CASITAS CARE CENTER
For profit - Partnership
99 Beds
CAMBRIDGE HEALTHCARE SERVICES
Data: November 2025
Trust Grade
60/100
#546 of 1155 in CA
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Casitas Care Center has a Trust Grade of C+, indicating that it is slightly above average but not without its concerns. It ranks #546 out of 1,155 facilities in California, placing it in the top half, as well as #93 out of 369 in Los Angeles County, meaning there are only a few local options rated higher. However, the facility's trend is worsening, with reported issues increasing from 13 in 2024 to 28 in 2025. Staffing is generally a strength, with a turnover rate of 31%, which is lower than the state average, but it has concerning RN coverage, being below 80% of California facilities, which could impact the quality of care. Notably, there were specific incidents where a resident did not receive a critical medication and staff failed to assist residents in participating in activities, potentially affecting their well-being and quality of life. Overall, while there are strengths in staffing and no fines reported, the facility needs to address significant care and activity deficiencies to improve resident experiences.
- Trust Score
- C+
- In California
- #546/1155
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 31% turnover. Near California's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most California facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 17 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 70 deficiencies on record. Higher than average. Multiple issues found across inspections.
60/100
Top 47%
No red flags
13 → 28 violations
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 13 issues
2025: 28 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (31%)
17 points below California average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
3-Star Overall Rating
Near California average (3.1)
Meets federal standards, typical of most facilities
Staff Turnover: 31%
15pts below California avg (46%)
Typical for the industry
Chain: CAMBRIDGE HEALTHCARE SERVICES
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 70 deficiencies on record
Aug 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0847
(Tag F0847)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure the admission Coordinator (AC) was aware that residents and their representative can rescind the facility's arbitration (a private p...
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Based on interview and record review, the facility failed to ensure the admission Coordinator (AC) was aware that residents and their representative can rescind the facility's arbitration (a private process where disputing parties agree that one or several other individuals can make a decision about the dispute after receiving evidence and hearing arguments) agreement (a written contract in which two or more parties agree to settle a dispute out of court) within 30 days after obtaining the signature for two of three sampled residents (Residents 2, and 5 ).These failures could potentially result in the residents and residents' representatives not knowing or understanding what an arbitration agreement is and potentially causing feelings of doubt and confusion.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 6/12/2025, with diagnoses including metabolic encephalopathy (your brain is having trouble processing information due to a chemical imbalance in your blood), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and pneumonia (an infection/inflammation in the lungs).During a review of Resident 2's History and Physical (H&P), dated 6/29/2025, the H&P indicated Resident 2 had capacity to understand and make decisions.During a review of Resident 2's Resident-Facility Arbitration Agreement, dated 6/16/2025, the Resident-Facility Arbitration Agreement indicated Resident Representative 1 (RR1), signed the agreement on 6/16/2025.During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 8/8/2025, with diagnoses including unspecified (unconfirmed) encephalopathy (damage or disease that affects the brain), abnormal posture (how you hold your body when you are standing, sitting, or moving), and unspecified visual loss (a partial or complete inability to see clearly).During a review of Resident 5's H&P, dated 8/9/2025, the H&P indicated Resident 5 did not have the capacity to understand and make decisions.During a review of Resident 5's Minimum Data Set (MDS- a resident assessment tool), dated 8/13/2025, the MDS indicated Resident 5's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired.During a review of Resident 5's Resident-Facility Arbitration Agreement, dated 8/11/2025, the Resident-Facility Arbitration Agreement indicated RR 2, signed the agreement on 8/11/2025.During an interview on 8/12/2025, at 1:47 p.m., with the AC, the AC stated she (AC) explained the arbitration agreement as a document that if ever the resident or resident representative decides to sue the facility that it will be done in front of a mediator (neutral third party who facilitates communication and negotiation between individuals or groups in a dispute) instead of in front of the judge or courthouse. The AC stated she (AC) then generates the packet and the resident or the representative signs it. The AC stated she (AC) did not know residents or their representative can make changes after signing the arbitration agreement.During an interview on 8/12/2025, at 2 p.m., with the AC, the AC stated she did not know if residents or their representative can rescind (take back or cancel) their signature on the arbitration agreement.During an interview on 8/13/2025, at 10:23 a.m., with the Administrator (ADM), the ADM stated residents, and resident representatives can rescind their signature within 30 days after signing the arbitration agreement. The ADM stated the AC is responsible for the residents' arbitration agreement. The ADM stated it is important to inform the residents, and their representative, of what arbitration agreement is and that they can rescind the agreement within 30 days after signing the arbitration agreement. The ADM stated that the residents and resident representatives have the right to be fully informed before allowing them to sign the arbitration agreement.During a review of facility's policy and procedure (P&P), titled, Arbitration, dated 1/2025, the P&P indicated, The facility will present the agreement and explain the agreement in a form and manner that is understood by the resident or resident's representative and the resident or resident's representative is to acknowledge that they understand the agreement. The agreement must grant the right to rescind the agreement within 30 calendar days of signing it. Advise the residents or residents' representatives that they have the right to rescind the agreement within 30 days of execution. Advice they can rescind the agreement by giving written notice to any of the following: Administrator, Director of Nursing, Admissions and/or Social Services Department.
Apr 2025
5 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a document desig...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan (a document designed to facilitate communication among members of the care team that summarizes a resident's health conditions, specific care needs, and current treatments) and implement care plan interventions for one of four sampled residents (Resident 1) to address Resident 1's refusal to allow body weight monitoring.
These deficient practices had the potential to negatively affect the delivery of care and services and placed Resident 1 at risk for impaired nutrition and decline in well-being.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted the resident on 1/14/2025 and readmitted on [DATE] with diagnoses that included hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body needs), diabetes mellitus (DM - a condition that happens when your blood sugar is too high), hypertension (abnormally high blood pressure), and morbid (severe) obesity (a medical condition where someone has excessive fat accumulation that presents a risk to health).
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/14/2025, the MDS indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS further indicated that Resident 1 required maximum assistance from staff with lower body dressing and transfer, moderate assistance with bed mobility and toileting hygiene, and independent with eating.
During a review of Resident 1's Order Summary Report, dated 1/14/2025, the Order Summary Report indicated to obtain weekly weights for four weeks one time a day every Wednesday for four weeks. Order Date 1/14/2025; Start Date 1/15/2025; and End Date 2/12/2025.
During a review of Resident 1's Physician Order Summary, dated 4/9/2025, timed at 12:38 p.m. indicated to obtain weekly weights for four weeks. Order Date 4/9/2025.
During a review of Resident 1's Weights and Vitals Summary dated 4/24/2025, the Weight Summary indicated Resident 1's weights as follows:
a. A strikethrough entry (often called a strikeout, is a formatting style where a horizontal line is drawn to indicate that the entry or information has been deleted) dated 1/18/2025, timed at 2:31 p.m. indicated Resident 1 weighs 309 pounds (lbs. - an abbreviation for pounds which is a unit of weight) measured by bed scale (a specialized weighing device designed to weigh residents who are bedridden or unable to stand).
b. A strikethrough entry dated 1/30/2025, timed at 8:37 a.m. and 3:16 p.m. indicated Resident 1 weighs 265 lbs. measured by mechanical lift (a device used to assist in the movement and transfer of individuals who need help with mobility due to limitations in weight-bearing or movement ability).
c. An entry dated 1/31/2025 timed at 9:12 a.m. entered by the Director of Nursing (DON) indicated declined order.
During a review of Resident 1's Nutrition/Dietary Progress Notes dated 4/24/2025 timed at 9:04 a.m., the Nutrition/Dietary Progress Note indicated Resident 1 had been refusing weights and that the last recorded weight obtained was in January. The Nutrition/Dietary Progress Note indicated to continue to encourage Resident 1 to allow facility staff to obtain weights for baseline assessment.
During a concurrent interview and record review on 4/24/2025 at 10:11 a.m., with RN 1, RN 1 reviewed Resident 1's progress notes and care plans (from Resident 1's original admission date of 1/14/2025 to 4/23/2025). RN 1 stated that RN 1 did not receive reports from any staff that Resident 1 had been refusing to be weighed. RN 1 stated she was unable to locate entries in Resident 1's progress notes and care plans (from 1/14/2025 to 4/23/2025) regarding Resident 1's refusal to be weighed. When RN 1 was asked what the facility protocol was for a resident refusing to be weighed, RN 1 stated that the facility should have notified the physician and should have developed a care plan to address Resident 1's refusal to allow body weight monitoring. RN 1 further stated there was no documented evidence found indicating Resident 1's physician was notified of Resident 1's refusal to allow body weight monitoring.
During a concurrent interview and record review on 4/25/2025 at 2:55 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 reviewed Resident 1's progress notes and care plans (from Resident 1's original admission date of 1/14/2025 to 4/23/2025). LVN 1 stated she was unable to locate care plans (from 1/14/2025 to 4/23/2025) regarding Resident 1's refusal to be weighed. LVN 1 stated that LVN 1 was unaware that Resident 1 had been refusing to be weighed because the resident's body weights were reported to the Director of Nursing (DON) directly. LVN 1 stated if a resident refused to have his or her weight checked three times in a row, the resident's physician should be notified and health education including the possible risk of not allowing for weight to be monitored should be provided to the resident. LVN 1 further stated a care plan should have been developed and interventions should have been implemented to address Resident 1's refusal and nutritional needs.
During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered last reviewed on 1/3/2025, indicated, A comprehensive, person-centered care plan that includes measurable objectives and the timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change,
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
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 conduct a nutritional assessment upon admission for one of four sam...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct a nutritional assessment upon admission for one of four sampled residents (Resident 1), as per the facility's policy and procedure (P&P) titled, Nutritional Assessment.
This deficient practice had the potential to place Resident 1 at risk for undetected nutritional status and at risk for medical complications related to impaired nutrition.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted the resident on 1/14/2025 and readmitted on [DATE] with diagnoses that included hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body needs), diabetes mellitus (DM - a condition that happens when your blood sugar is too high), hypertension (abnormally high blood pressure), and morbid (severe) obesity (a medical condition where someone has excessive fat accumulation that presents a risk to health).
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/14/2025, the MDS indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS further indicated that Resident 1 required maximum assistance from staff with lower body dressing and transfer, moderate assistance with bed mobility and toileting hygiene, and independent with eating.
During a review of Resident 1's Order Summary Report, dated 1/14/2025, the Order Summary Report indicated to obtain weekly weights for four weeks one time a day every Wednesday for four weeks. Order Date 1/14/2025; Start Date 1/15/2025; and End Date 2/12/2025.
During a review of Resident 1's Physician Order Summary, dated 4/9/2025, timed at 12:38 p.m. indicated to obtain weekly weights for four weeks. Order Date 4/9/2025.
During a review of Resident 1's Weights and Vitals Summary dated 4/24/2025, the Weight Summary indicated Resident 1's weights as follows:
a. A strikethrough entry (often called a strikeout, is a formatting style where a horizontal line is drawn to indicate that the entry or information has been deleted) dated 1/18/2025, timed at 2:31 p.m. indicated Resident 1 weighs 309 pounds (lbs. - an abbreviation for pounds which is a unit of weight) measured by bed scale (a specialized weighing device designed to weigh residents who are bedridden or unable to stand).
b. A strikethrough entry dated 1/30/2025, timed at 8:37 a.m. and 3:16 p.m. indicated Resident 1 weighs 265 lbs. measured by mechanical lift (a device used to assist in the movement and transfer of individuals who need help with mobility due to limitations in weight-bearing or movement ability).
c. An entry dated 1/31/2025 timed at 9:12 a.m. entered by the Director of Nursing (DON) indicated declined order.
During a review of Resident 1's General Acute Care Hospital 1 (GACH 1) discharge summary and orders for nursing home (discharge summary) dated 1/10/2025, the discharge summary indicated that Resident 1's weight was 309 lbs. on 1/8/2025.
During a review of Resident 1's GACH 2 History and Physical (H&P) dated 4/5/2025, the H&P indicated that Resident 1's weight was 300 lbs.
During a review of Resident 1's Nutrition assessment dated [DATE], the Nutrition Assessment was completed and signed by Registered Dietician 1 (RD 1) on 4/24/2025.
During a review of Resident 1's Nutrition/Dietary Progress Notes dated 4/24/2025 timed at 9:04 a.m., the Nutrition/Dietary Progress Note indicated Resident 1 had been refusing weights and that the last recorded weight obtained was in January. The Nutrition/Dietary Progress Note indicated to continue to encourage Resident 1 to allow facility staff to obtain weights for baseline assessment.
During a concurrent interview and record review on 4/25/2025 at 4:30 p.m., with the Director of Staff Development (DSD), the DSD reviewed Resident 1's Nutrition assessment dated [DATE]. The DSD stated he (DSD) was not able to find documented evidence indicating a Nutrition Assessment was completed by the dietician when Resident 1 was originally admitted on [DATE]. The DSD further stated that it is important to conduct an initial Nutrition Assessment because it serves as the baseline of Resident 1's nutritional status in order to identify any nutritional concerns and to implement interventions to address Resident 1's nutritional needs.
During a phone interview on 4/25/2025 at 4:49 p.m., with RD 1, RD 1 stated that the initial Nutrition Assessment should have been conducted within 14 days from the date of the admission. RD 1 stated she (RD 1) was unable to recall why Resident 1's initial Nutrition Assessment was not completed upon Resident 1's admission on [DATE]. RD 1 stated that Resident 1 was admitted during the transitional phases with the previous RD who is no longer working at the facility. RD 1 stated she (RD 1) thought that Resident 1's initial Nutrition Assessment was already completed by the previous RD. RD 1 stated she then conducted Resident 1's Nutrition Assessment upon Resident 1 return from the hospital in the middle of April 2025. When RD 1 was asked if RD 1 was aware that Resident 1 had been refusing to be weighed since January 2025, the RD stated that she was not aware until recently (4/24/2025).
During a review of the facility's P&P titled, Nutritional Assessment last reviewed 1/3/2025, indicated, As part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. The dietitian, in conjunction with the nursing staff and health care practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition,
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to:
1. Ensure that the on-coming nurse (Licensed Vocational Nurse 1 [L...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to:
1. Ensure that the on-coming nurse (Licensed Vocational Nurse 1 [LVN 1]) signed the Narcotic (a controlled medication or substance with a high potential for abuse that in moderate doses dulls the senses, affects mood or behavior, relieves pain and induces sleep) Count Sheet (NCS- a form used to account all controlled medications, and to transfer accountability from the out-going nurse to the on-coming nurse) on 4/24/2025 for 7 a.m. to 3 p.m. shift after counting the controlled medications with the out-going nurse (Licensed Vocational Nurse 2 [LVN 2]).
2. Ensure that the on-coming nurse (Licensed Vocational Nurse 3 [LVN 3]) signed the NCS on 4/9/2025, 11 p.m. to 7:00 a.m. shift in one of two inspected medication carts (MC 3) at the Nursing Station (NS).
3. Administer Levothyroxine Sodium (levothyroxine - a medication used to treat an underactive thyroid gland [a gland that makes and stores hormones that help regulate the heart rate, blood pressure, body temperature, growth development and energy]) scheduled to be given on 1/15/2025 at 6:30 a.m. in accordance with the physician's order for one of four sampled residents (Resident 1).
These deficient practices had the potential to result in unidentified controlled medication loss and increased the risk for drug diversion (transfer of a medication from a legal to an illegal use) and had the potential to result in unintended complications related to the management of hypothyroidism that includes fatigue (extreme tiredness resulting from mental or physical exertion or illness), weight gain, slow heart rate, and difficulty concentrating.
Findings:
1. During a concurrent interview and record review on 4/24/2025 at 7:40 a.m., with LVN 1, the MC3 NCS for the month of April 2025 was reviewed. The MC3 NCS dated 4/24/2025 (7:00 a.m. to 3:00 p.m. shift) was blank. LVN 1 stated LVN 1 forgot to sign the NCS form after counting the controlled medications with the out-going nurse (LVN 2). LVN 1 then proceeded to sign the NCS form. LVN 1 stated that two nurses (on-coming nurse and out-going nurse) should sign together at the same time right after counting the controlled medications.
2. During a concurrent interview and record review on 4/24/2025 at 7:45 a.m., with LVN 1, the MC3 NCS for the month of April 2025 was reviewed. The MC3 NCS dated 4/9/2025 (11:00 p.m. to 7:00 a.m. shift) was blank indicating that it was not signed by the on-coming nurse (LVN 3). LVN 1 stated that LVN 1 was unable to determine if the controlled medications were counted together by two licensed nurses per the facility protocol on 4/9/2025 at 11:00 p.m. because the on-coming nurse did not sign on the NCS.
During a concurrent interview and record review on 4/24/2025 at 9:54 a.m., with the Director of Nursing (DON), the DON reviewed the MC3 NCS for the month of April 2025. The DON stated that she (DON) received the report from LVN 1 that LVN 1 did not sign on 4/24/2025 after counting with the night shift nurse. The DON stated that the facility protocol indicated for two licensed nurses (on-coming nurse and out-going nurse) to sign the NCS at the same time (right after counting the controlled medications) to prove that both licensed nurses confirmed the controlled medication amounts matched and to be able to identify if there was any discrepancy with the controlled medication count. The DON further stated that LVN 1 and LVN 3 should have signed right after the count because no documentation meant no count done.
During a review of the facility's policy and procedure (P&P) titled, Controlled Substances last reviewed on 1/3/2025, indicated, This facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services,
3. During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted the resident on 1/14/2025 and readmitted on [DATE] with diagnoses that included hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body needs), diabetes mellitus (DM - a condition that happens when your blood sugar is too high), hypertension (abnormally high blood pressure), and morbid (severe) obesity (a medical condition where someone has excessive fat accumulation that presents a risk to health).
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/14/2025, the MDS indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS further indicated that Resident 1 required maximum assistance from staff with lower body dressing and transfer, moderate assistance with bed mobility and toileting hygiene, and independent with eating.
During a review of Resident 1's Order Summary Report, dated 1/14/2025, the Order Summary Report indicated levothyroxine 75 microgram (mcg - a unit of measurement); give one tablet by mouth in the morning for hypothyroidism.
During a review of Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 1/15/2025, the MAR indicated to administer levothyroxine 75 mcg at 6:30 a.m. however Registered Nurse 2 (RN 2) documented 'Other'.
During a review of Resident 1's Progress Notes; Type - Medication Administration Note, dated 1/15/2025, timed at 7:03 a.m., indicated Resident 1 was newly admitted and awaiting delivery of levothyroxine 75 mcg from the pharmacy.
During a concurrent interview and record review on 4/24/2025 at 10:14 a.m. with the Director of Nursing (DON), the DON reviewed Resident 1's physician order for levothyroxine dated 1/14/2025 and Resident 1's MAR for levothyroxine dated 1/15/2025, with scheduled administration time of 6:30 a.m. The DON stated that levothyroxine was not administered to Resident 1 on 1/15/2025 at 6:30 a.m. because the medication (levothyroxine) was not yet delivered to the facility. The DON further stated there was no documented evidence found indicating levothyroxine was given to Resident 1 upon receipt. The DON stated there was no documented evidence found Resident 1's physician was notified about the missed levothyroxine dose on 1/15/2025.
During a review of the facility's P&P titled, Administering Medications last reviewed on 1/3/2025, indicated, Medications are administered in a safe and timely manner, and as prescribed Medications are administered in accordance with prescribed orders, including any required time frame If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administrating the medication shall initial and circle the MAR space provided for that drug and dose,
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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to:
1. Notify one of four sampled residents (Resident 1) physician and...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to:
1. Notify one of four sampled residents (Resident 1) physician and Resident 1 regarding the missed dose of Levothyroxine Sodium (levothyroxine - a medication used to treat an underactive thyroid gland [a gland that makes and stores hormones that help regulate the heart rate, blood pressure, body temperature, growth development and energy]) scheduled to be given on 1/15/2025 at 6:30 a.m.
2. Notify one of four sampled residents (Resident 1) physician of Resident 1's refusal to allow body weight monitoring for a duration of 58 days (2/6/2025 to 4/4/2025).
These deficient practices may result in worsening symptoms, increased risk of hospitalization or complications and health decline.
Findings:
1. During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted the resident on 1/14/2025 and readmitted on [DATE] with diagnoses that included hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body needs), diabetes mellitus (DM - a condition that happens when your blood sugar is too high), hypertension (abnormally high blood pressure), and morbid (severe) obesity (a medical condition where someone has excessive fat accumulation that presents a risk to health).
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/14/2025, the MDS indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS further indicated that Resident 1 required maximum assistance from staff with lower body dressing and transfer, moderate assistance with bed mobility and toileting hygiene, and independent with eating.
During a review of Resident 1's Order Summary Report, dated 1/14/2025, the Order Summary Report indicated levothyroxine 75 microgram (mcg - a unit of measurement); give one tablet by mouth in the morning for hypothyroidism.
During a review of Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 1/15/2025, the MAR indicated to administer levothyroxine 75 mcg at 6:30 a.m. however Registered Nurse 2 (RN 2) documented 'Other'.
During a review of Resident 1's Progress Notes; Type - Medication Administration Note, dated 1/15/2025, timed at 7:03 a.m., indicated Resident 1 was newly admitted and awaiting delivery of levothyroxine 75 mcg from the pharmacy.
During a concurrent interview and record review on 4/24/2025 at 10:14 a.m. with the Director of Nursing (DON), the DON reviewed Resident 1's physician order for levothyroxine dated 1/14/2025 and Resident 1's MAR for levothyroxine dated 1/15/2025, with scheduled administration time of 6:30 a.m. The DON stated that levothyroxine was not administered to Resident 1 on 1/15/2025 at 6:30 a.m. because the medication (levothyroxine) was not yet delivered to the facility. The DON further stated there was no documented evidence found indicating levothyroxine was given to Resident 1 upon receipt. The DON stated there was no documented evidence found Resident 1's physician was notified about the missed levothyroxine dose on 1/15/2025.
During a concurrent interview and record review on 4/25/2025 at 4:35 p.m. with the Director of Staff Development (DSD), the DSD reviewed Resident 1's physician order for levothyroxine dated 1/14/2025, Resident 1's MAR for levothyroxine dated 1/15/2025, with scheduled administration time of 6:30 a.m. and the Medication Administration Audit Record for levothyroxine dated 1/15/2025 at 7:03 a.m. The DSD stated Resident 1's physician should have been notified that levothyroxine was not available to be administered on 1/15/2025 at 6:30 a.m. and should have been documented in Resident 1's clinical record.
During an interview on 4/25/2025 at 4:57 p.m. with Resident 1, Resident 1 stated that she (Resident 1) has not been informed of the missed levothyroxine dose on 1/15/2025.
2. During a review of Resident 1's Order Summary Report, dated 1/14/2025, the Order Summary Report indicated to obtain weekly weights for four weeks one time a day every Wednesday for four weeks. Order Date 1/14/2025; Start Date 1/15/2025; and End Date 2/12/2025.
During a review of Resident 1's Physician Order Summary, dated 4/9/2025, timed at 12:38 p.m. indicated to obtain weekly weights for four weeks. Order Date 4/9/2025.
During a review of Resident 1's Weights and Vitals Summary dated 4/24/2025, the Weight Summary indicated Resident 1's weights as follows:
a. A strikethrough entry (often called a strikeout, is a formatting style where a horizontal line is drawn to indicate that the entry or information has been deleted) dated 1/18/2025, timed at 2:31 p.m. indicated Resident 1 weighs 309 pounds (lbs. - an abbreviation for pounds which is a unit of weight) measured by bed scale (a specialized weighing device designed to weigh residents who are bedridden or unable to stand).
b. A strikethrough entry dated 1/30/2025, timed at 8:37 a.m. and 3:16 p.m. indicated Resident 1 weighs 265 lbs. measured by mechanical lift (a device used to assist in the movement and transfer of individuals who need help with mobility due to limitations in weight-bearing or movement ability).
c. An entry dated 1/31/2025 timed at 9:12 a.m. entered by the Director of Nursing (DON) indicated declined order.
During a concurrent interview and record review on 4/24/2025 at 10:05 a.m., with the DON, the DON reviewed Resident 1's Weight Summary dated 4/24/2025. The DON stated Resident 1's weight was last checked on 1/30/2025. The DON stated Resident 1 had been refusing to be weighted since then. The DON stated she (DON) was unable to locate documentation of Resident 1's refusal to have her (Resident 1) weight checked and unable to locate documentation indicating Resident 1's physician was notified.
During a concurrent interview and record review on 4/24/2025 at 10:11 a.m., with RN 1, RN 1 reviewed Resident 1's progress notes and care plans (from Resident 1's original admission date of 1/14/2025 to 4/23/2025). RN 1 stated that RN 1 did not receive reports from any staff that Resident 1 had been refusing to be weighed. RN 1 stated she was unable to locate entries in Resident 1's progress notes and care plans (from 1/14/2025 to 4/23/2025) regarding Resident 1's refusal to be weighed. When RN 1 was asked what the facility protocol was for a resident refusing to be weigh, RN 1 stated that the facility should notify the physician and develop a care plan to address Resident 1's refusal to allow body weight monitoring. RN 1 further stated there was no documented evidence found indicating Resident 1's physician was notified of Resident 1's refusal to allow body weight monitoring.
During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention last reviewed 1/3/2025, indicated, The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. Weights will be recorded in each unit's Weight Record chart or notebook and in the individual's medical record,
During a review of the facility's P&P titled, Change in a Resident's Condition or Status last reviewed 1/3/2025, indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatment,
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Assessment Accuracy
(Tag F0641)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS - a resident assessme...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS - a resident assessment tool) Assessment Section K (Swallowing/Nutritional Status) dated 4/14/2025 under Section K0200 (the section for a resident weight) and Section K0300 (the section for weight loss) by failing to indicate the resident's body weight based on most recent measure in last 30 days which then led to an inaccurate assessment data entered under Section K0300 for one of four sampled residents (Resident 1).
This deficient practice had the potential to negatively affect Resident 1's plan of care and delivery of services.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility originally admitted the resident on 1/14/2025 and readmitted on [DATE] with diagnoses that included hypothyroidism (when the thyroid gland doesn't make enough thyroid hormones to meet your body needs), diabetes mellitus (DM - a condition that happens when your blood sugar is too high), hypertension (abnormally high blood pressure), and morbid (severe) obesity (a medical condition where someone has excessive fat accumulation that presents a risk to health).
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 4/14/2025, the MDS indicated Resident 1's cognition (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was intact. The MDS further indicated that Resident 1 required maximum assistance from staff with lower body dressing and transfer, moderate assistance with bed mobility and toileting hygiene, and independent with eating.
Further review of Resident 1's MDS for Section K indicated as follows:
a. Under Section K0200 dated 1/17/2025 indicated Resident 1's weight was 309 pounds (lbs. - an abbreviation for pounds which is a unit of weight).
b. Under Section K0200 dated 4/14/2025 indicated Resident 1's weight was 265 lbs.
c. Under Section K0300 dated 4/14/2025 indicated zero (0) means no or unknown weight loss of five (5) percent (% - unit of measure) in the last month or weight loss of 10 % or more in the last 6 months.
During a review of Resident 1's Weights and Vitals Summary dated 4/24/2025, the Weight Summary indicated Resident 1's weights as follows:
a. A strikethrough entry (often called a strikeout, is a formatting style where a horizontal line is drawn to indicate that the entry or information has been deleted) dated 1/18/2025, timed at 2:31 p.m. indicated Resident 1 weighs 309 pounds (lbs. - an abbreviation for pounds which is a unit of weight) measured by bed scale (a specialized weighing device designed to weigh residents who are bedridden or unable to stand).
b. A strikethrough entry dated 1/30/2025, timed at 8:37 a.m. and 3:16 p.m. indicated Resident 1 weighs 265 lbs. measured by mechanical lift (a device used to assist in the movement and transfer of individuals who need help with mobility due to limitations in weight-bearing or movement ability).
c. An entry dated 1/31/2025 timed at 9:12 a.m. entered by the Director of Nursing (DON) indicated declined order.
During a review of Resident 1's General Acute Care Hospital 1 (GACH 1) discharge summary and orders for nursing home (discharge summary) dated 1/10/2025, the discharge summary indicated that Resident 1's weight was 309 lbs. on 1/8/2025.
During a review of Resident 1's GACH 2 History and Physical (H&P) dated 4/5/2025, the H&P indicated that Resident 1's weight was 300 lbs.
During a review of Resident 1's Nutrition/Dietary Progress Notes dated 4/24/2025 timed at 9:04 a.m., the Nutrition/Dietary Progress Note indicated Resident 1 had been refusing weights and that the last recorded weight obtained was in January. The Nutrition/Dietary Progress Note indicated to continue to encourage Resident 1 to allow facility staff to obtain weights for baseline assessment.
During a concurrent interview and record review on 4/25/2025 at 3:40 p.m., with Minimum Data Set Nurse 1 (MDSN - a specialized nurse who collects and documents information about residents to help ensure they receive quality care, and that the facility is compliant with government regulations), MDSN 1 reviewed Resident 1's MDS Section K dated 1/17/2025 and 4/14/2025, and Weight Summary dated 4/24/2025. MDSN 1 stated that the 265 lbs. weight entered under Section K0200 dated 4/14/2025 was taken from the Weight Summary report dated 1/30/2025. When MDSN 1 was asked if the facility should utilize Resident 1's weight over 30 days from the Assessment Reference Date (ARD - the specific endpoint for the observation periods in the MDS assessment process), the MDSN 1 stated a resident's weight should be monitored every month at a minimum. MDSN 1 stated he was not aware that Resident 1 had been refusing to be weighed. MDSN 1 further stated that he (MDSN 1) should not have utilized Resident 1's weight of 265 lbs. obtained on 1/30/2025 and entered under Section K0200 as Resident 1's weight on 4/14/2025. MDSN 1 stated that when he (MDSN 1) entered no data available under Section K0200, MDSN 1 was unable to proceed with the MDS process, so he (MDSN 1) entered an inaccurate data of 265 lbs. MDSN 1 stated he reviewed Resident 1's GACH 1 clinical records dated 1/8/2025 (within 30 days from the ARD 1/17/2025) which showed a weight of 309 lbs. and Resident 1's GACH 2 clinical records dated 4/5/2025, which showed a weight of 300 lbs. MDSN 1 stated he got confused which then led to an inaccurate data entered under Section K0300 (weight loss) dated 4/14/2025. MDSN 1 stated he should have ensured the accuracy of the data entered and should have ensured accurate assessment of Resident 1's body weight in order to develop a specific plan of care as it relates to Resident 1's nutritional status.
During a review of the facility's policy and procedure (P&P) titled, Comprehensive Assessments last reviewed 1/3/2025, indicated, Comprehensive MDS assessments are conducted to assist in developing person-centered care plans. The facility conducts comprehensive, accurate, standardized, reproducible assessments of each resident's functional capacity using the Resident Assessment Instrument (RAI) specified by Centers for Medicare & Medicaid Services (CMS),
During a review of the facility provided Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2023, indicated, Section K for Swallowing/Nutritional Status; Steps for assessment for K0200 B Weight indicated, 'Base weight on the most recent measure in the last 30 days If a resident cannot be weighed, for example because of extreme pain, immobility, or risk of pathological fractures, use the standard no information code (-) and document rational on the resident's medical record.' And the definition of weight loss for K0300 indicated, 10% weight loss in 180 days: Start with the resident's weight closest to 180 days ago and multiply it by .90 (or 90%). The resulting figure represents a 10% loss from the weight 180 days ago. If the resident's current weight is equal to or less than the resulting figure, the resident has lost 10% or more body weight.'
Apr 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to implement its policy and procedure titled Wandering (to walk around without any clear purpose or direction) and Elopement (leaving the faci...
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Based on interview and record review, the facility failed to implement its policy and procedure titled Wandering (to walk around without any clear purpose or direction) and Elopement (leaving the facility without notice or permission) and failed to ensure one of three sampled residents (Resident 1), who was observed with periods of confusion, agitation (a condition in which a person is unable to relax and be still) and was observed wandering and entering other resident rooms on 4/7/2025 was kept free from accidents and hazards by:
1. Failing to ensure Certified Nursing Assistant 1 (CNA 1) followed the facility's policy and procedure titled Wandering and Elopement to attempt to prevent Resident 1, who was at risk for unsafe wandering, from leaving the facility premises.
These deficient practices resulted in Resident 1 leaving the facility on 4/7/2025 at 11:10 p.m., without being stopped by CNA 1, who observed Resident 1 leave the facility. These deficient practices placed Resident 1's health and well-being at risk and could result to Resident 1 sustaining severe injury requiring hospitalization and death.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 4/7/2025 with diagnoses that included type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and asthma (a respiratory disease that causes difficulty in breathing).
During a review of Resident 1's admission Summary Progress Notes, dated 4/7/2025, timed at 6:52 p.m., the admission Summary Progress Notes indicated Resident 1 was observed with periods of confusion and agitation. The admission Summary Progress Notes further indicated Resident 1 was observed wandering and entering other resident rooms.
During a review of Resident 1's Health Status Note, dated 4/8/2025, timed at 1:34 a.m., the Health Status Note indicated that on 4/7/2025 at 10:30 p.m., Licensed Vocational Nurse 1 (LVN 1) observed Resident 1 sleeping in his (Resident 1) bed. The Health Status Note indicated that on 4/7/2025 at 11:20 p.m., while LVN 1 was providing care to another resident (not specified), LVN 1 was notified by a CNA (referring to CNA 1). The Health Status Note further indicated that CNA 1 saw Resident 1 on 4/7/2025 at 11:10 p.m. walked out of the building and did not know Resident 1 was a resident because Resident 1 was wearing his own clothes.
During a review of Resident 1's Health Status Note, dated 4/8/2025, timed at 7:30 a.m., the Health Status Note indicated that on 4/8/2025 at 10:40 a.m., a call was received from the local law enforcement informing the facility that Resident 1 was found and was taken to General Acute Care Hospital 1 (GACH 1) for evaluation.
During an interview on 4/15/2025, at 2:43 p.m., with CNA 1, CNA 1 stated that on 4/7/2025 at 11:10 p.m. he (CNA 1) saw Resident 1 leaving the facility but did not stop Resident 1 from leaving the facility because Resident 1 was wearing street clothes and was walking totally normal, he (referring to Resident 1) wasn't shuffling (to move or walk in a sliding dragging manner without lifting the feet) at all. CNA 1 then stated on 4/7/2025, about ten minutes later (after Resident 1 left the facility) a staff (not specified) informed him that Resident 1 was missing. CNA 1 stated that was when he (CNA 1) realized that the man he saw leaving the facility was probably Resident 1. CNA 1 stated that he did not but should have stopped the man he saw leaving the facility and asked the man to identify himself or who he had been visiting. CNA 1 further stated that even though Resident 1 may have been alert and oriented and safe to leave the facility as he wished, even at night, CNA 1 could not be certain of that because he did not stop Resident 1 and ask him questions. CNA 1 also stated that therefore, given that the time was well after dark, and that Resident 1 was not wearing reflective clothing, even if he had been alert and oriented with a normal walking gate, he (Resident 1) still could have been hit by a car or have fallen without being easily seen by others in the dark, which could have resulted in serious injury, hospitalization and death. CNA 1 stated that in the future, if ever he (CNA 1) sees someone leave the facility who he does not recognize, he (CNA 1) will immediately stop that person and ask them to identify themselves. In the event that person is a resident who wants to leave, CNA 1 stated he will not physically prevent the resident from leaving because the resident has a right to leave the facility at any time if the resident choose to, but CNA 1 will at least call for help from other staff and try to recommend to the resident to remain in the facility at least until the staff can call their responsible party or try to redirect the resident.
During an interview on 4/15/2025, 3:51 p.m., with the Director of Nursing (DON), the DON stated that the specific failure of the facility in this instance was that CNA 1 saw someone leave the building after dark who CNA 1 did not recognize and did not at least try to stop and identify them. The DON stated CNA 1 should have immediately stopped the person who turned out to be Resident 1 and at least tried to identify them. The DON stated that because it was well after dark, and that Resident 1 was not wearing reflective clothing, even if Resident 1 had been alert and oriented with a normal walking gate, he still could have been hit by a car or have fallen without being easily seen by others, which could have resulted in serious injury, hospitalization and death. The DON stated that all staff will be trained to stop anyone trying to leave the building after dark and attempt to identify them and call for help from other staff if that person turns out to be a resident wanting to leave the facility so that staff can call the responsible party and try to redirect them.
A review of the facility's policy and procedure titled Wandering and Elopements, last reviewed in 1/3/2025, indicated it is the policy of the facility to identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.
2. If an employee observes a resident leaving the premises, he/she should:
a. attempt to prevent the resident from leaving in a courteous manner;
b. get help from other staff members in the immediate vicinity, if necessary; and
c. instruct another staff member to inform the charge nurse or director of nursing services that a resident is attempting to leave or has left the premises.
Apr 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
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 prompt attempts were made to resolve the grievance of one of...
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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 prompt attempts were made to resolve the grievance of one of three sampled residents (Resident 1).
This deficient practice violated the residents' right to have his grievance addressed.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 4/27/2025 and readmitted on [DATE] with diagnoses that included pneumonitis (general inflammation of lung tissue) due to inhalation of food and vomit, urinary tract infection (UTI-an infection in the bladder/urinary tract), and gastrostomy status (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).
During a review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 3/6/2025, the MDS indicated Resident 1 had severely impaired cognition. The MDS also indicated Resident 1 was dependent on staff with oral hygiene, toileting hygiene, and personal hygiene.
During a review of Resident 1 ' Social Service Note, dated 3/20/2025, at 3:06 p.m., the Social Service Note indicated, Social Services Director (SSD) received a call from the Resident 1's family member (FM 1) regarding some concerns with nursing care. The note further indicated the SSD told FM 1 that SSD would speak to the Administrator (ADM) regarding FM 1's concerns. The SSD notified the Administrator regarding the FM's concerns.
During a review of Concern/Grievance Log, there was no documented evidence of a grievance filed for Resident 1 for the months of January 2025, February 2025, and March 2025.
During an interview on 4/1/2025 at 10:23 a.m., with FM 1, FM 1 stated that FM 1 spoke to the SSD regarding concerns about the care being provided to Resident 1, however, FM 1 stated that no one from the facility staff followed up with FM 1 to address FM 1's concerns.
During a concurrent interview and record review on 4/1/2025 at 4:18 p.m., with the SSD, reviewed the facility ' s Concern/Grievance Log for the months of January 2025, February 2025, and March 2025. The SSD stated that if a grievance/concern is reported the SSD will ask the resident or responsible party if they would like to file a grievance. The SSD stated that the report is then taken to the ADM and the Director if Nursing (DON). The SSD further stated that the SSD received a call from FM 1 on 3/20/2025, during which FM 1 reported concerns about the care being provided to Resident 1. The SSD stated that there is no documentation of a grievance from FM 1 documented in the Concerns/Grievance Log.
During an interview on 4/1/2025 at 4:29 p.m., with the ADM, the ADM stated that the SSD informed the ADM of the concerns that FM 1 reported. The ADM stated that because the concerns are nursing related, the ADM reported to the DON.
During an interview on 4/1/2025 at 4:37 p.m., with the DON, the DON stated that Resident 1 ' s family usually have concerns that are addressed immediately. The DON stated she did not follow up with FM 1 regarding the concerns FM 1 reported on 3/20/2025. The DON stated that she got busy and forgot about FM 1 ' s concerns.
During a follow up interview on 4/1/2025 at 4:50 p.m., with the SSD, the SSD stated that the SSD was too busy to follow up FM 1 ' s concerns. The SSD stated that a grievance/concern form and log should have been completed so that the appropriate follow up could have been done.
During a review of the facility's policy and procedure titled Grievances/Complaints, Filing, reviewed date 1/3/2025, the policy and procedure indicated residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The Administer and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response. Upon receipt of a grievance and/or complaint, the Grievance Officer will review and investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identifying problems.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the facility ' s intravenous (IV -fluids given directly into ...
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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 facility ' s intravenous (IV -fluids given directly into the blood stream) administration policy was implemented to prevent complications from intravenous therapy by failing to monitor a resident receiving intravenous hydration for Intake & Output (I&O- the careful tracking and recording of fluids a patient consumes [intake] and eliminates [output] to monitor fluid balance and overall hydration status) and failed to assess a resident prior to the administration of IV fluids for one of three sampled residents (Resident 1)
This deficient practice had the potential to place Resident 1 at risk for developing complications such as inflammation of the vein, fluid overload (a medical condition characterized by having too much fluid volume in the body, potentially leading to health complications like swelling, high blood pressure, and heart problems), electrolyte (minerals in your blood and other body fluids that carry an electric charge) imbalances , and infection.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 4/27/2025 and readmitted on [DATE] with diagnoses that included pneumonitis (general inflammation of lung tissue) due to inhalation of food and vomit, urinary tract infection (UTI-an infection in the bladder/urinary tract), gastrostomy status (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems).
During a review of Resident 1's Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 3/6/2025, the MDS indicated Resident 1 had severely impaired cognition. The MDS also indicated Resident 1 was dependent on staff with oral hygiene, toileting hygiene, and personal hygiene.
During a review of Resident 1 ' s physician ' s order dated 3/3/2025 at 5:28 p.m., the physician order indicated the followinmg order:
-D5W (a mixture of dextrose (glucose) and water) x 1 liter at 50cc (cubic centimeter- a unit of volume equal to one milliliter)/hr. (hour) every Tuesday & Friday one time a day every Tuesday, Friday. IV (Intravenous) Hydration. Start date: 3/4/2025
a. During a concurrent interview and record review on 4/1/2025 at 11:39 a.m. with Registered Nurse 1 (RN 1), reviewed Resident 1 ' s physicians orders. RN 1 stated that Resident 1 had an order for D5W x 1 liter at 50cc/hr. every Tuesday & Friday one time a day every Tuesday and Friday for hydration. RN 1 stated that the facility monitors I&O for 30 days only if the IV fluids order is a new order. After 30 days the facility no longer monitors I&O. RN 1 reviewed Resident 1 ' s physical chart and electronic medical record and stated that there was no documented evidence found that Resident 1 's I&O was monitored. RN 1 stated that the facility did not monitor Resident 1's I&Os because Resident 1 has been on IV hydration per the family ' s request for a few months and did not need to be monitored. RN 1 further stated that Resident 1 ' s I&Os should have been monitored and documented to see if Resident 1 was in fluid overload, if Resident 1 was retaining fluid, or if there was anything wrong, the facility could inform the physician for further interventions.
During a concurrent interview and record review on 4/1/2025 at 2:30 p.m. with the Medical Records Director (MRD), the MRD reviewed Resident 1 ' s medical records and stated that there was no documented evidence of Resident 1's I&O.
During a review of the facility's policy and procedure titled Intravenous Administration of Fluids and Electrolytes, reviewed 1/3/2025, the poliy and procedure indicated the purpose of this procedure is to provide guidelines for the safe and aseptic administration of intravenous fluids and electrolytes for hydration. Under steps in the procedure document procedure in the resident ' s medical record and on the intake/output record.
b.During an interview on 4/1/2025 at 3:30 p.m., with RN 1, RN 1 stated she did not assess Resident 1's lung/heart status and vital signs, prior to administering IV fluids because there was no physician's order. RN 1 stated that it is important to assess heart/lung status and vital signs prior to giving IV fluid hydration to monitor if Resident 1 was experiencing any complications due to the IV fluids such as fluid overload.
During a review of the facility's policy and procedure titled Intravenous Administration of Fluids and Electrolytes, reviewed 1/3/2025, the policy and procedure indicated under preparation assess resident ' s lung and heart status and vital signs before and during therapy to assess for fluid overload. Under general guidelines, Resident should be monitored frequently, per facility policy, when continuous fluids are infusing. Monitor for signs and symptoms of fluid overload, catheter and insertion site complications, and the resident ' s tolerance of the procedure. Fluids may be stopped by a nurse if signs of program are present.
Mar 2025
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0777
(Tag F0777)
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 laboratory services (refers to the collection, testing. and ...
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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 laboratory services (refers to the collection, testing. and analysis of a resident's specimen [such as blood, urine or stool] for health-care professionals to make decisions on the diagnosis and treatment of their residents) were provided to one of three sampled residents (Resident 1) timely per physician's order.
This deficient practice resulted in the delay of necessary care and services for Resident 1.
Findings:
During a review of Resident 1's admission Record, the admission Record indicated that the facility originally admitted the resident on 4/4/2024 and readmitted on [DATE] with diagnoses that included acute respiratory failure with hypoxia (a condition where the lungs struggle to deliver enough oxygen to the blood, leading to low levels of oxygen in your body tissues), urinary tract infection (UTI - when bacteria gets into your urine and travels up to your bladder [a hollow, muscular organ in the lower abdomen that stores urine]) and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing).
During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) dated 10/7/2024, the MDS indicated Resident 1 had intact cognitive (relating to the mental process involved in knowing, learning and understanding things) skills for daily decision making. The MDS further indicated that Resident 1 required supervision or touching assistance from staff with eating and oral hygiene, partial or moderate assistance with personal hygiene, and dependent on staff with toileting.
During a review of Resident 1's Change in Condition (COC - when there is a change in a resident's condition) Evaluation document, dated 2/28/2025, timed at 11:19 p.m., the COC indicated that Resident 1 was noted with hematuria (blood in urine). The COC further indicated Resident 1's physician recommended to obtain Complete Blood Count (CBC- a blood test that measures various components of the blood to assess overall health and diagnose various conditions) and Chemistry 7 (Chem 7 - a blood test that measures seven key substances in the blood to assess overall health and kidney [a body organ that removes waste and extra water from the blood {as urine} and help keep chemicals balanced in the body] function, and electrolytes [minerals in the blood]) STAT (signifies an urgent or immediate need for the results, typically ordered in critical or life-threatening situations, requiring a rapid turnaround time).
During a review of Resident 1's Physician's Order dated 2/28/2025, timed at 11:48 p.m., the Physician's Order indicated to obtain CBC with differential (CBC with diff - a blood test that measures the number of different types of white blood cells [WBC- essential for fighting infections] in your blood) and Comprehensive Metabolic Panel (CMP Panel- a blood test that measures 14 different substances to assess kidney and liver [a large organ located in the upper abdomen that cleanses the blood and aids in digestion] function, electrolyte levels and overall metabolism [chemical reactions in the body's cells that change food into energy]) one time only.
During a review of Resident 1's laboratory test Order Requisition, undated, indicated the following tests ordered:
-
CBC with diff - STAT
-
CMP Panel - STAT
The Order Requisition indicated a blood collection date of 3/1/2025 at 8:25 a.m.
During a concurrent interview and record review on 3/27/2025 at 11:23 a.m., with Registered Nurse 1 (RN 1), the COC dated 2/28/2025, Physician's Order dated 2/28/2025 and Laboratory Results Report dated 3/1/2025 were reviewed. RN 1 stated that Resident 1 was noted with hematuria on 2/28/2025. RN 1 stated that Resident 1's physician was made aware and ordered CBC and Chem 7 STAT on 2/28/2025. RN 1 stated that STAT labs should be collected within four (4) hours of the order. RN 1 stated that Resident 1's laboratory tests were ordered on 2/28/2025 and was not collected until 3/1/2025 at 8:25 a.m. RN 1 stated that sometimes we have a problem with our laboratory company as they do not come within the four hours timeframe for a STAT order. RN 1 further stated that STAT tests are crucial in the care of the resident and should have been obtained within the four hours timeframe from when the STAT blood tests were ordered.
A review of the facility provided policy and procedure titled Availability of Services, Diagnostic last revised in 12/2009, indicated it is the policy of the facility that Clinical laboratory and radiology services to meet the needs of our residents are provided by our facility.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0675
(Tag F0675)
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 implement its policy on quality of life by failing 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 implement its policy on quality of life by failing to ensure three of four sampled residents (Resident 2, Resident 3 and Resident 4) were assisted by staff to participate in activities.
This deficient practice had the potential to affect the resident's sense of well-being, self-esteem and self-worth.
Findings:
a. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 2/23/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing) and encounter for palliative care (specialized medical care focused on relieving suffering and improving the quality of life for residents with serious illnesses).
During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool) dated 2/5/2025, the MDS indicated Resident 2 had severely impaired cognition (the process of acquiring knowledge and understanding through thought, experience, and the senses). The MDS also indicated Resident 2 was dependent on staff with oral hygiene, toileting hygiene, and personal hygiene.
During a review of Resident 2's Order Summary Report, the Order Summary Report indicated Resident 2 may participate in activities not in conflict with treatment plan. Order date: 2/23/2024.
During an observation on 3/24/2025 at 9:00 a.m., in Resident 2's room, observed Resident 2 in bed.
During an observation on 3/24/2025 at 10:17 a.m., in Resident 2's room, observed Resident 2 in bed.
During a concurrent observation and interview on 3/24/2025 at 1:16 p.m., with Registered Nurse 1 (RN 1), in Resident 2's room, observed Resident 2 still in bed. When asked why Resident 2 is still in bed at this time, RN 1 stated because she (referring to Resident 2) is a hospice resident (an individual receiving care focused on comfort and quality of life, rather than curative treatments, during the final stages of a terminal illness).
b. During a review of Resident 3's admission Record, the admission Record indicated the facility originally admitted Resident 3 on 8/24/2012 and re-admitted the resident on 2/23/2025 with diagnoses that included dementia (a progressive state of decline in mental abilities) and encounter to gastrostomy (g-tube - a surgically placed tube inserted through the abdominal wall directly into the stomach, providing a pathway for delivering nutrition, fluids and medications).
During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 had severely impaired cognition. The MDS also indicated Resident 3 was dependent on staff with oral hygiene, toileting hygiene, and personal hygiene.
During a review of Resident 3's Order Summary Report, the Order Summary Report indicated Resident 3 may participate in activities not in conflict with treatment plan. Order date: 2/23/2025.
During an observation on 3/24/2025 at 10:18 a.m., in Resident 3's room, observed Resident 3 in bed, with the g-tube feeding turned off.
During an observation on 3/24/2025 at 9:10 a.m., in Resident 3's room, observed Resident 3 in bed, with the g-tube feeding turned off.
During an observation on 3/24/2025 at 11:25 a.m., in Resident 3's room, observed Resident 3 in bed, with the g-tube feeding turned off.
During a concurrent observation and interview on 3/24/2025 at 11:46 a.m., with Certified Nursing Assistant 1 (CNA 1), in Resident 3's room, observed Resident 3 still in bed with the g-tube feeding turned off. CNA 1 stated that she (CNA 1) did not offer Resident 3 to get out of bed and that Resident 3 is still in bed because Resident 3 has a g-tube. CNA 1 continued to state that she (CNA 1) did not get Resident 3 out of bed and did not bring Resident 3 to activities because no one instructed her to do so.
c. During a review of Resident 4's admission Record, the admission Record indicated the facility originally admitted Resident 4 on 8/23/2024 with diagnoses that included dementia, psychotic (severe mental disorders that cause abnormal thinking and perceptions) disturbance, mood disturbance (a significant change in a person's emotional state that persists for an extended period), and anxiety (a feeling of fear, dread, and uneasiness).
During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 had severely impaired cognition. The MDS also indicated Resident 3 required substantial/maximal assistance from staff with eating, oral hygiene, and personal hygiene.
During a review of Resident 4's Order Summary Report, the Order Summary Report indicated Resident 4 may participate in activities not in conflict with treatment plan. Order date: 8/23/2024.
During an observation on 3/24/2025 at 9:13 a.m., in Resident 4's room, observed Resident 4 in bed.
During an observation on 3/24/2025 at 10:19 a.m., in Resident 4's room, observed Resident 4 in bed.
During a concurrent observation and interview on 3/24/2025 at 11:50 a.m., with Certified Nursing Assistant 3 (CNA 3), observed Resident 4 still in bed. CNA 2 stated that she (CNA 2) did not get Resident 4 out of bed because Resident 4 needed a special chair and Resident 4 only gets out of bed once or twice a week. When asked if CNA 2 offered Resident 4 to get out of bed and attend the activities, CNA 2 stated that CNA 2 did not offer Resident 4 to get out of bed and bring to activities because Resident 4 does not speak. CNA 2 continued to state that residents only get up out of bed once or twice a week because it depends if the CNA has time.
During an interview on 3/24/2025 at 1:16 p.m., with RN 1, RN 1 stated that residents do not typically have an order to get out of bed. RN 1 stated that CNAs should be getting residents out of bed and bringing to activities to promote the resident's quality of life. When asked why Resident 2, Resident 3 and Resident 4 were in bed and not brought to activities, RN 1 did not respond. RN 1 continued to state that all residents should be getting out of bed as part of morning care. RN 1 stated Just because a resident is on a g-tube doesn't mean the resident should stay in bed the whole day. Residents should be up out of bed in activities during the day.
During a follow up interview on 3/27/2025 at 9:57 a.m., with CNA 3, CNA 3 stated that she (CNA 3) only gets residents out of bed when she is instructed to by licensed nursing staff. CNA 3 stated that sometimes she (CNA 3) offers to get residents out of bed and sometimes she doesn't depending on how busy she (CNA 3) is and how many showers she has to give to residents.
During an interview on 3/27/2025 at 10:08 a.m., with the Activities Director (AD), the AD stated that she (AD) is unable to take residents to activities unless the residents are up out of bed on their wheelchair. The AD stated that residents should be up out of bed and brought to activities so that resident can participate and have some social interaction. Even if a resident is unable to actively participate in an activity, stimulation will help a resident. The AD further stated that it is important for the resident's quality of life.
During an interview on 3/27/2025 at 10:14 a.m., with the Director of Staff Development (DSD), the DSD stated that part of the resident's morning care is to get residents groomed and out of bed. The DSD stated residents should be out and bed and encouraged to go to activities for stimulation. The DSD stated there is no excuse as to why residents should be in bed all day. The DSD continued to state that by not getting residents out of bed the facility is not providing residents with the best quality of life.
During an interview on 3/27/2025 at 4:38 p.m., with the Director of Nursing (DON), the DON stated that it is basic nursing to get residents out of bed.
During a concurrent interview and record review on 3/27/2025 at 4:45 p.m., with the Administrator (ADM), the ADM reviewed the facility's policy titled Quality of Life-Dignity, last revised in 8/2009. The ADM stated that the facility is not implementing the policy because facility staff should be assisting residents to get out of bed and bringing residents to participate in activities. The ADM stated staff should be offering residents to get out of bed for residents' stimulations to promote the health and enhance the residents' quality of life.
During a review of the facility's policy and procedure titled, Quality of Life- Dignity, last revised in 8/2009 indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be assisted in attending the activities of their choice, including activities outside the facility.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to implement its policy and procedure titled Activity Programs by failing to incorporate at least one activity a month held away from the faci...
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Based on interview and record review, the facility failed to implement its policy and procedure titled Activity Programs by failing to incorporate at least one activity a month held away from the facility and offer at least one evening activity per week to 93 residents residing in the facility for two of three sampled months (January 2025 and February 2025).
This deficient practice had the potential to result in psychosocial decline and a decreased quality of life.
Findings:
During a concurrent interview and record review on 3/27/2025 at 11:52 a.m., with the Activities Director (AD), the activity calendar for the month of January 2025 and February 2025 were reviewed. The AD stated that she (AD) is responsible in scheduling activities for the residents one month prior. The AD stated that there should be one scheduled activity held outside the facility such as outings for each month to provide a different environment to the residents. The AD stated that the facility should also schedule evening activities once a month. The AD stated that there were no outside activities such as outings and evening activities scheduled for the month of January 2025 and February 2025.
The facility policy and procedure titled Activity Programs, last revised in 8/2006, indicated it is the policy of the facility that activity programs designed to meet the needs of each resident are available on a daily basis. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. Activities are scheduled seven days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs. Weather permitting, at least one activity per month is held away from the facility. At least one evening activity is offered per week, depending on population needs.
Mar 2025
16 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide dignity to a resident by failing to ensure an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide dignity to a resident by failing to ensure an indwelling urinary catheter (a flexible tube inserted into the bladder [organ that stores urine] and left in place to continuously drain urine) collection bag (attached to the catheter tube for the purpose of collecting urine) was covered with a privacy bag (dignity bag- a bag that conceals urine in the collection bag) for one of one sampled resident (Resident 238).
This deficient practice had the potential to affect the resident's sense of self-worth and self-esteem.
Findings:
During a review of Resident 238's admission Record, the admission Record indicated that the facility admitted the resident on 3/7/2025 with diagnoses including infection and inflammatory reaction (the body's response to injury or infection) due to urinary catheter, and malignant neoplasm of bladder (an uncontrolled growth of abnormal cells that form a tumor in the bladder, the organ that stores urine).
During a review of Resident 238's Order Summary Report dated 3/7/2025, the Order Summary Report indicated an order to provide indwelling catheter care for the resident during every shift and as needed.
During an observation on 3/8/2025 at 8:52 a.m., inside Resident 238's room, observed Resident 238's urinary catheter bag not covered with a privacy bag.
During a concurrent observation and interview on 3/8/2025 at 8:54 a.m., with Registered Nurse 1 (RN 1) inside Resident 238's room, observed Resident 238's urinary catheter collection bag. RN 1 stated that Resident 238's urinary catheter collection bag was not covered with a privacy bag. RN 1 stated that urinary catheter collection bags are required to be covered with a privacy bag to promote dignity.
During an interview on 3/8/2025 at 9:10 a.m., with the Director of Nursing (DON), the DON stated that urinary catheter collection bags are required to be covered with a privacy bag. The DON stated Resident 238 was admitted to the facility on [DATE], and staff forgot to cover Resident 238's urinary catheter collection bag with a privacy bag. The DON stated the potential outcome is the lack of promoting a resident's dignity.
During a review of the facility's Policy and Procedure (P&P) titled, Quality of Lift-Dignity, the P&P indicated that residents shall be treated with dignity and respect at all times. Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by helping the resident to keep urinary catheter bags covered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a baseline care plan (a document that summarizes a 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 develop a baseline care plan (a document that summarizes a resident's needs, goals, and care/treatment) within 48 hours of admission and/or readmission for three of four sampled residents (Resident 21, 59, and 62) by failing to:
1. Develop a baseline care plan that addressed Resident 21 and 59's antibiotic (medication used to treat bacterial infections) use.
2. Develop a baseline care plan that addressed Resident 62's insulin (a hormone that works by lowering levels of glucose [sugar] in the blood) use.
These deficient practices had the potential to result in failure to deliver the necessary care and services.
Findings:
1.a. During a review of Resident 21's admission Record, the admission Record indicated that the facility originally admitted the resident on 7/20/2017 and readmitted the resident on 2/20/2025 with diagnoses including chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe) and gastro-esophageal reflux disease (stomach contents flow backward, up into the esophagus, the tube that carries food from your throat into stomach).
During a review of Resident 21's Minimum Data Set (MDS- a resident assessment tool) dated 2/6/2025, the MDS indicated that Resident 21's cognition (a mental process of acquitting knowledge and understanding) was intact. The MDS indicated Resident 21 required setup or clean-up assistance with oral hygiene, toileting hygiene, upper body dressing, lower body dressing, and personal hygiene.
During a review of Resident 21's physician orders, dated 2/20/2025, the physician orders indicated a order for ertapenem sodium injection solution (Invanz [brand name]-is used to prevent and treat a wide variety of bacterial infections) reconstituted one (1) gram (GM- unit of measurement), use one (1) GM intravenously (into or within a vein) one time a day for urinary tract infection (UTI- an infection in any part of the urinary system) for seven (7) days.
During a concurrent interview and record review on 3/9/2025 at 2:01 p.m., with Registered Nurse 1 (RN 1), reviewed Resident 21's physician orders dated 2/20/2025 for Invanz and Resident 21's care plans dated 2/20/2025 to 3/9/2025. RN 1 stated that for any antibiotic order and antibiotic order upon admission, a baseline care plan should be initiated or created within 48 hours. RN 1 stated the baseline care plan would establish the goals of treatment and outline the interventions on how to meet the goals and in this case, for the antibiotic therapy, the goal is for the infection to resolve with no adverse reactions (undesired harmful effect resulting from a medication or other intervention). RN 1 stated that if there is no baseline care plan, then the staff would not know what to monitor as far as potential adverse reactions from the antibiotic and how to intervene promptly to ensure the safety of the resident.
During a review of the facility's policy and procedure titled, Baseline Care Plan, last reviewed on 1/3/2025, the policy indicated, A baseline plan of care to meet the resident's needs shall be developed admission .for each resident within forty-eight (48) hours of the baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan .
1.b. During a review of Resident 59's admission Record, the admission Record indicated that the facility originally admitted the resident on 10/17/2022 and readmitted the resident on 11/13/2024, with diagnoses including urinary tract infection and gastro-esophageal reflux disease.
During a review of Resident 59's MDS dated [DATE], the MDS indicated that Resident 59's cognition was severely impaired. The MDS indicated Resident 59 is totally dependent on staff for oral hygiene, toileting hygiene, upper body dressing, lower body dressing, and personal hygiene.
During a review of Resident 59's physician orders, dated 2/11/2025, the physician orders indicated the following orders:
- Cefdinir (is used to treat bacterial infections in many different parts of the body) oral capsule 300 milligrams (mg- unit of measurement), give one (1) capsule via gastrostomy tube (G-tube- a tube inserted through the belly that brings nutrition and medication directly to the stomach) two times a day for G-tube site cellulitis for seven (7) days.
- Sulfamethoxazole-Trimethoprim (Bactrim [brand name]- a combination antibiotic used to treat ear infections and urinary tract infections) 800-160 mg, give one (1) tablet via G-tube two times a day for G-tube cellulitis (common bacterial infection of the skin and underlying tissues) for seven (7) days.
During a concurrent interview and record review on 3/8/2025 at 5:33 p.m., with RN 1, reviewed Resident 59's physician orders dated 2/11/2025 that included cefdinir and Bactrim and Resident 59's care plans dated 2/11/2025 to 3/8/2025. RN 1 stated that Resident 59 was readmitted from the hospital with these orders. RN 1 stated that Resident 59 was diagnosed with abdominal wall cellulitis, hence the antibiotic orders. RN 1 stated a baseline care plan should have been created to monitor Resident 59 while on antibiotic therapy. RN 1 stated the baseline care plan for antibiotic therapy would establish the goals of treatment and outline the interventions if a resident experiences adverse reactions from the antibiotic including notifying the physician promptly. RN 1 stated that without a care plan, staff would not be able to monitor or identify adverse reactions which could lead to serious complications such as an allergic reaction.
During a review of the facility's policy and procedure titled, Baseline Care Plan, last reviewed on 1/3/2025, the policy indicated, A baseline plan of care to meet the resident's needs shall be developed for each resident within forty-eight (48) hours of admission .the baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan .
2. During a review of Resident 62's admission Record, the admission Record indicated that the facility admitted the resident on 2/12/2025 with diagnoses including benign prostatic hypertension (BPH, enlarged prostrate [a gland] that makes it difficult to urinate), history of falling, and type two (2) diabetes mellitus (DM- a chronic condition that affects the way the body processes blood sugar).
During a review of Resident 62's MDS dated [DATE], the MDS indicated that the resident's cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired. The MDS indicated that Resident 62 required staff substantial/maximal assistance (helper does more than half the effort) for toileting hygiene, showering and bathing, lower body dressing, and putting on/talking off footwear.
During a review of Resident 62's Order Summary Report dated 2/12/2025, the Order Summary Report indicated an order to administer insulin lispro (a rapid-acting insulin) subcutaneously (SQ - administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) as per sliding scale (progressive increase in the insulin dosage, based on pre-defined blood glucose ranges) before meals and at bedtime.
During a review of Resident 62's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 2/12/2025-2/17/2025, the MAR indicated that Resident 62 received insulin lispro from 2/13/2025 through 2/17/2025.
During a concurrent interview and record review on 3/9/2025 at 10:10 a.m., with MDS Coordinator 1 (MDSC 1), reviewed Resident 62's baseline care plan signed 2/13/2025, MAR dated 2/2025, and medical diagnoses. MDSC 1 stated that he (MDSC 1) developed Resident 62's baseline care plan on 2/12/2025. MDSC 1 stated Resident 62 has a diagnosis of DM, and on 2/12/2025 Resident 62's physician ordered insulin lispro to be administered per sliding scale. MDSC 1 stated Resident 62 received insulin lispro from 2/13/2025 through 2/17/2025. MDSC 1 stated he did not indicate in Resident 62's baseline care plan that Resident 62 was taking insulin. MDSC 1 stated this was a mistake from his part. MDSC 1 stated that residents' base line care plans must be completed thoroughly reflecting all the pertinent information regarding residents within 48 hours of their admission to the facility. MDSC 1 stated the potential outcome of not thoroughly completing a resident's baseline care plan is the inability to meet the resident's immediate care needs and lack of care.
During an interview on 3/9/2025 at 3:15 p.m., with the Director of Nursing (DON), the DON stated a resident's baseline care plan is required to be completed within 48 hours of resident's admission to the facility. The DON stated upon admission, licensed staff are required to develop a complete and thorough baseline care plan for each resident accurately indicating the medications they are taking. The DON stated Resident 62's baseline care plan developed on 2/12/2025 was not completed thoroughly. The DON stated the potential outcome is the inability to meet the resident's immediate care needs and the delivery of necessary services to the resident.
During review of the facility's Policy and Procedure (P&P) titled, Care Plans-Baseline, last reviewed on 1/3/2025, the P&P indicated that a baseline care plan of care to meet the resident's immediate needs shall be developed for each resident within 48 hours of admission. The Interdisciplinary Team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan) will review the healthcare practitioner's orders such as medications, dietary needs and routine treatments and implement a baseline care plan to meet the resident's immediate care needs, including but not limited to initial goals based on admission orders, and physician orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to update and revise a resident's care plan (a document that summarizes a resident's needs, goals, and care/treatment) after the resident's ph...
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Based on interview and record review, the facility failed to update and revise a resident's care plan (a document that summarizes a resident's needs, goals, and care/treatment) after the resident's physician discontinued administration of Januvia (a medication that helps control blood sugar levels) on 10/25/2024, for one of two sampled residents (Resident 20).
This deficient practice had the potential to result in confusion regarding the care and services Resident 20 received at the facility.
Findings:
During a review of Resident 20's admission Record, the admission Record indicated that the facility originally admitted the resident on 10/25/2024 and readmitted the resident on 11/19/2024 with diagnoses including unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), type two diabetes mellitus (DM- a chronic condition that affects the way the body processes blood glucose [sugar]), and cerebral infarction (stroke, loss of blood flow to a part of the brain).
During a review of Resident 20's Minimum Data Set (MDS - a resident assessment tool) dated 1/27/2025, the MDS indicated that the resident's cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired. The MDS indicated that Resident 20 required staff partial/moderate assistance (helper does less than half the effort) for toileting hygiene, upper and lower body dressing, putting on/talking off footwear, and personal hygiene.
During a review of Resident 20's Order Summary Report dated 10/25/2024, the Order Summary Report indicated the order to administer Januvia 25 milligrams (mg-a unit of measurement) two tablets by mouth one time a day, was discontinued on 10/25/2024 at 9:22 p.m.
During a review of Resident 20's Care Plan for DM, initiated on 10/26/2024, the care plan indicated that the resident is currently taking Januvia and an intervention to administer DM medications as ordered by the physician.
During a concurrent interview and record review on 3/8/2025 at 6:30 p.m., with the Infection Preventionist (IP), reviewed Resident 20's care plan for DM dated 10/26/2024 and Resident 20's physician orders. The IP stated that Resident 20's physician order to administer Januvia was discontinued on 10/25/2024, however, Resident 20's care plan for DM still indicated that Resident 20 is taking Januvia. The IP stated Resident 20's care plan was not revised or updated to show that Januvia was discontinued on 10/25/2024. The IP stated licensed staff are required to revise a resident's care plan immediately after a medication is discontinued.
During an interview on 3/9/2024 at 4:15 p.m., with the Director of Nursing (DON), the DON stated that licensed nurses did not review or revise Resident 20's care plan for DM after the physician discontinued Januvia on 10/25/2024. The DON stated residents' care plans are required to be reviewed and revised when the physician is changing their medication. The DON further stated that residents' care plans need to reflect the correct medications that residents are taking and the current interventions that are being implemented. The DON stated the potential outcome of not updating/revising a resident's care plan is the inability to provide appropriate care and services to the resident.
During a review of the facility's Policy and Procedure (P&P) titled, Care Plans Comprehensive Person-Centered, last reviewed on 1/3/2025, the P&P indicated that care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to provide a resident with a communication board (a device that can help patients communicate with care providers and family usi...
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Based on observation, interview, and record review, the facility failed to provide a resident with a communication board (a device that can help patients communicate with care providers and family using symbols, photos, or illustrations) for one of two sampled residents (Resident 20) whose primary and preferred language was not English.
This deficient practice has the potential to prevent the resident from communicating with the staff and had the potential to delay receiving care/treatment the resident needed.
Findings:
During a review of Resident 20's admission Record, the admission Record indicated that the facility originally admitted the resident on 10/25/2024 and readmitted the resident on 11/19/2024 with diagnoses including unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), type two diabetes mellitus (DM- a chronic condition that affects the way the body processes blood glucose [sugar]), and cerebral infarction (stroke, loss of blood flow to a part of the brain). The admission Record further indicated that Resident 20's primary language was Korean (foreign language).
During a review of Resident 20's Minimum Data Set (MDS - a resident assessment tool) dated 1/27/2025, the MDS indicated that the resident's cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 20 required staff partial/moderate assistance (helper does less than half the effort) for toileting hygiene, upper and lower body dressing, putting on/talking off footwear, and personal hygiene. The MDS further indicated that Resident 20's preferred language was Korean.
During a review of Resident 20's Activity Participation Review form dated 1/27/2025, the Activity Participation Review form indicated that Resident 20 speaks Korean and very little English.
During a concurrent observation and interview on 3/8/2025 at 1:02 p.m., inside Resident 20's room, with Certified Nursing Assistant 1 (CNA 1), observed CNA 1 sitting next to Resident 20 and assisting her with her lunch. CNA 1 stated Resident 20 speaks Korean. CNA 1 stated that she is unable to communicate with Resident 20 and she uses hand gestures to get her point across. CNA 1 stated a communication board with pictures and signs is required for residents who do not speak English. CNA 1 started looking for a communication board/device at Resident 20's bedside, however, CNA 1 did not find one.
During an interview on 3/9/2025 at 2:39 p.m., with the Director of Social Services (DSS), the DSS stated that when she (DSS) performs residents' initial social service assessments upon their admission to the facility, she determines if the residents are able to comfortably communicate in English or not. The DSS stated that for the residents who are not able to communicate their needs in English, she (DSS) recommends the placement of a communication board/device at the residents' bedside. The DSS stated that Resident 20 speaks Korean and requires a communication board at her bedside to be able to make her needs known. The DSS stated she (DSS) did place a communication board/device at Resident 20's bedside, however, for some reason the board was removed. The DSS stated that the potential outcome of not having a communication board available and accessible to a resident who is not able to communicate effectively in English is insufficient care.
During an interview on 3/9/2025 at 4:00 p.m., with the Director of Nursing (DON), the DON stated staff are required to provide a communication board or device to the residents who do not speak English in the language that they speak. The DON stated Resident 20 was not provided a communication device/board in Korean. The DON stated the potential outcome of not providing a communication board/device to the residents who do not speak English is the inability to communicate with residents accurately and understand their needs.
During a review of the facility's Policy and Procedure (P&P) titled, Translation and/or Interpretation of Facility Services, last reviewed on 1/3/2025, the P&P indicated that when encountering limited English proficiency (LEP) individuals, staff members will conduct initial assessment and notify the staff person in charge of the language access program. The facility shall provide written translation of vital information pertaining to health services translation of information that is not available in written translation shall be provided in a timely manner and at no cost to the resident through the following means: communication devices, a staff member/or family/RP (resident representative), a staff interpreter who is trained and competent in the skill of interpreting, contracted interpreter service, and telephone interpretation service.
During a review of the facility's Policy and Procedure (P&P) titled, Activities of Daily Living (ADL- activities related to personal care), Supporting, last reviewed on 1/3/2025, the P&P indicated that appropriate care and services with be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with communication including speech, language, and any functional communication system.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide religious services to one of one sampled resident (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 provide religious services to one of one sampled resident (Resident 10) investigated under Activities.
This deficient practice violated the resident's right to have access and receive religious services which had the potential to affect the resident's sense of self-esteem and self-worth.
Findings:
During a review of Resident 10's admission Record, the admission Record indicated that the facility admitted the resident on 6/20/2023 with diagnoses that included hypertension (high blood pressure [the force of the blood pushing on the blood vessel walls is too high]) and anemia (blood has a lower than normal number of red blood cells).
During a review of Resident 10's Annual Minimum Data Set (MDS - a resident assessment tool) dated 6/21/2024, the MDS indicated in Section F that participating in religious services or practice is somewhat important to Resident 10.
During a review of Resident 10's Quarterly MDS dated [DATE], the MDS indicated the resident's cognitive (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making was moderately impaired and was partially dependent on staff for shower, dressing and personal hygiene.
During a concurrent observation and interview on 3/7/2025 at 7:31 p.m., observed Resident 10 sitting in bed with an open bible. Resident 10 stated that she wants to attend a church service but has not attended in a long time. Resident 10 stated the facility did not offer any religious service and that she just does her own bible study. Resident 10 stated no pastor nor priest have visited her in her room.
During a concurrent interview and record review on 3/9/2025 at 1:09 p.m., with the Activity Director (AD), reviewed Resident 10's Activity Participation Log for 1/2025 and 2/2025. The AD stated that Resident 10 has not participated in any religious activities for the months reviewed and there is no documentation that she was offered or invited to attend any religious service. The AD stated that on admission, residents are assessed regarding their religious practices or interests and inform them of the scheduled religious services in the facility. The AD stated that she doesn't know why there is no documented attendance for Resident 10 in any of the religious services. The AD stated that she understands and recognizes the spiritual needs of the residents especially in their condition and advanced age. The AD stated that it is the right of the resident to practice their own religion, and the facility will facilitate in providing for religious activities.
During a concurrent observation and interview on 3/9/2025 at 1:30 p.m., with the AD, observed the presence of a bible on Resident 10's bed. The AD asked Resident 10 if she would like to attend religious services and observed Resident 10's face lit up and smiled and Resident 10 stated that she wants to attend as long somebody will look after her stuff.
During a review of the facility's policy and procedure titled, Activity Programs-Staffing, last reviewed on 1/3/2025, the policy indicated, The activity director/coordinators responsibilities include: ensuring that the activity goals and approaches reflected in the residents' care plans are individualized to match the skills, abilities and interests/preferences of each resident .sufficient activity personnel are on duty to meet the needs of the residents and the functions of the activity programs.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 62) with an indwelling catheter (a hollow tube inserted into the bladder [organ that stores ur...
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Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 62) with an indwelling catheter (a hollow tube inserted into the bladder [organ that stores urine] to drain or collect urine) received proper care and services by failing to monitor the resident for signs and symptoms of urinary tract infection (UTI- an infection in the bladder/urinary tract) and pain associated with the catheter as indicated in the resident's care plan (a document that summarizes a resident's needs, goals, and care/treatment).
This deficient practice had the potential to result in Resident 62 receiving inadequate care and monitoring at the facility.
Findings:
During a review of Resident 62's admission Record, the admission Record indicated that the facility admitted the resident on 2/12/2025 with diagnoses including benign prostatic hypertension (BPH, enlarged prostrate [a gland] that makes it difficult to urinate), obstructive uropathy (a blockage in the urinary tract that prevents urine from draining normally), and reflux uropathy (when urine flows backward into the kidneys).
During a review of Resident 62's Minimum Data Set (MDS - a resident assessment tool) dated 2/17/2025, the MDS indicated that the resident's cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired. The MDS indicated that Resident 62 required staff substantial/maximal assistance (helper does more than half the effort) for toileting hygiene, showering and bathing, lower body dressing, and putting on/talking off footwear. The MDS further indicated that Resident 62 had an indwelling catheter.
During a review of Resident 62's Order Summary Report dated 2/13/2025, the Order Summary Report indicated an order to provide indwelling catheter care for the resident during every shift and as needed.
During a review of Resident 62's care plan for indwelling catheter initiated on 2/13/2025, the care plan indicated a goal that the resident will remain free from catheter related trauma through the review date. The care plan indicated interventions to monitor and document the resident's fluid intake and urine output as per facility's policy, monitor and document for pain/discomfort due to catheter, and to monitor/record and report to the physician any signs and symptoms of UTI such as pain, burning, blood tinged urine, urinary frequency (the need to urinate many times during the day), foul smelling (having an extremely unpleasant smell) urine, fever, chills, altered mental status (a change in mental function), and change in behavior and eating patterns.
During a review of Resident 62's Treatment Administration Record (TAR- a daily documentation record used by a licensed nurse to document treatments given to a resident) for 2/13/2025-2/28/2025, the TAR did not indicate any documented evidence that licensed staff monitored Resident 62 for pain due to the presence of an indwelling catheter, and signs and symptoms of UTI.
During a concurrent interview and record review on 3/8/2025 at 4:00 p.m., with MDS Coordinator 1 (MDSC 1), reviewed Resident 62's care plan for indwelling catheter initiated on 2/13/2025 and TAR dated 2/2025. MDSC 1 stated that Resident 62's indwelling catheter care plan interventions are to monitor and document for pain/discomfort due to presence of the catheter, and to monitor/record and report to the physician any signs and symptoms of UTI such as pain, burning, blood-tinged urine and urinary frequency. MDSC 1 stated there is no documentation regarding this monitoring anywhere in the resident's chart. MDSC 1 stated that licensed staff are required to monitor Resident 62 for pain due to presence of the indwelling catheter, and signs and symptoms of infection and document their monitoring in Resident 62's medical record as indicated in Resident 62's care plan. MDSC 1 stated that the potential outcome of not implementing a resident's care plan intervention is the inability to provide appropriate care and services to the resident.
During an interview on 3/9/2025 at 3:30 p.m., with the Director of Nursing (DON), the DON stated licensed staff are required to monitor the residents for complications associated with urinary catheter. The DON stated licensed staff are required to monitor and document in the resident's medical record their monitoring and observations such as a kinked (a tubing that has an unwanted, sharp bend or crease, which can obstruct or restrict fluid flow) or accidently removed catheter, urine color, presence of pain/discomfort, and signs and symptoms of UTI such as burning, blood-tinged urine, urinary frequency, foul smelling urine, fever and chills. The DON stated licensed staff did not document anywhere in Resident 62's chart regarding implementing the interventions of monitoring for Resident 62's indwelling catheter. The DON stated the potential outcome of not monitoring a resident's indwelling catheter is the risk of infection and the inability to provide appropriate care and services to the resident.
During review of the facility's Policy and Procedure (P&P) titled, Catheter Care-Urinary, last reviewed on 1/3/2025, the P&P indicated that the purpose of this procedure is to prevent catheter-associated UTI. Review the resident's care plan to assess for any special needs of the resident. Check the resident frequently to be sure he or she is not lying on the catheter and to keep the catheter and tubing free of kinks. Observe the resident for complications associated with urinary catheters. If the resident indicates that his or her bladder is full or that he or she needs to void, notify the physician. Check the urine for unusual appearance such as color, blood, etc. Notify the physician or supervisor in the event of bleeding, or if the catheter is accidently removed. Report any complaints the resident may have of burning, tenderness, or pain in the urethral area. Observe for other signs and symptoms of UTI or urinary retention. Report findings to the physician or supervisor immediately.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to follow the pharmacy's medication recommendation label of discarding two opened eye drop bottles after 28 days of opening from ...
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Based on observation, interview and record review, the facility failed to follow the pharmacy's medication recommendation label of discarding two opened eye drop bottles after 28 days of opening from one in five medications carts (Medication Cart 1 3-11 shift)
This deficient practice had the potential to compromise the therapeutic effectiveness of the medication and increase the risk of contamination, which could result in a negative impact to the health, and well-being of the residents.
Findings:
During a concurrent observation and interview on 3/7/2025 at 6:05 p.m. with Registered Nurse 2 (RN 2), observed Medication Cart 1 3-11 shift. Observed two opened eye drops: One opened eye drop container of Alpheagan (prescription eye drop that helps lower pressure in the eye and treats glaucoma [A group of eye conditions that can cause blindness]), labeled date open 1/20/2025 discard after 28 days and one opened eye drop container of Latanoprost ( medication that treats glaucoma), labeled date opened 1/24/2025 discard after 28 days. RN 2 stated that both eye drops should have been discarded after 28 days of opening because bacteria can grow in open bottles. RN 2 stated that Alpheagan should have been discarded on 2/18/2025 and Latanoprost should have been discarded on 2/22/2025. to ensure resident safety.
During an interview on 3/9/2025 at 11:04 a.m. with the Pharmacist Consultant (PC), the PC stated that the discard label on the eye drops is a pharmacy recommendation, and it is not a regulation.
During an interview on 3/9/2025 at 11:10 a.m., with the Director of Nursing (DON), the DON stated that because the pharmacy label indicated to discard the eye drops after 28 days, licensed nurses should have discarded the eye drops. Licensed nurses are to read the label prior to medications administration.
During a review of the facility's policy titled Procedures For All Medications, review date 1/3/2025, indicated to administer medications in a safe and effective manner. Read medication label before administering.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
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 call lights were within residents' reach while...
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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 call lights were within residents' reach while in bed for three of three sampled residents. (Resident 5, Resident 44, and Resident 45)
This deficient practice had the potential to delay the provision of services and residents' needs not being met.
Findings:
a. During a review of Resident 5's admission Record, the admission Record indicated the facility readmitted the resident on 7/5/2023 with diagnoses including acute respiratory failure (results from acute or chronic impairment of gas exchange between the lungs and the blood) with hypoxia (a condition in which the body's tissues do not receive enough oxygen), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body, often caused by damage to the brain) following unspecified cerebrovascular disease (a group of conditions that affect the blood vessels in the brain and spinal cord) affecting left non-dominant side.
During a review of Resident 5's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 3/3/2025, the MDS indicated Resident 5 has moderately impaired cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making. The MDS indicated Resident 5 required supervision or touching assistance from staff with eating, oral hygiene, personal hygiene.
During an observation on 3/7/2025 at 7:18 p.m. in Resident 5's room, observed Resident 5 in bed while the call was on the floor.
During an observation and concurrent interview on 3/7/2025 at 7:20 p.m. with the MDS Nurse (MDSN), observed Resident 5 in bed while Resident 5's call light was on the floor, out of Resident 5's reach. Observed the MDSN place the call light within Resident 5's reach next to her right hand and stated residents' call light should always be within reach for safety.
b. During a review of Resident 44's admission Record, the admission Record indicated the facility admitted the resident on 5/28/2024 with diagnoses that included metabolic encephalopathy (a condition where the brain's function is impaired due to an imbalance in the body's metabolism), urinary tract infection (UTI- an infection in the bladder/urinary tract), and abnormal posture.
During a review of Resident 44's MDS dated [DATE], the MDS indicated Resident 44's has severely impaired cognitive skills for daily decision making. The MDS indicated Resident 44 required setup or clean-up assistance with oral hygiene and required supervision or touching assistance from staff with toileting and personal hygiene.
During a review of Resident 44's care plan for ADL (activities of daily living) self-care performance deficit initiated on 6/1/2024, the care plan indicated an intervention to keep call light within easy reach.
During an observation on 3/7/2025 at 7:16 p.m. in Resident 44's room, observed Resident 44 in bed while Resident 44's call light on the floor and not within Resident 44's reach.
During an observation and concurrent interview on 3/7/2025 at 7:26 p.m. with Certified Nursing Assistant 2 (CNA 2), observed Resident 44 in bed while Resident 44's call light was on the floor and not within Resident 44's reach. CNA 2 stated that residents' call light should be within reach for the resident's safety.
c. During a review of Resident 45's admission Record, the admission Record indicated the facility readmitted the resident on 4/6/2023 with diagnoses that included Parkinsonism (clinical syndrome characterized by tremor, bradykinesia, rigidity, and postural instability).
During a review of Resident 45's MDS dated [DATE], the MDS indicated Resident 45 has severely impaired cognitive skills for daily decision making. The MDS indicated Resident 45 was dependent with oral hygiene, toileting hygiene, and personal hygiene.
During a review of Resident 44's care plan for ADL self-care performance deficit revised on 2/10/2025, the CP indicated an intervention to keep call light within reach and answer in timely manner.
During an observation on 3/8/2025 at 10:34 a.m. in Resident 45's room, observed Resident 45 in bed, with the call light hanging behind Resident 45's head of bed, and not within Resident 45's reach.
During an observation and concurrent interview on 3/8/2025 at 10:57 a.m. with CNA 3, observed Resident 45 in bed, with the call light hanging behind Resident 45's head of bed, and not within Resident 45's reach. Observed CNA 3 place the call light within Resident 45's reach next to his left hand. CNA 3 stated that resident's call light should be within reach at all times so the resident can ask for help. CNA 3 stated she provided care to Resident 45 and forgot to place Resident 45's call light back within his reach.
During an interview on 3/9/2025 at 5:15 p.m., with the Director of Nursing (DON), the DON stated that all residents' call light should always be within reach for their safety.
During a review of the facility policy titled Call Light reviewed 1/3/2025, the policy indicated residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member on a centralized workstation. Each resident is provided with a means to call staff directly for assistance from his/her bed. Upon admission and as needed, resident call light shall be within reach.
CONCERN
(E)
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 develop and implement a comprehensive person-centered care plan (a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a plan of care that summarizes a resident's health conditions, specific care and services facility staff need to provide a resident to promote healing and prevent a worsening of a condition, and current treatments) to meet the resident`s needs for four of four sampled residents (Resident 287, Resident 36, Resident 37, and Resident 20) by failing to:
1. Develop and implement a comprehensive person-centered care plan addressing Resident 287`s intravenous catheter (IV- a thin flexible tube inserted into a vein to allow for administration of fluids or medications).
This deficient practice had the potential to result in Resident 287`s inadequate care of IV site.
2. Develop and implement a comprehensive person-centered care plan addressing Resident 36's Ceftriaxone Sodium (antibiotic used to treat bacterial infections) use.
This deficient practice had the potential to result in complications due to Resident 36's use of antibiotics.
3. Develop and implement a comprehensive person-centered care plan addressing Resident 37's ability to safely use an electric kettle (a simple portable appliance that boils water quickly using electricity) in his room.
This deficient practice had the potential to result in injuries.
4. Develop and implement a comprehensive person-centered care plan addressing Resident 20's inability to communicate due to a language barrier.
This deficient practice had the potential to result in Resident 20`s inadequate care.
Findings:
1. During a review of Resident 287's admission Record, the admission Record indicated that the facility initially admitted Resident 287 on 4/27/2024 and readmitted the resident on 3/3/2025 with diagnoses including pneumonitis (lungs tissue inflammation, swelling, and irritation), urinary tract infection (an infection in any part of the urinary system), and type 2 diabetes mellitus (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly).
During a review of Resident 287's Minimum Data Set (MDS - a resident assessment tool) dated 10/12/2024, the MDS indicated that the resident had severely impaired cognition (a severely damaged mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS further indicated that Resident 287 was dependent on assistance of two or more helpers for activities of daily living (ADL-activities related to personal care).
During a review of Resident 287's History and Physical (H&P), dated 3/4/2025, the H&P indicated that the resident did not have the capacity to understand and make decisions.
During a review of Resident 287's Physician Orders, an order dated 2/21/2025 indicated to infuse 5% dextrose in water (D5W- intravenous sugar solution) one (1) Liter (L- 1000 milliliters) at 50 milliliters/hour (ml/hr.-infusion rate) every Tuesday and Monday via IV.
During an observation on 3/7/2025, at 8:40 PM, Resident 287 was observed in his room in his bed with IV infusing, D5W at 50 ml/hour.
During a concurrent interview and record review on 3/9/2025 at 2:30 PM, with MDS Coordinator 1(MDSN 1), Resident 287`s physician orders and care plans were reviewed. MDSC 1 stated Resident 287`s has a physician order for IV infusion of D5W. MDSC 1 stated licensed staff did not develop a comprehensive care plan with person-centered interventions for the resident`s IV site monitoring. MDSC 1 stated the potential outcome of not developing a person-centered care plan with goals and interventions for a resident who has an IV is the lack of care and the inability to implement the specific services and monitoring the resident requires.
2. During a review of Resident 36's admission Record, the admission Record indicated that the facility initially admitted Resident 36 on 5/18/2023 and readmitted the resident on 1/29/2025 with diagnoses including dislocation of internal joint prosthesis (the displacement or misalignment of a prosthetic joint that has been surgically implanted to replace a damaged or diseased joint), urinary tract infection (an infection in any part of the urinary system), and essential hypertension (high blood pressure).
During a review of Resident 36's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 5/20/2024, the MDS indicated that the resident had severely impaired cognition (a severely damaged mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS further indicated that Resident 36 was requiring touch up or supervision assistance with eating and moderate - to - maximal assistance for other activities of daily living (ADL-activities related to personal care).
During a review of Resident 36's Physician Orders, an order dated 1/30/2025 indicated to administer Ceftriaxone Sodium (antibiotic used to treat bacterial infections) one (1) gram (g) intravenously one time a day for urinary tract infection (UTI) until 02/202/2025.
During a concurrent interview and record review on 3/9/2025 at 2:30 PM, with MDS Coordinator 1(MDSC 1), Resident 36`s physician orders and care plans were reviewed. MDSC 1 stated Resident 36`s has a physician order for Ceftriaxone IV infusion. MDSC 1 stated licensed staff did not develop a comprehensive care plan with person-centered interventions for the antibiotic administration. MDSC 1 stated the potential outcome of not developing a person-centered care plan with goals and interventions for a resident who was receiving antibiotic therapy is the lack of care and the inability to implement the specific services and monitoring for side effects.
3. During a review of Resident 37's admission Record, the admission Record indicated that the facility initially admitted Resident 37 on 10/29/2019 with diagnoses including phlebitis of lower extremities (an inflammation that causes a blood clot [a clumps that occur when blood hardens from a liquid to a solid] to form in a vein[blood vessels that carry blood back to the [NAME]]), gangrene ( the death of body tissue, typically due to a lack of blood flow), and type 2 diabetes mellitus (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly).
During a review of Resident 37's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 12/19/2024, the MDS indicated that the resident had intact cognition (undamaged mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS further indicated that Resident 37 was required supervision or set up assistance for all activities of daily living (ADL-activities related to personal care).
During a review of Resident 37's History and Physical (H&P), dated 3/4/2025, the H&P indicated that the resident had the capacity to understand and make decisions.
During a concurrent observation and interview on 3/8/2025, at 8:30 AM, observed Resident 37 in bed and an electric tea kettle under the chair. Resident 37 stated he likes to make his own tea by boiling water in the kettle.
During an interview with on 3/8/2025, at 8:35AM with the Director of Nursing (DON), the DON stated that Resident 37 likes to make his own tea and is alert and oriented and had intact cognition. The DON stated that Resident 37 was not assessed for his ability to safely use an electrical equipment like tea kettle. The DON stated there is no care plan developed addressing Resident 37's use of an electric tea kettle. The DON stated that resident should have been assessed, and there should have been a care plan in place addressing use of an electric tea kettle to ensure resident safety.
During an interview on 3/9/2025 at 4:00 PM, with the Director of Nursing (DON), the DON stated licensed staff are required to develop a person-centered care plan based on the residents` needs and identified problems. The DON stated licensed staff did not develop a care plan with goal and interventions for Resident 287`s IV site, for Resident 36's Ceftriaxone administration and for Resident 37's ability to safely use an electric kettle. The DON stated that the potential outcome of not developing care plans with goal and interventions is the inability to monitor to see if there are any decline/improvement in the resident`s condition and consequently providing inadequate care to the residents.
During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed on 1/3/2025, the P&P indicated that a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident`s physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive person-centered care plan is developed within seven (7) days of completion of the required MDS assessment and no more than 21 days after admission. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident`s problem areas and their causes, and relevant clinical decision making.
4. During a review of Resident 20's admission Record (face sheet), the admission Record indicated that the facility originally admitted the resident on 10/25/2024, and readmitted on [DATE], with diagnoses including unspecified dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and cerebral infarction (stroke, loss of blood flow to a part of the brain). The admission records further indicated that Resident 20`s primary language was Korean.
During a review of Resident 20's Minimum Data Set (MDS - a resident assessment tool) dated 1/27/2025, the MDS indicated that the resident`s cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was severely impaired (never/rarely made decisions). The MDS indicated that Resident 20 required staff partial/moderate assistance (helper does less than half the effort) for toileting hygiene, upper and lower body dressing, putting on/talking off footwear, and personal hygiene. The MDS further indicated that Resident 20`s preferred language was Korean.
During a review of Resident 20`s Activity Participation Review form dated 1/27/2025, the Activity Participation form indicated that Resident 20 speaks Korean and very little English.
During a review of Resident 20's care plans, the care plans did not indicate a comprehensive care plan addressing Resident 20`s inability to communicate due to language barrier.
During a concurrent interview and record review on 3/8/2025 at 6:40 p.m., with the Infection Preventionist (IP), Resident 20`s care plans were reviewed. The IP stated that Resident 20`s preferred language is Korean. The IP stated Resident 20 does not speak or understand English. However, licensed staff did not develop a comprehensive care plan with person-centered interventions for the resident`s inability to communicate effectively. The IP stated it is required to develop a person-centered care plan with goals and interventions to address how the facility is going to accommodate Resident 20`s inability to communicate. The IP stated the potential outcome of not developing a care plan for a resident who is unable to communicate in English is the absence of care and the resident`s inability to communicate her needs with the staff.
During an interview on 3/9/2025 at 4:06 p.m., with the Director of Nursing (DON), the DON stated residents who do not speak and understand English, licensed staff are required to develop a person-centered care plan addressing the residents` communication skills, the language they speak, and the use of any communication tools. The DON stated licensed staff did not develop a care plan with goals and interventions for Resident 20`s inability to communicate due to a language barrier. The DON stated the potential outcome of not developing a person-centered care plan for a resident who does not speak and understand English is the lack of care and the inability to communicate effectively with the resident.
During a review of the facility's Policy and Procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed on 1/3/2025, the P&P indicated that a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident`s physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive person-centered care plan is developed within seven (7) days of completion of the required MDS assessment and no more than 21 days after admission. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident`s problem areas and their causes, and relevant clinical decision making.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a safe environment for three out of six residents (Resident 7...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide a safe environment for three out of six residents (Resident 70 and Resident 37) investigated under the care area of accidents when:
1. The facility failed to place a landing mat to Resident 70's right side of the bed while Resident 70 was in bed as indicated in the care plan and physician's order.
This deficient practice placed the resident at risk for avoidable pain and/or injury in an event of Resident 70 experiencing an actual fall.
2. The facility allowed Resident 37 to keep an electric tea kettle in his room.
This deficient practice had the potential to result in injuries to Resident 37.
Findings:
1. During a review of Resident 70's admission Record, the admission Record indicated the facility admitted the resident on 2/23/2024 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), encounter for palliative care (person and family-centered treatment, care and support for people living with a life-limiting illness), and unspecified sequelae of cerebral infarction (loss of blood flow to a part of the brain).
During a review of Resident 70's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 2/5/2025, the MDS indicated Resident 70 had severely impaired cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making. The MDS also indicated Resident 70 was dependent on staff with oral hygiene, toileting hygiene, and personal hygiene.
During a review of Resident 70's Fall Risk assessment dated [DATE], the Fall Risk Assessment indicated Resident 70 was at risk for falls.
During a review of Resident 70's physician's order dated 2/13/2025 at 10:56 a.m., the physician order indicated an order for one right side landing pad every shift less restrictive measures of fall and injury.
During a review of Resident 70's care plan titled Resident 70 is risk for unavoidable falls with injury related to generalized weakness, impaired mobility, cerebral infarction with right hemiparesis and hemiplegia initiated on 2/26/2024 indicated under interventions: right side landing pads.
During an observation on 3/7/2025 at 7:35 p.m., in Resident 70's room, observed Resident 70 in bed. Observed a landing mat under Resident 70's bed.
During a concurrent observation and interview on 3/7/2025 at 7:46 p.m., with Registered Nurse 2 (RN 2) in Resident 70's room, observed Resident 70 in bed and Resident 70's landing mat under Resident 70's bed. RN 2 stated that Resident 70's landing mat should be placed on Resident 70's right side as indicated in the physician's order. RN 2 stated that the Certified Nursing Assistant (CNA) placed the landing mat under Resident 70's bed when the CNA assisted Resident 70 for dinner. RN 2 further stated that Resident 70's landing mat should have been placed back on Resident 70's right side because the resident is at risk for falls.
During an interview with the Director of Nursing (DON) on 3/8/2025 at 5:05 p.m., the DON stated Resident 70's landing mat should have been on Resident 70's right side of bed to minimize injury if a fall were to occur.
During a review of the facility's policy and procedure titled, Falls and Fall Risk, Managing, review date 1/3/2025, the policy and procedure indicated based on previous evaluations and current data, the nursing staff will identify interventions related to the resident's specific risks and causes to try and prevent the resident from falling and try to minimize complications from falling. In conjunction with the attending physician, licensed staff will identify and implement relevant intervention (e.g., low position, floor pad, . ) to try to minimize serious consequences of falling.
2. During a review of Resident 37's admission Record, the admission Record indicated that the facility initially admitted Resident 37 on 10/29/2019 with diagnoses including phlebitis of lower extremities (an inflammation that causes a blood clot [a clumps that occur when blood hardens from a liquid to a solid] to form in a vein[blood vessels that carry blood back to the [NAME]]), gangrene ( the death of body tissue, typically due to a lack of blood flow), and type 2 diabetes mellitus (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly).
During a review of Resident 37's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 12/19/2024, the MDS indicated that the resident had intact cognition (undamaged mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS further indicated that Resident 37 was required supervision or set up assistance for all activities of daily living (ADL-activities related to personal care).
During a review of Resident 37's History and Physical (H&P), dated 3/4/2025, the H&P indicated that the resident had the capacity to understand and make decisions.
During a concurrent observation and interview on 3/8/2025, at 8:30 AM, surveyor observed Resident 37 in his room in his bed and a tea kettle under the chair. Resident 37 stated he likes to make his own tea by boiling water in the kettle.
During an interview with on 3/8/2025, at 8:35AM with the Director of Nursing (DON), the DON stated that Resident 37 liked to make his own tea and is alert and oriented and had intact cognition. The DON stated that Resident 37 was not assessed for his ability to safely use an electrical equipment like tea kettle. The DON stated there is no care plan developed addressing Resident 37's use of an electric tea kettle. The DON stated that resident should have been assessed, and there should have been a care plan in place addressing use of an electric tea kettle to ensure resident safety.
During an interview with on 3/8/2025, at 4:15 AM with the Maintenance Director (MD), the MD stated that he was not aware that Resident 37 is using electrical kettle to boil a water in his room. The MD stated that Resident 37 may not have any electrical appliances in the room because it placed the resident at risk for accidents.
During a review of the facility's Policy and Procedure (P&P) titled, Safety and Supervision of Residents, last reviewed on 1/3/2025, the P&P indicated: Our facility strives to make the environment as free from accident hazards as possible.
During a review of the facility's Policy and Procedure (P&P) titled, Electrical Appliances, last reviewed on 1/3/2025, the P&P indicated: Resident may not maintain any electrical appliances within their living area, unless approved, in writing, by the Administrator, or his/her designee.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
b. During a review of Resident 287's admission Record, the admission Record indicated that the facility initially aditted Resident 287 on 4/27/2024 and readmitted the resident on 3/3/2025 with diagnos...
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b. During a review of Resident 287's admission Record, the admission Record indicated that the facility initially aditted Resident 287 on 4/27/2024 and readmitted the resident on 3/3/2025 with diagnoses including pneumonitis (lungs tissue inflammation, swelling, and irritation), urinary tract infection (an infection in any part of the urinary system), and type 2 diabetes mellitus (a long-term medical condition in which the body does not use insulin [a hormone that lowers the level of sugar in the blood] properly).
During a review of Resident 287's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 10/12/2024, the MDS indicated that the resident had severely impaired cognition (a severely damaged mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS further indicated that Resident 287 was dependent on the assistance of two or more helpers for activities of daily living (ADL-activities related to personal care).
During a review of Resident 287's History and Physical (H&P), dated 3/4/2025, the H&P indicated that the resident did not have the capacity to understand and make decisions.
During a review of Resident 287' Care plan (a form where licensed nurses can summarize a person's health conditions, specific care needs, and current treatments), dated, 7/9/2024, the care plan indicated that Resident 287 had an altered respiratory status related to respiratory failure with hypoxia (the condition where the lungs are failing to adequately oxygenate the blood). The care plan interventions indicated an intervention to provide continuous oxygen as ordered.
During a review of Resident 287's Physician Order, dated 10/11/2024, the Physician Orders indicated the following orders:
1. Administration of oxygen at 2L/min (measurement of oxygen flow) via nasal canula (a device that gives additional oxygen through the nose) continuously.
2. Change oxygen humidifier every week on Monday and PRN, when consumed with name and date label.
During an observation on 3/7/2025, at 8:40 PM, Resident 287 was observed in bed, with oxygen being administered via nasal canula without a humidifier.
During a concurrent observation and interview on 3/7/2025 at 8:42 PM in Resident 287's room with LVN 1, observed the oxygen concentrator connected to the resident via nasal canula at three (3) liters/minute (L/min-measurement of oxygen flow) without a humidifier. LVN 1 checked the Physician order and stated that oxygen should be continuously administered to Resident 287 via nasal canula at 2 L/min and with a humidifier.
During an interview on 3/7/2025 at 8:50 PM with Director of Nursing (DON), the DON stated that oxygen should be administered to Resident 287 according to the physician order to prevent a possibility of hyperoxygenation and respiratory complications for the resident.
During a review the facility policy and procedure named Physician Services, last reviewed on 1/3/2025, the policy and procedure indicated: Drugs, biologicals, laboratory services, radiology and other diagnostic services shall be administered or performed only upon the written order of a person duly licensed and authorized to prescribe such drugs and services.
Based on observation, interview and record review, the facility failed to ensure that residents received continuous oxygen as ordered by the physician for two of three sampled residents. (Resident 70 and Resident 287).
The deficient practice had a potential to cause Resident 70 and Resident 287 to have shortness of breath that could lead to hypoxemia (a low level of oxygen in the blood).
Findings:
a. During a review of Resident 70's admission Record, the admission Record indicated the facility admitted the resident on 2/23/2024 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), encounter for palliative care (person and family-centered treatment, care and support for people living with a life-limiting illness), and dependence on supplemental oxygen.
During a review of Resident 70's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 2/5/2025, the MDS indicated Resident 70 had severely impaired cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making. The MDS also indicated Resident 70 was dependent on staff with oral hygiene, toileting hygiene, and personal hygiene.
During a review of Resident 70's Order Summary Report, the Order Summary Report indicated an order for:
- Oxygen (O2) at 2 liters/minute via nasal canula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) continuously for COPD and oxygen desaturation. May titrate to 5 liters as needed. Every shift. Order date: 2/27/2025. Start date: 2/27/2025
During an observation on 3/7/2025 at 7:30 p.m., in Resident 70's room, observed Resident 70 in bed. Observed an O2 concentrator at bedside. The O2 concentrator was on, Resident 70's nasal canula was connected to the O2 concentrator, however, Resident 70 was not wearing the nasal canula.
During a concurrent observation and interview on 3/7/2025 at 7:45 p.m., with Registered Nurse 2 (RN 2) in Resident 70's room, observed Resident 70's nasal cannula connected to an oxygen concentrator that was on, however, Resident 70 was not wearing the nasal cannula. RN 2 stated that its okay that Resident 70 is not wearing her nasal canula because Resident 70's oxygen order is as needed and not continuous. Observed RN 2 place Resident 70's nasal canula on Resident 70.
During an observation on 3/8/2025 at 10:40 a.m., in Resident 70's room, observed Resident 70 on the bed. Observed Resident 70's nasal cannula connected to an oxygen concentrator that was on, however, Resident 70 was not wearing the nasal cannula.
During a concurrent observation and interview on 3/8/2025 at 10:43 a.m., with Licensed Vocational Nurse 2 (LVN 2) in Resident 70's room, observed Resident 70's nasal cannula connected to an oxygen concentrator that was on, however, Resident 70 was not wearing the nasal cannula. LVN 2 stated that Resident 70 should have her nasal canula on but Resident 70 always removes it. LVN 2 stated that LVN 2 will get an order from Resident 70's physician to change the order because Resident 70 always removes it.
During an interview with the Director of Nursing (DON) on 3/9/2025 at 5:06 p.m., the DON stated that continuous oxygen via nasal cannula should have been provided to Resident 70 to ensure Resident 70 was provided supplemental oxygen to avoid complications such as labored breathing and/or shortness of breath.
During a review of the facility's policy and procedure titled, Oxygen Administration, review date 1/3/2025, the policy and procedure indicated oxygen therapy is administered by way of an oxygen mask, nasal cannula, and/or nasal catheter.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
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:
1. Ensure licensed nurses did not leave medications ...
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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. Ensure licensed nurses did not leave medications at residents' bedside unattended by a licensed nursed for one of three sampled resident (Resident 57)
This deficient practice increases the risks of harm to the resident from omitting the dose, double dosing, and mixing the medications that could cause adverse (unfavorable) or even fatal effects on the resident
2. Ensure a resident was given the first dose of antibiotic timely for one of three sampled residents (Resident 60)
This deficient practice resulted in the delay of medication administration of an antibiotic which has a potential to cause bacteria to reproduce.
Findings:
a. During a review of Resident 57's admission Record, the admission Record indicated the facility readmitted the resident on 2/15/2025 with diagnoses including chronic hematogenous osteomyelitis (a bone infection that occurs when bacteria spread through the bloodstream to the bone) right ankle and foot, type 2 diabetes mellites (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcer, non-pressure chronic ulcer on right heel and midfoot with necrosis of bone (a condition where bone tissue dies due to a loss of blood supply).
During a review of Resident 57's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 2/19/2025, the MDS indicated Resident 5's has intact cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making. The MDS indicated Resident 57 required setup or clean up assistance with eating, supervision or touching assistance from staff with oral hygiene, and required partial/moderate assistance with toileting hygiene.
During an observation on 3/7/2025 at 8:31 p.m. in Resident 57's room, observed Resident 57 in his wheelchair, observed two pills in an unlabeled medication cup (1 white round pill/1 clear oblong pill) on top of Resident 57's bedside table. The two pills in the unlabeled medication cup was unattended by a licensed nurse.
During a concurrent observation and interview on 3/7/2025 at 8:32 p.m., in Resident 57's room. Resident 57 stated that the two pills in the unlabeled medication on on his bedside table belongs to Resident 57. Resident 57 stated that his nurse left his medications for him to take at a later time. Resident 57 stated that his nurse leaves it at his bedside all the time and it's no big deal.
During an interview on 3/7/2025 at 8:35 p.m. with Registered Nurse 2 (RN 2), RN 2 stated that she is assigned to Resident 57 today (3/7/2025). RN 2 stated that she left Resident 57's two pills in a medication cup on Resident 57's bedside table. RN 2 stated that she left the medications at bedside because the 5:00 p.m. medications are only vitamins. RN 1 continued to state that Resident 57 is trustworthy. RN 1 stated that she always leaves his medications unattended at Resident 57's bedside table because RN 2 has no control to when Resident 57 takes his medication.
During a concurrent interview and record review with Registered Nurse 1 (RN 1) on 3/9/2025 at 11:34 a.m., RN 1 reviewed Resident 57's medication records and stated that there is no documented evidence of a Medication Self Administration Assessment prior to 3/7/2025. RN 1 stated that a Medication Self Administration Assessment should be done prior to allowing a resident to self administer his/her medication to assess if the resident is able to self administer their own medications safely. RN 1 continued to state that residents' medications should not be left at bedside unattended because licensed nurses have to ensure that residents take their medications safely and to avoid residents from choking.
During a review of the facility's policy and procedure titled Medication Adminitration- General Guidelines, review date 1/3/2025, indicated medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medication. The resident is always observed after medication administration to ensure that the dose was completely ingested.
b. During a review of Resident 60's admission Record, the admission Record indicated the resident was readmitted to the facility on [DATE] with diagnoses that included urinary tract infection (UTI- an infection in the bladder/urinary tract).
During a review of Resident 60's MDS dated [DATE], the MDS indicated the resident had moderately impaired cognition.
During a review of Resident 60's physician's orders dated 3/8/2025 at 3:22 a.m., the physician's order indicated an order for Cipro (Ciprofloxacin- antibiotic is used to treat bacterial infections in many different parts of the body) oral table. Give 500 mg by mouth every 12 hours for UTI for 10 days. Confirmed by: Registered Nurse 2 (RN 2).
During a review of Resident 60's care plan for resident is on antibiotic therapy related to culture result, the care plan indicated an intervention to administer medication as ordered.
During a concurrent interview and record review with the MDS Nurse (MDSN) on 3/8/2025 at 5:11 p.m., reviewed Resident 60's medical records. The MDSN stated Resident 60's physician's order and stated that RN 2 received an antibiotic order, Cipro 500 mg, on 3/8/2025 at 3:22 a.m. The MDSN reviewed Resident 60's MAR (Medication Administration Record) and stated that Resident 60 was administered his first dose of his new antibiotic order on 3/8/2025 at 9:00 a.m. The MDSN continued to state that Resident 60 is supposed to receive his first dose of his new antibiotic order within four hours of the antibiotic order being received. The MDSN further stated that RN 2 should have administered after receiving the new antibiotic order because Cipro is available in the facility's pharmacy e-kit.
During an interview on 3/9/2025 at 5:09 p.m. with the Director of Nursing (DON), the DON stated that Resident 60 was not administered his antibiotic timely. RN 2 should have administered Resident 60's antibiotic within 4 hours of receiving the new antibiotic order. The DON stated that there is no excuse because the antibiotic is available in he facility's e-kit.
During a review of the facility policy and procedure titled Provider Pharmacy Requirements, review date 1/3/2025, indicated medications should be promptly available such as anti-infectives, .are available within 4 hours.
During a review of the facility's policy and procedure titled Medication Administration- General Guidelines, review date 1/3/2025, indicated medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so.
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 leftover food brought from outside by residents' family and visitors were labeled with a resident identifier and use-b...
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Based on observation, interview, and record review, the facility failed to ensure leftover food brought from outside by residents' family and visitors were labeled with a resident identifier and use-by-date in one of one resident refrigerator (Refrigerator 1).
This deficient practice had the potential to result in foodborne illness (also called food poisoning, illness caused by eating contaminated food) for the residents.
Findings:
During a concurrent observation and interview on 3/7/2025 at 6:33 p.m., with Registered Nurse 3 (RN 3), observed the residents' refrigerator in the nurse's station. Observed in the refrigerator, two plastic bags of undetermined leftover food with one bag with a room number with no name and date and the other plastic bag containing undetermined food items with no resident's name and no date. RN 3 stated that this refrigerator is used to store resident's food and had to be labeled with an identifier and date. RN 3 stated that any leftover food that is more than three days old had to be discarded. RN 3 stated that leftover food that is more than three days old can possibly get contaminated with salmonella (bacteria that causes diarrhea, fever, and stomach pains) and result in food poisoning if ingested by the residents.
During a review of the facility's policy and procedure titled, Food Brought by Family/Visitors, last reviewed on 1/3/2025, the policy indicated that perishable (foods likely to spoil, decay, or become unsafe to consume if not kept refrigerated) foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item and the use by date .the nursing staff is responsible for discarding perishable foods on or before the use by date.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected multiple residents
Based on interview, and record review, the facility failed to ensure the facility had arranged provisions of hospice services by failing to:
1. Ensure the contracted hospice agency provided training p...
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Based on interview, and record review, the facility failed to ensure the facility had arranged provisions of hospice services by failing to:
1. Ensure the contracted hospice agency provided training programs to facility staff as per contractual agreement.
2. Ensure there is a designated staff to coordinate care and services provided by hospice and the facility.
3. Ensure documented evidence was provided to validate hospice staff was physically in the facility to provide hospice related services to one of three sampled residents (Resident 70)
These deficient practices has the potential to negatively affect the resident's physical comfort, psychosocial well-being, and has the potential to delay or have a lack of necessary care and services.
Findings:
During a review of Resident 70's admission Record, the admission Record indicated the facility admitted the resident on 2/23/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), encounter for palliative care (person and family-centered treatment, care and support for people living with a life-limiting illness), and dependence on supplemental oxygen.
During a review of Resident 70's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 2/5/2025, the MDS indicated Resident 70 had severely impaired cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making. The MDS also indicated Resident 70 was dependent on staff with oral hygiene, toileting hygiene, and personal hygiene.
During a review of Resident 70's Order Summary Report, the report indicated an order dated 5/7/2024 to admit the resident to hospice.
a. During an interview Registered Nurse 1 (RN 1) on 3/9/2025 at 8:39 a.m., RN 1 stated that the facility has only have one resident on hospice, Resident 70. RN 1 stated she has not received an in-service training from the hospice agency caring for Resident 70.
During an interview with Certified Nursing Assistant 4 (CNA 4) on 3/9/2025 at 9:05 a.m., CNA 4 stated CNA 4 was assigned to resident 70 today, 3/9/2025. CNA 4 stated that CNA 4 has worked in the facility as a CNA for about 1 year. CNA 4 further stated that she has not received in-service training from Resident 70's hospice agency.
During an interview with the MDS Nurse (MDSN) on 3/9/2025 at 9:14 a.m., the MDSN stated he has been employed at the facility since 6/2024 and has not had an in-service training conducted by the hospice agency.
During a concurrent interview and record review with the Administrator (ADM) on 3/9/2025 at 4:22 p.m., the ADM reviewed the facility's hospice contract dated 5/10/2010 and stated that hospice has not fulfilled their contract. The ADM stated that she was not aware that training should have been provided by the hospice agency. The ADM further stated that moving forward she will be coordinating with the facility Director of Staff Development to schedule in-service training from the hospice agency.
During an interview with the Director of Nursing (DON) on 3/9/2025 at 5:07 p.m., the DON stated that she was not aware of the hospice orientation and training portion of the hospice contract.
During a review of the facility's hospice contract dated 5/17/2010, indicated under Hospice Orientation and Training: The Hospice will provide educational resources to The Facility for purposes of orientation, teaching and/or continuing education on an as needed basis, but at least, on a quarterly basis, at the facilities request.
b. During an interview with the MDSN on 3/9/2025 at 9:12 a.m., the MDSN stated that the he was not sure of who the facility's hospice coordinator was. The MDSN stated that he thinks it is the Social Services Director.
During an interview RN 1 on 3/9/2025 at 9:54 a.m., RN 1 stated that the hospice coordinator is the ADM.
During an interview with the Social Services Director (SSD) on 3/9/2025 at 10:38 a.m., when asked who the facility's hospice coordinator was, the SSD stated that the hospice coordinator is the DON and the resident's physician. The SSD stated that she is not the facility's hospice coordinator. The SSD stated that if the facility needed something from hospice the charge nurses would call the hospice directly.
During an interview with the ADM on 3/9/2025 at 4:21 p.m., the ADM stated that the facility does not have a designated hospice coordinator. The ADM stated she is not the hospice coordinator.
During an interview with the DON on 3/9/2025 at 5:11 p.m., the DON stated that the facility does not have a hospice coordinator, and that the facility should have one. The DON stated that it is important to have a hospice coordinator in the facility so that the facility will be able to provide quality care.
During a review of the facility's policy and procedure titled, Hospice Program, reviewed on 1/3/2025, indicated the facility has designated . to coordinate care provided to the resident by our facility staff and the hospice staff. (Note: this individual is a member of the IDT with clinical and assessment skills who is operating within the state scope of practice act) He or she is responsible for the following: a. Collaborating with hospice representatives and coordinating facility staff participation in the hospice care planning process for residents receiving these services; b. Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions to ensure quality of care for the residents and family; c. ensuring that the LTC facility communicates with the hospice medical director, the resident's attending physician, and other practitioners participating in the provision of care to the residents as needed to coordinate the hospice care with the medical care provided by other physicians; e. Ensuring that facility staff provides orientation on the policies and procedures of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents.
c. During a current interview and record review with on 3/9/2025 at 9:27 a.m. with the MDSN, the MDSN reviewed Resident 70's hospice binder. The MDSN stated that there was no documented evidence that hospice staff was in the facility. There is no sign in sheet for hospice staff. The MDSN stated that when hospice staff is in the facility hospice staff should be signing on a sign-in sheet in Resident 70's hospice binder.
During a concurrent interview and record review on 3/9/2025 at 3:57 p.m., with the Director of Staff Development (DSD), the DSD stated that the DSD sees hospice staff in the facility. The DSD reviewed Resident 70's hospice binder and stated that there is no sign-in sheet for hospice staff. The DSD stated that there is no documented evidence that hospice staff is in the facility.
During an interview with the DON on 3/9/2025 at 5:12 p.m., the DON stated that the facility does not have sign-in sheets specifically for hospice staff. The DON stated that moving forward the facility will have a sign-in sheet dedicated to hospice staff. When hospice staff arrive to the facility hospice staff is to sign in on the hospice sign in sheet. The DON continued to state that by signing in in the hospice sign-in sheet, that ensures that hospice staff was physically in the facility to provide hospice care to the resident.
During a review of the facility's policy and procedure titled Charting and documentation, reviewed on 1/3/2025, indicated all services provided to the resident shall be documented in the resident's medical record.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to:
1. Ensure a resident's nasal cannula (a medical device that delivers supplemental oxygen therapy to people with low oxygen l...
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Based on observation, interview, and record review, the facility failed to:
1. Ensure a resident's nasal cannula (a medical device that delivers supplemental oxygen therapy to people with low oxygen levels) oxygen tubing was not touching the floor for one of one sampled resident (Resident 137).
2. Ensure a resident's nasal cannula was labeled with the date when it was last changed for one of three sampled residents (Resident 287).
These deficient practices had the potential to result in contamination of the resident's care equipment and risk of transmission of bacteria that can lead to infection.
Findings:
1. During a review of Resident 137's admission Record, the admission Record indicated the facility admitted the resident on 2/28/2025 with diagnoses including morbid obesity (a disorder that involves having too much body fat, which increases the risk of health problems) and heart failure (a chronic condition that occurs when the heart can't pump enough blood and oxygen to the body).
During a review of Resident 137's History and Physical (H&P- a formal assessment by a healthcare provider that involves a resident interview, physical exam, and documentation of findings) dated 2/28/2025, the H&P indicated that the resident had the capacity to understand and make decisions
During a review of Resident 137's physician orders dated 2/28/2025, the physician order indicated an order to administer oxygen at two (2) liters per minute (LPM- unit of measurement for oxygen) via nasal cannula continuously every shift.
During a concurrent observation and interview on 3/7/2025 at 7:53 p.m., with the Director of Nursing (DON), observed Resident 137's nasal cannula oxygen tubing on the floor. The DON stated that the tubing is already contaminated and can introduce infection to the resident and had to be replaced immediately.
During a review of the facility's policy and procedure titled, Policies and Practices-Infection Control, last reviewed on 1/3/2025, the policy indicated, This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.
During a review of the Centers for Disease Control and Prevention (CDC, national public health agency) source material, Guidelines for Environmental Infection Control in Health-Care Facilities, updated 7/2019, indicated floors can become rapidly contaminated from airborne microorganisms and those transferred from shoes, equipment wheels, and body substances.
2. During a review of Resident 287's admission Record, the admission Record indicated that the facility initially admitted Resident 287 on 4/27/2024 and readmitted the resident on 3/3/2025 with diagnoses including pneumonitis (lung tissue inflammation, swelling, and irritation), urinary tract infection (an infection in any part of the urinary system), and type two (2) diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]).
During a review of Resident 287's Minimum Data Set (MDS - a resident assessment tool) dated 10/12/2024, the MDS indicated that the resident had severely impaired cognition (mental abilities, including remembering things, making decisions, concentrating, or learning). The MDS further indicated that Resident 287 was dependent on assistance of two or more helpers for activities of daily living (ADL- activities related to personal care).
During a review of Resident 287's H&P dated 3/4/2025, the H&P indicated that the resident did not have the capacity to understand and make decisions.
During a review of Resident 287's care plan (a document that summarizes a resident's needs, goals, and care/treatment) dated 7/9/2024, the care plan indicated that Resident 287 had an altered (changed or modified) respiratory status related to respiratory failure with hypoxia (the condition where the lungs are failing to adequately oxygenate the blood). The care plan indicated an intervention to provide continues oxygen as ordered.
During a review of Resident 287's physician orders dated 10/11/2024, the physician orders indicated the following:
- Administration of oxygen at two (2) liters (L- measurement of oxygen flow) via nasal cannula continuously.
- Change oxygen nasal cannula every week on Monday and as needed (PRN) with name and date label.
During an observation on 3/7/2025 at 8:40 p.m., observed Resident 287 in bed with oxygen being administered to the resident via nasal cannula.
During a concurrent observation and interview on 3/7/2025 at 8:42 p.m., in Resident 287's room with LVN 1, observed Resident 287's nasal cannula oxygen tubing not labeled with the date when it was last changed. LVN 1 checked the physician order and stated that the nasal cannula oxygen tubing had to be changed every Monday and labeled with the date when it was last changed.
During an interview on 3/7/2025 at 8:50 p.m., with the DON, the DON stated that oxygen tubing had to be labeled with the date when it was last changed to prevent a possibility of respiratory infection in Resident 287.
During an interview on 3/9/2025 at 2:50 p.m., with the Infection Preventionist (IP), the IP stated that oxygen tubing should be changed in the facility every Monday and as needed and labeled with the date when it was last changed to prevent respiratory infection.
During a review of the facility's policy and procedure titled, Infection Control, last reviewed on 1/3/2025, the policy indicated, This facility's infection control policies and practices are intended to facilitate maintaining safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections.
MINOR
(B)
Minor Issue - procedural, no safety impact
Assessment Accuracy
(Tag F0641)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to conduct an accurate Minimum Data Set (MDS- a resident assessment 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 conduct an accurate Minimum Data Set (MDS- a resident assessment tool) assessment, reflecting a resident's status at the time of assessment for one of two sampled residents (Resident 62) by failing to indicate that the resident was receiving insulin (a hormone that works by lowering levels of glucose [sugar] in the blood) since his admission to the facility.
This deficient practice had the potential to negatively affect Resident 62's plan of care and the delivery of necessary care and services.
Findings:
During a review of Resident 62's admission Record, the admission Record indicated that the facility admitted the resident on 2/12/2025 with diagnoses including benign prostatic hypertension (BPH, enlarged prostrate [a gland] that makes it difficult to urinate), history of falling, and type two (2) diabetes mellitus (DM- a chronic condition that affects the way the body processes blood sugar).
During a review of Resident 62's MDS dated [DATE], the MDS indicated that the resident's cognitive skills (brain's ability to think, read, learn, remember, reason, express thoughts, and make decisions) for daily decision making was moderately impaired. The MDS indicated that Resident 62 required staff substantial/maximal assistance (helper does more than half the effort) for toileting hygiene, showering and bathing, lower body dressing, and putting on/talking off footwear. The MDS further indicated that Resident 62 did not receive insulin injections during the last seven (7) days or since his admission.
During a review of Resident 62's Order Summary Report dated 2/12/2025, the Order Summary Report indicated an order to administer insulin lispro (a rapid-acting insulin) subcutaneously (SQ - administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) as per sliding scale (progressive increase in the insulin dosage, based on pre-defined blood glucose ranges) before meals and at bedtime.
During a review of Resident 62's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 2/12/2025-2/17/2025, the MAR indicated that Resident 62 received insulin lispro from 2/13/2025 through 2/17/2025.
During a concurrent interview and record review on 3/9/2025 at 10:10 a.m., with MDS Coordinator 1 (MDSC 1), reviewed Resident 62's MAR dated 2/2025 and Resident 62's MDS dated [DATE]. MDSC 1 stated Resident 62 has a diagnosis of DM and on 2/12/2025 Resident 62's physician ordered insulin lispro to be administered per sliding scale. MDSC 1 stated Resident 62 received insulin lispro from 2/13/2025 through 2/17/2025. MDSC 1 stated Resident 62's MDS dated [DATE] was not coded for insulin use and it did not indicate that the resident has taken insulin since his admission to the facility. MDSC 1 stated that it was his mistake, and he (MDSC 1) has to make the correction for incorrect coding. MDSC 1 stated he (MDSC 1) did not conduct a correct MDS assessment for Resident 62's insulin use. MDSC 1 stated the potential outcome of an incorrect MDS assessment is the inability to make the correct care plan (a document that summarizes a resident's needs, goals, and care/treatment) for the resident, and lack of care.
During an interview on 3/9/2025 at 3:25 p.m., with the Director of Nursing (DON), the DON stated the facility's MDS Coordinator is required to accurately complete each portion of the MDS assessment to reflect the resident's status at the time of the assessment. The DON stated Resident 62's MDS assessment dated [DATE] did not indicate that Resident 62 was receiving insulin since his admission to the facility. The DON stated that the potential outcome of an inaccurate MDS assessment is the development of an incorrect care plan for the resident.
During review of the facility's Policy and Procedure (P&P) titled, Resident Assessments, last reviewed on 1/3/2025, the P&P indicated that the resident assessment coordinator is responsible for ensuring that the Interdisciplinary Team (IDT- a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan) conducts timely and appropriate resident assessments. The IDT uses the MDS form currently mandated by federal and state regulations to conduct the resident assessment. Assessments are completed by staff members who have the skills and qualifications to assess relevant care areas and who are knowledgeable about the resident`s strengths and areas of decline. All persons who have completed any portion of MDS resident assessment form must sign the document attesting to the accuracy of such information. The results of the assessments are used to develop, review and revise the resident's comprehensive care plan.
Feb 2024
13 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review the facility failed to provide a comfortable home-like environment by not providing an adequate and comfortable lighting per the facility's policy fo...
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Based on observation, interview, and record review the facility failed to provide a comfortable home-like environment by not providing an adequate and comfortable lighting per the facility's policy for one of six sampled residents (Resident 293).
This deficient practice had the potential to negatively impact the quality of life and increased risk for discomfort for Resident 239.
Findings:
A review of Resident 293's admission Record indicated the facility admitted the resident to the facility on 2/5/2024 with diagnoses including malignant neoplasm of palate and mouth (a cancer of mouth and roof of the mouth), acute respiratory failure (condition in which your blood does not get enough oxygen), and atrial fibrillation (an irregular and very rapid heart rhythm).
A review of Resident 293's Minimum Data Set (MDS - a standardized assessment and screening tool), dated 2/8/2024, indicated Resident 293's cognitive skill (mental action or process of acquiring knowledge and understanding) for daily decision-making were mildly impaired. The MDS indicated Resident 293 required moderate assistance from staffs for activities of daily living (ADL- activities related to personal care).
During a concurrent observation and interview on 2/23/2024 at 11:30 a.m., with Resident 293, observed Resident 293's overhead light with no cover and three light bulbs exposed. Resident 293 stated the overhead lights in her room had been uncovered since she was admitted , and it was sometimes too bright in her room.
During an interview on 2/24/2024 at 11:15 a.m., with the Maintenance Director (MTD), the MTD stated, the overhead lights in residents' rooms should have protective covers. The MTD confirmed by stating the overhead light for Resident 293's room was uncovered. The MTD stated this needs to be fixed and should be covered.
A review of the facility's policy and procedure titled, Homelike Environment, reviewed on 1/3/2024, indicated residents are provided with a safe, clean, comfortable, and homelike environment . the facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include comfortable (minimum glare) yet adequate (suitable to the task) lighting.
A review of the facility's policy and procedure titled, Maintenance Service, reviewed on 1/3/2024, indicated the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. Functions of maintenance personnel include but are not limited to: maintaining lighting levels that are comfortable.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
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 implement their policy and procedure for the use of r...
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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 their policy and procedure for the use of restraints (a device that restricts movements) by:
a. Failing to ensure a consent (the legal approval that a resident gives to a physician regarding health care decisions) was first obtained prior to utilizing bilateral (both sides) bed side rails for one of three sampled residents (Resident 77).
b. Failing to ensure licensed nurses obtained a physician's order for the use of bilateral bed siderails for one of three sampled residents (Resident 77).
This deficient practice placed Resident 77 at increased risk for complications of restraint use such as decline in functioning, injury, and entrapment (event in which a resident is caught, trapped, or entangled in a space where they are being restrained).
Findings:
a. A review of Resident 77's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis including metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body), chronic diastolic (the left side of the heart has stiffens) congestive heart failure (CHF- a progressive condition that affects the pumping power of the heart muscle), and depression (a mood disorder that causes persistent feeling of sadness and loss of interest).
A review of Resident 77's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 1/2/2024, indicated Resident 77's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired for daily decision-making and required moderate assistance from staff for activities of daily living (ADL- oral hygiene, toileting hygiene, shower/bathe self, upper and body dressing and personal hygiene).
During a record review on 2/23/2024 at 3:41 p.m., Resident 77's consents from 9/29/2023 to 2/23/2024 were reviewed. No documented consent for the use of bilateral side rails were found.
During an observation on 2/23/2024 at 11:42 a.m., observed Resident 77's room. Observed Resident 77 lying in bed with eyes closed, with bilateral bed siderails up.
During an interview with Registered Nurse 1 (RN 1) on 2/24/2024 at 8:22 a.m., RN 1 stated, Resident 77 is utilizing bed siderails for mobility and because he is at high risk for falls since admission on [DATE]. RN 1 reviewed chart with surveyor and confirmed by stating that there was no consent obtained for Resident 77 the use of bilateral bed siderails. RN 1 stated that the facility should have obtained a consent for the use of bilateral bed siderails for Resident 77.
b. During a record review of Resident 77's Physician Order Summary Report on 2/23/2024 at 3:42 p.m., indicated there was no physician order for the bilateral bed siderails.
During an observation on 2/23/2024 at 11:42 a.m., observed Resident 77's room. Observed Resident 77 lying in bed with eyes closed, with bilateral bed siderails up.
RN 1 stated that, and they had just added the physician's order for the bed siderails last night (2/23/2024). RN 1 stated, there should be a physician's order and consent when they started using the bilateral siderails for Resident 77.
During an interview with RN 1 on 2/24/2024 at 8:22 a.m., RN 1 stated that the facility did not obtain a physician order for the use of bilateral side rails for Resident 77 until the previous night on 2/23/2024.RN 1 stated, there should be a physician's order and consent when they started using the bilateral siderails for Resident 77.
A review of the facility's policy and procedure (P&P) titled, Use of Restraints reviewed on 1/3/2024, indicated that restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. The P&P also indicated, physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body . practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, include: using bedrails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed.
A review of the facility's P&P titled, Bed Safety and Bed Rails reviewed on 1/32024, the P&P indicated, The use of bedrails is prohibited unless the criteria for the use of bed rails have been met.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive care plan (a written document...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive care plan (a written document that summarizes a patient's needs, goals, and care) for one of three sampled residents (Resident 77) by failing to develop a comprehensive care plan for use of Resident 77's bilateral bed siderails.
This deficient practice had the potential to result in a negative impact on residents' health and safety, as well as the quality of care and services received.
Findings:
A review of Resident 77's admission Record indicated the facility admitted the resident on 9/29/2023 with diagnosis including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), chronic diastolic (measures the pressure in your arteries when your heart rests between beats) congestive heart failure (CHF- a progressive condition that affects the pumping power of the heart muscle), and depression (a mood disorder that causes persistent feeling of sadness and loss of interest).
A review of Resident 77's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 1/2/2024, indicated Resident 77's cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired for daily decision-making and required moderate assistance from staff for activities of daily living (ADL- activities related to personal care).
During an observation on 2/23/2024 at 11:42 a.m., observed Resident 77 lying in bed with bilateral (both) bed siderails up.
A review of Resident 77's care plans from 9/29/2023 to 2/23/2024, indicated there was no comprehensive care plan developed for the use of bilateral bed siderails.
During a concurrent interview and record review on 2/24/2024 at 8:22 a.m., with Registered Nurse 1 (RN 1), reviewed Resident 77's care plans from 9/29/2023 to 2/23/2024. RN 1 confirmed by stating there was no comprehensive care plan developed for Resident 77's use of bilateral bed siderails. RN 1 stated Resident 77 was utilizing bed siderails for mobility and because he is at high risk for falls since admission on [DATE].
A review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, reviewed on 1/3/2024, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to renew and revise a resident's comprehensive care plan (a care plan is a form where you can summarize a person's health conditions, specific...
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Based on interview and record review, the facility failed to renew and revise a resident's comprehensive care plan (a care plan is a form where you can summarize a person's health conditions, specific care needs, and current treatments) for high risk for fall for one of two residents sampled residents (Resident 40) investigated under Care Planning.
This deficient practice resulted in Resident 40 not being evaluated if the desired outcome or care plan goals have been met or if the plan of care needs to be updated with new interventions to prevent a fall incident.
Findings:
A review of Resident 40's admission Record indicated the facility admitted the resident on 1/30/2020 with diagnoses that included respiratory failure (condition in which not enough oxygen passes from your lungs into your blood) and type two (2) diabetes mellitus (a chronic condition that affects the way the body processes blood glucose [sugar]).
A review of Resident 40's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/6/2024, indicated that the resident's cognitive (thought processes) skills for daily decision making was severely impaired and the resident was totally dependent on staff for eating, oral hygiene, toileting hygiene, shower, and personal hygiene.
During a concurrent interview and record review on 2/24/2024 at 3:02 p.m., with the Director of Staff Development (DSD), reviewed Resident 40's Care Plan titled, High Risk for Fall, initiated on 2/7/2020 with a target date of 2/13/2024. The DSD stated that care plans are evaluated quarterly and as needed to ensure that the current plan is acceptable to the resident and to determine if the care plan goals have been met or if the care plan interventions are no longer appropriate for the resident. The DSD stated that the purpose of the evaluation is to assess the resident's progress or if any decline has been noted so the facility can intervene timely to prevent a fall incident. The DSD stated that if care plans are not evaluated for its effectiveness, it could potentially result to an avoidable fall. The DSD stated that Resident 40's Care Plan titled, High Risk for Fall, was due for evaluation on 2/13/2023. The DSD stated that at this time there is no care plan for high risk for fall because the care plan for high risk for fall had a target date of 2/13/2024.
A review of the facility's policy and procedures titled, Care Plans, Comprehensive Person-Centered, last reviewed on 1/3/2024, indicated that the facility will develop and implement a comprehensive, person-centered- care plan for each resident .the interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the residents' care plan) reviews and updates the care plan, at least quarterly, in conjunction with the required quarterly MDS assessment.
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 an environment free from accidents and hazard...
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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 an environment free from accidents and hazards by failing to:
A. Ensure the electrical extension cord that was connected to an electrical outlet was secured to the wall for one of 21 sampled residents (Resident 9).
B. Ensure the electrical power strip (a length of electrical sockets attached to the end of a flexible cable that plugs into an electrical receptacle) was not wrapped around the bed siderail while attached to another power strip for one of 21 sampled residents (Resident 48).
These deficient practices had the potential to place Resident 9 and Resident 48 at increased risk of electrical accidents which could then result in injury.
Findings:
A. A review of Resident 9's admission Record indicated the resident was admitted to the facility on [DATE] with diagnosis including type II diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), cognitive communication deficit (difficulty with thinking and how someone uses language), and other psychotic disorder (a mental disorder characterized by a disconnection from reality) not due to a substance or known physiological (relating to the body and its systems) condition.
During a record review of Resident 9's Minimum Data Set (MDS - a comprehensive assessment and screening tool), dated 1/11/2024, the MDS indicated Resident 9's cognitive skill (mental action or process of acquiring knowledge and understanding) for daily decision-making were moderately impaired and that Resident 9 required moderate assistance from staff for activities of daily living (ADLs- toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear).
During an observation on 2/23/2024 at 11:07 a.m., observed Resident 9's room. Observed Resident 9 in bed with the resident's electrical extension cord not secured to the wall while connected to the electrical outlet.
During a concurrent observation and interview with Maintenance Director (MTD) on 2/24/2024 at 11:13 a.m., Resident 9's electrical extension cord was observed. MTD stated, the electrical extension cord in Resident 9's room was falling off as it was not properly attached to the wall. MTD stated, this can cause an electrical hazard and the cord needs to be properly mounted to the wall.
B. A review of Resident 48's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest) and anxiety disorder (a mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities).
During a record review of Resident 48's MDS dated [DATE], the MDS indicated Resident 48's cognitive skill for daily decision-making were intact and that the resident required moderate assistance from staff for ADLs.
During an observation on 2/23/2024 at 9:57 a.m., observed Resident 48's room. Observed Resident 48 in bed with eyes closed while the resident's electrical power strip was wrapped around the bed siderails while plugged into another power strip that was left hanging off the floor.
During a concurrent observation and interview with MTD on 2/23/2024 at 9:57 a.m., Resident 48's power strip was observed. MTD stated that Resident 48's power strip should not be plugged into another power strip because it can cause power to overload the circuit.
A review of the facility's policy and procedure (P&P) titled, Maintenance Service reviewed on 1/3/2024, indicated, the maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. The same P&P also indicated, functions of maintenance personnel include, but are not limited to: maintaining the building in good repair and free from hazards.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Staffing Information
(Tag F0732)
Could have caused harm · This affected 1 resident
Based on observation, interview and record review, the facility failed to post in a visible and prominent place the actual hours worked by licensed and unlicensed nursing staffing directly responsible...
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Based on observation, interview and record review, the facility failed to post in a visible and prominent place the actual hours worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift for two of three sampled days (2/23/2024 and 2/24/2024).
This deficient practice resulted in the actual staffing information not being readily accessible and available to residents and visitors and had the potential to cause inadequate staffing.
Findings:
During an observation on 2/23/2024 at 10:31 a.m., a projected, not an actual Direct Care Services Hours Per Patient Day (DHPPD) was observed posted at the receptionist area and on the counter of one of one nurse's station (Nursing Station 1).
During an observation on 2/24/2024 at 8:18 a.m., a projected, not an actual DHPPD was observed posted at the receptionist area and on the counter of Nursing Station 1.
During an interview with Director of Staff Development (DSD) on 2/24/2024 at 4:28 p.m., the DSD stated that the facility posting of the DHPPD include only projection hours and not the actual hours. DSD stated that he is unsure if the actual hours should be posted.
During a follow-up interview with DSD on 2/25/2024 at 2:57 p.m., DSD stated that he checked the facility's policy and procedure. The DSD stated that it is the actual DHPPD hours that should be posted.
A review of the facility's policy and procedure (P&P) titled, Posting Direct Care Daily Staffing Numbers reviewed on 1/3/2024, indicated that the facility will post on a daily basis for each shift the nurse staffing daily, including the number of nursing personnel responsible for providing direct care to residents . the information recorded on the form shall include the following: the actual time worked during that shift for each category and type of nursing staff.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR) was acted upon for one of six sampled residents (Resident 21) investigated under the care area o...
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Based on interview and record review, the facility failed to ensure the Medication Regimen Review (MRR) was acted upon for one of six sampled residents (Resident 21) investigated under the care area of unnecessary medications by failing to act upon the facility's consultant pharmacist's recommendation for Resident 21's Ambien (medication used to treat insomnia [sleep disorder that can make it hard to fall asleep or stay asleep] as needed order.
This deficient practice had the potential to cause adverse side effects from the continued use of these medications.
Findings:
A review of Resident 21's admission Record indicated the facility admitted the resident on 12/20/2023 with diagnoses including diabetes mellitus (DM-a chronic condition that affects the way the body processes blood glucose [sugar]), neuropathy (weakness, numbness, and pain from nerve damage usually in the hands and feet), and insomnia.
A review of Resident 21's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 12/26/2023, indicated Resident 21's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making was severely impaired and requiring moderate assistance from staff with activities of daily living (ADLs- activities related to personal care).
A review of Resident 21's Order Summary Report, dated 1/9/2024, indicated a physician order for Ambien five milligram (mg- a unit of measurement) by mouth as needed at night for insomnia.
A review of Resident 21's Progress Notes from 1/9/2024 to 2/25/2024, indicated no documentation of the duration of Ambien use by the prescriber.
During a concurrent interview and record review on 2/25/2024 at 2:29 p.m., with the Director of Nursing (DON), reviewed the facility's record, titled, Consultant Pharmacist's Medication Regimen Review, dated 1/1/2024 to 1/31/2024. The Consultant Pharmacist's Medication Regimen Review indicated a pharmacist's recommendation for Resident 21 to add a duration of therapy for Ambien use and if a duration longer than 14 days was needed, the prescriber must document the rationale for the use. The DON stated there was no duration order for the Ambien use and that there was no documentation that the prescriber was made aware of the pharmacist's recommendation. The DON also stated it was important to report the pharmacist recommendations and document the physician's response.
A review of the facility's policy and procedure titled, Consultant Pharmacist Report: Medication Regimen Review (Monthly Report), reviewed on 1/3/2024, indicated that the recommendations are acted upon and documented by the facility staff and or the prescriber.
A review of facility's policy and procedure titled, Psychotropic (medications capable of affecting the mind, emotions, and behavior) Medication Use, reviewed on 1/3/2024, indicated that for psychotropic PRN (as needed) medications, if the physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure a resident was monitored for complications that included signs and symptoms of bleeding and side effects related to anticoagulant (m...
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Based on interview and record review, the facility failed to ensure a resident was monitored for complications that included signs and symptoms of bleeding and side effects related to anticoagulant (medications that help prevent blood clots) use for one of two sampled residents (Resident 190) investigated under Unnecessary Medications.
This deficient practice placed the resident at risk for undetected bleeding which could lead to blood loss and hemorrhage (loss of blood from a damaged blood vessel).
Findings:
A review of Resident 190's admission Record indicated that the facility admitted the resident on 2/22/2024 with diagnoses that included acute respiratory failure (occurs when the lungs can't release enough oxygen into your blood) and pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid).
A review of Resident 190's History and Physical (a term used to describe a physician's examination of a patient) dated 2/18/2024, indicated that the resident is deaf and non-verbal.
A review of Resident 190's physician's orders dated 2/23/2024, included heparin sodium injection solution 5000 unit/milliliter (ml- a unit of measurement) inject one ml subcutaneously (administering medication where a short needle is used to inject a medication into the tissue layer between the skin and the muscle) every 8 hours for deep vein thrombosis (DVT- a medical condition that occurs when a blood clot forms in a deep vein).
During a concurrent interview and record review on 2/25/2024 at 11:46 a.m., with the Director of Staff Development (DSD), reviewed Resident 190's physician's order for heparin dated 2/23/2024. The DSD stated that for any order of an anticoagulant medication there should be monitoring for signs and symptoms of bleeding. The DSD stated there was no documented monitoring for signs and symptoms of bleeding following Resident 190's physician order for heparin. The DSD stated that the resident can have undetected bleeding if not monitored and could lead to blood loss which can result to death from hemorrhage.
A review of the facility`s policy and procedure titled Anticoagulation-Clinical Protocol, last reviewed on 01/03/2024, indicated that the staff and physician will monitor for possible complications in individuals who are being anticoagulated, and will manage related problems .if an individual on anticoagulation therapy shows signs of excessive bruising, hematuria (blood in urine), hemoptysis (spitting of blood), or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 48) reviewed for unne...
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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 six sampled residents (Resident 48) reviewed for unnecessary medications, was free from unnecessary psychotropic medications (medications capable of affecting the mind, emotions, and behavior) by failing to ensure Resident 48 was adequately monitored for the amount of hours of sleep for the use of Trazodone (medication used to treat depression [mood disorder that causes a persistent feeling of sadness and loss of interest]).
These deficient practices had the potential to place residents at risk of receiving unnecessary medications and/or overuse of medication and adverse consequences while using the medications.
Findings:
A review of Resident 48's admission Record indicated the facility originally admitted the resident on 4/13/2021 and readmitted on [DATE] with diagnosis including sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest), and anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations).
A review of Resident 48's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 1/3/2024, indicated Resident 48's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were intact and required moderate assistance from staff for activities of daily living (ADLs- activities related to personal care).
A review of Resident 48's Order Summary Report, dated 10/17/2023, indicated a physician order for the following:
- Trazodone oral tablet 100 milligram (mg- a unit of measurement) by mouth at bedtime for inability to sleep related to major depressive disorder.
- Monitor hours of sleep every evening and night shift.
A review of Resident 48's Care Plan for the use of antidepressant medication related to depression manifested by inability to sleep, initiated on 4/13/2021, indicated an intervention to give antidepressant medications ordered by physician and monitor/document side effects and effectiveness.
A review of Resident 48's Medication Administration Record (MAR) for the month of 2/2024, indicated to monitor hours of sleep every evening and night shift. Resident 48's MAR did not indicate the amount of hours of sleep Resident 48 slept for the evening and night shift from 2/1/2024 to 2/23/2024.
During a concurrent interview and record review on 2/25/2024 at 10:52 a.m., with the Director of Nursing (DON), reviewed Resident 48's MAR for the month of 2/2024. The DON stated there are no documentation of monitoring done by the licensed nurses on how many hours Resident 48 sleeps during evening and night shift from 2/1/2024 to 2/23/2024. The DON stated the licensed nurses should document the hours of sleep so that they know Resident 48's response to the medication.
A review of facility's policy and procedure titled, Psychotropic Medication Use, reviewed on 1/3/2024, indicated a psychotropic drug is any medication that affects brain activities associated with mental processed and behavior, which includes but is not limited to antipsychotics (medication used to treat psychosis [a mental condition in which thought and emotions are so affected that contact is lost with external reality]), anxiolytics (medication used to treat anxiety [intense, excessive, and persistent worry and fear about everyday situations]), hypnotics (medication that induces or prolongs sleep) and antidepressants. The policy and procedure also indicated, facility should monitor behavior triggers, episodes, and symptoms, facility should document the number and/or intensity of symptoms and the resident's response to staff interventions.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to maintain complete and accurate medical records in accordance with ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards and practices for two of nine sampled residents (Resident 24, and 58) by failing to ensure the resident's Coronavirus Disease 2019 (COVID-19)- a deadly respiratory disease transmitted from person to person) and influenza (Flu-common viral infection that can be deadly, especially in high-risk groups) vaccination (A preparation that is used to stimulate the body's immune response against diseases) consents (the legal approval that a resident gives to a physician regarding health care decisions) contained the residents name.
This deficient practice had the potential to result in confusion regarding Resident 24 and Resident 58's condition and what care and services were provided to the residents.
Findings:
1. A review of Resident 24's admission Record indicated Resident 24 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including metabolic encephalopathy ( brain disease, damage, or malfunction usually related to inflammation within the body) and dysphagia (difficulty swallowing food or liquid).
A review of Resident 24's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 10/22/2023, indicated Resident 24's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making was severely impaired and that the resident required moderate assistance from staff with activities of daily living (ADLs- eating, toileting hygiene, shower/bathe self, upper and lower body dressing, and personal hygiene).
A review of Resident 24's COVID-19 immunization consent, dated 1/23/2024, consent form indicated that Resident 24's name was missing from the documentation.
During a concurrent record review and interview with the Infection Preventionist (IPN) on 2/25/2024 at 8:52 a.m., reviewed Resident 24's COVID-19 vaccination consent form date 1/23/2024. IPN stated after reviewing Resident 24's COVID-19 vaccination consent form that Resident 24's name was missing from the form. IPN stated that it is important to properly document the resident's name on every consent form.
During an interview with the Director of Nursing (DON) on 2/25/2024 at 9:19 a.m., DON stated that all consents should have the resident's name written on them.
2. A review of Resident 58's admission Record indicated Resident 58 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including metabolic encephalopathy, sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) and COVID-19.
A review of Resident 58's MDS, dated [DATE], indicated Resident 58's cognitive skills for daily decision-making were severely impaired and required moderate assistance from staff with ADLs.
A review of Resident 58's Flu vaccination consent form, dated 1/12/2024, consent form indicated that Resident 58's name was missing from the documentation.
During a concurrent record review and interview with IPN on 2/25/2024 at 8:52 a.m., reviewed Resident 58's flu vaccination consent form date 1/12/2024. IPN stated after reviewing Resident 58's flu vaccination consent form that Resident 58's name was missing from the form. IPN stated that it is important to properly document the resident's name on every consent form.
During an interview with the Director of Nursing (DON) on 2/25/2024 at 9:19 a.m., DON stated that all consents should have the resident's name written on them.
A review of facility's policy and procedure (P&P), titled, Charting and Documentation, reviewed on 1/3/2024, indicated that documentation in the medical record will be complete and accurate.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
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 maintain an infection control measure and prevention b...
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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 maintain an infection control measure and prevention by failing to ensure there was a personal protective equipment (PPE- specialized clothing or equipment worn by an employee for protection against infectious materials) cart outside of a resident's room and ensure staff wear full personal protective equipment (PPE- specialized clothing or equipment worn by an employee for protection against infectious materials) before entering and providing care to one of nine sampled residents (Resident 64) who had an order for enhanced standard precaution (an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that have become resistant to certain antibiotics] in nursing homes).
This deficient practice had the potential to result in the spread of disease and infection to residents, staffs, and visitors.
Findings:
A review of Resident 64's admission Record indicated the facility originally admitted the resident on 10/17/2022 and readmitted on [DATE] with diagnoses including type two (2) diabetes mellitus (DM-a chronic condition that affects the way the body processes blood glucose [sugar]), acute respiratory failure (condition in which your blood does not get enough oxygen), and urinary tract infection (UTI- an infection in any part of the urinary system).
A review of Resident 64's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 1/19/2024, indicated Resident 64's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were severely impaired and required total dependent from staff for activities of daily livings (ADLs- activities related to personal care).
A review of Resident 64's Order Summary Report dated 1/5/2024 indicated, enhanced standard precautions for gastrostomy tube (g-tube - a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration).
A review of Resident 64's Care Plan for enhanced standard precautions, initiated on 1/5/2024, indicated a goal of the resident will not develop a multi-drug resistant organism related infection with interventions including, provide gowns and gloves at door entry and use gown and gloves during high contact resident care activities.
During an observation on 2/23/2024 at 10:31 a.m., of Resident 48, observed Resident 48's room with no PPE cart outside Resident 48's room (door entry).
During a concurrent observation and interview on 2/24/2024 at 9:39 a.m., with Restorative Nursing Assistant 2 (RNA 2) and Certified Nursing Assistant 2 (CNA 2), observed RNA 2 and CNA 2 inside Resident 48's room about to provide morning ADL care to Resident 48. Observed CNA 2 wearing complete PPE (gowns, gloves, face protection, and mask) while RNA 2 was not wearing any gown and gloves. RNA 2 stated he should also be wearing full PPE since they are providing care and are in close contact with Resident 48. RNA 2 was observed grabbing a gown from a closet inside Resident 48's room.
During an interview on 2/24/2024 at 9:47 a.m., with Registered Nurse 1 (RN 1), RN 1 stated staff should don (put on) complete PPE before they enter an enhanced precaution room if they will be providing care to the residents.
During an interview on 2/25/2024 at 1:41 p.m., with the Infection Preventionist (IP), the IP stated staff should wear full PPE before they provide care to residents who are on enhanced standard precaution, if not, it puts others at risk of transferring bacteria or infections to others.
A review of the facility's policy and procedure titled, Enhanced Standard/Barrier Precautions, reviewed on 1/3/2024, indicated enhanced standard/barrier precautions employ targeted gown and glove use during high contact resident care activities, gloves and gown are applied prior to performing the high contact resident care activity . examples of high-contact resident care activities requiring the use of gown and gloves include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting. The policy also indicated PPE is available outside of the resident rooms.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' medical records were updated to indicate that adv...
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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 residents' medical records were updated to indicate that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information were provided to the residents and/or responsible parties for three of nine sampled residents (Resident 24, 53 and 67).
This deficient practice violated the residents' and/or the representatives' right to be fully informed of the option to formulate advanced directives and had the potential to cause conflict with health care wishes for Resident 24, 53 and 67.
Findings:
a. A review of Resident 53's admission Record indicated the facility originally admitted the resident on 10/16/2021 and readmitted on [DATE] with diagnoses including metabolic encephalopathy (a chemical imbalance in the blood affecting the brain), sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), and dysphagia (difficulty swallowing food or liquid).
A review of Resident 53's Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 1/30/2024, indicated Resident 53's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were severely impaired.
A review of Resident 53's Advance Healthcare Directive (AHCD) Acknowledgement form, dated 10/29/2023 indicated the resident did not have an advance directive.
During a concurrent interview and record review on 2/24/2024 at 3:37 p.m., with the Social Services Director (SSD), reviewed Resident 53's AHCD Acknowledgment form and medical record in regards to advance directive documentation. The SSD confirmed by stating there was no documentation that the facility informed and explained the AHCD Acknowledgment form to Resident 53 and/or the resident's responsible party when the responsible party specified that Resident 53 did not have an AHCD on 10/29/2023. The SSD stated the AHCD Acknowledgment form is important so that they will know what the resident and/or the resident's representative wishes are during a medical emergency.
b. A review of Resident 67's admission Record indicated the facility admitted the resident to on 8/9/2023 with diagnoses including cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue), type two (2) diabetes mellitus (DM-a chronic condition that affects the way the body processes blood glucose [sugar]), and dysphagia.
A review of Resident 67's MDS dated [DATE], indicated Resident 67's cognitive skills for daily decision-making were severely impaired.
A review of Resident 67's AHCD Acknowledgement form, dated 8/17/2023 indicated Resident 67's responsible party indicated Resident 67 did not have an AHCD.
During a concurrent interview and record review on 2/24/2024 at 3:42 p.m., with the SSD, reviewed Resident 67's AHCD Acknowledgement form and medical record in regards to advance directive documentation. The SSD confirmed by stating there was no documentation if the facility informed and explained the AHCD Acknowledgement form to Resident 67 and/or the resident's responsible party when the responsible party specified Resident 67 did not have an AHCD on 8/17/2023. The SSD stated the AHCD Acknowledgement form is important so that they will know what resident and/or resident's representative wishes are during a medical emergency.
c. A review of Resident 24's admission Record indicated the facility originally admitted the resident on 10/19/2023 and was readmitted on [DATE] with diagnoses including metabolic encephalopathy, dysphagia, and abnormal posture.
A review of Resident 24's MDS dated [DATE], indicated Resident 24's cognitive skills for daily decision-making was severely impaired and required moderate assistance from staff with activities of daily living (ADLs- eating, toileting hygiene, shower/bathe self, upper and lower body dressing, and personal hygiene). MDS also indicated Resident 24 did not have an advance directive.
A review of Resident 24's AHCD Acknowledgement form, dated 1/20/2024 indicated Resident 24's representative specified Resident 24 did not have an AHCD.
During a concurrent interview and record review on 2/24/2024 at 3:37 p.m., with the SSD, reviewed Resident 24's AHCD Acknowledgement form and medical records in regards to advance directive documentation. The SSD stated that the AHCD Acknowledgement form was not updated and stated there was no documentation indicating Resident 24 and/or their representative was given information regarding advance directives. The SSD stated she should have followed up with the resident and/or their representative. The SSD stated the facility should give information to the resident and/or the resident's representative regarding advance directives if they do not have one.
A review of the facility's policy and procedure titled, Advance Directive, reviewed on 1/3/2024, indicated the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to:
1. Ensure blood glucose (the amount of sugar in the blood) monito...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to:
1. Ensure blood glucose (the amount of sugar in the blood) monitoring (measure and display the amount of sugar in your blood) was done as per the physician orders for one of two sampled residents (Resident 46).
2. Ensure that one of three sampled residents (Resident 64) was provided with bilateral (both sides) upper bed side rails as ordered by the physician.
These deficient practice resulted to inappropriate management of Resident 46`s type 2 diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) which could potentially result to hypoglycemia (blood sugar level goes below the standard range) and hyperglycemia (high blood sugar) episodes which could lead to complications such as a condition called diabetic ketoacidosis (diabetic coma) and even death; and resulted in the failure to deliver the necessary care and services for Resident 64.
Findings:
1. A review of Resident 46`s admission Record indicated that the facility originally admitted the resident on 02/22/2022 and readmitted Resident 46 on 08/22/2023 with diagnoses that included type II diabetes mellitus and end-stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis).
A review of Resident 46's Minimum Data Set (MDS- a standardized assessment and screening tool), dated 02/05/2024, indicated the resident's cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision making was moderately impaired. The MDS indicated Resident 46 required moderate assistance for shower, upper body and lower body dressing, and maximal assistance for toileting.
A review of Resident 46`s physician`s orders dated 11/21/2023, indicated an order for Novolog ( a rapid-acting insulin that helps lower mealtime blood sugar increases) Subcutaneous (under the skin) Solution 100 Unit per Milliliter (U/ml- unit of measure), inject per sliding scale (a predetermined set amount of insulin that is given based on the level of blood glucose)two times a day at 6:30 a.m. and 5:00 p.m.
During a concurrent interview and record review on 202/25/2024 at 11:08 a.m. with Registered Nurse 1 (RN1), reviewed Resident 46`s Medication Administration Record (MAR- a report detailing the medications administered to a resident by a healthcare professional) for January 2024 was reviewed. RN 1 stated after reviewing Resident 46's MAR for January 2024 that there was no documentation to indicate that Resident 46's blood sugar levels were checked on the following dates as per the physician order:
1. 1/6/2024 at 6:30 a.m.
2. 1/7/2024 at 6:30 a.m.
3. 1/13/2024 at 6:30 a.m.
4. 1/20/2024 at 6:30 a.m.
5. 1/27/2024 at 6:30 a.m.
RN1 stated a resident could potentially develop undetected complications of hypoglycemia and hyperglycemia if blood glucose levels are not monitored and if insulin is not administered needed. RN1 stated that complication of hypoglycemia and hyperglycemia increase the risk for a resident to experience diabetic ketoacidosis.
A review of the facility`s policy and procedure titled Insulin Administration, last reviewed on 01/03/2024, indicated for the facility to provide guidelines for the safe administration of insulin to residents with diabetes .document the resident`s blood glucose result, as ordered, the dose and concentration of the insulin injection .notify supervisor if the resident refuses the insulin injection .
2. A review of Resident 64's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type II diabetes mellitus, acute respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide) and urinary tract infection (UTI- an infection in any part of the urinary system, including the kidney, bladder, or urethra).
A review of Resident 64's MDS dated [DATE], indicated Resident 64's cognitive skills for daily decision-making were severely impaired and that the resident was total dependent on staff for activities of daily livings (ADLs- eating, toileting hygiene, shower/bathing, upper and lower body dressing, and personal hygiene).
A review of Resident 64's Order Summary Report dated 1/3/2023 indicated, bilateral upper bed side rails up while in bed as enabler for mobility and positioning.
During an observation on 2/23/2024 at 10:34 a.m., observed Resident 64's room. Observed Resident 64 with eyes closed, lying on a bed with no bilateral upper siderails attached to the bed.
During a concurrent observation, interview, and record review with Registered Nurse 1 (RN 1) on 2/24/2024 at 9:39 a.m., RN 1 reviewed Resident 64's physician order dated 1/3/2023 for bilateral upper bed side rails. RN 1 observed Resident 64's bed and confirmed by stating that there is no bilateral upper bed siderails attached to the resident's bed. RN 1 further stated, they are not following physician's order and that they will inform the maintenance staff install the bed side rails per physician's order.
A review of the facility's policy and procedures titled, Bed Safety and Bed Rails reviewed on 1/3/2024, indicated, maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks . bed rails are properly installed and used according to the manufacturer's instructions, specifications, and other pertinent safety guidance to ensure proper fit.
Sept 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident ' s call light (a device used by a r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident ' s call light (a device used by a resident to signal his or her need for assistance from healthcare workers) was within reach for two of six sampled residents (Resident 2 and 3).
This deficient practice had a potential for the residents not able to call for assistance needed.
Findings:
A review of the Resident 2 ' s admission Record indicated the facility admitted the resident on 3/16/2022, with diagnoses including sepsis (body ' s overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure and death), diabetes mellitus (a disease that occurs when the body is unable to regulate the amount of glucose [sugar] in the blood) and hypertension (high blood pressure).
During a review of Resident 2 ' s Minimum Data Set et (MDS- a standardized assessment and screening tool) dated 9/20/2023, indicated the resident ' s cognition (ability to think, understand and reason) was severely impaired. The MDS indicated Resident 2 required total dependence from staff with transfer, dressing and toilet use. MDS also indicated that resident was incontinence with bowel and bladder.
During a concurrent observation and interview on 9/27/2023 at 8:54 a.m. with Certified Nursing Assistant 2 (CNA 2) of Resident 2 ' s room Resident 2's call light was observed hanging off the back of the resident ' s headboard. Observed CNA 2 immediately take the call light from the back of Resident 2 ' s headboard and placed the call light next to Resident 2 ' s hand. CNA 2 stated that Resident 2 ' s call light was not accessible to the resident.
A review of the Resident 3 ' s admission Record indicated the facility originally admitted the resident on 8/16/2021 and was readmitted on [DATE] with diagnoses including acute cholecystitis (gallbladder inflammation), depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and epilepsy (a disorder in which never cell activity in the brain is disturbed, causing seizures [involuntary movement]).
During a concurrent observation and interview on 9/27/2023 at 8:52 a.m. with CNA 2 of Resident 3 ' s room, Resident 3 ' s call light was observed on the floor. Observed CNA 2 then immediately pick up Resident 3 ' s call light from the floor and placed the call light next to Resident 3 ' s hand. CNA 2 stated that the call light was on the floor and was not accessible to Resident 3.
During an interview on 9/27/2023 at 8:54 a.m. with CNA 2, CNA 2 stated that all call light should always be accessible to the resident in case they needed something.
During an interview on 9/27/2023 at 10:24 a.m. with Director of Staff Development (DSD), DSD stated that a resident ' s call light should always be accessible to the resident. DSD stated that staff should always be checking on residents to ensure that their call light is within reach.
During a review of facility ' s policy and procedure titled Answering the call light reviewed date of 1/3/2023, indicated, that when the resident is in bed or confined to a chair, facility staff is to make sure the call light is within easy reach of the residents.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a person-centered care plan (a plan for an in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a person-centered care plan (a plan for an individual's specific health needs and desired health outcomes) for one of three sampled residents (Resident 1) by:
1.failing to develop a comprehensive care plan for Resident 1's incontinence (inability to control both bowel and bladder).
2. failing to ensure Resident 1's care plan for pain medication therapy included the reason the resident was on pain medication therapy.
These deficient practices had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services.
Findings:
1. A review of Resident 1 ' s admission record indicated the facility admitted the resident on 9/7/2023 with diagnoses including Coronavirus disease -2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection), fall and spinal stenosis (a narrowing of the spinal canal in the lower part of your back).
A review of Resident 1 ' s Minimum Data Set (MDS-a standardized assessment and screening tool) dated 9/13/2023 indicated Resident 1 had intact cognition (ability to think, understand and reason). The MDS further indicated that Resident 1 needed extensive assistance with the staff for bed mobility, transfer, dressing, and toilet use. The MDS indicated that Resident 1 was incontinence for both bowel and bladder.
During an interview on 9/27/2023 at 11:05 a.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated that Resident 1 was incontinence with bowel and bladder. CNA 1 stated that Resident 1 needed frequent perineal care (involves cleaning the private area, including the genital and rectal area of the body) because she urinates a lot.
During a concurrent interview and record review on 9/27/2023 at 12:27 p.m. with Director of Staff Development (DSD), Resident 1 ' s MDS dated [DATE] and Resident 1 ' s care plans from 9/7/2023 to 9/27/2023 were reviewed. DSD stated that Resident 1 was incontinence with both bowel and bladder. DSD stated that Resident 1 did not have a care plan for incontinence. DSD stated that Resident 1 should have had a care plan for incontinence created because a resident ' s care plan can tell facility staff how to help the resident based on the preference and history.
A review of the facility ' s policy and procedure titled Goals and Objectives, Care Plans reviewed on 1/3/2023; the policy indicated that care plans shall incorporate goals and objectives that lead to the resident ' s highest obtainable level of independence.
The policy further indicated that care plan goals and objectives are derived from information contained in the resident ' s comprehensive assessment and are resident oriented, behaviorally stated, are measurable and contain timetables to meet the resident ' s needs in accordance with the comprehensive assessment.
2. A review of Resident 1 ' s care plan dated 9/8/2023, indicated resident is on pain medication therapy. The portion where in it asks what the pain medication therapy is related to was left undocumented.
During a concurrent interview and record review on 9/27/2023 at 3:42 p.m. with the DSD, Resident 1 ' s care plan for pain medication therapy dated 9/8/2023 was reviewed. DSD stated that Resident 1 ' s care plan for pain medication therapy was not individualized and not resident center because the reason why Resident 1 was on pain medication therapy was left blank (not documented). DSD stated that a individualized care plan for pain should include the resident ' s medical history.
During a review of the facility ' s policy and procedure titled Goals and Objectives, Care Plans reviewed on 1/3/2023, the policy indicated that care plans shall incorporate goals and objectives that lead to the resident ' s highest obtainable level of independence. The policy further indicated that care plan goals and objectives are defined as the desired outcome for a specific resident problem.
Sept 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
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 a homelike environment was provided by:
1. Fail...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a homelike environment was provided by:
1. Failing to ensure that the window screen was not torn and had no cobwebs (a web spun by spiders) accumulating on the screen for one out three residents (Resident 2) investigated for clean and homelike environment.
2. Failing to ensure that room [ROOM NUMBER] and room [ROOM NUMBER] of the facility did not have torn window screens.
3. Failing to ensure that Rooms 1,2,3,4 and 5 did not have missing vertical window blind louvers (slats- a type of window covering).
These deficient practices violated the residents ' rights to a safe, clean, comfortable, sanitary, and homelike environment.
Findings:
1. A review of Resident 2 ' s admission Record (face sheet) indicated the resident was admitted to the facility on [DATE] with diagnoses that included difficulty in walking and hypertension (high blood pressure).
A review of Resident 2's Minimum Data Set (MDS- a standardized assessment and screening tool), dated 06/26/2023, indicated the resident's cognitive skills (cognition refers to conscious mental activities, and include thinking, reasoning, understanding, learning, and remembering) for daily decision making was intact. The MDS indicated Resident 2 required extensive assistance from staff for bed mobility, dressing, personal hygiene, bathing; and total dependence on staff for eating and toilet use.
During a concurrent observation and interview with Resident 2 on 9/25 at 3:29 p.m., observed Resident 2 inside her room. Observe Resident 2 then point to a tear in her window screen with cobwebs. Resident 2 stated that she likes her room to be clean and added that if she could have gotten rid of the cobwebs herself, she would. Resident 2 stated she was unable to get rid of the cobwebs because she is unable to walk. Resident 2 stated that it ' s not a homelike environment to have the cobwebs in the window screen. Resident 2 stated that the cobwebs on her window screen have been there for a long time.
During a concurrent observation on 9/25/2023 at 4:44 p.m. with the Infection Preventionist (IPN), Resident 2 ' s room was observed. IPN stated the gaps from the tears in Resident 2`s window screen can be an entry point for insects. IPN stated that Resident 2 ' s window screen should be cleaned to remove the cobwebs. IPN stated that the facility, including the resident`s rooms should be made into a homelike and the appearance of a clean environment in the facility will promote dignity for the residents. IPN stated it is not dignified for anyone to live in an unsanitary environment.
2. During a concurrent observation and interview on 9/25/2023 at 11:45 a.m., with Maintenance Supervisor (MS), Rooms 6 and room [ROOM NUMBER] were observed. Observed in room [ROOM NUMBER] and room [ROOM NUMBER] were torn window screens . MS stated that he will fix the torn window screens because it is not a homelike environment for the residents.
3. During a concurrent continuing observation and interview on 9/25/2023 at 11:45 a.m., with MS, Rooms 1,2,3,4 and 5 were observed. Observed inside the rooms were multiple vertical louver blinds missing from the window blinds. The MS stated that he would replace the missing vertical louver blinds because it is not a homelike environment for the residents.
During an interview on 9/26/23 at 1:30 p.m. with the Director of Nursing (DON), DON stated that the facility is the residents ' home and its very important that the facility is maintained. DON stated that the maintenance department should ensure that the residents ' rooms are homelike by fixing the screens for any tears and cleaning the screens to not allow accumulation of cobwebs. According to the DON, the physical environment of the resident must be homelike since they live at the facility.
A review of the facility`s policy and procedure titled Quality of Life- Homelike Environment, last reviewed on 1/3/2023, indicated that residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: cleanliness and order .
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on interview and record review, the facility failed to implement infection control practices by:
1. Failing to ensure one used commode (a type of chair with an opening to a large pot used by res...
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Based on interview and record review, the facility failed to implement infection control practices by:
1. Failing to ensure one used commode (a type of chair with an opening to a large pot used by residents as a toilet) containing soaked toilet papers with yellow substances were not left in the courtyard of the facility that is used by residents during smoking breaks and leisure time.
2. Ensure 13 empty trash bins and liners (plastic bags) used for disposal of Coronavirus disease -2019 (COVID-19, a highly contagious viral infection that can trigger respiratory tract infection) waste were not scattered in the vacant spaces between resident ' s room windows and the facility ' s fence.
These deficient practices had the potential to spread infection and cross contamination (the physical movement or transfer of harmful bacteria [germs] from one person, object, or place to another) among staff and other residents.
Findings:
1. During a concurrent observation and interview on 9/25/2023 at 11:45 a.m., with Maintenance Supervisor (MS), the facility ' s courtyard was observed. MS stated that he supervises both the maintenance department and the housekeeping department. During an observation of the courtyard along with the MS, observed a commode with a lid, and upon lifting the lid, the commode contained several soaked toilet papers with yellow liquid and yellow substances on the toilet paper. The MS stated that C1 is used by the residents` for smoke breaks and to socialize. MS stated that C1 is not a clean environment for residents to use in this situation where a dirty chair commode.
During an interview on 9/25/2023 at 4:44 p.m. with the Infection Preventionist (IPN) , the IPN stated that a commode should be cleaned before and after each use. The IPN stated that leaving a commode outside is an infection control issue because there is a chance of contamination and can be a source of infection.
During an interview on 9/26/2023 at 1:30 p.m. with the Director of Nursing (DON), DON stated that it is very important to keep the facility clean. DON stated that it is unsanitary and not safe for residents to leave commodes out that contain human waste.
A review of the facility ' s policy and procedure titled Blood or Body Fluids Exposure last reviewed on 7/2016 indicates that all blood or body fluids should be considered potentially infectious at all times.
2. During a concurrent observation and interview on 9/25/2023 at 11:45 a.m., with Maintenance Supervisor (MS), observed a total of 13 empty trash bins and plastic liners scattered throughout the vacant spaces between resident ' s windows and along the facility fence. MS stated that the trash bins and plastic liners will be removed because it is not sanity for the residents to have trash bins and trash liners alongside their room windows.
During an interview on 9/26/2023 at 1:30 p.m. with the DON, DON stated that it is very important to keep the facility clean. DON stated that the trash bins found alongside the facility fence are utilized during COVID-19 outbreaks, DON stated that the trash bins and liners should be organized in storage and not scatter outside as it is unsanitary.
A review of the facility ' s policy and procedure titled Infection Prevention and Control, undated, indicates that it is the policy of the facility to protect their residents, staff and others who may be in the facility from harm during emergency events. The policy further indicates that the facility has developed procedures for infection prevention and control to manage a COVID-19 outbreak. The policy indicates that the facility will ensure that waste from COVID unit is disposed via biohazard waste management.
Aug 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to develop and implement a baseline person-centered care plan for one of three sampled residents (Resident 6) that was identified to have been...
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Based on interview and record review, the facility failed to develop and implement a baseline person-centered care plan for one of three sampled residents (Resident 6) that was identified to have been assessed with discolorations and edema (swelling caused by too much fluid trapped in the body's tissues) upon admission.
This deficient practice had the potential to negatively affect the delivery of care and services to Resident 1.
Findings:
A review of Resident 6's admission Record indicated the facility admitted the resident on 7/25/2023, with diagnoses that included sepsis (a life-threatening complication of an infection), unspecified organism, pneumonia (an infection that affects one or both lungs), and unspecified fall.
A review of Resident 6's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated 7/27/2023 indicated Resident 6's cognition (relating to the process of acquiring knowledge and understanding) was moderately impaired. The MDS indicated Resident 6 was totally dependent on staff with bed mobility, transfer, and toilet use.
A review of Resident 6's admission Data Tool dated 7/25/2023, indicated under skin review: bilateral (both) upper extremities (BUE) discolorations, bilateral lower extremities (BLE) discolorations, and general body edema anasarca (general swelling throughout the body).
During an interview and concurrent record review on 8/10/2023 at 9:00 a.m., with Licensed Vocational Nurse 2 (LVN 2), reviewed Resident 6's care plans. LVN 2 stated that baseline care plans are done right away, upon admission. LVN 2 stated that any issues that the resident is admitted with should have a care plan. LVN 2 continued to state that care plans are documented with focused issues, have a goal, and have interventions to achieve that goal. LVN 2 stated there was no documented evidence that Resident 6 had baseline care plans for their documented BUE discolorations, BLE discolorations, and general body edema anasarca. LVN 2 stated that care plans are important because it will assist staff on how to care for Resident 6. LVN 2 further stated that care plans should have been developed so facility staff can implement interventions related to Resident 6's BUE discolorations, BLE discolorations, and general body edema anasarca to help resolve them.
During a concurrent interview and record review on 8/10/2023 at 12:22 p.m., with the Director of Nursing (DON), reviewed Resident 6's care plans. The DON stated that Resident 6's baseline care plans for BUE discolorations, BLE discolorations, and general body edema anasarca were missed and should have been done once identified.
A review of the facility-provided policy and procedure titled Care Plan- Baseline, revised 12/2016, indicated a baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. To assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within fort-eight (48) hours of the resident's admission .The baseline care plan will be used until the staff can conduct the comprehensive assessment and develop an interdisciplinary person-centered care plan.
Jun 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program by Housekeeping 1 (HK 1) not performing hand hygiene (HH - cleaning hand...
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Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program by Housekeeping 1 (HK 1) not performing hand hygiene (HH - cleaning hands by washing with soap and water or using an alcohol-based hand sanitizer) after handling a used mopping cloth and before touching a janitorial cart and other objects.
This deficient practice had the potential to result in cross contamination and spread of infections to staff and residents.
Findings:
On 6/6/2023, at 11:50 a.m., during a concurrent observation and interview, in the hallway and after mopping a resident ' s room, HK 1 removed the used mopping cloth with her bare hands, and she discarded it to the vinyl bag attached to the janitorial cart. After getting her hands contaminated with the mop, HK 1 did not perform HH and moved a wet floor sign from outside a resident ' s room and placed it outside another residents ' room at the doorway. HK 1 proceeded to open the janitorial cart with a key without and organized disinfectant bottles, and then moved the janitorial cart and left the area. When HK 1 was asked what she supposed to do after discarding the used mopping cloth with her bare hands, HK 1 stated that she just touched the edge of the used mopping cloth so that she did not need to perform HH at that moment.
On 6/6/2023, at 11:55 a.m., during an interview with the Inspection Preventionist (IP) in the presence of HK 1, HK 1 insisted she did not need to perform HH after discarding the used mopping cloth because she touched just the edge. The IP told HK 1 she was to perform HH right after discarding the contaminated mop.
A review of the facility ' s revised April 2012 policy and procedures titled, Infection Control - Standard Precautions: Handwashing/Hand Hygiene indicated, This facility considers hand hygiene the primary means to prevent the spread of infections All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors Employees must wash their hands for at least fifteen seconds using antimicrobial or non-antimicrobial soap and water under the following conditions After handling soiled equipment or utensils.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected 1 resident
Based on observation, interview, and record review, the facility failed to remain free of pests by not ensuring an effective pest control for one of three sampled residents ' rooms (Resident 1 ' s roo...
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Based on observation, interview, and record review, the facility failed to remain free of pests by not ensuring an effective pest control for one of three sampled residents ' rooms (Resident 1 ' s room). Two live cockroaches (small insects that carry and spread infectious diseases) and 10 dead cockroaches were found inside Resident 1 ' s room
This deficient practice placed the residents at risk vector-borne diseases (diseases that result from an infection transmitted to human by insects such as cockroaches).
Findings:
A review of Resident 1's admission Record indicated the facility admitted the resident on 1/28/2023 with diagnoses including chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems).
A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 5/4/2023 indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) status was independent, and Resident 1 needed extensive assistance from staff for activities of daily living (ADL - bed mobility, transfer, dressing, toilet use, and personal hygiene).
On 6/6/2023, at 1:05 p.m., during a concurrent observation inside Resident 1 ' s room; and interview with Resident 1, the Maintenance Supervisor (MS), and the Director of Nursing (DON), Resident 1 stated that he has previously seen cockroaches on the floor at his bedside. Resident 1 stated that he informed MS on 6/5/2023. When the surveyor checked the floor between Resident 1 ' s headboard and the nightstand table, three dead cockroaches were found on the floor. When MS moved Resident 1 ' s nightstand table, observed four additional dead cockroaches and two live cockroaches on the floor. The MS confirmed the observation and stated that a total of seven dead cockroaches and two live cockroaches were found inside Resident 1 ' s room. MS stated that he had provided pest control treatment to Resident 1 ' s room on 6/5/2023 when he observed one cockroach. MS stated that he had not yet contact the pest control company. The Director of Nursing (DON) stated that there were three more dead cockroaches on the corner of the floor when Resident 1 ' s roommate ' s (Resident 2) nightstand table was moved.
On 6/6/2023, at 4:55 p.m., during an interview with the DON, the DON stated that she observed two live cockroaches and a total of 10 dead cockroaches inside the room of Resident 1. DON stated that cockroaches are dirt and can carry germs which can then negatively affect the health of residents.
A review of the facility ' s policy and procedures titled, Pest Control, revised in August 2008 indicated, Our facility shall maintain an effective pest control program. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.
Nov 2022
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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to develop a comprehensive, person-centered care plan with measurable objectives and interventions for one of four sampled residents (Resident...
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Based on interview and record review, the facility failed to develop a comprehensive, person-centered care plan with measurable objectives and interventions for one of four sampled residents (Resident 1) to prevent pressure ulcer (PU, damage to an area of the skin caused by constant pressure on the area for a long time). Resident 1 ' s care plan did not address in the interventions to reposition the resident and the frequency Resident 1 needed repositioning.
This deficient practice resulted in Resident 1 developing a Stage I (intact skin with a localized area of non-blanchable redness) PU on the left buttock and was at risk for the PU to worsen.
Cross reference to F686 and F842
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 10/14/2022, with diagnoses including cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), wedge compression fracture (the front of the spinal column collapses but the back does not, forming a wedge shape), and muscle weakness (a full effort does not produce a normal muscle contraction or movement).
A review of Resident 1 ' s History and Physical exam, dated 10/16/2022, indicated the resident had the capacity to understand and make decisions.
A review of the Resident 1 ' s Braden Scale (a tool used to predict PU risk), dated 10/17/2022, indicated the resident was at risk for developing PU.
A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 10/20/2022, indicated the resident ' s cognition (mental action or process of acquiring knowledge and understanding) was intact (not affected), needed extensive assistance from staff on most areas of activities of daily living (ADLs – dressing, moving/turning in bed, transfer from and to bed, personal hygiene, toilet use, and bathing). Resident 1 was assessed at risk for PU development.
A review of Resident 1 ' s Care Plan initiated on 10/17/2022 indicated Resident 1 was at risk of developing unavoidable PU related to diagnoses. The interventions did not include repositioning and its frequency.
A review of Resident 1 ' s nursing Progress Notes, dated 10/31/2022, indicated the resident developed a left buttock PU Stage I and the physician was notified.
A review of Resident 1 ' s of certified nursing assistants (CNAs) Documentation Survey Report v2 for 10/2022 (to document assistance provided with the ADLs per shift) indicated bed mobility was provided every shift. The documentation did not indicate how often Resident 1 was repositioned.
A review of Resident 1 ' s nursing Progress Notes, dated 11/8/2022, indicated the resident was transferred to an acute hospital.
On 11/15/2022 at 11:23 a.m., an interview and concurrent review of Resident 1 ' s clinical record was conducted with the Director of Nursing (DON). The DON stated Resident 1 needed to be repositioned in bed at least every two hours and this should have been included in the plan of care and documented in ADLs form under bed mobility. The DON was unable to find any documentation Resident 1 was repositioned every two hours.
A review of the facility ' s policy and procedure titled, Comprehensive Assessment and the Care Delivery Process, revised on 12/2016, indicated a comprehensive assessment will be conducted to assist in developing person-centered care plans. Comprehensive assessments, care planning and care delivery process involve collecting and analyzing information, choosing, and initiating interventions, and then monitoring results and adjusting interventions.
A review of the facility ' s policy and procedures titled, Prevention of Pressure Ulcers/Injuries last reviewed on 7/2017, indicated the purpose of the procedure was to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Inspect the skin on a daily basis when performing or assisting with personal care or Activities of Daily Living (ADL). At least every two hours, reposition residents who are reclining and dependent on staff for repositioning, reposition more frequently as needed, based on the condition of the skin and the resident ' s comfort, and evaluate, report and document potential changes in the skin.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure one of four sampled residents , (Resident 1), who was at risk for pressure ulcers (PU, also known as pressure sores, pressure injuri...
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Based on interview and record review, the facility failed to ensure one of four sampled residents , (Resident 1), who was at risk for pressure ulcers (PU, also known as pressure sores, pressure injuries or bedsores, are injuries to skin and underlying tissue resulting from prolonged pressure on the skin), received care and services to prevent the development of PU. There was no evidence Resident 1 was repositioned every two hours as per policy. Resident 1's plan of care did not include repositioning and its frequency as intervention to prevent development of pressure sores.
This deficient practice resulted in Resident 1 developing a Stage I (intact skin with a localized area of non-blanchable redness) PU on the left buttock and was at risk for worsening of the PU.
Cross reference F656 and F842
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 10/14/2022, with diagnoses including cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), wedge compression fracture (the front of the spinal column collapses but the back does not, forming a wedge shape), and muscle weakness (a full effort does not produce a normal muscle contraction or movement).
A review of Resident 1 ' s History and Physical exam, dated 10/16/2022, indicated the resident had the capacity to understand and make decisions.
A review of the Resident 1 ' s Braden Scale (a tool used to predict PU risk), dated 10/17/2022, indicated the resident was at risk for developing PU.
A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 10/20/2022, indicated the resident ' s cognition (mental action or process of acquiring knowledge and understanding) was intact (not affected), needed extensive assistance from staff on most areas of activities of daily living (ADLs - dressing, moving/turning in bed, transfer from and to bed, personal hygiene, toilet use, and bathing). Resident 1 was assessed at risk for developing PUs.
A review of Resident 1 ' s Care Plan initiated on 10/17/2022 indicated Resident 1 was at risk of developing unavoidable PUs related to diagnoses. The interventions did not include repositioning and its frequency.
A review of Resident 1 ' s nursing Progress Notes, dated 10/31/2022, indicated the resident developed a left buttock PU Stage I and the physician was notified.
A review of Resident 1 ' s certified nursing assistants (CNAs) Documentation Survey Report v2 form for 10/2022 which indicated the assistance provided to Resident 1 with ADLs per shift, indicated bed mobility was provided every shift. The documentation did not indicate how often Resident 1 was repositioned.
A review of Resident 1 ' s nursing Progress Notes, dated 11/8/2022, indicated the resident was transferred to an acute hospital.
On 11/15/2022 at 11:23 a.m., an interview and concurrent review of Resident 1 ' s clinical record was conducted with the Director of Nursing (DON). The DON stated Resident 1 needed to be repositioned in bed at least every two hours and this should be documented in ADLs form under bed mobility. The DON was unable to find any documentation Resident 1 was repositioned every two hours.
A review of the facility ' s policy and procedures titled, Prevention of Pressure Ulcers/Injuries last reviewed on 7/2017, indicated the purpose of the procedure was to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Inspect the skin on a daily basis when performing or assisting with personal care or Activities of Daily Living (ADL). At least every two hours, reposition residents who are reclining and dependent on staff for repositioning, reposition more frequently as needed, based on the condition of the skin and the resident ' s comfort, and evaluate, report and document potential changes in the skin.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure medical records were complete and accurately documented for one of four sampled residents (Resident 1). For Resident 1, who was depe...
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Based on interview and record review, the facility failed to ensure medical records were complete and accurately documented for one of four sampled residents (Resident 1). For Resident 1, who was dependent of staff with moving and changing position in bed, there was no documentation Resident 1 was repositioned at least every two hours per facility ' s policy.
The pre-printed form for certified nursing assistants (CNAs) to document repositioning in bed was per shift.
This deficient practice resulted lack of information about the frequency Resident 1 was repositioned.
Cross reference to F656 and F686
Findings:
A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 10/14/2022, with diagnoses including cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it), wedge compression fracture (the front of the spinal column collapses but the back does not, forming a wedge shape), and muscle weakness (a full effort does not produce a normal muscle contraction or movement).
A review of Resident 1 ' s History and Physical exam, dated 10/16/2022, indicated the resident had the capacity to understand and make decisions.
A review of the Resident 1 ' s Braden Scale (a tool used to predict PU risk), dated 10/17/2022, indicated the resident was at risk for developing PU.
A review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 10/20/2022, indicated the resident ' s cognition (mental action or process of acquiring knowledge and understanding) was intact (not affected), needed extensive assistance from staff on most areas of activities of daily living (ADLs - dressing, moving/turning in bed, transfer from and to bed, personal hygiene, toilet use, and bathing). Resident 1 was assessed at risk for PU development.
A review of Resident 1 ' s nursing Progress Notes, dated 10/31/2022, indicated the resident developed a left buttock PU Stage I and the physician was notified.
A review of Resident 1 ' s of certified nursing assistants (CNAs) Documentation Survey Report v2 for 10/2022 (to document assistance provided with the ADLs per shift) indicated bed mobility was provided every shift. The documentation did not indicate how often Resident 1 was repositioned.
On 11/15/2022 at 11:23 a.m., an interview and concurrent review of Resident 1 ' s clinical record was conducted with the Director of Nursing (DON). The DON stated Resident 1 needed to be repositioned in bed at least every two hours and this should have been included ADLs form. The DON was unable to find any documentation Resident 1 was repositioned every two hours.
A review of facility's undated policy and procedure titled repositioning indicated that the the purpose of the procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed-or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. it also indicate that the following information should be record in the resident's medical record:
1. the position in which the resident was placed
2. the name and title of the individual who gave the care
3. any change in the resident's condition
4. any problems or complaints made by the resident related to the procedure
5. if the resident refused the care and the reason why
6. observation of anything unusual exhibited by the resident
7. the signature and title of the person recording the data.
Jul 2021
19 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services that promoted respect and dignity fo...
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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 services that promoted respect and dignity for one of one sampled resident reviewed for dignity, when Resident 187 was left feeling less than human, after he was left lying on his own feces.
This facility staff action had the potential to cause psychosocial harm to Resident 187.
Findings:
A review of Resident 187's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses that included myasthenia gravis (a disorder primarily characterized by muscle weakness and muscle fatigue), high blood pressure, and diabetes mellitus (a condition whereby the body is not able to regulate blood levels of sugar).
A review of Resident 187's Admission/readmission Data Tool dated 7/24/2021, indicated the resident was alert and oriented. Resident 187 needed one-person physical assistance for transferring. The tool also indicated the resident had left below-the-knee amputation (removal of a limb by trauma, medical illness, or surgery).
During an observation on 7/24/21 at 12:12 p.m., call light was on (activated) in Resident 187's room.
During an observation on 7/24/21 at 12:23 p.m., call light was still on in Resident 187's room.
During a concurrent interview, Resident 187 stated he had pressed the call light since 11:15 a.m. and was waiting for the staff to answer his call light. Resident 187 stated he had a bowel movement and he had been lying on his own feces since 11:15 a.m. He added that he felt less than human and felt uncomfortable.
During an observation and concurrent interview with Certified Nursing Assistant 8 (CNA 8), on 7/24/2021 at 12:27 p.m., CNA 8 stated she was in the other room and call light should be answered immediately. She added that she will clean the resident right away.
A review of the facility's policy and procedures titled Answering the Call Light, with revised date 03/2021 indicated if the resident's request is something you can fulfill, complete the task within five minutes if possible.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
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 obtain an informed consent (permission granted by a resident or res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain an informed consent (permission granted by a resident or resident representative to proceed with treatment after the physician had fully explained the benefits and possible risks or consequences) for the administration of psychotropic medications (mind altering medications) for one of three sampled residents (Resident 84).
This deficient practice had the potential for the residents and/or resident representatives not to be well informed of the medications and the potential risks and side effects (expected, well-known reaction that occurs with a predictable frequency and may or may not rise to the level of being an adverse consequence). The deficient practices also placed Resident 84 and or the resident representatives at risk of missing the opportunity to decide whether to proceed or to refuse the treatment.
Findings:
A review of the admission Record indicated Resident 84 was admitted to the facility on [DATE] with diagnoses including psychosis (mental disorder characterized by a disconnection from reality), depression (persistently depressed mood or loss of interest in activities causing significant impairment in daily life) and hypertension (high blood pressure). The record further indicated that Resident 84 was self-responsible for own decision making.
A review of Resident 84's Minimum Data Set (MDS- a standardized assessment and screening tool) dated 10/12/2020, indicated Resident 84 had capacity to understand and make decisions.
A review of Resident 84's Order Summary Report, dated 4/25/2021, indicated a physician order for Venlafaxine (medication to treat depression) 37.5 mg (milligrams-unit of measurement) one (1) tablet by mouth, one time a day for verbalization of sadness related to depression.
A review Resident 84's Facility Verification of informed consent, dated 11/29/2020, indicated that Resident 84 had a consent for the use of Venlafaxine 37.5 mg by mouth daily, signed by Resident 84's friend via telephone.
A review of Resident 84's Order Summary Report, dated 7/2/2021, indicated an order for Olanzapine (medication to treat schizophrenia [disorder that affects a person's ability to think, feel, and behave clearly]) 10 mg, one (1) tablet by mouth at bedtime for outburst of anger related to psychosis.
A review of Resident 84's Facility Verification of informed consent, dated 11/29/2020, indicated that Resident 84 had a consent for the use of Olanzapine, signed by Resident 84's friend via telephone.
A review of Resident 84's Order Summary Report, dated 7/21/2021, indicated an order for Quetiapine (medication to treat schizophrenia) 25 mg, one (1) tablet by mouth at bedtime for calm to hostile behavior related to psychosis.
A review of Resident 84's Facility's Verification of Informed Consent, dated 11/29/2020, indicated Resident 84 had a consent for the use of Quetipine 50 mg one (1) tablet by mouth every night, signed by Resident 84's friend via telephone.
During an interview, on 7/25/2021 at 11:54 a.m., Registered Nurse 1(RN1) stated that Resident 84 refused to sign the informed consent for the psychotropic medication, so she called the friend listed on the resident's face sheet regarding the psychotropic medications, and she consented.
During an interview, on 7/25/2021 at 12:10 p.m. Social Services Director (SSD) stated that if resident was alert, the staff should not get consent from the family or friends.
A review of facility's policy titled psychotropic medication use dated 10/2017, indicated that when physician orders a psychotropic medication for a resident, facility should ensure that physician has conducted a comprehensive assessment of the resident and has documented in the clinical record that psychopharmacologic medication is necessary. The facility should also inform resident of the initiation, reason for use and the risk associated with the use of psychotropic medications, per facility policy or applicable state regulation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 71) was...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 71) was assessed to self-administer the medications. Resident 71 stored his own Atrovent inhaler (medication to help with breathing) at the bedside without physician order and there was no documented evidence the resident was assessed to be safe to self-administer the medication.
This failure had the potential for Resident 71 to receive unnecessary medications and placed the resident at risk for medication administration errors.
Findings:
A review of Resident 71's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses that included emphysema (lung condition that causes shortness of breath) and respiratory failure (condition when not enough oxygen passes from the lungs to the blood).
A review of Resident 71's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 6/28/2021, indicated the resident's cognition (mental action or process of acquiring knowledge and understanding) was intact. The MDS indicated the resident had limited assistance with staff with transfer, toilet use, personal hygiene, and bathing.
During an observation and a concurrent interview, on 7/24/2021 at 8:14 a.m., Resident 71 was on bed and Atrovent inhaler (medication to help with breathing) was at the bedside. Resident 71 stated that he had that medication since he was admitted to the facility.
During a record review of Resident 71's physician orders and a concurrent interview with the Minimum Data Set Nurse (MSDN) on 7/24/2021 at 12:08 p.m., MDSN stated that there was no order for Atrovent inhaler for Resident 71.
A review of Resident 71's Admission/readmission Data Tool dated 6/29/2021, indicated resident did not want to self-administer medications.
A review of the facility's policy and procedures titled Self-Administration of Medication, revised in 12/2016 indicated residents have the right to self-administer medications if the interdisciplinary team determined that it is clinically appropriate and safe for the resident to do so.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that call lights were responded to in a timely...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that call lights were responded to in a timely manner for one of 25 residents (Resident 187).
This failure had resulted in resident's needs not being met.
Findings:
A review of Resident 187's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses that included myasthenia gravis (a disorder primarily characterized by muscle weakness and muscle fatigue), high blood pressure, and diabetes mellitus (a condition whereby the body is not able to regulate blood levels of sugar).
A review of Resident 187's Admission/readmission Data Tool dated 7/24/2021, indicated the resident was alert and oriented. Resident 187 needed one-person physical assistance for transferring. The tool also indicated the resident had left below-the-knee amputation (removal of a limb by trauma, medical illness, or surgery).
During an observation on 7/24/21 at 12:12 p.m., call light was on (activated) in Resident 187's room.
During an observation on 7/24/21 at 12:23 p.m., call light was still on in Resident 187's room.
During a concurrent interview, Resident 187 stated he had pressed the call light since 11:15 a.m. and was waiting for the staff to answer his call light. Resident 187 stated he had a bowel movement and he had been lying on his own feces since 11:15 a.m
During an observation and concurrent interview with Certified Nursing Assistant 8 (CNA 8), on 7/24/2021 at 12:27 p.m., CNA 8 stated she was in the other room and call light should be answered immediately. She added that she will clean the resident right away.
A review of the facility's policy and procedures titled Answering the Call Light, with revised date 03/2021 indicated if the resident's request is something you can fulfill, complete the task within five minutes if 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 provide a safe, clean comfortable and homelike environ...
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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 a safe, clean comfortable and homelike environment for one of eight sampled residents (Resident 13) reviewed by failing to repair peeling paint and damaged dry wall next tothe resident's bed.
This deficient practice had the potential to negatively affect the residents' comfort and well-being.
Findings:
A review of the admission Record (face sheet) indicated Resident 13 was admitted to the facility on [DATE], with diagnoses including cerebrovascular disease (group of conditions that affect blood flow and the blood vessels in the brain), hemiplegia (loss of muscle function in part of the body), and aphasia (a language disorder that affects a person's ability to communicate).
A review of the Minimum Data Set (MDS- standardized assessment and screening tool), dated 04/24/2021, indicated Resident 13's cognition (mental action or process of acquiring knowledge and understanding) was severely impaired. The MDS indicated Resident 13 required extensive assistance with most areas of activities of daily living (ADLs) including transfer, walking in room and in corridor, dressing, and personal hygiene.
During an observation on 07/24/2021 at 10:29 a.m., observed damaged drywall and peeling paint on the wall next to the resident's bed.
During an interview on 7/24/2021 at 10:34 a.m., with the Maintenance Supervisor (MS), the MS stated he is aware there is damage in the dry wall and peeling paint on the wall in Resident 13's room. The MS stated he is busy completing other projects in the facility.
A review of the facility policy and procedures titled, Interior Maintenance: Resident Rooms and Equipment, dated 01/04/2021, indicated it is the policy of the facility to maintain in good repair, all interior surfaces, fixtures, equipment, appliances, and furnishings to provide a safe, clean, comfortable environment for residents
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a comprehensive, person-centered care plan wit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a comprehensive, person-centered care plan with measurable objectives and interventions to address multiple skin discoloration to resident's bilateral upper extremities and shoulders for one (Resident 76) of two residents investigated under the care area of skin conditions (non-pressure related).
This deficient practice had the potential to result in a delay or lack of delivery of care and services to Resident 76.
Findings:
A review of the admission Record (face sheet) indicated Resident 76 was initially admitted to the facility on [DATE], and was most recently readmitted on [DATE], with diagnoses including sepsis (a life-threatening complication of an infection), acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), and acute kidney failure.
A review of Resident 76's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 06/30/2021, indicated the resident's cognition (mental action or process of acquiring knowledge and understanding) was moderately impaired. The MDS indicated the resident is totally dependent on staff with transfer and bathing, and required extensive assistance from staff with bed mobility, dressing, toilet use, and personal hygiene.
During an observation and concurrent interview on 7/24/2021 at 8:35 a.m., observed resident in bed watching television. Resident 76 was observed with multiple reddish discolorations on bilateral upper extremities and bilateral shoulder area. During an interview, the resident stated he has sensitive skin and prefers the staff using the sheet in turning and repositioning him instead of staff holding him.
During a concurrent interview and record review on 07/24/2021 at 2:35 p.m., with Minimum Data Set Nurse (MDSN), Resident 76's medical records including progress notes, care plans, change of condition (COC) notes, and weekly licensed notes were reviewed. MDSN stated there was no documentation in the resident's medical records addressing resident's multiple skin discolorations. The MDSN stated there was no care plan in place addressing the resident's skin discolorations.
During a concurrent observation and interview on 07/24/2021 at 2:41 p.m., with the Director of Nursing (DON) and MDSN in Resident 76's room, DON verified the presence of multiple reddish discolorations in the resident's bilateral upper extremities and bilateral shoulders. The DON stated the change in resident's condition should have been documented and monitored and the physician should have been notified.
A review of the facility policy and procedures titled, Care Plans, Comprehensive Person-Centered, with revised date of 12/2016, indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The care plan process will facilitate resident and /or representative involvement; incorporate the resident's personal and cultural preference in developing the goals of care; include measurable objectives and timeframes; describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; incorporate identified problem areas; reflect treatment goals, timetables and objectives in measurable outcomes; reflect currently recognized standards of practice for problem areas and conditions.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 20's admission Record indicated Resident 20 was admitted to the facility on [DATE], and re-admitted on [...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 20's admission Record indicated Resident 20 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses including dementia (a group of symptoms that affects memory, thinking and interferes with daily life) without behavioral disturbance, schizoaffective disorder (characterized by unstable mood and unstable thought processes), and unspecified convulsions (sudden, violent, irregular movement of a limb or of the body).
A review of Resident 20's Minimum Data Set (MDS- a standardized assessment and screening tool), dated 5/5/2021, indicated Resident 1 had severely impaired cognitive (knowledge and understanding through thought, experience, and senses) skills for daily decision making. The MDS indicated Resident 1 required limited assistance with one-person physical assist with bed mobility, transfers, dressing, toilet use, and personal hygiene.
A review of Resident 20's Care plan titled Resident 20 was a high risk for falls/injuries related to confusion, psychoactive drug use, Parkinson's disease (disorder causing stiffness, slow movements, and difficulty walking), and dementia, initiated on 12/14/2017, with revision 4/13/2021, indicated the staff's interventions were to anticipate and meet the resident needs, resident's call light to be within reach, encouragement for resident to use it for assistance as needed, to keep the environment free from clutter and for the resident to have a low bed.
A review of Resident 20's Care plan, titled Resident 20 had an actual fall with unsteady gait, dated 3/3/2021, indicated staff's interventions were to keep surrounding free from clutter, check range of motion daily, monitor residents for any changes, and report to the doctor.
During a concurrent interview and record review, on 7/25/2021 at 3:38 p.m., the Minimum Data Set Nurse (MDSN) stated Resident 20 had a falls on 2/27/2021. MDSN stated when Resident 20's fell on 2/27/2021, the resident's care plan was updated on 3/3/2021 and Interdisciplinary Team meeting (IDT) was done on 3/10/2021. MDSN stated that care plan should have been be updated right away.
During an interview, on 7/25/2021 at 8:10 p.m., Director of Nursing (DON) stated that every time resident falls, the facility should update the care plan. The DON stated that the care plan should be specific and resident centered.
A review of facility's policy titled Comprehensive person-centered care plans with revised date of 12/2016, indicated that the interdisciplinary team must review and update the care plan including when there has been a significant change in the resident's condition and when the desired outcome is not met.
Based on interview and record review, the facility failed to:
1. Review and revise the resident's care plan to reflect a change in the physician's order of duloxetine (antidepressant and nerve pain medication) for one (Resident 26) out of five residents reviewed for unnecessary medications.
This deficient practice had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services for Resident 26.
2. Revise a care plan for at risk for falls for one of two sampled residents (Resident 20), who sustained a fall.
This deficient practice had the potential to place Resident 20 at risk for recurrent falls.
Findings:
a. A review of the admission Record (face sheet) indicated Resident 26 was initially admitted to the facility on [DATE], and was most recently readmitted on [DATE], with diagnoses including acute and chronic respiratory failure (condition when not enough oxygen passes from the lungs to the blood), anxiety disorder (state of excessive worry or fear), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest).
A review of Resident 26's Minimum Data Set (MDS - a standardized assessment and screening tool) dated 05/18/2021, indicated the resident had intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated the resident was receiving antidepressant medication in the last five days during the seven day look-back period (time frame for observation).
A review of a physician's order dated 07/02/2021 indicated duloxetine hydrocholoride (HCl) capsule delayed release particles 60 milligrams (mg - unit of measurement), one capsule by mouth one time a day for verbalization of sadness related to major depressive disorder, recurrent, unspecified. The order indicated the reason for discontinuing the order was due to the pharmacist's recommendation for drug interaction with another medication Zyvox (an antibiotic medication).
During a concurrent interview and record review with Minimum Data Set Nurse (MDSN) on 7/25/2021 at 8:17 a.m., Resident 26's care plans were reviewed. Resident 26's care plan for antidepressant medication duloxetine initiated on 02/03/2021 indicated the care plan as an active care plan with target date of 08/12/2021. The MDSN stated the medication duloxetine was discontinued on 07/02/2021 and the resident's care plan should have been discontinued on the same date since the resident was no longer receiving the medication.
A review of the facility policy and procedures titled, Care Plans, Comprehensive Person-Centered, with revised date of 12/2016, indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to meet professional standards of quality for two of thr...
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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 meet professional standards of quality for two of three sampled residents, (Residents 62 and 17) by failing to:
1. Ensure to identify Resident 17 using identifiers such as checking identification band, checking photograph attached to the medical record and verify resident's identity with another staff. This deficient practice placed a potential risk to result in medication administration to the wrong resident and placed Resident 17 at risk for adverse reactions such as, hypoglycemia (a condition characterized by an abnormally low level of blood sugar (glucose), your body's main energy source).
2. Ensure Resident 17 received medication as prescribed by the physician. There was no order by physician to crushed medication prior to administration and license staff did not notify physician regarding resident unable to swallow pills. This deficient practice placed Resident 17 at risk for not receiving her medications as prescribed by the physician safely.
3. Ensure the expiration date was checked prior to administering medications for Resident 62. This deficient practiced placed Resident 62 at risk of receiving expired medications which may be at risk of bacterial growth and no guarantee the medications will be safe and effective.
These deficient practices placed Resident 17 and Resident 62 at risk for unsafe patient care and lead to a delay in the ability to evaluate the appropriateness of the care delivered.
Findings:
1. A review of Resident 17's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included Type II diabetes (a disease in which your blood glucose, or blood sugar, levels are too high), Parkinson's disease (a brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination) and aphasia (loss of ability to understand or express speech, caused by brain damage).
A review of Resident 17's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 6/21/2021, indicated Resident 17 has severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making.
During a medication pass observation on 7/25/2021 at 7:47 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 prepared and administered metformin (medication used to treat high blood sugar levels that are caused by a type of diabetes mellitus or sugar diabetes called type 2 diabetes) to Resident 17. LVN 2 failed to verify Resident 17's identification prior to administering the medication. LVN 2 did not look for an identification armband, ask the resident to state her name, nor look at the photo attached in the medical records.
During an interview on 7/25/2021 at 7:59 a.m., with LVN 2, LVN 2 confirmed that he did not check identifiers for Resident 17 prior to administering medications. LVN 2 stated, he should've check for an identification armband or the photo in the chart prior to giving medications. LVN 2 further stated, if identification was not checked, medication might not be given to the correct resident.
2. During a medication pass observation on 7/25/2021 at 7:47 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 prepared and administered metformin (medication used to treat high blood sugar levels that are caused by a type of diabetes mellitus or sugar diabetes called type 2 diabetes) to Resident 17. LVN 2 was observed crushing the medication metformin and mixing it with apple sauce prior to administering the medication to Resident 17.
During an interview on 7/25/2021 at 11:12 a.m. with LVN 2, LVN 2 stated that in the past, Resident 17 could not swallow pills, therefore he routinely crushed the medication and mixed them with apple sauce. When asked if physician was notified regarding Resident 17 being unable to swallow pills, LVN 2 did not respond. When asked if there is an order by physician to crushed medication, LVN 2 did not respond.
During an interview with Registered Nurse 1 (RN 1) on 7/25/2021 at 11:16 a.m., RN 1 stated if a resident is unable to swallow pills, the physician, and Speech Therapist (responsible for assessing and treating speech, language disorders and oral/feeding/swallowing skills to identify problem) should be notified. When asked if the physician and or Speech Therapist was notified of Resident 17 inability to swallow pills, RN 1 stated, no.
A review of the facility's policy titled, Administering Medications, revised 12/2012, indicated the individual administering medications must verify 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.
A review of the facility's policy titled, Administering Medications, revised 12/2012, indicated medications must be administered in accordance with the orders.
3. A review of Resident 62's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included, but not limited to metabolic encephalopathy (a problem in the brain) and Type II diabetes.
A review of Resident 62's MDS dated [DATE], indicated Resident 62 has moderately impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making.
During a medication pass observation on 7/25/2021 at 8:11 a.m., with Licensed Vocational Nurse (LVN 2), LVN 2 prepared and administered medications to Resident 62. LVN 2 did not check and verify the expiration dates on seven of eight medications.
i.
Amlodipine (medication to treat high blood pressure and chest pain) five (5) milligrams (mg-unit of measure) tablet
ii.
Folic acid (treat certain type of anemia [condition in which the blood doesn't' have enough healthy red blood cells]) one (1) mg
iii.
Steglatro (helps lower blood sugar levels in adults with type II diabetes) five (5) mg
iv.
Colace (makes bowel movements softer and easier to pass) 100 mg
v.
Cranberry Supplement (to assist with prevention of Urinary Tract Infection [UTI-infection in any part of your urinary system]) 450 mg, one tablet
vi.
Multiple Vitamins (dietary supplement containing all or most of the vitamins that may not be readily available in the diet), one tablet
vii.
Rena Vite (treat or prevent vitamin deficiency)
During an interview on 7/25/2021 at 8:35 a.m. with LVN 2, LVN 2 confirmed that he did not check the expiration dates of the medication prior to administering them to the Resident 62. LVN 2 stated that he had never seen bubble pack medications (medications dispensed in special packages) being expired. LVN 2 stated that the only time he had seen it expired is if it's as needed medications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess multiple skin discoloration to resident's bilat...
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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 multiple skin discoloration to resident's bilateral upper extremities and shoulders and promptly notify the physician of the change of condition for one of two (Resident 76) of two residents investigated under the care area of skin conditions (non-pressure related).
This deficient practice had the potential to result in a delay or lack of delivery of care and services to Resident 76.
Findings:
A review of the admission Record (face sheet) indicated Resident 76 was initially admitted to the facility on [DATE], and was most recently readmitted on [DATE], with diagnoses including sepsis (a life-threatening complication of an infection), acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), and acute kidney failure.
A review of Resident 76's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 06/30/2021, indicated the resident's cognition (mental action or process of acquiring knowledge and understanding) was moderately impaired. The MDS indicated the resident is totally dependent on staff with transfer and bathing, and required extensive assistance from staff with bed mobility, dressing, toilet use, and personal hygiene.
During an observation and concurrent interview on 7/24/2021 at 8:35 a.m., observed resident in bed watching television. Resident 76 was observed with multiple reddish discolorations on bilateral upper extremities and bilateral shoulder area. During an interview, the resident stated he has sensitive skin and prefers the staff using the sheet in turning and repositioning him instead of staff holding him.
During a concurrent interview and record review on 07/24/2021 at 2:35 p.m., with Minimum Data Set Nurse (MDSN), Resident 76's medical records including progress notes, care plans, change of condition (COC) notes, and weekly licensed notes were reviewed. MDSN stated there was no documentation in the resident's medical records addressing resident's multiple skin discolorations.
During a concurrent observation and interview on 07/24/2021 at 2:41 PM, with the Director of Nursing (DON), in Resident 76's room, the DON verified the presence of multiple reddish discolorations in the resident's bilateral upper extremities and bilateral shoulders. The DON stated the change in resident's condition should have been documented and monitored and the physician should have been notified.
A review of the facility policy and procedure titled, Change in a Resident's Condition or Status, revised on 05/2017, indicated it is the facility policy to promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and /or status; prior to notifying the physician or healthcare provider, the nurse shall make detailed observations and gather relevant pertinent information for the provider.
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 ensure residents who smoked were assessed and smoked ...
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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 who smoked were assessed and smoked only at the designated smoking area for one of ten smoker residents (Resident 185).
This deficient practice had a potential to put the resident at risk for smoking-related injuries.
Findings:
A review of Resident 185's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], with diagnoses that included sepsis (blood infection), osteomyelitis (infection of the bone), and diabetes mellitus (a condition whereby the body is not able to regulate blood levels of sugar).
A review of Resident 185's Admission/readmission Data Tool dated 7/15/2021, indicated the resident was alert and oriented. Resident 185 needed one-person physical assistance for activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).
During an observation on 7/24/2021 at 8:15 a.m., Resident 185 was smoking in the patio just outside his room.
During a record review of Resident 185's medical records and interview with Minimum Data Set Nurse (MSDN), on 7/24/2021 at 11:24 a.m., MDSN stated Resident 185 was not a smoker based on the Admission/readmission Data Tool dated 7/15/2021. MDSN added that the social worker should have done a smoking assessment if the resident was a smoker.
During an interview with the Director of Nursing (DON), on 07/25/2021 at 12:15 p.m., the DON stated there was a designated area for smoking. Residents should only smoke at the designated smoking area for safety reason.
A review of the undated facility's policy and procedures titled Smoking Policy - Residents, indicated the facility shall establish and maintain safe resident smoking practices.
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 observation, interview, and record review the facility failed to provide appropriate treatment and services by failing ...
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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 treatment and services by failing to promptly assess changes in the characteristics of the resident's urine and by failing to notify the physician of the change of condition (COC) for one (Resident 83) out of two residents investigated under the care area of urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) or urinary tract infection (UTI-an infection in any part of the urinary system, bladder, or urethra [the tube through which urine leaves the body]).
This deficient practice had the potential to result in a delay of care and services and had the potential to cause discomfort to the resident.
Findings:
A review of the admission Record (face sheet) indicated Resident 83 was admitted to the facility on [DATE], with diagnoses including traumatic subdural hemorrhage (a pool of blood between the brain and its outermost covering) and benign prostatic hyperplasia (BPH - enlargement of the prostate gland that can cause blocking the flow of urine out of the bladder).
A review of Resident 83's Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 06/18/2021, indicated the resident's cognition (mental action or process of acquiring knowledge and understanding) was severely impaired. The MDS indicated the resident required extensive assistance with most areas of activities of daily living (ADLs) including transfer, bed mobility, toilet use, and bathing.
A review of the Medication Administration Order (MAR) for 07/2021 indicated a physician's order dated 06/12/2021, to monitor urine for abnormal color, sediments (substances present in the urine that separate and accumulate at the bottom of a container of urine), cloudiness, hematuria (presence of blood in urine) every shift, and report finding to physician every shift.
During an observation and concurrent interview, on 07/24/2021 at 9:10 a.m., with the Director of Staff Development (DSD), at Resident 83's bedside, observed resident's urinary catheter (a tube that drains urine from the bladder) tubing with reddish colored urine and presence of white sediments. The DSD stated the urinary catheter should have been changed and the physician should have been notified if hematuria and sediments were observed in the urine.
During a concurrent interview and record review, on 07/24/2021 at 9:30 a.m., with Licensed Vocational Nurse 6 (LVN 6), Resident 83's progress notes, COC note, and Medication Administration Record (MAR) for 07/2021 were reviewed. LVN 6 stated there was no documentation of the resident having hematuria. LVN 6 also stated there was no documentation of a change of condition.
During an interview with the Director of Nursing (DON), on 07/25/2021 at 10:55 a.m., the DON stated Resident 83's urine has an ongoing monitoring by staff. The DON stated the physician should have been notified if the resident's urine was observed with hematuria, cloudiness in color, and presence of sediment.
A review of the facility policy and procedures, titled, Catheter Care, Urinary, revised in 09/2014, indicated to observe the resident for complications associated with urinary catheters; check the urine for unusual appearance (i.e., color, blood); observe for other signs of urinary tract infection or urinary retention. Report findings to the physician or supervisor immediately.
A review of the facility policy and procedures titled, Change in a Resident's Condition or Status, revised in 05/2017, indicated it is the facility policy to promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical/mental condition and /or status. Prior to notifying the physician or healthcare provider, the nurse shall make detailed observations and gather relevant pertinent information for the provider.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
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 that one of eight sampled residents (Resident 6...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that one of eight sampled residents (Resident 64) with gastrostomy tube (GT- a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration) was positioned with head of the bed (HOB) elevated while being administered enteral feeding (refers to intake of food via the gastrointestinal [GI] tract).
This deficient practice placed Resident 64 at risk for aspiration (inhaling small particles into the lungs).
Findings:
A review of Resident 64's admission Record indicated that he was re-admitted on [DATE], with the diagnoses including sepsis (a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs), pancreatitis (condition characterized by inflammation of the pancreas), respiratory failure (condition in which your blood does not get enough oxygen or has too much carbon dioxide), quadriplegia (paralysis of all four limbs [arms/legs]) and gastrostomy.
A review of Resident 64's Minimum Data Set (MDS-standardized screening and assessment tool for all residents of long-term care facilities) dated 6/14/2021, indicated Resident 64 has severely impaired cognition (a person has trouble remembering, learning new things, concentrating, or making decisions that affect everyday life), is totally dependence on functional status (individual's ability to perform normal daily activities required to meet basic needs) and is on a feeding tube.
A review of Resident 64's Order Summary Report, dated 3/16/2021, indicated that the head of the bed should be elevated at 30-45 degrees angle during feeding.
During a concurrent observation and interview, on 7/24/2021 at 8:34 a.m., Resident 64 was observed with lowered head of the bed. Licensed vocational nurse 7 (LVN7) confirmed the observation and stated that the head of the bed was at 15 degrees. LVN 7 stated that Resident 64's HOB should be elevated at least 30-45 degrees when feeding due to high risk of aspiration.
A review of Resident 64's care plan for tube feeding, revised 3/25/2021, the goal was to have resident remain free of side effects or complications related to tube feeding.
A review of facility's policy and procedure (P&P) titled, Enteral Feedings-Safety Precautions, revised 11/2018, indicated under preventing aspiration to Elevate the head of the bed (HOB) at least 30 degree during tube feeding and at least 1 hour after feeding.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to implement their protocol for Antibiotic (medicines that fight bacterial infections) Stewardship (the effort to measure and improve how anti...
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Based on interview and record review, the facility failed to implement their protocol for Antibiotic (medicines that fight bacterial infections) Stewardship (the effort to measure and improve how antibiotics are prescribed by clinicians and used by residents) for one of three sampled residents (Resident 8).
This deficient practice had the potential for Resident 8 to develop antibiotic resistance (when the medication is no longer effective to treat bacterial infection) from unnecessary or inappropriate antibiotic.
Findings:
A review of Resident 8's admission Record indicated the resident was admitted to the facility, on 4/13/2021, with diagnoses including osteomyelitis ( inflammation or swelling that occurs in the bone) of the back, diabetes (diseases that result in too much sugar in the blood), and depression.
A review of Resident 8's Minimum Data Set (MDS- a standardized assessment and screening tool), dated 4/19/2021, indicated that the resident had the capacity to understand and make decisions.
A review of Resident 8's Physician Order dated 5/3/2021, indicated an order for Cefazolin sodium (antibiotic medication to treat infection) two (2) grams (g-unit of measure) intravenously (medication given within the vein) every eight (8) hours until 5/18/2021 related to osteomyelitis of the back.
During an interview and concurrent record review on 7/25/2021 at 4:00 p.m. with the Infection Preventionist (IP), Resident 8's medical record from 4/13/2021 to 7/25/2021 was reviewed. IP stated that for all residents receiving antibiotics, they are to be evaluated by the antibiotic stewardship program to validate and monitor the need for the prescribed antibiotic. IP stated that after reviewing Resident 8's medical records, she confirmed that the resident was not evaluated by the antibiotic stewardship program of the facility. IP stated that by failing to evaluate the need for the antibiotic, it placed Resident 8 at risk for developing antibiotic resistance in the future.
A review of facility's undated policy titled Antibiotic Stewardship Program indicated that the facility's policy to implement an antimicrobial stewardship program with the goal of optimizing clinical outcomes, minimize unintended consequences of antimicrobial use, including toxicity, the selection of pathogenic organisms and the emergence of resistance, while reducing treatment-related costs.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 65's admission record indicated that he was re-admitted to the facility, on 6/7/2021, with the diagnoses...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 65's admission record indicated that he was re-admitted to the facility, on 6/7/2021, with the diagnoses that included chronic obstructive pulmonary disease (COPD - group of lung diseases that block airflow and make it difficult to breathe), asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing), arteriosclerotic heart disease (build-up of fats, cholesterol, and other substances in and on the artery walls) and diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]).
A review of Resident 65's MDS, dated [DATE], indicated Resident 65 had severely impaired cognition (a person has trouble remembering, learning new things, concentrating or making decisions that affect everyday life), limited assistance on functional status (individual's ability to perform normal daily activities required to meet basic needs). The MDS indicated Resident 65 was on palliative care (an interdisciplinary caregiving approach aimed at optimizing quality of life and mitigating suffering among people with serious, complex and possibly end of life illness) and has COPD. No indication of oxygen therapy was documented under special treatments, procedures, and programs.
A review of Resident 65's Order Summary Report, dated 7/13/2021, indicated to give oxygen at two (2) Liters (L- unit of measure) via nasal cannula (device used to deliver oxygen) as needed (PRN) and change oxygen nasal cannula every week on Sunday and as needed with name and date label.
During an observation and concurrent interview on 7/24/2021 at 9:33 a.m., Resident 65 was observed using oxygen at 2 L via nasal cannula with Licensed Vocational Nurse 7 (LVN 7). LVN 7 confirmed the observation.
During a record review of Resident 65's Medication Administration Record (MAR- flow sheet to document when a medication is given to a resident) dated 7/2021, it was noted that there was no documentation that Resident 65 was provided with oxygen as ordered by the physician.
During an interview and concurrent record review with LVN 7 on 7/25/2021 at 10:53 a.m., Resident 65's MAR for 7/2021 was reviewed. LVN 7 confirmed that there was no documentation was Resident 65 was provided with the PRN oxygen in the MAR. LVN 7 stated that she should have documented in the MAR that Resident 65 was provided with oxygen.
During a review of facility's Preparation and General Guideline policy and procedure (P&P), undated, indicated that when a PRN medications are administered, the following documentation is provided:
a. Date and time of administration
b. Complaints or symptoms for which the medication was given.
c. Results achieved from giving the dose and the time results were noted.
d. Signature or initials of person recording administration and signature or initials of person recording effects, if different from the person administering the medication.
Based on observation, interview and record review, the facility failed to provide the necessary respiratory care and services for two (Residents 186 and 65) out of six residents reviewed for oxygen care area by failing to:
1. Ensure that a resident received oxygen as ordered by the physician for Resident 186.
2. Ensure Resident 65's as needed (PRN) oxygen was documented in the Medication Administration Order (MAR) and update Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool).
These deficient practices had the potential for Resident 186 to have complications related to improper treatment while receiving oxygen therapy and have the potential for Resident 65 to negatively impact the resident's well-being and individualized assessment.
Findings:
a. A review of Resident 186's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], with diagnosis that included congestive heart failure (CHF - a condition in which the heart can't pump enough blood to meet the body's needs).
A review of Resident 186's Admission/readmission Data Tool dated 7/21/2021, indicated the resident was alert and oriented. Resident 186 needed two-person physical assistance for transfer and bed mobility. Resident 186 also received oxygen at 2 liters per minute (LPM) via nasal cannula (tube that provides oxygen through the nose).
During the observation on 7/24/2021, Resident 186 was lying on bed with oxygen at 5 LPM via nasal cannula.
During an interview with Licensed Vocational Nurse (LVN 9) on 7/24/2021 at 9:09 a.m., she stated the oxygen should be at 2 LPM and not 5 LPM. LVN 9 adjusted the oxygen to 2 LPM.
A review of Resident 186's physician's order dated 7/20/2021 indicated oxygen at 2 LPM via nasal cannula as needed for congestive heart failure.
A review of the facility's undated policy and procedures titled, Medication Administration - General Guidelines, indicated medications are administered in accordance with written orders of the attending physician.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored appropriately by failing to:
1.
Ensure that hazardous materials were stored se...
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Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored appropriately by failing to:
1.
Ensure that hazardous materials were stored separately from the medications in one of two sampled medication carts.
2.
Ensure the removal of discontinued, expired, or medications not approved for resident administration.
3.
Ensure tuberculin (a protein used in skin test to help diagnose tuberculosis [TB -an infectious bacterial disease that mainly affects the lungs]) vial was stored in the refrigerator and discarded after more than 30 days of use.
These deficient practices had the potential to compromise the therapeutic effectiveness of the stored medication or cause medication errors and lead to unsafe nursing practice.
Findings:
During a concurrent observation and interview on 7/24/2021, at 3:33 p.m., the Licensed Vocational Nurse 3 (LVN 3), Station 1 Medication Cart was observed. Noted inside the medication cart was a pack of cigarettes and a bag filled with medication bottles in the bottom drawer. LVN 3 stated that the cigarettes belong to a resident and confirmed that they should not have been kept inside the medication cart. LVN 3 stated that the bag filled with medications were either discontinued, expired, and or medications that were brought in by the residents. LVN 3 stated that any medications not in use should be locked inside the medication room to prevent erroneously giving the wrong medications to residents.
During an interview, on 7/25/2021 at 12:08 p.m., the Director of Nursing (DON) stated cigarettes should not be kept inside the medication cart. DON further stated discontinued and expired medications should be kept inside a locked cabinet and not be mixed with other medications inside the medication cart.
A review of the facility's policy titled, Storage of Medications, revised 11/2020, indicated the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.
On 7/25/2021 at 12:36 p.m., during an observation of Medication Cart 3 and an interview with Licensed Vocational Nurse 10 (LVN 10), observed one opened vial of tuberculin (a protein used in skin test to help diagnose tuberculosis [TB -an infectious bacterial disease that mainly affects the lungs]) with open date of 6/18/2021. The tuberculin label indicated refrigerate. LVN 10 stated tuberculin should be stored in the refrigerator and once opened should be discarded after 30 days.
A review of the product label of tuberculin (Aplisol - brand name) dated 3/2016 indicated the product should be stored between 2 and 8 Centigrade (scale of temperature measurement) and protected from light. Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency (effectiveness).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and effective cleaning and sanitization practices in the kitchen as evidenced by:
1.
...
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Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and effective cleaning and sanitization practices in the kitchen as evidenced by:
1.
Failing to ensure food that was to be served for lunch was not placed in the dirty area of the kitchen.
2.
Failing to ensure food located in the refrigerator, freezer and dry storage area were labeled with a date.
3.
Failing to ensure staff followed manufacturer's instructions for the disinfectant spray when cleaning the meal carts.
These deficient practices had the potential to compromise the integrity of the food and placed the residents at risk for foodborne illnesses (illness caused by the ingestion of contaminated food or beverages) for 73 of 79 residents who received food and water from the kitchen and the unit refrigerator.
Findings:
1.
During an observation and concurrent interview on 7/24/2021 at 10:17 a.m. with DA 1, the kitchen dirty area was observed. Noted was an icy, creamy orange colored substance in a container placed in between the two-compartment sink alongside dirty pans soaked in water, soap, and the red sanitizer bucket. DA 1 stated that the orange substance was sorbet that was to be served for lunch.
During an interview, on 7/24/2021 at 5:49 p.m., DS 1 stated that there should not have food anywhere in the dirty area and especially next to the sanitizing solution. DS 1 stated that this has the potential to cross contaminate food.
A review of the 2017 U.S. Food and drug Administration Food Code indicated that food shall be protected from contamination by storing the food in a clean, dry location and where it is not exposed to splash, dust or other contamination.
2.
During an observation and concurrent interview of the facility refrigerator with the [NAME] on 7/24/2021 at 7:17 a.m., the following were observed and confirmed by the Cook:
a.
glasses of skim milk, 2% milk, and water on a tray with no labeled date.
b.
19 yogurt cups and two fruit bowls in cups with no dates
c.
Four opened bags of bread with no label or dates.
During an observation and concurrent interview of the facility's freezer with the [NAME] on 7/24/2021 at 7:20 a.m., the following were observed and confirmed by the Cook:
a.
A bag of French fries with a date of 5/20/21 inside the freezer.
b.
A frozen bag of hotdog and hamburger buns with no labeled date.
During an observation and concurrent interview of the facility's dry storage area with the [NAME] on 7/24/2021 at 7:30 a.m., the following were observed and confirmed by the Cook:
a.
Cake mix inside a clear, plastic bag was observed with no label date.
During a concurrent interview on 7/24/2021 at 7:30 a.m., with the Cook, the [NAME] stated that all opened food and poured drinks should be labeled with an open date ( the date the package was opened, or the drink was poured). This is to ensure that no food is stored past their expiration period.
A review of facility's policy titled Recommended storage practices with revised date of 2017, indicated that all opened and partially used foods shall be dated, labeled, and sealed before being returned to the storage area. it also indicated that all cooked food or other products removed from original containers in clean, sanitized, covered containers with proper label and date.
A review of the 2017 U.S. Food and Drug Administration Food Code indicated For commercially prepared, refrigerated, ready-to-eat TCS food, the food is to be marked with the time the container is opened. If the food will be held for more than 24 hours, it is to indicate the date or day it will be consumed or discarded.
3.
During a concurrent observation and interview, on 7/24/2021 at 10:15 a.m., Dietary Aide 1 (DA 1) was observed cleaning the meal carts. DA 1was observed spraying the meal carts with the disinfectant spray and then immediately wiping the meal cart with a rag. DA 1 stated that they were unaware of the contact time (the time that the disinfectant needs to stay wet on a surface to ensure efficacy) of the disinfectant spray.
A review of the disinfectant spray direction indicated that to disinfect food processing premises, allow this product to penetrate and remain wet for 3 minutes.
A review of facility's in-services agenda titled disinfecting equipment face shield and etc. dated 2/1/2021 indicated that when using the disinfectant wipes or spray, always follow the directions on the label to ensure safe and effective use of the disinfectant product.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program ...
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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 maintain an infection prevention and control program by failing to:
1. Ensure that nasal cannula tubing (NC - a lightweight tube with two prongs that are placed in the nostrils to deliver supplemental oxygen) was changed weekly as indicated in the facility's policy and procedure to six of seven residents (Residents 32, 54, 65, 69, 76 , and 286) reviewed under the respiratory care area.
2. Ensure that Coronavirus disease (COVID-19 - contagious disease causing serious complications) screening was properly done and completed to all staff and visitors.
3. Ensure appropriate transmission-based precaution (TBP-precautionary measures to prevent spread of infection) signages were posted on five residents' rooms in the yellow zone area (isolation unit for newly admitted and readmitted residents, residents who were exposed with tests pending, residents with signs and symptoms pending test results, residents with frequent external appointments).
These deficient practices had the potential to result in spread of infections; staff members spreading COVID-19 infection, and possibly cause an outbreak at the facility.
Findings:
A review of Resident 32's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included, acute respiratory failure with hypoxia (when not enough oxygen passes from your lungs to your blood) and hypoxemia (a low level of oxygen in the blood).
A review of Resident 32's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 5/25/2021, indicated Resident 32 has severely impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and required total dependence from staff for dressing, eating, and bathing.
A review of the physician's order dated 6/18/2021, indicated to change oxygen nasal cannula every week on Sundays and as needed (with name & date label) one time a day every Sunday.
During the initial tour of the facility on 7/24/2021 at 8:38 a.m., observed Resident 32's oxygen nasal cannula tubing with label dated 7/11/2021.
During an interview and concurrent observation on 7/24/2021 at 10:49 a.m. with Licensed Vocational Nurse 1 (LVN 1), Resident 32's oxygen nasal cannula tubing was observed. LVN 1 confirmed that the last date the oxygen tubing was changed as per the date is 7/11/2021. LVN 1 stated the oxygen tubing should hve been changed once a week on sundays.
During an interview, on 7/24/2021 at 11:27 a.m., Director of Nursing (DON) stated oxygen tubing should be changed weekly or as needed to prevent infection.
A review of Resident 69's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included pneumonia (infection in one of both of the lungs) and sepsis (body's extreme response to an infection).
A review of Resident 69's MDS, dated [DATE], indicated Resident 69 has severely impaired cognition for daily decision-making.
A review of the physician's order dated 7/7/2021, indicated to change oxygen nasal cannula every week on Sundays and as needed (with name & date label) one time a day every Sunday.
During the initial tour of the facility on 7/24/2021 at 10:47 a.m., observed Resident 69's oxygen nasal cannula tubing with label dated 7/11/2021.
During an interview with Licensed Vocational Nurse (LVN 1) on 7/24/2021 at 10:49 a.m. , LVN 1 stated oxygen tubing is to be changed once a week on Sundays. When to asked to observe the nasal cannula tubing for Resident 69, LVN 1 stated and acknowledged the oxygen nasal cannula tubing was last changed on 7/11/2021.
During an interview with Director of Nursing (DON) on 7/24/2021 at 11:27 AM, DON stated oxygen tubing should be changed weekly or as needed to prevent infection.
A review of the facility policy and procedures titled, Departmental (Respiratory Therapy) -Prevention of Infection, with revised date of 11/2011, indicated one of the steps in the procedure for Infection Control Considerations Related to Oxygen Administration is to change the oxygen cannula and tubing every seven days ,or as needed.
A review of the admission record indicated that Resident 65 was re-admitted to the facility, on 6/7/2021, with the diagnoses that included chronic obstructive pulmonary disease (COPD-group of lung diseases that block airflow and make it difficult to breathe), asthma (respiratory condition marked by spasms in the bronchi of the lungs, causing difficulty in breathing), arteriosclerotic heart disease (build-up of fats, cholesterol, and other substances in and on the artery walls) and diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]).
A review of the Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 6/14/2021, indicated Resident 65 had severely impaired cognition (a person has trouble remembering, learning new things, concentrating or making decisions that affect everyday life), limited assistance on functional status (individual's ability to perform normal daily activities required to meet basic needs). The MDS indicated Resident 65 was on palliative care (an interdisciplinary caregiving approach aimed at optimizing quality of life and mitigating suffering among people with serious, complex and possibly end of life illness) and had COPD.
A review of Resident 65's Order Summary Report, dated 7/13/2021, indicated to change oxygen nasal cannula every week on Sunday and as needed with name and date label.
During the initial tour of the facility on 7/24/2021 at 9:33 a.m., Resident 65's oxygen nasal cannula tubing was observed with a label dated 7/11/2021.
During an observation and concurrent interview, on 7/24/2021 at 9:40 a.m., Licensed Vocational Nurse 7 (LVN 7) acknowledged that Resident 65's nasal cannula has not been changed since 7/11/2021 according to the label. LVN 7 stated that the NC tubing is supposed to be changed every week to reduce the possible risk of infection.
During an interview, on 7/24/2021 at 11:39 a.m., the Director of Nursing (DON) stated oxygen tubing and or oxygen nasal cannula should be changed weekly or as needed to prevent infection.
A review of the admission record indicated Resident 286 was re-admitted to the facility on [DATE], with diagnoses that included acute respiratory failure (condition in which your blood suddenly doesn't have enough oxygen), COPD, and congestive heart failure (a condition that affects the pumping power of the heart muscle).
A review of the MDS, dated [DATE], indicated Resident 286 had cognitively intact cognition. The MDS indicated Resident 286 was on an oxygen therapy under respiratory treatments.
A review of Resident 286's physician's order dated 6/26/2021, indicated to change oxygen nasal cannula every week on Sundays and as needed (with name & date label) one time a day every Sunday.
During the initial tour of the facility, on 7/24/2021 at 9:33 a.m., Resident 286's observed oxygen nasal cannula tubing were labeled and dated 7/11/2021.
During an observation and concurrent interview on 7/24/2021, at 9:40 a.m., Licensed Vocational Nurse 7 (LVN 7), acknowledged that Resident 286's nasal cannula tubing was not changed since 7/11/2021 and that the nasal cannula tubing is suppose to be changed every week for to reduce the possible risk of infection.
During an interview on 7/24/2021 at 11:39 a.m., the Director of Nursing (DON) stated oxygen tubing and or oxygen nasal cannula should be changed weekly or as needed to prevent infection.
A review of the facility's titled, Departmental (Respiratory Therapy)-Prevention of Infection with revised date of 11/2011, indicated one of the steps in the procedure for infection control considerations related to oxygen administration is to change the oxygen cannula and tubing every seven days, or as needed.
During an observation of a screening process at the main entrance of the facility and a concurrent interview, on 7/25/2021, at 7:36 a.m., Screener 1 asked the temperature reading of Staff 1 who was reporting to work. Staff 1 was asked if she was experiencing any COVID-19 signs and symptoms but was not asked about her recent exposure to someone with COVID-19, or recent travel. Screener 1 stated that she did not get a formal training to do screening for staff and visitors.
During an interview with the Infection Preventionist (IP) on 7/25/2021 at 7:56 a.m., he stated that the screener should have asked all the questions listed in the form. IP added that he had given a training to the screener, but he cannot show any documentation of the training.
A review of the facility's undated policy and procedures titled, Infection Prevention and Control, indicated the Infection Preventionist is responsible for overseeing screening of all individuals entering the facility and will maintain records that all screening occurs in accordance with All Facilities Letter (AFL).
During an observation in the yellow zone (isolation unit for newly admitted and readmitted residents, residents who were exposed with tests pending, residents with signs and symptoms pending test results, residents with frequent external appointments), and a concurrent interview with the Infection Preventionist (IP), on 7/25/2021 at 10:29 a.m., five rooms were occupied for isolation. Each room had an isolation stop signage. The stop isolation signage contained five colored boxes: red for blood, yellow for urine, brown for stool, green for skin, and blue for respiratory. The five posted stop isolation signages did not indicate or check mark which body fluid or body parts was infectious. IP stated that a check should have been marked for the corresponding color of the infectious body fluid. He added that this will help the CNA and nurses know what kind of isolation the resident had.
A review of the facility's policy and procedures titled, Isolation - Categories of Transmission-Based Precautions, revised in 10/2018, indicated when a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. The signage informs the staff of the type of Center for Disease Control (CDC) precautions, instructions for personal protective equipments, and/or instructions to see a nurse before entering the room.
A review of the admission Record (face sheet) indicated Resident 54 was admitted to the facility on [DATE], with diagnoses including displaced fracture (broken bone) of second cervical vertebrae (neck bone), muscle weakness, and dependence on supplemental oxygen.
A review of Resident 54's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 06/14/2021, indicated the resident's cognition (mental action or process of acquiring knowledge and understanding) was severely impaired. The MDS indicated the resident was totally dependent with staff with transfer, toilet use, personal hygiene, and bathing. The MDS also indicated the resident was receiving oxygen therapy during the 14-day look-back period (time frame for observation).
A review of Resident 54's Order Summary Report indicated the following physician's orders dated 06/08/2021:
1. Oxygen at two liters per minute (2 L/min) via nasal cannula (NC - a lightweight tube which on one end splits into two prongs that are placed in the nostrils and from which supplemental oxygen is delivered) continuously every shift.
2. Change oxygen NC every week on Sunday and as needed (PRN) with name and date label every day shift.
During a concurrent observation and interview on 07/24/2021, at 9:10 a.m., with the Director of Staff Development (DSD), in Resident 54's room, observed the resident receiving oxygen at two liters per minute via nasal cannula. The oxygen tubing was labeled with date of 07/11/2021. The DSD stated oxygen tubing is changed weekly, every Sunday or as needed. The restorative nursing assistants (RNAs) are responsible for changing the oxygen tubing. The DSD also stated the oxygen tubing should have been changed last Sunday (07/18/2021) per facility infection control policy.
A review of the facility policy and procedures titled, Departmental (Respiratory Therapy) -Prevention of Infection, with revised date of 11/2011, indicated one of the steps in the procedure for Infection Control Considerations Related to Oxygen Administration is to change the oxygen cannula and tubing every seven days ,or as needed.
A review of the admission Record (face sheet) indicated Resident 76 was initially admitted to the facility on [DATE], and was most recently readmitted on [DATE], with diagnoses including sepsis (a life-threatening complication of an infection), acute respiratory failure with hypoxia (an absence of enough oxygen in the tissues to sustain bodily functions), and acute kidney failure.
A review of Resident 76's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 06/30/2021, indicated the resident's cognition (mental action or process of acquiring knowledge and understanding) was moderately impaired. The MDS indicated the resident is totally dependent on staff with transfer and bathing, and required extensive assistance from staff with bed mobility, dressing, toilet use, and personal hygiene. The MDS also indicated the resident was receiving oxygen therapy during the 14-day look-back period (time frame for observation).
A review of Resident 76's Order Summary Report indicated a physician's order dated 07/13/2021, for oxygen at two liters per minute (2 L/min) every shift for shortness of breath.
During a concurrent observation and interview on 07/24/2021, at 9:10 a.m., with Licensed Vocational Nurse 7 (LVN 7), in Resident 76's room, observed the resident receiving oxygen at two liters per minute via nasal cannula. The oxygen tubing and the oxygen bag were labeled with date of 07/11/2021. LVN 7 stated Resident 76's oxygen tubing should have been changed on 07/18/2021. LVN 7 also stated oxygen tubing is changed weekly for infection control purposes and to ensure cleanliness in the oxygen tubing.
A review of the facility policy and procedures titled, Departmental (Respiratory Therapy)-Prevention of Infection with revised date of 11/2011, indicated one of the steps in the procedure for Infection Control Considerations Related to Oxygen Administration is to change the oxygen cannula and tubing every seven days ,or as needed.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide reason for refusal for pneumococcal vaccine (prevents infec...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide reason for refusal for pneumococcal vaccine (prevents infection of the lungs) and flu vaccine for one of five residents (Resident 185), and failed to provide current flu vaccine (prevents a highly contagious viral illness that infect the nose, throat, and lungs) information for one out of five (Resident 185) reviewed for immunization.
These deficient practices violated Resident 185's right to have current information in order to make an informed choice and the right to receive or not to receive pneumococcal vaccine. These deficient practices also had the potential for not tracking proof of immunization history of receiving and or declining vaccinations, which could spread infections.
Findings:
A review of Resident 185's admission Record (face sheet) indicated the resident was admitted to the facility on [DATE], with a diagnosis of, but not limited to, sepsis (blood infection), osteomyelitis (infection of the bone), and diabetes mellitus (a condition whereby the body is not able to regulate blood levels of sugar).
A review of Resident 185's admission assessment dated [DATE], indicated the resident was alert and oriented. Resident 185 needed one-person physical assistance for activities of daily living.
During a review of Resident 185's Pneumococcal Vaccination Consent Form dated 7/14/2021, the record indicated Resident 185 refused to the receive pneumococcal vaccine (prevents infection of the lungs). However, the record did not indicate the reason why Resident 185 refused the pneumococcal vaccine.
During a review of Resident 185's Influenza Vaccination Consent Form dated 7/14/2021, the record indicated Resident 185 refused to receive the influenza vaccine (prevents a highly contagious viral illness that infect the nose, throat, and lungs). However, the record did not indicate the reason why Resident 185 refused the influenza vaccine.
During an interview with the Infection Preventionist (IP), on 7/25/2021 at 10:29 a.m., the IP stated there was no documentation for the reason for declining the pneumococcal vaccine and influenza vaccine. IP further stated that there should be a specific reason for declining the vaccination.
During the same interview with the IP, he stated the facility is giving an influenza vaccine information statement (VIS) as an educational material for influenza vaccine. A copy of the influenza VIS given to Resident 185 indicated a date of 8/7/2015. A review of the Center for Disease Control (CDC) website (https://www.cdc.gov/vaccines/hcp/vis/vis-statements/flulive.pdf) indicated the current influenza VIS is dated 8/15/2019.
MINOR
(B)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected multiple residents
Based on observation, interview, and record review, the facility failed to ensure that the staffing information posted in the facility on 7/24/2021 was accurate and reflected the actual number of staf...
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Based on observation, interview, and record review, the facility failed to ensure that the staffing information posted in the facility on 7/24/2021 was accurate and reflected the actual number of staffs working who are directly responsible for the resident care per shift.
This deficient practice resulted to inaccurate information being provided to residents` and visitors and has the potential to affect the delivery of care and services.
Findings:
During an observation on 7/24/2021 at 7:29 a.m., the facility's Nurse Staffing Information was observed posted at the front desk. The date on the Nurse Staffing Information form was noted to be 7/15/2021.
During an interview on 7/24/2021 at 10:11 a.m., the Director of Staff Development (DSD) confirmed that the Nurse Staffing Information posted at the front desk was not updated. DSD stated that he was the only person updating the facility staffing information and that confirmed it was not done as per the facility policy and procedure.
A review of facility's policy titled Posting Direct Care Daily Staffing Numbers Policy and Procedure, revised 7/2016, indicated that within two hours of the beginning of each shift, the number of licensed nurses and the number of unlicensed nursing personnel directly responsible for the resident care will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most California facilities.
- • 31% turnover. Below California's 48% average. Good staff retention means consistent care.
Concerns
- • 70 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 60/100. Visit in person and ask pointed questions.
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About This Facility
What is Casitas's CMS Rating?
CMS assigns CASITAS CARE CENTER an overall rating of 3 out of 5 stars, which is considered average nationally. Within California, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Casitas Staffed?
CMS rates CASITAS CARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 31%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Casitas?
State health inspectors documented 70 deficiencies at CASITAS CARE CENTER during 2021 to 2025. These included: 67 with potential for harm and 3 minor or isolated issues. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.
Who Owns and Operates Casitas?
CASITAS CARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by CAMBRIDGE HEALTHCARE SERVICES, a chain that manages multiple nursing homes. With 99 certified beds and approximately 91 residents (about 92% occupancy), it is a smaller facility located in GRANADA HILLS, California.
How Does Casitas Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, CASITAS CARE CENTER's overall rating (3 stars) is below the state average of 3.1, staff turnover (31%) is significantly lower than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Casitas?
Based on this facility's data, families visiting should ask: "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?"
Is Casitas Safe?
Based on CMS inspection data, CASITAS CARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in California. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Casitas Stick Around?
CASITAS CARE CENTER has a staff turnover rate of 31%, 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 Casitas Ever Fined?
CASITAS CARE CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Casitas on Any Federal Watch List?
CASITAS CARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.