residents' rooms were small and the facility submits room waiver every recertification survey yearly.
During a review of Room Waiver letter, dated 9/16/2024, provided by the ADM, the Room Waiver letter indicated, that rooms had enough space to provide for each resident's care, dignity, and privacy. The letter indicated the lack of space on the new building code has no adverse effect in the resident's health and safety or in maintaining the wellbeing of the residents. The following rooms were included in the Room Waiver request: Rooms 1, 2, 3, 4, 5, 6, 7. 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 29, 21, 22, 23, 25, 26.
During a review of Room Waiver letter, dated 9/16/2024, provided by the ADM, the Room Waiver letter indicated, Any concerns regarding room space expressed by any of the resident will be discussed during the Interdisciplinary Team ([IDT a group of professionals that plan, coordinate and deliver personalized health care) meeting for proper Intervention.
During an observations, from 9/30/24 through 10/3/24, the residents residing in these rooms had enough space to move freely inside the rooms. Each resident in the above rooms had beds and side tables with drawers. There was adequate room for the operation and use of wheelchairs, walkers, or canes. Resident room size did not affect the nursing care or privacy provided to the residents.
Jul 2024
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Notification of Changes
(Tag F0580)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's physician was notified when the resident had ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's physician was notified when the resident had a change of condition (COC) for one of three sampled residents (Resident 1). The facility failed to:
1. Ensure Licensed Vocational Nurse 1 (LVN 1) and LVN 2 promptly notified Resident 1's physician when Resident 1 had loose/watery stools for five days as indicated in the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status.
2. Ensure nursing staff implemented Resident 1's Care Plan titled, Resident at Risk for Constipation, by monitoring the amount, consistency, and frequency of Resident 1's bowel movements.
This deficient practice resulted in a delay in care and treatment for Resident 1, who was eventually transferred to a General Acute Care Hospital (GACH) on 7/6/24 where she underwent an emergent total colectomy (a surgical procedure to remove the entire colon), a gastric wedge resection (a surgical procedure in which a wedge shaped portion of the stomach is removed), a partial omentectomy (a surgical procedure to remove a portion of the omentum [a fold of tissue that surrounds the stomach and other organs]), and a temporary abdominal (stomach) closure in the setting of fulminant (something that happens suddenly and with great intensity or severity) clostridoides difficile colitis ([C. Diff- results from the disruption of normal healthy bacteria in the colon, often from antibiotics. Can lead to severe damage to the colon and can be fatal).
Findings:
During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated, Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses included hypernatremia (high sodium levels in the blood), hypertensive heart disease (a condition in which the blood vessels have persistently raised pressure), chronic kidney disease ([CKD] kidney damage lasting three months or more) heart failure (a condition in which the heart cannot pump enough blood to meet the body's needs), hemiplegia (paralysis on one side of the body) and hemiparesis (weakness or paralysis on one side of the body) following a cerebral infarction ([stroke] lack of oxygen to tissues in the brain).
During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 4/25/2024, the MDS indicated Resident 1's cognition (thinking) was moderately impaired.
During a review of Resident 1's History and Physical (H&P), dated 11/17/2023, the H&P indicated, Resident 1 had a fluctuating capacity (situations where a person's decision-making ability varies) to understand and make decisions.
During a review of Resident 1's Care Plan, titled Resident at Risk for Constipation, dated 6/18/2024, the Care Plan indicated Resident 1's goal was to maintain passage of soft formed stools at a frequency perceived as normal through 9/16/2024. The Care Plan's intervention included to monitor the amount, consistency, and frequency of Resident 1's bowel movements.
During a review of Resident 1's Physician's Order Summary Report dated 6/14/2024, the Physician Orders indicated Resident 1 was to receive Cefuroxime Axetil (an antibiotic used to treat a wide variety of bacterial infections) 250 milligrams ([mg] a unit of measurement) two times a day for a urinary tract infection ([UTI] a bacterial infection in any part of the urinary tract) caused by Escherichia coli ([E. coli] a type of bacteria that can cause severe bloody diarrhea) for seven days.
During a review of Resident 1's Medication Administration Record (MAR), dated 6/2024, the MAR indicated Resident 1 received Cefuroxime Axetil from 6/14/2024 through 6/20/2024.
During a review of Resident 1's Bowel and Elimination form, dated 7/1/20204 through 7/5/2024, the Bowel and Elimination form indicated the following:
1. On 7/1/2024 at 2:59 p.m. and 10:59 p.m., Resident 1 had two episodes of large loose/diarrhea (loose and watery stools).
2. On 7/2/2024 at 2:30 p.m., Resident 1 had one episode of a large loose/diarrhea.
3. On 7/3/2024 at 11:14 a.m. and 9:14 p.m., Resident 1 had two episodes of large loose/diarrhea.
4. On 7/4/2024 at 6:09 a.m., 1:29 p.m., and 9:46 p.m., Resident 1 had three episodes of large loose/diarrhea.5. On 7/5/2024 at 9:31 p.m., Resident 1 had one episode of a large loose/diarrhea.
During a review of Resident 1's Clinical Record, the Clinical Record indicated there was had no documentation to indicate licensed nurses monitored Resident 1's stool, per the Care Plan or that Resident 1's physician was notified of Resident 1's loose/diarrhea.
During a review of Resident 1's General Laboratory Work, dated 7/5/2024, the General Laboratory Work indicated Resident 1's Comprehensive Metabolic Panel ([CMP] a blood test that gives doctors information about the body's chemical fluid balance) illustrated Resident 1 had a critically high Creatinine (a waste product that comes from the breakdown of muscle tissue and the digestion of protein in food, [reference range = 0.55 mg/dl- 1.02 mg/deciliter (dl)]) level of 7.6 mg/dl, a critical high blood urea nitrogen ([BUN] a waste product that the kidneys remove from the blood) [reference range = 9.0 mg/dl 23.0 mg/dl) level of 108 mg/dl, and a high sodium (a mineral needed by the body to keep the body fluids in balance, [reference range= 135 milliequivalents per liter (mEq/L - 145 mEq/L]) level of 155 mEq/L.
During a review of Resident 1's Progress Notes, dated 7/6/2024, the Progress Notes indicated at 7:15 a.m. (7/6/2024), Resident 1 was awake and refused breakfast and medications. At 12:30 p.m., Resident 1's vital signs ([v/s] measurements of the body's most basic functions such as breathing, heart rate [HR], temperature, and blood pressure [B/P]) were taken. Resident 1's b/p was unobtainable, HR was 51 beats per minute ([bpm] reference range 60-100 bpm), respiratory rate (RR) was 48 breaths per minute (reference range 12-20 breaths per minute), and the resident's Oxygen Saturation level ([O2 Sat] a measure of how much oxygen is circulating in the blood, reference range 95% - 100%) was 91%. The Progress Notes indicated Resident 1 was lethargic (a condition marked by drowsiness) and unresponsive to verbal commands. The Progress Notes indicated 911 was called and Resident 1 was taken by paramedics to a GACH.
During a review of Resident 1's Situation, Background, Assessment, and Recommendation ([SBAR] a structured framework that provides communication between members of the health care team about a patient's condition), dated 7/6/2024, the SBAR indicated Resident 1 was lethargic, her B/P could not be obtained, and she was short of breath (SOB) with shallow breathing (when you only draw small amounts of air into your lungs, not using full capacity).
During a review of the GACH's Emergency Department (ED) Documentation, dated 7/6/2024, the GACH'S ED Documentation indicated upon admission to the GACH on 7/6/2024, Resident 1 was not alert, her skin was dry, cool, and pale, and her oral mucous membranes (the moist inner lining of some organs and body cavities such as the nose, mouth, lungs, and stomach) were dry. The ED's Documentation indicated Resident 1's B/P was 64/30 millimeters of mercury ([mmHg]the reference range is 120/ 80 mmHg), and her HR was 150 bpm. The ED's Documentation indicated Resident 1 was admitted to the Medical Intensive Care Unit ([MICU] a hospital ward that provides intensive continuous 24-hour care for patients who are critically ill or injured) with a diagnosis of septic shock (a life-threatening condition that happens when your blood pressure drops to dangerously low levels after an infection). The ED's Documentation indicated while in MICU Resident 1's laboratory results on 7/6/2024 indicated the resident had metabolic acidosis (a condition in which the body's fluids have too much acid, resulting in an abnormally low pH [describes the acidity or basicity of a solution]). Resident 1's laboratory results dated [DATE] indicated the following:
1. pH level 7.30 (reference range 7.35- 7.45).
2. Arterial blood carbon dioxide level (indicates how well the lungs remove carbon dioxide [a clear, odorless, and colorless gas] from the blood, reference range 35-45) 20.
3. Bicarbonate level (a form of carbon dioxide, a low level indicates metabolic acidosis) reference range 22-27) 10.
4. [NAME] blood cell count ([WBC] part of the body's immune system that helps the body fight infections and other diseases [reference range 4,000- 11,000 per microliter [cells/ul of blood) 33.4 ul.
5. Creatinine level 9.14 mg/dl.
6. Sodium 153 milliequivalents per liter (mEq/L).
7. Lactate level (a byproduct caused by any type of severe viral or bacterial infection) [reference range= 0.5 mg/dl- 2.2 mg/dl]) 6.9 mg/dl.
The GACH's ED Documentation indicated on 7/7/2024, Resident 1 underwent an emergent total colectomy, gastric wedge resection, partial omentectomy, and temporary abdominal closure in the setting of fulminant C. Diff.
During a concurrent interview and record review on 7/26/2024, at 3:02 p.m., with a certified nursing assistant (CNA 1), Resident 1's Bowel and Elimination documentation was reviewed. CNA 1 stated on 7/2/2024, she notified the charge nurse (CN 1) whose name she does not recall, that Resident 1 had 2 episodes of watery stools and on 7/4/2024.
During an interview on 7/29/2024, at 9:59 a.m., the licensed vocational nurse (LVN 1) stated, no one reported to him that Resident 1 had loose watery stool during the time he worked from 7/1/2024 through 7/4/2024. LVN 1 stated, if he had been notified that Resident 1 had loose watery stool, he would have notified Resident 1's physician, reported this in their morning huddle (a short stand-up meeting 10 minutes or less that is typically conducted at the start of each shift), and completed a COC form.
During an interview on 7/29/2024, at 1:31 p.m., LVN 2 stated, she was not notified by anyone that Resident 1 had loose watery stool, if this was reported to her, she would have notified Resident 1's physician.
During an interview on 7/29/2024, at 2:19 p.m., Resident 1's Physician stated, no one notified him that Resident 1 had loose watery stool, had he known that Resident 1 had loose watery stool for five days, was not eating or drinking along with his abnormal/critical labs results, he would have suspected C. Diff, colitis (a swelling of the large intestine or colon), or diverticulitis (inflammation or infection of small pouches or sacs called diverticula that form in the wall of a hollow organ such as the colon) and would have given instructions to transfer Resident 1 to the GACH sooner than 7/6/2024.
During an interview on 7/29/2024, at 2:45 p.m., the Director of Nursing (DON) stated, the CNAs should have reported when Resident 1 had loose/watery stool to the charge nurse so the charge nurse could call the physician for treatment orders. The DON stated loose/watery stools could lead to dehydration and trigger other medical conditions.
According to Medlineplus.gov https://medlineplus.gov (a national library of medicine), Cefuroxime Axetil can cause serious side effects such as watery or bloody stool, stomach cramps or fever during treatment or for up to two or more months after stopping treatment.
During a review of the facility's P&P titled, Change in a Resident's Condition or Status, dated 12/2016, the P&P indicated, the facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. The P&P indicated prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider.
Jul 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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement one of four sampled resident ' s (Resident 1) care plan t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement one of four sampled resident ' s (Resident 1) care plan to ensure Resident 1 was wearing his Wander guard (bracelets that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time), and that Resident 1 was not going to leave the premises unassisted.
As a result of these deficient practices, Resident 1 eloped from the facility on 7/3/2024 and was without his medications including olanzapine (medication to treat schizophrenia) 15 milligrams twice a day for ten days. Resident 1 was located by facility staff on 7/13/2024 and subsequently transferred to a general acute care facility (GACH) for further evaluation. At the GACH, Resident 1 was admitted with diagnoses including acute psychosis (collection of symptoms that affect the mind, where there has been some loss of contact with reality), severe anemia (not enough red blood cells in the body), and Resident 1 received a blood transfusion (process of transferring blood products). According to psychiatric (mental health specialist) consult, Resident 1 was agitated and aggressive was given a sitter (a healthcare worker who will provide continuous supervision to a resident) for safety and placed on a 5150 hold (72-hour involuntary hold in the hospital). The consult indicated Resident 1 required inpatient hospitalization for further stabilization of behavioral symptoms.
Findings:
During a review of Resident 1 ' s admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including paranoid (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly) schizophrenia, type 2 diabetes (problem in the way the body regulates and uses sugar as fuel), and hypertension (when the force of blood pushing against the walls of blood vessels is too high).
During a review of Resident 1 ' s Psychiatric Evaluation, dated 6/12/2024, the mental status examination indicated Resident 1 ' s judgement and insight were moderately impaired. The evaluation indicated Resident 1 was disheveled, very disorganized and was a poor historian. The evaluation indicated Resident 1 had delusions (altered reality that is persistently held despite evidence or agreement to the contrary) and auditory hallucinations (when the person hears voices or noises that don't exist in reality). The evaluation indicated Resident 1 was diagnosed with psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality).
During a review or Resident 1 ' s History and Physical (H&P), dated 6/13/2024, the H&P indicated Resident 1 was unable to communicate/ make decisions for self.
During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 6/15/2024, the MDS indicated Resident 1 had severe cognitive (ability to learn, remember, understand, and make decision) impairment for skills on daily decision making. The MDS indicated Resident 1 needed set up assistance with eating, supervision (helper provides verbal cues) with oral hygiene, upper body dressing, personal hygiene, and needed partial assistance (helper less than half the effort to complete the task) with toilet hygiene, and lower body dressing.
During a review of Resident 1 ' s Admission/readmission Initial Assessment, dated 6/11/2024, the assessment indicated Resident 1 was a high risk for elopement because Resident 1 was independently mobile and had a history of elopement.
During a review of Resident 1 ' s Weekly Summary, dated 6/30/2024 at 2:38 a.m., the summary indicated Resident 1 was alert and confused.
During a review of Resident 1 ' s Order Summary Report, active orders as of 7/5/2024, the summary indicated the following orders, starting on 6/11/2024:
a. May have wander guard to the left hand to alert staff of resident trying to leave facility unassisted.
b. Check wander guard placement every shift.
c. Monitor Resident 1 for episodes of wandering behavior (a behavioral problem of disorientation and difficulty relating to the environment with aimless or purposeful motor activity that causes a social problem such as getting lost, leaving a safe environment, or intruding in inappropriate places) around hallway and patio every shift.
d. Check for wander guard function every Sunday during 7-3 p.m. shift.
e. Olanzapine 15 milligrams one tablet orally two times a day for schizophrenia.
During a review of Resident 1 ' s untitled care plan, focus indicated Resident 1 was at risk for elopement related to cognitive impairment, and mood and behavioral symptoms, initiated 6/17/2024. The care plan goal indicated Resident 1 will not leave the facility unsupervised. Care plan interventions included:
a. May have wander guard on left hand to alert staff if resident was trying to leave the facility unassisted.
b. Check wander guard function every Sunday during day shift.
c. Check wander guard placement on the left hand every shift
d. Monitor Resident 1 for wandering behavior every shift around the hallway and patio.
e. Frequent rounds by staff
f. Remind resident that he needs to remain in the facility unless family of staff member was with them.
During a review of Resident 1 ' s Monitoring side effects/Behaviors/black box (added to the labeling of drugs when serious adverse reactions or special problems occur) warnings for 7/2024, the monitoring indicated:
a. Starting 6/11/2024, check wander guard placement every shift. On 7/2/2024 night shift, Resident 1 was absent from the facility without meds on 7/2/2024 night shift.
b. Staring on 6/11/2024, monitor Resident 1 for episodes of wandering behavior, around hallway and patio every shift. In 7/1/2024, Resident 1 was observed with this behavior 4 times. On 7/2/2024, Resident 1 was observed wandering 4 times.
During a review of a document titled Situation Background Assessment Appearance Request (SBAR) Communication Form- General, 7/3/2024 at 1:45 a.m., for Resident 1, the form indicated the following:
a. At 11:00 p.m , Resident 1 was seen lying in bed comfortably watching television in no apparent distress, denied pain or discomfort, and respirations were even and unlabored and no respiratory distress.
b. At 12:00 midnight Resident 1 remained in bed, sitting at the edge of the bed watching television.
c. At approximately 1:15 a.m. the Certified nurse assistant (CNA) noticed Resident 1 was not in the resident ' s room or restroom and made charge nurse aware.
d. At 1 :20 a.m. staff searched for Resident 1 in the facility. Resident 1 ' s wander guard was noted fully stretched on the floor.
e. At 1:36 a.m., the police was notified of Resident 1 ' s elopement.
f. At 1:52a.m. sheriffs arrived.
g. At 2:13 a.m. writer finished giving report to the Sheriff and the Sheriff was made aware Resident 1 was alert and oriented times 2 with episodes of confusion and diagnosed with paranoid Schizophrenia.
During a review of Resident 1 GACH Emergency Department Physician note, dated 7/13/2024 at 7:17 p.m., the note indicated facility staff found Resident 1 wandering around the streets and was brought in by ambulance to GACH for further evaluation. The note indicated Resident 1had acute psychosis, severe anemia, and type 2 diabetes. Resident 1 received a blood transfusion for the anemia.
During a review of GACH Psychiatric consult, 7/14/2024, the consult indicated Resident 1 was agitated and aggressive in the emergency room and Resident 1 was placed with a sitter (a healthcare worker who will provide continuous supervision to a resident) for safety and placed on a 5150 hold (72-hour hold in the hospital). The consult indicated Resident 1 required inpatient hospitalization for further stabilization of symptoms.
During a continued observation and interview on 7/4/2024 at 9:50 a.m., with RNS, it was noted that Resident 1 ' s room was right by the front door that exits to the parking lot (Door 2). Door 2 was also noted with two unsecure (can be opened without a key or a code) latches. The RNS stated that Door 2 does not alarm when opened and at night no one was monitoring the residents exiting Door 2. The RNS stated since Resident 1 removed his wander guard he probably just opened the latches and exited. RNS stated it was not safe to have an unsecure Door 2 because if residents can remove the wonder guard bracelet and open the latches, they can leave at night undetected.
During an interview with Licensed Vocational Nurse (LVN)1 on 7/4/2024 at 2:00 p.m., LVN 1 stated at approximately 1 a.m. CNA 4 stated Resident 1 was not in his room or the restroom. After a search was conducted in the facility the [NAME] was notified and three sheriffs also searched in the premises to no avail.
During a concurrent interview and record review with LVN 1, on 7/5/2024 at 10:53 a.m., Resident 1 ' s records were reviewed. Resident 1 ' s Elopement assessment on admission, dated 6/11/2024, indicated Resident 1 was a high risk for elopement. Resident 1 ' s SBAR, dated 7/3/2024, was reviewed, and the SBAR indicated the stretched out and damaged wander guard was observed on the floor. LVN 1 stated Resident 1 should have had the wander guard on. LVN 1 stated Resident 1 should not have left the facility undetected because it was not safe.
During an interview with the administrator (ADM) on 7/5/2024 at 4:00 p.m., the ADM stated the doors should be secure and adequate monitoring of high risk for elopement residents should be done. The ADM stated to prevent further elopements, in services was completed. The ADM stated the facility will install magnetic door locks to Doors 1 and 2. The ADM stated until the locks were installed the facility staff will be assigned to monitor the door area to ensure no residents elope. The ADM also stated the facility will ensure monitoring of the high risk for elopement residents were being done by documenting the residents ' whereabouts on an hourly basis. The ADM stated this will be a systematic change that will be immediately implemented.
During a review of the facility ' s policy and procedure (P&P) titled Behavioral Assessment, Intervention and Monitoring, revised 3/2019, the P&P indicated the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with comprehensive assessment and plan of care. Residents will have minimal complications associated with the management of altered or impaired behavior. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm.
During a review of the facility ' s P&P titled Care plans, Comprehensive Person-Centered, care plan policy, revised 12/2016, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident.
CONCERN
(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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two facility exit doors, the lobby door (Door 1...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two facility exit doors, the lobby door (Door 1) and front door (Door 2), were secured to prevent the elopement (an unauthorized departure of a resident without the facility's knowledge and supervision) of one of four sampled residents (Resident 1), a resident who had a history of elopement and assessed as high risk for elopement.
As a result of these deficient practices, Resident 1 eloped from the facility on 7/3/2024 and was without his medications including olanzapine (medication to treat schizophrenia) 15 milligrams twice a day for ten days. Resident 1 was located by facility staff on 7/13/2024 and subsequently transferred to a general acute care facility (GACH) for further evaluation. At the GACH, Resident 1 was admitted with a diagnosis including acute psychosis (collection of symptoms that affect the mind, where there has been some loss of contact with reality), severe anemia (not enough red blood cells in the body), and Resident 1 received a blood transfusion (process of transferring blood products). According to psychiatric (mental health specialist) consult, Resident 1 was agitated and aggressive was given a sitter (a healthcare worker who will provide continuous supervision to a resident) for safety and placed on a 5150 hold (72-hour involuntary hold in the hospital). The consult indicated Resident 1 required inpatient hospitalization for further stabilization of behavioral symptoms.
Findings:
During a review of Resident 1 ' s admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including paranoid (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly)schizophrenia, type 2 diabetes (problem in the way the body regulates and uses sugar as fuel), and hypertension (when the force of blood pushing against the walls of blood vessels is too high).
During a review of Resident 1 ' s Psychiatric Evaluation, dated 6/12/2024, the mental status examination indicated Resident 1 ' s judgement and insight were moderately impaired. The evaluation indicated Resident 1 was disheveled, very disorganized and was a poor historian. The evaluation indicated Resident 1 had delusions (altered reality that is persistently held despite evidence or agreement to the contrary) and auditory hallucinations (when the person hears voices or noises that don't exist in reality).
The evaluation indicated Resident 1 was diagnosed with psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality).
During a review or Resident 1 ' s History and Physical (H&P), dated 6/13/2024, the H&P indicated Resident 1 was unable to communicate/ make decisions for self.
During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 6/15/2024, the MDS indicated Resident 1 had severe cognitive (ability to learn, remember, understand, and make decision) impairment for skills on daily decision making. The MDS indicated Resident 1 needed set up assistance with eating, supervision (helper provides verbal cues) with oral hygiene, upper body dressing, personal hygiene, and needed partial assistance (helper less than half the effort to complete the task) with toilet hygiene, and lower body dressing.
During a review of Resident 1 ' s Admission/readmission Initial Assessment, 6/11/2024, the assessment indicated Resident 1 was high risk for elopement because Resident 1 was independently mobile and has a history of elopement.
During a review of Resident 1 ' s Order Summary Report, active orders as of 7/5/2024, the summary indicated, starting on 6/11/2024, Resident 1 may have wander guard to the left hand to alert staff of resident trying to leave facility unassisted. Resident 1 also had Olanzapine 15 milligrams one tablet orally two times a day for schizophrenia.
During a review of Resident 1 ' s Weekly summary, dated 6/30/2024 at 2:38 a.m., the summary indicated Resident 1 was alert and confused.
During a review of Resident 1 ' s Situation Background Assessment Appearance Request (SBAR) Communication Form- General, 7/3/2024 at 1:45 a.m., the form indicated the following:
a. At 11:00 p.m , Resident 1 was seen lying in bed comfortably watching television in no apparent distress, denied pain or discomfort, and respirations were even and unlabored and no respiratory distress.
b. At 12:00 midnight Resident 1 remained in bed, sitting at the edge of the bed watching television.
c. At approximately 1:15 a.m. the Certified nurse assistant (CNA) noticed Resident 1 was not in the resident ' s room or restroom and made charge nurse aware.
d. At 1 :20 a.m. staff searched for Resident 1 in the facility. Resident 1 ' s wander guard was noted fully stretched on the floor.
e. At 1:36 a.m., the police was notified of Resident 1 ' s elopement.
f. At 1:52a.m. sheriffs arrived.
g. At 2:13 a.m. writer finished giving report to the Sheriff and the Sheriff was made aware Resident 1 was alert and oriented times 2 with episodes of confusion and diagnosed with paranoid Schizophrenia.
During a review of Resident 1 GACH Emergency Department Physician note, dated 7/13/2024 at 7:17 p.m., the note indicated facility staff found Resident 1 wandering around the streets and brought in by ambulance to GACH for further evaluation. The note indicated Resident 1had acute psychosis, severe anemia, and type 2 diabetes. Resident 1 received a blood transfusion for the anemia.
During a concurrent observation and interview on 7/4/2024 at 9:50 a.m., with Registered Nurse Supervisor (RNS), the left side of the double doors to Door 1 was opened and no alarm was heard. RNS stated the alarm should trigger whenever either door was opened and this time it did not. RNS stated the alarm not triggering was not safe for residents.
During a continued observation and interview on 7/4/2024 at 9:50 a.m., with RNS, it was noted that Resident 1 ' s room was right by Door 2. Door 2 was also noted with two unsecure (can be opened without a key or a code) latches. The RNS stated Door 2 does not alarm when opened and at night no one was monitoring the residents exiting Door 2. The RNS stated since Resident 1 removed his wander guard he probably just opened the latches and exited. RNS stated it was not safe to have an unsecure Door 2 because if residents can remove the wonder guard bracelet and open the latches they can leave at night undetected.
During an interview with the Maintenance Supervisor (MS) on 7/4/2024 at 12:15 p.m., the MS stated the Door 1 was deactivated and the MS just activated it right now. The MS stated Resident 1 could have also walked out through the Door 1 because the alarm would not have been triggered.
During an interview with Licensed Vocational Nurse (LVN)1 on 7/4/2024 at 2:00 p.m., LVN 1 stated at approximately 1 a.m. CNA 4 stated Resident 1 was not in his room or the restroom. After a search was conducted in the facility the [NAME] was notified and three sheriffs also searched in the premises to no avail.
During an interview with the Administrator (ADM) on 7/4/2024 at 3:55 p.m., the ADM stated the Door 2 was not safe for the resident ' s safety. The ADM stated the Door 1 should have been triggered when opened.
During an observation and interview on 7/5/2024 at 10:28 a.m., with MS, at Door 1, the alarms on the door was observed to have the code or password clearly labeled on the alarms. The MS stated the codes were labeled there so anyone who can read can disarm it if needed; that makes the door alarms unsecure because anyone can punch the code and can exit undetected. MS stated Resident 1 might have exited from here (Door 1) or Door 2.
During a concurrent interview and record review with LVN 1, on 7/5/2024 at 10:53 a.m., Resident 1 ' s records were reviewed. Resident 1 ' s Elopement assessment on admission, dated 6/11/2024, indicated Resident 1 was a high risk for elopement. Resident 1 ' s SBAR, dated 7/3/2024, was reviewed, and the SBAR indicated the stretched out and damaged wander guard was observed on the floor. LVN 1 stated Resident 1 should not have left the facility undetected because it was not safe.
During an interview with the ADM on 7/5/2024 at 4:00 p.m., the ADM stated the doors should be secure. The ADM stated to prevent further elopements, in services was completed. The ADM stated the facility will install magnetic door locks to Doors 1 and 2. The ADM stated until the locks were installed the facility staff will be assigned to monitor the door area to ensure no residents elope.
During a review of the facility ' s policy and procedure (P&P) titled Behavioral Assessment, Intervention and Monitoring, revised 3/2019, the P&P indicated the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with comprehensive assessment and plan of care. Residents will have minimal complications associated with the management of altered or impaired behavior. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm.
During a review of the facility ' s P&P titled, Environment, Maintenance, revised 12/2009. The P&P indicated the facility shall be maintained in a clean and safe manner. The P&P indicated equipment and supplies must be maintained in good working condition.
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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement one of four sampled resident ' s (Resident 1) care plan t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement one of four sampled resident ' s (Resident 1) care plan to ensure Resident 1 was wearing his Wander guard (bracelets that residents wear, sensors that monitor doors and a technology platform that sends safety alerts in real time), and that Resident 1 was not going to leave the premises unassisted.
As a result of these deficient practices, Resident 1 eloped from the facility on 7/3/2024 and was without his medications including olanzapine (medication to treat schizophrenia) 15 milligrams twice a day for ten days. Resident 1 was located by facility staff on 7/13/2024 and subsequently transferred to a general acute care facility (GACH) for further evaluation. At the GACH, Resident 1 was admitted with a diagnosis including acute psychosis (collection of symptoms that affect the mind, where there has been some loss of contact with reality), severe anemia (not enough red blood cells in the body), and Resident 1 received a blood transfusion (process of transferring blood products). According to psychiatric (mental health specialist) consult, Resident 1 was agitated and aggressive was given a sitter (a healthcare worker who will provide continuous supervision to a resident) for safety and placed on a 5150 hold (72-hour involuntary hold in the hospital). The consult indicated Resident 1 required inpatient hospitalization for further stabilization of behavioral symptoms.
Findings:
During a review of Resident 1 ' s admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis including paranoid (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly) schizophrenia, type 2 diabetes (problem in the way the body regulates and uses sugar as fuel), and hypertension (when the force of blood pushing against the walls of blood vessels is too high).
During a review of Resident 1 ' s Psychiatric Evaluation, dated 6/12/2024, the mental status examination indicated Resident 1 ' s judgement and insight were moderately impaired. The evaluation indicated Resident 1 was disheveled, very disorganized and was a poor historian. The evaluation indicated Resident 1 had delusions (altered reality that is persistently held despite evidence or agreement to the contrary) and auditory hallucinations (when the person hears voices or noises that don't exist in reality). The evaluation indicated Resident 1 was diagnosed with psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality).
During a review or Resident 1 ' s History and Physical (H&P), dated 6/13/2024, the H&P indicated Resident 1 was unable to communicate/ make decisions for self.
During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 6/15/2024, the MDS indicated Resident 1 had severe cognitive (ability to learn, remember, understand, and make decision) impairment for skills on daily decision making. The MDS indicated Resident 1 needed set up assistance with eating, supervision (helper provides verbal cues) with oral hygiene, upper body dressing, personal hygiene, and needed partial assistance (helper less than half the effort to complete the task) with toilet hygiene, and lower body dressing.
During a review of Resident 1 ' s Admission/readmission Initial Assessment, 6/11/2024, the assessment indicated Resident 1 was high risk for elopement because Resident 1 was independently mobile and has a history of elopement.
During a review of Resident 1 ' s Weekly summary, dated 6/30/2024 at 2:38 a.m., the summary indicated Resident 1 was alert and confused.
During a review of Resident 1 ' s Order Summary Report, active orders as of 7/5/2024, the summary indicated the following orders, starting on 6/11/2024:
a. May have wander guard to the left hand to alert staff of resident trying to leave facility unassisted.
b. Check wander guard placement every shift.
c. Monitor Resident 1 for episodes of wandering behavior (a behavioral problem of disorientation and difficulty relating to the environment with aimless or purposeful motor activity that causes a social problem such as getting lost, leaving a safe environment, or intruding in inappropriate places) around hallway and patio every shift.
d. Check for wander guard function every Sunday during 7-3 p.m. shift.
e. Olanzapine 15 milligrams one tablet orally two times a day for schizophrenia.
During a review of Resident 1 ' s untitled care plan, focus indicated Resident 1 was at risk for elopement related to cognitive impairment, and mood and behavioral symptoms, initiated 6/17/2024. The care plan goal indicated Resident 1 will not leave the facility unsupervised. Care plan interventions included:
a. May have wander guard on left hand to alert staff if resident was trying to leave the facility unassisted.
b. Check wander guard function every Sunday during day shift.
c. Check wander guard placement on the left hand every shift
d. Monitor Resident 1 for wandering behavior every shift around the hallway and patio.
e. Frequent rounds by staff
f. Remind resident that he needs to remain in the facility unless family of staff member was with them.
During a review of Resident 1 ' s Monitoring side effects/Behaviors/black box (added to the labeling of drugs when serious adverse reactions or special problems occur) warnings for 7/2024, the monitoring indicated:
a. Starting 6/11/2024, check wander guard placement every shift. On 7/2/2024 night shift, Resident 1 was absent from the facility without meds on 7/2/2024 night shift.
b. Staring on 6/11/2024, monitor Resident 1 for episodes of wandering behavior, around hallway and patio every shift. In 7/1/2024, Resident 1 was observed with this behavior 4 times. On 7/2/2024, Resident 1 was observed wandering 4 times.
During a review of Resident 1 ' s Situation Background Assessment Appearance Request (SBAR) Communication Form- General, 7/3/2024 at 1:45 a.m., the form indicated the following:
a. At 11:00 p.m , Resident 1 was seen lying in bed comfortably watching television in no apparent distress, denied pain or discomfort, and respirations were even and unlabored and no respiratory distress.
b. At 12:00 midnight Resident 1 remained in bed, sitting at the edge of the bed watching television.
c. At approximately 1:15 a.m. the Certified nurse assistant (CNA) noticed Resident 1 was not in the resident ' s room or restroom and made charge nurse aware.
d. At 1 :20 a.m. staff searched for Resident 1 in the facility. Resident 1 ' s wander guard was noted fully stretched on the floor.
e. At 1:36 a.m., the police was notified of Resident 1 ' s elopement.
f. At 1:52a.m. sheriffs arrived.
g. At 2:13 a.m. writer finished giving report to the Sheriff and the Sheriff was made aware Resident 1 was alert and oriented times 2 with episodes of confusion and diagnosed with paranoid Schizophrenia.
During a review of Resident 1 GACH Emergency Department Physician note, dated 7/13/2024 at 7:17 p.m., the note indicated facility staff found Resident 1 wandering around the streets and brought in by ambulance to GACH for further evaluation. The note indicated Resident 1had acute psychosis, severe anemia, and type 2 diabetes. Resident 1 received a blood transfusion for the anemia.
During a continued observation and interview on 7/4/2024 at 9:50 a.m., with RNS, it was noted that Resident 1 ' s room was right by the front door that exits to the parking lot (Door 2). Door 2 was also noted with two unsecure (can be opened without a key or a code) latches. The RNS stated Door 2 does not alarm when opened and at night no one was monitoring the residents exiting Door 2. The RNS stated since Resident 1 removed his wander guard he probably just opened the latches and exited. RNS stated it was not safe to have an unsecure Door 2 because if residents can remove the wonder guard bracelet and open the latches they can leave at night undetected.
During an interview with Licensed Vocational Nurse (LVN)1 on 7/4/2024 at 2:00 p.m., LVN 1 stated at approximately 1 a.m. CNA 4 stated Resident 1 was not in his room or the restroom. After a search was conducted in the facility the [NAME] was notified and three sheriffs also searched in the premises to no avail.
During a concurrent interview and record review with LVN 1, on 7/5/2024 at 10:53 a.m., Resident 1 ' s records were reviewed. Resident 1 ' s Elopement assessment on admission, dated 6/11/2024, indicated Resident 1 was a high risk for elopement. Resident 1 ' s SBAR, dated 7/3/2024, was reviewed, and the SBAR indicated the stretched out and damaged wander guard was observed on the floor. LVN 1 stated Resident 1 should have had the wander guard on. LVN 1 stated Resident 1 should not have left the facility undetected because it was not safe.
During an interview with the administrator (ADM) on 7/5/2024 at 4:00 p.m., the ADM stated the doors should be secure and adequate monitoring of high risk for elopement residents should be done. The ADM stated to prevent further elopements, in services was completed. The ADM stated the facility will install magnetic door locks to Doors 1 and 2. The ADM stated until the locks were installed the facility staff will be assigned to monitor the door area to ensure no residents elope. The ADM also stated the facility will ensure monitoring of the high risk for elopement residents were being done by documenting the residents ' whereabouts on an hourly basis. The ADM stated this will be a systematic change that will be immediately implemented.
During a review of the facility ' s policy and procedure (P&P) titled Behavioral Assessment, Intervention and Monitoring, revised 3/2019, the P&P indicated the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with comprehensive assessment and plan of care. Residents will have minimal complications associated with the management of altered or impaired behavior. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm.
During a review of the facility ' s P&P titled Care plans, Comprehensive Person-Centered, care plan policy, revised 12/2016, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident.
Mar 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a plan of care was developed and implemented for one of five sampled residents (Resident 1) addressing Resident 1's laceration (a wo...
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Based on interview and record review, the facility failed to ensure a plan of care was developed and implemented for one of five sampled residents (Resident 1) addressing Resident 1's laceration (a wound that occur when skin or muscle is torn or cut open) on the forehead.
This deficient practice had the potential to result in an infected laceration that could pose as a threat to Resident 1's overall health and wellbeing.
Findings:
During a review of Resident 1's admission Record (Face sheet), the face sheet indicated Resident 1 was admitted at the facility on 7/12/2024 with a diagnosis that included chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), hypertension (a blood pressure [force it takes for blood to circulate in the body] higher than normal) and dementia (a condition when the loss of cognitive function such as thinking, remembering and reasoning interferes with a person's daily life and activities).
During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/16/2024, the MDS indicated Resident 1 was forgetful, made inconsistent decisions and was understood by staff. The MDS indicated Resident 1 required partial/ moderate assistance with one-person assist (helper does less than half the effort) to complete the resident's' activities of daily living such as toileting, personal hygiene, dressing and transferring from bed-to-chair and vice-versa.
During a review of Resident 1's SBAR (Situation Background Assessment Recommendation) Communication Form dated 2/29/2024 at 11:38 p.m., the SBAR Communication Form indicated Resident 1 was found sitting on top of the floor pad beside his bed in his room on 2/29/2024 at 8:03 p.m. with swelling and a laceration to his forehead.
During a review of Resident 1's comprehensive care plans, there were no care plans indicating a specific goal and interventions directed to address Resident 1's sustained laceration after an unwitnessed fall.
During an interview on 3/21/2024 at 4:32 p.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated for every resident change of condition, there must be a care plan formulated for continuous monitoring and evaluation such as of Resident 1's laceration.
During an interview and record review on 3/22/2024 at 12:50 p.m., with Treatment Nurse 1 (TX 1), Resident 1's care plans were reviewed and there were no care plans addressing Resident 1's laceration post fall. TX 1 confirmed there was no specific plan of care formulated for Resident 1's laceration since 2/29/2024.
During an interview on 3/22/2024 at 2:17 p.m., with the Director of Nursing (DON), the DON stated the residents' plan of care must be specific to address specific interventions and/or monitoring of Resident 1's laceration every shift to identify any worsening of Resident 1's wound site and escalate care and treatment, if necessary.
During a review of the facility's Policy and Procedure (P/P) titled, Care Plans, Comprehensive Person-Centered revised 12/2016, the P/P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented by the facility for each resident.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one of five sampled resident's (Resident 1) laceration (a wound that occur when soft tissue such as skin or muscle is torn or cut op...
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Based on interview and record review, the facility failed to ensure one of five sampled resident's (Resident 1) laceration (a wound that occur when soft tissue such as skin or muscle is torn or cut open) on the forehead had documented monitoring for signs and symptoms of infection and complications after the resident sustained a fall on 2/29/2024.
This deficient practice had the potential to result in an infected laceration that could pose as a threat to Resident 1's overall health and wellbeing.
Findings:
During a review of Resident 1's admission Record (Face sheet), the face sheet indicated Resident 1 was admitted at the facility on 7/12/2024 with a diagnosis that included chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), hypertension (a blood pressure [force it takes for blood to circulate in the body] higher than normal) and dementia (a condition when the loss of cognitive function such as thinking, remembering and reasoning interferes with a person's daily life and activities).
During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/16/2024, the MDS indicated Resident 1 was forgetful, made inconsistent decisions and was understood by staff. The MDS indicated Resident 1 required partial/ moderate assistance with one-person assist (helper does less than half the effort) to complete the resident's' activities of daily living such as toileting, personal hygiene, dressing and transferring from bed-to-chair and vice-versa.
During a review of Resident 1's SBAR (Situation Background Assessment Recommendation) Communication Form dated 2/29/2024 at 11:38 p.m., the SBAR Communication Form indicated Resident 1 was found sitting on top of the floor pad beside his bed in his room on 2/29/2024 at 8:03 p.m. with swelling and a laceration to the forehead.
During a review of Resident 1's comprehensive care plans, there were no care plans indicating specific goals and interventions of monitoring directed to address Resident 1's sustained laceration after a fall.
During a review of Resident 1's Treatment Administration Record (TAR) dated 3/2024, the TAR indicated there was no monitoring of Resident 1's laceration/ wound status every shift.
During a telephone interview on 3/21/2024 at 4:10 p.m., with Responsible Party 1(RP1), RP1 stated she was worried of how the staff was monitoring Resident 1's wound because when she visited Resident 1 during the day of 3/7/2024, Resident 1's face was swollen, and the wound looked worse.
During an interview on 3/21/2024 at 4:32 p.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated Resident 1's laceration should have had documented monitoring every shift.
During an interview and record review on 3/22/2024 at 12:50 p.m., with Treatment Nurse 1 (TX 1), TX 1 confirmed there was no documented monitoring for Resident 1's laceration since 2/29/2024 and TX 1 confirmed there was no order in the TAR indicating to monitor Resident 1's laceration every shift.
During an interview on 3/22/2024 at 2:17 p.m., with the Director of Nursing (DON), the DON stated Resident 1's laceration should have had documented monitoring every shift to identify any worsening of Resident 1's wound site and escalate care and treatment, if necessary.
During a review of the facility's Policy and Procedure (P/P) titled, Quality of Care revised 8/2009, the P/P indicated each resident shall be cared for in a manner that promotes and enhances quality care. The P/P indicated quality health care can be defined in many ways but there is growing acknowledgement that quality health services should be:
1. Effective - providing evidence-based healthcare services to those who need them.
2. Safe - avoiding harm to people for whom the care is intended; and
3. Resident-centered - providing care that responds to individual preferences, needs, and values.
To realize the benefits of quality health care, health services must be:
1. Timely - reducing waiting times and sometimes harmful delays.
2. Integrated - providing care that makes available the full range of health services throughout the life course.
3. Efficient - maximizing the benefit of available resources and avoiding waste.
Oct 2023
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a certified nursing assistant (CNA 1) did not turn and repos...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a certified nursing assistant (CNA 1) did not turn and reposition a resident (Resident 1), who required a two-person physical assist with bed mobility, by himself, without the assistance of another staff for one of two sampled residents (Resident 1).
This deficient practice resulted in Resident 1 falling from bed and sustaining a left parietal (near the back and top of head) scalp hematoma (an injury that causes blood to collect and pool under the skin resulting in a spongy, rubbery, lumpy feel) and laceration (a deep cut or tear in the skin or flesh) with a potential for Resident 1 to sustain more serious consequences such has a brain injury, fractures (a partial or complete break in the bone) and death. On 10/14/2023 Resident 1 was transferred to a General Acute Care Hospital (GACH) for evaluation and treatment of her head wound.
Findings:
A review of Resident 1's admission Record (Face Sheet) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including dysphagia (difficulty swallowing), contractures (when muscles, tendons, joints, or other tissues tighten or shorten leading to a deformity) of the right and left knee and muscle weakness.
A review of Resident 1's History and Physical (H&P), dated 1/22/2023, indicated Resident 1 did not have the capacity to understand and make decisions.
A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 7/10/2023, indicated Resident 1's cognitive skills for daily decision-making were severely impaired. The MDS indicated Resident 1 was totally dependent on staff for bed mobility and required a two or more-persons physical assistance with bed mobility.
A review of Resident 1's Situation, Background, Assessment, and Recommendation ([SBAR] a technique which is used to facilitate prompt and appropriate communication within the healthcare team), dated 10/14/2023, and timed at 9 a.m., indicated Resident 1 fell while CNA 1 turned and repositioned Resident 1, while she was in bed, by himself. The SBAR indicated Resident 1 slid off the bed, hit her head on the dresser located beside Resident 1's bed, then landed on the floor.
A review of Resident 1's Transfer Form dated 10/14/2023, and timed at 11:33 a.m., indicated Resident 1 was transferred to a GACH for evaluation and treatment related to her fall.
A review of Resident 1's GACH admission Record, indicated Resident 1 was admitted to the GACH on 10/14/2023 at 6:30 p.m.
A review of the GACH H&P, dated 10/15/2023, indicated Resident 1 sustained a fall with head trauma resulting in a hematoma and left parietal scalp laceration.
A review of Resident 1's head Computed Tomography ([CT] an imaging test used to detect internal injuries by providing cross-sectional images of bones, blood vessels and soft tissues in the body) scan dated 10/15/2023, indicated Resident 1 had a left parietal scalp hematoma.
A review of Resident 1's General Surgeon Consultation report, dated 10/15/2023 indicated Resident 1 had a left parietal occipital (back of head) scalp hematoma measuring 3 centimeters ([cm] a unit of measurement) by 3 cm with a small laceration with scabbing and eschar (dead tissue that forms over healthy skin and then, over time, falls off).
During an interview on 10/26/2023, at 12:06 p.m., CNA 2 stated, Resident 1 could not get up by herself or move from side to side on her own and required two people to assist when she was turned and repositioned. CNA 2 stated when two people are required to turn and reposition a resident, a staff member should stand on each side of the resident's bed to prevent the resident from falling off the bed.
During a concurrent interview and record review with the MDS Nurse on 10/26/2023 at 1:23 p.m., Resident 1's Activities of Daily Living ([ADL] task required to independently care for oneself such as eating, bathing, dressing, grooming and toileting) Performance Self Care Deficit Care Plan dated 12/21/2020, was reviewed. The Care Plan Indicated Resident 1 had muscle weakness and osteoarthritis (mechanical wear and tear on the joints). The Care plan goals included moving Resident 1, while in bed, using a two-person assist. The MDS Nurse stated the purpose of the Care Plan was to assist the nursing staff in providing individualized care to residents based on their needs. The MDS Nurse stated, if the staff had followed Resident 1's care plan to use two people when moving Resident 1 in bed, Resident 1's fall could have been prevented.
During a telephone interview on 10/26/2023 at 1:59 p.m., CNA 1 stated he raised Resident 1's bed to the level of his (CNA 1's) waist (approximately three to four feet from the ground), to change Resident 1's bed linens. CNA 1 stated he was standing behind Resident 1, on the left side of Resident 1's bed, with Resident 1's backside facing him (CNA 1), when Resident 1 leaned to her right side. CNA 1 stated Resident 1 rolled off the bed and hit her head on the bedside dresser before she fell to the floor. CNA 1 stated he was not able to prevent Resident 1 from falling off the bed because he was on the opposite side of the bed from where Resident 1 fell and he did not have enough time to prevent Resident 1 from falling. CNA 1 stated it would have been safer if another staff assisted him when he repositioned Resident 1. CNA 1 stated he was not aware Resident 1 required two people to assist with turning and repositioning Resident 1.
During a concurrent interview and record review with the Director of Rehabilitation (DOR) on 10/26/2023 at 2:38 p.m., Resident 1's Occupational Therapy Notes for 10/2022 were reviewed. The Occupational Therapy Notes indicated Resident 1 required total assistance with bed mobility and rolling left to right. The DOR stated Resident 1 was a full assist, required two or more persons to roll from left to right because Resident 1 could not roll by herself. The DOR stated Resident 1 does not have a protective reaction (how resident would guard or protect themselves if they were falling) due to her immobility and contractures of her upper and lower extremities. The DOR stated there should have been two staff members assisting with Resident 1's repositioning to prevent her from falling out of bed.
During a concurrent interview and record review with the Director of Nursing (DON) on 10/26/2023 at 2:56 p.m., Resident 1's Interdisciplinary Team ([IDT] team members from different departments working together, with a common purpose, to set goals, make decisions that ensure residents receive the best care) notes dated 10/26/2023, and timed at 1:03 p.m., were reviewed. Resident 1's IDT notes indicated Resident 1 had a fall while CNA 1 was turning and repositioning Resident 1 by himself. The IDT notes indicated Resident 1 slid off the bed and hit her head on the dresser that was beside her bed, then landed on the floor. The DON stated CNA 1 reported to her that he was repositioning Resident 1 without assistance when the incident occurred. The DON stated Resident 1's fall should not have happened and could have been avoided if there was another staff member standing with Resident 1 and assisting him (CNA 1) in holding Resident 1 while he (CNA 1) was changing Resident 1's bed linen.
During an interview on 10/28/2023 at 12:51 p.m., the Director of Staff Development (DSD) stated when a resident requires two or more people to assist with bed mobility and is totally dependent on staff with moving from side to side in bed, there should always be another CNA assisting to prevent the resident from falling off the side of the bed.
A review of the facility's policy and procedure (P/P) titled, Activities of Daily Living (ADL), Supporting, revised 3/2018, indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, in accordance with the plan of care, including appropriate support and assistance with mobility.
A review of the facility's CNA Job Description revised 10/2020, indicated duties and responsibilities include monitoring and evaluating the resident's response to care plan interventions in accordance with facility policies, and to review care plans daily to determine if changes in the resident's daily care routine have been made on the care plan.
A review of the facility's P/P, titled Falls and Fall Risk, Managing, revised 3/2018, indicated the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize the complications from falling.
Oct 2023
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed obtain recommended Level II preadmission screening and resident review ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed obtain recommended Level II preadmission screening and resident review evaluation ([PASARR]-a mental health evaluation done to determine if an individual can benefit from specialized mental health services) for two of 12 sampled residents (Resident 4 and Resident 38)
This deficient practice placed Resident 4 and Resident 38 at risk of inappropriate placement, not receiving necessary care, and unidentified specialized services.
Findings:
a. During a review of Resident 4's admission Record (Face Sheet), indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a serious mental disorder that affects how a person thinks, feels and behaves), dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities), and epilepsy (a brain disorder that cause recurring seizures (a sudden uncontrolled burst of electrical activity in the brain).
During a review of Resident 4's History and Physical (H&P), dated 7/31/2023, the H&P indicated, Resident 4 did not have the capacity to make decisions.
During a review of Resident 4's Level I PASARR, dated 7/31/2023, the Level I PASARR indicated, a Level II Mental Health Evaluation was required.
During a review of Resident 4's Minimum Data Set [(MDS)- a standardized assessment and care screening tool], dated 8/2/2023, the MDS indicated Resident 4 was not able to recall the year, month, and day. The MDS indicated Resident 4 required extensive assistance with bed mobility, transferring, walking, locomotion on and off the unit, dressing and toilet use. The MDS indicated Resident 4 needed limited assistance with personal hygiene, and supervision with eating. The MDS indicated Resident 4 had a diagnosis of schizophrenia.
b. During a review of Resident 38's admission Record (Face Sheet), indicated Resident 38 was admitted to the facility on [DATE] with diagnoses including mood disorder(mental health condition that primarily affects emotional state), dementia , and psychosis (a condition of the mind that results in difficulties determining what is real and what is not real).
During a review of Resident 38's History and Physical (H&P), dated 1/24/2023, the H&P indicated, Resident 38 did not have the capacity to understand and make decisions.
During a review of Resident 38's Level I PASARR, dated 3/22/2023, the Level I PASARR indicated, a Level II Mental Health Evaluation was required.
During a review of Resident 38's MDS dated [DATE], the MDS indicated Resident 38 could not recall the year, month, and day. The MDS indicated Resident 4 was totally dependent on staff for transferring, locomotion on the unit, dressing, toilet use, personal hygiene, and required extensive assistance with bed mobility, locomotion off the unit, and eating. The MDS indicated Resident 38 had a psychotic (symptoms that affect the mind) disorder.
During an interview on 9/30/2023 at 9:17 am with the Director of Nursing (DON), stated Resident 4 had a Level I PASARR done on 7/31/2023. The DON stated there was no Level II PASARR done for Resident 4. The DON stated, Resident 4 should have had a Level II PASARR screening. The DON stated it was the responsibility of medical records staff and the DON to follow up with the PASARR Level II. The DON stated, she did not do the PASARR Level II examination for Resident 4.
During an interview on 10/1/23 at 1:24 pm with the DON, the DON stated the PASARR was checked weekly. The DON stated Resident 38 does not have a PASARR II. The DON stated Resident 38 PASRR II screening was not done because she missed it.
During a review of the facility's policy and procedure (P&P) titled, Pre-admission Screening Level II Resident Review (PASARR), revised 10/2014, the P&P indicated, The facility staff will coordinate the recommendations from the Level II PASARR determination and the PASARR evaluation report with the resident's assessment, care planning and transitions of care. The facility will refer all level II residents and all residents with a newly evident possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 24) re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 24) received proper assistive devices to maintain hearing abilities by not assisting in arranging for audiologist (diagnose, manage, and treat patients who have hearing, balance, or related problems) referral consults to replace missing hearing aids.
This deficient practice resulted in delay of services and Resident 24 not able to hear adequately during a conversation, and provision of care.
Findings:
During an observation on 9/29/2023 at 9:45 a.m. in Resident 24's room, observed Resident 24 lying in bed with no hearing aids in both ears.
During a review of Resident 24's admission Record (Face Sheet) dated 10/24/2021, indicated Resident 24 was admitted to the facility with diagnoses including blindness of the left eye, hypertension (high blood pressure) and stage 4 pressure ulcer (damage to the skin and tissue loss, reaching into muscle and bone).
During a review of Resident 24's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 9/12/2023, indicated Resident 4 was hearing impaired, requires the use of a hearing aid. and has bilateral (in each ear) hearing aids. MDS indicated Resident 24 usually understands some of a conversation but only if a hearing device was used.
During a review of Resident 24's Care Plan (CP) dated 6/23/2023, indicated Resident 24 reported his right hearing aid was missing from the General Acute Care Hospital (GACH) during his admission on 6/2023. The CP dated 10/27/2021 indicated Resident 24 had moderate hearing loss. The CP interventions included audiology (study of hearing) consult as needed, hearing evaluation as needed and to provide communication devices as needed.
During a review of Resident 24's Physician Order dated 6/13/2023, indicated Resident 24 an order for Audiology consult as needed which includes impedance (assessment method of the function of the middle ear) and tympanometry (how well the eardrum is vibrating when sound strikes).
During a review of Resident 24's Social Service admission assessment dated [DATE], indicated Resident 24 had bilateral hearing aids on admission to the facility on [DATE]. It also indicated Resident 24 used his hearing aide to communicate with staff.
During a concurrent observation and interview on 9/30/2023 at 10:46 a.m. with Certified Nurse Assistant (CNA) 1, in Resident 24's room, observed CNA 1 asked Resident 24 in his left ear, if he was wet (soiled in urine). Resident 24 responded Yes, I am drinking my coffee. CNA 1 stated Resident 24 could not hear well, especially in his right ear. CNA 1 stated Resident 24 hears better in his left ear. CNA 1 stated Resident 24 was hard of hearing, and she must repeat herself for Resident 24 to hear what was being said. CNA 1 stated Resident 24 has two hearing aids, but they are not in his ears currently. CNA 1 stated it was important for Resident 24 to have his hearing aids so staff can communicate well with Resident 24, and he can feel good and let the staff communicate well with him and know what he wants.
During a concurrent observation and interview on 9/30/2023 at 11:54 a.m. with the Social Worker (SW), stated Resident 24 was not wearing both his hearing aids and hasn't been wearing both hearing aids since 6/13/2023 after Resident 24 returned from GACH hospitalization. Observed SW asked Resident 24, how was his breakfast and Resident 24 responded not appropriate with SW question. The SW stated it was important for Resident 24 to have his hearing aids so he can communicate his needs to staff. The SW stated if Resident 24 could not communicate his needs, he may feel frustrated. Observed Resident 24 leaned forward and attempted to understand what the SW was saying, but still unable to hear SW correctly.
During a review of the facility's policy and procedure (P&P) titled Resident Rights revised 10/2016, the P&P indicated the resident has the right to communication and a dignified existence.
During a review of the facility P&P Accommodation of Needs, revised 1/2020, the P&P indicated The resident's individual needs and preferences will be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. The P&P indicated the resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, shall be evaluated upon admission and reviewed on an ongoing basis to accommodate individual needs and preferences, staff attitudes and behaviors must be directed towards assisting the residents in maintaining independence, dignity, and well-being to the extent possible and in accordance with the residents' wishes.
a.Staff will interact with the residents in a way that accommodates the physical or sensory limitations of the residents, promotes communication, and maintains dignity. (For example, staff shall face the resident and speak to him or her at eye level if the resident is hearing impaired and can read lips.)
b.Staff will help to keep hearing aids, glasses and other adaptive devices clean and in working order for the resident.
During a review of the facility P&P titled Care of the Hearing-Impaired Resident dated revised 2/2018, the P&P indicated staff will assist the resident with locating available resources, scheduling appointments, and arranging transportation to obtain needed services. The P&P indicated the staff will help residents who have lost or damaged hearing devices in obtaining services to replace the devices.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 5) who was admitted...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 5) who was admitted to the facility with an indwelling suprapubic urinary catheter (tube inserted into the bladder through the stomach to drain urine) received appropriate care, services and followed physician orders to send a urine specimen for urinalysis (UA -urine test) and urine culture and sensitivity (urine C/S- used to diagnose a urinary tract infection [UTI] an infection in any part of the urinary system, the kidneys, bladder, or urethra) when Resident 5 complained of burning sensation on urination.
This deficient practice resulted in continued discomfort to Resident 5 and had the potential for Resident 5 to experience continued signs and symptoms of UTI and the potential to have a kidney or prostate (a gland in the male reproductive system) infection that could lead to sepsis (blood stream infection).
Findings:
During a review of Resident 5's admission Record (Face Sheet) the Face Sheet indicated Resident 5 was admitted to the facility on [DATE] with diagnoses including retention of urine (bladder does not empty urine), obstructive uropathy (blockage in urinary flow) and quadriplegia (paralysis from the neck down).
During a review of Resident 5's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 9/18/2023, indicated Resident 5 was alert and oriented and able to make independent decisions on activities of daily living (ADL'S).
During a review of Resident 5's Care Plan dated 7/19/2023, indicated the facility should observe/monitor for signs and symptoms of redness, itchiness, and rashes on insertion site of the suprapubic catheter from urine. The Care Plan indicated Resident 5 was at risk for developing UTI related to suprapubic catheter.
During a review of Resident 5's Physician Order dated 9/26/2023, indicated order for a urinalysis and urine culture and sensitivity related to Resident 5's complained of burning sensation when urinating.
During a review of Resident 5's Nursing Note dated 9/26/2023 at 10:20 p.m. indicated Resident 5 was being monitored for complaint of burning sensation while urinating.
During a review of Resident 5's Nurses Notes dated 9/28/2023 at 4:10 p.m., indicated a urine sample was sent to the lab for UA and C/S on 9/28/2023. (days after receiving the physician order on 9/26/2023)
During a concurrent interview and record review on 9/30/2023 at 2:28 p.m. with the Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 5 complained of burning sensation when he urinates and requested her (LVN 1) to call the physician. LVN 1 stated Resident 5 told her I know when I have a UTI. LVN 1 stated physician was called and ordered to send Resident 5's urine for UA and urine C/S on 9/26/2023. LVN 1 stated he failed to send Resident 5's urine specimen on 9/26/2023. LVN 1 further stated delay in sending the urine to the laboratory can delay necessary treatment needed for Resident 5. LVN 1 stated he failed to follow up if the urine specimen was sent.
During an interview on 9/30/2023 at 3:07 p.m. with the Infection Preventionist (IP), the IP stated if a resident complained of burning sensation on urination, the licensed nurse will notify the doctor and get an order to send urine for a UA and urine C/S. The IP stated LVN 1 should have sent the urine sample on 9/26/2023. The IP stated delay in sending urine specimen to the laboratory can result in continued discomfort for Resident 4 and potential for any undetected infection and delay in treatment.
During a record review on 9/30/2023 at 3:45 p.m. of a Resident 4's laboratory report, indicated the results of Resident 5's urinalysis sample sent to the lab on 9/28/2023 and resulted on 9/29/2023 at 1:15 p.m. indicated small amount of bacteria in his urine, white blood cells 107 ([WBC-increase level indicates infection] normal range 0-5), positive for nitrite ([indicates a sign of a UTI] normal range: negative).
During a review of the facility policy and procedure (P&P) titled Physician Orders revised 2/2014, the P&P indicated the receiving nurse with physician orders will carry out the physician order. The P&P indicated new orders will be communicated to the responsible party, charge nurse and other departments as indicated.
During a review of the facility P&P Lab and Diagnostic test results-Clinical Protocol revised 11/2018, the P&P indicated, the physician will identify, and order diagnostic and lab testing based on the resident's diagnostic and monitoring need. The P&P indicated the staff will process test requisitions and arrange for tests.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to:
1. Check residents' identification band (wrist band) p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to:
1. Check residents' identification band (wrist band) prior to medication administration for four of five sampled residents (Resident 17, 21, 23 and 37).
This deficient practice had the potential for medication error including administering medication to the wrong resident.
2. Ensure Licensed Vocation Nurse (LVN) 3 signed narcotics reconciliation record ( a record of narcotic or controlled substance inventory) after taking the controlled (a medication with a high abuse potential) medication for one of one sampled residents (Resident 99) according to facility's policy and procedure.
This deficient practice had the potential for loss of accountability, which affected the controls against drug loss, diversion, or theft.
Findings:
1. During a review of Resident 17's admission Record (Face Sheet) indicated Resident 17 was admitted to the facility on [DATE] with diagnoses including essential hypertension, diabetes mellitus and dysphagia (difficulty of swallowing).
During a review of Resident 17's MDS dated [DATE] indicated Resident 17 had severe cognitive impairment and requires total assistance for bed mobility, eating, toilet use and personal hygiene.
During a review of Resident 21's admission Record (Face Sheet) indicated Resident 21 was admitted to the facility on [DATE] with diagnoses including essential hypertension, cardiomegaly (enlargement of the heart), dementia (loss of memory, language, problem-solving and other thinking abilities).
During a review of Resident 21's MDS dated [DATE] indicated Resident 21 had severe cognitive impairment and requires total assistance for eating and toilet use and requires extensive assistance for bed mobility, dressing and personal hygiene.
During a review of Resident 23's admission Record (Face Sheet) indicated Resident 23 was admitted to the facility on [DATE] with diagnoses including essential hypertension (high blood pressure), diabetes mellitus (a condition in which the body fails to metabolize (process) glucose (sugar) correctly), and muscle weakness.
During a review of Resident 23's Minimum Data Sheet (MDS-a comprehensive assessment and care planning tool) dated 06/15/2023 indicated Resident 23 had no cognitive (ability to learn, remember, understand, and make decision) impairment for daily decision making.
During a review of Resident 37's admission Record (Face Sheet) indicated Resident 37 was admitted to the facility on [DATE] with diagnoses including dysphagia, diabetes mellitus and cardiomegaly.
During a review of Resident 37's Minimum Data Sheet dated 08/24/2023 indicated Resident 37 had severe cognitive impairment and requires total extensive assistance for bed mobility, dressing and personal hygiene.
During a medication pass observation on 09/30/20236 at 1:21 pm, with Licensed Vocational Nurse (LVN) 3, observed LVN 3 administer medications to Resident 17,21,23 and 37 without checking identification band (wrist band) prior to giving the medications.
During an interview on 10/01/2023 at 9:56 am, with LVN 3, stated she forgot to check Resident 17, 21, 23 and 37 identification band prior to giving their medications to identify if it was the right resident.
During an interview on 10/1/2023 at 10:56 am, with LVN 3, stated identification band (wrist band) should be checked prior to giving residents' medication to ensure resident safety, prevent medication error and the risk of giving medication to the wrong resident.
During a review of facility's policy and procedure (P&P) titled Medication Administration revised 09/2019 indicated Medications are administered in a safe and timely manner, and as prescribed. The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include checking identification band, checking photograph attached to medical record; and if necessary, verifying resident identification with other facility personnel.
2. During a review of Resident 99's admission order (Face Sheet) indicated Resident 99 was admitted to the facility on [DATE] with diagnoses including pain in left hand, muscle weakness, diabetes mellitus (high blood sugar), heart failure and pain in left ankle and joints of left foot.
During a review of Physician's Order dated 09/22/2023 indicated to administer Baclofen (used to treat pain and certain types of spasticity [muscle stiffness and tightness]) 10 milligram (mg a unit of measurement) one tablet by mouth four times a day for muscle relaxant, and Carisoprodol ( drug indicated for the relief of discomfort associated with acute, painful musculoskeletal conditions) 350 mg one tablet four times a day for musculoskeletal (muscle and bone ) pain
During a review of Resident 23's Minimum Data Sheet (MDS-a comprehensive assessment and care planning tool) dated 09/26/2023 indicated Resident 23 had no cognitive (ability to learn, remember, understand, and make decision) impairment.
During a medication pass observation on 9/30/2023 at 12:51 pm, observed LVN 3 took Baclofen 10 mg from the bubble pack (a card holding tablets or capsules that are individually packaged in a clear plastic case sealed to a card) and Carisoprodol 350 mg from a bottle and administer to Resident 99. LVN 3 did not record and sign the narcotic reconciliation record book after taking the controlled medication for Resident 99.
During an interview on 10/01/2023 at 9:56 am with LVN 3, LVN 3 stated she forgot to record, and sign the narcotic reconciliation record book after taking the controlled medication from the bubble pack and medication bottle.
During a review of facility's policy and procedure titled Controlled Drug undated indicated Drugs with high abuse potential will be subject to special handling, storage, disposal, and record keeping.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed, and served food in a sanitary manner to prevent foodborne illness (also called...
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Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed, and served food in a sanitary manner to prevent foodborne illness (also called food poisoning caused by eating contaminated food or eating food not kept at appropriate temperatures) by failing to:
1.Ensure dishes were washed and rinsed at the correct temperature of 120-140 degrees Fahrenheit ([ °F] a scale of temperature) on a low temperature dishwasher.
2.Ensure frozen health shakes have been thawed by immersing under running water
3.Ensure cream pies and pastries were properly sealed, stored in the freezer and labeled with an open date.
These deficient practices had the potential to result in foodborne illnesses with symptoms including upset stomach, stomach cramps, nausea (feeling of sickness with an inclination to vomit), vomiting (eject matter from the stomach through the mouth), diarrhea (loose stool), and fever and can lead to other serious medical complications and hospitalization for 49 residents residing in the facility.
Findings:
1. During a concurrent observation and interview on 9/30/2023 at 11:35 a.m. with the Dietary Supervisor (DS) 1, observed the dishwasher wash cycle temperature in the kitchen at 105 degrees Fahrenheit ([ °F] a scale of temperature). The dishwasher rinse cycle completed at 119 degrees ° F (normal range 120-140 degrees Fahrenheit per manufacturer guidelines). The DS 1 stated it usually takes two to three wash and rinse cycles to reach the desired water temperature of 120-140 degrees ° F. The DS 1 stated per facility's policy and procedure dishwasher wash, and rinse cycle temperatures should reach between 120-140 degrees °F.
During an observation on 9/30/2023 at 12:45 p.m. in the kitchen with DS 1, observed dishes went through the dishwashing machine with a temperature of wash cycle at 100 degrees °F and the final rinse temperature at 119 degrees °F.
During an interview on 10/1/2023 at 9:49 a.m. with the DS 2, stated the dishwasher wash temperature cycle should be between 120-140 degrees °F. DS 2 stated the temperature should at least reach 120 degrees °F on the first cycle. DS 2 stated it was important to have the correct temperature during wash and rinse cycle, to ensure proper cleaning and sanitizing of dishes. DS 2 stated that if temperature was not correct, dishes were not cleaned and sanitized properly and can result in food borne illnesses to residents.
During an interview on 10/1/2023 at 10:09 a.m. with the Maintenance Director (MD), MD stated the dishwasher wash and rinse cycle temperatures should be at a minimum of 120 degrees F. MD stated it was important to run at the right temperature to get rid of bacteria and viruses to prevent residents from getting sick and spread any infection throughout the facility.
During an interview on 10/1/2023 at 11:50 a.m. with the Dietary Aide (DA), stated the kitchen staff must run multiple cycles in the dishwasher to get the correct temperature of at least 120 degrees ° F. The DA stated this has been going on for a long time in the kitchen. (unable to give exact time frame)
2. During an observation on 9/30/2023 at 11:45 a.m. in the kitchen, observed frozen health shakes were immerse in a pot of water on the sink without any water running over it.
During a concurrent observation and interview on 9/30/2023 at 11:50 a.m. with DS 1, DS1 stated health shakes should be thawed submerged under running water.
During an interview on 9/30/2023 at 11:55 a.m. with the Dietary Aide (DA), the DA stated the health shakes were immerse in the pot of water to be thawed. The DA stated, putting the health shakes in a pot immerse in water without water running over it to thaw was incorrect.
3. During a concurrent observation and interview on 9/30/2023 at 12:30 p.m. with DS 1, observed banana cream pie and frozen pastries inside the reach in freezer in the kitchen, both packages were open without an open date label and not store properly. DS1 stated both items should not be in the freezer open and stored without proper seal. DS 1 stated both items were at risk of contamination and the residents could get sick from it.
During a review of the facility's policy and procedure (P&P) dated 2018, titled Dishwashing, the P&P indicated a temperature log will be kept to assure that the dish machine was working correctly. The P&P indicated if you cannot achieve the correct temperature, alert the dietetic supervisor, or cook who will alert the maintenance personnel and stop washing dishes. The P&P indicated for a low temperature dishwashing machine, the temperature range should be between 120-140 degrees ° F.
During a review of the dishwashing machine owner's manual (OM) of the low temperature dishwasher machine dated 12/13/2014, the owner's manual indicated the minimum wash temperature should be 120 degrees ° F.
During a review of the facility policy and procedure (P&P) dated 12/2014, titled Refrigerators and Freezers, the P&P indicated the facility will ensure safe freezer maintenance and sanitation. The P&P indicated all food shall be appropriately dated, and the supervisor will be responsible for ensuring foods in the freezer are not expired or past perish dates.
During a review of the facility P&P dated 12/2014, titled Refrigerators and Freezers, the P&P indicated the facility will ensure safe freezer maintenance and sanitation. The P&P all food shall be appropriately dated, and the supervisor will be responsible for ensuring foods in the freezer are not expired or past perish dates.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 21 of 25 residents rooms met of 80 square feet ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 21 of 25 residents rooms met of 80 square feet ([sq. ft] a unit of area measurement) per residents in multi-bed resident rooms. Rooms 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 15, 16, 17, 18, 20, 21, 22, 23, 25, and 26 were occupied with two residents and room [ROOM NUMBER] was occupied with three residents per room, and room [ROOM NUMBER] was occupied with four residents per room.
This deficient practice had the potential to result in an inadequate provision of safe nursing care, and privacy for the residents.
Findings:
On 9/29/23 at 9:23 am, during the initial tour of the facility, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 25, and 26, residents' rooms did not meet the requirement of 80 sq. ft per resident.
A review of Client Accommodations Analysis form, provided by the facility Maintenance Supervisor (MS) rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,12 ,14,15, 16, 17, 18, 19,20,21,22,23, 25, and 26 were occupied by two residents each and total square feet measurement ranged between 139.43 square feet to 148.19 square feet.
During an interview on 10/1/23 at 1:27 pm with the Administrator (ADM), the ADM stated all the residents' rooms were small and the facility submits room waivers every recertification survey.
During a review of Room Waiver letter, dated 9/29/2023, provided by the ADM, the Room Waiver letter indicated, that rooms had enough space to provide for each resident's care, dignity, and privacy. The letter indicated the lack of space on the new building code has no adverse effect in the residents' health and safety or in maintaining the wellbeing of the residents. The following rooms were included in the Room Waiver request: Rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 29, 21, 22, 23, 25, 26.
During a review of Room Waiver letter, dated 9/29/2023, provided by the ADM, the Room Waiver letter indicated, Any concerns regarding room space expressed by any of the resident will be discussed during the Interdisciplinary Team ([IDT] a group of professionals that plan, coordinate and deliver personalized health care) meeting for proper Intervention.
During observations, from 9/29/23 through 10/1/23, the residents residing in these rooms had enough space to move freely inside the rooms. Each resident in the above rooms had beds and side tables with drawers. There was adequate room for the operation and use of wheelchairs, walkers, or canes. Resident room size did not affect the nursing care or privacy provided to the residents.
Apr 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility's nursing staff failed to ensure the suprapubic (situated, occu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility's nursing staff failed to ensure the suprapubic (situated, occurring, or performed from above the pubis [a structure located between the abdomen and thighs]) drainage bag for one of three sampled residents (Resident 1), who was diagnosed with urine retention and had a cystostomy (the surgical creation of an opening into the bladder),was covered when in the presence of other residents in a communal area (shared by all members in the community).
This deficient practice resulted in Resident 1's suprapubic drainage bag being left exposed to other residents and possible visitors and had the potential to cause Resident 1 feelings of embarrassment and shame.
Findings:
During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including retention of urine and cystostomy.
During a review of Resident 1's History and Physical (H/P), dated 3/2/2023, the H/P indicated, Resident 1 had a fluctuating capacity to understand and make decisions.
During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and screening tool), dated 3/3/2023, the MDS indicated, Resident 1 made independent decisions that were consistent and reasonable and had the ability to understand and be understood by others. The MDS indicated, Resident 1 required limited one-person physical assist with toilet use the other ADLs didn't have to do with the deficient practice.
During an observation and concurrent interview on 3/13/2023, at 9:10 a.m., Resident 1 was sitting on the facility's patio area, her suprapubic catheter collection bag was exposed. Resident 1 stated, she does not like that everybody can see her drainage bag and it makes her feel embarrassed and ashamed.
During an interview on 3/13/2023, at 9:15 a.m., with Certified NursingAssistant 1 (CNA 1), CNA 1 stated, residents urinary drainage bags should be covered with a privacy bag to preserve the resident's dignity. CNA 1 stated, when the urinary drainage bag is not covered, it could make the resident feel embarrassed.
During an interview on 3/13/2023, at 9:45 a.m., CNA 2 stated, a resident's drainage bag should be covered with a privacy bag to protect the resident's privacy. CNA 2 stated, it could make the resident feel ashamed when the drainage bag is exposed.
During an interview on 3/13/2023, at 9:52 a.m., with License Vocational Nurse (LVN) 1, LVN 1 stated, it is important to cover a urinary bag so other people cannot see it, because having the urinary bag exposed could embarrass the resident.
During an interview on 3/13/2023, at 11:55 a.m., with the Director of Nursing (DON), the DON stated, the urinary drainage bag should be covered with a dignity bag, because of how the resident might feel about walking around with the bag being exposed. The DON stated, if the urinary drainage bag is exposed the resident could feel embarrassed and ashamed.
During a review of the facility's P&P titled, Catheter Care, Urinary, dated 2019, the P&P indicated, provide a privacy bag when the resident is out of the room as indicated.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility's nursing staff failed to ensure the suprapubic (situated, occu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility's nursing staff failed to ensure the suprapubic (situated, occurring, or performed from above the pubis [a structure located between the abdomen and thighs]) drainage bag for one of three sampled residents (Resident 1), who was diagnosed with urine retention and had a cystostomy (the surgical creation of an opening into the bladder),was positioned lower than Resident 1's bladder and was not allowed to become overfull.
These deficient practices had the potential to cause backflow of urine into Resident 1's bladder leading to a possible ([UTI] an infection involving any part of the urinary system).
Findings:
During a review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including retention of urine and cystostomy
During a review of Resident 1's History and Physical (H/P), dated 3/2/2023, the H/P indicated, Resident 1 had a fluctuating capacity to understand and make decisions.
During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and screening tool), dated 3/3/2023, the MDS indicated, Resident 1 made independent decisions that were consistent and reasonable and had the ability to understand and be understood by others. The MDS indicated, Resident 1 required limited one-person physical assist with toilet use.
During an observation and concurrent interview on 3/13/2023 at 9:10 a.m., Resident 1's suprapubic catheter drainage bag was noted to be anchored to the back of a wheelchair that was sitting in front of Resident 1. The suprapubic catheter drainage bag was placed above Resident 1's bladder and had 1400 millimeters ([ml] a unit of measurement) of urine in the drainage bag. Resident 1 stated, she did not know where her drainage bag should be located, but stated she felt the bag was too full and should be emptied.
During an interview on 3/13/2023, at 9:15 a.m., with the Certified Nurse Assistant 1 (CNA 1), CNA 1 stated, 1000-2000 ml is a lot of urine to have in a resident's drainage bag and it should have been emptied. CNA 1 stated, the urine could back flow into Resident 1's bladder and cause an infection.
During an interview on 3/13/2023, at 9:45 a.m., with CNA 2, CNA 2 stated, a drainage bag should not have more than 1000 mls of urine in it and it should have been emptied. CNA 2 stated, if the drainage bag has too much urine in it and/or it is placed above the resident's bladder, the urine could backflow and cause the resident to get an infection.
During an interview on 3/13/2023, at 9:52 a.m., with License Vocational Nurse 1 (LVN 1), LVN 1 stated, CNAs are responsible for emptying the drainage bags and documenting the urine output. LVN 1 stated, if the drainage bag is above the resident's bladder it could cause the urine to go back into the resident's bladder and the resident could get a UTI.
During an interview on 3/13/2023, at 11:55 a.m., with the Director of Nursing (DON), the DON stated, the drainage bag should be below the bladder. The DON stated there is a line on the drainage bag that shows when the bag should be emptied, and the urine could back flow in the resident's bladder and cause the resident to get an infection.
During a review of the facility's policy and procedure (P&P) titled, Catheter Care, Urinary, dated 2020, the P&P indicated, the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.
Dec 2022
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a plan of care was developed for one of two sampled resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a plan of care was developed for one of two sampled residents (Resident A), who had a high risk for fall to prevent falls. Resident A, who had high risk for falls, fell and sustained a fracture (broken bone) nose.
This deficient practice resulted in Resident A falling from the bed and requiring an emergency transfer to a general acute care hospital (GACH) for care and treatment (for one day).
Findings:
During a review of Resident A's admission Record (face sheet), the face sheet indicated Resident A was admitted to the facility on [DATE], with diagnosis that included cerebral infarction (a stroke resulting from the interruption of blood flow) affecting the right side of the body.
During a review of Resident A's history and physical (H/P), dated 3/8/2019, the H/P indicated Resident A had the capacity to understand and make decisions.
During a review of Resident A's Minimum Data Set (MDS), a standardized assessment and care-screening tool, dated 3/13/2019, the MDS indicated Resident A was able to understand and be understood. According to the MDS, Resident A was able to move from one location to another with supervision with the use of a wheelchair for mobility.
During a review of the admission Nursing Assessment (ANA), dated 3/6/2019, a licensed nurse documented Resident A had a fall risk.
During a review of Resident A's base line care plan, date 3/6/2019, there was no care plan to address Resident A's risk for falls.
During a review of Resident A's Fall Risk Assessment (FRA) dated 3/7/2019, the FRA indicated Resident was at high risk for fall.
During a review of Resident A's Licensed Progress Notes (LPN), dated 10/4/2019 and timed at 2 p.m., the LPN indicated at 1:58 p.m., Certified Nurse Assistance 1 (CNA 1) heard Resident A yelling and crying and the call light was on. The LPN indicated upon CNA 1 entering the room the CNA found the resident face down on the floor and with the help of another staff member the resident was put back into the bed. The LPN indicated the nurse assessed the resident (Resident A) and the resident had a bump on the forehead, an abrasion (an area damaged by scraping or wearing away) on the nose and the nose was bleeding. According to the LPN, 911 (emergency services) was called and Resident A was transferred to a GACH.
During a review of the GACH Emergency Record (ER), dated 10/4/2019, the ER note indicated a computerize tomography ([CT scan]) special x-ray to create detailed pictures) was done of the resident's head on 10/4/2019. The CT Scan indicated there was a fracture to the nasal bone with overlying soft tissue swelling, but the CT scan was negative for intracranial bleed (when blood vessels rupture in the brain).
According to the GACH's discharge note, Resident A was discharged back to the facility with a follow-up to be done with the resident's primary care physician.
During an interview on 12/13/2022 at 10:30 a.m., with the Director of Nurses (DON), the DON was asked what the importance was of having a care plan for falls and the DON replied it was important for all staff on every shift to know how to provide care needs of the residents.
During a review of the facility's policy and procedure (P/P) titled, Care Plans, Comprehensive Person-Centered, dated 12/2016, the P/P indicated to incorporate risk factors associated with identified problems.
Jan 2022
12 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Infection Control
(Tag F0880)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement acceptable infection control practices to pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement acceptable infection control practices to prevent the spread and transmission of coronavirus (COVID-19, a potentially severe respiratory illness caused by a coronavirus and characterized by fever, coughing, and shortness of breath) for seven of 13 sampled residents (Residents 1, 6, 9, 17, 20, 31, 48).
The facility failed to:
A. Ensure a Certified Nurse Assistant (CNA 1) wore gown and gloves while in Residents 1's and Resident 17's room, who were residing in the yellow zone (zone for residents who are mixed quarantine or symptomatic) to prevent transmission of COVID-19 infection.
B. Ensure CNA 1, who was designated to work in the red zone, remained in the red zone (zone for residents that are COVID-19 positive) and was not going to a yellow zone after providing care to Resident 6, 9, 20, 31 and 48, in the red zone.
C. Ensure the Maintenance Director (MD) was not going from a red zone to a yellow zone while wearing personal protective equipment [([PPE) equipment designed to protect the wearer from the spread of infection or illness]- used to transfer Resident 31 on bed to the red zone.
D. Ensure the Administrator (ADM) and Physical Therapy Assistant (PTA 1) wore a face-shield while in the yellow zone to prevent transmission of COVID-19 infection.
These failures placed residents 1, 6, 9, 17, 20, 31, 48, staff, visitors, and the community at a high risk for cross contamination and increased spread of COVID-19 infection.
On 1/20/2022, at 5:10 p.m., Immediate Jeopardy ([IJ] a situation in which the provider's non-compliance with one or more requirements of participation had caused or was likely to cause serious injury, harm, impairment, or death to a resident) related to the facilities failure to implement acceptable infection control practices was called in the presence of the ADM and the Director of Nursing (DON).
On 1/21/2022, at 4:16 p.m., the ADM and DON were informed the IJ situation was lifted after implementation of an acceptable Plan of Action ([POA] a detailed plan outlining actions needed to reach one or more goals) was verified onsite through observation, interview, and record review.
Finding:
A. During a review of Resident 1's admission record, the record indicated Resident 1 was readmitted to the facility on [DATE] with diagnoses that included quadriplegia (paralysis of all four limbs), hypertension [(HTN) high blood pressure], and kidney failure (a condition in which the kidneys lose the ability to filter waste products from blood).
During a review of Resident 1 's Minimum Data Set [(MDS), a standardized assessment and care-screening tool], dated 10/18/2021, the MDS indicated Resident 1 had no impairment in cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making, required extensive assistance with bed mobility, dressing, and personal hygiene, and was totally dependent on staff for transfers, toileting, and bathing.
During a review of Resident 17's admission record, the record indicated Resident 17 was readmitted to the facility on [DATE] with diagnoses that included cerebrovascular accident [(CVA) damage to the brain from interruption of its blood supply], Type 2 diabetes mellitus (a condition in which the body fails to metabolize (process) glucose (sugar) correctly), hypertension (high blood pressure), bipolar disorder (a mental condition marked by alternating periods of elation [extreme happiness], and depression).
During a review of Resident 17 's MDS, dated [DATE], the MDS indicated Resident 17 had no impairment in cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making, required extensive assistance with bed mobility, dressing, and personal hygiene, and was totally dependent on staff for transfers, toileting, and bathing.
During an observation on 1/19/2022, at 12:47 p.m., in the yellow zone, in the east hall adjacent to nursing Station 2, CNA1 was observed entering Resident 1 and Resident 17's room without donning a gown and gloves. CNA1 was observed entering Resident 1 and Resident 17's room with a lunch tray. CNA1 was then observed exiting Resident 1 and Resident 17's room, retrieving another lunch tray from the metal tray cart in the yellow zone and reentering Resident 1 and Resident 17's room without donning gown and gloves.
During an interview on 1/19/2022, at 12:50 p.m., CNA1 stated when entering the room in the yellow zone she wore a face shield and a N95 (protective device designed to achieve a close facial fit and filters 95% of airborne particles) mask. CNA1 stated she did not put on gown and gloves because she wanted to distribute the lunch trays quickly. CNA1 stated she was aware of the PPE signs posted outside each resident's room indicating the required PPE before entering the room. CNA1 stated it was important to wear required PPE to prevent the spread of COVID-19 infection to residents and staff.
During an interview on 1/21/2021, at 1:46 p.m., the Infection Preventionist (IP) 1 stated due the COVID-19 outbreak staff and visitor entering the facility must wear a face shield and N95 mask. IP 1 stated it is the facility's policy that all staff who was entering a residents' room must also wear gown and gloves in both the yellow and red zones. IP 1 stated it is important to wear the required PPE when entering a resident's room to prevent the spread of pathogens (bacteria, virus, or other microorganism that can cause disease) on clothes which can put resident, staff, and the community at risk of developing COVID-19 infection.
During an interview on 1/22/2021, at 3:40 p.m., the DON stated staff was required to wear full PPE, including gown, gloves, face shield, and N95 mask when entering a resident's room in both the yellow and red zones. DON stated to prevent the spread of COVID-19 staff should not enter a resident's room without wearing the proper PPE.
A review of the facility's Mitigation Plan (MP), dated 1/10/2022 indicated the facility will train staff on selecting, donning, and doffing appropriate PPE. Signage indicating the required PPE will be posted immediately outside the resident's room indicating appropriate infection control and prevention precautions and required PPE in accordance with California Department of Public Health (CDPH) guidance. The MP indicated the facility will implement a staffing plan to limit transmissions during an outbreak and have dedicated consistent staffing team who directly interacts with residents that are Covid-19 positive.
During a review of All Facilities Letter (AFL) 20-74.1 CDPH, Healthcare-Associated Infections Program COVID-19 PPE, Resident Placement/Movement, and Staffing Considerations by Resident Category, dated 7/22/2021, the AFL indicated gowns and gloves must be worn upon room entry in the yellow and red zones.
According to the website https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html healthcare personnel must use personal protective equipment appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with a resident or a resident's environment. Donning PPE upon room entry and properly discarding it before exiting a resident room is done to contain pathogens.
B. During a review of Resident 31's admission record, the record indicated the resident was readmitted to the facility on [DATE] with diagnoses that included seizures (disorder in which nerve cell activity in the brain is disturbed, causing seizures, schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), Type 2 diabetes mellitus (a condition in which the body fails to metabolize (process) glucose (sugar) correctly), and acquired COVID-19 on 1/17/2022.
During a review of Resident 31's MDS, dated [DATE], the MDS indicated the resident had severe impairment in cognitive (ability to learn remember, understand and decisions) skills for daily decision making, required supervision with eating, extensive assistance with bed mobility, transfers, dressing, personal hygiene, and was totally dependent with toileting and bathing.
During a review of Resident 48's admission record, the record indicated the resident was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease ([COPD] progressive disease that makes it hard to breath), glaucoma (a group of eye conditions that can cause blindness), hypertension [(HTN) high blood pressure], osteoarthritis (type of arthritis that occurs when flexible tissue at the ends of bones wears down) and acquired COVID-19 on 1/17/2022.
During a review of Resident 48's MDS, dated [DATE], the MDS indicated the resident had moderately impaired cognitive skills for daily decision making, required supervision from staff with bed mobility, transfers, walking in room, dressing, eating, and toileting and needed limited assistance from staff with personal hygiene, and required extensive assistance from staff with bathing.
During a review of the Resident 6's admission record, the record indicated the resident was admitted to the facility on [DATE] with diagnoses including Type 2 diabetes mellitus (a condition in which the body fails to metabolize (process) glucose (sugar) correctly), essential hypertension (high blood pressure), schizoaffective disorders (mental health condition), and unspecified asthma (condition in which airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe).
During a review of Resident 6 's MDS, dated [DATE], the MDS indicated the resident had an intact cognitive skill for daily decision making and required staff supervision with bed mobility, transfer, dressing, walk in corridor, toilet use, personal hygiene, and bathing.
During a review of the Resident's 9 admission record, the record indicated the resident was admitted to the facility on [DATE] with diagnoses including sepsis (presence of harmful microorganisms in the blood), chronic obstructive pulmonary disease ([COPD] progressive disease that makes it hard to breath), type 2 diabetes mellitus (a condition in which the body fails to metabolize (process) glucose (sugar) correctly).
During a review of Resident 9 's MDS, dated [DATE], the MDS indicated the resident had intact cognitive skills for daily decision making and required extensive assistance from staff with bed mobility, dressing, personal hygiene, and was totally dependent on staff for toilet use and bathing.
During a review of Resident 20's admission record, the record indicated Resident 20 was readmitted to the facility on [DATE] with diagnoses that included dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities), seizures (disorder in which nerve cell activity in the brain is disturbed, causing seizures, schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), and hypertension [(HTN) high blood pressure].
During a review of Resident 20 's MDS), dated [DATE], the MDS indicated the resident had severe impairment in cognitive skills for daily decision making, required extensive assistance from staff with bed mobility, eating, and toileting, and was totally dependent on staff for transfer, dressing, personal hygiene, and bathing.
During an interview on 1/19/2022 at 11:00 a.m., IP 2 stated the facility received COVID-19 response testing (twice a week covid testing of residents and staff) results dated, 1/17/2022 and Residents 31, and 48 were tested positive. IP 2 stated Resident 31, and 48 will remain in their rooms and PPE and red zone signage will be posted on their doors. IP 2 stated she will contact the facility's assigned Public Health Nurse (PHN) for guidance on room change.
During an observation on 1/19/2022, at 1:23 p.m. in the East hallway, CNA1 was observed entering Resident 9's and Resident 48's room in the red zone wearing a full PPE. At 1:25 p.m. CNA 1 was observed exiting Resident 9's and Resident 48's room in the red zone. CNA1 removed her gown and gloves before exiting the resident's room and went to the nursing station where she washed her hands.
On 1/19/2022, at 1:31 p.m. CNA1 was observed entering Resident 20's and Resident 31's room in the red zone wearing full PPE. At 1:35 p.m. CNA1 was observed exiting Resident 20's and Resident 31's room in the red zone. CNA1 removed her gown and gloves before exiting the residents' room and proceeded to the nursing station where she washed her hands.
During a concurrent observation and interview on 1/19/2022, at 1:38 p.m. on the East hallway, CNA1 was observed re-entering Resident 20's room wearing full PPE. CNA1 stated she was going to feed Resident 20 and would be in the room for a while. CNA1 was observed entering Resident 20's room with a lunch tray. On 1/19/2022, at 2:30 p.m. in the east hallway, CNA1 was observed exiting a yellow zone room holding a dirty linen after caring for Residents 9, 20, 31, and 48, in the red zone.
During an observation on 1/19/2022, at 2:38 p.m. in the East hallway, CNA1 was observed entering Resident 6's room in the yellow zone holding a clean linen after she previously was caring for Residents 9, 20, 31, and 48, in the red zone.
During an interview on 1/21/2022, at 1:46 p.m., IP 1 stated when staff assigned to the red zone they are designated to work only in that area and cannot care for the residents in the yellow zone. IP 1 stated staff can start their day in the yellow zone and end their day in the red zone, but after being in the red zone staff cannot return to the yellow zone. Going from the red zone to the yellow zone staff are placing both the residents and other staff at risk of becoming infected with COVID-19.
During an interview on 1/22/2022, at 3:40 p.m., DON stated it was the facility's policy for no going back and forth between the red and yellow zones, when staff is designated to work in the red zone they are not allowed to go back into the yellow zone, staff must end their day in the red zone. DON stated, crossing from the red zone to the yellow zone will affect residents and staff and put everyone at risk of getting COVID-19.
According to the website http://publichealth.lacounty.gov/acd/ncorona2019/healthfacilities/snf/prevention/ under special staff considerations, in cohort areas staff assigned to the Red Cohort (area designated for COVID-19 positive residents) should not care for residents in other cohorts if possible. If staff must care for residents in multiple cohorts, they should visit the Red Cohort last and should doff PPE and perform hand hygiene prior to moving between cohorts.
C. During an observation on 1/19/2022, at 4:18 p.m., in the red zone, Resident 31 was observed in bed in the hallway awaiting transfer to the room in the red zone. Maintenance Director (MD) was observed pushing Resident 31 on bed to his room in the red zone. MD was observed wearing full PPE including N95 mask, face shield, gown, and gloves. After MD brought Resident 31 into the room MD was observed exiting the red zone room wearing the same PPE, walking down the hall in the red zone, and with gloved hand opened the fire door leading to the yellow zone, and entered the yellow zone.
During a concurrent observation and interview on 1/19/2022 at 4:25 p.m., in the red zone, MD was observed re-entering the red zone from the yellow zone through the closed fire door wearing the same PPE used to move Resident 31 to the red zone. MD stated DON informed him that it was OK to leave the red zone and enter the yellow zone without removing PPE. MD stated it was the facility's policy to remove PPE when going from the red zone to the yellow zone and it was OK to return to the yellow zone after working in the red zone. MD stated the reason the facility had red and yellow zones and the requirement to wear PPE was to prevent spreading COVID-19 infection.
During an interview on 1/22/2022 at 9:41a.m., the MD stated on 1/19/2022 when he crossed from the red zone to the yellow zone and back to the red zone wearing the same PPE, he was going to transfer Resident 48 from the yellow zone to the red zone. MD stated he was not sure if he should have crossed over zones wearing the same PPE.
During an interview on 1/21/2022, at 1:46 p.m., IP1 stated staff should not leave the red zone in full PPE and cross into the yellow zone. IP1 stated if a staff cross from the red zone to the yellow zone wearing the same PPE that staff is cross contaminating the yellow zone. IP1 stated if cross contamination occurs, resident in the yellow zone that are negative for COVID-19 are being exposed to COVID-19 and can become infected with the virus.
During a review of the facility's policy and procedure (P&P) titled, Infection Prevention Quality Control Plan, revised 5/2020, the P&P indicated transmission-based precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent the spread of infection.
According to the website https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html healthcare personnel must use PPE appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and discarding before exiting the patient room was done to contain pathogens.
D. During a concurrent observation and interview on 1/19/2022, at 1:19 p.m., in the east hall, PTA was observed entering the yellow zone without wearing a face shield. PTA stated she forgot to put on her face shield after leaving the therapy room. PTA stated it was the facility's policy that staff must wear a face shield and N95 mask when in the yellow zone. PTA stated it was important to wear proper PPE to prevent spreading infection to keep everyone safe.
During a concurrent observation and interview on 1/20/2022, at 12:55 p.m., ADM was observed entering the yellow zone without the face shield from the courtyard. ADM stated it was the facility's policy that everyone entering the facility must wear a N95 mask and a face shield or goggles due to the current COVID outbreak.
During an interview on 1/21/2021, at 1:46 p.m., IP1 stated due to the facility's current COVID-19 outbreak staff must wear a face shield and N95 mask.
According to the website http://publichealth.lacounty.gov/acd/nCorona2019/B73COVID/SNF/index.htm once a Covid-19 outbreak has been identified, facility should immediately initiate standard, contact, droplet precautions, plus N95 respiratory and eye protection must be used in both the yellow and red zones.
A review of the facility's Mitigation Plan, dated 1/10/2022 indicated the facility will train staff on selecting, donning, and doffing appropriate PPE. Signage will be posted immediately outside resident's room indicating appropriate infection control and prevention precautions and required PPE in accordance with CDPH guidance. The facility will implement a staffing plan to limit transmissions during an outbreak and have dedicated consistent staffing team who directly interact with resident that are Covid-19 positive.
e. During an observation on 1/20/22, at 1:55 p.m., observed laundry staff (LS) 1 exited laundry room wearing a gown and gloves, proceeded in entering room [ROOM NUMBER], exited room [ROOM NUMBER] wearing the same gown and gloves, entered room [ROOM NUMBER] wearing the same gown and gloves, walked to the hallway, and entered room [ROOM NUMBER], exited room [ROOM NUMBER] wearing the same gown and gloves.
During a concurrent interview on 1/20/22, at 2:00 p.m., with LS 1 and LS 2, LS 2 as an interpreter for LS 1. LS 1 stated that she does not know that she needs to change gowns and gloves when she enters the resident's room. LS 1 stated that nobody shows me.
During an interview on 1/22/2022, at 3:30 p.m., with Infection Preventionist (IP) 1, IP 1 stated all staff should don and doff Personal Protective Equipment (PPE) every time they enter and exit resident's room.
f. During a review of the Resident's 12 admission record (Face Sheet), the face sheet indicated Resident 99 was admitted to the facility on [DATE]. Resident 12 diagnoses included encephalopathy (damage or disease that affects the brain), gastrostomy (an artificial opening into the stomach to deliver medication, nutrition, and hydration), dysphagia (difficulty of swallowing), Parkinson's disease (brain disorder that leads to shaking, stiffness, and difficulty with walking), dementia ( (loss of memory, language, problem-solving and other thinking abilities)
During a review of Resident 12 's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/3/2021, the MDS indicated Resident 12 had severe impairment in cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. Resident 12 needs extensive assistance with bed mobility, dressing, personal hygiene, and total dependence with transfer, toilet use and bathing.
During an observation on 1/19/2022, at 9:05 a.m., in Resident 12 room, observed syringe used for flushing enteral feeding (liquid food) had a date changed of 1/17/2022.
During an interview on 1/20/2022 11:25 a.m., with Licensed Vocational Nurse (LVN) 1, in the Resident 12's room, LVN 1 stated that syringe used for flushing enteral feeding should be changes daily for infection control.
During an interview on 1/22/2022, at 3:30 p.m., with Infection Preventionist (IP) 1, IP 1 stated syringes used to flush enteral feeding should be changed daily for infection control
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide reasonable accommodation to meet the resident'...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide reasonable accommodation to meet the resident's needs of one of one sampled residents (Resident 25) by failing to ensure that Resident 25 had a right size incontinence brief (diaper) that fits and not use his own incontinence brief.
This deficient practice had the potential for Resident 25 to have skin irritation and negatively impact the psychosocial well-being of the residents.
Findings:
During a review of the Resident's 25 admission record (Face Sheet), the face sheet indicated Resident 25 was admitted to the facility on [DATE]. Resident 25 diagnoses included chronic kidney disease (loss of kidney function), Type 2 diabetes mellitus (a condition in which the body fails to metabolize (process) glucose (sugar) correctly), essential hypertension (high blood pressure), obesity (excessive body fat that increases the risk of health problems).
During a review of Resident 25 's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/28/2021, the MDS indicated Resident 25 had no impairment in cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. Resident 25 needs extensive assistance with bed mobility, dressing, toilet use, and personal hygiene, and total dependence with bathing. Resident 25 had no episodes of continent (able to control bowel movements.
During concurrent observation and interview with Resident 25 on 1/19/22 at 9:35 a.m., Resident 25 stated that the incontinence brief he was wearing was too small. Observed Resident 25 incontinent briefs covering his perineal area and does not goes over Resident 25's hip to close.
During concurrent observation and interview with Resident 25 on 1/20/22 at 11:00 a.m., Resident 25 stated that they continue to use small diaper, licensed staff told him that the facility do not have double extra large diaper and he needs to use his own diaper. Resident 25 stated I felt terrible, why should I be responsible for my own diaper. Resident 25 stated that he feels he does not have dignity.
During an interview on 1/21/22, at 3:45 p.m., with Maintenance Director (MD). MD stated that he is responsible in ordering incontinent briefs for the facility. MD stated that the facility had a double extra-large incontinent brief, but licensed staff had not requested for a particular resident.
During an interview on 1/22/22, at 11:05 a.m., with Certified Nursing Assistant (CNA) 4, CNA 4 stated, that it is important for Resident 25 to have a well fitted incontinence brief to prevent skin irritation and for Resident 25 dignity.
During an interview on 1/22/22, at 1:25 p.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated, that facility needs to provide incontinence brief to residents. LVN 4 stated that it should be well fitted to the resident to prevent skin irritation.
During an interview on 1/22/22, at 3:30 p.m., with Director of Nursing (DON), DON stated, resident should have well fitted incontinence briefs to prevent skin irritation. DON stated that facility was responsible in providing well fitted incontinent briefs to residents.
During a review of the facility's policy and procedure (P&P) titled, Quality of Life-Accommodation of Needs, revised 8/ 2009, the P&P indicated, The resident's individual needs and preferences shall be accommodated to the extent possible .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were provided a homelike environment...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were provided a homelike environment for one of 13 sample residents (Resident 9) by failing to:
a. removed all personal belongings of previous resident occupying room [ROOM NUMBER].
b. providing Resident 9 with personal remote control for his room television.
c. ensure Resident 9 personal belongings were on his possession when he transferred to his new room.
These deficient practices had resulted in the resident's increased level of discomfort, had negatively impacted Resident's 12 psychosocial wellbeing.
Findings:
During a review of the Resident's 9 admission record (Face Sheet), the face sheet indicated Resident 9 was admitted to the facility on [DATE]. Resident 9 diagnoses included sepsis (presence of harmful microorganisms in the blood), chronic obstructive pulmonary disease ([COPD] progressive disease that makes it hard to breath), type 2 diabetes mellitus (a condition in which the body fails to metabolize (process) glucose (sugar) correctly).
During a review of Resident 9 's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 11/24/2021, the MDS indicated Resident 9 had no impairment in cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. Resident 9 needs extensive assistance with bed mobility, dressing, personal hygiene, and total dependence with toilet use and bathing.
a. During a concurrent observation and interview on 1/22/22, at 10:30 a.m., with Resident 12, Resident 12 room was observed to have a cork board with Christmas cards and personal pictures, LA Lakers poster, and a white board with personal cards and drawings. Resident 12 stated, that was from the other resident occupying his current room. Observed an electric fan, a digital video disc player (a device that plays video [DVD]), nightstand filled with personal items. Resident 12 stated that all the belongings belong from the previous resident. Resident 12 stated that he feels alienated and uncomfortable to have other residents' belongings still inside his room.
b. During a concurrent observation and interview on 1/22/22, at 10:30 a.m., with Resident 12, Resident 12 stated that he cannot watch television without asking the staff to turn it on. Resident 12 stated that he was not provided a remote control for his television.
c. During an interview on 1/22/2022, at 10:30 a.m., with Resident 12, Resident 12 stated that he had belongings from his previous room that have not moved with him during the transfer.
During an interview on 1/22/2022, at 11:10 a.m., with Certified Nursing Assistant (CNA) 4, CNA 4 stated, it is important to have a home like environment, where all your personal belongings were with you. CNA 4 stated that all belongings from previous residents should have been cleared prior to transferring Resident 12 to his new room. CNA 4 stated that all his personal belongings should have been transfer to his new room.
During an interview on 1/22/22, at 1:25 p.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated, that Resident 12 rooms should had been prepared prior to him transferring to his new room. LVN 4 stated that there should not be any belongings from previous residents on Resident 12's room.
During an interview on 1/22/2022, at 3:30 p.m., with Director of Nursing (DON), DON stated that resident's room should have a home like environment. Resident's room should have family pictures, books, personal belongings for their psychological wellbeing.
During a review of the facility's policy and procedure (P&P) titled, Resident Rights, revised 12/2016, the P&P indicated, Resident's right to retain and use personal possessions to the maximum extent that space and safety permit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview the facility failed to ensure the residents have the right to be free from neglect, physical...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview the facility failed to ensure the residents have the right to be free from neglect, physical, verbal, and mental abuse for one of one sampled resident (Residents 25).
This deficient practice had Resident 25 felt humiliated, and degraded.
Findings:
During a review of the Resident's 25 admission record (Face Sheet), the face sheet indicated Resident 25 was admitted to the facility on [DATE]. Resident 25 diagnoses included chronic kidney disease (loss of kidney function), Type 2 diabetes mellitus (a condition in which the body fails to metabolize (process) glucose (sugar) correctly), essential hypertension (high blood pressure), obesity (excessive body fat that increases the risk of health problems).
During a review of Resident 25 's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/28/2021, the MDS indicated Resident 25 had no impairment in cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. Resident 25 needs extensive assistance with bed mobility, dressing, toilet use, and personal hygiene, and total dependence with bathing.
During an interview on 1/19/22 at 9:35 a.m. with Resident 25, Resident 25 stated that couple of days ago, during the night shift he had a bowel movement and needed to be cleaned and changed incontinent briefs. Resident 25 stated that the Certified Nursing Assistant (CNA) was rough on me , and make him feel it was his fault that he had an accident.
During an interview on 1/20/22 at 11:00 a.m., with Resident 25, Resident 25 stated that the the night staff was mad and made me feel it was my fault that I had a bowel movement. Resident 25 stated that the CNA was mad at him for using a towel to wipe him down. Resident 25 stated that he felt mad because he does not have any control of the situation. Resident 25 stated that I feel my dignity was affected.
During an interview on 1/22/2022, at 11:05 a.m., with Certified Nursing Assistant (CNA) 4, CNA 4 stated, resident should be treated with respect. CNA 4 stated that staff should not talked down to any resident, regardless of the situation.
During an interview on 1/22/22, at 1:25 p.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated, all staff in the facility should treat residents with respect an dignity. LVN 4 stated that it was not appropriate to blame or get mad to resident when they asked to be cleaned or changed due to incontinence.
During an interview on 1/22/2022, at 3:30 p.m., with Director of Nursing, DON stated that staff should treat all residents with respect and dignity. DON stated that any remarks that made resident feel humiliated, and degraded is considered verbal abuse.
During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention, revised 12/2018, the P&P indicated, The facility assures that residents are free from neglect by having the structures and processes to provide needed care and services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of four sampled residents (Resident 26) with a negative p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of four sampled residents (Resident 26) with a negative pre-admission screening and resident review (PASARR) level I who had a newly diagnosed mental disorder was referred for PASARR level II resident review.
This deficient practice placed Resident 26 at risk for not receiving necessary care and services they need.
Findings:
During a review of Resident 26's admission Record, the admission record indicated resident 26 was readmitted to the facility on [DATE] with diagnoses that included schizophrenia (a mental disorder that affects a person's ability to think, feel, and behave clearly), major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities).
During a review of Resident 26's Minimum Data Set (MDS-comprehensive screening tool), dated 12/9/21, the MDS indicated Resident 26 had severe cognitive (ability to learn remember, understand and decisions) impairment for daily decision making, limitation in range of motion in both legs, used a wheelchair and walker for mobility, and was required totally dependent on staff for personal hygiene and bathing.
During a review of Resident 26's Preadmission Screening and Resident Review (PASARR) Level I, dated 5/27/21, the PASRR I was negative and indicated the resident had mental illness and there was no PASARR II.
During a review of Resident 26's medical chart there was no new referral to the Department of Mental Health for an evaluation after being newly diagnosed with schizophrenia (a mental disorder that affects a person's ability to think, feel, and behave clearly) and major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest.
During an interview on 1/21/22 at 11:00 a.m., with the Business Office Manager (BOM), BOM stated he initiate the PASRR upon admission and he did not know he had to send a new referral for residents who have new mental disorder diagnoses.
During an interview on 1/22/22 at 10:23 a.m., with the Administrator (ADM), Director of Nursing (DON), and Business Office Manager (BOM), ADM, DON, and BOM stated there is no one at the facility assigned to follow up on the PASRR II recommendations and there is no one assigned to resubmit the PASRR after resident are newly diagnosed with mental disorders.
During an interview on 1/22/22 at 3:40 p.m., with the Director of Nursing (DON), DON stated PASRR is for residents with mental disorders and residents with newly diagnosed mental disorder must have an updated PASRR evaluation with the Department of Mental Health (DMH). DON stated she is not aware of any new request sent from the facility to DMH for reevaluation following a new mental disorder diagnosis.
During a review of Policy and Procedure (P&P) titled, Pre-admission Screening Level II Resident Review NP-104B (PASRR Level II), revised 2017, the P&P indicated, the facility will refer all level II residents and all residents with newly evident possible serious mental disorder or related conditions for level II resident review upon a significant change in status assessment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff members failed to provide oral hygiene (cleaning the mout...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff members failed to provide oral hygiene (cleaning the mouth and tongue) for one of 13 sampled residents (Resident 12), who needed total physical assistance with oral hygiene.
This deficient practice had the potential to place Resident 12 at risk for diseases of the mouth, gums, and teeth.
Findings:
During a review of the Resident's 12 admission record (Face Sheet), the face sheet indicated Resident 99 was admitted to the facility on [DATE]. Resident 12 diagnoses included encephalopathy (damage or disease that affects the brain), gastrostomy (an artificial opening into the stomach to deliver medication, nutrition, and hydration), dysphagia (difficulty of swallowing), Parkinson's disease ( brain disorder that leads to shaking, stiffness, and difficulty with walking ), dementia ( (loss of memory, language, problem-solving and other thinking abilities)
During a review of Resident 12 's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 12/3/2021, the MDS indicated Resident 12 had severe impairment in cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. Resident 12 needs extensive assistance with bed mobility, dressing, personal hygiene, and total dependence with transfer, toilet use and bathing.
During an observation on 1/19/2022, at 9:05 a.m., in Resident 12 room, observed Resident 12 had a dry lip, and his mouth had a thick brown substance on his teeth. Resident 12 had a hard time speaking due to the thick substance on his mouth.
During a concurrent observation and interview on 1/20/2022 11:25 a.m., with Licensed Vocational Nurse (LVN) 1, in the Resident 12's room, LVN 1 stated that Resident 12's lips were very dry, and his mouth was dirty and needs mouth care. LVN 1 stated that it is important for Resident 12 to have his mouth care to prevent fungal infection. LVN 1 stated that oral care was part of resident's morning care.
During an interview on 1/22/2022, at 11:05 a.m., with Certified Nursing Assistant (CNA) 4, CNA 4 stated, oral care was part of morning routine for all residents. CNA 4 stated that resident's on enteral feeding (liquid food) had a potential for their mouth to get dry. CNA 4 stated that it is important for Resident 12 to have a good oral care to prevent infection.
During an interview on 1/22/22, at 1:25 p.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated, residents on enteral feeding needs constant oral care to prevent dry mouth, mouth odor and infection.
During an interview on 1/22/2022, at 3:30 p.m., with Director of Nursing, DON stated oral care is a basic nursing care tasks that will be provided for each resident and residents on enteral feeding shall have oral care performed regularly to prevent dry mouth and infection.
During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living, revised 3/2018, the P&P indicated, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that Health Facilities Inspection Division (HFID) received th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that Health Facilities Inspection Division (HFID) received the report of Resident 26's fall with injury that occurred on 1/14/22.
This deficiency had the potential to result in inadequate monitoring, managing, and trending of incidents reported to the Department of Public Health to improve healthcare systems in preventing future harm.
Findings:
During a review of Resident 26's admission Record, the admission record indicated resident 26 was readmitted to the facility on [DATE] with diagnoses that included schizophrenia (a mental disorder that affects a person's ability to think, feel, and behave clearly), major depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), and dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person's ability to perform everyday activities).
During a review of Resident 26's Minimum Data Set (MDS-comprehensive screening tool), dated 12/9/21, the MDS indicated Resident 26 had severe cognitive (ability to learn remember, understand and decisions) impairment for daily decision making, limitation in range of motion in both legs, used a wheelchair and walker for mobility, and was required totally dependent on staff for personal hygiene and bathing.
During a review of Resident 26's Situation, Background, Assessment, Recommendation (SBAR) Communication form and progress note dated 1/14/2022, it was indicated Resident 26 was found on the floor bleeding, with a laceration on her forehead. The paramedics were called, and Resident 26 was transferred to the acute hospital for further evaluation.
During a review of Resident 26's care plan, dated, 12/9/2020, history of fall on 7/17/2021, and revised 1/19/2022 it was indicated resident 26 was at risk for recurrent fall/injury.
During a review of Resident 26's care plan, dated, 1/15/2022 it was indicated resident 26 was found on the floor after having an unwitnessed fall related to trying to get out of bed unassisted and trying to be independent.
During a review of Resident 26's care plan, dated, 1/15/2022 it was indicated resident 26 had alteration in skin integrity due to right forehead laceration that was treated with steri strip.
During a review of Resident 26's Fall risk assessment, dated 12/8/2020, indicates the fall risk assessment is to be completed on admission, quarterly, or significant change in condition. A score of 10 or above represents high risk. Resident 26's score was 7, indicating she was not high risk for falls.
During a review of Resident 26's Fall risk assessment, dated 5/16/2021, indicates the fall risk assessment is to be completed on admission, quarterly, or significant change in condition. A score of 10 or above represents high risk. Resident 26's score was 5, indicating she was not high risk for falls.
During a review of Resident 26's Fall risk assessment, dated 5/27/2021, indicates the fall risk assessment is to be completed on admission, quarterly, or significant change in condition. A score of 10 or above represents high risk. Resident 26's score was 8, indicating she was not high risk for falls.
During a concurrent interview and record review on 1/21/22 at 2:47 p.m., with Licensed Vocational Nurse (LVN) 3, LVN3 stated Resident 26 was hospitalized on [DATE] for a fall that was not classified. LVN3 stated Resident 26 had a fall and sustained a forehead laceration and this is considered a fall with injury. LVN3 stated the care plan was updated but the fall risk assessment has not been updated since 5/21.
During an interview on 1/22/22 at 10:33 a.m., with Director of Nursing (DON) and Administrator (ADM), both DON and ADM stated they are both responsible for reporting unusual occurrence to Health Facilities Inspection Division (HFID). DON stated a fall with injury is not a reportable incident and ADM stated a fall with injury is a reportable incident. Both DON and ADM stated Resident 26's fall with forehead laceration that required Resident 26 be transferred via paramedics to the hospital on 1/14/22 was not reported to HFID and the fall was a fall with injury.
During a concurrent interview and record review on 1/22/22 at 4:01 p.m., with Director of Nursing (DON), DON resident 26 is a fall risk due to her multiple falls. DON stated the fall risk assessment is completed by a LVN or RN and must be completed quarterly and or after every incident (fall). DON stated while reviewing resident 26's electronic medical record (EMR), resident 26's last fall was on 1/14/22 and the last fall risk assessment was completed 5/27/21 which show resident was not a fall risk at that time. There was no fall risk assessment completed after residents 1/14/22 fall with injury.
During a review of Policy and Procedure (P&P) titled, Unusual Occurrence Reporting, dated, 2007, the P&P indicated the facility is required to report events which affect the health, safety, or welfare of resident, employees, or visitors. Unusual occurrence shall be reported via telephone to appropriate agencies as required by current law and/or regulation within 24 hours.
Please note on 1/25/22 a letter was forwarded to me from the ADM with investigative information referencing resident 26's fall with injury and the facilities failure to report the fall.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to ensure nutritional interventions were evaluated to prevent unplanned weight loss for two of 13 resident's (Resident 10 and Res...
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Based on observation, interview and record review, the facility failed to ensure nutritional interventions were evaluated to prevent unplanned weight loss for two of 13 resident's (Resident 10 and Resident 11) by failing to:
1.
Ensure facility followed the physician orders to offer additional nourishments to prevent weight loss and provide additional calories for Resident 10.
2.
Follow Minimum Data Set (MDS - a comprehensive assessment and care screening tool) by providing assistance and supervision with meals for Resident's 10 and 11, who both had significant weight loss.
3.
Failed to prevent unplanned significant weight loss in Resident 10 who is blind and Resident 11 who has dementia.
These deficient practices resulted in Resident 10 (R10) to experience significant unplanned weight loss of 5.39% in 3 months and 12% in 90 days (previous admit weight was 186 pounds) and Resident 11 had a 9 pound weight loss, in one week (June) and 17 pound weight loss in one month, 14.6% (July). Resident 11 had an overall weight loss of 8.2% by December 2021.
Findings:
A.During an observation on 1/19/22 at 12:30 p.m., Resident 10 was eating lunch without assistance or any staff in the room for assistance. Resident 10 stated she is blind.
During an observation on1/21/22 and 1/22/22 of Resident 10's lunch tray, the lunch tray was observed without a sugar free high protein nourishment ordered by the for breakfast and lunch.
During a review of the facility admission record for Resident 10 dated January 21, 2022, the admission record indicated that Resident 10 had diagnosis of dysphagia (difficulty swallowing), legal blindness and nutritional anemia (lack of iron, protein, vitamin B-12 and other vitamins and minerals needed in the blood).
During a review of the facility physician orders dated December 23, 2021, the physician orders indicated Resident 10 had a diet order of Consistent Carbohydrate (diabetic diet), no added salt with Regular texture. Resident 10 also had an order for pro-stat sugar free (dietary supplement for wound healing and malnutrition) three times a day as a supplement, and a sugar free high protein nourishment 4 ounces (dietary supplement to provide calories) twice a day with breakfast and lunch.
During a review of the facility dietary slips dated 1/21/22 and 1/22/22, there was no indication of a house nourishment order on the dietary slip for the dietary aide to place on Resident 10 lunch tray.
During a review of the facility History and Physical dated November 15, 2021, the history and physical stated that Resident 10 had a history of oral dysphagia (difficulty in swallowing).
During a review of the facility care plan dated November 22, 2021, the care plan indicated that resident 10 had a weight loss of 6 pounds in 1 month and oral (by mouth) intake of 25-100%. It indicated Resident 10 remained at risk for weight changes. It also indicated that Resident 10 has potential for nutritional problems and will maintain have no signs and symptoms of malnutrition and consume at least 75% of 2 meals daily.
During a review of the facility Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated November 18, 2021, the MDS indicated that Resident 10 has severely impaired vision. It also indicated that Resident 10 needed supervision with meals, oversight and cueing. MDS, section B also indicated Resident 10 had severe vision impairment.
During a review of the facility weight summary dated 7/1/21-1/21/222, the weight and vitals summary indicated that Resident 10 had:
-9/14/21 weight 160 pounds
-11/16/21: 7.5% weight change from 9/14/21-11/23/21 of 13 pounds (147 pounds)
-11/23/21: 7.5% weight change of 13 pounds (weight 147 pounds)
-12/1/21: 7.5 % weight change of 12 pounds (weight 148 pounds)
-1/5/22: 10% weight change of 10.1.% of 16 pounds (weight 142 pounds)
Weight loss from 9/14/21 to 1/5/21 was 16 pounds. Weight loss percentage of 11.25 % in 4 months.
During a review of the facility Situation Background Assessment Request (SBAR- document when a resident has a change of condition) forms dated 11/10/21, 11/17/21 and 1/6/22, the SBAR indicated that Resident 10:
11/10/21-Indicated Resident 10 had a weight loss of 6 pounds in 2 weeks
11/17/21-Indicated that Resident 10 had a weight loss of 4 pounds in 1 week
1/6/22-Indicated that Resident 10 had a weight loss of 6 pounds in 1 month
During an interview on 01/19/22 at 1:30 p.m. Interview with CNA 2, CNA 2 stated that Resident 10 is blind. CNA 2 stated, he just passed Resident 10 lunch tray and did not stay in the room to feed her because she only needs minimal assistance. CNA 2 stated he told Resident 10, what was on her plate and sit her plate on her lap and told her where everything was on the plate. CNA 2 also stated, it showed independence for Resident 10 and the staff monitored what she eats.
During an interview on 01/22/22 1:02 p.m. with LVN 4, LVN 4 confirmed that there wasn't a nourishment on Resident 10 lunch as ordered by the physician. LVN 4 confirmed Resident 10 was blind. LVN 4 also indicated that it is important for Resident 10 not to lose weight to prevent infection and dehydration.
During an interview on 1/22/22 at 1:30 p.m. with the Dietary Supervisor (DS), The DS stated that he is responsible for checking the trays prior to leaving the kitchen. The DS states that dietary orders for nourishments are given to him and he enters them in the computer to be printed on the dietary slip. The DS stated that the house nourishment order for Resident 10 was never entered in the computer system and the order was missed by him. The DS stated that if a nourishment is not given as ordered, things can go wrong for residents. The DS also stated it was important to give the nourishments as ordered to provide additional calories as needed to promote wound healing and prevent dehydration. The DS stated that if the order for nourishment was entered in the computer system, it would have been on Resident 10 tray. DS also stated that Resident 10 had been losing weight and was discussed in the IDT weight loss meeting with the RD. The DS confirmed that Resident 10 lost 6 pounds in one month.
During an interview with the Registered Dietician (RD) on 01/22/22 at 2:48 p.m., the RD stated that she comes to the facility weekly on Wednesdays. The RD stated, she meets weekly with the facility staff to monitor residents who were just recently admitted back from the hospital and check their weights for the next month. The RD stated, if residents have significant weight change at 1, 3 and 6 months, they are on weekly monitoring for weight loss. The RD stated, Resident 10 is not currently on the weekly weight variance meeting, only a monthly weight review and currently eating 25-100%. The RD stated Resident 10 was hospitalized in November and was on weight variance and eating 25-75 % in November. RD stated, Resident 10 had a significant weight loss in November and lost 10 pounds. RD stated there is no one to follow up on resident's weight loss when she is off and stated she was off for the holidays on vacation in November and came back somewhere around 11/29/21. The RD stated it is the responsibility of the nurses to follow up on recommendations and notify the DS to implement in dietary. RD stated Resident 10 do not currently need to be in the weight variance meeting weekly or monthly and her weight loss for good for Resident 10. RD stated, I like her weight loss.
During an interview on 01/22/22 at 2:40 p.m. with the DON, the DON stated that the meal trays are checked by the treatment nurse prior to them being passed to the resident rooms. The DON stated that if there is a discrepancy, it should be reported to the DS. The DON confirmed the nourishment should have been on Resident 10 tray that was ordered by the physician. The DON also stated that it was important that Resident 10 received the nourishment that was ordered so she would not get sick, dehydrated, malnourished or be at risk for falls.
B. During an observation on 1/19/22 at 1:15 p.m., Resident 11 was observation eating lunch without supervision. Resident 11 had a mechanical soft chopped diet and was eating the meat with her hands. Resident 11 was observed with food all over her mouth and falling down on her chest. Upon review of Resident 11 tray, it was observed she ate around 25%.
During a review of the facility admission record dated November 18, 2021, the admission record indicated Resident 10 had diagnoses of: unspecified severe protein-calorie malnutrition, dysphagia (difficulty in swallowing), muscle weakness, Stage 3 pressure ulcer (sore on the skin that extends into the tissue beneath the skin) on the sacrum and dementia (a chronic disorder of the mental processes caused by brain disease and marked by memory disorders and impaired reasoning).
During a review of the facility physician orders dated November 18, 2021, the physician orders indicated that Resident 11 had an order for a Mechanical soft-finely chopped meat and vegetable texture diet and Remeron 7.5 mg (medication to stimulate the appetite) manifested by Resident 11 eating less than 75%.
During a review of the facility weight summary dated from 10/3/21-12/15/22, the weight summary stated that Resident 11 had a total weight loss of 12 pounds. The weight change indicated:
10/3/21-weight 147 pounds
11/2/21-weight 137 pounds (-6.8%)
11/19/21-weight 135 pounds (-7.5%) weighed in wheelchair
12/15/21-weight 135 pounds (-8.2%)
1/5/21-current weight 136 pounds
During a review of the facility care plan dated April 28, 2021, the care plan indicated that Resident 11 was at risk for choking aspiration (fluid going down into the lungs). The care plan indicated that Resident 11 is totally dependent on staff for eating. The care plan also indicated that Resident 11 had the potential for nutritional problems and previously had a gastrostomy tube (tube inserted directly into the stomach to provide food and nutrition) on 4/22/21 but had it removed on 5/21/21.
During a review of the facility care plan dated November 3, 2021, the care plan indicated that Resident 11 had a10 pound weight loss in one month.
During a review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated May 5, 2021, the MDS indicated that Resident 11 needed extensive assistance with all meals.
During a review of the Minimum Data Set quarterly (MDS - a comprehensive assessment and care screening tool) dated November 2, 2021, the MDS stated that Resident 11 needed supervision, with all meals.
During a review of the General Acute Care Hospital (GACH) records dated November 10, 2021, indicated Resident 11 was admitted to the hospital with a diagnosis of poor oral intake, increasing weight loss for one week duration and decline in function.
During a review of the facility Situation Background Assessment Request (SBAR- document when a resident has a change of condition) forms dated November 9, 2021, the SBAR indicated that Resident 11 had a change of condition and had generalized body weakness and significant weight loss.
During a review of the facility Situation Background Assessment Request (SBAR- document when a resident has a change of condition) forms dated November 10, 2021, the SBAR indicated that Resident 11 had a change of condition with a weight loss of 10 pounds that started on 11/3/21.
During a review of the facility Situation Background Assessment Request (SBAR- document when a resident has a change of condition) forms dated January 1, 2022, the SBAR indicated that Resident 11 had a change of condition with an episode of hypoglycemia (low blood sugar) 41 and 56. Normal blood sugar is 70-120.
During a review of the facility progress notes dated January 13, 2022, at 12:56 p.m., the progress note indicated that Resident 11, refused to eat lunch. Resident 11 blood sugar was 36.
During a review of the facility progress note dated January 15, 2021, at 3:44 p.m., the progress indicated that Resident 11 ate 76% of breakfast and 50% of lunch.
During a review of the facility progress note dated January 17, 2022, at 4:20 p.m., the progress note indicated that Resident 11 ate 20% of her dinner.
During a review of the facility progress note dated January 19, 2022, at 2:37 p.m., the progress note indicated that Resident 11 refused to eat lunch and was noted with an episode of vomiting. Resident 11 was later transferred to the GACH.
During an interview with on 1/19/22 at 4:21 p.m. with Resident 11 Responsible Party (RP), the RP stated that he noticed Resident 11 had lost weight. The RP stated, he wanted to bring Resident 11 food from the outside so she would eat, but the facility is always on lock down for Covid. The RP also stated he is looking for another facility to put Resident 11 in for safety.
During an interview on 1/22/22 at 1:52 p.m. with the DS, the DS stated that Resident 11 weight was fluctuating. The DS stated Resident 11 was recently re-admitted to the facility from GACH. The DS stated that Resident 11 is not currently being seen in the weight variance weekly meeting, only on monthly weight review. The RD stated Resident 11 was hospitalized in November to mid- December. RD stated Resident 11 had significant weight loss in November. RD stated she couldn't find her monthly weight review for Resident 11. RD also stated she did not write a note for Resident 11 recently because she only writes a progress note if they lost any amount of weight that is significant and that a note for documentation is only needed when the weight loss is greater than 3 pounds. The RD stated continued weight loss could lead to malnutrition and infection because their immune system is compromised which could lead to poor wound healing if they have a pressure ulcer and wounds could get bigger.
During an interview on 1/22/22 at 2:43 p.m. with the MDS, the MDS stated that Resident 11 needed extensive assistance with meals.
During an interview on 1/22/22 at 2:40 p.m. with the DON, the DON stated that if a resident has weight loss, that is considered a change of condition and the nurse needs to call to doctor for orders and labs and put them on weekly weights. The DON also stated it needs to be reported to the dietician and monitored for 4 weeks.
A review of the facility policy Weight Assessment and Intervention dated August 2021, the policy indicated that significant and undesired weight loss is based on 5% or 5 pounds in month.
A review of the facility policy Quality of Life-Accommodation of Needs dated August 2009, the policy indicated that the facility shall interact with the residents in a way that accommodates the physical or sensory limitations of the residents and maintains dignity.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure nebulizer mask (a drug delivery device used to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure nebulizer mask (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) for two of two sampled residents (Resident 6 and 99) were labelled with a change date and stored in a sanitary place based on facility's policy and procedure.
This deficient practice had the potential for respiratory infections for Resident 6 and 99.
Findings:
During a review of the Resident's 6 admission record (Face Sheet), the face sheet indicated Resident 6 was admitted to the facility on [DATE]. Resident 6 diagnoses included Type 2 diabetes mellitus (a condition in which the body fails to metabolize (process) glucose (sugar) correctly), essential hypertension (high blood pressure), schizoaffective disorders ( mental health condition), unspecified asthma ( condition in which airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe).
During a review of Resident 6 's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/5/2021, the MDS indicated Resident 6 had no impairment in cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. Resident 6 needs supervision with bed mobility, transfer, dressing, walk in corridor, toilet use, personal hygiene, and bathing.
During a review of the Resident's 99 admission record (Face Sheet), the face sheet indicated Resident 99 was admitted to the facility on [DATE]. Resident 99 diagnoses included chronic kidney disease (kidneys are damaged), paranoid schizophrenia (mental disorder in which people interpret reality abnormally), chronic obstructive pulmonary disease (progressive disease that makes it hard to breath).
During a review of Resident 99 's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 10/27/2021, the MDS indicated Resident 99 had no impairment in cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. Resident 99 needs extensive assistance with bed mobility, transfer, dressing, and personal hygiene and total dependence with toilet use, and bathing.
During a concurrent observation and interview on 1/19/22, at 10:00 a.m., in Resident 6 room, observed Resident 6 nebulizer mask oily, dirty and with no date change label. Resident 6 stated that licensed staff had change it every week but had not change it for more than a month.
During a concurrent observation and interview on 1/20/22, at 10:40 a.m., in Resident 6 room with Licensed Vocational Nurse (LVN), LVN 1 stated that nebulizer face mask had no date change label and observed to be oily and dirty. LVN 1 stated that nebulizer face mask should be labelled with a changed date and changed weekly for infection control.
During an observation on 1/19/2022, at 9:50 a.m., in Resident 99 room, observed nebulizer mask with no date change label and mixed with Resident's 99 personal toiletries.
During a concurrent observation and interview on 1/20/22, at 10:43 a.m., in Resident 99 room LVN 1, LVN 1 stated that nebulizer face mask had no date change label and observed mixed with Resident 99 personal toiletries and used towel on top of the nebulizer mask. LVN 1 stated that nebulizer face mask should be labelled with a changed date and changed weekly for infection control.
During an interview on 1/22/22, at 3:30 p.m., with Director of Nursing (DON), DON stated, nebulizer mask should be changed every week and had a date change label and store in sanitary place to prevent respiratory infection.
A review of the facility's policy and procedure (P&P) titled Administering Medications through a Small Volume (Handheld) Nebulizer, indicated Change equipment and tubing every seven days, or according to facility protocol.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an annual Basic Cardiac Life Support (certification that tea...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an annual Basic Cardiac Life Support (certification that teaches emergency lifesaving interventions [BCLS]) were up to date for two out of five randomly selected staff.
This deficient practice had the potential for the facility not be able to assess the skills necessary to provide emergency life savings intervention for the residents in the facility.
Findings:
During a concurrent interview and record review with the Infection Preventionist (IP) 1 on [DATE] at 1:43 p.m., stated she covers for the Director of Staff Development (DSD) in his absence. Five random employee files were checked. Registered Nurse (RN) 1, and Certified Nurse Assistant (CNA) 4 did not have updated BCLS certification. RN 1 BCLS certification expired on 6/2021, and no BCLS certification found on CNA 4 file.
During an interview on [DATE], at 1:43 p.m., with IP 1, IP 1 stated, all staff need to meet the licensure and certification requirements yearly. IP 1 stated that these requirements are needed to perform their job if emergency life savings treatment is needed.
During an interview on [DATE], at 3:30 p.m., with Director of Nursing (DON), DON stated staff file should have a copy of up-to-date licensure and certification. DON stated that facility cannot confirm certification unless a copy of the certification is in your file.
A review of the facility's Job Description for Registered Nurse, Licensed Vocational Nurse and Certified Nurse Assistant dated 5/2017, the Job Description indicated, Qualification Requirements: Current BCLS certification.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 29's admission Record, the admission record indicated resident 29 was readmitted to the facility ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During a review of Resident 29's admission Record, the admission record indicated resident 29 was readmitted to the facility on [DATE] with diagnoses that included paraplegia (paralysis that affects all or part of the trunk, legs, and pelvic organs), hearing loss, diabetes (chronic condition that affects how the body processes sugar), and hypertension (high blood pressure).
During a review of Resident 29's Minimum Data Set (comprehensive screening tool [MDS]), dated 10/21/21, the MDS indicated Resident 29 had intact cognition, was able to make himself understood, and was able to understand others. The MDS indicated the resident had highly impaired hearing ability, needed extensive assistance with bed mobility, dressing, and personal hygiene and was totally dependent on staff for transfers, toileting, and bathing.
During an interview on 1/20/22 at 12:30 p.m. with Resident 29 stated he cannot hear my questions. Resident 29 was able to read lips and verbally respond to questions written on paper or his communication pad. Resident 29 stated he have hearing aids, but they do not work and prior to covid he was seeing a hearing doctor and being worked up for cochlear surgery. Resident 29 stated he would like to have surgery to fix his hearing.
During a concurrent interview and record review on 1/21/22 at 3:00 p.m., with Licensed Vocational Nurse (LVN) 3, LVN3 stated resident 29 is hard of hearing and staff use a communication board to communicate with him. LVN3 stated she is not sure if resident 29 has hearing aids and she do not know if resident 29 has ever seen a hearing specialist. LVN3 stated Resident 29 has never told her he needed an appointment to see the hearing specialist. LVN3 stated while reviewing resident 29's electronic medical record (EMR), she is not seeing any consult notes or progress notes from an audiologist but there is a standing doctors order for an audiology consult as needed in resident 29's EMR.
During an interview on 1/21/22 at 3:15 p.m. with Resident 29 stated he is ok with using the communication board to communicate with staff. Resident 29 stated it has been a long time since he saw the hearing doctor and he asked four staff to help make an appointment, but no one will help, everyone just blew me off. Resident 29 stated he asked social service and she told him to ask the charge nurse and the charge nurse said ok, but nothing has a happened. Resident 29 stated the hearing doctor was working him up for cochlear surgery and Resident 29 stated he really want to have the surgery but no one at the facility will help him get an appointment.
During an interview on 1/22/22 at 11:50 a.m. with Director of Nursing (DON) and Administrator (ADM), DON stated the admission coordinator is covering for the director of social service and the social service department is responsible for coordinating resident appointments. DON stated she is not sure of the facility's policy on the timeframe for ancillary appointments. DON stated if a resident verbalizes a concern, social services or the charge nurse can call the doctor's office to arrange an appointment and when an as needed appointments is arranged either the provider come to the facility or the facility staff arrange transportation to the doctor's office.
During an interview on 1/22/22 at 4:15 p.m. with Minimum Data Set Coordinator (MDS), MDS stated she was not aware resident 29 had hearing aids, she was not aware there was a care plan on resident 29's chart related to his hearing aids, and resident 29 never asked her for assistance with making an appointment to see the audiologist. MDS stated she would check into the status of the audiologist appointment for resident 29.
On 1/22/22 at 5:25 p.m., after the exit conference I was approached by MDS who stated she reviewed resident 29's chart and resident 29 does have a care plan for his hearing aids to be kept at his bedside and that the hearing aids are not working. MDS stated she will put resident 29 on the list to be seen by the audiologist next week.
During a review of Policy and Procedure (P&P) titled, Availability of Consult and Ancillary Service, revised 2007, the P&P indicated, consult service such as podiatry, vision, dental, audiology, and other ancillary consults will be provided to each resident when indicated and social service will be responsible for making necessary appointment.
F 685 Treatment/Devices to maintain Vision and Hearing
Based on observation, interview, and record review, the facility staff failed to ensure residents maintained working assistive devices to maintain hearing abilities by not assisting in arranging for audiologist referral consults and arranging for transportation to replace the broken devices for two of 13 sampled residents (Resident 4 and 29).
This deficient practice resulted in a delay of services, inability in hearing/communication and Residents 4 and 29 not being able to hear adequately during a conversation.
Findings:
During a concurrent observation and interview on 01/19/22 12:30 p.m. with Resident 4, Resident 4 was observed sitting in the wheelchair in his room eating lunch with bilateral (in both ears) hearing aids hanging from ears. Resident 4 stated, my hearing aids don't work, and I need new ones. Resident 4 stated he has told staff members at the facility that his hearing aids are not working and he could not hear well.
During a review of Resident 4's Physician's Order dated October 25, 2021, the Physician Order indicated Resident 4 has an order for an Audiology consult prn (prn-whenever necessary or needed) to include impedance and tympanometry (how well the eardrum is vibrating when sound strikes).
During a review of the facility Social Service admission Assessment effective date, October 25, 2021, the Social Service admission Assessment indicated that Resident 4 has bilateral hearing aids on admission. It also indicated that Resident 4 use hearing to aide in communication.
During a review of the facility care plan dated October 27, 2021, the care plan indicated that Resident 4 had hearing problems manifested by moderate hearing loss. It also indicated that Resident 4 needed to facilitate the use of hearing aids to communicate.
During a review of the Minimum Data Set (MDS - a comprehensive assessment and care screening tool), Section B dated October 28, 2021, the MDS indicated that Resident 4 is hearing impaired and has bilateral hearing aids. MDS indicated that Resident 4 usually understands some of a conversation but only if a hearing device is used. The MDS also indicated in section I that Resident 4 also had progressive Neurological conditions, generalized muscle weakness, vision impairment (blind in left eye) and has a history of falls.
During an interview on 01/20/22 at 3:13 p.m. with LVN 2, LVN 2 stated that the Social Worker (SW) has been out sick since the first of the year. LVN 2 stated that he is aware that Resident 4 is hard of hearing and wears hearing aids. LVN 2 stated, he doesn't know who is covering for the social worker while she is out.
During an interview on 01/21/22 12:38 p.m. with CNA 3, CNA 3 stated that Resident 4 is very hard of hearing.
During a concurrent observation and interview on 01/21/22 12:55 p.m. LVN 2 and Resident 4, LVN stated Resident 4 only understood about 50% of what he is said. LVN 2 verified hearing aids were hanging out of Resident 4 ear and not effective. LVN 2, stated that he believed this practice was ok and he thought Resident 4 could understand their conversation, but not sure. LVN 2 was observed yelling to help Resident 4 hear but Resident 4 is asking about another subject matter as the LVN 2 is explaining about a doctor's appointment. Resident 4 states he only hears a little bit and didn't understand what LVN 2 was talking about.
During an interview on 01/21/22 02:07 p.m. with LVN 2, LVN 2 stated I noticed since yesterday that Resident 4 is hard of hearing. LVN 2 stated that Resident 4 hearing aid battery is low. LVN 2 was asked why the hearing aids were hanging from Resident 4 ears. LVN 2 stated that the hearing aids were not in correctly for Resident 4. LVN 2 stated that when he found the hearing was not working, he spoke slowly to Resident 4 and when Resident 4 didn't respond, LVN 2 spoke louder. LVN 2 stated that Resident 4 stated he only heard a little of the conversation. LVN 2 stated that communication is important so Resident 4 can ask what he needs and verbalize his needs. LVN 2 stated that the Director of Nurses (DON) was aware that the hearing aids were broken. LVN 2 stated that he does sign language with the resident for treatment and medications by pointing at Resident 4 finger to do his accu-chek (device to check blood sugar levels) and points at Resident 4 mouth to give his medications. LVN 2 stated that Resident 4 had an order since 1/3/22 to see the Ear Nose and Throat (ENT) physician, but the ENT has not come yet. LVN 2 stated that he is not sure if anyone followed up on the order since 1/3/22 because the SW is out sick.
During an interview on 01/22/22 10:52 a.m. with the MDS, the MDS stated that Resident 4 will be seen on Thursday, 1/27/22. MDS stated that on admission, Resident 4 had bilateral hearing aids, but it was still difficult for him to hear. MDS stated that the audiologist was called to put Resident 4 on the priority list on 1/20/21 and Resident 4 will be seen next week.
During an interview on 01/22/22 at 2:40 p.m. with the DON, the DON stated that she is not sure if the facility had a timeframe to complete consultations. The DON stated that Resident 4 has hearing aids, but it is still hard for Resident 4 to understand and he is not able to hear completely. The DON confirmed the hearing aids should be fixed. The DON stated the hearing aids were hanging out of Resident 4 ears.
During an interview on 01/22/22 at 2:43 p.m. with the MDS, the MDS stated that Resident 4 has hearing aids in both ears and know that it is hard for Resident 4 to understand, because Resident 4 cannot hear completely. MDS stated that Resident 4 hearing aids should be fixed because Resident 4 is not able to understand, and it is a safety risk.
During a review of the facility policy Change of Condition dated revised, December 2016, the policy indicated that the facility shall promptly notify the resident, his or her Attending Physician and representative of changing in the resident 's medical/mental condition and or status, including level of care.
During a review of the facility policy Availability of Consult and Ancillary Services dated September 2007, the policy indicated:
- that Social Services will be responsible for making necessary appointments.
-Inquiries concerning the availability of ancillary services should be referred to Social Services or to the DON.
-All request for other consult/ancillary services should be directed to Nursing Services to assure that appointments can be made in a timely manner.
-Inquiries concerning the availability of consult/ancillary services should be referred to Nursing Services or Social Services or the DON.
During a review of the facility policy Quality of Life-Accommodation of Needs dated August 2009, the policy indicated that the facility staff shall help keep hearing aids and other adaptive devices clean and in working order for the resident.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0912
(Tag F0912)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 21 of 25 residents rooms met the 80 square feet...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 21 of 25 residents rooms met the 80 square feet (sq. ft.) per residents in multiple resident rooms. Rooms 1, 2, 3, 4, 5, 6, 7, 8,10,11, 15, 16, 17, 18, 20, 21, 22, 23, 25, and 26 housed two and room [ROOM NUMBER] housed three residents per room, and room [ROOM NUMBER] housed four residents per room.
Findings:
On 1/19/22 at 12:10 p.m., during the initial tour of the facility, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 ,14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 25, and 26, residents' rooms did not meet the requirement of 80 sq. ft. per residents.
A review of Client Accommodations Analysis form, provided by the facility Maintenance Supervisor (MS) rooms 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 ,14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 25, and 26 are occupied by two residents each and ranged in total square feet measurement between 139.43 square feet to 148.19 square feet.
During an interview on 1/22/22, at 12:15 p.m. with the Administrator (ADM), ADM stated the facility had requested a room waiver and was waiting for the approval letter.
During a review of Room Waiver letter dated 11/10/2021 provided by the ADM, indicated that rooms had enough space to provide for each resident's care, dignity, and privacy. The letter indicated the lack of space on the new building code has no adverse effect in the residents' health and safety or in maintaining the wellbeing of the residents. The following Rooms were included in Room Waiver request 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 ,14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 25, and 26.
During a concurrent observation and interview on 1/22/22, at 10:30 a.m., with Resident 9, Resident 9 room was observed to have an extra wide bed and night table was positioned at the foot of the bed. Resident 9 stated that he feels the room was small and feels claustrophobic (having an extreme fear of confined places). Resident 9 stated that he does not feel claustrophobic in his previous room since the door was opened.
During a review of Room Waiver letter dated 11/10/2021 provided by the ADM, indicated, any concerns regarding room space expressed by any of the resident will be discussed during the Interdisciplinary Team (IDT) meeting for proper intervention.
During the survey observations from 1/19/22 to 1/22/22, the other resident's room were observed with sufficient space to move around freely within the room, and the nursing staff had enough space to provide care. There was space for the beds, side tables, dressers, and resident care equipment.
The survey team recommended approval of the Room Waiver Request.
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
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 40% turnover. Below California's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 2 harm violation(s), $40,870 in fines. Review inspection reports carefully.
- • 35 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $40,870 in fines. Higher than 94% of California facilities, suggesting repeated compliance issues.
- • Grade D (43/100). Below average facility with significant concerns.
Bottom line: Trust Score of 43/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is West Gardena Post Acute's CMS Rating?
CMS assigns WEST GARDENA POST ACUTE an overall rating of 4 out of 5 stars, which is considered above average nationally. Within California, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is West Gardena Post Acute Staffed?
CMS rates WEST GARDENA POST ACUTE's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 40%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at West Gardena Post Acute?
State health inspectors documented 35 deficiencies at WEST GARDENA POST ACUTE during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 2 that caused actual resident harm, 29 with potential for harm, and 3 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates West Gardena Post Acute?
WEST GARDENA POST ACUTE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by ABRAHAM BAK & MENACHEM GASTWIRTH, a chain that manages multiple nursing homes. With 50 certified beds and approximately 46 residents (about 92% occupancy), it is a smaller facility located in GARDENA, California.
How Does West Gardena Post Acute Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, WEST GARDENA POST ACUTE's overall rating (4 stars) is above the state average of 3.2, staff turnover (40%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting West Gardena Post Acute?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "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 facility's Immediate Jeopardy citations.
Is West Gardena Post Acute Safe?
Based on CMS inspection data, WEST GARDENA POST ACUTE has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in California. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at West Gardena Post Acute Stick Around?
WEST GARDENA POST ACUTE has a staff turnover rate of 40%, 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 West Gardena Post Acute Ever Fined?
WEST GARDENA POST ACUTE has been fined $40,870 across 2 penalty actions. The California average is $33,488. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is West Gardena Post Acute on Any Federal Watch List?
WEST GARDENA POST ACUTE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.