What is CAMINO HEALTHCARE's CMS rating?

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

How many inspection deficiencies does CAMINO HEALTHCARE have?

CAMINO HEALTHCARE has 61 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at CAMINO HEALTHCARE?

CAMINO HEALTHCARE has a three-star staffing rating from CMS with 0.35 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is CAMINO HEALTHCARE located?

CAMINO HEALTHCARE is located in HAWTHORNE, CA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does CAMINO HEALTHCARE have?

CAMINO HEALTHCARE has 99 certified beds.

Who owns CAMINO HEALTHCARE?

CAMINO HEALTHCARE is a for profit - limited liability company facility and is part of the THE ENSIGN GROUP chain.

Is CAMINO HEALTHCARE safe?

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

Do nurses at CAMINO HEALTHCARE stick around?

CAMINO HEALTHCARE has average staff turnover at 46%, which is typical for the nursing home industry.

Was CAMINO HEALTHCARE ever fined?

No, CAMINO HEALTHCARE has no federal fines on record, indicating a clean compliance history with Medicare and Medicaid requirements.

Is CAMINO HEALTHCARE on any federal watch list?

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

What have inspectors found at CAMINO HEALTHCARE?

Medicare inspectors have found 61 deficiencies at CAMINO HEALTHCARE: 2 serious, 59 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting CAMINO HEALTHCARE?

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

How does CAMINO HEALTHCARE compare to other nursing homes?

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

CAMINO HEALTHCARE | 40/100 (Grade D)

Aug 2025 2 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · 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 and accident-free environment for one ...

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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 and accident-free environment for one of three sampled residents (Resident 1), who had impaired functional mobility (a reduction in a person's ability to move independently and perform daily activities) by failing to: -Ensure Certified Nursing Assistants (CNAs) 1 and 2 transferred Resident 1 from the wheelchair to Resident 1's bed by using appropriate assistive device (any item, piece of equipment that are designed to help individuals with disabilities increase, maintain, or improve their functional capabilities) such as the Hoyer lift (a mechanical device used to safely transfer patients who have limited mobility from one surface to another, such as from a bed to a chair or wheelchair) as indicated in Resident 1's untitled care plan dated 2/1/2025. This deficient practice resulted in Resident 1 screaming out in pain on 7/16/2025, when CNAs 1 and 2 transferred Resident 1 from the wheelchair to Resident 1's bed. Resident 1 also experiencing right foot pain and swelling to the right lower extremity, and was transferred to the General Acute Care Hospital (GACH) on 8/2/2025 where Resident 1 was diagnosed with a right trimalleolar fracture (a break in all three bony prominences of the ankle [medial {inner ankle}, lateral {outer ankle} and posterior {back part of shin}], a serious type of ankle fracture requiring surgical intervention). At the GACH Resident 1 received general anesthesia (a drug-induced state of unconsciousness, typically used for major surgical procedures) and had an open reduction and internal fixation (ORIF- a type of surgery used to stabilize and repair broken bones; some form of hardware is used to hold the bone together so it can heal) surgery of the right ankle. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total paralysis to one side of body) and hemiparesis (slight muscle weakness or partial paralysis) affecting both right and left (dominant) side, muscle wasting and atrophy (gradual decline in effectiveness and causing a person or a part of the body to become progressively weaker). During a review of Resident 1's untitled care plan, dated 2/1/2025, the care plan indicated Resident 1 had Impaired Functional Mobility with Activities of Daily Living (ADL) self-care deficit. The care plan goal indicated to reduce the risk of complications related to impaired mobility. The care plan interventions indicated the facility would use the appropriate assistive device (non-specified) and provide a level of assistance that meets the residents' needs. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/21/2025, the MDS indicated Resident 1 was usually able to express ideas and usually able to understand others. The MDS indicated required substantial / maximal assist (helper did more than half the effort) from sitting to lying, was not able to stand or walk 10 feet, and was dependent (helper does all the effort) on staff to transfer from chair to bed. During a review of Resident 1's Occupational Therapy (OT, a branch of health care that helps people of all ages who have physical, sensory, or cognitive problems) Progress Report for certification period 5/26/2025 - 6/22/2025, the report indicated Resident 1 used a Hoyer lift for transfers.During a review of Resident 1's Physical Therapy (PT, a healthcare profession focused on improving movement and function through various techniques like exercise, manual therapy, and education) Progress Report for certification period 5/26/2025 - 6/22/2025, the report indicated Resident 1's baseline was total dependence with bed mobility. The report indicated Resident 2 was mostly bedbound and occasionally up in her wheelchair via Hoyer lift. The report indicated Resident 1 needed maximum assistance with bed mobility and was non-ambulatory for a long time. During a review of Resident 1's Transfer Level Notes, undated, the notes indicated Resident 1 required a Hoyer lift for transfer. During a review of Resident 1's July 2025 Medication Administration Record (MAR), the MAR indicated from 7/1 - 7/15/2025 Resident 1 received Tramadol (medication used to treat moderate pain in adults) 50 milligrams (mg, unit of measurement) four times out of fifteen days. The MAR indicated on 7/10/2025 Resident 1's highest pain rating score during this time was a 6 out of 10, using the zero to ten pain scale (zero indicating no pain and 10 indicating most severe pain, 6 indicated moderate pain) and there was no location of the pain documented. During a review of Resident 1's MAR dated 7/16/2025 at 2:43 p.m. (date of transfer incident), the note indicated Resident 1 was given Tramadol 50 mg for complaint of body pain rated at seven out of 10 (seven indicated strong / severe pain). During a review of Resident 1's MAR dated from 7/16 - 7/31/2025, Resident 1 received Tramadol 50 mg fourteen times out of sixteen days (almost every day). The MAR indicated Resident 1's highest pain rating score of seven on 7/16 for body pain, 7/23 for knee pain with no score, and 7/28/2025 for feet pain with no score documented. During a review of Resident 1's Nursing Note, dated 7/31/2025 (two weeks after Resident 1 screamed out in pain), the note indicated FM 1 was concerned about swelling to Resident 1's ankles. The nursing note indicated, FM 1 requested an X-ray (photographic or digital image of the internal part of the body) to be sure, and Resident 1's Physician / Medical Doctor (MD) 1 ordered a STAT (immediate) X-ray to both ankles. During a review of Resident 1's Radiology Results Report, dated 7/31/2025, the report indicated Resident 1 had an acute mildly displaced fracture of the right medial malleolus (bone on the inner side of the ankle) and an acute nondisplaced fracture of the lateral malleolus (bone on the outer side of the ankle). The Radiology Results Report indicated Resident 1's fracture appeared recent. During a review of Resident 1's Change in Condition (COC, a noticeable alteration in a person's physical or mental state, or in the circumstances surrounding a situation, often triggering a [NAME] for reassessment or intervention) Evaluation, dated 8/1/2025, the evaluation indicated FM 1 reported after Resident 1 went to a doctor's appointment on 7/16/2025, CNAs 1 and 2 tried to transfer Resident 1 back to bed. The COC evaluation indicated while FM 1 was outside of Resident 1's room, FM 1 heard Resident 1's scream. FM 1 entered the room and asked Resident 1 what happened. Resident 1 reported that her leg hurts so bad. FM 1 stated Resident 1 had complained of pain since that time (7/16/2025). The COC evaluation indicated FM 1 requested an X-ray and the X-ray result indicated a fracture of Resident 1's right ankle. The COC evaluation indicated the Nurse Practitioner ordered to transfer Resident 1 to the hospital (GACH). During a review of the GACH Emergency Department (ED) Physical Exam Note dated 8/2/2025, the ED note indicated Resident 1 had significant right lateral malleoli (outer ankle) tenderness to palpitation and right foot swelling. The ED note indicated at 2:15 p.m., Resident 1 received Morphine Sulfate (a controlled substance to treat severe pain) 2 mg intravenous (into a vein) for severe pain rated at 7-10, received Norco 5/325 one tablet (an opioid pain reliever), for moderate pain, received Tylenol 650 mg for mild pain, and Ambien (a sedative, hypnotic medication). The ED note indicated Resident 1's Radiology Results and findings indicated soft tissue swelling with fracture of medial malleolus (inner ankle), distal fibula (outer side of ankle, resulting from twisting or rolling the ankle, or from a direct impact), and posterior tibia (break in back part of shin bone). The GACH ED Physical Exam note indicated the impression of Resident 1 was a trimalleolar fracture (a break in all three bony prominences of the ankle [medial, lateral and posterior], a serious type of ankle fracture requiring surgical intervention). During a review of Resident 1's GACH Progress Notes, the notes indicated Resident 1 was admitted to the hospital on [DATE] and underwent an ORIF surgery of the right ankle on 8/3/2025. During a review of the GACH Operative Report dated 8/3/2025, the report indicated Resident 1's post-operative diagnosis as a right trimalleolar ankle fracture. During an interview on 8/5/2025 at 11:53 a.m., Family Member (FM) 1 stated Resident 1 went out to a doctor's appointment on 7/16/2025 and when she returned staff (CNA 1 and 2) transferred Resident 1 back to bed. FM 1 stated Resident 1 was bedbound (being confined to a bed due to illness or physical limitations) and was supposed to be transferred with a Hoyer lift. CNA 1 requested for another Certified Nursing Assistant (CNA 2) to come assist with the transfer. FM 1 stepped out into the hallway (to provide privacy) and the door was closed. FM 1 stated she heard Resident 1 scream, You broke my foot! FM 1 entered the room and found Resident 1 in bed crying and asking for pain medication. FM 1 asked CNA 1 what happened, and CNA 1 did not respond, shrugged his shoulders and left the room. On 7/31/2025 (15 days later) FM 1 noticed Resident 1's legs were swollen, reported it to the nurse (RN Supervisor) and requested an X-ray be done. FM 1 was notified the next day (8/1/2025) the Xray was completed and showed the right ankle was fractured. During a concurrent observation outside Resident 1's door and interview on 8/5/2025 at 12:40 p.m. - 1:30 p.m., the Director of Staff Development stated the red circle sticker outside a resident's door indicated two persons assist and the red heart sticker indicated Hoyer Lift. The observation outside Resident 1's door revealed there was a red heart which indicated the resident required a Hoyer lift with two persons assist for transfer. During an interview on 8/6/2025 at 10:50 a.m., CNA 1 stated that on 7/16/2025 he assisted transferring Resident 1 to the bed using a 2-person assist. CNA 1 stated Resident 1 had a red sticker outside her door which indicated a two-person assist. CNA 1 did not indicate if it was a red circle or a red heart. CNA 1 stated he and the assigned nurse (CNA 2) placed an arm under Resident 1's armpit and held her waistline, then transferred Resident 1 to bed. CNA 1 stated if you (staff in general) do not use the right technique to transfer a resident they can be injured. During an interview on 8/6/2025 at 1:43 p.m., the Registered Nurse Supervisor (RN) stated Resident 1 was assessed on 7/31/2025 and Resident 1 complained of soreness when the right ankle was touched. The RN stated, This was a new injury and how it happened was unknown. The RN stated FM 1 then told the RN (on 7/31/2025) that when staff (CNAs 1 and 2) were transferring Resident 1 back to Resident 1's bed on 7/16/2025, FM 1 heard Resident 1 scream My leg is hurting. The RNS stated FM 1 informed RN that Resident 1 complained of pain since that day (7/16/2025). During a concurrent observation of Resident 1's legs and interview on 8/7/2025 at 11:55 a.m. with Resident 1, Resident 1 was observed in bed with a splint to the right lower leg/ankle. Resident 1 stated on the date of incident (7/16/2025) staff called in a tall man (CNA 1) to help transfer her to bed from the wheelchair. Resident 1 stated, The guy, grabbed Resident 1's feet and the lady (CNA 2) grabbed her shoulders. Resident 1 stated when the CNA 1 grabbed her feet during the transfer she screamed. Resident 1 stated FM 1 entered the room right away and asked why she was crying. Resident 1 stated, He hurt my foot. Resident 1 stated staff (in general) have not transferred her like that, before and all that night (7/16/2025) she had right foot pain. Resident 1 stated staff (in general) used a Hoyer lift to transfer her and that when Resident 1 found out the ankle was fractured, she cried.During an interview on 8/7/2025 at 1:40 p.m., the Director of Staff Development (DSD) stated the proper technique for a 2-person transfer from wheelchair to bed was to have a staff member on both sides under the resident's arm, so the weight was evenly distributed, then stand and pivot in one or two steps to move the resident to the bed. The DSD stated staff should not have transferred Resident 1 by grabbing her feet and another person on her shoulders, because this method could not properly transfer the resident to bed. The DSD stated when staff used the wrong transfer technique the resident can be injured or dropped (fallen). The DSD stated Resident 1 could be transferred using a 2-person assist technique or using a Hoyer lift. The DSD stated Resident 1 was able to provide accurate information and was very precise on the description of CNA 1. The DSD stated Resident 1 was bedbound, did not stand, and did not walk, so it was not typical to get an ankle fracture if you did not walk. The DSD stated it was not okay for Resident 1 to be injured by staff during care. During the review of the facility investigative document, undated, received to the Department on 8/7/2025, the document indicated Resident 1 was noted as a two-person assist or Hoyer lift transfer. The document indicated CNA 2 was interviewed and stated, On the afternoon of 7/16/2025, she transferred Resident 1 back to bed with another CNA (CNA 1) for assistance. The investigative document indicated CNA 2 stated Resident 1 complained of toe pain, but CNA 2 was not aware the resident bumped her foot. CNA 2 stated she went to get the charge nurse (unidentified) who gave Resident 1 pain medication. CNA 2 stated Resident 1 complained of soreness to the right ankle on 7/30/2025. The document indicated Resident 1 was interviewed and stated, I hurt my foot when they (CNA 1 and 2) were transferring me when I came back from my doctor's appointment (on 7/16/2025). The document indicated the facility ruled out abuse and injury of unknown origin. Policies and procedures for the Use of Hoyer Lift, Resident Transfer Techniques, Two Person Transfers were requested from the facility. Medical Records personnel and the facility Administrator stated the facility did not have these policies.During a review of the facility's P&P, titled Fall Management System, dated December 2023, the P&P indicated the facility would provide an environment that remains as free of accident hazards as possible. The P&P indicated to provide each resident with appropriate assessment and interventions to prevent accidents.

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report an unusual occurrence to the state agency. Fin...

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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 report an unusual occurrence to the state agency. Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with a readmission on [DATE]. Resident 1's diagnoses included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN- high blood pressure), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 1's History and Physical (H&P), dated 2/6/2025, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/22/2025, the MDS indicated Resident 1 was not able to stand, or walk 10 feet. Resident 1 was dependent (helper does all the effort) on staff to transfer from chair to bed.During a review of Resident 1's care plan, dated 2/1/2025, the care plan indicated Resident 1 had impaired mobility. The care plan interventions indicated the facility would use the appropriate assistive device. The facility would provide the level of assistance that meets the residents' needs. The Charge Nurse will be notified if the resident complained of pain when performing or receiving assistance.During a review of Resident 1's Physical Therapy Progress Report for certification period 5/26/2025-6/22/2025, the report indicated Resident 1 was mostly bedbound and occasionally up in her wheelchair via hoyer lift. The report further indicated Resident 1needed maximum assist with bed mobility and was non-ambulatory for a long time. Resident 1's baseline was total dependence with bed mobility.During a review of Resident 1's Occupational Therapy Progress Report for certification period 5/26/2025-6/22/2025, the report indicated Resident 1 used a hoyer lift for transfers.During a review of Resident 1's Radiology Results Report, dated 7/31/2025, the report indicated Resident 1 had a mildly displaced fracture of the right medial malleolus (bone on the inner side of the ankle) and a nondisplaced fracture of the lateral malleolus (bone on the outer side of the ankle).During a review of Resident 1's General Acute Care Hospital (GACH) records, dated 8/2/2025-8/4/2025, the records indicated Resident 1 was admitted to the hospital on [DATE] and underwent an open reduction and internal fixation (ORIF- a surgical procedure used to treat a bone fracture) of the right ankle on 8/3/2025.During an interview on 8/5/2025 at 11:53 a.m. with the Family Member (FM), the FM stated Resident 1 went out to a doctor's appointment on 7/16/2025 and when she returned staff transferred Resident 1 back to bed. The FM stated Resident 1 is bedbound (being confined to a bed due to illness or physical limitations) and is supposed to be transferred with a hoyer lift (a mechanical device used to safely transfer patients who have mobility limitations). Staff requested another Certified Nursing Assistant (CNA) to come assist with the transfer. The FM stepped out into the hallway and the door was closed. The FM heard Resident 1 scream You broke my foot. The FM entered the room and found Resident 1 in bed crying and asking for pain medication. The FM asked the CNA what happened, and the CNA did not respond, just shrugged his shoulders and left the room. On 7/31/2025 the FM noticed Resident 1's legs were swollen and reported it to the nurse. The FM requested an X-ray be done. The FM was notified the next day the Xray was completed and showed the right ankle was fractured. During an interview on 8/6/2025 at 10:50 a.m. with the CNA, the CNA stated on 7/16/2025 he assisted transferring Resident 1 to the bed using a 2-person assist. The CNA stated he and the assigned nurse placed an arm under Resident 1's armpit and held her waistline, then transferred her to bed. Resident 1 did not have complaints after being placed in bed. The CNA stated he received training on how to transfer residents during his CNA course. If you don't use the right technique to transfer a resident they can be injured. The CNA received training on use of the hoyer lift at the facility. During an interview on 8/6/2025 at 1:43 p.m. with the Registered Nurse (RN), the RN stated on 8/1/2025 X-ray results were received and indicated Resident 1 had a right ankle fracture. Resident 1 was assessed and there was no swelling, redness, or bruising noted on the ankle. Resident 1 complained of soreness when the right ankle was touched. The RN notified the FM Resident 1 had an ankle fracture and we don't know how it happened. The RN stated, This was a new injury and how it happened was unknown. The RN had not previously heard anything about the Resident having a fracture. The FM then told the RN staff were placing Resident 1 back to bed on 7/16/2025 and the FM heard Resident 1 scream. Resident 1 stated my leg is hurting. The RN stated this is a red flag because Resident 1 was complaining of pain and no one knew what happened. The RN stated the FM informed her Resident 1 has complained of pain since that day. The RN stated the signs of abuse are bruising, fractures, and swelling. Resident 1 has a fracture. The fracture is unknown, so it looks like it can possibly be abuse. The RN reported the fracture and information received from the FM to the Director of Nursing (DON). The DON just said okay, and she would continue the process. It was important to notify the DON because the DON needed to notify the Administrator (ADM). The ADM needs to report the incident to police, the state department, and the ombudsman. You must report it immediately to the state department so they will know there is abuse in the facility. You must report to ensure the resident is safe. The RN did not report the incident to state agencies because the DON did not inform her to. The DON and ADM usually report incidents to agencies.During an interview on 8/7/2025 at 10:57 a.m. with the DON, the DON stated she received the X-ray results on 7/31/2025. The doctor requested a repeat X-ray to confirm the findings. The DON started an investigation and completed and incident report because the incident was classified as an unusual occurrence. The DON refused to state when the investigation was started. The DON stated the FM told her someone hit Resident 1's foot on something. The DON stated the resident was injured in the facility. The DON stated the CNA used a 2-person transfer to assist Resident 1 back to bed. DON stated she cannot say with 100% certainty the resident's foot was hit on something. The DON stated the incident is not an injury of unknown origin, It's an unusual occurrence. Resident 1 said staff bumped her foot. Staff denied bumping Resident 1's foot. The DON stated she did not report the incident because they know how it happened. The DON trusts what Resident 1 told her. Injuries of unknown origin must be reported to the California Department of Public Health (CDPH) so someone can investigate to find out what happened. You should report within 24 hours. It takes a bit of force to cause a fracture. The fracture could have happened here or while she was out. Staff would know if Resident 1's foot got caught on something. The DON stated she trusts what Resident 1 told her because the resident is alert and oriented. During an interview on 8/7/2025 at 11:55 a.m. with Resident 1, Resident 1 stated on the date of incident staff called a tall man (confirmed by staff as the CNA) to help transfer her to bed. Resident 1 was in her wheelchair. The guy grabbed Resident 1's feet and a lady grabbed her shoulders. Resident 1 stated when the CNA grabbed her feet during the transfer she screamed. When Resident 1 screamed the FM entered the room and asked why she was crying. Resident 1 stated He hurt my foot. Resident 1 stated staff have not transferred her like that before. Resident 1 doesn't know what came in contact with her foot. Resident 1 stated staff sometimes use a hoyer to transfer her. Resident 1 had pain all night after the incident. When Resident 1 found out her ankle was fractured, she cried. During an interview on 8/7/2025 at 1:40 p.m. with the Director of Staff Development (DSD), the DSD stated the proper technique for a 2-person transfer from wheelchair to bed is to have a staff member on both sides under the resident's arm so the weight is evenly distributed, then stand and pivot in one or two steps to move the resident to the bed. Staff should not transfer someone by grabbing their feet and another person at their shoulders because you can't properly transfer the resident to bed. If you use the wrong transfer technique the resident can be injured or dropped. The staff receives information on how a resident needs to be transferred from the rehab department. The DSD stated the Resident 1 can be transferred using a 2-person assist or using a hoyer. Resident 1 is able to provide accurate information and was very precise on the description of the CNA. DSD stated Resident 1 and staff are telling different stories, so she can't confirm what happened. The DSD can't say 100% but thinks something was bumped during the transfer. The DSD stated it's not common for a resident to be injured during transfer or while receiving care. It shouldn't happen. You shouldn't be bumped. Something had to have happened. Resident 1 is bedbound and doesn't stand. Resident 1 doesn't walk, so it is not typical to get an ankle fracture if you don't walk. The DSD thinks the source of the injury was something that occurred during transfer. It's not okay for a resident to be injured by staff during care. The DSD didn't report the incident when she heard about it because the resident's story made sense. You should report if the reason for the injury is unknown. The DSD stated due to this incident occurring the facility plans to have the rehab department provide training on proper transfer techniques. During an interview on 8/7/2025 with the ADM, the ADM stated staff reported to him Resident 1's leg was bumped during transfer. The ADM stated he didn't feel he needed to report the incident because the resident told them what happened. Stated he can't say with complete certainty the injury occurred in the stated manner. Further stated, if it's unknown how an injury occurred, it should be reported to CDPH, ombudsman, and police, the same as abuse, within 2 hours.During a review of the facility's policy and procedure (P&P), titled Abuse: Prevention of and Prohibition Against, dated April 2025, the P&P indicated allegations of abuse/neglect will be reported to the appropriate State or Federal agencies in the applicable timeframes.During a review of the facility's P&P, titled Unusual Occurrence, dated January 2021, the P&P indicated unusual occurrences shall be reported within 24 hours to the local health officer and the department. The P&P further defined unusual occurrences as those that threaten the welfare, safety, or health of patients.During a review of the facility's P&P, titled Resident Rights: Elder Justice Act Reporting, dated October 2011, the P&P indicated reasonable suspicion of crimes against individuals receiving care from a skilled nursing facility must be reported as required by the Elder Justice Act. The incident must be reported to local law enforcement and the State Survey Agency within two hours if the alleged victim sustained serious bodily injury, or within 24 hours if the victim did not sustain serious bodily injury.

May 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 F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed ensure the Post Discharge Plan of Care was completed and contained the...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed ensure the Post Discharge Plan of Care was completed and contained the amount and lists of post discharge medications, for 1 of 4 sampled residents (Resident 1) who was discharged to a Board and Care facility ([B&C] a small residential facility, often referred to as a residential care facility for the elderly (RCFE) or assisted living facility, that provides room, board, and personal care services for a small group of individuals, typically 6 to 10 residents), as indicated in the facility ' s policy and procedure (P&P) titled Discharge Summary. This failure resulted in Resident 1 being discharged with 78 controlled medications (drug prescription specifically regulated by the government due to potential for abuse or harm) and placed the resident at risk for drug overdose, hospitalization and death. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of Alzheimer ' s disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain), cardiomegaly (occurs when the heart is abnormally thick or overly stretched), difficulty walking and a history of falling. During a review of Resident 1 ' s Minimum Data Set (MDS -a resident assessment tool) dated 2/9/2025, the MDS indicated Resident 1 had clear speech, had difficulty communicating some words or finishing thoughts but was able, if prompted or given time, and usually understands. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching assistance as resident completes the activity) with eating, oral hygiene, and personal hygiene. During a review of Resident 1 ' s Order Summary Report, dated 3/1/2025, the order summary report indicated a physician order of Norco (strong pain medicine) oral tablet 5-325 milligrams ([mg] a unit of measurement), give 1 tablet by mouth every 4 hours as needed for moderate pain (4-6) (a numerical pain scale used in a facility with 0 no pain, 1-3 mild pain, 4-6 moderate pain, 7-8 severe pain, 9-10 worst pain possible), and give 2 tablets by mouth every 4 hours as needed for severe pain (7-10). During a review of Resident 1 ' s Controlled Medication Count Sheet, the count sheet indicated the facility received 81 tablets of Norco 5-325 mg on 3/30/2025 and dispensed 2 tablets of Norco 5-325 mg on 3/30/2025 for severe pain. The count sheet indicated Norco 5-325 mg 1 tablet was dispensed on 3/31/2025 for moderate pain. The bubble pack (a pack containing medications) had a total of 78 Norco 5-325 mg tablets left. During a review of Resident 1 ' s physician order dated 4/2/2025, at 9:25 a.m., the physician order indicated may discharge Resident 1 home per family request on 4/2/2025. The physician order did not indicate the name of medication or amount of medication to provide upon discharge. The physician order had a printed date of 2/14/2025, at 10:15 a.m. During a review of Resident 1 ' s Post Discharge Plan Of Care (DC plan document), dated 4/2/2025, the DC plan document indicated the discharge planning was developed with the responsible party and Resident 1 was being transferred to a B&C facility. The medication section of the DC plan document was left blank indicating See med charts. The DC plan document did not indicate the name of medications, frequency, special instructions or the amount of medications released. The DC plan document had no name of the Interdisciplinary Team (IDT) representative who completed the Post Discharge Plan of Care document, was undated and did not indicate signature who accepted the Post Discharge Plan of Care. During a review of Resident 1 ' s Transfer/Discharge Report, dated 5/14/2025, the report indicated a list of Resident 1 ' s current medications and the date and time last of administration. The Transfer/Discharge Report did not indicate the name and amount of each medication provided to resident/resident family. During a telephone interview on 5/20/2025 at 1:15 p.m., with Resident 1 ' s family member (FM 1), FM1 stated the B&C facility received 81 tables of Norco several days before Resident 1 was discharged (date unspecified). FM 1 stated the facility provided 75 tablets of Norco on the day of discharge. FM 1 stated she felt the facility had committed fraud and was stealing resident ' s narcotics. During a concurrent interview and record review on 5/22/2025 at 10:55 a.m. with Licensed Vocational Nurse (LVN 2), Resident 1 ' s physician order dated 4/2/2025, at 9:25 a.m., indicating may discharge Resident 1 home per family request on 4/2/2025 was reviewed. LVN 2 stated there was a new discharge order (date not known) found that indicated to discharge home with all medications. The newly found discharge order with all medications did not specify any medications. During a telephone interview on 5/22/2025 at 3:40 p.m. with Resident 1 ' s attending physician, the Attending Physician stated he and his Nurse Practitioner were not informed of the medications Resident 1 was discharging home with. The Attending Physician stated he would not discharge Resident 1 home with Norco because it ' s a narcotic and too harmful. During a telephone interview on 5/23/2025 at 2 p.m. with the discharging Registered Nurse (RN 1), RN 1 recalled Resident 1 had a physician order to discharge home with all medications. RN 1 was unable to recall the specific medications and amount of medications Resident 1 was discharged with. RN 1 stated the normal process of discharging a resident with a narcotic was to indicate amount of narcotic on Transfer/Discharge Report and Discharge Summary and have the resident sign and date when received. RN 1 stated the Transfer/Discharge Report and Discharge Summary had inaccurate documentation because she was in a hurry and did not want Resident 1 and FM waiting. RN 1 stated not indicating the amount of Norco dispensed during Resident 1 ' s discharge had the potential to cause drug overdose and respiratory depression which could lead to death. During a review of the facility ' s P&P titled Discharge Summary, dated 12/2023, the P&P indicated it is the policy of this facility that a discharge summary be prepared when a resident is expected to be discharged . The P&P indicated when the facility anticipated a resident ' s discharge, the discharge summary should include a reconciliation of all pre-discharge medications with the resident ' s post discharge medications (both prescribed and over the counter).

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 ensure the Norco (strong pain medicine) medication removed on 3/1 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 ensure the Norco (strong pain medicine) medication removed on 3/1 at 5 p.m., 3/13 at 4 p.m., 3/14 at 9 p.m., and the 2 tablets on 3/18 (no years indicated), as indicated in the Controlled Medication (drug prescription specifically regulated by the government due to potential for abuse or harm) Count Sheet dated 8/5/2024, for 1 of 4 sampled residents (Resident 1), were documented in the resident ' s e-MAR (Electronic Medication Administration Record) . This failure had the potential to cause drug diversion (unlawful use of drugs), healthcare personnel miscommunication and cause the resident, drug overdose. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of Alzheimer ' s disease (progressive mental deterioration that can occur in middle or old age, due to generalized degeneration of the brain), cardiomegaly (occurs when the heart is abnormally thick or overly stretched), difficulty walking and a history of falling. During a review of Resident 1 ' s Minimum Data Set (MDS -a resident assessment tool) dated 2/9/2025, the MDS indicated Resident 1 had clear speech, difficulty communicating some words or finishing thoughts but was able, if prompted or given time, and usually understands. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching assistance as resident completes the activity) with eating, oral hygiene, and personal hygiene. During a review of Resident 1 ' s Order Summary Report, dated 3/1/2025, the order summary report indicated a physician order of Norco oral tablet 5-325 milligram (mg- a unit of measurement), give 1 tablet by mouth every 4 hours as needed for moderate pain (4-6) (a numerical pain scale used in a facility with 0 no pain, 1-3 mild pain, 4-6 moderate pain, 7-8 severe pain, 9-10 worst pain possible), and give 2 tablets by mouth every 4 hours as needed for severe pain (7-10). During a review of Resident 1 ' s Controlled Medication Count Sheet, dated 8/5/2024, the count sheet indicated a licensed staff removed one tablet of Norco 5/325 mg on 3/1 at 5 p.m. (no year indicated), 3/13 at 4 p.m. (no year indicated), 3/14 at 9 p.m. (no year indicated), and two (2) tablets on 3/18 at 10 p.m. (no year indicated). During a review of Resident 1 ' s March 2025 e-MAR, the e-MAR did not indicate Resident 1 received Norco 5/325 mg, one tablet on 3/1 at 5 p.m., 3/13 at 4 p.m., 3/14 at 9 p.m., and the 2 tablets on 3/18 at 10 p.m. During a concurrent interview and record review on 5/22/2025 at 10:55 a.m., with the Licensed Vocational Nurse (LVN 2), Resident 1 ' s Controlled Medication Count Sheet, dated 8/5/2024, for the medication Norco 5/325 mg, and the MAR for March 2025 were reviewed. LVN 2 stated nurses did not sign the e-MAR to reflect what was removed from the narcotic count sheet. LVN 2 stated not signing the e-MAR may result to drug overdose, altered level of consciousness and harm the resident. During a review of the facility ' s policy and procedure (P&P) titled Medication Administration Controlled Medications, dated 5/2020, the P&P indicated when a controlled medication is administered, the licensed nurse administering the medication should immediately enter all the following information on the accountability record after the medication is actually administered. · Date and time of administration. · Amount administered. · Signature of the nurse administering the dose.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement its policy and procedure (P&P) titled Infect...

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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 and procedure (P&P) titled Infection Control Policy/Procedure, by failing to disinfect the wrist blood pressure monitor before and after use, by 1 of 4 sampled residents (Resident 2). This failure had the potential to spread germs and increase the risk of infections among residents and staff. Findings: During a concurrent observation and interview on 5/14/2025 at 10:05 a.m. with the Licensed Vocational Nurse (LVN 1) at Resident 2 ' s bedside, LVN 1 was observed putting the wrist blood pressure monitor on Resident 2 ' s wrist, had several attempts to check and was unsuccessful in obtaining the blood pressure readings. LVN 1 removed the monitor from the resident ' s wrist, put the blood pressure monitor inside the drawer of the Medication cart 1 without disinfecting. LVN 1 stated she failed to disinfect the wrist blood pressure monitor before and after using on the resident. LVN 2 stated failing to disinfect the wrist blood pressure monitor may spread germs and increase the risk of infection. During an interview on 5/14/2025 at 1:10 p.m. with the Infection Preventionist Nurse (IPN), the IPN stated failure to clean the wrist blood pressure monitor before and after use will increase the risk of spreading a communicable disease to the residents. During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and was re-admitted on [DATE]. Resident 2 ' s diagnoses included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change), chronic obstructive pulmonary disease (COPD- is a lung disease that makes it difficult to breathe), and muscle weakness. During a review of Resident 2 ' s Minimum Data Set (MDS - resident assessment tool), dated 3/12/2025, the MDS indicated Resident 2 had clear speech, difficulty communicating some words or finishing thoughts but is able if prompted or given time, and usually understood. The MDS indicated Resident 2 was dependent on staff for assistance with eating, toileting hygiene and personal hygiene. During a review of Resident 2 ' s care plan, no title, date initiated 3/28/2024, the care plan indicated Resident 2 had actual impairment to skin integrity related to left hip wound infection. The care plan goals indicated Resident 2 will have no complications related to skin injury/infection. One of the interventions indicated to avoid scratching and keeping hands and body parts from excessive moisture, keeping fingernails short, and educate resident/family/caregivers of causative (effective or operating as a cause or agent) factors and measures to prevent skin injury. During a review of the facility ' s undated P&P titled, Infection Control Policy/Procedure, the P&P indicated it is the policy of this facility to provide supplies and equipment that are adequately cleaned, disinfected or sterilized. The P&P indicated supplies, and equipment should be cleaned immediately after use.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide an environment free of accident hazards as possible for two...

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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 an environment free of accident hazards as possible for two of three residents (Residents 2 & 3), by failing to: 1. Ensure Resident 2 ' s care plan was individualized with interventions provided after the fall on 4/1/2025. 2. Conduct an Interdisciplinary Team ([IDT] group of healthcare professionals, including resident/ resident representative, working together to provide residents with needed care) to discuss safety interventions after Resident 2 ' s fall on 4/1/2025. 3. Conduct an accurate fall risk assessment after Resident 3 ' s fall on 1/26/2027. Resident 3. 4. Implement the rehabilitation services recommendations after Resident 3 ' s fall on 2/7/2025 which indicated to apply bed railings, and cushion pad along the bedside to reduce the risk of falls and soften fall. These failures placed Residents 2 and 3 at risk for severe injury, hospitalization and death. Findings: 1). During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses of muscle weakness and cognitive communication deficit (occurs when communication problems are caused by issues with cognitive processes like attention, memory, rather than speech or language difficulties). During a review of Resident 2 ' s Fall Risk Evaluation dated 9/12/2024, the fall risk evaluation indicated Resident 2 was at high risk for falls. During a review of Resident 2 ' s Minimum Data Set ([MDS], a resident assessment tool), dated 3/19/2025, the MDS indicated Resident 2 was sometimes able to understand and be understood by others. The MDS indicated Resident 2 required supervision for eating, and upper body dressing. The MDS indicated Resident 2 required set up for eating, oral hygiene, upper body dressing, and personal hygiene. The MDS indicated Resident 2 required supervision for toileting hygiene, lower body dressing, for putting/on taking off footwear and required moderate assistance for showers. The MDS indicated Resident 2 required setup with rolling left to right, sitting to lying/lying to sitting on side of bed, and supervision for chair/bed-to-chair transfer, tub/shower transfer, and walking 10, 50 and 150 feet. During a review of Resident 2 ' s Change of Condition (COC) dated 4/1/2025 at 10:46 a.m., the record indicated Resident 2 had a witnessed fall when Resident 2 had a witnessed fall. During a review of Resident 2 ' s Care Plan titled Resident 2 had a fall with no injury with no injury, revised 4/1/2025, the interventions indicated to check range of motion and report mental changes. During a concurrent interview and record review on 4/30/2025 at 9:36 a.m. with LVN 1, Resident 2 ' s Care Plan, revised 4/1/2025, LVN 1 stated the record did not include interventions did not address when Resident 2 sled off his wheelchair. LVN 1 stated the interventions should have included elevating the resident ' s legs with pillows to prevent the resident from sliding down the wheelchair. LVN 1 stated there was no IDT meeting conducted after the fall. LVN 1 stated Resident 2 ' s care plan was not individualized and did not focus on the causes why Resident 2 sled down his wheelchair. 2). During a review of Resident 3 ' s admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses of difficulty walking and low back pain. During a review of Resident 3 ' s Care Plan titled Resident 3 had an actual fall with no injury, poor balance, poor communication/comprehension, unsteady gate, dated 1/26/2025, one of the interventions indicated to provide floor mat and determine and address causative factor for the fall. During a review of Resident 3 ' s fall risk assessment after the fall on 1/26/2025, the fall risk assessment did not reflect the fall Resident 3 had on 1/26/2025. During a review of Resident 3 ' s MDS, dated [DATE], the MDS indicated Resident 3 was able to understand and be understood by others. The MDS indicated Resident 3 required supervision for eating, and upper body dressing and substantial assistance (helper lifts, holds, or supports trunk or limbs, and provides more than half the effort) with oral hygiene, and upper dressing. The MDS indicated Resident 3 was dependent with showers, lower body dressing and putting on/taking off footwear. The MDS indicated Resident 3 required supervision with rolling left to right, moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) sit to lying, lying to sitting on side of bed and substantial assistance with sitting to standing, chair/bed-to-chair transfer, and walking 10 feet. During a review of Resident 3 ' s COC dated 2/7/2025 at 12:00 a.m., the COC indicated Resident 3 was observedon the floor, on his back, next to his bed. The COC indicated that Resident 3 verbalized he rolled over and fell on the floor. During a review of Resident 3 ' s Rehabilitation Service Screening Tool dated 2/7/2025 at 1:50 p.m., the notes indicated Resident 3 reported he fell out of bed two times. The notes indicated the resident reported he tried to stay off his wound, but he felt he was at risk of falling because his bed had no barriers. The notes indicated recommendations for bed railings, and cushion pad along the bedside to reduce the risk of falls and soften fall. During a concurrent interview and record review on 4/30/2025 at 9:36 a.m. with Licensed Vocational Nurse (LVN 1), Resident 3 ' s Fall Risk Evaluation dated 1/26/2025 at 6:45 a.m. was reviewed. LVN 1 stated the fall risk evaluationdid not reflect the fall Resident 3 had on 1/26/2025. LVN 1 stated Resident 3 had a poor balance and did not reflect in the fall risk assessment which resulted in the resident being a medium risk for falls. LVN 1 stated Resident 3 was on Lasix (water pill that may reduce blood pressure), Lisinopril (medication that lowers blood pressure), and Amitriptyline (medication used for low mood and to help sleep) which could cause drowsiness and increase the resident ' s risk of falling. LVN 1 stated if the fall risk evaluation was conducted correctly, the assessment would have indicated Resident 3 was at a higher risk for falls. LVN 1 stated that it was important to have a correct fall evaluation to identifyResident 3 ' s risk for falling and i appropriate interventions will be implemented. LVN 1 stated there was no care plan created after the fall on 2/7/2025, and placedResident 3 at higher risk of falls because there were no interventions to prevent him from falling. During a concurrent observation, interview, and record review on 4/30/2025 at 12:54 p.m., with Physical Therapy (PT), Resident 3 ' s Rehabilitation Service Screening Tool dated 2/7/2025 at 1:50 p.m., PT stated the record indicated Resident 3 rolled off the bed and the recommendation was to place bed railings, and cushion pad along bedside to reduce the risk of falls and soften fall. PT stated there were no bed railings, no cushion pads and no floor mats noted in Resident 3 ' s room. PT stated not implementing interventions could lead to additional falls and they could lead to injury and hospitalization. During a review of the facility ' s policies and procedures (P&P) titled, Fall Management System, dated 11/2021, the P&P indicated the facility should provide residents with appropriate assessments and interventions to prevent and to minimize falls and complications. The P&P indicated that the IDT would review and updated care plan and would reassess resident for fall risks.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain a safe and hazard free environment for one of...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain a safe and hazard free environment for one of 9 sampled residents (Resident 1) by failing to: 1) Implement its Policy and Procedure (P&P) titled, Smoking Policy which indicated, no cigarette/tobacco products were allowed to be kept in the possession of the residents. 2) Review, update and document a quarterly Smoking Evaluation for the resident. 3) Ensure Resident 1's smoking Care Plan had current and accurate interventions. These failures had the potential to endanger the health and safety of residents, staff and visitors. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 1's diagnoses included nicotine dependence (a chronic condition characterized by a compulsive and uncontrollable urge to use tobacco products containing nicotine, despite negative consequences), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing) and chest pain. During a review of Resident 1's Minimum Data Set (MDS -a resident assessment tool) dated 3/16/2025, the MDS indicated Resident 1 had clear speech, the ability to express ideas and wants, and had clear understanding. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with upper and lower body dressing and was independent with eating. During a review of Resident 1's Smoking Evaluation dated 11/05/2024, the Evaluation indicated Resident 1 liked to smoke in the morning, afternoon, evening, and smoked 6 times a day. The Smoking Evaluation indicated Resident 1 was educated on safe smoking practices and able to locate the designated smoking area. During a review of Resident 1's Medical Records, the Records did not indicate Resident 1's Smoking Evaluation was completed reviewed and updated at least quarterly. During a review of Resident 1's smoking care plan dated 3/10/2025, the care plan indicated Resident 1 has a potential for injury related to smoking. The care plan goal indicated Resident 1 would have no injury related to smoking. The care plan interventions indicated nursing staff would complete smoking assessment, monitor to assess compliance with facility smoking policy/individual plan, and provide Resident 1 with metal lock box to safely maintain smoking materials in her possession. During a concurrent observation and interview on 04/14/2025 at 1:22 p.m. with the Registered Nurse (RN 1), at Resident 1's bedside, a pack of approximately 18 cigarettes was observed. RN 1 stated Resident 1 should not have the cigarettes in her possession because it was against the facility's policy and may jeopardize the resident's safety. There was no metal lock box observed at Resident 1's bedside. During telephone interviews on 04/22/2025 at 11 a.m. and 4/25/2025 at 12 p.m., with the Director of Nursing (DON), the DON stated Resident 1's Smoking Evaluation was last completed on 11/5/2024 and should have been done at least quarterly, however it was not done. The DON stated, the Smoking Evaluation should be done quarterly to evaluate Resident 1's safety to smoke. The DON stated Resident 1's care plan interventions to provide a lock box was an old rule and should not have been included as it conflicted the facility's policy which indicates residents should not have any smoking materials in their possession and to maintain the resident's safety. During a review of the facility P&P titled, Smoking Policy dated 12/2029, indicated it is the policy of this facility to provide those residents who choose to smoke a means in which to do so that does not jeopardize their safety or the safety of others residing in the facility. The P&P indicated, no lighting materials, tobacco products, or smoking devices will be allowed to be kept in the possession of the residents, either on their person or in the facility. The P&P indicated, upon quarterly review by the interdisciplinary team (IDT -involves professionals from various disciplines, including doctors, nurses, therapists, social workers, and others, working collaboratively to coordinate patient care), or at any time a significant change of condition occurs, smoking residents will be re-assessed as to their ability to smoke safely, either independently or under supervision, and their ability to understand and comply with facility non-smoking policy using the Smoking Assessment form.

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to notify one of three sampled residents ' (Resident 1) p...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to notify one of three sampled residents ' (Resident 1) physician, for the resident ' s scratch marks on the left hand. This deficient practice had the potential to worsen the skin condition when left untreated. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included cerebral infarction (a stroke, specifically the death of brain tissue due to a lack of blood flow), bipolar disorder (a mental health condition characterized by significant and persistent mood swings), and aphasia (a language disorder that affects a person ' s ability to communicate). During a review of Resident 1 ' s History and Physical (H&P), dated 4/1/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool), dated 2/27/2025, the MDS indicated Resident 1 had an unclear speech. The MDS indicated Resident 1 had difficulty communicating some words or finishing thoughts but is able if prompted or if given enough time. The MDS indicated Resident 1 misses some part or intent of the message but comprehends most of the conversation. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort/ helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for toileting hygiene, showering, and dressing. During an observation on 4/1/2025 at 11:00 a.m. in Resident 1 ' s room, there were two scratch marks on resident ' s left hand. During an interview on 4/1/2025 at 3:42 p.m. with Director of Staff Development (DSD), the DSD stated the staff have not done the resident ' s skin assessment and have not notified the physician. The DSD stated it was important to follow up with the physician to check if were any additional orders to treat the skin. During an interview on 4/1/2025 at 4:10 p.m. with Director of Nursing (DON), the DON stated the scratches were mentioned by the ADM during the time of the five-day investigation. The DON stated we should have done the skin assessment and obtained treatment order for the resident. The DON stated if the skin goes untreated the skin could get worse. During an interview on 4/1/2025 at 4:07 p.m. with the ADM, the ADM stated Resident 1 had scabbed scratches on her left hand. The ADM stated the DON and DSD were notified about the scratches on the resident ' s left hand. The ADM stated it was important to do a skin assessment and notify with the physician so there would be no complications of the resident ' s skin. During a review of the facility ' s policy and procedure (P&P) titled, Nursing Administration, dated 5/2020, the P&P indicated it is the policy of the facility that all changes in resident ' s conditions will be communicated to the physician. The P&P indicated the licensed nurse in charge will notify the physician.

CONCERN (D) 📢 Someone Reported This

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

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

Laboratory Services (Tag F0770)

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 three sampled residents ' (Resident 1), urinalysis (...

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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 three sampled residents ' (Resident 1), urinalysis ([UA]- a laboratory test that examines a urine sample to detect a urinary tract infection [UTI, infection in the urinary system-kidneys, bladder, urethra]) order was carried out and sent to the laboratory (facility conducting the urine test) per the physician ' s order. This deficient practice had the potential for delayed treatment if Resident 1 had an unidentified UTI. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE]. Resident 1 ' s diagnoses included cerebral infarction (a stroke, specifically the death of brain tissue due to a lack of blood flow), bipolar disorder (a mental health condition characterized by significant and persistent mood swings), and aphasia (a language disorder that affects a person ' s ability to communicate). During a review of Resident 1 ' s History and Physical (H&P), dated 4/1/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool), dated 2/27/2025, the MDS indicated Resident 1 had cognitive impairment. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for toileting hygiene, showering, and dressing. During a record review of Resident 1 ' s Change of Condition Evaluation (COC), dated 3/20/2025, the COC indicated Resident 1 had physical aggressive behavior towards staff on 3/20/2025. The COC indicated the physician recommendation was for Resident 1 to have a urinalysis (UA, urine test) done. During a review of Resident 1 ' s Order Summary Report, dated 3/20/2025, the Order Summary Reported indicated an order do UA with culture and sensitivity. During a concurrent interview and record review on 4/1/2025 at 3:31 p.m. with Director of Staff Development (DSD), Resident 1 ' s COC, dated 3/20/2025 was reviewed. The DSD stated theCOC indicated Resident 1 had physical aggressive behavior towards staff on 3/20/2025, and the physician recommended to have a UA done on the resident. The DSD stated Resident 1 ' s UA was not done. The DSD stated the reason for the UA was because Resident 1 had shown signs of aggressive behavior and was confused, which could be a sign of a UTI. The DSD stated it was important the UA was done to check if Resident 1 had an infection and would need treatment. The DSD if the resident had UTI, it had the potential for the resident to become more aggressive and more confused. During a review of facility ' s policy and procedure (P&P) titled, Significant Change of Condition, Response, dated 12/2023, the P&P indicated the facility must ensure each resident receives quality of care and services to attain and maintain the highest practicable physical mental and psychosocial well-being. The P&P indicated, any time it is recognized by anyone of the team members that the condition or care needs of the resident have changed, the nurse should perform, document, and implement any new orders or interventions.

Dec 2024 17 deficiencies

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set ([MDS] a resident assessment tool) was ...

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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 Minimum Data Set ([MDS] a resident assessment tool) was completed accurately for one of 21 sampled residents (Resident 20). This deficient practice had the potential to negatively affect the plan of care and delivery of care and services for Resident 20. Findings: During a review of Resident 20's admission Record, the admission Record indicated, Resident 20 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease ([ESRD] irreversible kidney failure), heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and cirrhosis of liver (a condition in which the liver is scarred and permanently damaged). During a review of Resident 20's History and Physical (H&P) dated 7/23/2023, the H&P indicated, Resident 20 had the capacity to understand and make decisions. During a review of Resident 20's MDS assessment dated [DATE], the MDS indicated, Resident 20's cognitive (ability to think and reason) skills for daily decision making was intact. The MDS indicated, Resident 20 required set up assistance (staff sets up, resident completes activity) for Activities of Daily Living (ADLs) such as oral hygiene and personal hygiene. During a concurrent interview and record review on 12/18/2024 at 4:30 p.m., with the MDS Nurse (MDSN), Resident 20's MDS assessment, dated 11/10/2024 was reviewed. The MDSN stated, the previous MDS Nurse completed Resident 20's MDS, section O0250 (Influenza Vaccine) inaccurately. The MDSN stated Resident 20 MDS, section O0250 was coded 1 (yes), however should have been coded as 0 (No) because the resident last received Influenza Vaccine on 9/25/2023 and there was no documentation to indicate Resident 20 received, was offered, or declined the Influenza vaccine this year. During a review of the facility's policy and procedure (P&P) titled, Resident Assessment and Associated Processes, dated 12/2023, the P&P indicated, Each individual who completes a portion of the assessment will electronically sign and certify the accuracy of that portion of the assessment. The P&P indicated the facility will electronically transmit encoded, accurate, and complete MDS data to the CMS system.

CONCERN (D)

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

Deficiency F0645 (Tag F0645)

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 five residents (Resident 21) received a Pre-admission...

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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 five residents (Resident 21) received a Pre-admission Screening and Resident Review ([PASRR] a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care) level II assessment. This deficient practice had the potential to result in Resident 21 not receiving the required services for her mental health condition. Findings: During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was admitted to the facility on [DATE] with diagnoses including depression (mood disorder that causes a persistent feeling of sadness and loss of interest that could interfere with daily living), Schizophrenia (a mental illness that is characterized by disturbances in thought), and anxiety (a feeling of fear, dread, and uneasiness). During a review of Resident 21's Care Plan, dated 7/31/2023, the Care Plan indicated staff will follow PASRR level II recommendations. During a review of Resident 21's History and Physical (H&P), dated 5/6/2024, the H&P indicated Resident 21 had fluctuating capacity to understand and make decisions. During a review of Resident 21's Minimum Data Set ([MDS] a resident assessment tool), dated 10/30/2024, the MDS indicated Resident 21's cognition (the ability to think and reason) was intact. The MDS indicated Resident 21 was dependent on staff for Activities of Daily Living (ADLs) such as toileting, showering, and lower body dressing. During a concurrent interview and record review on 12/18/2024 at 12:18 p.m. with the MDS nurse (MDSN), Resident 21's PASRR level I was reviewed. The MDSN stated, Resident 21's PASRR level I, dated 7/30/2023, was positive and a PASRR level II assessment needed to be completed however, was not done for the resident. The MDSN stated, a PASRR II was needed to determine if a resident needed mental health services and to determine the appropriate care/services for the resident. The MDSN also stated, due to the PASRR level II not being completed, Resident 21 could potentially not receive the required services for the resident's mental health condition. During a review of the facility's policy and procedure (P&P) titled, PASSR, dated 12/2021, the P&P indicated the facility would review the need for PASRR level II referral.

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 initiate a comprehensive care plan for one out of two ...

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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 initiate a comprehensive care plan for one out of two sampled residents (Resident 20) who was non-compliant with fluid restriction (medical treatment that limits the amount of fluid a person can consume each day) as ordered by the physician. This deficient practice had the potential to place Resident 20 at risk for not receiving the appropriate interventions to prevent fluid overload (a condition where the body has too much water). Findings: During a review of Resident 20's admission Record, the admission Record indicated, Resident 20 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease ([ESRD] irreversible kidney failure), heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and dependence on renal dialysis ( a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney (s) have failed). During a review of Resident 20's History and Physical (H&P), dated 7/23/2023, the H&P indicated, Resident 20 had the capacity to understand and make decisions. During a review of Resident 20's MDS assessment dated [DATE], the MDS indicated, Resident 20's cognitive (ability to think and reason) skills for daily decision making was intact. The MDS indicated, Resident 20 required set up assistance (staff sets up, resident completes activity) for Activities of Daily Living (ADLs) such as oral hygiene and personal hygiene. The MDS also indicated, Resident 20 required dialysis treatment. During a review of Resident 20's Order Summary Report (a document containing active orders), the Order Summary Report indicated, Resident 20 had a physician's order for fluid restriction of 1200 cubic centimeter ([cc] unit of measurement in volume; equivalent to milliliter [ml]) per 24 hours. The physician's order for fluid restriction included: Dietary 720 cc (breakfast 240 cc lunch 240 cc and for dinner 240 cc) and Nursing 480 cc, day shift (7 a.m. to 3 p.m.) 200 cc, evening shift (3 p.m. to 11 p.m.) 200 cc, night shift (11 p.m. to 7 a.m.) 80 cc. During an observation on 12/17/2024 at 9:50 a.m., in Resident 20's room, Resident 20 had 12 cans of lime soda (355 ml per can), 1 case of 24 water bottle (500 ml each bottle), and 1 case of 18 orange juice (200 ml each bottle) on top of the resident's rollator walker with seat (a mobility aid that helps people walk with more stability and independence). During a concurrent observation and interview on 12/18/2024 at 7:50 a.m., with Resident 20 in his room, Resident 20 was observed with 21 water bottles (500 ml each bottle) and 16 bottles of orange juice (200 ml each bottle) on top of the resident's rollator walker with seat. Resident 20 stated he did not remember the staff telling him or reminding him not to drink a lot of fluid daily. Resident 20 stated the nurses have not explained to him about the problems associated with drinking excess fluids. During an interview on 12/18/2024 at 8:15 a.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated Resident 20 was on fluid restriction, but was not sure of the total amount of FR per day and how many fluids he can drink in day shift. LVN 4 stated Resident 20 was non-compliant with the fluid restriction. During a review of Resident 20's electronic clinical records, the records did not indicate there was a care plan addressing Resident 20's non-compliance with the fluid restriction. During an interview on 12/18/2024 at 11:46 a.m., with the Director of Nursing (DON), the DON stated Resident 20 had been non-compliant with the fluid restriction since he was admitted to the facility. The DON stated Resident 20's family member (unnamed) was bringing water, soda, and orange juice for the resident. The DON stated, there was no care plan to address Resident 20's noncompliance with the fluid restriction. The DON stated Resident 20 was at risk for fluid overload since he was non-compliant with the fluid restriction. The DON also stated it was important to develop a comprehensive care plan for continuity of care for the resident. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 12/2023, the P&P indicated It was the policy of the facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. The P&P also indicated, in the event that a resident refused certain services posing a risk to resident's health and safety, the comprehensive care plan would identify care, or services declined, the associated risks, IDT's effort to educate the resident and resident representative and any alternate means to address risk.

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of one resident, Resident 16, received gro...

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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 one resident, Resident 16, received grooming of his long fingernails. This deficient practice had the potential to cause the resident to scratch and cause skin break down, potentially causing skin infection. Findings: During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was admitted to the facility on [DATE] with diagnoses including diabetes (a disorder characterized by difficulty in blood sugar control), hypertension ([HTN]-high blood pressure), and dementia (a progressive state of decline in mental abilities). During a review of Resident 16's History and Physical (H&P), dated 11/1/2024, the H&P indicated Resident 16 did not have the capacity for medical decision making. During a review of Resident 16's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 11/8/2024, the MDS indicated Resident 16 had severe cognitive impairment. Resident 16 was dependent on staff for all activities of daily living ([ADLs]- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 16's care plan, dated 6/16/2023, the care plan indicated if resident has thick nails, staff will refer to podiatry (area of medicine that treats conditions of the foot and nail disorders). During an observation on 12/17/24 at 4:20 p.m., Resident 16 was noted to have long thick nails on both thumbs. The thumb nails had debris (junk matter) underneath. During a concurrent observation and interview on 12/18/24 at 12:28 p.m. with Licensed Vocational Nurse (LVN) 1, LVN1 stated Resident 16's nails need to be cut for infection control. LVN1 stated the Social Services Director (SSD) will arrange the podiatry appointment and the podiatrist will cut the thumb nails due to the resident having diabetes. LVN1 stated he did not notify the SSD about Resident 16's long nails on both thumbs. During an interview on 12/18/24 at 12:34 p.m., the SSD stated the nurse notifies her when a resident needs podiatry services for nail grooming. The SSD stated no one has notified her of Resident 16's need for podiatry services for his nails. During a review of the facility's policy and procedure (P&P) titled, Dignity and Respect, dated 10/2015, the P&P indicated residents will be well groomed. During a review of the facility's P&P titled, ADL Care, dated 11/2021, the P&P indicated the podiatrist will provide nail care to all residents with diabetes.

CONCERN (D)

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 observation, interview, and record review, the facility failed to ensure one of 1 sampled resident, Resident 16, who ha...

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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 1 sampled resident, Resident 16, who had a 10 pounds weight loss within 30 days, was reported to the physician. This deficient practice had the potential to result in a delay in care for Resident 16. Findings: During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was admitted to the facility on [DATE] with diagnoses including diabetes (a disorder characterized by difficulty in blood sugar control), hypertension ([HTN]-high blood pressure), and dementia (a progressive state of decline in mental abilities). During a review of Resident 16's History and Physical (H&P), dated 11/1/2024, the H&P indicated Resident 16 did not have the capacity for medical decision making. During a review of Resident 16's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 11/8/2024, the MDS indicated Resident 16 had severe cognitive impairment. Resident 16 was dependent on staff for all activities of daily living ([ADLs]- activities such as bathing, dressing and toileting a person performs daily). During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1 on 12/19/2024 at 2:39 p.m., Resident 16's weights were reviewed. LVN1 stated the facility should provide interventions for weight loss greater than three pounds. LVN1 stated the nurse should call the doctor and complete a change condition ([COC]- a communication tool used by healthcare workers when there is a change of condition among the residents) form. LVN1 stated weight loss is critical. LVN1 stated Resident 16's clinical records indicated on 11/7/2024, Resident 16's weight was 147 pounds and on 12/7/2024 the weight was 137 pounds (10 pound/6.8% loss). The clinical record indicated a COC was completed on 12/18/2024 indicating a 19-pound weight loss in three months. LVN1 stated the COC should have been completed on 12/7/2024. The doctor should have been notified to obtain new orders to care for Resident 16. During a concurrent interview and record review on 12/20/2024 at 12:15 p.m. with the Director of Staff Development (DSD), Resident 16's clinical record was reviewed. The DSD stated on 12/7/2024 a COC should have been completed and the doctor notified of the 10-pound weight loss over 30 days. The DSD stated an Interdisciplinary Team ([IDT] group of healthcare professionals, including resident/ resident representative, working together to provide residents with needed care) meeting was not been completed. An IDT is important to plan care for the resident. During a review of the facility's policy and procedure (P&P) titled, Nutrition Status Management, dated December 2023, the P&P indicated any resident weight that varies from the previous reporting period by 5% or 5 pounds in 30 days will be evaluated by the interdisciplinary team ([IDT]-a group of various health professionals that plan and coordinate care). The P&P indicated the nurse will notify the physician.

CONCERN (D)

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 observation, interview, and record review, the facility failed to ensure a peripheral intravenous line ([IV] - a thin t...

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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 peripheral intravenous line ([IV] - a thin tube inserted into a vein for administration of medications, fluids and/or blood products) was removed after IV antibiotic (a drug used to treat infections caused by bacteria) was completed for one of two sampled residents (Resident 75). This deficient practice had the potential for the IV insertion site to develop infection and/or hospitalization for Resident 75. Findings: During a review of Resident 75's admission Record, the admission Record indicated, Resident 75 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated, Resident 75's diagnoses included End Stage Renal Disease ([ESRD] - irreversible kidney failure), sepsis (a life-threatening blood infection), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 75's History and Physical (H&P), dated 9/27/2024, the H&P indicated, Resident 75 could make needs known but could not make medical decisions. During a review of Resident 75's Minimum Data Set ([MDS] - a resident assessment tool), dated 11/2/2024, the MDS indicated, Resident 75's cognitive (ability to think and reason) skills for daily decision making was severely impaired. The MDS indicated, Resident 75 was totally dependent (helper does all of the effort) from staff with toileting hygiene and lower body dressing. The MDS indicated, Resident 75 required dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney (s) have failed) treatment. During a review of Resident 75's Order Summary Report (a document containing active orders), dated 12/18/2024, the Order Summary Report indicated, Resident 75 had a physician's order of Meropenem (medication to treat infection) 500 milligrams ([mg] - metric unit of measurement, used for medication dosage and/or amount) IV once day for bacteria (microscopic living organisms that have only one cell) in the blood until 12/14/2024. During a concurrent observation and interview on 12/17/2024 at 2:20 p.m., with Registered Nurse 2 (RN 2), in Resident 75's room, Resident 75 had an IV line on the left forearm with dressing dated 11/26/2024. RN 2 stated Resident 75's IV antibiotic was completed last week. RN 2 stated the licensed nursing staff who administered the last dose of IV antibiotic of Resident 75 should have removed the IV peripheral line immediately to prevent infection on the IV site. During a review of the facility's policy and procedure (P&P) titled, Insertion of Peripheral IV Catheter, dated 5/2022, the P&P indicated to remove the IV line whenthe therapy is discontinued.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 39) h...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 39) had her oxygen saturation ([O2 sat]- a measurement of how much oxygen the blood is carrying as a percentage) levels checked to keep the oxygen (O2) saturation above 90% as indicated in the physician's orders and care plan. This deficient practice had the potential to result in Resident 39 experiencing respiratory distress. Findings: During an observation on 12/18/2024 at 12:41 p.m., Resident 39 had an oxygen concentrator machine (a machine used to deliver oxygen to an individual) and a nasal cannula ([NC]- a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) by her bedside, but the equipment was not in use. During a review of Resident 39's admission Record (Face Sheet), the admission Record indicated Resident 39 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction (CVA-stroke, loss of blood flow to a part of the brain), and heart failure (a condition where the heart can't pump enough blood and oxygen to the body's organ). During a review of Resident 39's Order Summary Report, the order summary report indicated an order was placed on 10/18/2024 to apply oxygen via NC at 2 liters per minute ([LPM]- amount of oxygen delivered per minute) continuously to keep O2 sat at or above 90% as needed for shortness of breath (SOB). During a review of Resident 39's Minimum Data Set ([MDS]- a federally mandated assessment tool), dated 10/23/2024, the MDS indicated Resident 39 was not cognitively intact (able to reason, understand, remember, judge, and learn). During a review of Resident 39's Care Plan, dated 11/4/2024, it indicated to apply oxygen via NC at 2 LPM continuous to keep saturation at or above 90% as needed for SOB. Another order was placed on 11/12/2024 to apply oxygen via NC up to 2 LPM to keep O2 sat at or above 90% and titrate (continuously measure and adjust as needed) as needed for SOB/wheezing. During a review of Resident 39's Weights and Vitals Summary, it indicated Resident 39 had her O2 sat checked on the following dates: 10/19/2024 at 1:15 p.m. 11/5/2024 at 5:35 p.m. 12/5/2024 at 2:46 p.m. 12/14/2024 at 8:59 a.m. During a concurrent interview and record review on 12/19/2024 at 12:05 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 39's care plan, order summary report, and vital signs were reviewed. LVN 1 stated vital signs are generally taken at least once a day or as ordered and should include heart rate, temperature, blood pressure, respiratory rate, and O2 sat. LVN 1 reviewed Resident 39's care plan, order summary report, and vital signs and stated there was an order on 10/18/2024 and 11/12/2024 to keep Resident 39's O2 sat above 90% and stated O2 sat was only checked once each month in October and November and twice in December. LVN 1 stated for staff to determine if O2 sat was above 90% it would have to be checked more often than once a month, and the staff could have clarified with the doctor how frequent the O2 sat should have been checked. LVN 1 stated if O2 sat was not above 90%, the staff would not know when to give the resident oxygen. During a review of the facility's policy and procedure (P&P), titled Monitoring Weights and Vital Signs, dated 7/2018, the P&P indicated monitor the weights and vital signs of residents as ordered by the physician and monthly per facility protocol.

CONCERN (D)

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

Deficiency F0698 (Tag F0698)

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, two of three sampled residents (Resident 20 a...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure, two of three sampled residents (Resident 20 and 75), who received hemodialysis ([HD] - a treatment to cleanse the blood of wastes and extra fluids artificially through a machine) treatment, received care in accordance with professional standards of practice by failing to: 1. Implement Resident 20's fluid restriction (medical treatment that limits the amount of fluids a person can consume each day) order accurately. This deficient practice placed Resident 20 at risk for swelling, discomfort, and shortness of breath. 2. Collaborate and communicate with the dialysis center, which hypertensive medications (drugs that can lower blood pressure) were to be held for Resident 20 before dialysis treatment. This deficient practice had the potential to result in adverse condition for Resident 20 during dialysis treatment. 3. Ensure Resident 75's dialysis emergency kit (E-KIT - supplies to help meet the needs of a dialysis resident in the event of an emergency) was readily available at the bedside, in case of excessive bleeding from the dialysis site. This deficient practice had the potential to result in staff inability to manage and control the bleeding from Resident 75's dialysis site, resulting in complications, hospitalization and death. Findings: 1. During a review of Resident 20's admission Record, the admission Record indicated, Resident 20 was admitted to the facility on [DATE]. The admission Record indicated, Resident 20's diagnoses included End Stage Renal Disease ([ESRD] - irreversible kidney failure), heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and dependence on renal dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney (s) have failed). During a review of Resident 20's History and Physical (H&P), dated 7/23/2023, the H&P indicated, Resident 20 had the capacity to understand and make decisions. During a review of Resident 20's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 11/10/2024, the MDS indicated, Resident 20's cognitive (ability to think and reason) skills for daily decision making was intact. The MDS indicated, Resident 20 required set up assistance (helper sets up, resident completes activity) from staff with oral hygiene and personal hygiene. The MDS indicated, Resident 20 required dialysis treatment. During a review of Resident 20's Order Summary Report (a document containing active orders), the Order Summary Report indicated, Resident 20 had a fluid restriction order of 1200 cubic centimeter ([cc] - unit of measurement in volume) per 24 hours. The fluid restriction breakdown were as follows: Dietary 720 cc's for breakfast 240 cc's, lunch 240 cc's and for dinner 240 cc's. Nursing was to give 480 cc's, day shift ( 7 a.m. to 3 p.m.) 200 cc's, evening shift (3 p.m. to 11 p.m.) 200 cc's, night shift (11 p.m. to 7 a.m.) 80 cc's. The Order Summary Report indicated, Resident 20 was to receive HD treatment every Tuesday, Thursday, and Saturday from 8:30 a.m. to 12:30 p.m. During a review of Resident 20's Meal Ticket, the Meal Ticket did not indicate Resident 20 was on fluid restriction and its breakdown. During a review of Resident 20's care plan titled Dependence on Renal Dialysis, revised and initiated on 2/16/2023, the care plan goal indicated Resident 20 will have no signs and symptoms of complications from dialysis through the review date on 2/13/2025. The care plan intervention was to monitor intake and output. The care plan did not indicate the total amount of fluid restriction and how to manage and monitor resident's fluid intake accurately. During a review of Resident 20's Nutrition Interdisciplinary Team Update, dated 12/8/2024, the Nutrition Interdisciplinary Team Update indicated, Resident 20 had no fluid restriction order. During an observation on 12/17/2024 at 9:50 a.m., in Resident 20's room, observed 12 cans of lime soda (355 milliliter ([ml] - unit of measurement in volume) per can), 1 case of 24 water bottle (500 ml each bottle), and 1 case of 18 orange juice (200 ml each bottle) sitting in rollator walker with seat (a mobility aid that helps people walk with more stability and independence). During a concurrent observation and interview on 12/18/2024 at 7:50 a.m., with Resident 20 in his room, observed 21 water bottle (500 ml each bottle) and 16 orange juice (200 ml each bottle) sitting in rollator walker with seat. Resident 20 stated he did not remember the staff telling him or reminding him not to drink a lot of fluid on a daily basis. Resident 20 stated the nurses have not explained to him about the problems associated with drinking excess fluids. During an observation on 12/18/2024 at 7:57 a.m., in Resident 20's room, observed Resident 20 drinking 200 ml of sunny delight orange juice. Resident 20 consumed 200 ml of orange juice. During an interview on 12/18/2024 at 7:59 a.m., with Certified Nurse Assistant 2 (CNA 2), CNA 2 stated she was not aware Resident 20 was on fluid restriction. CNA 2 stated Resident 20's family member had been bringing bottled water and orange juice. CNA 2 stated she could not track and monitor Resident 20's fluid intake in day shift accurately. During a concurrent observation and interview on 12/18/2024 at 8:15 a.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated Resident 20 had 15 orange juices (200 ml each bottle) and 20 water bottles sitting on his rollator walker. LVN 4 stated Resident 20 was on fluid restriction but was not sure the total amount of fluid restriction per day and how many fluids he can drink in day shift. LVN 4 stated Resident 20's fluid restriction was not being enforced as per physician's order and fluid intake was not being monitored accurately. LVN 4 stated it was very important to follow and monitor Resident 20's fluid restriction order accurately since the resident was receiving HD treatment and too much fluid would cause swelling and chest pain that would likely require hospitalization. During an interview on 12/18/2024 at 11:46 a.m., the Director of Nursing (DON) stated she was aware Resident 20's family member was bringing water, soda, and orange juice. The DON stated the facility did not monitor Resident 20's fluid intake consistently and implement 1200 cc fluid restriction as ordered by the physician because resident had stock of water and orange juice kept at his bedside. During a review of the facility's policy and procedure (P&P) titled, Significant Change of Condition, Response, under Quality of Care, dated 12/2023, the P&P indicated, It is the policy of the facility to ensure each resident receives quality of care and services to attain and maintain the highest practicable physical, mental and psychosocial well-being in accordance with the interdisciplinary comprehensive assessment and plan of care. 2. During a review of Resident 20's Order Summary Report, dated 12/18/2024, the Order Summary Report indicated, Resident 20 was to receive the following medications: A. Amlodipine 10 mg (mg- unit of measurement, used for medication dosage and/or amount) to give 1 tablet once a day (9 a.m.) for hypertension ([HTN] high blood pressure), to hold for systolic blood pressure ([SBP] - force caused by contraction of left ventricle) less than 110, pulse rate ([PR] - the number of times the heat beats per minute) less than 60. B. Hydralazine 50 mg to give 1 tablet every 8 hours (6 a.m., 2 p.m., and 10 p.m.) for HTN, to hold for SBP less than 110, PR less than 60. C. Losartan 50 mg to give once a day (9 a.m.) for HTN. D. Carvedilol 3.125 mg to give 1 tablet every 12 hours (9 a.m., and 9 p.m.) for HTN, to hold for SBP less than 110. During a concurrent interview and record review on 12/18/2024 at 12:29 p.m., with the Minimum Data Set Nurse (MDSN), Resident 20's Electronic Medication Administration ([EMAR] - daily documentation record used by a licensed nurse to document medications and treatment given to a resident) from 12/1/2024 to 12/18/2024, was reviewed. The MDSN stated Resident 20 was scheduled to HD treatment 3x/week every Tuesday, Thursday, and Saturday at 8:30 a.m. The MDSN stated, Resident 20's medications of amlodipine10 mg 9 a.m. dose, losartan 50 mg 9 a.m. dose, and carvedilol 3.125 mg 9 a.m. doses were not given and coded as 2 (hold/see nurses notes) on dialysis days (Tuesday, Thursday and Saturday). The MDSN stated Resident 20's Hydralazine 50 mg 6 a.m. dose was given on dialysis days. The MDSN the physician would indicate if to hold or give the hypertensive medications of Resident 20 during hemodialysis days. The MDSN stated the facility had no documentation indicating facility staff coordinated with the dialysis center staff if Resident 20's hypertensive medications should be administered, adjusted, or withheld prior to dialysis. During a review of facility's P&P, titled Pre- and Post-Care Dialysis, dated 1/2022, the P&P indicated, It is the policy of the facility to participate in ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. The P&P also indicated medications scheduled for administration while at dialysis during dialysis days may be held unless otherwise specified by the provider. 3. During a review of Resident 75's admission Record, the admission Record indicated, Resident 75 was initially admitted to the facility on [DATE] and readmitted on [DATE]. The admission Record indicated, Resident 75's diagnoses included ESRD, and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 75's H&P, dated 9/27/2024, the H&P indicated, Resident 75 could make needs known but could not make medical decisions. During a review of Resident 75's MDS, dated [DATE], the MDS indicated, Resident 75's cognitive skills for daily decision making was severely impaired. The MDS indicated, Resident 75 was totally dependent (helper does all of the effort) from staff with toileting hygiene and lower body dressing. The MDS indicated, Resident 75 required dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney (s) have failed) treatment. During a review of Resident 75's Order Summary Report, dated 12/18/2024, the Order Summary Report indicated, Resident 75 was to receive HD treatment every Tuesday, Thursday, and Saturday from 6:30 a.m. to 10:00 a.m. During an interview on 12/17/2024 at 10:22 a.m., LVN 3 stated Resident 75 had an arteriovenous shunt ([AV] - a connection between an artery and a vein that allows for hemodialysis access) on right upper arm. LVN 3 stated she had not seen and was not sure what the purpose of an HD e-kit for a dialysis resident. During a concurrent observation and interview on 12/17/2024 at 10:31 a.m., with Registered Nurse 2 (RN 2), in Resident 75's room. RN 2 acknowledged and verified there was no dialysis e-kit available at bedside. RN 2 stated dialysis e-kit consisted of dressing, gauze, alcohol swab and torniquet (a device that checks bleeding or blood flow by compressing blood vessels). RN 2 stated dialysis e-kit should be accessible and available at resident bedside at all times in case of emergency bleeding. RN 2 stated too much bleeding would cause hemorrhagic shock (a life-threatening condition that occurs when the body loses a significant amount of blood in a short period of time) that would likely require hospitalization. During a concurrent observation and interview on 12/17/2024 at 10:43 a.m., with the Director of Nursing (DON), the DON confirmed there was no dialysis e-kit available at the bedside of Resident 75. The DON stated dialysis e-kit should be easily accessible to prevent further bleeding complication. During a review of facility's P&P, titled Pre- and Post-Care Dialysis, dated 1/2022, the P&P indicated, Any problems with a resident's access should be addressed immediately. Excessive bleeding from graft site, redness, swelling, pain, or non-functioning graft requires medical attention.

CONCERN (D)

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

Deficiency F0740 (Tag F0740)

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 one of one sampled resident (Resident 60) was provided ...

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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 one of one sampled resident (Resident 60) was provided necessary behavioral health care services for treatment of the residents mental condition by ensuring a psychiatrist (a physician who specializes in psychiatry - the branch of medicine devoted to the diagnosis, prevention, study, and treatment of mental disorders) was notified when Resident 60 had episodes of refusal of care. This deficient practice had the potential to result in lack of interventions to Resident 60's refusal of care and worsening of his mental health condition. Findings: During a review of Resident 60's admission Record, the admission Record indicated, Resident 60 was admitted to the facility on [DATE]. Resident 60's diagnoses included multiple myeloma (a cancer that begins in plasma cells), anemia (a condition where the body does not have enough healthy red blood cells), and hypertension ([HTN] - high blood pressure). During a review of Resident 60's History and Physical (H&P), dated 12/2/2023, the H&P indicated, Resident 60 had the capacity to understand and make decisions. During a review of Resident 60's Minimum Data Set ([MDS] - a resident assessment tool), dated 9/28/2024, the MDS indicated, Resident 60's cognitive (ability to think and reason) skills for daily decision making was intact. The MDS indicated, Resident 60 required set up assistance (helper sets up and resident completes activity) from staff with oral hygiene and personal hygiene. During a review of Resident 60's Order Summary Report (a document containing active orders), dated 12/19/2024, the Order Summary Report indicated, Resident 60 had a physician order, dated 11/11/2024, for psychiatric evaluation. During a review of Resident 6's Situation, Background, Assessment and Recommendation ([SBAR] - a communication tool used by healthcare workers when there is a change of condition among the residents), dated 11/11/2024, the SBAR, indicated Resident 60 had episode of refusal of care such as showering, bathing, and changing clothes. The SBAR indicated, Resident 60's physician recommended psychiatric evaluation. During an interview on 12/19/2024 at 11:30 a.m., with the Social Service Director (SSD), the SSD stated she was responsible in referring residents to psychiatrist. The SSD acknowledged Resident 60 exhibited behavior of refusal of care and assistance from staff multiple times. The SSD stated the licensed nursing staff did not communicate to her about the physician order for Resident 60's psychiatric referral. The SSD stated the risk of Resident 60's not being evaluated by psychiatrist would continue his same behavior of refusing care that would jeopardize his health condition and affect his quality of life. During an interview on 12/19/2024 at 11:48 a.m., with the Director of Nursing (DON), the DON stated Resident 60 was noncompliant with care. The DON verified the psychiatric referral was not followed through by facility staff. The DON stated the psychiatrist would be able to help and manage Resident 60's behavior, develop treatment plan and provide accurate diagnosis. During a review of the facility's policy and procedure (P&P) titled, Behavioral Health Services, dated 12/2023, the P&P indicated, the facility will provide residents with necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The P&P indicated the physician in collaboration with the IDT team, will determine the appropriate psychiatric or psychological services needed and treatment will be provided as ordered by the physician.

CONCERN (D)

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

Deficiency F0745 (Tag F0745)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Ensure a follow-up appointment for urology (a me...

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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 a follow-up appointment for urology (a medical and surgical specialty that deals with diseases of the urinary tract and male reproductive system in both men and women) evaluation/referral was completed for one of one sampled resident (Resident 80). This deficient practice had the potential to result in the delay of necessary care and services for Resident 80. Findings: During a review of Resident 80's admission Record, the admission Record indicated, Resident 80 was admitted to the facility on [DATE]. The admission Record indicated, Resident 80's diagnoses included urinary retention (a condition that makes it difficult to empty the bladder), obstructive uropathy (a condition in which the flow of urine is blocked), and acute cystitis (infection of the bladder). During a review of Resident 80's History and Physical (H&P), dated 724/2024, the H&P indicated, Resident 80 had the capacity to understand and make decisions. During a review of Resident 80's Minimum Data Set ([MDS - a resident assessment tool), dated 10/27/2024, the MDS indicated, Resident 80's cognitive (ability to think and reason) skills for daily decision making was intact. The MDS indicated, Resident 80 had indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine). During a review of Resident 80's Order Summary Report (a document containing active orders), dated 12/18/2024, the Order Summary Report indicated, Resident 80 had a physician order, dated 10/10/2024, for urology consult due to obstructive uropathy. During an observation and interview on 12/17/2024 at 12:25 p.m., with Resident 80 in his room, Resident 80 was observed in bed with indwelling urinary catheter. Resident 80 stated he wanted to see a medical doctor so he could remove his catheter. Resident 80 stated he had been getting urine infection. During a concurrent interview and record review on 12/18/2024 at 1:07 p.m., with the Director of Nursing (DON), Resident 80's electronic clinical records were reviewed. The DON stated Social Services was responsible for setting up transportation and medical appointments for residents. The DON stated there was no documentation indicating the facility staff scheduled Resident 80's appointment for urology consult. The DON stated it was important for Resident 80 to be seen by a urologist (a medical doctor who specializes in diagnosing and treating diseases of the urinary system and reproductive organs) to evaluate the reason why Resident 80 had a blockage on his bladder (a hollow, muscular organ that stores urine and is part of the urinary system) and having urinary retention. The DON stated the risk of not following up with a urology referral could result in bladder infection since Resident 80 had an indwelling urinary catheter. During a concurrent interview and record review on 12/19/2024 at 11:15 a.m., with the Social Service Director (SSD), Resident 80's Social Services Progress Notes, dated 10/24/2024, was reviewed. The SSD stated Resident 80 needed a urology referral directly from his primary physician. The SSD stated she did not follow-up with Resident 80's primary physician for urology referral. The SSD stated she did not schedule Resident 80's medical appointment for urology consult. The SSD stated it was important for Resident 80 to be referred to a urologist in a timely manner to prevent delay of care and treatment. During a review of the facility's policy and procedure (P&P) titled, Provision of Medically Related Social Services, dated 12/2023, the P&P indicated, it is the policy of the facility to provide medically related social services to attain or maintain the highest practicable physical, mental, or psychosocial well-being of each resident. The P&P indicated the Social Services is responsible for providing for the medically related social services needs of each resident that includes scheduling of appointments.

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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

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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 pharmaceutical services to meet the needs of two of 7 sampled residents (Residents 3 and 55), by failing to ensure: a. Resident 3's jardiance (medication used to control high blood sugar), apixiban (medication given to thin the blood to prevent blood clots), breo ellipta (medication used to improve air flow in lung disease), metoprolol tartrate (medication used to lower the blood pressure), and sitagliplin (medication used to control high blood sugar) were ordered timely from the pharmacy to prevent outage. This deficient practice put Resident 3's health at risk due to missed doses of the medications. b. Licensed Vocational Nurse (LVN) 1 documented the administration of carvedilol (medication used to treat high blood pressure) in a timely manner. This deficient practice had the potential to result in Resident 55 receiving a duplicate dose of Carvedilol. Findings: a). During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including diabetes (a disorder characterized by difficulty in blood sugar control), hypertension ([HTN]-high blood pressure), and dementia (a progressive state of decline in mental abilities). During a review of Resident 3's History and Physical (H&P), dated 11/1/2024, the H&P indicated Resident 3 can make needs known but cannot make medical decisions. During a review of Resident 3's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 9/2/2024, the MDS indicated Resident 3 had severe cognitive impairment. Resident 3 was dependent on staff for all activities of daily living ([ADLs]- activities such as bathing, dressing and toileting a person performs daily). During a concurrent observation and interview on 12/19/24 at 9:18 a.m. with Licensed Vocational Nurse (LVN) 1 during medication administration, LVN1 stated Resident 3's Jardiance is not available to be given today. LVN1 stated Resident 3 did not receive the medication yesterday because it is out of stock. LVN1 stated missing a dose of this medication can potentially result in Resident 3's high blood sugar levels. LVN1 stated medications should be ordered when there are three remaining to prevent you from running out. During a concurrent interview and record review with the Director of Staff Development (DSD), Resident 3's medication administration record ([MAR] - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) was reviewed. The MAR indicated on 12/14/2024, sitagliptin, metoprolol, breo ellipta, jardiance, and apixiban were not available to be administered. The MAR indicated on 12/5/2024, Apixiban and Breo Ellipta we not available to be given. The MAR indicated on 11/24/2024, Jardiance was not available to be given. The DSD stated medications should be reordered when it gets down to three pills to ensure there is time for delivery to prevent missed doses. The DSD stated missed doses can affect the resident's health. During a review of the facility's policy and procedure (P&P) titled, Administration of Medications and Fluids, Intravenous, dated December 2019, the P&P indicated medications will be administered within the prescribed time frames. During a review of the facility's P&P titled, Medication Errors and Adverse Reactions, dated December 2023, the P&P indicated a medication error includes doses that are ordered but not administered. During a review of the facility's job description, titled Licensed Vocational Nurse, dated December 2021, the job description indicated the LVN will ensure adequate stock levels of medications are maintained. b). During a review of Resident 55's admission Record, the admission Record indicated Resident 55 was admitted to the facility on [DATE] with diagnoses including HTN, heart failure (a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and muscle weakness. During a review of Resident 55's H&P, dated 6/15/2024, the H&P indicated Resident 55 had the capacity to understand and make decisions. During a review of Resident 55's MDS dated [DATE], the MDS indicated Resident 55's cognition was intact. The MDS indicated Resident 55 needed moderate assistance with ADLs such as toileting, showering, and lower body dressing. During a concurrent interview and record review on 12/19/24 at 9:23 a.m. LVN 1, Resident 55's MAR was reviewed. LVN 1 stated he administered carvedilol to Resident 55 at 8:40 a.m. and had not documented it. LVN 1 stated he should have documented administration right away after administering the medication to Resident 55. During an interview on 12/19/24 at 9:48 a.m. with the Assistant Director of Nursing (ADON), the ADON stated medications should be documented as soon as they are given to prevent confusion. The ADON stated, a resident could possibly receive a double dose of the medication due to a lack of documentation. During a review of the facility's P&P titled, Administration of Medications and Fluids, Intravenous, dated 12/2019, the P&P indicated to ensure safety and accuracy of administration, staff would document administration after administration. During a review of the facility's job description, titled Licensed Vocational Nurse, dated 12/2021, the job description indicated the LVN would chart in a professional and appropriate manner that timely and accurately reflects the care provided.

CONCERN (D)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Ensure Resident 3 received her Jardiance (medicat...

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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 Resident 3 received her Jardiance (medication used to control high blood sugar) dose as ordered by the physician. This deficient practice put Resident 3's health at risk due to a missed dose of medication. Findings: During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including diabetes (a disorder characterized by difficulty in blood sugar control), hypertension ([HTN]-high blood pressure), and dementia (a progressive state of decline in mental abilities). During a review of Resident 3's History and Physical (H&P), dated 11/1/2024, the H&P indicated Resident 3 can make needs known but cannot make medical decisions. During a review of Resident 3's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 9/2/2024, the MDS indicated Resident 3 had severe cognitive impairment. Resident 3 was dependent on staff for all activities of daily living ([ADLs]- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 3's care plan, dated 3/31/2023, the care plan indicated staff will give diabetes medication as ordered by the doctor. During a concurrent observation and interview on 12/19/24 at 9:18 a.m. with Licensed Vocational Nurse (LVN)1 during medication administration, LVN1 stated Resident 3's Jardiance is not available to be given. LVN1 stated Resident 3 did not receive Jardiance yesterday. LVN1 stated Resident 3 missing a dose of this medication can potentially result in high blood sugar levels. During a review of the facility's policy and procedure (P&P) titled, Administration of Medications and Fluids, Intravenous, dated December 2019, the P&P indicated medications will be administered within the prescribed time frames. During a review of the facility's policy and procedure (P&P) titled, Medication Errors and Adverse Reactions, dated December 2023, the P&P indicated a medication error includes doses that are ordered but not administered. During a review of the facility's job description, titled Licensed Vocational Nurse, dated December 2021, the job description indicated the LVN will administer medications as ordered by the physician.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to: 1. Ensure the medication refrigerator did not contain an emergency kit (a box that contains a small supply of medications) a...

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Based on observation, interview, and record review, the facility failed to: 1. Ensure the medication refrigerator did not contain an emergency kit (a box that contains a small supply of medications) and three bags of ertapenem (medication given to treat infection) that were past the discard date. This deficient practice had the potential to result in harm to a resident if administered. Findings: During a concurrent observation and interview with the Assistant Director of Nursing (ADON) in the medication storage room, the medication refrigerator was observed with an emergency kit labeled to be discarded after September 2024. and three bags of ertapenem that were past the discard date. The ertapenem bags indicated they should be discarded on 12/13/2024, 12/14/2024, and 12/16/2024. The ADON stated the emergency kit and ertapenem should not be there. The ADON stated, if the medications were used, a resident could have harmful effects. During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated May 2022, the P&P indicated outdated medications are immediately removed from inventory.

CONCERN (D)

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

Laboratory Services (Tag F0770)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Ensure Resident 16 had a Complete Blood Count ([C...

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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 Resident 16 had a Complete Blood Count ([CBC] a blood test that measures the number and type of cells in your blood), Comprehensive Metabolic Panel ([CMP] a blood test that measures 14 substances in your blood to provide an overall picture of your body's chemical balance), Hemoglobin A1C ([HgA1c] a blood test that measures the average blood sugar level over the past two to three months), Thyroid Synthesizing Hormone ([TSH] a blood test used to determine the level of hormones being produced by the thyroid), and Lipid panel (a blood test that determines the level of fat in the blood) completed on 11/4/2024 per physician's order. This deficient practice had the potential to result in a lack of required monitoring of Resident 16's health conditions. Findings: During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was admitted to the facility on [DATE] with diagnoses including diabetes (a disorder characterized by difficulty in blood sugar control), hypertension ([HTN]-high blood pressure), and dementia (a progressive state of decline in mental abilities). During a review of Resident 16's History and Physical (H&P), dated 11/1/2024, the H&P indicated Resident 16 did not have the capacity for medical decision making. During a review of Resident 16's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 11/8/2024, the MDS indicated Resident 16 had severe cognitive impairment. Resident 16 was dependent on staff for all activities of daily living ([ADLs]- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 16's care plan, dated 6/16/2023, the care plan indicated staff will obtain and monitor lab work as ordered. Staff will report results to the physician and follow up as indicated. During a review of Resident 16's Order Summary Report, the report indicated Resident 16 had a physician's order to complete a CBC, CMP, HgA1C, TSH, and Lipid Panel on 11/4/2024. During a concurrent interview and record review on 12/16/2024 at 2:39 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 16's laboratory results were reviewed. LVN 1 stated Resident 16 did not have lab tests completed on 11/4/2024 as ordered. LVN1 stated staff cannot monitor Resident 16's health status if lab tests were not completed per physician's order. LVN1 cannot state why the tests were not completed. During a review of the facility's policy and procedure (P&P) titled, Diagnostic Test Results Notification, dated December 2023, the P&P indicated the facility will obtain laboratory services when ordered by a physician and promptly notify the provider of test results.

CONCERN (D)

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

Deficiency F0849 (Tag F0849)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the hospice (compassionate care for people who are near...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the hospice (compassionate care for people who are near end of life) services meet professional standards for one of one sampled resident (Resident 71) by failing to: 1. Ensure hospice representative participates with facility interdisciplinary team ([IDT] - team members from different disciplines who come together to discuss resident care) care conference meeting. Findings: During a review of Resident 71's admission Record, the admission Record indicated, Resident 71 was admitted to the facility on [DATE]. The admission Record indicated, Resident 71's diagnoses included protein calorie malnutrition ([PCM] - a nutritional condition that occurs when a person doesn't consume enough protein and calories to meet their nutritional needs), chronic obstructive pulmonary disease ([CPOD] - a chronic lung disease causing difficulty in breathing), and adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity). During a review of Resident 71's Minimum Data Set ([MDS] - a resident assessment tool), dated 10/23/2024, the MDS indicated, Resident 71's cognitive (ability to think and reason) skills for daily decision making was severely impaired. The MDS indicated, Resident 71 was on hospice care. During a concurrent interview and record review on 12/18/2024 at 1:43 p.m., with the Social Service Director (SSD), Resident 71's IDT Care Plan Review, dated 7/25/2024, was reviewed. The SSD stated the IDT Care Plan Review record did not indicate a hospice representative was among the members attended the meeting. The SSD stated if it was not written then it did not happen. The SSD stated she was responsible in coordinating with hospice representative for the IDT care plan meeting. The SSD stated there was no IDT care plan meeting held with hospice representative in October 2024. The SSD stated IDT care plan meeting should be conducted every 3 months per state and federal requirement. The SSD stated the hospice staff should be actively involved in the care for Resident 71 by participating in the IDT care plan meeting. The SSD stated it was mandatory for the hospice representative to attend scheduled IDT care plan meeting with the facility staff so there would be continuity in the care provideed to Resident 71. The SSD stated the purpose of the IDT care plan meeting was to coordinate and collaborate the plan of care of resident. During a review of the facility's policy and procedure (P&P) titled, End of Life, Hospice and/or Palliative Care, dated 12/2023, the P&P indicated, Hospice services will be integrated into the overall individualized, interdisciplinary care plan. The P&P indicated collaboration with hospice will include processes for orienting staff to facilities polices and procedures.

CONCERN (E)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a clean air vent above Resident 15's bed and to ensure the r...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a clean air vent above Resident 15's bed and to ensure the room temperature was between 71- and 81-degrees Fahrenheit for Residents' 5, 38, and 301's rooms. These deficient practices had the potential for the resident to be exposed to dust and allergens affecting her respiratory health and the increased level of discomfort and to negatively impact the residents' quality of life. Findings: a). During an initial tour on 12/17/2024 at 11:31 a.m., the air vent above the head of Resident 15's bed was covered with dust. During a review of the admission Record, the admission record indicated Resident 15 was admitted to the facility on [DATE] with diagnoses that included breast cancer, muscle weakness, and difficulty walking. During a review of the Minimum Data Set (MDS - a resident assessment tool) dated 11/19/2024, the MDS indicated that Resident 15 usually made herself understood and was usually able to understand others. During a review of the document titled HVAC Maintenance Log dated 11/25/2024, the log indicated a written comment from the MS All, vents clean. During an interview on 12/17/2024 at 1:44 p.m. with Resident 15, Resident 15 stated when she looked up at the vent and the dust is moving, it looked like there were bugs there. During an interview on 12/19/2024 at 11:15 a.m. with the Maintenance Supervisor (MS), the MS stated the vents in the resident rooms are cleaned monthly. The MS agreed the vent above Resident 15's bed was dirty, but that the vent is a return vent to recycle air. The MS stated the vent sucks air in and should not affect the resident. b). During an interview on 12/18/2024 at 8:45 a.m. with Resident 5, Resident 5 was observed in bed under two blankets up to her neck and a blanket covering her face. Resident 5 stated she was cold and would leave her bed when it was time for physical therapy. Resident 5 stated she was given an extra blanket and she used it to cover her head due to the cold room. A review of the admission Record indicated Resident 5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included legal blindness and muscle weakness. During a review of the MDS dated [DATE], the MDS indicated Resident 5 had the ability to understand others and to be understood. c). During an interview on 12/18/2024 at 11:53 a.m. with Resident 38, Resident 38 stated he is freezing at night in bed even with the extra blanket he asked for. During a review of the admission Record, the admission record indicated Resident 38 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included heart failure and chronic cough. During a review of the MDS dated [DATE], the MDS indicated Resident 38 had the ability to understand others and to be understood. d). During an interview on 12/19/2024 at 1:13 p.m. with Resident 301, Resident 301 was sitting in a wheelchair next to her bed and stated the temperature in her room was good. Her bed was by the window and the window was open. Resident 301 stated she liked to keep her window open for fresh air. The thermostat on the wall indicated a temperature of 69 degrees Fahrenheit. During a review of the admission Record, the admission record indicated Resident 301 was admitted to the facility on [DATE] with diagnoses that included spinal stenosis (a narrowing of the spine [backbone]) and major depression. During a review of the MDS dated [DATE], the MDS indicated Resident 301 had the ability to understand others and to be understood. During a concurrent observation and interview on 12/20/2024 at 11:15 a.m. with the MS, the MS observed and confirmed the wall thermostat in Resident 301's room indicated a temperature of 69 degrees Fahrenheit. The MS stated that the thermostat controlled the temperature in rooms 1, 2, 3, 5, 7, and 9. The MS stated he tried to maintain a temperature of 76 degrees Fahrenheit in the rooms, but anyone can change the temperature on the thermostat, and it would affect all the above-mentioned rooms. During a review of the facility's revised policy and procedure (P&P) dated 11/2019, titled Physical Environment, the P&P indicated the facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public through monthly environmental rounds.

CONCERN (E)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

Based on observation, and interview, the facility failed to ensure two sharps container (a puncture-proof container used to contain used and discarded needles and other sharp tools for patient care) o...

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Based on observation, and interview, the facility failed to ensure two sharps container (a puncture-proof container used to contain used and discarded needles and other sharp tools for patient care) on Medication Cart #2 and Medication Cart #4 were replaced with a new one when it reached the Full line. This deficient practice had the potential to result in staff or residents to sustain an injury. Findings: During an observation on 12/19/2024 at 9:26 a.m., the sharps container on Medication Cart #4 was full and had objects protruding out from the sharp's container lid. During an observation on 12/19/2024 at 9:33 a.m., the sharps container on Medication Cart #2 had objects in it that was past the Full line. During a concurrent observation and interview on 12/19/2024 at 2 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Medication Cart #2 and Medication Cart #4 was past the full line and Medication Cart #4 had items that were protruding out of the container lid. LVN 1 stated the sharps container had to be switched to a new one once items in the container have reached the Full line on the container. LVN 1 stated a staff or resident may be injured due to a full sharp's container.

Dec 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Pressure Ulcer Prevention (Tag F0686)

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 3 residents' (Resident 2) low air loss m...

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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 3 residents' (Resident 2) low air loss mattress (LAL, a medical mattress that uses air to prevent and treat pressure wounds, also known as bed sores) was set in the appropriate mattress setting. This deficient practice had the potential to delay wound healing process and risk for further skin breakdown. Findings: During a review of Resident 2s admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 2 ' s Minimum Data Set ([MDS] a resident assessment tool), dated 10/27/2024, the MDS indicated Resident 2 had no cognitive (the ability to think and reason) impairment. The MDS indicated Resident 2 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) for Activities of Daily Living (ADLs) such as rolling left to right and requires partial/moderate assistance (helper does less than half of the effort. Helper lefts or holds trunk or limbs and provides less than half the effort) with toileting hygiene. During an review of Resident 2 ' s Order Summary Report dated 12/6/2024, the order indicated Low Air Loss (LAL) for management of Stage 4 sacral (tailbone) ulcer (full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bones). During a review of Resident 2 ' s care plan dated 1/20/2023, the intervention indicated low air loss mattress for skin management. During a review of Resident 2 ' s Treatment Administration Record (TAR) dated 1/23/2023, the TAR indicated to monitor LAL for proper function and setting (not specified) every shift. During a review of Resident 2 ' s weight dated 11/7/2024, Resident 2 had a weight of 141 pounds (lbs). During an observation on 12/5/2024 at 10:10 a.m. in Resident 2 ' s room, Resident 2 ' s LAL mattress was observed with the setting set to firm with the dial pointed to 350. During an interview on 12/5/2024 at 1:41 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated that the pressure to be set on a LAL mattress should be set the same as the resident ' s weight. During a concurrent observation and interview on 12/5/2024 at 2:10 p.m. with LVN 2 at Resident 2 ' s bedside, LVN 2 observed the setting for Resident 2 ' s bed to be set at 350. LVN 2 stated that Resident 2's weight was 141 lbs, so the pressure should have been set at 141. During an interview on 12/6/2024 at 12:47 p.m. with LVN 3, LVN 3 stated Resident 2 ' s LAL mattress setting should be checked to ensure it is on the correct setting. LVN 3 stated, 350 is not the right setting and it should match Resident 2 ' s weight that was 141 lbs. LVN 3 stated, If the LAL mattress is not at the right setting, it could mess up the wound and could also create a new wound. During an interview on 12/6/2024 at 3:28 p.m. with Director of Nursing (DON), DON stated that it is important for the setting to be appropriate for the resident because it would help prevent breakdown of a sore and that staff are to check and ensure that it is in the right setting. During a record review of facility ' s manual for facility ' s current air loss mattresses titled, Med-Aire 8 Alternating Pressure Mattress Replacement System with Low Air Loss, undated, the manual indicated when setting up the mattress, adjust the dial to correspond the patient ' s appropriate weight setting or comfort level. During a record review of facility ' s P&P titled, Skin and Wound Monitoring and Management, dated 12/2023, the P&P indicated, a resident who have a pressure injury(s) should receive the necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. The P&P indicated in order to prevent development of skin breakdown or prevent existing pressure injuries from worsening, nursing staff should implement approaches consistent with the resident ' s care plan such as, use pressure relieving/reducing and redistributing devices (including but not limited to low air loss mattresses, wedges, pillows, etc.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of 3 residents' (Resident 2) urinal contain...

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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 3 residents' (Resident 2) urinal containing urine was not placed on the bedside table when meal tray was served. This deficient practice had the potential for food cross contamination. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 2 ' s Minimum Data Set ([MDS] a resident assessment tool), dated 10/27/2024, the MDS indicated Resident 2 had no cognitive (the ability to think and reason) impairment. The MDS indicated Resident 2 required setup or clean-up assistance (helper sets up or cleans up; resident completes activity) for Activities of Daily Living (ADLs) such as rolling left to right and requires partial/moderate assistance (helper does less than half of the effort. Helper lefts or holds trunk or limbs and provides less than half the effort) for toileting hygiene. During a review of Resident 2 ' s care plan dated 5/26/2021, the care plan indicated Resident 2 preferred to place urinal on the bedside table. The intervention (action to address or solve) indicated to observe and monitor resident every shift for appropriate placement of urinal. During an observation on 12/5/2024 at 12:59 p.m. in Resident 2 ' s room, Certified Nursing Assistant (CNA) 2 was observed passed meal tray in Resident 2 ' s room. CNA 2 placed Resident 2 ' s meal tray on Residen 2t ' s bedside table next to the urinal with urine. During an interview on 12/5/2024 at 1:05 p.m., CNA 2 stated the urinal should have been emptied and removed on the bedside table prior to putting REsident 2's food on the bedside table. CNA 2 stated meal tray should never be placed next to a food tray due to potential contamination. During an interview on 12/6/2024 at 11:43 a.m., Licensed Vocational Nurse (LVN) 1 stated , if staff observed a urinal on a resident's bedside table when passing meal trays, staff should explain to residents who had preference in keeping a urinal on the bedside table for it to be moved during meal times. LVN 1 stated the staff should remove the urinal, clean the table, then put the meal tray to avoid cross contamination. During an interview on 12/6/2024 at 3:28 p.m., the Director of Nursing (DON) stated that nurses should throw out any urine from the urinal before setting a meal tray on the bedside table for infection control. During a record review of facility ' s policy and procedure (P&P) titled, Infection Prevention and Control Program, dated 06/2021, the P&P indicated the facility personnel should conduct themselves and provide care in a way that minimizes the spread of infection.

Nov 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure one out of four residents (Resident 1), had telephone order...

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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 out of four residents (Resident 1), had telephone orders for Hydroxyzine given by the ordering provider entered into the electronic medical record ([EMR]- a digital version of a resident ' s medical history). This deficient practice had the potential for Resident 1 not being able to receive the medication if they ask for it. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE]. Resident 1 ' s diagnoses included osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the right hip, muscle weakness, and pain in the right hip. During a review of Resident 1 ' s Minimum Data Set ([MDS]- a resident assessment tool), dated 10/12/2024, the MDS indicated Resident 1 was cognitively intact (ability to reason, understand, remember, judge, and learn). During a concurrent interview and record review on 11/20/2024 at 3:19 PM with Registered Nurse (RN) 1, Resident 1 ' s EMR and Order Summary Report was reviewed. RN 1 stated licensed nurses may use a facility issue cell phone that can be used to text the healthcare providers to follow up on care for the residents. RN 1 was asked to look through the phone for any communication between the facility and Resident 1 ' s psychiatric provider (a person trained in mental disorders and its treatment). RN 1 showed a text on 10/28/2024 at 10:18 PM that showed the doctor ordered Hydroxyzine (a medication that can treat anxiety) 50mg PO (by mouth) Q4H (every 4 hours) PRN (as needed) for 14 days for Resident 1 for anxiety. RN 1 checked Resident 1 ' s Order Summary Report and stated the medication, Hydroxyzine, was not entered into the system. RN 1 stated that if it is not entered into the system, the medication could not be ordered and would not show up on the list of medications the resident can take. RN 1 further stated that because the medication was not ordered, if the resident asked for the medication, there would be no medication to give. During a record review of the facility ' s policy and procedure (P&P) titled, Medication Administration- Administration of Drugs, the P&P indicated medications shall be administered as prescribed by the attending physician and all current drugs and dosage schedules must be recorded on the resident ' s medication administration record (MAR)

Oct 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide respiratory care and services for one out of ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide respiratory care and services for one out of four residents (Resident 3) by failing to: 1. Administer continuous oxygen (O2) 2 liters per minute (L/min) to Resident 3 via nasal cannula ([NC] a small plastic tube, which fits into the person ' s nostrils for providing supplemental O2) according to the physician ' s orders. 2. Ensure Resident 3 ' s O2 equipment was labelled and dated according to its Policy and Procedure (P&P). These failures had the potential to lead to respiratory distress and infection for Resident 3. Findings: During a review of Resident 3 ' s admission Record, the admission record indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 3 ' s diagnoses included pneumonitis (swelling and irritation of lung tissue) due to inhalation (breathing in) of food and vomit and chronic pulmonary obstructive disease ([COPD], a chronic lung disease causing difficulty in breathing). During a review of Resident 3 ' s History and Physical (H&P), dated 8/27/2024, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3 ' s Minimum Data Set ([MDS] a federally mandated resident assessment tool), dated 9/7/2024, the MDS indicated Resident 3 was dependent (staff does all the effort) for Activities of Daily Living (ADLs) such as lower body dressing and toileting hygiene. During a review of Resident 3 ' s Physician ' s Order dated 9/13/2024, the Order indicated to administer continuous O2 at 2L/min via NC to keep the O2 saturation above 90% every shift. Resident 3 had an order to receive continuous oxygen at 2 L/min via N/C to keep O2 saturation ([O2 sat], a measurement of how much O2 the blood is carrying as a percentage. above 90%. The Order also indicated to change O2 tubing every Monday on the night shift. During an observation on 10/23/2024 at 9:51 a.m., in Resident 3 ' s room. Resident 3 was observed asleep in bed without the O2 N/C on and the O2 off. Resident 3 ' s N/C tubing was observed unlabeled and placed on top of the O2 concentrator (device that that provides supplemental O2). During a concurrent observation and interview on 10/23/2024 at 1:02 p.m., with Licensed Vocational Nurse (LVN) 2, in Resident 3 ' s room, LVN 2 stated that Resident 3 ' s N/C was off and not labeled. LVN 2 stated, the resident ' s O2 was given as as needed (PRN) and he did not need it for now. During a concurrent interview and record review on 10/23/2024 at 1:08 p.m., with LVN 2, Resident 3 ' s Physician ' s Orders dated 9/2024 were reviewed. LVN 2 stated Resident 3 should have been receiving continuous O2. During a concurrent interview and record review on 10/23/2024 at 3:05 p.m., with Registered Nurse (RN) 1, Resident 3 ' s orders and care plans dated 9/2024 were reviewed. RN 1 stated Resident 3 had a physician ' s Order for continuous O2 and not PRN. RN 1 stated, Resident 3 ' s care plan indicated Resident 3 had altered cardiovascular (relating to the heart) status and nursing interventions for this problem was to give O2 as ordered by the physician. During a concurrent interview and record review on 10/23/2024 at 3:05 p.m., with RN 1, a picture of Resident 3 ' s O2 equipment was reviewed. RN 1 stated O2 equipment should have been labeled to know when it needed to be replaced and to indicate the equipment was for the resident. During a concurrent interview and record review on 10/23/2024 at 3:58 p.m., with the Director of Nursing (DON), Resident 3 ' s O2 orders dated 9/2024 were reviewed. The DON stated Resident 3 should have been administered continuous O2 order however the order was not followed. The DON stated it was important to follow the physician ' s orders. During a review of the facility ' s P&P titled, Infection Control Policy/Procedure: Oxygen, Use Of, dated 5/2021, P&P indicated, It is the policy of this facility to promote resident safety in administering oxygen. The P&P indicated, the O2 cannula or mask will be changed at least every 7 days, as well as the disposable humidifier. Tubing, masks, humidifiers, and other disposables used for oxygen administration will be dated in an identifiable fashion. The P&P also indicated, labeled, and dated bags should be provided for cannulas and masks to be placed in when not in use.

Oct 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure an abuse allegation was reported to the State Survey Age...

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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 an abuse allegation was reported to the State Survey Agency in a timely manner for one of 3 sampled residents (Resident 1). This deficient practice had the potential to result in further abuse to Resident 1. Findings: During a review of Resident 1 ' s admission record (face sheet), the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis that include chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidneys), urinary tract infection (an infection in any part of the urinary system), osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), and Type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). During a review of Resident 1 ' s Minimum Data Set (MDS- an assessment and care screening tool), dated 6/25/2024, indicated Resident 1 was cognitive skills was intact. The MDS also indicated Resident 1 required supervision and partial assistance with toileting, showering, and lower and upper body dressing. During an interview on 10/9/2024, at 12:02 p.m., with the Social Services Director (SSD), the SSD stated the protocol for reporting abuse was to report it immediately. The SSD stated Resident 1 informed her of someone hitting her arm on 10/3/2024. The SSD stated she documented what Resident 1 told her and went back to interview Resident 1. The SSD stated once she interviewed Resident 1 a second time, Resident 1 denied being struck by anyone. The SSD stated she did not inform any facility staff and should have reported Resident 1 ' s allegation of abuse. The SSD stated the risk of not reporting abuse in a timely manner could result in a potential for further abuse. During an interview, on 10/9/2024, at 12:38 p.m., with the Director of Nursing (DON), the DON stated any allegation of abuse must be reported within 2 hours. The DON stated Resident 1 ' s allegations should had been reported immediately. The DON stated the risk of not reporting in a timely manner could result in the resident not feeling safe and could potentially cause further abuse. The DON stated, We should have investigated the allegation of abuse if we had known about it, we have just found out about the allegation today. During an interview, on 10/9/2024, at 1:04 p.m., with the Administrator (Admin), the Admin stated he was the abuse coordinator and all allegations of abuse was to be reported to him. The Admin stated Resident 1 ' s abuse allegation was not reported. The Admin stated the risk of not reporting abuse in a timely manner could result in further abuse. A review of the facility ' s policy and procedures, revised 4/2019, titled Abuse: Prevention Of and Prohibition Against, indicated All allegations of abuse, neglect, misappropriation of resident property, or exploitation are to be reported to the Administrator immediately.

Jul 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon interview and record review, the facility failed to: 1. Ensure a new prescription order for Bethanechol (a medication...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon interview and record review, the facility failed to: 1. Ensure a new prescription order for Bethanechol (a medication used to relieve, prevent, or lowers the incidence of urinary muscle spasms) was carried out for one of 3 sampled residents (Resident 1). This deficient practice has the potential to result in developing complications of illness and delay of care. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on 9/2019 and readmitted on [DATE], with diagnoses that included osteoarthritis of the right hip (type of arthritis that occurs when flexible tissue at the ends of bones wears down), benign prostatic hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty), alcohol dependence (a chronic disease in which a person craves drinks that contain alcohol and is unable to control his or her drinking) and anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues). A review of Resident 1's Minimum Data Set (MDS- an assessment and care planning tool), dated 4/7/2024, indicated Resident 41 was cognitively intact. The MDS also indicated Resident 1 required set up dependence with toileting and dressing and required partial assistance from staff members with bathing. A review of Resident 1's physician's order dated 6/21/2024, indicated to give the resident Bethanechol 50 milligram (mg) by mouth three times a day for urinary antispasmodic, neuromuscular dysfunction bladder for 30 days. A review of Resident 1's June 2024 Medication Administration Record (MAR) indicated Resident 1 began receiving the Bethanechol medication on 6/28/2024. During a concurrent interview and record review, on 7/9/2024 at 10:15 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 1 recently had a new order for Bethanechol 50 mg from his urologist with a start date of 6/21/2024. LVN 1 stated the order should had been carried out on 6/21/2024 but Resident 1 did not receive the first dose until 6/28/24 due to a licensed staff member not carrying out the physician's order. LVN 1 stated the risk of not carrying out the physician's order resulted in a delay of care. During a concurrent interview and record review, on 7/9/2024 at 11:20 a.m., with the Assistant Director of Nursing (ADON), the ADON stated Resident 1 had received a new medication order from his urology doctor. The ADON stated upon returning from his appointment, the licensed staff did not input the new order into Resident 1's medical chart. The ADON stated on 6/28/2024, Resident 1 had complained about not receiving his new medication for 1 week. The ADON stated she reviewed Resident 1's physician orders and saw an incomplete order for the new medication. The ADON stated she then carried the order out herself on 6/28/24 so Resident 1 would began receiving the medication. The ADON stated the risk of not carrying out a physician's order resulted in a delay of care and potential complications. The ADON stated This order should have been communicated with all licensed staff. The resident did not get his medication that he should have gotten in a timely manner. During an interview, on 7/9/2024 at 11:45 a.m., with the DSD, the DSD stated Resident ' s Bethanechol medication had an initial order dated for 6/21/2024. The DSD stated Resident 1 did not receive his medication until 6/28/2024. The DSD stated a licensed staff member (who was no longer working at the facility) did not complete the order. The DSD stated the risk of not carrying out a physician's order resulted in a delay of care and possible complications for Resident 1. A review of the facility's policies and procedures, titled Medication Administration , revised 5/2020, indicated Medications must be administered in accordance with the written orders of the attending physician.

Feb 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0660 (Tag F0660)

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 three sampled residents (Resident 1) discharge planni...

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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 three sampled residents (Resident 1) discharge planning was developed and implemented per the facility ' s policy and procedure by failing to: 1. Ensure Resident 1 ' s discharge needs were identified on admission. 2. Ensure the Interdisciplinary Team (IDT) was involved in developing Resident 1 ' s discharge plan. 3. Ensure Resident 1 ' s discharge plan was developed and implemented timely. These deficient practices had the potential to result in psychological stress, ineffective discharge planning, and can lead to delay and unsafe discharge. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including diabetes (high blood sugar), hypertension (high blood pressure), and muscle weakness (weakness (a lack of strength in the muscles). During a review of Resident 1 ' s History and Physical (H&P) dated 10/13/2023, the H&P indicated Resident 1 could make needs known but could not make medical decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS] a comprehensive standardized assessment and care-screening tool) dated 1/18/2024, the MDS indicated Resident 1 could make himself understood, understand others, and was totally dependent on staff for dressing, toilet use, personal hygiene, and bathing. During an interview on 2/9/2024 at 2:00 PM with Resident 1 ' s, in Resident 1's room, Resident 1 stated he wanted to be discharged from the facility. Resident 1 stated he wanted to go back home but the facility would not discharge him. Resident 1 stated he feels upset and stressed out. During a concurrent interview and record review on 2/9/2024 at 2:30 PM with the Director of Nursing (DON), Resident 1 ' s Electronic Medical Record (EMR) was reviewed. The DON stated there was no evidence of an IDT (a group of different disciplines working together towards a common goal of a resident) meeting involving the resident to develop a discharge plan that reflects Resident 1 ' s discharge needs, goals, and preferences. There was no evidence Resident 1 was asked about interest in returning to the community. There was no comprehensive resident centered care regarding the discharge planning process. During an interview on 2/9/2024 at 3:30 PM with the Social Services Designee (SSD), the SSD stated she discussed discharge planning with Resident 1 but did not document it. The SSD stated there was no IDT meeting for discharge planning. During a review of the facility ' s policy and procedure (P&P) titled, Comprehensive Resident Centered Care Plan, discharge planning process, revised 9/2021, the P&P indicated: 1. Ensure that the discharge needs of each resident are identified on admission, and that a discharge plan for each resident is developed and implemented in a timely manner. 2. Include the Interdisciplinary team (IDT) in the ongoing process of developing the discharge plan. 3. Involve the resident and resident representative in the development of the discharge plan. 4. Document the resident has been asked about their interest in receiving information regarding returning to the community, the facility shall document any referrals to local contact agencies or other appropriate entities made for this purpose.

Dec 2023 8 deficiencies

CONCERN (D)

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

Deficiency F0559 (Tag F0559)

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 notify one of five Residents (Resident 133) of the roo...

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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 notify one of five Residents (Resident 133) of the room change on 12/13/2023 per the facility's policy. This deficient practice resulted to Resident 133 feeling frustrated with the room change. Findings: During a review of Resident 133's admission Record (Face Sheet), the Face Sheet indicated Resident 133 was admitted to the facility on [DATE]. Resident 133's diagnoses included metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction), spinal stenosis (a narrowing of the spinal canal putting the pressure on the spinal cord and nerves), and osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). During a review of Residents 133's History and Physical (H&P), dated 11/28/2023, the H&P indicated, Resident 133 had the fluctuating capacity to understand and make decisions. During a review of Resident 133's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 12/4/2023, the MDS indicated the cognition (the ability to think and process information) of Resident 133 was able to recall information. The MDS indicated Resident 133 is independent and required moderate assistance with Activities of Daily Living (ADLs) including toileting, personal hygiene, and locomotion. During an observation on 12/12/2023 at 10:15a.m., Resident 133 was in room [ROOM NUMBER]-A and on 12/13/2023 Resident 133's room was changed to room [ROOM NUMBER]-A. During an interview on 12/13/2023 at 8:29 a.m., with Resident 133, Resident 133 stated I was moved to this room in the middle of the night and the facility had not informed her of the room change. Resident 133 stated there was a lack of effort by the social worker explaining what is going on with her stay at the facility and leaving the facility. Resident 133 stated she was happy in the previous room, and no one came to check on how she felt about the room change. Resident 133 stated I felt frustrated about the lack attention I received from the Social Worker. During an interview on 12/14/2023 at 1:30 p.m., with Certified Nurse Assistant (CNA) 2, CNA 2 stated every time a room would happen, Social Services would explain the room change to the resident and the resident would sign a form. CNA 2 stated she was not aware if Resident 133 filled out the form to notify the resident and the family about the room change. During an interview on 12/14/2023 at 2:00 p.m. with Licensed Vocational Nurse (LVN) 3, the LVN 3 stated it was important for the facility to notify Resident 133 before the room was changed. LVN 3 stated notifying the residents about a room change ahead of time provide them the opportunity to refuse or agree. LVN 3 stated Social Services should provide a room change form for the residents or family to fill up and document about the room change. LVN 3 stated making room changes without proper communication could make Resident 133 feel confused, uncomfortable, and potentially make the roommates uncomfortable. During a concurrent interview and record review on 12/15/2023 at 8:49 a.m., with Director of Nursing (DON) 1 of the facility's policy and procedure (P&P) titled, Room to Room Transfer, dated 1/2022, the P&P indicated, resident will receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed. The DON 1 stated Resident 133 was moved to make space for the residents who tested positive for COVID-19 (a virus to potentially cause severe respiratory illness). The DON 1 confirmed there were no documentation Resident 133 was informed of the room change. The DON 1 stated the Social Services should have done wellness checks with Resident 133 since she was moved last 12/13/2023. The DON stated it was important to conduct the wellness check on Resident 133 to make sure Resident 133 had adjusted well with the room change. During an interview on 12/15/2023 at 10:21 a.m., with Social Services Director (SSD) 1, the SSD 1 stated the residents were to be notified reasons for the room change prior to being done. SSD 1 stated residents were provided a form of notification when there is a room change. The SSD 1 was unable to locate the form for Resident 133's room change on 12/12/2023 to 12/13/2023. SSD1 stated the room change form should have been done at least 24 hours after Resident 133 moved to the new room. SSD 1 stated there are no documentations wellness check were conducted to Resident 133 since the room change. The SSD 1 stated it was important to notify Resident 133 of the room change, provide the form and conduct the wellness checks to make sure Resident 133 did not have a negative psychosocial outcome and to make sure Resident 133 was comfortable with the new roommates. During a review of the facility's policy and procedure (P&P) titled, Room to Room Transfer, dated 1/2022, the P&P indicated, where feasible, and with the consent of the involved residents, the facility will make room to room transfers when requested by the resident or as may become necessary to meet the resident's physical, mental, or psycho-social needs .Prior to the transfer, the resident, his or her roommate, and the resident's representative will be provided with information concerning the decision to make the room transfer. Such notice will include the reason why the move is recommended .Resident will receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed.

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure one of 10 sampled residents (Resident 52) medical record...

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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 one of 10 sampled residents (Resident 52) medical records were updated to show documentation 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 was provided to the residents and/or responsible parties. 2. Ensure the Physician Orders for Life-Sustaining Treatment (POLST, a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) was completed for one out five Residents (Resident 133). This deficient practice had the potential to cause conflict with the residents' treatment wishes regarding health care in case of medical emergencies. Findings: 1. During a review of Resident 52's admission record, the admission record indicated Resident 52 was initially admitted to the facility on [DATE] with diagnoses included type 2 diabetes mellitus (abnormal blood sugar), congestive heart failure (chronic condition where the heart does not pump blood effectively), and pulmonary hypertension (a condition that affects the blood vessels in the lungs). During a review of Resident 52's history and physical (H&P), dated 12/2/2022, the H&P indicated Resident 52 had the capacity to understand and make decisions. During a review of Resident 52's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 9/10/2023, the MDS indicated Resident 52 had clear cognition (ability to learn, reason, remember, understand, and make decisions). During a concurrent interview and record review on 12/14/2023 at 7:59 a.m. with the Social Service Director (SSD), Resident 52's Social Services Assessment/Evaluation, dated 9/13/2023 was reviewed. The SSD stated Resident 52 does not have an advance directive. The SSD stated, No you can't tell if the resident or family was educated, none of the other boxes are checked off. The SSD stated an advance directive is a document that shows what your healthcare wishes are when you can't express it. The SSD stated it is very important to give residents and/or family education on advance directives so they are informed to make the appropriate decision. During an interview on 12/15/2023 at 1:52 p.m. with the Assistant Director of Nursing (ADON), the ADON stated an advance directive is completed if a resident in incapacitated. The advance directives indicate the wishes for their healthcare or who they want to speak up for them. The ADON stated it is important to provide education regarding advance directives. The ADON stated it is the resident's right to be able to make an informed decision. During a review of the facility's policy and procedure (P&P) titled, Advance Directives, dated 11/2019, the P&P indicated, it is the policy of this facility to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. If the resident is incapacitated at the time of admission and is unable to receive information or indicate whether he/she has executed an advance directive, the facility may give advance directive information to the resident's representative in accordance with existing State law. 2. During a review of Resident 133's admission Record (Face Sheet), the Face Sheet indicated Resident 133 was admitted to the facility on [DATE]. Resident 133's diagnoses included metabolic encephalopathy (an alteration in consciousness caused due to brain dysfunction), spinal stenosis (a narrowing of the spinal canal putting the pressure on the spinal cord and nerves), and osteoarthritis (a degenerative joint disease, in which the tissues in the joint break down over time). During a review of Residents 133's History and Physical (H&P), dated 11/28/2023, the H&P indicated, Resident 133 had the fluctuating capacity to understand and make decisions. During a review of Resident 133's MD, dated 12/4/2023, the MDS indicated Resident 133 was able to recall information. The MDS indicated Resident 133 is independent and required moderate assistance with Activities of Daily Living (ADLs) including toileting, personal hygiene, and locomotion. During a concurrent interview and record review on 12/14/2023 at 2:29 p.m., with Director of Staff Development (DSD) 1 of Resident 133's POLST dated 11/27/2023, the POLST indicated sections B and D were incomplete. DSD 1 stated the POLST form was not fully filed out. DSD 1 stated it was important to completely fill out the POLST for Resident 133 to know and implement what her treatment wishes would be in case of medical crisis. During a concurrent interview and record review on 12/15/2023 at 8:49 a.m., with Director of Nursing (DON) 1 of Resident 133's POLST dated 11/27/2023, the POLST indicated, section B and D were incomplete. DON 1 stated Resident 133 POLST was not completely filed out. DON 1 stated it was important to complete the POLST form because the POLST would direct the care and level of care that needs to be given for Resident 133. During a concurrent interview and record review on 12/15/2023 at 10:21a.m., with Social Services Director (SSD) 1, Resident 133's POLST, dated 11/27/2023 was reviewed. The POLST indicated, sections B and D were incomplete. SSD 1 stated Resident 133's POLST section B and D was not completed. SSD 1 stated it was important to complete the POLST for Resident 133 so if a medical emergency would happen, the POLST would tell the staff what her treatment needs and wishes were. During a review of the facility's policy and procedure (P&P) titled, Advance Directive, dated 11/2019, the P&P indicated, the facility will be utilizing the POLST form for residents with the capacity to make decisions and legal representatives to communicate their choices of medical interventions and procedures and end-of-life decisions .The facility has defined advance directives to include preferences regarding treatment options. During a review of the facility's P&P titled, Social Services, dated 8/2017, the P&P indicated, it is the policy of this facility to provide medically related social services to attain or maintain the highest practicable physical, mental, or psychosocial well-being of each resident . Assisting residents with advance care planning, including but not limited to completion of advance directive.

CONCERN (D)

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

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a preadmission screening and resident review Level I screeni...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a preadmission screening and resident review Level I screening document (PASRR) was completed accurately for one of one residents (Resident 2) who was diagnosed with a mental illness prior to admission in the facility. This deficient practice had the potential to result in Resident 2 not receiving the necessary and appropriate psychiatric level of treatment and evaluation in the facility. Findings: During a review of Resident 2's admission record, the admission record indicated Resident 52 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dementia (loss of the ability to think, remember, and reason to levels that affect daily life and activities), schizoaffective disorder (a mental disorder with symptoms of hallucinations or delusions and mood disorder like depression), and schizophrenia (a mental disorder that affects a person's ability to think, feel and behave clearly). During a review of Resident 2's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 9/9/2023, the MDS indicated Resident 2 usually understands, missed some part/intent of the message but comprehends (ability to learn, reason, remember, understand, and make decisions) most of the conversation. During a review of Resident 2's history and physical (H&P), dated 10/6/2023, the H&P indicated Resident 2 could make needs known but could not make medical decisions. During a review of Resident 2's medical record indicated a care plan titled, unspecified dementia, unspecified severity, without behavioral disturbance, mood disturbance, and anxiety was initiated on 01/01/2021. During a review of Resident 2's medical record indicated a care plan titled, potential for psychosocial well-being problem schizophrenia unspecified, schizoaffective disorder unspecified was initiated on 1/8/2021. During a concurrent interview and record review on 12/14/2023 at 10:26 a.m. with the Director of Nursing (DON), the PASRR, dated 1/8/2021 was reviewed. The PASRR indicated, no to the questions: Is there a diagnosis or other evidence of a neurocognitive disorder (decreased mental function due to a medical disease other than a psychiatric illness), e.g., other dementias and Does the resident have a diagnosed mental disorder such as schizophrenia/schizoaffective disorder? The DON stated Resident 2 did have a diagnosis of dementia and schizoaffective disorder diagnosed on [DATE] and a diagnosis of schizophrenia diagnosed on [DATE]. The DON stated the facility should have checked off Yes to those questions and no was checked off. The DON stated PASRR's should be filled out correctly upon admission, significant change of condition, a significant new diagnosis, and if insurance changes to Medicare. The DON stated that if the PASRR was filled out correctly there would have been a positive PASRR II for Resident 2 which would have benefited Resident 2. The DON stated if the PASRR is not filled out correctly the resident could miss out on some of the services that PASRR is rendering. During a review of the facility's policy and procedure (P&P) titled, PASRR, dated 12/2021, the P&P indicated, It is the policy of this facility to ensure that each resident is properly screened using the PASRR specified by the State. Based upon the assessment, the facility will ensure proper referral to appropriate state agencies for the provision of specialized services to residents with ID/RC (Intellectual Disability or Related Condition) or SMI (Serious Mental Illness).

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** c). During a review of Resident 4's admission records indicated Resident 4 was admitted to the facility on [DATE], and readmitte...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c). During a review of Resident 4's admission records indicated Resident 4 was admitted to the facility on [DATE], and readmitted on [DATE] with a diagnosis that included arthritis (swelling and tenderness of one or more joints), Behavioral disturbance (a pattern of disruptive behaviors that cause problems in social situations), centrilobular emphysema (a form of chronic lung disease), hypertensive heart (a problems that occur because of high blood pressure that is present over a long time), dementia (the loss of cognitive functioning), anxiety disorder (persistent and excessive worry that interferes with daily activities), legal blindness (vision is 20/200 or less in the field of vision is less than 20 degrees). During a review of Resident 4's MDS dated [DATE], indicated no cognitive patterns was completed. During an interview and observation on 12/12/2023 at 10:22 a.m. with Resident 4. Resident 4 was awake, alert, and stated she was very annoyed. Resident 4 stated she had been requesting to see a podiatrist for several months. Resident 4 stated she saw the podiatrist on several occasions and was told to remove the ingrown toenail and she would have to come to the podiatry office. A review of Resident 4's records did not indicate a care plan for bilateral great toe ingrown toenails. Based on interview and record review, the facility failed to develop a comprehensive and resident centered care plan for three of nine sampled resident (Residents 52, 283 and 4) by failing to: 1. Develop a care plan to address Resident 52's behavior of changing the amount of oxygen infused from 2 liters to 3.5 liters which was not consistent with the physician's order. 2. Ensure Resident 283 had a plan of care and a physician's order to receive continuous oxygen at 2 liters per minute. 3. Develop a care plan to address Resident 4's bilateral great ingrown toenail. This deficient practice had the potential to a poor quality nursing care provided to Residents 52, 283 and 4. Findings: a). During an observation on 12/12/2023 at 1:11 p.m. in Resident 52's room, the oxygen was infusing at 3.5L and Resident 52 was putting the nasal canula back on. The oxygen tubing, bag and humidification bottle were dated 11/29/2023. Resident 52 did not appear to have any discomfort or respiratory distress at the time. During a review of Resident 52's admission record, the admission record indicated Resident 52 was initially admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (abnormal blood sugar), congestive heart failure (chronic condition where the heart does not pump blood effectively), and pulmonary hypertension (a condition that affects the blood vessels in the lungs). During a review of Resident 52's history and physical (H&P), dated 12/2/2022, the H&P indicated Resident 52 had the capacity to understand and make decisions. During a review of Resident 52's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 9/10/2023, the MDS indicated Resident 52 had clear cognition (ability to learn, reason, remember, understand, and make decisions). During a review of Resident 52's order summary report (physician orders), dated 12/1/2023, the physician orders indicated continuous oxygen at (2)L/min via nasal cannula/mask to keep oxygen saturation above 90%. During an interview on 12/13/2023 at 4:00 p.m. with Resident 52, Resident 52 stated I do sometimes turn up my oxygen when I feel I need more. Resident 52 stated The nurses do let her know that she is not supposed to change it. During an interview on 12/14/2023 at 11:48 a.m. with the Director of Staff Development (DSD), the DSD stated Resident 52's oxygen should be at 2L. The DSD stated Resident 52 changes the settings. The DSD further stated Resident 52 is educated on the risks and benefits on why not to change the settings on the oxygen machine. The DSD stated there should be a care plan showing this noncompliance from the resident. During a concurrent interview and record review on 12/14/2023 at 12:00 p.m. with DSD, Resident 52's care plans were reviewed. The DSD stated there was no care plan for the oxygen noncompliance. The DSD stated care plans are initiated to set up a plan of care and shows you how to take care of a resident. The DSD stated a care plan is a form of communication for the whole team such as nurses, doctors and therapist. The DSD stated if a care plan is not developed you could not meet the needs of the resident. During a concurrent interview and record review on 12/14/2023 at 12:15 p.m. with the Director of Nursing (DON), Resident 52's care plans were reviewed. The DON stated there was no care plan for the noncompliance that Resident 52 changes the oxygen levels. The DON stated that care plans are developed to help direct the care of the patients. b). During a review of Resident 283's admission Record, dated 12/14/2023, the admission Record indicated Resident 283 was admitted to the facility on [DATE] with the following diagnoses which included, chronic obstructive pulmonary disease (COPD - a common lung disease causing restricted airflow and breathing problems) with acute exacerbation (a sudden worsening of symptoms), heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs), hypertension (high blood pressure) and hyperlipidemia (an abnormally high concentration of fat particles in the blood). During a review of Resident 283's History and Physical (H&P) dated 12/8/2023, the H&P indicated Resident 283 had the capacity to understand and make decisions. During a review of Resident 283's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 11/5/2023, the MDS indicated Resident 283 had problems with memory and was moderately impaired in cognitive skills for making decisions. Resident 283 also required maximal assistance with toileting, bathing and dressing the lower body. During a review of Resident 283's Order Summary Report, dated 12/8/2023, the Order Summary Report indicated an active order for continuous oxygen at 2 liters per minute via nasal cannula/mask to keep oxygen saturation above 90% every shift. During a review of Resident 283's COPD care plan, initiated on 11/1/2023, the COPD care plan indicated that Resident 283 will be free of signs and symptoms of respiratory infection and will display optimal breathing pattern daily. The care plan did not include goals and interventions for the administration of oxygen at 2 liters per minute via nasal cannula/mask to keep oxygen saturation above 90 percent for Resident 283 as ordered by the physician. During a concurrent interview and record review on 12/15/2023 at 10:15 a.m., with Registered Nurse (RN) 1, RN 1 was asked to provide Resident 283's care plan for oxygen administration. RN 1 stated that she was unable to find a care plan for oxygen administration for Resident 283. She stated that she could only locate the physician's order for Resident 283 to receive continuous oxygen 2 liters per minute and confirmed that there is no care plan for the oxygen order. RN 1 stated Resident 283 should have a care plan for oxygen. RN 1 also stated that a care plan is needed to manage the resident's care and without a care plan, there is no way to know how to care for the resident. During a concurrent interview and record review on 12/15/2023 at 11:19 a.m., with the Director of Nursing (DON), the DON was asked to locate the Resident 283's care plan for oxygen. The DON stated that Resident 283 did not have a care plan for oxygen administration. The DON stated that the care plans are created for continuous care and gives the nursing staff instructions on how to care for the residents. The DON stated that the care plan for oxygen can be completed by any licensed nurse, and the care plans must be completed on admission and should be followed up by the MDS coordinator. The DON stated that the lack of a care plan can cause a disruption in the resident's care. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Resident Centered Care Plan, dated 1/2021, the P&P indicated, the facility, shall develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Resident Centered Care Plan, dated 1/2021, the P&P indicated, the facility shall develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing and mental and psychosocial needs.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b). During a review of Resident 283's admission Record, dated 12/14/2023, the admission Record indicated Resident 283 was admitt...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b). During a review of Resident 283's admission Record, dated 12/14/2023, the admission Record indicated Resident 283 was admitted to the facility on [DATE] with the following diagnoses which included, chronic obstructive pulmonary disease (COPD - a common lung disease causing restricted airflow and breathing problems with acute exacerbation (a sudden worsening of symptoms), heart failure (a chronic condition in which the heart does not provide adequate blood flow to meet the body's needs), hypertension (high blood pressure) and hyperlipidemia (an abnormally high concentration of fat particles in the blood). During a review of Resident 283's History and Physical (H&P) dated 12/8/2023, the H&P indicated that Resident 283 had the capacity to understand and make decisions. During a review of Resident 283's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 11/5/2023, the MDS indicated Resident 283 had problems with memory and was moderately impaired in cognitive skills for making decisions. Resident 283 also required maximal assistance with toileting, bathing and dressing the lower body. During a review of Resident 283's Order Summary Report, dated 12/8/2023, the Order Summary Report indicated an active order for continuous oxygen at 2 liters per minute via nasal cannula/mask to keep oxygen saturation above 90% every shift. During a review of Resident 283's Medication Administration Record (MAR), for the month of December 2023, the MAR indicated that continuous oxygen at 2 liters per minute was signed off by a licensed nurse from December 9, 2023, through December 14, 2023. During a review of Resident 283's COPD care plan, initiated on 11/1/2023, the COPD care plan indicated that Resident 283 will be free of signs and symptoms of respiratory infection and will display optimal breathing pattern daily. During an observation on 12/13/2023, at 12:41 p.m., in the dining area, observed Resident 283's oxygen running at 2.5 LPM while connected to a portable cylinder oxygen tank. During an interview on 12/14/2023 at 11:52 a.m., with the DSD, the DSD stated that Resident 283 has an order to receive oxygen at 2 LPM. The DSD stated that there is a reason the oxygen is ordered at a certain level because the resident may have COPD. The DSD stated that it is important to follow the doctor's orders because oxygen is considered a mediation and too much oxygen can cause a problem for some residents. During a concurrent interview and record review on 12/14/2023 at 2:15 p.m., with LVN 2, LVN 2 reviewed the Order Summary Report, dated 12/8/2023, for Resident 283's oxygen order. LVN 2 stated that Resident 283's oxygen should be at 2 LPM per doctor's orders and not at 2.5 LPM. LVN 2 stated that the oxygen level should be checked every shift. LVN 2 also states that a higher level of oxygen could be too much for Resident 283's lungs to handle. During a concurrent observation, interview, and record review on 12/15/2023 at 10:15 a.m., with RN 1, RN 1 confirmed that resident was receiving 2.5 LPM oxygen. RN 1 reviewed the Order Summary Report, dated 12/8/2023 and confirmed that Resident 283 is ordered to receive 2 LPM oxygen and not 2.5 LPM. RN 1 stated that Resident 283 is diagnosed with COPD and getting too much oxygen can trap his carbon dioxide and could lead to death. During a concurrent interview and record review on 12/15/2023 at 11:19 a.m., with DON, DON reviewed Resident 283's Order Summary Report, dated 12/8/2023 and confirmed that Resident 283 was ordered to receive continuous oxygen at 2 LPM not 2.5 LPM. The DON stated that if Resident 283 has COPD and too much oxygen can cause in increase in the resident's carbon dioxide. The DON stated, They can basically die. Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Resident 52 and Resident 283) received respiratory care consistent with professional standards of practice by failing to: 1. Ensure the oxygen (air) nasal cannula (a device used to deliver supplemental oxygen) tubing, storage bag and humidifier (liquid that moistens the air) bottle were changed after seven days from 11/29/2023 and the oxygen nasal cannula tubing, storage bag, and humidifier bottle was labeled with the date of change to be used as reference for changing humidifier bottles in seven days for Resident 52. 2. Ensure Resident 283 received the correct amount of oxygen ordered at 2 liters per minute as by the physician. These failures had the potential to result in unsafe use or storage of oxygen equipment, respiratory infection and respiratory distress (being unable to breathe comfortably), and/or hospitalization. Findings: a). During an observation on 12/12/2023 at 1:11 p.m. in Resident 52's room, the oxygen was infusing, and Resident 52 was putting the nasal canula back on. The oxygen tubing, bag and humidification bottle were dated 11/29/2023. Resident 52 did not appear to have any discomfort or respiratory distress at the time. During a review of Resident 52's admission record, the admission record indicated Resident 52 was initially admitted to the facility on [DATE], with diagnoses that included type 2 diabetes mellitus (abnormal blood sugar), congestive heart failure (chronic condition where the heart does not pump blood effectively), and pulmonary hypertension (a condition that affects the blood vessels in the lungs). During a review of Resident 52's history and physical (H&P), dated 12/2/2022, the H&P indicated Resident 52 had the capacity to understand and make decisions. During a review of Resident 52's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 9/10/2023, the MDS indicated Resident 52 had clear cognition (ability to learn, reason, remember, understand, and make decisions). During a review of Resident 52's order summary report (physician orders), dated 12/1/2023, the physician orders indicated to change the oxygen tubing and remove humidifier if at 2L or below every nightshift every Monday. During an interview on 12/14/2023 at 11:36 a.m. with Registered Nurse Supervisor (RN) 1, RN 1 stated the oxygen tubing should be changed every seven days or as needed. RN 1 stated that it must be changed to prevent resident's from potentially getting an infection. During an interview on 12/14/2023 at 11:48 a.m. with the Director of Staff Development (DSD), DSD stated the oxygen tubing, bag and humidification bottle should be changed weekly. The DSD stated it is important to change these things for infection control. The DSD stated that there could be issues with the tubing and it could not be working properly. The DSD stated that if the humidification bottle is dried up the resident nares could potentially dry, causing cracking, bleeding, and respiratory illness. During an interview on 12/14/2023 at 12:15 p.m. with the Director of Nursing (DON), the DSD stated the oxygen tubing, bag and humidification bottle should be labeled with the date that the tubing was last changed. The DON stated that these items should be changed every week regularly and as needed. The DON stated that if not changed timely it can potentially cause an infection. The DON stated that if the humidification bottle is not changed regularly and is dried out it can cause dryness, bleeding, and possible infection. During a review of the facility's policy and procedure (P&P) titled, Oxygen, Use of, dated 5/2021, the P&P indicated, it is the policy of this facility to promote resident safety in administering oxygen. The O2 cannula or mask will be changed at least every seven days, as well as the disposable humidifier. Tubing, masks, humidifier, and other disposables used for Oxygen administration will be dated in an identifiable fashion.

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** b). During a review of Resident 46's admission Record, dated 12/14/2023, the admission Record indicated Resident 46 was initiall...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b). During a review of Resident 46's admission Record, dated 12/14/2023, the admission Record indicated Resident 46 was initially admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses which included dementia (a loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves), adult failure to thrive (when an older adult has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal), personality disorder (a mental health condition where people have a lifelong pattern of seeing themselves and reacting to others in ways that cause problems), intellectual disabilities (limited ability to learn at an expected level and function in daily life) and palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness). During a review of Resident 46's Diagnosis Report, dated 12/14/2023, the Diagnosis Report indicated Resident 46 also had diagnoses which included acute respiratory failure with hypoxia and hypercapnia (a condition where there is not enough oxygen in the tissues the body and there is too much carbon dioxide in the blood), pneumonitis (inflammation of lung tissue) due to inhalation of other solids and liquids) and dysphasia (difficulty swallowing). During a review of Resident 46's History and Physical (H&P) dated 5/31/2023, the H&P indicated that Resident 46 did not have the ability to understand and make decisions. During a review of Resident 46's Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 10/24/2023, the MDS indicated Resident 46 had a Brief Interview for Mental Status (BIMS - a screening tool used to identify the cognitive condition of residents upon admission into a long-term care facility) of three (severe impairment, normal BIMS score is 13-15). The MDS also indicated Resident 46 requied substantial assistance with eating and total dependence with dressing, toileting, and personal hygiene. During a review of Resident 46's care plan with focus on nutritional problems, initiated on 4/13/2021 and revised on 12/12/2023, the care plan indicated that Resident 46 has dysphagia and needed staff to assist setting up to eat. The care plan also indicated that Resident 46 prefers to lay flat at all times including during meals. Interventions included monitoring, documenting, and reporting to the doctor as needed for signs and symptoms of dysphagia and also monitoring for choking and aspiration (to accidentally inhale food or liquid into the airway instead of the food pipe). During a review of Resident 46's care plan with focus on nutritional problems, initiated on 3/11/2022 and revised on 5/25/2022, the care plan indicated that Resident 46 was at risk for choking due to refusal to have her head elevated while feeding herself flat in bed. Interventions included monitoring, documenting, and reporting to the doctor for any signs and symptoms of chocking, coughing, drooling, holding food in mouth, several attempts at swallowing or appearing concerned during meals. During an observation on 12/12/2023 at 11:17 a.m., in Resident 46's room, Resident 46 was lying flat on her back in bed, attempting to eat from her meal tray that was sitting next to her in the bed. Observed Resident 46's call light hooked to a cord that was above the bed and out of the reach of Resident 46. During a concurrent observation and interview on 12/12/2023 at 11:32 a.m., with the Director of Staff Development (DSD), in Resident 46's room, the DSD observed the call light hooked to the wall above Resident 46's head. The DSD immediately unhooked the call light and placed it next to Resident 46. The DSD stated that the call light should be within reach of the resident, but that Resident 46 does not like her call light in the bed. The DSD also stated that Resident 46 prefers to eat while lying flat and that this could be a choking hazard. The DSD stated, We should probably get a care plan for that, since she does not like to have the call light within reach, but we do check on her periodically. During an observation on 12/14/2023 at 8:40 a.m., observed Resident 46's door closed shot. Opened the door to find Resident 46 lying flat on her back in bed with her breakfast tray sitting next to her in the bed. Resident 46's call light was wedged between her mattress and headboard and out of reach to the resident. During a concurrent observation and interview on 12/14/2023 at 8:50 a.m. with certified nursing assistant (CNA) 1, CNA 1 came into the room and located the call light that was wedged between the mattress and the headboard. CNA 1 stated that the call light was tucked under the sheet and wedged between the headboard and the mattress. CNA 1 was asked if this was the appropriate place for Resident 46's call light. CNA 1 stated that this was not an appropriate place for the Resident 46's call light. CNA 1 also stated that Resident 46 should not have her door closed while eating because she is at risk of choking, and she would not be able to reach her call light in case of an emergency. During an interview on 12/14/2023 at 2:16 p.m., with licensed vocational nurse (LVN) 2, LVN 2 stated that Resident 46 likes to eat while lying down which puts her at an increased risk of choking. LVN 2 says this is why it is important to keep her door open and have her call light within reach when she is eating. During an interview on 12/14/2023 at 11:19 a.m., with RN 1, RN 1 stated that the door is not supposed to be closed to Resident 46's room while she is eating, and the call light should be where Resident 46 can reach it in case of an emergency. RN 1 stated that the resident could aspirate or choke. RN 1 stated that the CNAs need to be educated of the potential risk of placing Resident 46's call light out of reach. RN 1 stated, This is so dangerous! During an interview on 12/15/2023 with the DON, the DON stated that it is unacceptable to have Resident 46's call light hooked to a cord above her head or wedged between the mattress and the headboard. The DON stated that something could be going on with the resident and she would not be able to get to the call light. The DON stated that there should be increased rounds on Resident 46 during certain times and someone should monitor her during the times when she is eating. During a review of the facility's policy and procedure (P&P) titled, Call Light/Bell, dated 5/2007, the P&P indicated, the policy of the facility is to provide the resident a means of communication with nursing staff. The P&P also indicated to place the call device within resident's reach before leaving the room. Based on observation and interview the facility failed to ensure three of 18 sampled residents (Residents 236, 46 and 20) call light device were placed within reach at all times. This deficient practice had the potential to result in a delay in the residents to obtain necessary care and services. Findings: a). During a review of Resident 236's admission record, the admission record indicated Resident 236 was initially admitted to the facility on [DATE], with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) and retention of urine, urinary retention (a condition in which you are unable to empty all the urine from your bladder). During a review of Resident 236's history and physical (H&P), dated 11/8/20203, the H&P indicated Resident 236 could make needs known but could not make medical decisions. During a review of Resident 236's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 11/14/2023, the MDS indicated Resident 236 sometimes understand verbal content, and was sometimes understood when making concrete requests. The MDS indicated Resident 236 was dependent with the assistance of two or more helpers for toileting, bathing, dressing, personal hygiene and rolling left and right. During an observation on 12/12/2023 at 2:20 p.m. in Resident 236's room, the resident's call light was wrapped around the intravenous ([IV] a thin bendable tube that slides into a vein) pole (a pole that provides a secure place to hang bags of medicine or fluid for administration to a patient) next to the bed, not within reach to the resident. Licensed Vocational Nurse (LVN) 1 was coming in and out of the room checking on Resident 236. The Director of Nursing (DON) came in to start the IV medication, but resident 236 was not feeling too good. The DON told the resident and family that the doctor would be notified. During an interview on 12/12/2023 at 2:32 p.m. with LVN 1, LVN 1 stated No, the call light wasn't near the resident, it wasn't within reach. LVN 1 stated if the call light is not within reach the resident would not receive the services they need in a timely manner. During an observation on 12/14/2023 at 2:28 p.m. in Resident 236's room, the resident's call light was laying on the ground and not within reach to the resident. During a concurrent observation and interview on 12/14/2023 at 3:40 p.m. with the Director of Staff Development (DSD), in resident 236's room. Resident 236's call light was on the floor. The DSD stated the call light is on the floor not within reach of the resident. The DSD stated that call lights should always be within reach of the resident. The DSD stated that if the call light is not within reach there is no way their needs would be met when needed. The DSD stated this could possibly delay care for the resident. During an interview on 12/15/2023 at 1:46 p.m. with the DON, the DON stated call lights should be at the bedside within reach. The DON stated if the call light is not within reach of the resident, the resident will not be able to call for help. The DON stated that this could potentially be harmful to the resident. c). During a review of Resident 20's admission Record (Face Sheet), the Face Sheet indicated Resident 20 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 20's diagnoses included cerebrovascular disease (a condition that affects blood flow and the blood vessels in the brain), aphasia (damage in a specific area of the brain that controls language expression and comprehension), dysphagia (swallowing difficulties) and hemiplegia (is one sided muscle paralysis or weakness). During a review of Residents 20's History and Physical (H&P), dated 10/19/2023, the H&P indicated, Resident 20 was able to nod and shake his head to simple questions. During a review of Resident 20's MDS dated [DATE], the MDS indicated the cognition (the ability to think and process information) of Resident 20 was able to make daily decisions with some difficulty in new situations only. The MDS indicated Resident 20 is dependent and required physical assistance with Activities of Daily Living (ADLs) including toileting, personal hygiene, and locomotion. During an observation on 12/12/2023 at 11:00 a.m., in Resident 20's room, Resident 20 had a press button call light. Resident tried to press the call light but had difficulty with trying to press the call light button. Resident 20 was not able to efficiently pick up the call light and pressed the button. During a concurrent observation and interview on 12/14/2023 at 1:30 p.m., with Certified Nurse Assistant (CNA) 2 in Resident 20's room, Resident 20 attempted to press the call light and was not able to successfully press the button. CNA 2 stated Resident 20 should have a call light to tap instead of a press button. CNA 2 stated it would benefit Resident 20 if he had the tap call light. CNA 2 stated it would be easier for Resident 20 to use. CNA 2 stated if he had the call light to tap his needs would be met faster. During a concurrent observation and interview on 12/14/2023 at 2:00 p.m., with Licensed Vocational Nurse (LVN) 3 in Resident 20's room, Resident 20 attempted to press the call light and was not able to successfully press the button. LVN 3 stated Resident 20 should have a tap call light instead of pressing the button call light. LVN 3 stated it was important to have the correct call device so Resident to call us for assistance. During an interview on 12/15/2023 at 8:49 a.m., with Director of Nursing (DON) 1, DON 1 stated Resident 20 should have a tap call light device. DON 1 stated Resident 20 had changed his room and failed to set up the correct call light device. DON 1 stated it was important to have the correct call light device so Resident 20 can get the care he needs in a timely manner. During a review of the facility's P&P titled, Accommodation of Needs and Preferences and Homelike Environment, (undated), the P&P indicated, that it is the policy of the facility to identify and provide reasonable accommodations of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. The P&P also indicated that the facility will assess and interview residents for the need to make reasonable accommodations for call light in reach for room and bathroom for resident's use and adaptive devices to maintain restore resident at their highest level of functioning. During a review of the facility's policy and procedure (P&P) titled, Call Light/Bell, dated 05/2007, the P&P indicated, it is the policy of this facility to provide the resident a means of communication with nursing staff. Leave the resident comfortable. Place the call device within resident's reach before leaving the room.

CONCERN (E)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to accurately account for five doses of controlled medications (medications with a high potential for abuse) affecting Residents...

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Based on observation, interview, and record review, the facility failed to accurately account for five doses of controlled medications (medications with a high potential for abuse) affecting Residents 17, 22, 25, 46, and 133 in one of two inspected medication carts (Station 2 Cart 2) This deficient practice increased the risk that Residents 17, 22, 25, 46, and 133 could have received too much or too little medication due to lack of documentation potentially resulting in serious health complications requiring hospitalization. Findings: During a concurrent observation and interview on 12/15/2023 at 12:25 p.m. with Licensed Vocational Nurse (LVN) 2 at Station 2 Cart 2 the following discrepancies were found between the Controlled Medication Count Sheet (a log signed by the nurse with the date and time each controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication): 1. Resident 17's Controlled Medication Count Sheet for apap/codeine (a medication used to treat pain) 300-60 milligrams (mg - a unit of measure for mass) indicated there were 59 doses left, however, the medication card contained 58 doses. 2. Resident 22's Controlled Medication Count Sheet for clonazepam (a medication used to treat panic disorder, anxiety) 1 mg indicated there were 18 doses left, however, the medication card contained 17 doses. 3. Resident 25's Controlled Medication Count Sheet for lorazepam (a medication used to treat anxiety) 0.5 mg indicated there were 11 doses left, however, the medication card contained 10 doses. 4. Resident 46's Controlled Drug Record for clonazepam 0.5 mg indicated there were 25 doses left, however, the medication card contained 24 doses. A review of Resident 46 admission record indicated Resident 46 was admitted to the facility with diagnosis of schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves), personality disorder, mental disorder, dementia (a condition characterized by progressive or persistent loss of intellectual functioning) and personal history of other mental and behavioral disorders. 5. Resident 133's Controlled Medication Count Sheet for hydrocodone/apap (a medication used to treat pain) 5-325 mg indicated there were 19 doses left, however, the medication card contained 18 doses. A review of Resident 133 indicated Resident 133 was admitted to the facility with diagnosis of spinal stenosis (narrowed space inside the backbone, causing pressure and pain), polyneuropathy (simultaneous malfunction of many peripheral nerves throughout the body). A review of Resident 133's December 2023 medication orders indicated hydrcodone-acetaminophen oral tablet 5-325 milligrams (mg), give one tablet by mouth every six hours as needed for severe pain (7-10). LVN 2 stated she administered all five of the missing doses of controlled medications earlier today and failed to sign the Controlled Medication Count Sheet because she was distracted by other tasks. LVN 2 stated she is required to sign the Controlled Medication Count Sheet at the time of administration to ensure there is accountability of the medication counts and to ensure residents don't receive more medications or receive it more often than prescribed. LVN 2 stated giving medication more often that prescribed could cause residents to overdose leading to medical complications. During an interview on 12/15/2023 at 1:01 p.m. with the Director or Staff Development (DSD), the DSD stated that you should sign the Controlled Medication Count Sheet immediately it is a tally of what has been given. The DSD stated that not filling out the controlled medication count sheet could result in the resident to possibly get an extra dose of medication. The DSD stated this could lead to the resident becoming over medicated or under medicated and potentially could be harmful to the resident. During an interview on 12/15/2023 at 1:46 p.m. with the Director of Nursing (DON), the DON stated the Controlled Medication Count Sheet should be filled out as soon as you are done passing the mediation. The DON stated the purpose of the Controlled Medication Count Sheet is to keep an accurate record of the narcotics with the date and time the medication was given. The DON stated if the form is not filled out correctly there could potentially risk for overdose which could be harmful to the resident. During a review of the facility's policy and procedure (P&P) titled, Controlled Mediations - Storage and Reconciliation, dated 1/2022, the P&P indicated, When a controlled medication is administered, the licensed nurse administering the medication immediately enters all of the following information on the accountability record .Signature of the nurse administering the dose, completed after the medication is actually administered.

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: 1. Ensure the indwelling urinary catheter drainage ba...

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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 the indwelling urinary catheter drainage bag (a tube that allows urine to drain from the bladder into a bag that is usually attached to the thigh) for one of one sampled resident (Resident 236) was not touching the floor. This failure placed the patient at risk for acquiring urinary tract infections. 2. Ensure a correct stocking process was folllowed when restocking supplies in the red zone (COVID-19 [a virus to potentially cause severe respiratory illness] confrmed area). This failure placed the residents and staffs at risk for contracting COVID-19 and the spread of COVID-19 the entire facility 3. Ensure laundry personnel wore a gown (personal protective equipment) while handling contaminated linen and failed to change soiled gloves after handling contaminated linen that had feces and body fluid. This failure placed the facility residents and staffs at increased risk for infection. Findings: a). During a review of Resident 236's admission record, the admission record indicated Resident 236 was initially admitted to the facility on [DATE] with diagnoses that included cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) and retention of urine urinary retention (a condition in which you are unable to empty all the urine from your bladder). During a review of Resident 236's history and physical (H&P), dated 11/8/20203, the H&P indicated Resident 236 could make needs known but could not make medical decisions. During a review of Resident 236's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 11/14/2023, the MDS indicated Resident 236 sometimes understand verbal content, was sometimes understood when making concrete requests. The MDS indicated Resident 236 was dependent with the assistance of two or more helpers for toileting, bathing, dressing, personal hygiene and rolling left and right. During an interview on 12/12/2023 at 2:32 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 236's catheter bag was on the floor. LVN 1 stated the catheter bag should never be touching the floor. LVN 1 stated that it could affect the resident by putting the resident at risk for urinary tract infection ([UTI], common infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract). During a review of the facility's policy and procedure (P&P) titled, Catheter Drainage Bag, dated 11/2019, the P&P indicated, position the drainage bag below the level of the resident's bladder and the drainage bag should be kept off the floor. b.) During an observation on 12/14/2023 at 12:52 p.m. in the hallway of the Red Zone (designated area for Covid-19 [a virus to potentially cause severe respiratory illness] positive residents), the Central Supply staff member was stocking Personal Protective Equipment (PPE) in the Red Zone. The Central Supply staff member, after stocking (provide supply) in the Red Zone, went to the non-COVID-19 area and stocked PPE supplies. The Red Zone had a red tape on the floor and red signs posted noting the Red Zone. The Assistant Directive of Nursing (ADON) 1 was observed present while Central Supply staff member crossed from the Red Zone to the non-COVID zone. During an interview on 12/14/2023 at 1:15 p.m. with Central Supply personnel (CS) 1, CS 1 stated the Residents in the Red Zone are sick with COVID-19. CS 1 stated he was at the Red Zone restocking the gloves. CS 1 stated he did not see the red tape nor the signs at the Red Zone, and he was not aware he could not walk through the Red Zone. CS 1 stated I should have stocked the non-COVID area first and the COVID-19 area last. The CS 1 stated it was important to follow the protocol of stocking supplies to prevent the spread of COVID-19. During an interview on 12/15/2023 at 9:30 a.m. with Assistant Director of Nursing (ADON) 1, ADON 1 stated CS 1 walked through the Red Zone, then wne to the non-COVID-19 area to stock the PPE. The ADON 1 stated CS 1 should have given the supplies to the staff who were already in the Red Zone. ADON 1 stated CS 1 put the residents and staffs at risk for exposure to COVID-19 and the spread of COVID-19 in the facility. During an interview on 12/15/2023 at 2:49 p.m. with Director of Staff Development (DSD) 1, the DSD 1 stated CS 1 should have started stocking from the clean (non-COVID) area and finished stocking in the Red Zone. The DSD 1 stated when CS 1 reached the Red Zone, CS 1 should have handed the supplies to the staff designated at the Red Zone to stock the supplies. The DSD 1 stated this stocking process should have been followed to prevent the spread of COVID. During a review of the facility's policy and procedure (P&P) titled, Infection Control, dated 10/2022, the P&P indicated, the infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program .The facility personnel will conduct themselves and provide care in a way that minimizes the spread of infection .Facility personnel will handle, store, process, and transport linens so as to prevent the spread of infection. c). During a concurrent observation and interview on 12/14/2023 at 3:41 p.m. with Laundry Room Aid (LRA1), LRA1 was sorting contaminated linen at the laundry area and was not using a gown. LAR1 stated she was trained on proper handling of soil/contaminated linen, and she was supposed to wear a gown when handling soiled/contaminated linen. During a concurrent observation and interview on 12/15/2023 at 8:57 a.m. with LRA2, LRA2 had a pair of gloves while placing the linen in the washing machine, however, did not remove the contaminated gloves before touching the laundry equipment. LRA2 stated she should have changed her gloves after handling the soiled/contaminated linen and before touching equipment with contaminated gloves. During a review of the facility policy and procedure (P&P) titled, Infection Control Policy/ Procedure [Laundry], dated 11/2022, the P&P indicated, it is the policy of this facility that careful precautionary procedures must be followed by laundry personnel to prevent the spread of infectious diseases to other staff members, residents, and visitors. Special procedures will be observed for the safe handling of infected of contaminated linen, In the laundry, hand washing facilities and protective barriers (gowns, gloves, and masks) should be made available to personnel who sort laundry. Laundry personnel should wash their hands and remove protective barriers before going into the clean linen areas.

Dec 2023 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

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 implement their Infection prevention and control poli...

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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 Infection prevention and control policy and procedure (P&P) by failing to report the facility ' s Coronavirus Disease ([Covid-19] a highly contagious infection caused by a virus that could easily spread from person to person) outbreak (at least one confirmed case of Covid-19 who had resided in the facility for at least 7 days) to the California Department of Public Health (CDPH) District Office. These deficient practices had the potential to result in the spread of Covid-19 and infections to residents, staff, and visitors. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted on [DATE] with diagnoses including diabetes (high blood sugar), hypertension (high blood pressure), and heart failure (the heart is unable to pump blood around the body). During a review of Resident 1 ' s History and Physical (H&P), the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Change of Condition ([COC] a clinical deviation from a resident's baseline) dated 12/01/2023, the COC indicated Resident 1 tested positive for Covid-19. During a review of Resident 1 ' s Test Results Final Report dated 12/04/2023, the Report indicated Resident 1 Covid-19 was detected. During an interview on 12/06/2023 at 12:15 a.m. with the Infection Preventionist (IP), IP stated there were five residents positive for Covid-19 in the facility. IP stated their first case of COVID 19 positive resident was Resident 1, who tested positive on 12/01/2023. The IP stated facility Covid-19 outbreak was not reported to the state licensing district office on 12/01/2023 because she was not aware that it needed to be reported. During an interview on 12/06/2023 at 4:00 p.m. with the ADM, the ADM stated the facility Covid-19 outbreak was not reported to the state licensing district office because he was not aware that it needed to be reported. During a review of the facility ' s P&P titled Infection Prevention and Control Program dated 2023, the P&P indicated outbreaks will be reported, should any resident(s) or staff suspected or diagnosed a reportable communicable/infectious disease, such information shall be promptly reported to appropriate local and/or state health department officials. During a review of Los Angeles County Department of Public Heath guidelines titled, Guidelines for Preventing and Managing Covid-19 in Skilled Nursing Facilities (SNF), dated 08/11/2023, the guidelines indicated SNFs are required to report within 24 hours any suspected Covid-19 outbreaks. During a review of All Facilities Letter (AFL), dated 01/18/2023, the AFL indicated Health facilities licensed by CDPH are required to report outbreaks and unusual infections disease to the local public health officer and their respective District Office.

Nov 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 F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who receive dialysis (the process of removing was...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who receive dialysis (the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so) was provided proper transportation to and from hemodialysis appointments at a dialysis facility for Resident 1. This deficient practice had the potential for delayed dialysis treatments and safety issues. Findings: During a review of Resident 1's admission record, Resident 1 was admitted on [DATE] with diagnoses that included end stage renal disease (ESRD- a medical condition in which a person's kidneys stop functioning on a permanent basis leading to the need for dialysis treatment or a kidney transplant to maintain life), hypertension (high blood pressure), heart failure (a condition in which the heart doesn't pump blood as well as it should and depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities). During a review of Resident 1's Minimum Data Set (MDS) assessment dated [DATE], indicated the resident's cognitive patterns were intact, and is independent with bed mobility, transfer, walking in the room and corridor, locomotion on and off the unit, dressing, toilet use, and personal hygiene. During a review of the Physician Orders dated 10/17/2023, indicated Resident 1 ' s dialysis appointments were every Monday, Wednesday, and Friday at 8:30 a.m.-12:00 p.m. During an interview on 11/17/2023, at 9:20 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 confirmed that Resident 1 received hemodialysis at an offsite dialysis center every Monday, Wednesday, and Friday of the week. LVN 1 stated Resident 1 would always wait in front of the facility ' s lobby for transportation pick up at 7:25 a.m. to go to dialysis appointments. LVN 1 stated transportation picked up Resident 1 around 8:00 a.m. - 8:30 a.m. on all dialysis appointment days. LVN 1 stated the risk of not having a resident transported to and from dialysis appointments in a timely manner could result in resident developing complications and/or calling 911 due to potential life-threatening complications. During an interview on 11/17/2023, at 10:15 a.m., with Social Services Director (SSD), SSD admitted that she had to pick up Resident 1 from dialysis treatment in her personal car a fair number of times due to LA Care ' s delayed transportation with Resident 1 ' s pick up and drop off. SSD stated Resident 1 ' s Physician Certification Statement (PCS- a form used by physicians to communicate to the transportation company regarding specific transportation restrictions of a patient/member due to a medical condition) authorization form for transportation was recently approved yet transportation does not pick resident up for dialysis treatment at times and/or is late when picking up the resident from the dialysis facility. SSD stated the facility sometimes sends an Uber to pick up/drop off resident. SSD stated the risk of resident not having adequate transportation or not having a resident picked up from dialysis in a timely manner can cause complications for the resident. During an interview on 11/17/2023, at 10:50 a.m., with the admission Coordinator (AC), AC stated that upon Resident 1 ' s admission, AC received 3 courtesy trips for resident to attend his dialysis treatment. AC stated she knows transportation had been late when picking up or dropping off Resident 1 to and from the dialysis facility. AC stated she knew of one instance when Resident 1 had come back to the facility late but did not know the time, as she was off of work at 4:30 p.m. AC also admitted that she had to pick up Resident 1 in her own car due to transportation issues. AC stated the risk of not having a resident transported to and from dialysis in a timely manner can result in the resident missing dialysis, possibly have complications for missing treatment and even death. During an interview on 11/17/2023, at 11:00 a.m., with the Director of Nursing (DON), DON stated sometimes the dialysis facility calls the insurance to transfer the resident back to the facility after Resident 1 ' s dialysis treatment is completed. DON stated if the dialysis facility cannot get a hold of insurance/transportation company, then the facility will be called where the facility will follow up with transportation for Resident 1. DON stated there was no transportation log to show Resident 1 ' s picks up and drop off times. DON stated there had been several times when the transportation company had not picked up or dropped off Resident 1 to and from both facilities. DON admitted to having to Uber the resident to and from the dialysis facility or at times, have staff members pick Resident 1 up. DON stated the risk of not having a resident picked up/dropped off for dialysis in a timely manner is not safe for the resident as it is a safety issue and a lot of things can happen. During a review of policy and procedures, titled ' Transportation Arrangements for Dialysis ' , dated on 11/2017 and revised on 01/2022, indicated, If a resident requires dialysis appointments as part of his/her care and treatment plan at an off-site certified dialysis facility, the facility should coordinate with resident or resident representative in establishing transportation arrangements.

Nov 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

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 ensure the floormat (a material placed on the floor to...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the floormat (a material placed on the floor to protect the resident from injury during a fall) as indicated in the comprehensive person-centered care plan, for one of 3 sampled resident's (Resident 2), who had episodes of fall, was implemented. This deficient practice had the potential that Resident 2 will not be protected during another fall and placed the resident at risk to sustain severe injuries. Findings: During a review of Residents 2's admission Record indicated that Resident 2 was re-admitted to the facility on [DATE], with diagnosis that included history of abnormalities of gait (manner of walking) and mobility (ability to move) and muscle weakness. During a review of Resident 2's History and Physical (H/P) dated 8/5/2023, the H/P indicated Resident 2 had the capacity to understand and to make decisions. During a review of Resident 2's MDS Set (MDS, a standardized assessment and care screening tool), dated 9/8/2023, the MDS indicated Resident 2 usually had the ability to understand and be understood by others. The MDS indicated Resident 2 required two-person assist for bed mobility, transfer, and one-person assist for locomotion (moving from place to place), dressing, eating, toilet use and personal hygiene. During a review of Resident 2's document that indicated at risk for falls related to diagnosis of frequent falls and unsteady gait, initiated on 8/5/2023, revised 8/7/2023, indicated an intervention of floormats at bedside. During a review of Resident 2's document that indicated an actual fall, initiated on 8/7/2023, revised 8/7/2023, indicated an intervention of floormat. During a review of Resident 2's document that indicated falls triggered, and care planned because resident is at risks for injuries skin breakdown and functional decline, initiated on 8/5/2023, revised 8/29/2023, indicated interventions that included to place call light within reach, bed in lowest position and floor mats. During a review of Resident 2's Progress Notes dated 9/1/2023, indicated the interdisciplinary team met and discussed resident's fall incident. The notes also indicated that a certified nurse assistant reported that Resident 2 was found on the floor on 9/1/2023. During a review of Resident 2's Change in Condition Evaluation dated 9/3/2023, indicated Resident 2 had sustained a fall. During a concurrent observation and interview with Resident 2 on 11/1/2023 at 10:37 a.m., there wasno mat observed on the floor at the Resident 2's bedside. Resident 2 stated that he did not know anything about the interventions to prevent his falls. Resident 2 stated he did not know anything about having a mat by his bed, he had not seen one. During a concurrent observation and interview with the Licensed Vocational Nurse (LVN 1) on 11/1/2023 at 1:20 p.m., LVN 1 stated that the care plan indicated that there should be floor mats but there were none. LVN 1 stated that when care plans are not followed, it could hinder reaching resident's goals and placed the resident's safety at risk and could lead to further falls. During an interview with the Director of Nursing (DON) on 11/1/2023 at 3:06 p.m., DON stated that not following the care plan could lead to future falls and it would deter (prevent) from reaching the resident's goals.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the care plan for 1 of 3 sampled residents (Resident 2), who...

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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 care plan for 1 of 3 sampled residents (Resident 2), who had a recurrent fall and a status post fall episode dated 9/1/2023, was reassessed and revised. This deficient practice placed the resident at risk to sustain severe injuries and affect the highest practicable physical, mental and psychosocial well-being of the affected resident. Findings: During a review of Residents 2's admission Record indicated that Resident 2 was re-admitted to the facility on [DATE], with diagnosis that included history of abnormalities of gait (manner of walking) and mobility (ability to move) and muscle weakness. During a review of Resident 2's History and Physical (H/P) dated 8/5/2023, the H/P indicated Resident 2 had the capacity to understand and to make decisions. During a review of Resident 2's MDS Set (MDS, a standardized assessment and care screening tool), dated 9/8/2023, the MDS indicated Resident 2 usually had the ability to understand and be understood by others. The MDS indicated. The MDS indicated Resident 2 required two-person assist for bed mobility, transfer, and one-person assist for locomotion (moving from place to place), dressing, eating, toilet use and personal hygiene. During a review of Resident 2's document that indicated at risk for falls related to diagnosis of frequent falls and unsteady gait, initiated on 8/5/2023, revised 8/7/2023, indicated an intervention of floormats at bedside. During a review of Resident 2's document that indicated an actual fall, initiated on 8/7/2023, revised 8/7/2023, indicated an intervention of floormat. During a review of Resident 2's document that indicated falls triggered, and care planned because resident is at risks for injuries skin breakdown and functional decline, initiated on 8/5/2023, revised 8/29/2023, indicated interventions that included to place call light within reach, bed in lowest position and floor mats. During a review of Resident 2's Progress Notes dated 9/1/2023, indicated the interdisciplinary team met and discussed resident's fall incident. The notes also indicated that a certified nurse assistant reported that Resident 2 was found on the floor. During a review of Resident 2's Change in Condition Evaluation dated 9/3/2023, indicated Resident 2 had sustained a fall. Resident 2's clinical record did not indicate any revision of the plan of care after the 9/1/2023 fall. During an interview with Resident 2 on 11/1/2023 at 10:37 a.m., Resident 2 stated that he did not know anything about interventions to prevent his falls, but they had provided a larger bed after his last fall, because the previous bed was too small. During an interview with the Licensed Vocational Nurse (LVN 1) on 11/1/2023 at 1:20 p.m., LVN 1 stated that the care plan for Resident 2 was not revised. LVN 1 also stated that if the care plan was updated specifically to Resident 2's needs, they could have prevented another fall. LVN 1 stated it was important to update the care plan to promote safety and prevent injury. During an interview with the Director of Nursing (DON) on 11/1/2023 at 3:06 p.m., DON stated that they could have updated the care plan. DON also stated it was a missed opportunity to prevent future falls for Resident 1. During a review of the facility's policy and procedure titled, Care Planning , revised 5/2019, a comprehensive care plan is developed within seven days of completion of resident minimum data set and will be updated as needed.

CONCERN (D) 📢 Someone Reported This

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

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three residents (Resident 1), who did not have a ment...

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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 three residents (Resident 1), who did not have a mental health disorder diagnosis, was not prescribed Seroquel medication, an antipsychotic medication to treat mental health conditions including schizophrenia and bipolar disorder. This failure resulted to Resident 1's unnecessary use of the antipsychotic medication and placed the resident at risk for life-threatening adverse reactions which could lead to serious injury or death. Findings: During a review of Residents 1's admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 had diagnosis that included history of dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and history of fall. During a review of Resident 1's Hospital History and Physical (H/P) dated 9/15/2023, indicated Resident 1 can make needs known but could not make medical decisions. During a review of Residents 1's Order Summary Report dated 9/15/2023 Quetiapine Fumarate (Seroquel) tablet 25 mg (measurement of mass) give 0.25 mg by mouth two times a day for psychosis manifested by self-harm as exhibited by pulling foley catheter out and other tubings out. During a review of Residents 1's Order Summary Report dated 9/25/2023 indicated Quetiapine Fumarate (Seroquel) tablet 25 mg (measurement of mass) give 0.25 mg by mouth two times a day for psychosis manifested by self-harm as exhibited by pulling foley catheter out and other tubings out. During a review of Residents 1's Order Summary Report dated 9/25/2023 indicated Psych consult and follow up treatment as indicated. During a review of Resident 1's Care plan titled Psychotropic medication use high risk for medication side effect Quetiapine Fumarate dated 10/3/2023, one of the interventions indicated for pharmacy consult for med review and a psych consult. During a review of Resident 1's Minimum Data Set ([MDS] a standardized care assessment and care screening tool) dated 9/25/2023, indicated Resident 27 had the ability to understand and be understood by others. The MDS indicated Resident 1 did not exhibit behavioral symptoms. The MDS indicated Resident 27 required one-person assist for bed mobility, walk in room, locomotion (ability to move from one place to another), dressing, toilet use, personal hygiene, a two-person assist for transfers and set up only for eating. During a review of Resident 1's Medication Administration Record schedule for September 2023, indicated to monitor episodes of psychotic behavior manifested by self-harm as evidence by pulling foley catheter out and other tubings (Seroquel) every shift: 1. 9/15/2023 to 9/18/2023, Resident 1 had 0 episodes of psychotic behavior manifested by self-harm as evidence by pulling foley catheter out and other tubings in the morning shifts. 2. 9/15/2023 to 9/17/2023, Resident 1 had 0 episodes psychotic behavior manifested by self-harm as evidence by pulling foley catheter out and other tubings in the evening and night shifts. 3. 9/21/2023 to 9/28/2023, Resident 1 had 0 episodes psychotic behavior manifested by self-harm as evidence by pulling foley catheter out and other tubings in morning, evening, and night shift. During a review of Resident 1's Verification Informed Consent for Antipsychotic Medication dated 9/14/2023, the consent indicated The Food and Drug Administration (FDA) had issue Black Box Warnings associated with some psychoactive medications. During an interview with Licensed Vocational Nurse (LVN 1) on 11/1/2023 at 1:20 p.m., LVN 1 stated that Resident 1 was on Seroquel twice a day and he had not seen a psychiatrist assessed Resident 1, and there were no records with a psychiatrist assessment in the chart. LVN 1 stated Resident 1 had episodes of pulling out foley, but he did not have any other tubes. LVN 1 stated he had not seen Resident 1 being aggressive, but he would try to get out of bed and try to pull his foley. During an interview with Resident 27 on 3/7/2023 at 3:20 p.m., Resident 27 stated she had never been diagnosed with schizophrenia as a child nor as an adult. During an interview with Assisting Director of Nursing (ADON) on 11/1/2023 at 3:06 p.m., the ADON stated that Resident 1 came from the general acute hospital with Seroquel, and they just continued it. ADON stated there was no assessment for indication of the medication and the triggered evaluation tool for antipsychotics was blank and was not filled in the electronic medical record. During an interview with Assisting Director of Nursing (ADON) on 11/14/2023 at 11:18 a.m., the ADON stated that the Nurse Practitioner (NP) was at the facility to assess Resident 1 but Resident 1 had left the facility to the hospital and was not able to do the assessment. ADON stated Resident 1 did not have suicidal ideations and was only very concern about going home and pulling on his foley catheter. ADON stated Seroquel had a black box warning indicating that it increased mortality in elderly patients with dementia. During an interview with the Consultant Pharmacist (CP) on 11/14/2023 at 11:55 a.m., the CP stated Seroquel is an antipsychotic and usually required a psychiatric diagnosis. During an interview with Physician (MD) on 11/14/2023 at 12:45 p.m., MD stated the mediation was started by the hospital and they continued it at the facility. MD stated he does not discontinue nor adjust dosages for anti-psychotropic medications. The MD further stated that it was the psychiatrist responsibility to adjust or discontinue the medication. The MD also stated he was not familiar with the facility's policies as regards to prescribing and managing anti-psychotropic medications. During a review of the facility's policy and procedure (P/P) titled, Psychotropic Drug Use , dated 9/1/2017, indicated the Attending Physician will review the resident's treatment plan, in collaboration with the consultant pharmacist to re-evaluate the use of the psychotropic medication and consider whether or not the medication can be reduced or discontinued upon admission or soon after admission, during initial physician admission visit. Policy further indicated that indications for use were the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals and that were consistent with manufacturer's recommendations and/or clinical practice guidelines, clinical standards of practice, medication references, clinical studies or evidence-based review articles that were published in medical and/or pharmacy journals.

Aug 2023 1 deficiency 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Notification of Changes (Tag F0580)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was assessed 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 one of three sampled residents (Resident 1) was assessed and the physician was notified immediately on 8/5/2023 and 8/6/2023, for a decline in condition. Resident 1 exhibited a change in level of consciousness (a person's awareness and understanding of what is happening in his or her surroundings) and had a decreased meal consumption on 8/5/2023, 8/6/2023 and 8/7/2023. As a result of this deficient practice Resident 1 received a delay in emergency medical care. Resident 1 sustained a stroke (damage to the brain from blood flow interruption) and was hospitalized on [DATE] for acute encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition) secondary to a stroke, with nasogastric tube (a tube inserted through the nose into the stomach for food and medication to bypass the throat in high risk choking patients) placement for dysphasia (difficulty swallowing). Findings: During a review of Resident 1's admission Record, dated 8/9/2023, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), seizures (a sudden, uncontrolled burst of electrical activity in the brain), and dependence on renal dialysis (a treatment for people whose kidneys are unable to filter out waste in the blood). During a review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 5/8/2023, the MDS indicated Resident 1 required supervision (oversight, encouragement or cueing) for eating, and had moderate cognitive impairment. During a review of Resident 1's Order Summary Report, dated 3/25/2023, the order summary report indicated a physician's order to monitor for complications related to dialysis (a treatment to clean your blood when your kidneys are not able to) every shift, such as changes in level of consciousness. During a review of Resident 1's Meal Log - Documentation Survey Report, for the month of August 2023, the meal log indicated on 8/5/2023, there was no documented meal percentages recorded. The meal log indicated on 8/6/2023, Resident 1 had no documentation of meals eaten for breakfast or lunch, and 0 - 25 percent (%) for dinner. The meal log indicated on 8/7/2023, Resident 1 had no documentation of meals eaten for breakfast and lunch. During a review of Resident 1's Progress Note, dated 8/7/2023, at 1:13 p.m., the progress note indicated Resident 1 did not eat breakfast, and was noted to be lethargic (sluggish) with altered mental status (a change in mental function). The progress note indicated 911 was called for Resident 1's unresponsiveness. During a review of Resident 1's Physician's Telephone Order, dated 8/7/2023, untimed, (authored by LVN 2), the physician's order indicated to transfer Resident 1 to the hospital via 911 ambulance. During a review of Resident 1's general acute care hospital (GACH) History and Physical (H&P), dated 8/7/2023, at 3:33 p.m., the GACH H&P indicated Resident 1 presented to the GACH with slurred, muffled speech, was disoriented (confused) with weakness of the left upper and lower extremity (left arm and leg). The GACH H&P indicated Resident 1 was admitted for acute encephalopathy secondary to a stroke, with nasogastric tube placement for dysphasia. During a review of Resident 1's GACH Magnetic Resonance Imaging (MRI, a medical examination used to generate images of the body) report of the brain, dated 8/7/2023, at 4:36 p.m., the MRI report indicated Resident 1 had ischemic (tissue death due to lack of oxygen) changes consistent with an acute stroke. During a review of Resident 1's GACH Progress Note, dated 8/9/2023, at 12:39 p.m., the Progress Note indicated Resident 1 was not alert and oriented, pupils were sluggish (abnormally slow to respond to light), the resident did not withdraw from painful stimuli, and was unable to follow commands. During an interview on 8/8/2023, at 2:32 p.m., with Certified Nursing Assistant (CAN) 1, CNA 1 stated on 8/6/2023, during the 7 a.m. to 3 p.m. shift, Resident 1 was restless and called CNA 1 by a different name. CNA 1 stated Resident 1was normally alert and oriented. CNA 1 stated she was not sure if she reported Resident 1's change of condition to anyone. CNA 1 stated when there was a change of condition, she must report it to the charge nurse and document it. CNA 1 stated on 8/7/2023, she tried to feed Resident 1 breakfast but was unable to because the resident was not fully awake. During an interview on 8/8/2023, at 2:38 p.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated on 8/7/2023, Resident 1 did not eat breakfast that morning because she was tired, and the resident was still noted to be lethargic at lunch time. LVN 2 stated 911 was called at approximatly1 p.m. on 8/7/2023. During an interview on 8/8/2023, at 3:04 p.m., with the Director of Nursing (DON), the DON stated on 8/7/2023, at approximately 11:00 p.m., Resident 1 appeared lethargic despite normal vital signs (measurements to assess the body's physical health) and did not respond to the sternal rub (a technique to test an unconscious person's responsiveness) and pinch. The DON stated she told Registered Nurse (RN) 1 to call 911. During an interview on 8/9/2023, at 2:15 p.m., with CNA 2, CNA 2 stated on 8/5/2023 in the morning, prior to dialysis, Resident 1 was wide awake. CNA 2 stated Resident 1 came back exhausted from dialysis and would not wake up for dinner. CNA 2 stated normally Resident 1 had a good appetite. CNA 2 stated she notified LVN 1 that Resident 1 did not eat dinner because of being too tired. CNA 2 stated Resident 1 was last able to feed herself 1 week prior. During an interview on 8/9/2023 at 3:15 p.m., with Resident 1's Roommate (Resident 2), Resident 2 stated she noticed Resident 1 had not been unable to fully wake up since 8/5/2023. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had mild cognitive impairment. During an interview on 8/11/2023, at 11:40 a.m., with CNA 3, CNA 3 stated on 8/6/2023, Resident 1's responsible party (RP) 1 was visiting and was concerned about Resident 1 acting strange. CNA 3 stated RP 1 asked her what was going on with Resident 1. CNA 3 stated she informed LVN 3 of RP 1's concern. CNA 3 stated at approximately 5 p.m., on 8/6/2023, CNA 1 tried to wake up Resident 1 to eat dinner but Resident 1 was not able to wake up, so she notified LVN 3. CNA 3 stated LVN 3 told CNA 3 Resident 1 was tired due to dialysis (last dialysis treatment was on 8/5/2023). During an interview on 8/16/2023, at 9 a.m., with RP 1, RP 1 stated on 8/6/2023, at approximately 4 p.m., Resident 1 was difficult to arouse and would not wake up during his visit. RP 1 stated after 15 minutes, he was able to wake up Resident 1. RP 1 stated Resident 1 was staring off to the right towards the sky, and had trouble speaking. RP 1 stated when Resident 1 opened her eyes he tried to snap his fingers in front of her eyes to get the resident's attention, but the resident would not blink. RP 1 stated he asked CNA 3 what was wrong with Resident 1 and requested to speak to a nurse. RP 1 stated he spoke to LVN 3 who took Resident 1's vital signs and blood sugar and told RP 1 the results were normal. RP 1 informed LVN 3 that Resident 1 would not stop looking up to the right. RP 1 stated LVN 3 did not assess Resident 1's pupils. RP 1 stated that normally when Resident 1 returned from dialysis, the resident was tired but able to communicate verbally without difficulty. RP 1 stated Resident 1 did not get out of bed on 8/6/2023 for dinner, nor did the resident have anything to eat. During an interview on 8/16/2023, at 10 a.m., with LVN 3, LVN 3 stated on 8/6/2023, at approximately 5:30 p.m., Resident 1 had family members visiting that evening. LVN 3 stated RP 1 was upset and complained about the other nurses. LVN 3 stated she did not remember RP 1's complaint. LVN 3 stated she remembered Resident 1 was awake and alert on 8/6/2023, while up in a chair eating without any problems. During an interview on 8/16/2023, at 12:45 p.m., with Resident 1's Physician/Medical Doctor (MD) 1, MD 1 stated the last time he visited Resident 1 was in July 2023, and on that day, the resident was alert and oriented, able to discuss her medical condition, and answered questions. MD 1 stated he was informed of Resident 1's change of condition on 8/7/2023, via text or email. MD 1 stated he could not remember at what time, but he told the facility to transfer Resident 1 to the GACH. MD 1 stated if there was an emergency, the facility did not need his permission to call 911. During an interview on 8/16/2023, at 2:29 p.m., with LVN 1, LVN 1 stated she worked on 8/5/2023, from 3 p.m. to 11 p.m., and did not remember who was working that day, or which CNAs she was working with. LVN 1 stated CNA 2 did not informed her Resident 1 was tired and not eating. LVN 1 stated she remembered that Resident 1 was sleepy and could not feed herself but did not remember whether that was on 8/5 or 8/6/2023. LVN 1 stated Resident 1 seemed OK. During an interview on 8/24/2023, at 8:10 a.m., with CNA 2, CNA 2 stated that on 8/5/2023, Resident 1 ate 60% of her breakfast before leaving for dialysis, and 0% for dinner after coming back from dialysis because the resident was too tired. CNA 2 stated she informed the charge nurse (LVN 1). CNA 2 stated on 8/6/2023, Resident 1 ate 0% of breakfast and lunch, and she (CNA 2) was unable to awaken the resident. During an interview on 8/24/2023, at 8:37 a.m., with the DON, the DON stated on 8/7/2023, she made rounds at approximately 11 a.m. The DON stated FM 1 was present when she tried to stimulate Resident 1, but the resident was not very responsive. The DON stated Resident 1 was just grunting and she (DON) told one of the nurses to call 911. During an interview on 8/24/2023, at 2:43 p.m., with Family Member (FM) 1, FM 1 stated on 8/7/2023 at approximately 12 pm, she went to visit Resident 1. FM 1 stated Resident 1 looked dead. FM 1 stated she asked the DON when was the last time they (facility's nurses) checked on Resident 1, and the DON stated Resident 1 ate and was OK after taking her vital signs. FM 1 stated she told the DON Resident 1 was not OK and she was not going to leave Resident 1 at the facility like that. FM 1 stated LVN 2 stated he was going to text MD 1 for approval to send Resident 1 to the emergency room. FM 1 stated LVN 1 tried to wake Resident 1 up but she was not responsive. FM 1 stated she told LVN 2, Obviously she needs to go to the hospital so can you call an ambulance? During a review of the facility's policy and procedure (P&P) titled, Change of Condition Reporting, dated 5/20/2020, the P&P indicated all changes in residents' medical condition are to be communicated to the physician. The P&P further indicated changes in physical or mental behavior will be communicated to the physician by the licensed nurse and documented.

Jul 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four sampled resident ' s (Resident 1) medication lis...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four sampled resident ' s (Resident 1) medication list was reconciled (process of reviewing resident medications to identify the most accurate list of all medications and resolve any discrepancies) in a timely manner upon admission to the facility. This deficient practice resulted in a delay in Resident 1 ' s antibiotic treatment for urinary tract infection ([UTI], infection of the bladder) and had the potential to result in worsening of Resident 1 ' s condition. Findings: During a review of Resident 1 ' s admission Record, the admission record indicated that Resident 1 was admitted to the facility on [DATE] with diagnoses including a displaced commuted fracture (broken bone) of the left femur (thigh bone), UTI, pressure ulcer of sacral, Diabetes Type II (high blood sugar), history of falls, anemia, and elevated white blood cell count. During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care planning tool) dated 7/5/23, the MDS indicated Resident 1 had no cognitive (thought process) impairment. During a review of Resident 1 ' s General Acute Care Hospital (GACH) Discharge summary dated [DATE], the Summary indicated Resident 1 ' s current and active medication list included Meropenem (an antibiotic) 1000 milligrams ([mg], unit of measurement)/ Sodium Chloride ([NaCl), IV solution)100 milliliters ([ml], unit of measurement) at 200 ml per hour every 12 hours intravenous ([IV], giving medicines through a needle or tube that goes into a vein). The Summary indicated Meropenem was started on 6/25/2023 at 2:00 p.m. and should be continued till 7/2/2023 at 11:55 p.m. The Summary also indicated the last Meropenem dose was given on 6/27/23 at 1:55 a.m. During a review of Resident 1 ' s GACH Medication Reconciliation Transfer Orders, the Orders indicated Resident 1 ' s active therapies included Meropenem 1000 mg/NaCl 0.9% 100 ml every 12 hours IV. During a review of Resident 1 ' s Progress Notes documented by Registered Nurse (RNS 2) dated 6/28/2023 at 11:26 p.m., the Notes indicated Resident 1 was admitted from GACH to the facility. During a review of Resident 1 ' s Progress Notes documented by the Primary Physician (MD 1), dated 6/30/2023 at 6:47 p.m., the Notes indicated Resident 1 had cystitis (inflammation of the bladder usually caused by UTI) and was prescribed amoxicillin (antibiotic) 500 mg for one week. The Notes indicated Resident 1 had 4 days left of meropenem and white blood cell was elevated so would complete treatment. The Notes also indicated he was not notified of the resident ' s admission to the facility. During an interview on 7/3/2023 at 12:50 p.m. with Resident 1, Resident 1 stated she was informed by a nurse that they were going to give IV antibiotics but Resident 1 did not have an IV upon admission and was not given any IV antibiotics during her time at the facility. During an interview on 7/5/20233 at 3:38 p.m. with MD1, MD1 stated he did not know Resident 1 was at the facility until Pharmacy contacted him regarding a medication authorization on 6/29/23 and was looking at the resident ' s chart on 6/29/2023 around 3:30 p.m. MD1 stated there was a delay in care as Resident 1 had orders to get IV antibiotics. During an interview on 7/5/2023 at 4:06 p.m. with Registered Nurse (RNS 2), RNS 2 stated when residents were admitted to the facility, the nurse should assess the resident, call the physician to review the medications, go over the progress notes and enter the orders after verifying with the physician. RNS 2 stated Resident 1 was admitted late at night on 6/28/2023 and she attempted multiple times to reach the physician however she did not get a response and had to endorse to the following shift to follow-up with the physician. During an interview on 7/20/2023 at 9:00 a.m. with RNS 3, RNS 3 stated she was assigned to Resident 1 on 6/28/2023 11 p.m.- 7 a.m. shift and had not contacted the physician to follow up on the admission medication reconciliation for Resident 1 because she had the understanding this was already completed, and it was not endorsed to her. During an interview on 7/20/2023 at 10:48 a.m. with RNS 1, RNS 1 stated she worked on 6/29/2023 7 a.m.- 3 p.m. shift and had not conducted the medication reconciliation with the physician for Resident 1 on her shift. During interviews on 7/20/2023 at 12:47 p.m. and 2:39 p.m. with Director of Nursing (DON), DON stated the medication reconciliation and clarification of the meropenem IV antibiotic was not completed until the physician came into the facility on the evening of 6/30/2023. DON stated, it was important to ensure the physician was contacted upon admission and complete the medication reconciliation timely for continuity of care and to be able to administer correct resident medications as ordered by the physician. DON also stated a delay in administering IV antibiotic could lead to worsening of the resident ' s infection. During a review of the facility ' s Policy and Procedure (P&P) revised in 2020, the P&P indicated the purpose was to provide a safe and effective process for obtaining, documenting, and communicating medications across a patient ' s continuum of care. The P&P indicated upon the patient ' s admission and with the involvement of the resident, a list of the patient ' s current medications was obtained and documented in the patient ' s health record. The P&P indicated a list of the patient ' s current medications upon discharge from GACH was obtained and reviewed by the physician prior to ordering the medications.

Jun 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to have a hemodialysis (process of purifying the blood of a person whose kidneys are not working normally) E-Kit (emergency kit)...

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Based on observation, interview, and record review, the facility failed to have a hemodialysis (process of purifying the blood of a person whose kidneys are not working normally) E-Kit (emergency kit) accessible on site for one of three residents (Resident 3). This failure may result in the inability to manage bleeding from the hemodialysis access site in the event of complications such as uncontrolled bleeding. Findings: A review of Resident 3's admission Record indicated the facility admitted Resident 3 on 1/29/2023 with diagnosis which included type 2 diabetes (when your blood sugar is too high), abnormal gait (way of walking) and mobility, and end stage renal disease ([ESRD] kidneys can no longer support your body's needs). A review of Resident 3's Minimum Data Set (MDS, standardized care and screening tool), dated 5/08/2023, indicated Resident 3 was moderately impaired with cognitive (processes of thinking and reasoning) skills for daily decision making. The MDS indicated Resident 3 required extensive assistance (resident involved in activity, staff provide weight bearing support) on bed mobility, transfer, personal hygiene, and total dependence (full staff performance every time during the entire 7-day period) with dressing, and toilet use. The MDS indicated Resident 3 used a wheelchair for mobility, and received dialysis during the last 14 days. A review of Resident 3's Order Summary dated 1/29/2023 at 4:18 PM indicated Resident 3 was to receive dialysis every Tuesday, Thursday, and Saturday at 12:30 PM at an offsite dialysis treatment center. Transportation Call a Car pick up time at 11:40 AM via gurney every Tueday, Thursday, and Saturday related to dependence on renal dialysis: End stage renal disease. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 1 on 6/21/2023 at 1:30 PM, LVN 1 stated there was no dialysis E-kit found in Resident 3's room and bed side drawers. LVN 1 stated the dialysis E-kit was supposed to be visible and readily accessible for nurses in case of emergency bleeding. LVN 1 stated the dialysis E-kit consisted of a torniquet (used to compress a limb with a cord or tight bandage to stop the flow of blood), clamp, gauze, and tape. LVN 1 confirmed Resident 3 was receiving dialysis every Tuesday, Thursday, and Saturday and the resident had a right arteriovenous (AV) fistula (connection surgically made between an artery and a vein for dialysis access). During an interview with the Director of Nursing (DON) on 6/22/2023 at 12:55 PM, the DON stated it was important for Resident 3 to have E-kit in her room easily accessible to staff who took care of Resident 3. The DON stated the E-kit was used to control bleeding in case of an emergency. The DON stated the dialysis E-Kit consisted of tourniquet, gauze, and tape.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to: 1. Ensure the call light device was within reach for two of three sampled residents (Resident 1 and Resident 2). 2. Ensure t...

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Based on observation, interview, and record review, the facility failed to: 1. Ensure the call light device was within reach for two of three sampled residents (Resident 1 and Resident 2). 2. Ensure the bed control was within reach for one of three sampled residents (Resident 2). These deficient practices had the potential to result in a delay in or in an inability for Resident 1 and 2 to obtain necessary care and services. Findings: a. A review of Resident 1's admission record indicated the facility admitted Resident 1 on 4/11/2023 with diagnosis which included lack of coordination, anemia (a condition in which the body does not have enough healthy red blood cells. Red blood cells provide oxygen to body tissues), urinary tract infection ([UTI] infection in any part of the urinary system). A review of Resident 1's Minimum Data Set (MDS, standardized care and screening tool), dated 4/15/2023, indicated Resident 1 was severely impaired with cognitive (processes of thinking and reasoning) skills for daily decision making. The MDS indicated Resident 1 required extensive assistance (resident involved in activity, staff provide weight bearing support) with bed mobility, and personal hygiene, and total dependence (full staff performance every time during the entire 7-day period) with dressing and toilet use. During a concurrent observation and interview on 6/21/2023 at 11:13 AM with Certified Nursing Assistant (CNA) 1, in Resident 1's room, Resident 1 was observed to be alert and oriented laying on the bed. CNA 1 verified Resident 1's call light was tied on the left side of the resident's bed rail hanging and facing towards the floor. Resident 1 unable to reach the call light. CNA 1 described Resident 1 as a total care resident and stated if Resident 1 could not reach the call light it would delay care for Resident 1. During a concurrent observation and interview on 6/21/2023 at 1:13 PM with CNA 2, in Resident 1's room, CNA 2 instructed Resident 1 to press the call light. Resident 1 looked for the call light but was unable to locate it informing CNA 2. CNA2 verified the call light was difficult for Resident 1 to find because it was tied on the left side rail of the bed hanging below the mattress. CNA 2 stated call lights were supposed to be within the residents reach, and easily accessible. CNA 2 stated if Resident 1 could not access his call light easily it might cause a delay of care, like changing of the diaper. CNA 1 stated it was possible Resident 1 might fall if the resident did not get the assistance he needed in time. During a review of Resident 1's care plan, titled, Care Plan Detail, review start date 4/24/2023, the care plan indicated Resident 1 was at risk for falls, confusion, deconditioning bowel incontinence (the inability to control bowel function), and a language barrier. The goal indicated for reduced risk for injury from falls for 3 months. The staff's interventions indicated to be sure the call light was within reach and encourage Resident 1 to use it to call for assistance as needed, keep floor free from spills and/or clutter; adequate glare free light; a working and reachable call light, the bed in low position, and personal items within reach. b. A review of Resident 2's admission record indicated the facility admitted Resident 2 on 6/13/2023 with diagnosis which included hypertension (blood pressure that is higher than normal), anxiety (is a feeling of fear, dread, and uneasiness), and overactive bladder (frequent and sudden urge to urinate that may be difficult to control). During a concurrent observation and interview with CNA 1 on 6/21/2023 at 11:11 AM, in Resident 2's room, observed Resident 2 laying on the bed, clean and comfortable. Resident 2's bed control was observed on the floor and the call light clipped on the curtain between beds A and B. Resident 2 was unable to reach the call light. Observation was verified by CNA 1. CNA 1 stated Resident 2 was bed bound, and able to make needs known. CNA 1 stated if Resident 2 cannot reach the call light it would cause a delay of care for Resident 2. Resident 2 was observed being unable to change positions due to the bed control being on the floor. During an interview on 6/21/2023 at 11:30 AM with the Assistant Director of Nursing (ADON), the ADON stated call lights were supposed to be within the resident's reach. The ADON stated the call light was used by residents to communicate their needs, and unreachable call lights could cause delay of care and residents would not be able to take their pain medication quickly when requested. During an interview on 6/22/2023 at 12:55 PM with the Director of Nursing (DON), the DON stated call lights were supposed to be within the residents reach, for alert and non-alert residents if not contraindicated, so residents could call anytime if help or care was needed as soon as possible. The DON stated if the call light was not accessible it may cause a delay of the resident's care. A review of the facility's policy and procedure (P&P) titled, Call light / Bell, revised date 5/2007, indicated it is the policy of this facility to provide the resident a means of communication with nursing staff. The P&P indicated to: 1. Answer the light/bell within reasonable time. 5. Leave the resident comfortable. Place the call device within resident's reach before leaving room. If call light is defective, immediately report this information to the unit supervisor.

May 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

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 the cord to operate an overhead, wall-mounted l...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the cord to operate an overhead, wall-mounted light was within reach for one of three sampled residents (Resident 1). This deficient practice had the potential to negatively affect the psychosocial well-being, cause difficulty in seeing and reading, as well as accidents with injuries for Resident 1. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnosis of cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting the left side, cardiomegaly (enlargement of the heart) and glaucoma (condition of increased eye causing gradual loss of sight). During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care planning tool) dated 4/9/2023, the MDS indicated Resident 1 had clear speech, the ability to express ideas and wants, and had the ability to see in adequate light. The MDS also indicated Resident 1 required extensive assistance (Resident involved in activity, staff provide weight-bearing support) for Activities of Daily Living (ADL ' s) including bed mobility (how resident moves to and from lying position, turn side to side, and position body while in bed or alternative sleep furniture), dressing, and toilet use. During a concurrent observation and interview on 5/17/2023 at 11:00 a.m. with Resident 1 in the resident ' s room, the cord to operate the overhead wall-mounted light for the resident was approximate 4 feet away from the resident ' s bed. Resident 1 stated he was unable to reach the light cord and had notified facility staff several times about the issue however nothing was done to resolve it. Resident 1 also stated he felt ignored and was inconvenienced because he had to call staff when he wanted to turn the light on or off. During a review of Resident 1 ' s Care Plan (CP) for impaired mobility, ADL self-care deficits, glaucoma, impaired balance and unsteady gate dated 7/22/2021, the CP indicated Resident 1's goal was to have reduced risk for complications related to impaired mobility and falls with injuries through next review. The CP also indicated nursing interventions included nursing to anticipate needs, assist the resident with ADL ' s, provide level of assistance that met the resident ' s need, use appropriate assistive devices and encourage the resident to perform ADL ' s as much as the resident was able. During an interview on 5/25/2023 at 3:45 p.m. with the Director of Nursing (DON). The DON stated not being able to reach the cord for the light and be dependent on staff to turn the light on and off could cause Resident 1 to feel frustrated. During a review of the facility ' s Policy and Procedure (P/P) titled, Physical Environment, revised dated 11/2022. The P/P indicated it was the policy of the facility to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public though monthly environmental rounds. The P/P also indicated Resident rooms must be designed and equipped for adequate nursing care, comfort and privacy of the residents.

Apr 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure one of three residents (Resident 1) received treatment 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 one of three residents (Resident 1) received treatment and care in accordance with professional standards practice to meet the resident's physical, mental and psychological needs by failing to carry out the physician's (MD) orders for Resident 1 in a timely manner. Resident 1's MD ordered General Surgery consult, Cardiology (heart doctor) consult and oncology (cancer doctor) follow-up for the resident on 1/19/2023 and facility did not carry out the orders until 3/13/2023 for Oncology and 4/6/2023 for General Surgery and Cardiology. These deficient practices resulted in delayed health evaluations and had the potential to result in delayed treatments and harm for Resident 1. Findings: During a review of Resident 1's admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including multiple myeloma (a cancer of the plasma [white blood cells that make antibodies that protect us from infection] cells), hypertension ([HTN] high blood pressure), anemia (blood produces a lower-than-normal amount of healthy red blood cells) and atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart). During a review of Resident 1's Minimum Data Set ([MDS], a comprehensive standardized assessment and care screening tool) dated 12/31/2022, the MDS indicated Resident 1 had clear speech, and the ability to understand and be understood. The MDS indicated the Resident 1 required extensive assistance (resident involved in activity, staff provide weight-bearing support) for activities of daily living (ADL'S) including bed mobility, transfer (how resident moves between surfaces to or from; bed, chair; wheelchair, standing positions), dressing, toilet use, and personal hygiene. The MDS also indicated Resident 1 required limited assistance with walking in the room, and locomotion (how resident moves between locations). During a review of Resident 1's History and Physical (H&P), dated 1/19/2023, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's MD Orders dated 1/19/2023, the MD orders indicated Resident 1 had an order for follow-up and/or consultation with Oncology for myeloma, General Surgeon for buttock fistula (abnormal opening), and Cardiologist. During a review of the facility's Communications Note (internal document) dated 1/19/2023 at 10:51 p.m., the Note indicated Resident 1 had new orders and to see order notes for the resident. During a review of Resident 1's Skin Ulcer Non- Pressure Weekly assessment dated [DATE], the assessment indicated Resident 1 had multiple fistula all over his buttocks. The assessment also indicated Resident 1 required a general surgery consult for his buttock fistula. During an interview on 4/7/2023 at 10:40 a.m. with Resident 1, Resident 1 stated he needed to see an Oncologist and General Surgeon however had not seen one since admission to the facility. During a concurrent interview and record review on 4/7/2023 at 11:54 a.m., with the Social Worker (SW), Resident 1's doctor orders dated 1/19/2023 were reviewed. The orders indicated Resident 1 had an order for oncology follow-up, General Surgery, and Cardiology consults. SW stated she was not aware of the orders because she was not notified by nursing. During interviews on 4/7/2023 at 12:16 p.m. and 4/21/2023 at 9:09 a.m. with the Case Manager (CM), CM stated she never saw the orders on 1/19/2023 for Resident 1's Oncology follow up, Cardiology consult, and General Surgery consult. CM stated the orders were never communicated to her by nursing and appointments and transportation arrangements had not been made until 3/13/2023 for Oncology and 4/6/2023 for General Surgery and Cardiology. During an interview on 4/7/2023 at 1:09 p.m. with the Registered Nurse (RN) 1, RN 1 stated when she received an MD order for resident appointments, she would enter the order in the computer, notified the SW to book the appointment and entered the information in the Communications for follow-up. RN 1 stated she could not remember if she verbally made the SW aware because it was late at night, but she placed it in Communications Note however had forgotten to specify note for SW. RN 1 also stated the importance for proper communication was to ensure the facility arranged resident's appointments and transportation to get the care the residents' needed as ordered by the MD. During interviews on 4/7/2023 at 2:18 p.m. and 4/21/2023 at 11:11 a.m. with the Director of Nursing (DON), DON stated the importance of carrying out doctor orders was to ensure the continuity of care for the residents. DON also stated, it was the facility's process and best practice for nurses to ensure MD orders were carried out and to follow-up with SW and CM as needed. During an interview on 4/13/2023 at 10:40 a.m., with the Administrator (ADM), ADM stated the facility did not have specific policy & procedure (P&P) regarding staff carrying out MD orders. During a review of email correspondence dated 4/14/2023 with the Administrator (ADM), ADM indicated facility did not have a P&P for appointments. During a review of the facility's P&P titled, Social Services revised on 8/2017, the P&P indicated it was the policy of the facility to provide medically related social services to attain or maintain the highest practical physical mental or psychological well-being of each resident, advocate for residents and assisting them in the assertation of their rights within the facility, made referrals and obtained needed services from outside entities, and would arrange for needed services from outside entities in the community. During a review of the facility's P&P titled, Physician's Orders, Telephone Orders and Recapitulation Process revised on 1/2021, the P&P indicated, all orders must be specific and complete with all necessary details to carry out the prescribed order without any question.

Mar 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify one (Resident 1) of one sampled residents responsible person...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify one (Resident 1) of one sampled residents responsible person (RP; person designated as being responsible for another person's medical and financial decisions) of a change in condition (COC). This deficient practice resulted in Resident 1's RP not being informed of the resident's COC. Findings: During a review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE] under hospice care (end of life care) with the diagnoses that include Parkinson's disease (a progressive disorder of the brain, dementia (loss of memory), congestive heart failure (the heart muscles dose not pump blood well ) and chronic obstructive pulmonary disease (a lung disease that block airflow and make it difficult to breathe). During a review of Resident 1's history and physical (H&P) dated [DATE] indicated, Resident 1 was nonverbal and does not follow commands. During a review of the resident's physician order dated [DATE] indicated, Resident 1 was admitted to the facility with a with terminal diagnoses. Further review disclosed Resident 1 was listed as do not resuscitate (DNR: No CPR) and to contact the hospice agency for any change in condition. A review of Resident 1's Progress notes dated [DATE], indicated wound care treatment was done at approxiamately 7 a.m. and at 8:45 a.m., the resident was found not breathing. The notes further indicated facilty staff notified the hospice agency agency and not the RP. During an interview on [DATE] at 11: 00 a.m., the assistant director of nursing (ADON) stated that staff should notify any change in condition to Resident's physician, Hospice and resident's responsible parties. During an interview on [DATE] at 10:40 a.m., the director of nursing (DON), stated it is the facility policy to notify resident's responsible party of any change in resident's condition. A review of the facility's policy and procedures dated 05/2019 [NAME] Nursing Administration: Change of Condition Reporting Indicated, The responsible party will be notified that there has been a change in the resident's condition and steps are being taken.

Feb 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement interventions to prevent the risk of accide...

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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 interventions to prevent the risk of accident hazards for one of one sampled resident (Resident 1) by failing to: 1. Ensure adequate supervision was provided and interventions (actions) were implemented for Resident 1 who was cognitively impaired, exhibited exit-seeking behavior and expressed wanting to leave the facility. 2. Ensure lock on the gate to exit facility premises was properly functioning. These deficient practices resulted in Resident 1 eloping from the facility, was found 12 hours later in a general acute care hospital (GACH) and placed the resident at risk for exposure to harsh environmental conditions including excessive cold, dehydration (not enough water in the body), injuries and death. Findings: During a review of Resident 1 ' s admission record (Face Sheet), the face sheet indicated Resident 1 was admitted on [DATE] with diagnoses including sepsis (a life-threatening complication of an infection, cognitive communication deficit (problem with communication), and dementia (impaired ability to remember, think or make decisions). During a review of Resident 1 ' s History and Physical (H&P) dated 12/7/2022, the H&P indicated Resident 1 had the capacity to make his needs known however could not make medical decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized care assessment and care screening tool) dated 12/12/2022, the MDS indicated Resident 1 had severely impaired cognitive (thought process) skills and required extensive assistance from staff for activities of daily living (ADL) such as transfer (moving between surfaces to and from bed, chair, wheelchair), dressing, toilet use, and personal hygiene. The MDS indicated Resident 1 was completely dependent (unable to perform activity independently) on staff for bathing and was not stable when walking. During a review of Resident 1 ' s SBAR (Situation, Background, Assessment, Recommendation) Communication Form dated 12/13/2022 and timed at 12:30 a.m., the form indicated Resident 1 had increased confusion or disorientation and new or worsened delusions or hallucinations. The form also indicated at 11:45 p.m., Resident 1 was seen at the exit door, was brought back to his room and at 12:00 a.m. was not found in his room. During a review of Resident 1 ' s nursing progress notes (NPN) dated 12/13/2022 and timed at 4:29 a.m., the NPN indicated code pink (code used within the facility to alert staff of an emergency or event) was announced and staff began looking for Resident 1 within and outside of the facility however could not find the resident. The NPN also indicated the police department was notified and the resident was declared missing. During an interview on 12/15/2022 at 12:00 p.m. with Administrator (Admin), Admin stated Resident 1 walked out of the facility with socks and a thick comforter. Admin also stated police notified her that the resident was found trying to get inside a school because he was cold, and an ambulance was called by the school security. During a concurrent observation and interview on 12/15/2022 at 12:32 p.m. with Admin, surveillance camera footages dated 12/12/2022 and timed at 11:26 p.m. showed Resident 1 exited the facility through an unlocked door next to the rehabilitation gym. Admin stated the door did not have an alarm to alert staff when it was opened, and the resident was then able to leave the facility premises because the lock to the facility's gate did not work. During an interview on 12/15/2022 at 12:34 p.m. with Maintenance Personnel (MP), MP stated he was not aware that the magnet that kept the facility gate shut was not working and assumed the gate locked because he constantly walked in and out it. MP also stated the facility did not have a system in place to log if the gate was functioning properly. During an interview on 12/15/2022 at 1:07 p.m. with Certified Nurse Assistant (CNA 1), CNA 1 stated on the morning shift prior to Resident 1's elopement, LVN 1 instructed her to monitor the resident closely for safety. CNA 1 stated she needed to redirect Resident 1 multiple times because he kept getting out of bed, was taking his blankets, and expressed he wanted to go home. CNA 1 stated that she did not report the behavior changes to the charge nurse (Licensed Vocational Nurse [LVN 1]) because she did not think the resident would elope. During an interview on 12/15/2022 at 1:36 p.m. with LVN 1, LVN 1 stated she told CNA 1 to monitor Resident 1 closely for safety. LVN 1 also stated she was not notified by CNA 1 of the resident expressing he wanted to leave the facility and had exit-seeking behaviors during the shift. During a review of the facility's policies and procedures (P&P) titled Elopement/Unsafe Wandering with a revision date of 6/2018, the P&P indicated each resident was assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision to prevent unsafe wandering. The P&P also indicated staff would promptly report any resident who was trying to leave the premises or was suspected of being missing to the charge nurse or supervisor to evaluate the need for further interventions.

Feb 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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) wa...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided care and services to maintain good grooming and personal hygiene by failing to provide toenail care for Resident 1. This deficient practice resulted in Resident 1 feeling disrespected, embarrassed and had the potential to cause injury and infection to the resident. During a review of Resident 1's admission Record (Facesheet), the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Human Immunodeficiency Virus ([HIV], virus that attacks good cells that fight off infection), paraplegia (loss of movement and sensation to both legs), right hand contracture (tightening of muscle or joint), and blindness of the left eye. During a review of Resident 1's careplan dated 8/18/2022, the careplan indicated the resident's focus problems included activities of daily living (ADL) self care performance deficit (inability to perform self-care on his own) related to limited mobility, activity intolerance (inadequate mental or physical activity to accomplish daily activities), musculoskeletal impairment, fatigue, impaired balance and limited range of motion ([ROM], how far a joint or muscle can be moved in various directions). During a review of Resident 1's Minimum Data Set ([MDS], a standardize care assessment and care screening tool) dated 11/25/2022, the MDS indicated Resident 1 had the capacity to understand and make decisions. The MDS also indicated the resident required extensive assistance (staff provide guided maneuvering of limbs or other non-weight bearing assistance) or was totally dependent on staff for ADL's including bed mobility, transfer, eating, toilet use, personal hygiene and dressing. During a concurrent observation and interview on 1/6/2023 at 10:14 a.m. with Resident 1, Resident 1 was observed to have long jagged toenails on both feet. Resident 1 stated he had requested facility staff to trim his toenails, however no one assisted him for approximately five months since he had been at the facility. The resident stated his toenails were so long it would always get caught on his blanket and it was difficult to wear socks. The resident also stated he felt embarrassed, disrespected and did not understand why the facility staff could not assist with trimming his toenails. During an interview on 1/6/2023 at 11:00 a.m. with the Certified Nursing Assistant (CNA1), CNA1 stated Resident 1 complained about his toenails being too long and jagged however did not trim the resident's toenails because she was not allowed to. CNA 1 also stated she had notified a Licensed Vocation Nurse (LVN) to follow-up on the resident's complaint however could not recall which LVN she had notified. During an interview on 1/26/2023 at 1:38 p.m. with Director of Nursing (DON), DON stated facility nurses were trained to assist with trimming resident's toenails and was not sure why this was not done for Resident 1. DON also stated it was important to ensure toenail care was provided to promote resident's quality of life, prevent skin breakdown and maintain self-esteem. During a review of the facility's P&P titled, Quality of Care: ADL Care dated November 2021, the P&P indicated residents should be given treatment and service to maintain or improve her/his abilities and nail care may be provided by staff except residents with diabetes.

Dec 2022 3 deficiencies

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 record review and interview, the facility failed to provide an adequate indication for prescribing Abilify (medication ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide an adequate indication for prescribing Abilify (medication used to treat mental disorders) for one out of three sampled residents (Resident 53). This deficient practice had the potential to result in Resident 53 experiencing significant risk of serious or even life-threatening adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) such as death due to receiving an unnecessary medication. Findings: During a review of Residents 53's Face Sheet (admission record), indicated Resident 53 was originally admitted to the facility on [DATE], with diagnoses that included nicotine dependence, sequelae of cerebral infarction (disrupted blood flow to the brain), and newly diagnose as of 3/15/2022 with paranoid schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves) and delusional disorders (a type of mental health condition in which a person can't tell what's real from what's imagined). During a review of Resident 53's History and Physical (H/P) dated 4/12/2021, the H/P indicated Resident 53 had the capacity to understand and to make decisions. During a review of Resident 53's physician orders dated 3/15/2022, the physician's order indicated to give Abilify tablet 15 milligrams ([mg] unit of measurement), give 1 tablet, by mouth, one time a day, for schizophrenia. During a review of Residents 53's psychiatric (a medical doctor who has special training in preventing, diagnosing, and treating mental, emotional, and behavioral disorders) note dated 3/16/2022, indicated Resident 53 was being evaluated for metabolic encephalopathy (chemical problem in the brain), confusion, cerebral infarction, dementia (inability to remember, think or make decisions that interferes with doing everyday activities), and fluctuating capacity (decision-making ability varies). During a review of Resident 53's MDS ([MDS] a standardized care assessment and care screening tool) dated 3/22/2022, the MDS indicated Resident 53 did not have mood symptoms and behavioral symptoms. During a review of Residents 53's psychiatric note dated 10/7/2022, indicated Resident 53 was being evaluated for metabolic encephalopathy, confusion, cerebral infarction, dementia, and schizophrenia. During a review of Resident 53's Care plan titled Psychotropic Medication High Risk for Medication Adverse Reaction Abilify Related to Schizophrenia dated 4/18/2022, the care plan indicated Abilify increased mortality in elderly patients with dementia related psychosis. Care plan interventions included to consult with the pharmacy and the physician to consider dosage reduction when clinically indicated for Resident 53. During an interview with Licensed Vocational Nurse (LVN 5), on 12/9/2022, at 12:23 p.m. LVN 5 stated Resident 53 was always quiet, did not display aggression, and did not make-up stories. During an interview with Certified Nurse Assistant (CNA 4) on 12/9/2022, at 12:39 p.m., CNA 4 stated Resident 53 was always calm and quiet. CAN 4 stated she had not heard or seen Resident 53 making up stories or display aggression. CAN 4 stated Resident 53 had always been quiet and compliant with care. During an interview with Resident 53 on 12/09/2022, at 12:58 p.m., Resident 53 stated she had never been diagnosed with schizophrenia. Resident 53 stated she did not made-up stories about taking anyone's television (T.V.). Resident 53 stated she already had a T.V. set in her room. Resident 53 stated she did not know what the medication Abilify was and stated she did not give consent to take Abilify. During an interview with Director of Nursing (DON), on 12/9/2022, at 1:23 p.m., DON stated the staff did not raise any concerns about Resident 53 making up stories. During an interview with Psychiatrist (PHD) ON 12/9/2022, at 2:06 p.m., PHD stated Social Services Director (SSD) reported to him, over the phone, that Resident 53 was making up stories about her (SSD) such as taking residents to Resident 53's house and taking Resident 53's T.V. and money. PHD stated that was when he prescribed Abilify for Resident 53. PHD stated when he interviewed Resident 53, Resident 53 denied she had made these stories, but PHD listened to the staff. PHD stated he did not remember who the other staff were who informed him about Resident 53 fabricating stories. PHD further stated the diagnoses of dementia and metabolic encephalopathy would not be an indicative of schizophrenia. PHD stated he did not order any non-pharmacological interventions prior to prescribing Abilify for Resident 53. During an interview with SSD on 12/9/2022, at 2:59 p.m., SSD stated Resident 53 made up a story about her (SSD) taking residents to Resident 53's house and taking her T.V. During an interview with DON on 12/9/2022, at 3:38 p.m., the DON stated the side effects of Abilify could have led to poor quality of life for Resident 53. A review of the facility's policy (P/P) titled Psychotropic Drug Use revised 1/2021, indicated psychotropic mediations (any drug that affects brain activities associated with mental processes and behavior) should only be administered after non-pharmacological interventions have been attempted and failed. The attending physician would review in collaboration with the consultant pharmacist to re-evaluate the use of psychotropic medication and consider whether the medication should be reduced or discontinued. The psychotropic drug review committee and/or psychiatrist should ensure the prescribed medication was not to treat behavior related to delirium or other reversible conditions.

CONCERN (D)

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

Deficiency F0849 (Tag F0849)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its hospice agreement to coordinate care for one out of thre...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its hospice agreement to coordinate care for one out of three sampled residents (Resident 24). The facility staff and the hospice staff did not develop an effective communication process about Resident 24 plan of care, visitation, physician's orders, and documentation. This deficient practice had the potential to result in Resident 24 chocking and having to be hospitalized . Findings: During a review of Resident 24's clinical records, the admission Record indicated Resident 24 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnoses included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement) and Alzheimer's disease (progressive mental deterioration) dysphagia (difficulty swallowing) and dementia (memory loss). During a review of Resident 24's clinical records, the Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 10/30/2022, indicated Resident 24 was total dependent of one-person assist with bed mobility, dressing, eating, toilet use and personal hygiene. The MDS also indicated Resident 24 received hospice care while a resident in the facility. During a review of Resident 24's clinical records, the Care Plan for Encounter for Palliative Care (comfort care) dated 10/22/2022 did not indicated the frequency of the hospice visit for Resident 24. During a review of Resident 24's clinical records, The Order Summary report dated 12/09/2022, indicated Resident 24 active orders dated 10/20/2022 included: 1. Crush all medications and mix with apple sauce or pudding. 2. Donepezil hydrochloride (medication used to treat Alzheimer's disease) tablet 10 mg, by mouth, daily. 3. Famotidine (medication used to treat acid reflex) tablet 20 mg, by mouth daily before breakfast. 4. Memantine hydrochloride (medication used to treat Alzheimer's disease) tablet 10 mg, by mouth, daily. 5. Ondansetron hydrochloride (medication used to treat nausea and vomit) tablet 4 mg, by mouth, every six hours, as needed for nausea and vomiting. During a review of Resident 24's Hospice records, the Physician and Telephone Orders dated 10/22/2022, indicated Resident 24 orders included: 1. Diet order nothing via the mouth route for aspiration (inhalation of oropharyngeal or gastric contents into the larynx and lower respiratory tract) precaution, 2. All medications were to be crushed. 3. Memantine hydrochloride tablet 10 mg, via gastrostomy tube ([GT] a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medication), daily. During a concurrent interview and record, with Registered Nurse 2 (RN 2), on 12/8/2022, at 2:47 p.m., RN 2 stated she was the Hospice Coordinator for the facility. RN 2 stated the hospice visitation records for Resident 24 were kept in Resident 24's hospice binder. RN 2 stated the nurses knew when the hospice nurse visited the resident by looking in Resident's hospice binder. RN 2 stated the hospice staff communicated with the charge nurse about the care for the residents. RN 2 stated she could not find documentation of the care for Resident 24 in the hospice binder. RN 2 stated the charge nurse should have documented the hospice communication in Resident 24 medical records. RN2 stated the hospice staff orders were written in the hospice binder for the facility to carry out. RN 2 stated that facility licensed nurses were responsible for transcribing (when someone transfers a physician's prescription order to the clinical records) the hospice order to Resident 24 electronic medical record (e-MR). RN 2 verified the hospice visit description log for Resident 24 and stated the log was incomplete. During an interview and concurrent record review, with RN 4, on 12/09/2, 11:08 AM., , RN 4 verified Resident 24's hospice orders dated 10/22/2022, the order indicated Resident 24 diet was nothing via the oral route for aspiration (inhalation of oropharyngeal or gastric contents into the larynx and lower respiratory tract) precaution, medications were to be crushed and given via a GT. RN 4 confirmed he did not transcribe these hospice orders to Resident 24 e-MR. RN 4 stated he thought he had transcribed all the orders, but he did not. During a concurrent interview and record, with RN 2, on 12/8/2022, 12:50 p.m., RN 2 stated was unsafe for Resident 24 not to have the hospice order carried out in the e-MR. The facility's hospice agreement dated 3/1/2015, indicated the hospice provider retained responsibility to ensure required related hospice medical records were met. The agreement indicated the facility should allow the hospice company access to appropriate medical records and the hospice company should coordinate with the facility to ensure documentation of services was completed. The agreement indicated the facility's obligations included developing a plan of care which was consistent with the hospice plan of care, meet the resident's personal care and nursing needs in coordination with the hospice company. The agreement indicated the hospice company would receive and transcribe physicians' orders in the facility's clinical records for any resident hospice patient. Both the hospice company and the facility would communicate pertinent information with each other and document the communication in the resident's hospice medical records. A review of the facility's policy and procedure titled End of Life; Hospice and/or Palliative Care revised 12/2019, indicated hospice services would be offered as appropriate and as ordered by the physician and would be integrated into the overall individualized, interdisciplinary care plan. The policy indicated collaboration with hospice would include processes for orienting staff to facility policies and procedures which may include resident's rights, documentation, and record keeping requirements.

CONCERN (E)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two out of three sample residents (Resident 89...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two out of three sample residents (Resident 89 and Resident 145) who had an indwelling catheter (a flexible plastic tube inserted into the bladder to provide continuous urinary drainage) received the necessary service to maintain the indwelling catheter (a flexible plastic tube inserted into the bladder to provide continuous urinary drainage) clean. Resident 89 and Resident 145 who required assistance with indwelling catheter care did not receive the proper treatment. This deficient practice had the potential to result in the development of an urinary infection for Resident 89 and 145. Findings: During a review of Residents 89 medical records, the Face Sheet indicated Resident 89 was admitted to the facility on [DATE] with diagnoses that include intracranial hemorrhage (bleeding into the brain), respiratory failure (difficulty in breathing), and urine retention (a condition in which a person is unable to empty all the urine in the bladder). During a review of Resident 89's Minimum Data Set ([MDS] an assessment and care screening tool) dated 11/11/22, indicated Resident 89 was severely impaired with cognitive skills (a person ability of thinking, reasoning, or remembering) for daily decision-making. The MDS indicated Resident 89 required total assistance from the staff with bed mobility and transfer, eating, toilet use, bathing, grooming, and dressing. During a review of Resident 89 medical record, the Physician Order Summary Report dated 12/8/22, indicated Resident 89 had an order dated 11/4/22 for the use of the indwelling catheter due to retention. The order indicated Resident 89 would receive indwelling catheter care every shift and as needed. During a review of Resident 145 medical records, the Face Sheet indicated Resident 145 was admitted to the facility on [DATE] with diagnoses that include cerebral infarction (a condition caused by inadequate blood supply to the brain), hemiplegia and hemiparesis (weakness or loss of strength on one side of the body). During a review of Resident 145 medical record, the Physician Order Summary Report dated 12/8/22, indicated Resident 145 had an order dated 10/24/22 for the use of the indwelling catheter due to retention. The order indicated Resident 145 would receive indwelling catheter care every shift and as needed. During a review of Resident 145 medical records the MDS dated [DATE], indicated Resident 145 was severely impaired with cognitive skills for daily decision-making. The MDS indicated Resident 145 required total assistance from the staff with bed mobility and transfer, eating, toilet use, bathing, grooming, and dressing. During an observation on 12/8/12, at 9:45 a.m., certified nursing assistant (CNA 9) cleaned the indwelling catheter for Resident 89 and Resident 145. CNA 9 did not clean the indwelling catheter insertion site and the tube connected to the drainage bag for Resident 89 and Resident 145. During an interview on 12/8/22, at 10:35 a.m., with CNA 9, CNA 9 stated during resident care she cleaned around the indwelling catheter to clean any stool. CNA 9 stated the treatment nurse was responsible to perform catheter care on residents with an indwelling catheter. During an interview on 12/8/22, at 12:30 p.m., with the treatment nurse (LVN 1), LVN 1 stated she did catheter care for the residents by observing the CNAs provided indwelling catheter care and making sure the CNAs properly cleaned the resident's indwelling catheter. During a concurrent interview and record review on 12/8/22, at 2:40 p.m., with the director of nursing (DON), the Care Plan for Resident 89 and 145 indicated the LVN and the Registered Nurse (RN) were responsible to perform indwelling catheter care. The DON agreed the LVNs, and RNs should perform indwelling catheter care for Residents 89 and 145 instead of the CNAs. During a review on the facility's policy and procedure (P&P) titled, Catheter Care indwelling revised on 12/2017, the P&P indicated each resident with an indwelling catheter would receive catheter care daily and as needed to promote hygiene, comfort, and decrease risk of infection. The P&P described the procedure catheter care as using disposable wipes, claiming the catheter insertion in a downward motion (front to back), and clean the length of the foley catheter from the resident towards the drainage bag.

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

Deficiency F0726 (Tag F0726)

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 nine sampled residents (Resident 6) 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 nine sampled residents (Resident 6) was fully assessed after the resident had a fall in his room. This deficient practice had the potential to lead to an inaccurate evaluation and treatment for Resident 6 Findings: During a review of Residents 6 ' s Face Sheet (admission record), the face sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included a history of abnormalities of gait and mobility and muscle weakness. During a review of Resident 6 ' s Care plan titled High Risk for Repeat Falls dated 10/04/2022, the care plan ' s interventions included to anticipate and meet the resident ' s needs, place Resident 6 ' s call light within reach and encourage the resident to use the call light. During a review of Resident 6 ' s History and Physical (H/P), dated 9/25/2022, the H/P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 6's most recent Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 9/30/2022, the MDS indicated Resident 6 had the ability to understand and be understood by others. The MDS indicated Resident 6 required one-person assist for bed mobility, transfer, walk in room, locomotion (ability to move from one place to another), dressing, and toilet use. The MDS indicated Resident 6 required setup help for eating and personal hygiene. During an observation on 10/12/2022 at 12:45 p.m., Licensed Vocational Nurse (LVN) 1 and Activities Staff (AS) 1 entered Resident 6 ' s room and Resident 6 was observed on the floor. LVN 1 told AS 1 to ask Resident 6 if the resident was okay. AS 1 asked Resident 6 in Spanish if he was okay and the resident agreed. AS 1 and LVN 1 did not asked any other questions to the resident. LVN 1 did not assess Resident 6 after observing Resident 6 on the floor. LVN 1 and AS 1 were observed walking out of Resident 6 ' s room. During an interview with LVN 1 on 10/12/2022 at 1:10 p.m., LVN 1 stated after Resident 6 ' s fall she was supposed to assess the resident from head to toe to ensure there were no injuries. LVN 1 stated she was supposed to check if the resident was able to move his limbs and assist the resident to get up. LVN 1 stated she had to assess the area and ensure that the area was free of clutter and the resident ' s call light was within reach. LVN 1 stated she did not fully assessed Resident 6 because she though the resident had a visitor and did not want to disturb him. LVN 1 stated if Resident 6 had hit his head there could have been a risk for brain bleed and possible death. During a review of the facilities undated policies and procedures (P/P) titled Resident Assessment, (P/P) indicated the facility provided each resident with appropriate assessment and interventions to prevent falls and to minimize complications if a fall occurred. The P/P indicated when a resident sustained a fall, a physical assessment would be completed by a licensed nurse with results documented in the Nursing Progress Notes. The P/P indicated a follow-up assessment and documentation would be conducted for a minimum of 72 hours following the incident.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow its plan of care and policies to ensure 4 out ...

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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 follow its plan of care and policies to ensure 4 out of 5 sampled residents (Resident 1, 2, 4 and 5) in the red zone (area that separates and restricts the movement of people who are confirmed with a contagious disease) were administered their prescribed morning medications. This failure had the potential to exacerbate a patient's health condition, increase the risk of disease progression, and lead to transplant (a surgery that replaces a diseased organ with a healthier organ from another person) rejection, and prolonged hospitalization. Findings: A review of Residents 1 ' s Face Sheet (admission record), indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included a history of dependence on renal dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), diabetes mellitus ([DM] a disease in which the body does not control the amount of sugar in the blood), seizures (a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements (stiffness, twitching or limpness), behaviors, sensations or states of awareness) and liver transplant (a surgery that replaces a diseased liver with a healthier liver from another person). During a review of Resident 1's Minimum Data Set ([MDS] a standardized care assessment and care screening tool) dated 8/21/2022, the MDS indicated Resident 1 had the ability to understand and be understood by others. The MDS indicated Resident 1 required one-person assist with bed mobility, dressing, toilette use, and personal hygiene. During a review of Resident 1 ' s History and Physical (H/P) dated 9/25/2022, the H/P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident ' s 1 Order Summary Report, dated 8/1/2022 to 10/31/2022, indicated: 1. Rifaximin (medication used to treat infection in the stomach) 550 milligrams ([mg] unit of measurement), by mouth, two times a day. 2. Valproic Acid (medication used to treat and stop seizures) 250 mg, by mouth, three times a day. 3. Amlodipine Besylate (medication used to lower blood pressure) tablet 10 mg, by mouth, one time a day. 4. Tacrolimus capsule (medication use to prevent the body from rejecting a transplanted organ) 0.5 mg, by mouth, two times a day. During a review of Resident 1 ' s Care Plan titled Antibiotic Therapy dated 8/22/2022, indicated the care plan intervention included administer the medication as ordered. During a review of Resident 1 ' s Care Plan titled Has Hypertension ([HTN] elevated blood pressure) dated 9/6/2022, indicated the care plan intervention included administer the medication as ordered, measure the blood pressure under the same conditions. During a review of Resident 1 ' s Care Plan for diabetes dated 9/6/2022, indicated the care plan interventions included to administer the medication as ordered During a review of Resident 1 ' s Care Plan for seizures dated 9/6/2022, indicated the care plan interventions included administer the medication as ordered, monitor, and document for effectiveness and side effects (an unwanted undesirable effects related to a medication). During a review of Resident 1 ' s Care Plan for liver disease related to cirrhosis of liver (liver disease) and liver transplant dated 9/6/2022, indicated the care plan interventions included administer the mediations as ordered, monitor, and document for medication effectiveness and side effects. During a review of Resident 1 ' s Medication Administration Record (MAR) dated 10/2022, the MAR indicated on 10/13/2022, at 9 a.m., Resident 1 did not receive rifaximin 500 mg, valproic acid 250 mg, Amlodipine Besylate 10 mg, and tacrolimus capsule 0.5 mg During an interview with Resident 1, in the red zone, on 10/13/2022, at 12:40 p.m., Resident 1 stated she did not remember getting her 9 a.m. medications on 10/13/2022. During an interview with Director of Nursing (DON), on 10/13/2022, at 5:06 p.m., the DON stated was important for Resident 1 to receive her seizure prevention medication as ordered by the physician because it prevented Resident 1 from having seizures. The DON stated seizures when left untreated could lead to brain damage. The DON stated if Resident 1 did not received tacrolimus capsules Resident 1 liver transplant could be rejected by her body and could be fatal for Resident 1. During a review of Residents 2 ' s Face sheet, the face sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including a history of acquired absence of left leg above knee, chronic pain, hypertension (high blood pressure), and diabetes. During a review of Resident 2 ' s H/P dated 9/20/2022, the H/P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 had the ability to understand and be understood by others. The MDS indicated Resident 2 required one-person assist for bed mobility, dressing, toilet use, and personal hygiene. During a review of Resident ' s 2 Order Summary Report dated 8/1/2022 to 10/31/2022, indicated: 1. Bumetanide (medication used remove fluid from the body) tablet 2 mg, by mouth, one time a day. 2. Clopidogrel Bisulfate (blood thinner) tablet 75 mg, by mouth, one time a day. 3. Diltiazem hydrochloride (HCL) (medication used to treat blood pressure and chest pain) tablet 60 mg, by mouth, one time a day. During a review of Resident 2 ' s Care Plan on Diuretic Therapy dated 9/28/2022, the care plan intervention included administer the medication as ordered. During a review of Resident 2 ' s Care Plan has an alteration in gastro-intestinal (stomach area) status related to gastro-intestinal management dated 9/29/2022, the care plan interventions included to administer the medication as ordered, monitor, and document medication side effects and effectiveness. During a review of Resident 2 ' s MAR dated 10/2022, the MAR indicated Resident 2, on 10/13/2022, at 9 a.m. did not received bumetanide tablet 2 mg, clopidogrel bisulfate 75 mg, and diltiazem HCL 60 mg. During an interview with Resident 2, in the red zone, on 10/13/2022, at 12:20 p.m., Resident 2 stated he did not receive his morning medications. A review of Residents 4 ' s Face Sheet, indicated Resident 4 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus and hypertension. During a review of Resident 4 ' s H/P dated 10/8/2022, the H/P indicated Resident 4 had the capacity to understand and make decisions. During a review of Resident 4's MDS dated [DATE], the MDS indicated Resident 4 had the ability to understand and be understood by others. The MDS indicated Resident 4 required extensive assistance of one-person with transfer, dressing, toilet use, and personal hygiene. During a review of Resident ' s 4 Order Summary Report dated 8/1/2022 to 10/31/2022, indicated: 1. Losartan Potassium (medication used to lower blood pressure), tablet 100 mg, by mouth, one time a day. During a review of Resident 4 ' s MAR dated 10/2022, indicated Resident 4, on 10/13/2022 at 9 a.m. did not received losartan potassium tablet 100 mg. During an interview with Resident 4, in the red zone, on 10/13/2022, at 12:30 p.m., Resident 4 stated he did not receive any of his medications this morning. During an interview with DON, on 10/13/2022, at 11:45 p.m., the DON stated she could not find the pill cards (a card holding medication tablets or capsules that are individually packaged in a clear plastic case) for Resident 4 in the medication cart. The DON stated she did not know where Resident 4 medications were and could not verify Resident 4 morning medications were administered to Resident 4. During a review of Residents 5 ' s Face Sheet, the Face Sheet indicated Resident 5 was admitted to the facility on [DATE] with diagnoses that included high blood pressure and communication deficit. During a review of Resident 5 ' s H/P dated 9/20/2022, the H/P indicated Resident 5 had the capacity to understand and make decisions. During a review of Resident 5's MDS dated [DATE], the MDS indicated Resident 5 usually had the ability to understand and be understood by others. The MDS indicated Resident 5 required one-person assist with bed mobility, transfer, dressing, toilette use, and personal hygiene. During a review of Resident ' s 5 Order Summary Report, dated 8/1/2022 to 10/31/2022, indicated: 1. Amlodipine Besylate tablet 10 mg, by mouth, one time a day. 2. Lisinopril tablet 20 mg, by mouth, two times a day, for hypertension 3. Lovenox Solution (blood thinner) Prefilled Syringe 40 mg/ 0.4 milliliters ([ml] unit of measurement), subcutaneously (under de skin), daily. 4. Metoprolol tartrate (medication used to treat blood pressure) table 50 mg, by mouth two times a day. During an interview with Resident 5, in the red zone, on 10/13/2022, at 1:15 p.m., Resident 5 was not able to confirm if she had received her morning medications. During a concurrent interview and record review of the Medication Administration Records (MAR) with Licensed Vocational Nurse (LVN 1), on 10/13/2022, at 11:45 a.m., for Resident 1, 2, and 5. LVN 1 stated the red icons, on the screen, for the electronic MAR meant the 9 a.m. medication administration for Resident 1, 2, and 5 were not documented. LVN 1 stated she thought the night shift nurse gave the 9 a.m. medications for Resident 1, 2, and 5. LVN 1 looked at the pill card for Resident 1, 2, and 5 and could not identify which medications had been given at 9 a.m. for Resident 1, 2, and 5. LVN 1 stated she did not administer or witness the 9 a.m. medications being administered for Resident ' s 1, 2, and 5. LVN 1 stated she could not verify the schedule medications were administered for Resident 1, 2, and 5 as ordered by the physician. During an interview with the DON, on 10/13/2022, at 12:00 p.m., the DON stated the process to administering medications was to have the staff verify the doctor ' s orders, collect the medications, explain to the resident ' s what medications were being administered, and after the medications were given, document in the MAR. The DON stated the staff did not follow the medication administration protocol for the residents in the red zone. The DON stated when the resident ' s medications were delayed could worsen their health conditions. During an interview with DON on 10/13/2022, at 5:06 p.m., the DON stated by looking at the pill card for Resident 1, 2, and 5 the amount of medication left did not match with the medication administration, and she could not say the morning medications were administered for the residents in the red zone. The DON stated it was important to provide the residents with their blood pressure medications to prevent the residents from suffering a stroke (occurs when something blocks blood supply to part of the brain) and cardiomegaly (enlarge heart). The DON further stated not following the facility ' s medication administration protocols could lead to serious medication errors for the residents. During an interview with Licensed Vocational Nurse (LVN 2) on 10/13/2022 at 1:35 p.m. LVN 2 stated the DON told the staff they were not able to go into the red zone during their shift. They could only go into the red zone at the end of the shift due to infection control. During a review of the facility ' s policy Preparation for Medication Administration (P/P) undated, indicated medications were administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. The P/P indicated the individual who administered the medication dose recorded the administration on the resident's MAR directly after the medication was given. It further indicated at the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented and in no case should the individual who administered the medications report off-duty without first recording the administration of any medications.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the call lights was within reach and accessibl...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the call lights was within reach and accessible for three out of nine sampled residents (Resident 2 and Resident 7) who needed assistance. This deficient practice had the potential to result in Residents 2 and 7, not having their needs met. Findings: 1.During a review of Residents 2's Face Sheet (admission record), the facesheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including a history of acquired absence of left leg above knee, hypertension (high blood pressure) and diabetes (abnormal blood sugar). During a review of Resident 2's History and Physical (H/P), dated 9/20/2022, the H/P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 9/26/2022, the MDS indicated Resident 2 had the ability to understand and be understood by others. The MDS indicated Resident 2 required one-person assist for bed mobility, dressing, toilet use, and personal hygiene. The MDS indicated Resident 2 required setup help for locomotion (moving from place to place) and for eating. The MDS indicated Resident 2 had one fall since admission and without injury. During a review of Resident 2's Care plan titled High Risk for Repeat Falls dated 9/22/2022, the care plan's interventions included to place the resident's call light is within reach and encourage to use it to call for assistance as needed. During a concurrent observation and interview with Resident 2 on 10/13/2022 at 12:20 p.m., Resident 2's call light was towards the wall and away from him. Resident 2 stated he could not reach the call light and it made him angry not being able to get assistance when he needed it. Resident 2 stated that the staff did not come into his room when he needed help because he could not find the light so he would just yell for help. During a concurrent observation and interview with CNA 4 on 10/13/2022 at 12:35 p.m., noted CNA 4 looking for Resident 2's call light and he could not find it. CNA 4 stated the call light was not at reach for Resident 4 and it was a problem because it could have led to Resident 2 to fall. CNA 4 further stated that the call light should have at reach. 2.During a review of Residents 7's Face Sheet indicated, the face sheet indicated Resident 7 was originally admitted to the facility on [DATE], with diagnoses that included paraplegia (the inability to voluntarily move the lower parts of the body) and right-hand contracture (a disorder that causes permanent shortening and stiffness of the joints). During a review of Resident 7's H/P, dated 8/19/2022, the H/P indicated Resident 7 had the capacity to understand and make decisions. During a review of Resident 7's most recent MDS, dated [DATE], the MDS indicated Resident 7 had the ability to understand and be understood by others. The MDS indicated Resident 7 required one-person assist for bed mobility, transfer, walk in room, locomotion, dressing, eating, toilette use, and personal hygiene. During a review of Resident 7's Care plan titled At Risk for Falls Related to Decrease Mobility, Contracture, Unaware of Safety Needs dated 8/18/2022, the care plan's interventions included to place the resident's call light and personal items within reach. During a concurrent observation and interview with Resident 7 on 10/12/2022 at 12:20 p.m., Resident 7's call light was observed next to his pillow by his head. Resident 7 stated he could not reach his call light because he could not really move his arms. Resident 7 stated he was able to press his call light if placed on his chest. Resident 7 stated not being able to get assistance when he needed made him feel isolated and lonely. During a concurrent observation and interview with CNA 1 on 10/12/2022 at 12:30 p.m., CNA 1 stated Resident 7's call light was not in reach CNA 1 stated that the Resident 7's needs could not be met if the call light was not in reach. CNA 1 stated without Resident 7's call light in place, the resident might attempt to self-transfer and get injured. During a review of the facility's policy and procedures (P/P) titled Call Light/Bell revised 5/2007, the P/P indicated the facility provided residents a means of communication with nursing staff. The P/P indicated call lights were place within residents' reach at all times.

CAMINO HEALTHCARE

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The Ugly 61 deficiencies on record

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CAMINO HEALTHCARE

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