FREEDOM VILLAGE HEALTHCARE CENTER
For profit - Partnership
52 Beds
FREEDOM MANAGEMENT COMPANY
Data: November 2025
Trust Grade
60/100
#582 of 1155 in CA
Last Inspection: October 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Freedom Village Healthcare Center in Lake Forest, California, has a Trust Grade of C+, indicating it is slightly above average, but still in the bottom half of California facilities, ranked #582 out of 1155. In Orange County, it sits at #42 out of 72, meaning there are only a few local options that are better. The facility is showing improvement, with issues decreasing from 24 in 2024 to just 1 in 2025. Staffing is a strength, rated 4 out of 5 stars, with a turnover rate of 38%, aligning with the state average, suggesting that staff tend to stay and build relationships with residents. While the facility has no fines on record, which is a positive sign, there have been concerns regarding food safety, including improper food storage temperatures and cleanliness issues in the kitchen, which could pose risks for residents. Overall, while there are strengths in staffing and recent improvements, families should be aware of the ongoing concerns related to food safety and sanitation.
- Trust Score
- C+
- In California
- #582/1155
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 38% turnover. Near California's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most California facilities.
- Skilled Nurses ✓ Good
- Each resident gets 45 minutes of Registered Nurse (RN) attention daily — more than average for California. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 44 deficiencies on record. Higher than average. Multiple issues found across inspections.
60/100
Top 50%
No red flags
24 → 1 violations
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 24 issues
2025: 1 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (38%)
10 points below California average of 48%
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
3-Star Overall Rating
Near California average (3.1)
Meets federal standards, typical of most facilities
Staff Turnover: 38%
Near California avg (46%)
Typical for the industry
Chain: FREEDOM MANAGEMENT COMPANY
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 44 deficiencies on record
Sept 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of four sampled residents ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one of four sampled residents (Resident 3) received the appropriate services needed to maintain optimal nutritional status. * The facility failed to timely notify Resident 3's physician of the RD recommendations when Resident 3 had a weight loss of 6 pounds in six days. This failure had the potential for the resident to not receive the necessary care and intervention timely to maintain the resident's nutrition status and/or prevent further weight loss.Findings: Review of the facility's P&P titled Weight Management (undated) showed the residents' weights are monitored for undesirable or unintended weight loss or gain. Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. The physician and multidisciplinary team identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. Review of the facility's P&P titled Weight Assessment and Intervention revised 11/16/24, showed the interdisciplinary team will strive to monitor and intervene for undesirable weight change for the residents. Medical record review for Resident 3 was initiated on 9/19/25. Resident 3 was admitted to the facility on [DATE]. Review of Resident 3's H&P examination dated 9/5/25, showed Resident 3 had the capacity to make medical decisions. Review of Resident 3's Weights and Vitals Summary showed Resident 3's weight was documented as follows:- dated 9/3/25, 139 lbs, and- dated 9/9/25,133 lbs, a loss of 6 lbs (4.3%) in six days compared to 9/3/25; Review of Resident 3's Nutrition assessment dated [DATE], showed current PO (oral) intake inadequate for meeting the ENN (estimated nutrient/nutrition needs) due to variable intake. The RD assessment further showed recommend: 1. MVI/min (multivitamin with minerals supplement) daily, 2. snacks TID, 3. Glucerna shakes (a nutritional supplement for individuals with diabetes) TID w/meals (with meals). Review of the facility's document titled RD Recommendations dated 9/9/25, showed the RD made the following recommendations for Resident 3:- MVI/min daily;- snacks TID; and- Glucerna shakes one can with meals. Review of Resident 3's Physician Order Summary showed a physician's order dated 9/18/25, for the above RD recommendations for Resident 3, nine days after the RD had made the recommendations. On 9/25/25 at 1412 hours, a concurrent interview and medical record review for Resident 3 was conducted with LVN 1. LVN 1 verified the nutrition assessment and recommendations were conducted by the RD on 9/9/25. LVN 1 stated she received the RD recommendation on 9/18/25, from the DON and immediately followed up with the physician to obtain the orders on the same day. LVN 1 further stated a delay in carrying out the RD recommendations and following up with the physician had the potential to put the resident at risk for more weight loss, dehydration, and poor wound healing. On 9/25/25 at 1639 hours, the DON was informed and acknowledged the above findings. The DON stated the charge nurses were responsible for ensuring the RD recommendations were relayed to the physician timely. The DON further it was an honest miss this time.
Dec 2024
1 deficiency
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Medical Records
(Tag F0842)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the medical record was accurate for one of two sampl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the medical record was accurate for one of two sampled residents (Resident 1). This failure posed the risk for Resident 1 to not receive the accurate and necessary care.
Findings:
Review of the facility's P&P titled Fall Incident Management and Intervention revised 10/2024 showed in part, it is the policy .to promote resident's safety and prevent injury. The procedure section showed, fall risk assessment and care plans updated for all residents at risk for falling and/or residents that have fallen more than once.
Review of the facility's P&P titled Charting and Documentation revised 11/2023 showed all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition shall be documented in the resident's medical record. The policy interpretation and implementation section showed documentation in the medical record will be objective, complete, and accurate.
Medical record review for Resident 1 was initiated on 12/19/24. Resident 1 was admitted to the facility on [DATE].
Review of Resident 1's MDS dated [DATE], showed Resident 1's cognition was moderately impaired. Further review of Resident 1's MDS showed the resident had a fall in the last month prior to admission.
Review of Resident 1's progress note dated 12/10/24, showed Resident 1 was found lying on the floor by the bed. Further review of the progress note showed Resident 1 stated she stood up and tripped on other foot, then fell on the floor.
However, review of Resident 1's fall risk assessment dated [DATE], showed Resident 1 had no history of falls within the last six months.
On 12/24/24 at 1138 hours, a concurrent interview and medical record review was conducted with LVN 1. LVN 1 verified Resident 1's fall risk assessment was inaccurate. LVN 1 stated it should have been documented as one to two times instead of no falls. LVN 1 further stated the licensed nurse did the fall risk assessment. LVN 1 stated the fall risk assessment could be misinterpreted because of the inaccuracy.
On 12/26/24 at 1010 hours, a concurrent interview and medical record review was conducted with the ADON. The ADON acknowledged the licensed nurse documented Resident 1 had no history of falls within the last six months. The ADON stated the service could be delayed if the fall risk assessment was not accurate. The ADON stated the licensed nurse should have updated Resident 1's Fall Risk Assessment to one to two times for the current fall.
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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to follow the abuse protocol during the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to follow the abuse protocol during the facility investigation period for one of two sampled residents (Resident 1).
* The facility failed to suspend CNAs 2 and 3 from work when Resident 1 reported an allegation of physical abuse against these two CNAs on 11/10/24. This failure had the potential to place Resident 1 and other residents at risk of not being protected against the alleged abusers.
Findings:
Review of the facility's P&P titled Abuse Policy and Procedure revised 3/1/24, showed during and after the investigation, the residents will be protected from the alleged harm through the following methods:
- staff will closely and frequently supervise the resident, and
- if a staff member is accused or suspected of abuse, that staff member will be suspended pending the completion of the investigation.
On 11/12/24, the CDPH, Licensing and Certification Program received a report from the facility regarding Resident 1's allegation of physical abuse by CNAs 2 and 3 on 11/10/24.
Medical record review for Resident 1 was initiated on 11/26/24. Resident 1 was admitted to the facility on [DATE].
Review of Resident 1's H&P examination dated 11/5/24, showed Resident 1 could make her own medical decisions.
On 11/26/24 at 0920 hours, a review of the facility's investigation file was conducted. The document showed the interviews and statements of the facility's staff members and residents. However, further review of the documents failed to show the two alleged CNAs were suspended during the investigation period from 11/10/24 to 11/13/24.
On 11/26/24 at 1042 hours, a telephone interview was conducted with CNA 2. CNA 2 stated she was aware Resident 1 just had a hip surgery and being gentle when providing the care to Resident 1. When asked if she had worked from 11/10/24 to 11/13/24, CNA 2 stated the Administrator consented her to return to work the following day after the reported abuse allegation, but she was given a different assignment and not working directly with Resident 1.
On 11/26/24, at 1115 hours, a telephone interview was conducted with CNA 3. CNA 3 stated she helped CNA 2 changed the brief for Resident 1. CNA 3 further stated Resident 1 was calm and did not complain of any issues related to the care they provided. When asked if she worked from 11/10 to 11/13/24, CNA 3 stated she was instructed to not provide care to Resident 1 but could return to work immediately after the reported abuse allegation.
Review of the facility's Staffing Sheets for 11/11 to 11/13/24, showed CNAs 2 and 3 were not assigned to Resident 1. However, CNA 2 worked from 11/11 and 11/13/24, and CNA 3 worked on 11/11/24.
On 12/6/24 at 1230 hours, an interview and concurrent medical record review for Resident 1 was conducted with the DON. The DON verified the facility's abuse investigation was initiated on 11/10/24, and completed on 11/13/24. The DON acknowledged the findings and stated both the alleged CNAs should have been suspended during the investigation period to ensure the safety of Resident 1 and other residents in the facility.
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 medical record review, the facility failed to provide the necessary care and services to ensure one of tw...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to provide the necessary care and services to ensure one of two sampled residents (Resident 1) attained and/or maintained her highest practicable physical well-being.
* The facility failed to monitor Resident 1's safety and psychosocial wellbeing and developed a care plan after Resident 1 had reported an abuse allegation on 11/10/24. This failure had the potential for Resident 1 not to receive the necessary care and services.
Findings:
On 11/12/24, the CDPH, Licensing and Certification Program received a report from the facility regarding Resident 1's allegation of physical abuse by CNAs 2 and 3 on 11/10/24.
Medical record review for Resident 1 was initiated on 11/26/24. Resident 1 was admitted to the facility on [DATE].
Review of Resident 1's Progress Note dated 11/10/24, showed Resident 1 alleged two CNAs were changing her diaper and being rough with care. The note also showed the CNAs were laughing at her. Further review of Resident 1's Progress Note failed to show Resident 1 was monitored for 72 hours after reporting the abuse allegation.
In addition, further review of Resident 1's medical record failed to show a care plan was established to include the goals and interventions to address Resident 1's safety and psychosocial wellbeing after reporting the physical abuse allegation against the two CNAs.
On 12/6/24 at 0915 hours, an interview and concurrent interview was conducted with RN 1. RN 1 verified the above findings and further stated Resident 1's medical record should have a care plan developed for the abuse allegation as well as the 72 hours monitoring from the nursing and social services.
On 12/6/24 at 1230 hours, an interview was conducted with the DON. The DON was made aware and acknowledged the above findings. The DON stated Resident 1 should have a care plan and 72 hours monitoring for the resident's safety from the nursing and social services after the allegation of abuse.
Oct 2024
21 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure whether it was sa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure whether it was safe to self-administer the medications for one of 14 final sampled residents (Resident 24).
* Resident 24 was observed to have two Voltaren (topical pain medication) gel tubes at bedside. Resident 24 did not have the physician's order or care plan problem addressing the self-administration of medications. This failure had the potential for Resident 24 to administer the medications inaccurately.
Findings:
Review of the facility's P&P titled Self-Administration of Medications revised 6/5/24, showed the facility should comply with facility policy, applicable law, and the State Operations Manual with respect to resident self-administration of medications. Facility, in conjunction, with the interdisciplinary care team, should assess and determine, with respect to each resident, whether self-administration of medications is safe and clinically appropriate, based on the resident's functionality and health condition. Facility should ensure that orders for self-administration list the specific medication(s) the resident may self-administer. Facility should document the self-administration and self-storage of medications in the resident's care plan.
On 10/21/24 at 1059 hours, an observation was made at Resident 24's bedside. Two Voltaren gel tubes were observed inside an open drawer of the resident's nightstand.
On 10/21/24 at 1101 hours, an observation and concurrent interview was conducted with RN 1. RN 1 verified the above findings and stated she was not aware of the medications at the resident's bedside.
On 10/23/24 at 0843 hours, an interview was conducted with Resident 24. Resident 24 stated she would apply the Voltaren gel herself for the right knee pain.
Medical record review for Resident 24 was initiated on 10/22/24. Resident 24 was admitted to the facility on [DATE].
Review of Resident 24 H&P examination dated 10/22/24, showed Resident 24 had the capacity to understand and make medical decisions.
Review of Resident 24's Self-Administration of Medications assessment dated [DATE], showed Resident 24 was not a candidate for safe self-administration of medications.
Further review of Resident 24's medical record failed to show documented evidence of the physician's order and care plan problem addressing Resident 24's self-administration of the medications.
On 10/23/24 at 1001 hours, an interview and concurrent medical record review was conducted with RN 1. RN 1 verified Resident 24 was not a candidate for self-administration of the medications and did not have a physician's order or care plan in place.
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, medical record review, and facility P&P, the facility failed to ensure the advance directive information was...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P, the facility failed to ensure the advance directive information was documented and/or the information on how to formulate an advance directive was offered to three of 14 final sampled residents (Residents 22, 24, and 25).
* The facility failed to ensure the copies of the advance directives were obtained and placed in the medical records for Residents 22 and 24.
* The facility failed to ensure the POLST for Resident 25 was updated to show the advance directive was formulated.
These failures had the potential for the facility to provide the treatments and services against the residents' wishes.
Findings:
Review of the facility's P&P titled Advance Directive revised 11/16/23, showed the following:
- Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment to formulate an advance directive if he or she chooses to do so;
- Information about whether or not the resident has executed an advance directive, the advance directive shall be displayed prominently in the medical records; and
- The plan of care for each resident will be consistent with his or her documented treatment preferences and/ or advance directive.
1. Medical record review for Resident 22 was initiated on 10/21/24. Resident 22 was admitted to the facility on [DATE].
Review of Resident 22's POLST dated 2/17/24, showed Resident 22 had an advance directive dated 12/2019, and had a legally recognized decision maker.
On 10/23/24 at 1640 hours, an interview was conducted with the SSD. When asked regarding the facility's process for advance directive, the SSD stated she asked the residents or family if they had advance directive. The SSD verified Resident 22's POLST showed the resident had an advance directive.
On 10/23/24 at 1649 hours, a follow-up interview and concurrent medical record review was conducted with the SSD. The SSD stated there was no copy of the advance directive in Resident 22's medical record and stated she did not contact the family for a copy of the advance directive.
3. Medical record review for Resident 25 was initiated on 10/24/24. Resident 25 was admitted to the facility on [DATE].
Review of Resident 25's POLST, Section D (advance directives), dated 10/19/23, showed Resident 25 had no advance directive.
Review of Resident 25's Power of Attorney for Healthcare dated 10/30/23, showed Resident 25 had formulated an advance healthcare directive.
Further review of Resident 25's medical record failed to show the resident's POLST was updated to show an advance directive was formulated.
On 10/24/24 at 1103 hours, an interview and concurrent medical record review for Resident 25 was conducted with the SSD. The SSD verified Resident 25 had formulated an advance healthcare directive; however, the POLST was not updated to show an advance healthcare directive was formulated.
2. Medical record review for Resident 24 was initiated on 10/22/24. Resident 24 was admitted to the facility on [DATE].
Review of Resident 24's H&P examination dated 10/22/24, showed Resident 24 had the capacity to understand and make medical decisions.
Review of Resident 24's POLST dated 10/27/23, showed Resident 24's advance directive was not available.
Review of Resident 24's Social Services assessment dated [DATE], showed Resident 24 had an advance directive.
Review of Resident 24's Social Service Quarterly assessment dated [DATE], showed Resident 24's family member would bring in a copy of the advance directive.
On 10/23/24 at 0936 hours, an interview and concurrent medical record review for Resident 24 was conducted with the SSD. The SSD acknowledged Resident 24's advance directive was not available in the medical record and should have been followed up.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
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 the Notice of Medicare Non-Coverage (NOMNOC) after the term...
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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 the Notice of Medicare Non-Coverage (NOMNOC) after the termination Medicare Part A services for two nonsampled residents (Resident 45 and 47). This failure had the potential for violating the residents' rights to be informed of changes for coverage.
Findings:
1. Review of Resident 45's admission Record showed the resident was admitted to the facility on [DATE], and the last covered day of Medicare Part A Services was on 8/3/24.
Review of Resident 45's SNF Beneficiary Protection Notification Review dated 5/17/24, showed the resident's representative was notified regarding the resident's last covered Medicare day. However, the representative was provided copy of the CMS 20052 SNF Beneficiary Protection Notification Review as the ABN (Advance Beneficiary Notification).
2. Review of Resident 47's admission Record showed the resident was admitted to the facility on [DATE] and readmitted on [DATE]; and the last covered day of Medicare Part A Services was 5/15/24.
Review of Resident 47's SNF Beneficiary Protection Notification Review dated 5/13/24, showed the resident's representative was notified regarding the resident's last covered Medicare day. However, the representative was provided copy of the CMS 20052 SNF Beneficiary Protection Notification Review as the ABN.
On 10/22/24, at 0842 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD stated Residents 45's and 47's representatives were informed of the notification of the residents' last covered day for Medicare. The SSD stated they did not give the residents or their representatives a copy of the ABN.
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, medical record review, and facility document review, the facility failed to ensure the staff implemented two...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility document review, the facility failed to ensure the staff implemented two-person assist for transfers one of two final sampled residents (Resident 18) as per the plan of care, resulting the right ankle fracture treated with the right ankle splint. This failure had the potential to negatively impact the resident's well-being.
Findings:
Medical record review of Resident 18 was initiated on 10/21/24. Resident 18 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 18's quarterly MDS dated [DATE], showed under section GG (Functional Abilities and Goal), sit to lying, sit to stand, chair/bed to chair transfer was coded as substantial or maximal assistance.
Review of Resident 18's care plan dated 9/5/24, showed a problem of activity daily living self-care performance deficits related to impaired mobility as manifested by having generalized weakness/deconditioning/debility. The interventions included to require two persons assist for extensive to total care for transfers.
Review of Resident 18's progress note dated 10/2/24, showed the resident care assistant reported the resident's right ankle was slightly swelling. The resident care assistant stated she helped the resident transfer from the shower chair to the bed, and the resident stated she twisted her right ankle during the transfer. Per the resident, I will be okay. My foot always gets caught from the carpet.
Review of Resident 18's progress note dated 10/3/24, showed the resident had the right ankle fracture with right ankle splint back from the acute care hospital.
On 10/21/24 at 0920 hours, a concurrent observation and interview was conducted with Resident 18. Resident 18 was observed sitting upright in bed with a cast on the right leg. Resident 18 stated when the nurse helped her transfer from the wheelchair to the bed, the resident put her leg under the bed cabinet drawer and her foot got caught under the drawer. Resident 18 stated she did not pay attention to her legs, had weakness in her knee, and twisted her ankle.
On 10/21/24 at 1545 hours, an interview was conducted with CNA 2. CNA 2 was asked what happened on 10/2/24. CNA 2 stated she transferred Resident 18 from the shower chair to bed by herself. Resident 18's leg was caught between the nightstand. CNA 2 stated she was not aware Resident 18 needed a two-person assist. CNA 2 stated she knew other staff were assisting the resident without another person assisting.
On 10/22/24 at 0915 hours, a concurrent interview and medical record review for Resident 18 was conducted with the Case Manager. The Case Manager verified Resident 18's quarterly MDS for sitting to stand, sit to stand and transfer for maximal assistance which needed two-person assist. The Case Manager stated he assessed the resident, interviewed staff, and reviewed the rehabilitation notes to develop the care plan for ADL needs. The Case Manager acknowledged the care plan was developed in the beginning of the 2024 and verified Resident 18 needed two-person assist for transfers. The Case Manager verified the findings.
On 10/23/24 at 0920 hours, a concurrent interview and medical record review was conducted with the Director of Rehabilitation. The Director of Rehabilitation stated Resident 18 had the right knee osteoarthritis and right knee weakness. The Director of Rehabilitation further stated the resident had decreased tolerance to activity. The Director of Rehabilitation verified Resident 18 needed two-person assist for transfers since admission.
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 interview, medical record review, and facility P&P review, the facility failed to ensure the timely intervention for on...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure the timely intervention for one of three final sampled residents (Resident 22) reviewed for weight loss.
* Resident 22 experienced a 5.32% weight loss in one month. There was no assessment from nutritional services, RD intervention, care plan, and notification to the MD and family regarding the weight loss. This failure had the potential to result in continued nutritional decline and negative outcomes.
Findings:
Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.18.11 dated 10/2023 showed if a resident is losing a significant amount of weight, the facility should not wait for the 30- or 180-day timeframe to address the problem. Weight changes of 5% in 1 month, 7.5% in 3 months, or 10% in 6 months should prompt a thorough assessment of the resident's nutritional status.
Review the facility's P&P titled Weight Management Guidelines revised 2/2022 showed a weight change is significant per RAI manual definition with a weight loss of 5% and/or 5# in one month. The P&P also showed the following tasks at the time of identification of weight loss:
- A Nutrition at Risk Review should be completed and should be initiated by the Dietary Manager and completed and assessed by the Dietitian.
- Nursing should notify the physician and family of significant weight loss.
- Weight loss should be care planned and have nutritional goals and approaches.
Medical record review for Resident 22 was initiated on 10/21/24. Resident 22 was admitted on [DATE].
Review of Resident 22's Weights and Vitals Summary dated 10/21/24, showed the following weights:
- On 5/3/24, 100 lbs
- On 6/3/24, 97 lbs
- On 7/3/24, 98 lbs
- On 8/1/24, 96 lbs
- On 9/3/24, 94 lbs
- On 10/2/24, 89 lbs (a -5.32 % and 5 lbs weight loss from 9/3/24)
Review of Resident 22's medical record failed to show an assessment from nutritional services or RD intervention was completed after the weight loss was identified. Further review of Resident 22's medical record failed to show a care plan for weight loss was initiated and the MD/family were notified of the significant weight loss.
On 10/24/24 at 1508 hours, a concurrent interview and medical record review was conducted with RN 2 and LVN 1. RN 2 stated the RNAs took the weights and reported weight changes to the DON and charge nurses. If there was a weight loss, the meal percentages would be checked. If the dietary intake was poor, the MD would be notified and asked for medications to increase appetite. RN 2 further stated the RNA would report the significant weight changes of five lbs in a week or month to the charge nurse or RN. Then, the RN would notify the physician, put the change of condition for three days, and document the oral intake. RN 2 stated the new admitted residents would be weighed weekly for four weeks and then monthly. LVN 1 stated the interventions would be documented in the change of condition and the resident was monitored for 72 hours. The nurses used a communication board on the electronic health record system to document changes of condition, weight loss changes and to alert the RD of a change. The care plan was also updated to reflect the weight loss. RN 2 and LVN 1 both confirmed there was no care plan in place for weight loss nor was there a progress note to document the MD or family was notified for Resident 22's weight loss. RN 2 and LVN 1 further verified a change of condition was not initiated for Resident 22.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the accurate reconciliat...
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Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to provide the pharmaceutical services to ensure the accurate reconciliation and disposal of medications.
* The facility failed to ensure the count performed for all controlled medications in the Omnicell (automatic drug delivery system) as per the facility's P&P. This failure posed the risk for diversion of medications.
Findings:
Review of the facility's P&P titled Automatic Drug Delivery Systems (ADDS) CA- Omnicare revised 2022 showed the following:
- The Pharmacy tracks the AADS and generates complete and accurate user records of all transactions including all medications and other inventory added to or removed from the ADDS.
- Authorized facility shall count each controlled substance and verify their count against the count according to the ADDS system.
- The two authorized facility stall will each sign the ADDS daily temperature and cycle count log after the cycle count is completed.
On 10/23/24 at 1620 hours, and interview was conducted with Pharmacy Staff 1. When Pharmacy Staff 1 was asked how the nurses verified the count for the controlled narcotics (class II-class VI medications) in the Omnicell, Pharmacy Staff 1 stated that the nurses were to conduct an Omnicell count at least daily. When Pharmacy Staff 1 was asked what the meaning of the Cycle-Count Non-Compliant Report was, he stated the facility was not compliant because there was a discrepancy when the controlled medications were checked.
On 10/23/24 at 1448 hours, a concurrent facility documents review and interview was conducted with the DON. Review of the facility document titled ADDS Daily Temperature and Cycle Log dated September 2024 and October 2024 with the DON regarding the Omnicell was conducted. When the DON was asked how the medications in the Omnicell were accounted for, the DON stated the night shift nurses were only counting the controlled medications categorized as touched. The DON stated if the controlled medications were not touched on the day of the count, the nurses did not have anything to account for. However, the log showed the controlled medications were reconciled from 7 AM-7 PM, and 7 PM-7 AM daily. When the DON was asked why the Cycle Count log showed, non-compliant, the DON stated and verified it was because the facility was not compliant with counting the controlled medications daily. The DON verified the findings.
Review of the facility document titled Cycle Count Non-Compliant Report dated 10/23/24 at 0600 hours, showed the following medications were listed:
- acetaminophen-cod #3 tablet (treats mild to moderate pain) with the last cycle counted on 9/17/24.
- alprazolam 0.25 mg tablet (treats anxiety and panic disorder) with the last cycle counted on 10/2/24.
- hydrocodone-acetaminophen 10-325 mg tablet (treats severe pain) with the last cycle counted on 9/11/24.
- hydrocodone-acetaminophen 7.5-325 mg tablet (treats severe pain) with the last cycle counted on 10/1/24.
- hydromorphone 2 mg tablet (treats pain) with the last cycle counted on 7/12/24.
- lorazepam 0.5 mg (treats anxiety) with the last cycle counted on 7/12/24.
- lorazepam 1 mg tablet (treats anxiety) with the last cycle counted on 10/6/24.
- morphine Sulfate ER 15 mg tablet (pain medication with extended release) with the last cycle counted on 8/14/24.
- morphine Sulfate IR 15 mg tablet (pain medication with immediate release) with the last cycle counted on 8/14/24.
- oxycodone immediate 5 mg tablet (pain medication with immediate release) with the last cycle counted on 10/15/24.
- oxycodone-acetamin 5-325 mg tablet (treats mild to moderate pain medication) with the last with the cycle counted on 10/15/24.
- oxycodone-acetamin 10-325 mg tablet (treats moderate to severe medication) with the last cycle counted on 7/12/24.
- oxycontin ER 10 mg tablet (moderate to severe pain) with the last cycle counted on 7/12/24.
- pregabalin 50 mg capsule (treats nerve pain, prevents seizures) with the last cycle counted on 10/15/24.
- pregabalin 75 mg capsule (treats nerve pain, prevents seizures) with the last cycle counted on 10/15/24.
- temazepam 15 mg capsule (controlled medication to treat inability to sleep) with the last cycle counted on 10/15/24.
- temazepam 7.5 mg capsule ( controlled medication to treat inability to sleep) with the last cycle counted on 7/12/24.
- tramadol HCL 50 mg tablet (treats moderate to severe pain) with the last cycle counted on 8/14/24.
- zolpidem tartrate 5 mg tablet (controlled medication to treat inability to sleep) with the last cycle counted on 9/18/24.
On 10/24/24 at 1615 hours, an interview and concurrent document review was conducted with the DON. The DON was informed and verified the findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 12) was properly monitored for the stool softener medications. This failure had the potential to negatively impact the resident's health condition.
Findings:
Review of the facility's P&P titled Medication Administration revised 11/16/23, showed the following:
- The facility policy regarding medication administration in accordance with Applicable law and the State Operations Manual when administering medications.
- The licensed nurse should confirm the MAR reflects the most recent medication order.
Medical record review for Resident 12 was initiated on 10/21/24. Resident was admitted to the facility on [DATE].
Review of Resident 12's Order Summary Report dated 9/29/24, showed Colace 100 mg (stool softener) one capsule by mouth two times a day for bowel management and to hold for loose stool.
On 10/22/24 at 0916 hours, a medication administration observation of Resident 12 was conducted with LVN 2. LVN 2 administered Colace to Resident 12 without inquiring if the resident was having any loose stools.
On 10/22/24 at 1349 hours, an interview was conducted with LVN 2. When asked about the process of administering stool softeners, LVN2 stated the facility would print out a list of all the residents with loose stool. When asked for the list, LVN2 stated it was not given to her today. LVN 2 was asked if she checked the point click care dashboard to assess for Resident 12's stool pattern, she stated no. LVN 2 was asked if she checked what the resident stool pattern was with the CNA today, she stated no. LVN 2 verified she did not check if the resident had loose stools prior to administering the medication.
On 10/24/24 at 1615 hours, an interview and concurrent medical record review was conducted with the DON. The DON was informed and verified the findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of five final sampled residents (Resident 25) reviewed for unnecessary medications was free from the unnecessary psychotropic medications (medication that affects the mind, emotions, and behavior). This failure had the potential for Resident 25 to have adverse complications from the medication.
Findings:
Review of the facility's P&P titled Antipsychotic Medication and Informed Consent Policy updated June 2024 showed antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavior symptoms have been identified and addressed. The policy interpretation and implementation include among others the following:
- The attending physician and other staff will gather and document information to clarify a resident's behavior, mood function, medical condition, specific symptoms, and risks to the residents and others;
- Diagnoses alone do not warrant the use of antipsychotic medication. The antipsychotic medication will generally only be considered if behavioral interventions have been attempted and included in the plan of care;
- Pertinent non-pharmacological interventions must be attempted.
Medical record review for Resident 25 was initiated on 10/24/24. Resident 25 was admitted to the facility on [DATE]. Resident 25 had diagnoses including Parkinson's disease (a chronic brain disorder that causes movement problems and mental health issues) and unspecified dementia (a chronic condition that causes a gradual decline in cognitive abilities, such as thinking, remembering and reasoning).
Review of Resident 25's Order Note dated 10/9/24, showed an obtained clarification of manifestation for Nuplazid (antipsychotic medication) 34 mg tablet by mouth for psychosis (a condition that causes a person to lose touch with reality) related to Parkinson's disease manifested by paranoid ideation (a pattern of thinking characterized by persistent feelings of suspicion and distrust).
Review of Resident 25's MAR for October 2024 failed to show for behavioral monitoring of the episodes for paranoid ideation. There was no documented evidence of any non-pharmacological interventions provided for Resident 25.
Review of Resident 25's progress notes for the months of September and October 2024 failed to show documentation regarding Resident 25's manifestation of paranoid ideation.
Further review of Resident 25's care plan problems addressing the use of Nuplazid medication failed to show it was for the manifestation for paranoid ideation and documentation of interventions for the nonpharmacological implementation for the use of the Nuplazid medication.
On 10/24/24 at 1004 hours, a concurrent interview and medical record review was conducted with the DON. The DON stated Resident 25 was ordered Nuplazid on 10/9/24, for psychosis related to Parkinson's disease manifested by paranoid ideation. However, the DON was unable to show documentation of Resident 25's episodes of paranoid ideation. Furthermore, the DON was unable to find any monitoring of episodes and documentation for the nonpharmacologic intervention provided to Resident 25. The DON also verified there was no care plan for the use Nuplazid medication for psychosis related to Parkinson's disease manifested by paranoid ideation.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed ensure proper storage and label of medications in Medication Cart 1 and medication storage room when:
* Resident 7's eye drop medication in Medication Cart 1 was not kept in the refrigerator as per the medication instruction.
* Resident 22's cough medication was stored with the topical ointment medication in Medication Cart 1.
* Resident 686's inhalation medication in Medication Cart 1 was not labeled with an opened date as per the facility's policy .
* The bottom drawer of Medication Cart 1 was not kept clean and free from spill residue.
* The expired medication was stored in the medication storage room.
In addtion, the licensed nurse left the medications for Resident 27 unattended while performed other tasks.
These failures had the potential for the medications misuse, medication ineffectiveness, and potential exposure to harmful pathogens (bacteria, viruses, fungi) from expired medications for the residents.
Findings:
Review of the facility's P&P titled Storage and Expiration Dating of Medications, Biologicals, Syringes, and Needles revised on 8/1/24, showed the following:
- Facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding.
- Facility should ensure that external use medications and biologicals are stored separately from internal use medications and biologicals.
- Topical (external) use medications or other medications should be stored separately from oral medications when infection control issues may be a consideration.
- Medications with a manufacturer's expiration date expressed in month and year will expire on the last day of the month.
Review of the facility's P&P titled Medication Administration Revised 11/16/23, showed the following:
- Licensed Nurse should enter the date opened on the label of medications with shortened expiration dates.
- Licensed Nurse should not leave medications or chemicals unattended.
1. On 10/22/24 at 0850 hours, a medication observation was conducted with LVN 2. A bottle of aspirin (blood thinner) 81 mg was observed without an open date in Medication Cart 1.
On 10/22/24 at 1403 hours, a medication cart inspection for Medication Cart 1 was conducted with LVN 2. The following was observed:
- One opened box of latanoprost 0.005% (treats glaucoma and high eye pressure) eye drops for Resident 7 was placed in a plastic bag which had instructions to refrigerate until opened. The latanoprost eye drops were kept in the top drawer of the medication cart. LVN 2 verified the medication was to be stored in the refrigerator.
- One guaifenesin DM (cough medication) 10-100 mg/5 ml oral solution bottle for Resident 22 was placed in the bottom drawer of Medication Cart 1 along with topical ointment cream: Diclofenac (treats pain) 1%.
- One opened box of ipratropium-albuterol (used for difficulty breathing) inhalation aerosol 0.5-3 mg/3 ampoule for Resident 686 was observed without an open date.
- The bottom drawer of Medication Cart 1 was observed with paper lining stained with green residue and dried medication debris.
LVN 2 verified the above findings.
2. On 10/23/24 at 1039 hours, an observation and concurrent inspection of the Medication Storage Room was conducted with the DON and RN 1. One bottle of aspirin EC (blood thinner) 325 mg was observed with the expiration date 1/2024. The DON and RN 1 verified the findings.
3. On 10/23/24 at 0833 hours, a medication administration observation for Resident 27 was conducted with LVN 1. LVN 1 was observed leaving two eye drop medication bottles: brimonidine tartrate (treats glaucoma) solution 0.1% and dorzolamide HCL-Timolol Mal PF (treats glaucoma) Ophthalmic solution 22.3-6.8 mg/ml unattended on Resident 27's overhead table to wash her hands in the bathroom. At 0836 hours, LVN 1 was observed for the second time stepping out of Resident 27's room and leaving the two eye drops (brimonidine tartrate and dorzolamide HCL) unattended on Resident 27's overhead table to call for assistance.
Medical record review was was intiated for Resident 27 on 10/21/24. Resident 27 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 27's Order Summary Report dated 10/23/24, showed a physician's orders as follows:
- brimonidine tartrate solution 0.1% instill one drop in the left eye two times a day for glaucoma.
- dorzolamide HCL-Timolol Mal PH ophthalmic solution 22.3-6.8 mg/ml (dorzolamide HCL-timolol maleate) instill one drop in both eyes two times a day for glaucoma.
On 10/23/24 at 1421 hours, an interview was conducted with LVN 1. LVN 1 acknowledged Resident 27's eye drops were left unattended. When asked where Resident 27's eye drops were when she stepped out of the room, LVN 1 stated she left them unattended at Resident 27's overhead table.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected 1 resident
Based on interview and facility document review, the facility failed to ensure the DSS who was responsible to oversee the satellite kitchen which produced food for the skilled nursing facility was qua...
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Based on interview and facility document review, the facility failed to ensure the DSS who was responsible to oversee the satellite kitchen which produced food for the skilled nursing facility was qualified in managing the day-to-day functions of the food services department. This failure had the potential to negatively affect the health and well-being of 42 residents who received the food prepared in the kitchen.
Findings:
Review of the facility's matrix showed 42 residents who consumed food prepared in the kitchen.
According to the California Code, Health, and Safety Code - HSC § 1265.4, a licensed health facility shall employ a full-time, part-time, or consulting dietitian. A health facility that employs a registered dietitian less than full time, shall also employ a full-time dietetic services supervisor who meets the requirements of subdivision (b) to supervise dietetic service operations.
On 10/23/24 at 0802 hours, an interview was conducted with the DSS. The DSS stated she was responsible to manage the SNF satellite kitchen. The DSS stated the food for the SNF residents was prepared in the main kitchen and transported to the SNF. The DSS stated the main kitchen was managed by the executive chef. The DSS stated the RD was employed part-time and would work two days a week.
During the recertification survey from 10/21/24 to 10/24/24, multiple issues were found in the main kitchen and satellite kitchen, including kitchen utensils and equipment were not clean and in good working condition, kitchen equipment not cleaned and dried properly, and failure to ensure there was an air gap for a juice machine.
Review of the facility's documents for qualifications of the DSS failed to show evidence she met the qualifications under the California Code, Health and Safety Code - HSC § 1265.4.
On 10/23/24 at 1400 hours, an interview was conducted with the Administrator. The Administrator acknowledged the above findings.
Cross references to F812 examples #1, #2, and #3.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to ensure the food allergy item was not serve...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to ensure the food allergy item was not served to one of 14 final sampled Residents (Resident 27). This failure had the potential for the resident's medical complication.
Findings:
Medical record review of Resident 27 was initiated on 10/21/24. Resident 27 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 27 Dietary Communication dated 4/12/24, showed the resident had allergies to cucumber.
On 10/21/24 at 1210 hours, Resident 27 was observed eating his lunch independently and was served cucumber in his main plate.
On 10/21/24 at 1230 hours, an interview and concurrent diet card review was conducted with the Dietary Service Supervisor. The DSS was asked if the resident had allergies to cucumber. The DSS stated yes and asked why the resident was served with the cucumber. The DSS stated, I will replace it now. The DSS verified the findings.
On 10/24/24 at 1457 hours, an interview was conducted with Resident 27. Resident 27 stated he had allergy with cucumber and if he ate it, he would throw up and got sick.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected 1 resident
Based on interview, facility document review, and facility P&P review, the facility failed to ensure the education was provided to the staff and family/visitors on safe food handling of outside food. ...
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Based on interview, facility document review, and facility P&P review, the facility failed to ensure the education was provided to the staff and family/visitors on safe food handling of outside food. This failure had the potential to cause foodborne illnesses to the medically vulnerable resident population who consumed food brought from outside sources.
Findings:
Review of CMS S&C-09-39 dated 5/29/09, showed the residents have the right to choose to accept food from visitors, family, friends, or other guests according to their rights to make choices. The CMS guideline further showed the facility has the responsibility under the food safety regulation to help the visitors to understand safe food handling practices such as not holding or transporting foods containing perishable ingredients at temperatures above 41 degrees Fahrenheit.
Review of the facility's P&P titled Foods Brought by Family/Visitors revised 11/16/21, showed the food brought by the visitors and family is permitted. The facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. The family/visitors are asked to prepare and transport food using safe food handling practices.
On 10/23/24 at 0802 hours, an interview and concurrent medical record review was conducted with the DSS. The DSS was about her role when the food was brought from the outside for the residents to consume. The DSS stated she educated the residents, responsible parties, and visitors regarding how long the food would be kept in the refrigerator at the facility. When asked about the education provided to the visitors and responsible party regarding the safe food handling practices, the DSS stated she instructed the family/visitors to ensure for proper cool down of food intended for storage. When asked about the specifics of the education provided, the DSS stated she did not address for the proper cooking and cooling temperatures of the foods. When asked if she provided the family/visitors with any literature regarding safe food handling practices, the DSS stated she did not.
On 10/23/24 at 0827 hours, an interview and concurrent facility document review was conducted with the DSD/IP. When asked about the education/in-services were provided to the staff regarding safe food handling practices, the DSD/IP stated she reminded staff to ensure the food items were labeled properly and they were appropriate according to the resident's diet. The DSD/IP stated she only provided in-services to the CNAs and not the licensed staff regarding outside food policy. The DSD/IP stated she did not provide education to the staff regarding safe food handling practices for the preparation of food or educate about safe cooking and cooling temperatures. The DSD/IP stated the licensed staff reheat food for the residents.
On 10/23/24 at 1411 hours, an interview was conducted with LVN 2. When asked about what education she provided to the resident's family regarding the food brought from outside, LVN 2 stated she did not provide education to the visitor/responsible party about safe food handling practices. LVN 2 stated reheating of the food was done by the cooks in the kitchen and not the licensed staff or aides.
On 10/24/24 at 1500 hours, the Administrator, DON, and DSS were informed and acknowledged the above findings.
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, medical record review, and facility P&P review, the facility failed to provide the necessary care and servic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to provide the necessary care and services for one of 14 final sampled residents (Resident 22) reviewed for hospice services.
* The facility failed to ensure Resident 22 received hospice aide visit one time per week as ordered by the physician.
* The facility failed to ensure the hospice log showed documentation regarding the CHHA visit.
* The facility failed to ensure the hospice RN was included in Resident 22's Care Conference/Care Plan Meeting on 9/27/24.
These failures had the potential for not providing necessary care and services to the resident recievieng hospice services.
Findings:
Review of the facility's P&P titled Hospice Services revised 11/16/24, showed the following:
- Hospice providers who contract with this facility are held responsible for meeting the same professional standards and timelines of service as any contracted individual or agency associated with the facility.
- In general, it is the responsibility of the hospice to manage the resident's care as it relates to the terminal illness and related conditions including changing the level of services provided when it is deemed appropriate.
- In general, it is the responsibility of the facility to meet the resident's the resident's personal care and nursing needs in coordination with the hospice representative and ensure that the level of care provided is appropriately based on the individual resident's needs. This includes communicating with the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day.
Medical record review for Resident 22 was initiated on 10/21/24. Resident 22 was admitted to the facility on [DATE].
Review of Resident 22's Physician Order Summary Report dated 10/24/24, showed SN visits 2x/week (two visits a week), CHHA 1x/week, SW and SC for evaluation.
On 10/24/24 at 0338 hours, an interview and concurrent facility document review was conducted with the DON. Review of the document titled California Hospice Proposed calendar visit Schedule dated September and October 2024, showed there were no visitations from a CHHA. When the DON was asked if the CHHA's signature should be reflected on the visitation schedule, she stated yes. The DON verified the CHHA visit was to be once a week.
In addition, review of the document titled California Hospice Interdisciplinary Note and Vital dated 3/19/24 to 10/17/24, showed the visits were completed by a CHHA and was documented on 5/8, 5/14, and 5/22/24. The DON verified there was no additional visits completed by the CHHA on the California Hospice Interdisciplinary Notes and Vitals from 3/19/24 to 10/17/24.
Further review of the IDT Note dated 9/27/24, showed the Hospice Case Manager was unable to attend the meeting and would be calling the POA. Review of the Care Conference sign-in sheet dated 9/27/24, showed the hospice was unable to attend the meeting and would call the POA. Review of the document failed to show the hospice's involvement in Reside 27's care conference.
On 10/24/24 at 1538 hours, the DON was informed and verified the above findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility documentation review, the facility failed to ensure the QA ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility documentation review, the facility failed to ensure the QA committee identified and developed action plans to address the focused areas from the last recertification survey. The QA committee failed to have documented evidence to show they identified and developed action plan to correct the identified concern of the respiratory care and medication storage. This failure had the potential to result in residents at risk for possible infection and causing adverse side effects for expired medication.
Findings:
Review of the facility's previous recertification survey completed on [DATE], showed the following deficient practices were cited: respiratory care (F695) and medication storage (F761). These deficient practices were the repeated deficient practices cited during this Recertification Survey.
During the QAA interview with the Administrator and DON on [DATE] at 1320 hours, the DON was asked how the QAA committee identified current and ongoing issues for actions to improve care and performance related to respiratory care and medication storage. The DON stated for the respiratory care, the CNAs were trained to label the respiratory tubings or equipment, dated, and put them in the bag. They changed the tubing on Sundays. When asked about the documentation, the DON was unable to provide the documentation. The DON was asked for the medication strorage improvement performance process. The DON stated the charge nurse checked the medication chart and medication storage room daily every shift. The DON was asked to provide the log or documentation; the DON was unable to provide the documentation. The DON verified the findings.
On [DATE] at 1431 hours, an interview was conducted with LVN 3. LVN 3 stated he would check his medication chart once a week but not daily. LVN 3 stated he only check the morning medication that he would administer and not checking the whole cart.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Handwashing/Hand Hygiene revised 11/16/23, showed the following:
- All personnel shall fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Handwashing/Hand Hygiene revised 11/16/23, showed the following:
- All personnel shall follow the hand washing/ hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors; and
- Wash hands by scrubbing for twenty seconds using soap and water for the following situations:
a. Before direct contact with a resident.
b. Before preparing or handling medications.
c. After removing gloves.
Medical record review for Resident 27 was initiated on 10/21/24. Resident 27 was admitted to the facility on [DATE], and readmitted on [DATE].
On 10/23/24 at 0840 hours, a medication pass observation for Resident 27 was conducted with LVN 1. LVN 1 was observed administering eye drops to Resident 27. Following the administration of the eyedrops to Resident 27, LVN 1 doffed her gloves and put into the trash can and did not perform hand hygiene before proceeding to put on a new pair of gloves.
On 10/23/24 at 0842 hours, LVN 1 was observed washing her hands in the bathroom. LVN 1 then handed the television remote and call light to Resident 27's roommate. LVN 1 donned the new gloves without performing hand hygiene after touching the TV remote and call light of Resident 27's roommate, to administer the medications to Resident 27.
On 10/23/24 at 1421 hours, an interview was conducted with LVN 1. When LVN 1 was asked about hand hygiene after instilling eyedrops to Resident 27 and doffing gloves, LVN 1 verified hand hygiene should have been completed before donning the new gloves. Furthermore, when LVN 1 was asked if she should have conducted hand hygiene after touching the remote control and call light of Resident 27's roommate, LVN 1 verified hand hygiene should have been conducted before resuming care for Resident 27.
Based on observation, interview, medical record review, facility document review, and facility P&P review, the facility failed to implement the safe and sanitary environment to help prevent the development and transmission of infection when:
* The facility failed to maintain the accurate infection surveillance program for September and October 2024.
* The facility failed to ensure the infection control practices were implemented in the facility's laundry room.
* The facility failed to ensure the licensed nurse (LVN 1) performed hand hygiene in between changing gloves during the medication administration observation for Resident 27.
* The facility failed to ensure Foley catheter care for Resident 686 was done in the safe and sanitary manner.
These failures posed the risk for not identifying the residents' infections and thereby, preventing the implementation of interventions to control the potential transmission of communicable diseases to other residents in the facility. In addition, these failures posed the risk for transmission of disease-causing microorganisms.
Findings:
1. Review of the facility's P&P titled Infection Prevention and Control Guidelines revised 11/16/23, showed guidelines for general infection prevention and control for caring for resident includes methods of preventing their spread and how to recognize and report signs and symptoms of infection. Standard precautions will be used in care of residents regardless of suspected or confirmed presence of infectious disease.
Review of CDC's Core Infection Prevention Practices for Safe Healthcare Delivery in All Settings dated 4/12/24, showed the following:
- Identify and monitor adherence to infection prevention practices and infection control requirements; and
- Monitor the incidence of infections that may be related to care provided at the facility and act on data and use information collected through surveillance to detect transmission of infectious agents in the facility.
a. Review of the Infection Surveillance Report for the week 8/30/24 to 9/5/24, showed Resident 20 was on ciprofloxacin 500 mg (an antibiotic medication) for urinary tract infection for five days.
Medical record review for Resident 20 was initiated on 10/23/24. Resident 20 was admitted to the facility on [DATE].
However, review of Resident 20's Infection Screening Evaluation dated 8/25/24, under the Infection Analysis section, showed Resident 20 met the Mcgeer's Criteria (criteria for definitive infection) for gastroenteritis (an inflammation of the stomach), not urinary tract infection as per the Infection Surveillance Report.
b. Review of the Infection Surveillance Report for the week 9/20/24 to 9/26/24, showed Resident 9 was on azithromycin 250 mg (an antibiotic medication) for cough for five days.
Medical record review for Resident 9 was initiated on 10/23/24. Resident 9 was readmitted to the facility on [DATE].
Review of Resident 9's Infection Screening Evaluation dated 9/19/24, under the Infection Analysis section, showed the section for the criteria was not marked to show whether Resident 9's infection met the criteria for true infection or not.
c. Review of the Infection Surveillance Report for the week of 10/4/24 to 10/10/24, showed Resident 945 was on doxycycline 100 mg (an antibiotic medication) for an unknown infection for 10 days.
Medical record review for Resident 945 was initiated on 10/23/24. Resident 945 was admitted to the facility on [DATE].
Review of Resident 945's Infection Screening Evaluation dated 10/1/24, under the Infection Analysis section, showed Resident 945 met the Loeb's Criteria (a set of minimum signs and symptoms that indicate a resident is likely to have an infection and may need antibiotics) for suspected skin and soft tissue infection and the McGeer's Criteria for soft tissue or wound infection.
d. Review of the Infection Surveillance Report for the week of 10/4/24 to 10/10/24, showed Resident 25 was on Augmentin 100-125 mg (an antibiotic medication) for pneumonia for seven days.
Medical record review for Resident 25 was initiated on 10/23/24. Resident 25 was admitted to the facility on [DATE].
However, review of Resident 25's Infection Screening Evaluation dated 10/5/24, under the Infection Analysis section, showed Resident 25 met the McGeer's Criteria for gastroenteritis, not pneumonia as per the Infection Surveillance Report.
On 10/23/24 at 1356 hours, an interview and concurrent facility document review was conducted with the DSD/IP and RN 1/IP. Both verified the above findings. The DSD/IP confirmed the Infection Control Surveillance should be accurate because it showed the information readily available to report to their weekly Infection Control meeting. Both confirmed some of the McGeer's Criteria forms were inaccurate and not completed.
Cross reference to F881, examples #1, #2 and #3.
2. On 10/21/24 at 1154 hours, an inspection of the laundry area and concurrent interview with the Director of Housekeeping was conducted. The following was observed:
- Radio and charger observed on top of the folding area touching the clean linen.
- Folded staff sweater and hat observed on top of the folding area, blue mesh bags (used for clean clothes) were observed on top of the sweater and hat.
- Clean clothes observed touching the staff sweater, hat, and the radio.
The Director of Housekeeping verified the above findings.
3. Medical record review for Resident 686 was initiated on 10/24/24. Resident 686 was admitted to the facility on [DATE].
Review of Resident 686's H&P examination dated 10/14/24, showed Resident 686 could make her needs known.
On 10/24/24 at 0950 hours, an observation and concurrent interview for Resident 686 was conducted with CNA 1. CNA 1 was observed emptying the urine from Resident 686's urinary catheter drainage bag into Resident 686's urinal. CNA 1 was then observed putting the tip of Resident 686 urinary catheter tubing back into the end-port without cleaning the tip. CNA 1 was then observed rinsing out Resident 686's urinal with water. Furthermore, CNA 1 was observed storing Resident 686's urinal on a wall wire shelf next to the toilet used by Resident 686's roommate. When asked about cleaning the tip of Resident 686's urinary catheter tubing after draining the urine, CNA 1 stated sometimes she wiped off the tip before returning it to the valve. CNA 1 verified she did not wipe the tip. When asked about keeping Resident 686's urinal clean, CNA 1 verified she rinsed out the urinal with water. CNA 1 verified she stored Resident 686's urinal on a wire shelf next to the toilet used by Resident 686's roommate.
On 10/24/24 at 1128 hours, an interview was conducted with the DSD. When asked about what to do after draining urine from a resident's urinary catheter bag, the DSD stated the staff should clean the urine catheter tubing tip after draining urine, and the urinal should be washed with soap and water.
Review of Resident 686's October 2024 Order Summary Report showed Resident 686 had a physician's order dated 10/14/24, for urinary catheter for urinary retention.
According to www.myhealth.ucsd.edu, after draining urine from a urinary catheter bag, the tip of the drainage valve is to be cleaned with an alcohol wipe.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, facility document, and facility P&P review, the facility failed to implement the antibiotic stewardship prog...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, facility document, and facility P&P review, the facility failed to implement the antibiotic stewardship program.
* The facility failed to ensure the appropriate use of antibiotics for one final sampled resident (Resident 25) and two nonsampled residents (Residents 9 and 20). This failure had the potential for inappropriate use and increased risk of drug resistant organisms.
Findings:
According to the CDC, the antibiotics are among the most frequently prescribed medications in nursing homes, with up to 70% of residents in a nursing home receiving one or more courses of systemic antibiotics over a year. Studies have shown that 40-75% of antibiotics prescribed in nursing homes may be unnecessary or inappropriate. Harms from antibiotic overuse are significant for the frail and older adults receiving care in nursing homes. These harms include risk of serious diarrheal infections from Clostridium difficile, increased adverse drug events and drug interactions, and colonization and/or infection with antibiotic-resistant organisms.
Review of the facility's P&P titled Antibiotic Stewardship Program - Review and Surveillance revised on 11/16/23, showed the IP or designee will review the antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics.
1. Review of the Infection Surveillance Report for the week of 8/30/24 to 9/5/24, showed Resident 20 was on ciprofloxacin 500 mg (an antibiotic medication) for urinary tract infection for five days.
Medical record review for Resident 20 was initiated on 10/23/24. Resident 20 was admitted to the facility on [DATE].
Review of Resident 20's Infection Screening Evaluation dated 8/25/24, under the Infection Analysis section, Resident 20 met the Mcgeer's Criteria for gastroenteritis (an inflammation of the stomach).
However, review of Resident 20's medical record did not show documented evidence the physician was informed the resident did not meet the Mcgeer's Criteria for urinary tract infection.
2. Review of the Infection Surveillance Report for the week 9/20/24 to 9/26/24, showed Resident 9 was on Azithromycin 250 mg (an antibiotic medication) for cough for five days.
Medical record review for Resident 9 was initiated on 10/23/24. Resident 9 was readmitted to the facility on [DATE].
Review of Resident 9's Infection Screening Evaluation dated 9/19/24, under the Infection Analysis section, showed the section for the criteria was not marked to show whether Resident 9's infection met the criteria for true infection or not.
Review of the Infection Surveillance Report for the week 9/20/24 to 9/26/24, showed Resident 9 was on azithromycin 250 mg (an antibiotic medication) for cough for five days.
3. Review of the Infection Surveillance Report for the week 10/4/24 to 10/10/24, showed Resident 25 was on Augmentin 100-125 mg (an antibiotic medication) for pneumonia for seven days.
Medical record review for Resident 25 was initiated on 10/23/24. Resident 25 was admitted to the facility on [DATE].
Review of Resident 25's Infection Screening Evaluation dated 10/5/24, under the Infection Analysis section, showed Resident 25 met the McGeer's Criteria for gastroenteritis.
Furthermore, medical record review for Resident 20 did not show documented evidence the physician was informed that the resident did not meet the Mcgeer's Criteria for pneumonia.
On 10/23/24 at 1356 hours, an interview and concurrent facility document review was conducted with the DSD/IP and RN 1/IP. Both verified the above findings. The DSD/IP stated the facility should have notified the physician if the residents did not meet the criteria or obtain clarification for the use of antibiotics.
On 10/24/24 at 1615 hours, the Administrator and DON acknowledged the above findings.
Cross reference to F880, examples #1.a, b, and d.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and the facility P&P review, the facility failed to ensure two of 14 final sampled re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and the facility P&P review, the facility failed to ensure two of 14 final sampled residents (Residents 4 and 25) were offered the influenza vaccine (vaccine given to protect the resident from influenza disease) and pneumococcal vaccine (a vaccine given to protect the resident from pneumococcal disease) when the residents were eligible to receive in accordance with the current CDC's guidelines and recommendations. This posed the risk of Residents 4 and 25 acquiring influenza and pneumonia.
Findings:
Review of the facility's P&P titled Immunization revised 11/16/23, showed immunization policy is to offer influenza and pneumococcal to residents and staff, in accordance with CDC and CDPH regulations and recommendations to reduce mortality and morbidity. Under the Procedure section, the residents and staff will be informed regarding the risks and benefits and potential side effects associated with the vaccine.
1. Medical record review for Resident 4 was initiated on 10/23/24. Resident 4 was originally admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 4's H&P examination dated 9/30/24, showed Resident 4 had no capacity to make medical decisions.
Review of Resident 4's Pneumococcal Vaccine consent form showed the consent and decline to receive the pneumococcal vaccine sections were both blank.
Review of Resident 4's Pneumococcal Vaccine consent showed the PCV 13 vaccination was received on 7/12/18, per the CAIR report.
On 10/23/24 at 1356 hours, an interview and concurrent medical review was conducted with the DSD/IP and RN 1/IP. The DSD/IP and RN 1/IP both verified the above findings. The DSD/IP stated Resident 4 was offered PPV 23 on 12/2/23; however, Resident 4 refused the pneumococcal vaccine. The DSD/IP and RN 1/IP were unable to provide documentation for Resident 4's refusal. Furthermore, both DSD/IP and RN 1/IP were unable to provide documentation for the risk and benefits and potential side effects associated with the vaccine were discussed with Resident 4 or the resident's representative.
2. Medical record review for Resident 25 was initiated on 10/23/24. Resident 25 was admitted to the facility on [DATE].
Review of Resident 25's H&P examination dated 10/22/24, showed Resident 25 had no capacity to make medical decisions.
Review of Resident 25's Influenza Vaccine consent signed by the resident on 10/19/23, showed an X mark for the declination to receive the influenza vaccine during the flu season from September 1 through April 1 due to the reason that Resident 25 did not take flu vaccine.
Review of Resident 25's Pneumococcal Vaccine consent signed by the resident on 10/19/23, showed an X mark for the declination to receive the pneumococcal vaccine due to the reason that Resident 25 did not take the pneumonia vaccine.
Review of Resident 25's Progress Note dated 8/27/24, showed the flu vaccine was offered but Resident 25 needed more time to think about it.
On 10/23/24 at 1356 hours, an interview and concurrent medical review was conducted with the DSD/IP and RN 1/IP. Both verified the above findings. The DSD/IP stated Resident 25 refused both the pneumococcal and influenza vaccines. Furthermore, both the DSD/IP and RN 1/IP were unable to provide documentation the risk and benefits and potential side effects associated with the vaccines were discussed with Resident 25 or the resident's representative.
On 10/24/24 at 1615 hours, the Administrator and DON acknowledged the above findings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based on interview, facility document review, and facility' P&P review, the facility failed to maintain the safe operating conditions.
* The facility failed to maintain the essential temperature logs...
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Based on interview, facility document review, and facility' P&P review, the facility failed to maintain the safe operating conditions.
* The facility failed to maintain the essential temperature logs for the safe operating conditions of the Omnicell Anatomic Drug Dispensing system. This failure had the potential for the equipment to not function in the way intended, which could negatively affect the residents' medications.
Findings:
Review of the facility's P&P titled Storage and Expiration Dating of Medications, Biologicals, Syringes, and Needles revised 8/01/24, showed the facility should ensure that medications and biologicals are stored at their appropriate temperatures according to the United States Pharmacopeia (USP) guidelines for temperature ranges and manufacturer guidance.
-Facility should monitor the temperature of medication storage areas at least once a day.
Review of the facility's P&P titled Automated Drug Delivery System (ADDS) CA-Omnicare revised 2020 showed the following:
-The facility shall maintain the ADDS Daily Temperature and Cycle Count Log.
-The two authorized facility staff will each sign the ADDS Daily Temperature and
On 10/23/24 at 1046 hours, an interview and concurrent document review titled ADD Daily Temperature and Cycle Count Log dated 5/2024, 8/2024, and 9/2024 was conducted with the DON and RN 1. The DON was asked how often the temperature for the ADDS system should be recorded, she stated every day. Review of the Log showed the following:
- Dates 05/18-05/21, the ADDs Temp gauge for 7 PM-7 AM was blank.
- Dates 08/22-08/23, the ADDs Temp gauge for 7 PM-7 AM was not working.
- Dates 08/24-08/27, the ADDs Temp gauge for 7 PM-7 AM was blank.
- Date 08/28, the ADDs Temp gauge for 7 PM-7 AM was not working.
- Dates 08/29-08/30, the ADDs Temp gauge for 7 PM-7 AM was blank.
- Dates 09/02-09/03, the ADDs Temp gauge for 7 PM-7 AM was blank.
- Dates 09/04-09/05, the ADDs Temp gauge for 7 PM-7 AM was not working.
- Dates 09/06-09/10, the ADDs Temp gauge for 7 PM-7 AM was blank.
- Dates 09/11-09/12, the ADDs Temp gauge was not working.
- Dates 09/13-09/27, the ADDs Temp gauge was blank.
On 10/23/24 at 1058 hours, an interview and concurrent facility document review was conducted the DON. Review of the Pharmacy ADDS Checklist dated 7/30/24-8/21/24, showed the following:
- Report all concerns to the DON and the pharmacy upon discovery (e.g., temperature out of range, ADDS binder issues, inventory discrepancies).
- Document who was notified, and the action taken to resolve temperature excursion or other concerns.
When the DON was asked about the missing temperatures documentation on the ADD Daily Temperature and Cycle Count Log for the months of August and September, the DON and RN 1 stated a work order was placed to replace the temperature thermometer, but the night shift nurses were still leaving the temperature log uncompleted. When asked what could potentially happen if temperature monitoring was not accurately recorded, the DON and RN 1 stated it could potentially affect the residents' medications.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and facility document review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen when:
* The facility failed to ensure t...
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Based on observation, interview, and facility document review, the facility failed to ensure the food safety and sanitation requirements were met in the kitchen when:
* The facility failed to ensure the kitchen utensils and equipment were stored or kept in sanitary conditions.
* The facility failed to ensure the kitchen equipment were cleaned properly.
* The facility failed to ensure a juice machine had an air gap for back flow prevention.
These failures had the potential to pose the risk for exposure to food-borne illnesses in a medically vulnerable population of 42 residents received food prepared in the kitchen.
Findings:
Review of the facility's matrix showed 42 residents consumed food prepared in the facility's kitchen.
1. According to the USDA Food Code 2022, Section 4-101.11, Multiuse, Characteristics, for materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be safe, durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.
According to the USDA Food Code 2022, Section 4-501.12, Cutting Surfaces, for surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize. As a result, pathogenic microorganisms transmissible through food may build up or accumulate. These microorganisms may be transferred to the foods that are prepared on such surfaces.
According to the USDA Food Code 2022, 4-601.11 Equipment, Food - Contact Surfaces, Nonfood Contact Surface, and Utensils, the equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations; and the nonfood- contact surface of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris.
On 10/22/24 at 1405 hours, during an observation of the main kitchen with the supervision of the DSS and Executive Chef, the following items were observed:
- Multiple metal sheet trays stacked flat wet with dripping water
- Multiple metal sheet trays and rectangular baking pans with solid black residue on outer and inner surfaces
- One whisk with burnt handle
- One melted spatula with red handle
- One cracked spatula with brown handle
- Multiple heavily marred cutting boards
- One gray plastic bin holding clean and dried kitchen tools with water and black particles on inner bottom surface
2. On 10/22/24 at 1405 hours, during an observation of the main kitchen, Dietary Aide 1 was observed to be handling clean plates with the same gloves used to handle dirty dishes. Dietary Aide 1 was observed to not change gloves or wash hands in between changing of the gloves.
3. According to the USDA Food Code 2022 5-402.11 Backflow Prevention, (A) a direct connection may not exist between the sewage system and a drain originating from equipment in which food, portable equipment, or utensils are placed.
On 10/21/24 at 0814 hours, during an initial tour of the kitchen, a juice machine was observed without an air gap.
On 10/22/24 at 1448 hours, an observation and concurrent interview was conducted with the Maintenance Technician. The Maintenance Technician verified the finding and stated the juice machine was used to provide juices for the residents.
On 10/24/24 at 1500 hours, the Administrator, DON, and DSS were notified and acknowledged the above findings.
Cross reference to F801.
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Respiratory Care
(Tag F0695)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Oxygen Administration dated 11/16/23, showed to change and date oxygen tubing, mask, or c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Oxygen Administration dated 11/16/23, showed to change and date oxygen tubing, mask, or cannula every Sunday by night shift staff.
Medical record review for Resident 22 was initiated on 10/21/24. Resident 22 was admitted to the facility on [DATE].
Review of the Order Summary Report dated 9/29/24, showed a physician's order dated 3/19/24, for oxygen at 3 liters per minute via nasal cannula as needed for SOB.
On 10/21/24 at 0931 hours, an observation for Resident 22 was conducted. Resident 22 was observed lying in bed watching the television. Resident 22's nasal cannula and respiratory storage bag were observed hanging on the oxygen concentrator undated and unlabeled on the right side of Resident 22's bedside.
On 10/21/24 at 1044 hours, an observation and concurrent interview for Resident 22 was conducted with LVN 2 at Resident 22's bedside. LVN 2 verified there was no date on Resident 22's nasal cannula and respiratory storage bag.
Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 14 final sampled residents (Resident 22) and one nonsampled resident ( Resident 17) reviewed for respiratory care were provided with the appropriate respiratory services.
* The facility failed to ensure Resident 17's nasal cannula was stored in a sanitary manner when not in use.
*The facility failed to ensure Resident 22's nasal cannula tubing and respiratory storage bag were dated.
These failures had the potential to affect the respiratory health and well-being of the residents received respiratory care in the facility.
Findings:
1. Medical record review for Resident 17 was initiated on 10/21/24. Resident 17 was admitted to the facility on [DATE].
Review of Resident 17's Order Summary Report dated 10/24/24, showed a physician's order dated 5/29/24, to administer oxygen two liters per minute via nasal cannula as needed for shortness of breath and oxygen saturation level less than 90%.
During an initial tour of the facility on 10/21/24 at 0927 hours, Resident 17's nasal cannula tubing was observed hanging on the concentrator and not stored in a bag when not in the use.
On 10/21/24 at 0935 hours, a concurrent observation and interview for Resident 17 was conducted with LVN 3. LVN 3 acknowledged the oxygen tubing was dated 10/21/24, was just hanging on the concentrator and not stored in a Ziploc/set-up bag when not in use. LVN 3 verified the above findings.
On 10/24/24 at 1340 hours, the DON was informed and acknowledged the above findings.
MINOR
(B)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Menu Adequacy
(Tag F0803)
Minor procedural issue · This affected multiple residents
Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the main menus were followed for 42 of 42 residents who consumed food prepared in the ...
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Based on observation, interview, facility document review, and facility P&P review, the facility failed to ensure the main menus were followed for 42 of 42 residents who consumed food prepared in the kitchen. This failure had the potential for the residents to not receive the menus as planned.
Findings:
Review of the facility's matrix showed 42 residents consumed food prepared in the facility's kitchen.
Review of the facility's P&P titled Menu Alternatives dated 2018 showed the Director of Food and Nutrition Services is responsible for supervising meal preparation and service to ensure the menu is followed and served as planned. Residents/patients who do not like the menu entrée will be given the menu alternative.
Review of the facility's document titled Daily Spreadsheet Tuesday Day 17, showed the following items were to be served for the lunch main menu on 10/22/24:
- Burgundy Beef Tenderloin Tips
- Parslied Noodles
- Seasoned Spinach
- Choice of Bread
- Margarine
Review of the facility's document titled Daily Spreadsheet Tuesday Day 17, showed the following items served for lunch alternate menu on 10/22/24:
- Turkey Pot Pie
- Seasoned Spinach
- Choice of Bread
- Margarine
On 10/22/24 at 1130 hours, an observation was conducted of the lunch meal tray line with the DSS. The alternate menu was observed being prepared in the kitchen. The DSS stated the alternate menu was being followed today and not the main menu.
Further review of the facility's documents failed to show evidence the residents were notified of the menu change.
On 10/23/24 at 0802 hours, an interview and concurrent facility document review was conducted with the DSS. The DSS acknowledged and verified the main menu was not followed and the residents were not notified of the menu change.
Feb 2023
14 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0553
(Tag F0553)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure a quarterly care conference wa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure a quarterly care conference was conducted for one of 14 final sampled residents (Resident 14).
* Resident 14's last quarterly care conference was conducted on 9/20/22. The residents' care conferences were scheduled on a quarterly basis. However, there was no documentation of any other care conferences conducted for Resident 14 after 9/20/22. This posed the risk of violating the rights of Resident 14 and/or responsible party to participate in choosing the treatment options and making the decisions in care planning.
Findings:
Review of the facility's P&P titled Care Plan Meetings dated 11/2022 showed the Social Worker will schedule the care plan meetings. The resident, resident's family, and/or resident's legal representative/guardian or surrogate are encouraged to attend the scheduled quarterly care plan meetings.
Medical record review for Resident 14 was initiated on 2/8/23. Resident 14 was admitted on [DATE], and readmitted on [DATE].
Review of Resident 14's annual MDS dated [DATE], showed Resident 14 was cognitively intact.
On 2/8/23 at 0951 hours, an interview was conducted with Resident 14. Resident 14 was asked when she was last offered a care conference and stated, I don't know.
On 2/8/23 at 1456 hours, an interview and concurrent medical record review was conducted with the SSD. The SSD verified Resident 14's care conferences were conducted on 3/18, 6/16, and 9/20/22, as shown in Resident 14's medical record. The SSD stated for the long-term care residents, the care conferences were scheduled quarterly, annually, significant change of condition, and as needed. The SSD confirmed Resident 14 did not have a scheduled quarterly care conference after 9/20/22, and should have had one in December 2022.
On 2/8/23 at 1530 hours, an interview was conducted with the SSD. The SSD verified Resident 14 did not have a quarterly care conference for December of 2022, and it was missed. The SSD stated the care conferences were important for the communication in the resident's care updates and care choices with treatments.
On 2/10/23 at 0748 hours, an interview was conducted with the DON. The DON verified the above findings and stated the care conference should be scheduled and conducted within seven days upon admission, quarterly, annually, during a significant change of condition, and as needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review and facility P&P review, the facility failed to ensure one nonsampled res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review and facility P&P review, the facility failed to ensure one nonsampled resident (Resident 736) who could not safely self-administer medications had the medication at the bedside. This failure had the potential for Resident 736 to administer medications inaccurately.
Findings:
Review of the facility's P&P titled Omnicare 2.1 Self Administering Medications revised 5/2010 showed the facility, in conjunction with the Interdisciplinary Care Team, should assess and determine, with respect to each resident, whether self-administration of medications is safe and appropriate.
On 2/7/23 at 0949 hours, two packets of unopened hydrocortisone cream 1% (a medicated cream used to reduce inflammation of the skin) were seen on the bedside table of Resident 736. When asked what the medication cream was for, Resident 736 stated she did not know why it was there.
On 2/7/23 at 1014 hours, a concurrent interview and observation was conducted with LVN 1. When asked about the packets of hydrocortisone cream 1% on Resident 736's bedside table, LVN 1 stated it should have not been left in the room. LVN 1 stated there was no order for the hydrocortisone cream 1%.
On 2/8/23 at 0853 hours, an interview was conducted with RN 1. RN 1 stated the hydrocortisone cream 1% was to be stored in the treatment cart. RN 1 further stated the expectation was to discard the creams after use and would not leave them at the bedside.
On 2/10/23 at 0924 hours, an interview was conducted with the DON. When asked where the medications should be kept, the DON stated they should be kept in the medication cart, medication room, or treatment cart for ointments and supplies. The DON stated the medications should not be kept at bedside if the resident was not able to administer their own medications; if they wanted to self-administer, then they would have to be cognitively and physically able; other than that, the medications should not be kept at the bedside. When asked how the residents were evaluated to self-administer medication, the DON stated there was a checklist which would be completed if the resident wished to self-administer their medications. When asked if it was appropriate to keep medications at the bedside if the resident was evaluated as not able to self-administer medications, the DON stated no. The DON stated the hydrocortisone cream 1% was considered a medication.
Medical record review of Resident 736 was initiated on 2/10/23. Resident 736 was admitted to the facility on [DATE].
Review of Resident 736's History and Physical Examination dated 2/7/23, showed Resident 736 did not have capacity to understand and make decisions.
Review of Resident 736's Order Summary Report failed to show an order for hydrocortisone cream 1%.
Review of Resident 736's evaluations for Self-Administration of Medication dated 2/6/23, showed Resident 736 was not a candidate for safe self-administration of medications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility document review, the facility failed to ensure the Long-Term Care Ombuds...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility document review, the facility failed to ensure the Long-Term Care Ombudsman (a person who routinely visits the facility and advocated for the residents) was notified of the discharge for one of three closed record sampled residents (Resident 28). This failure had the potential of not providing Resident 74 with access to an advocate who could inform them of their options and rights related to discharge.
Findings:
Closed medical record review for Resident 28 was initiated on 2/9/23. Resident 28 was admitted to the facility on [DATE], and discharged on 2/1/23.
Review of the facility's document titled Notice of Transfer and Discharge with effective discharge date of 2/1/23, failed to show the State Long-Term Care Ombudsman was notified of Resident 28's discharge to home.
On 2/9/23 at 1245 hours, an interview and concurrent facility document review was conducted with the SSD. The SSD was asked if the facility had notified the Long-Term Care Ombudsman of Resident 28's discharge to home on 2/1/23. The SSD checked the facility's Notice of Transfer and Discharge document and noted the box for notifying the Long-Term Care Ombudsman was blank. The SSD stated the Long-Term Care Ombudsman was not notified and the Notice of Discharge document was not sent because the SSD was on medical leave at that time, and no one else had notified the ombudsman. The SSD stated the facility notified the Long-Term Care Ombudsman once the resident was discharged from the facility on a routine basis. The SSD further stated the importance of notifying the Long-Term Care Ombudsman was for the residents to have an advocate for information regarding their discharge, rights, and options for appeal processes.
On 2/10/23 at 0750 hours, an interview was conducted with the DON. The DON verified the above findings and stated the Long-Term Care Ombudsman should have been notified for the resident's discharge or transfer.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to provide an individualized and ongoing acti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility document review, the facility failed to provide an individualized and ongoing activity program to meet the needs and interests of one of 14 final sampled residents (Resident 2) and one nonsampled resident (Resident 11).
* The facility failed to provide activities for Residents 2 and 11 to meet the resident's identified interests. The facility failed to ensure the TV remote controls were provided for Residents 2 and 11. This had the potential for the residents to experience feelings of social isolation and frustration.
Findings:
1. On 2/7/23 at 0948 hours, Resident 2 was observed in bed and awake. There was no in-room sensory stimulation observed. The TV was observed turned off.
On 2/8/23 at 0853 hours, Resident 2 was observed in bed and awake. Resident 2 was observed staring at the window. There was no in-room sensory stimulation observed. The TV was observed turned off. When asked if she wanted to watch TV, Resident 2 nodded her head and said yes.
On 2/8/23 at 0856 hours, a staff was observed going into the resident's room, but was observed going out of the room immediately. The staff was observed not talking to the resident or turning the TV on.
Medical record review for Resident 2 was initiated on 2/7/23. Resident was readmitted to the facility on [DATE].
Review of Resident 2's History and Physical examination dated 12/21/22, showed Resident 2 could make needs known but could not make medical decisions.
Review of Resident 2's Activity Department assessment dated [DATE], showed Resident 2's activity preferences included arts and crafts, cards, puzzles, games, exercise, sports, movies, and television.
Review of Resident 2's Activity Quarterly assessment dated [DATE], showed Resident 2 participated with 1:1 room activities of interest and enjoyed group activities. The assessment also showed Resident 2 interacted and engaged in conversation with the staff and residents.
Review of Resident 2's plan of care showed a care plan problem dated 2/7/23, addressing activity participation. The interventions/tasks included group activities on hold, in-room visits provided, activity staff provided contact/room visits as needed.
Review of Resident 2's Activity Participation Log (Group/ Room Visits) for January 2023 showed Resident 2 was provided activities on 1/1, 1/4, 1/6, 1/9, 1/10, 1/11, 1/15, 1/18, and 1/21/23. The log showed the independent room activities provided to Resident 2 were reading, watching TV, and sitting outside/patio. There was a total of nine days when Resident 2 was provided activities in January 2023.
On 2/8/23 at 1442 hours, an interview and concurrent medical record review for Resident 2 was conducted with the Activity Director. The Activity Director verified the above findings. When asked what activities were provided to Resident 2, the Activities Director stated Resident 2 liked entertainment, exercises, watching classic movies, and listening to classical music on TV. When asked how often they provided one-to-one room visits, the Activity Director stated the activity staff provided one-to-one room visits at least three times per week.
On 2/8/23 at 1515 hours, an observation for Resident 2 and concurrent interview was conducted with the Activity Director. Resident 2 was observed in bed and awake. Resident 2 was observed staring at the window. There was no in-room sensory stimulation observed. The TV was observed turned off. The Activity Director tried to turn the television on but could not find the remote control. The Activity Director stated she would file a work order to the maintenance department for a TV remote control.
2. On 2/7/23 at 0945 hours, Resident 11 was observed in bed and awake. There was no in-room sensory stimulation observed. The TV was observed turned off.
On 2/7/23 at 0951 hours, Resident 11 was observed getting out of bed and walking out of the room. CNA 4 was observed assisting Resident 11 back to bed.
On 2/7/23 at 0957 hours, after assisting Resident 11 back to bed, CNA 4 was observed asking Resident 11 if she wanted the TV on, and Resident 11 answered yes. CNA 4 was observed looking for the remote control but could not find it.
Medical record review for Resident 11 was initiated on 2/7/23. Resident was readmitted to the facility on [DATE].
Review of Resident 11's History and Physical Examination dated 11/8/22, showed Resident 11 could make needs known but could not make medical decisions.
Review of Resident 11's Activity Quarterly assessment dated [DATE], showed Resident 11 enjoyed group and independent activities.
Review of Resident 11's Activity Department assessment dated [DATE], showed Resident 11's activity preferences included arts and crafts, cards, puzzles, games, exercise, sports, movies, and television.
Review of Resident 11's plan of care showed a care plan problem dated 12/6/22, addressing activity participation. The interventions/tasks included group activities on hold, in-room visits provided, activity staff provided contact/room visits as needed, and socialize with resident three to five times weekly.
Review of Resident 11's Activity Participation Log (Group/ Room Visits) for January 2023 showed Resident 11 was provided activities on 1/1, 1/6, 1/8, 1/9, 1/11, 1/13, 1/16, and 1/19/23. The log showed the independent room activities provided to Resident 11 were watching TV and sitting outside/patio. There was a total of eight days when Resident 2 was provided activities in January 2023.
On 2/8/23 at 1500 hours, an interview and concurrent medical record review for Resident 11 was conducted with the Activity Director. The Activity Director verified the above findings.
On 2/8/23 at 1516 hours, an observation for Resident 11 and concurrent interview was conducted with the Activity Director. Resident 11 was observed sitting in the wheelchair and awake. There was no in-room sensory stimulation observed. The TV was observed turned off. The Activity Director tried to turn the TV on but could not find the remote control. The Activity Director stated she would file a work order to the maintenance department for a TV remote control.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to en...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the necessary care and services to ensure one of 14 final sampled residents (Resident 10) on hospice services attained and maintained their highest practicable well-being.
* The facility failed to communicate with the hospice agency regarding the RN/ LVN and CHHA visitation when Resident 10 was in isolation for Covid-19. This had the potential of a delay in hospice care regarding changes in Resident 10's condition.
Findings:
Medical record review for Resident 10 was initiated on 2/7/23. Resident 10 was admitted to the facility on [DATE].
Review of the Order Summary Report showed a physician's order dated 7/20/22, for Resident 10 to be admitted to hospice services under routine level of care.
Review of the hospice calendar for January and February 2023 showed the RN/LVN was scheduled to visit two times per week, and the CHHA was scheduled to visit three times per week. Further review of the hospice calendar showed the RN/LVN was scheduled to visit on 1/2, 1/6, 1/9, 1/13, 1/16, 1/20, 1/23, 1/27, 1/30, 2/3, 2/6, 2/10, 2/13, 2/17, 2/20, 2/24 and 2/27/23.
Review of the Hospice Visit Summary Log showed the RN/LVN visited Resident 10 on 1/2, 1/6, 1/13, 1/16, 1/20, 1/23, 1/27, and 2/6/23. In addition, the summary log dated 1/2/22, showed Resident 10 was in isolation for Covid-19. Further review of the log showed the RN/LVN missed to visit Resident 10 on 1/9/23.
Review of the CHHA Sign-In Form for January 2023 showed the CHHA visited Resident 10 on 1/12, 1/16, 1/18, 1/19, 1/24, 1/25, 1/26, and 1/31/23. Further review of the form showed the CHHA failed to visit Resident 10 from 1/1 to 1/11/23.
Review of the CHHA Sign-In Form for February 2023 showed a blank form.
On 2/9/23 at 0920 hours, an interview and concurrent medical record review for Resident 10 was conducted with RN 1. When asked about the RN/LVN and CHHA visits, RN 1 stated the RN/LVN was scheduled to visit two times per week and the CHHA was scheduled to visit three times per week as per the hospice calendar. When asked why there were missing RN/LVN and CHHA visits, RN 1 he had to ask the DON about it.
On 2/9/23 at 0922 hours, an interview and concurrent medical record review for Resident 10 was conducted with the DON, with the SSD and RN 1 present. The DON and SSD verified the findings. When asked why there were missing the RN/LVN and CHHA visits, the DON stated because Resident 10 was in isolation for Covid-19. When asked if they stopped the hospice staff visitation and services when Resident 10 had Covid-19, the DON answered no. The SSD stated she would follow-up with the hospice agency.
On 2/10/23 at 1020 hours, a follow-up interview was conducted with the DON. The DON stated the SSD had followed up with the hospice agency and it was the hospice agency's policy to stop sending their hospice staff to the facility because of Covid-19. When asked for documentation of when the hospice agency communicated to the facility regarding their policy, the DON could not find any documentation. When asked if the facility communicated with the hospice agency regarding their RN/LVN and CHHA not providing visitations when Resident 10 was in isolation for Covid-19, the DON could not locate any documentation. When asked if they communicated with the hospice agency regarding the missed visits, the DON stated the hospice staff should have signed in when they visited Resident 10.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility document review, the facility failed to ensure one of 14 fi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility document review, the facility failed to ensure one of 14 final sampled residents (Resident 10) who required hearing aids received proper treatment and assistive device to maintain her hearing abilities.
* The facility failed to ensure Resident 10's hearing aids were applied as ordered by the physician. This had the potential for the resident's communication to be impaired by not being to hear conversations clearly.
Findings:
On 2/7/23 at 1008 hours, during the initial tour of the facility, Resident 10 was observed awake in bed. When Resident 10 was greeted, she did not respond but cupped her hand behind her ear and moved her head closer. When asked if she had hearing aids on or needed her hearing aids on, Resident 10 answered, it would probably make it better.
Medical record review for Resident 10 was initiated on 2/7/23. Resident 10 was admitted to the facility on [DATE].
Review of Resident 10's MDS dated [DATE], showed Resident 19 was able to make herself understood and able to understands others.
Review of Resident 10's Monarch Physician H&P examination and Progress Note dated 2/11/23, showed Resident 10 was hard of hearing.
Review of Resident 10's Order Summary Report showed a physician's order dated 6/22/2020, to apply the left and right hearing aids every shift.
Review of Resident 10's plan of care showed a care plan problem addressing the risk for communication problem related to hearing loss. The interventions/tasks included to assist with hearing aide storage and application daily.
On 2/8/23 at 0851 hours, Resident 10 was observed awake in bed. When greeted, Resident 10 stated she did not have her hearing aids on.
On 2/9/23 at 0835 hours, Resident 10 was observed awake in bed. Resident 10 stated she did not have hearing aids on and it would be nice if I can hear better.
On 2/9/23 at 0839 hours, an observation for Resident 10 and concurrent interview was conducted with CNA 5. CNA 5 verified Resident 10 did not have her hearing aids on. CNA 5 stated she offered Resident 10 to put on her hearing aids this morning, but Resident 10 refused. When Resident 10 was asked if she wanted her hearing aids on, Resident 10 answered yes. CNA 5 was observed applying Resident 10's hearing aids to both ears. Resident 10 smiled and stated, my hearing is better.
On 2/9/23 at 1420 hours, an interview and concurrent facility document and medical record review for Resident 10 was conducted with LVN 2. LVN 2 verified the above findings. When asked if Resident 10 had refused to have her hearing aids applied, LVN 2 answered no. LVN 2 verified there was no documentation to show Resident 10 refused to have her hearing aids applied. When asked how they monitored when Resident 10 had her hearing aids applied, LVN 2 answered she checked if the resident's hearing aids applied when she went to the room and passed medications. LVN 2 showed the facility's document titled Hearing Aide Log showing the licensed staff initialed when the residents' hearing aids were taken in and out of the medication cart. LVN 2 verified there was no documentation to show Resident 10 was monitored when her hearing aids were applied.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary car...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the necessary care and services related to pressure injuries (areas of damaged skin caused by staying in one position for a long time which reduces blood flow to the area and causes the skin to die and develop a sore to promote wound healing) were provided to one of 14 final sampled residents (Resident 17).
* The facility failed to ensure the low air loss mattress setting was consistently monitored to ensure the appropriate settings of the low air loss mattress for Resident 17. This failure posed the risk for complications and delayed wound healing.
Findings:
Review of the facility's P&P titled Skin Integrity/Prevention of Pressure Injuries revised 11/16/22, showed the policy is to identify and reduce risk factors for the development of pressure injuries. The treatment nurse and Medical practitioner will review the interventions and treatment for effectiveness on an on-going basis.
Medical Record Review for Resident 17 was initiated on 2/9/23. Resident 17 was admitted to the facility on [DATE].
Reviw of Resident 17's plan of care showed a care plan problem initiated on 11/2/22, addressing the potential for pressure ulcer development related to impaired mobility. The care plan problem included intervention for a LAL mattreess every shift for skin management.
Review of Resident 17's MDS dated [DATE], showed Resident 17 was admitted with a Stage IV (full thickness tissue loss with exposed bone, tendon, or muscle) pressure injury.
On 2/8/23 at 1014 hours, Resident 17 was observed laying on a LAL mattress. The LAL mattress was turned on and set at 150 pounds.
On 2/9/23 at 1441 hours, an observation and concurrent interview was conducted with Resident 17. Resident 17 was observed laying on a LAL mattress. The LAL mattress was turned on and set at 150 pounds.
Review of Resident 17's Order Summary Report dated 2/7/23, showed a physician's order dated 11/4/22, for a LAL mattress every shift for skin management.
On 2/10/23 at 0905 hours, a concurrent observation and interview was conducted with RN 1 and Resident 17. Resident 17 was observed with the LAL mattress turned on and set at 150 pounds. When RN 1 was asked how he knew if the setting was correct, RN 1 stated the weight setting should be based on Resident 17's weight. Resident 17 stated the staff weighed her at the beginning of the month and her most recent weight was 110 pounds. RN 1 verified Resident 17's weight was 110 pounds. RN 1 stated the LAL mattress settings needed to be adjusted down to 120 pounds since the next setting from 120 pounds was 80 pounds.
On 2/10/23 at 1041 hours, a follow-up interview was conducted with RN 1. RN 1 stated the initial setting was set by the person who installed it from the medical equipment company. RN 1 stated the weight should have been adjusted when it was installed. RN 1 also stated the charge nurse may adjust the LAL mattress setting; however, the treatment nurses would check if the LAL mattress was set at the correct setting. When asked why it was important for the LAL mattress to be set at the correct setting, RN 1 stated it was important for the healing of wounds and to prevent pressure injuries. RN 1 further stated if the LAL mattress was not inflated properly, it could make the wounds worse.
On 2/10/23 at 1115 hours, an interview was conducted with the DON and Administrator. When asked regarding the use of the LAL mattress and the expectations when a resident using a LAL mattress, the DON stated it was used for the residents who were high risk for pressure injuries and most of them were with wounds. The Administrator stated if the setting was not set correctly for a long period of time, there was a potential of not providing the maximum potential benefit to the resident.
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 medical record review, the facility failed to provide the necessary respiratory care and se...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to provide the necessary respiratory care and services for one of 14 final sampled residents (Resident 538).
* The facility failed to ensure Resident 538's nasal cannula tubing (medical device use to deliver supplemental oxygen) was dated. This had the potential for increased risks of infection.
Findings:
Medical record review for Resident 538 was initiated on 2/7/23. Resident 538 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including congestive heart failure (a chronic condition in which the heart does not pump blood as well as it should).
Review of the Order Summary Report showed a physician's order dated 1/31/23, to provide oxygen at two liters per minute via nasal cannula every shift and change oxygen tubing and humidifier every Sunday.
On 2/7/23 at 1009 hours, during the initial tour of the facility, an observation of Resident 538 was conducted. Resident 538 was observed in bed receiving oxygen via nasal cannula at two liters per minute. The nasal cannula tubing was observed undated.
On 2/7/23 at 1433 hours, an observation and concurrent interview was conducted with CNA 1. Resident 538 was observed in bed receiving oxygen via nasal cannula at two liters per minute. The nasal cannula tubing was observed undated. CNA 1 stated Resident 538 used the nasal cannula.
On 2/7/23 at 1441 hours, an observation and concurrent interview was conducted with LVN 1. Resident 538 was observed in bed receiving oxygen via nasal cannula at two liters per minute. The nasal cannula tubing was again observed undated. LVN 1 verified and acknowledged the above findings. LVN 1 further stated Resident 538 was on continuous oxygen therapy, and the nasal cannula tubing should have been dated for infection control reasons.
On 2/8/23 at 1044 hours, an interview was conducted with the DSD/IP. The DSD/IP acknowledged the above findings and further stated it should have been dated for infection control reasons.
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, medical record review, and facility P&P review, the facility failed to provide the necessary ph...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the necessary pharmacy services for one of 14 final sampled residents (Resident 12) and two nonsampled residents (Residents 7 and 18).
* Resident 18's hydrocodone-acetaminophen (a narcotic pain medication) Controlled Drug Record documentation did not match Resident 18's MAR. This failure posed the risk of diversion of the controlled medication.
* Resident 12's chewable aspirin medication (medication used to lower the chance of heart attack) was administered without the instructions for the resident to chew, and the resident swallowed the aspirin tablet. This posed the risk of decreased absorption of Resident 12's medication.
* Resident 7's ferrous sulfate (iron supplement) and calcium (calcium supplement) were administered at the same time. This posed the risk of decreased absorption of Resident 7's ferrous sulfate.
Findings:
Review of the facility's P&P titled Medication Administration revised date 11/16/22, showed the following:
- During the medication administration, the Licensed Nurse should take all measures required by the facility's policy and applicable law to document the administration of controlled substances in accordance with applicable law and provide the resident with any necessary instructions (e.g., rotating transdermal patch sites, providing medication with fluids or foods, shaking medications prior to pouring).
- After the medication administration, the Licensed Nurse should take all measures by the facility's policy and applicable law to document the necessary medication administration/treatment (e.g., when medications are opened, when medications are given, injection site of the medication, if medications are refused, PRN medications, application site) on appropriate forms.
1. On 2/7/23 at 1120 hours, during the inspection of Medication Cart 1, the Controlled Drug Records were reviewed with LVN 1.
Resident 18's Controlled Drug Record for hydrocodone-acetaminophen was reviewed with LVN 1. The Controlled Drug Record showed Resident 18 was administered hydrocodone-acetaminophen 7.5 mg-325 mg one tablet on 2/6/23 at 2100 hours, for pain.
Resident 18's MAR for February 2023 was reviewed with LVN 1. Resident 18's MAR did not show an administration documentation of Resident 18's hydrocodone-acetaminophen on 2/6/23 at 2100 hours. LVN 1 verified Resident 18's Controlled Drug Record for hydrocodone-acetaminophen did not match Resident 18's MAR for February 2023.
Medical record review of Resident 18 was initiated on 2/7/23. Resident 18 was admitted to the facility on [DATE].
Review of Resident 18's Order Summary Report showed a physician's order date 1/9/23, to administer hydrocodone-acetaminophen 7.5 mg-325 mg one tablet by mouth every four hours as needed for moderate to severe pain; and a physician's order dated 1/18/23, to administer hydrocodone-acetaminophen 7.5 mg-325 mg one tablet by mouth every day shift one hour prior to therapy.
On 2/9/23 at 1309 hours, an interview was conducted with the DON. When asked regarding the controlled drug documentation, the DON stated the nurse should sign the Controlled Drug Record and MAR right away when the controlled drug was administered.
2. On 2/7/23 at 0835 hours, a medication administration observation for Resident 12 was conducted with LVN 1. LVN 1 prepared and administered Resident 12's medications. LVN 1 was observed administering Resident 12's chewable aspirin by mouth using a spoon and Resident 12 swallowed the chewable aspirin tablet with a sip of water.
Medical record review for Resident 12 was initiated on 2/7/23. Resident 12 was admitted to the facility on [DATE].
Review of Resident 12's Order Summary Report showed a physician's order dated 8/19/22, to administer aspirin chewable 81 mg one tablet by mouth one time a day.
On 2/7/23 at 1600 hours, an interview was conducted with LVN 1. When asked if Resident 12 chewed her aspirin, LVN 1 stated Resident 12 swallowed her aspirin tablet. LVN 1 verified she did not instruct Resident 12 to chew the aspirin medication. LVN 1 acknowledged this could decrease the absorption of the medication.
3. On 2/8/23 at 0940 hours, a medication administration observation for Resident 7 was conducted with LVN 1. LVN 1 prepared and administered Resident 7's medications. LVN 1 was observed administering Resident 7's ferrous sulfate and calcium at the same time.
Review of Lexicomp (clinical drug resource) guide updated on 1/28/23, showed antacids may decrease the absorption of iron preparation. Consider separating the doses of oral iron and antacids in the patients who require chronic use of both agents and monitor for reduced iron efficacy.
Medical record review for Resident 7 was initiated on 2/8/23. Resident 7 was admitted to the facility on [DATE], and readmitted to the facility on [DATE].
Review of Resident 7's Order Summary Report showed a physician's order dated 4/8/22, to administer calcium tablet 600 mg by mouth one time a day for supplement.
Review of Resident 7's MAR for February 2023 showed an order dated 10/22/22, to administer ferrous sulfate 325 mg one tablet by mouth one time a day for supplement.
Review of Resident 7's MAR for February 2023 showed the ferrous sulfate and calcium tablet were to be administered daily at 0900 hours.
On 2/8/23 at 1110 hours, an interview was conducted with LVN 1. When asked if Resident 7's ferrous sulfate and calcium supplements were administered at the same time, LVN 1 stated Resident 7's ferrous sulfate and calcium supplements were given at the same time. LVN 1 acknowledged calcium could decrease the absorption of ferrous sulfate.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure four of 14 final sampled resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, and facility P&P review, the facility failed to ensure four of 14 final sampled residents (Residents 2, 21, 30, and 537) were free from unnecessary psychotropic medications (medication that affects the brain activity).
* The facility failed to provide the physician's documentation to extend Resident 30's Xanax medication (psychotropic medication) after 14 days of PRN use and the facility failed to provide a stop date on Resident 30's PRN Xanax ordered on 1/29/23.
* The facility failed to provide the non-pharmacological interventions to Resident 21's depression, anxiety, and poor intakes to minimize the use of alprazolam, mirtazapine, and escitalopram medications (psychotropic medications).
* The facility failed to accurately document Resident 21's monthly behavior tracking for mirtazapine use.
* The facility failed to provide the non-pharmacological interventions to Resident 2's depression to minimize the citalopram use.
* The facility failed to ensure Resident 537's episodes of behaviors for the use of mirtazapine (antidepressant medication) were accurately documented in the eMAR.
These failures had the potential for the physician to not have the necessary information and the residents to receive the unnecessary medications.
Findings:
Review of the facility's P&P titled Psychopharmacologic medication Use revised 11/31/11, showed the facility should comply with the Psychopharmacologic Dosage Guidelines created by the Centers for Medicare and Medicaid Services (CMS), the State Operations Manual, and all other applicable law relating to the use of psychopharmacologic medications including gradual dose reduction.
1. Review of Resident 30's medical record was initiated on 2/8/23. Resident 30 was admitted to the facility on [DATE], and readmitted to the facility on [DATE].
Review of Resident 30's MAR for January 2023 showed an order to administer Xanax 0.25 mg by mouth every eight hours as needed for anxiety for 14 days, with the start date of 1/2/23, and end date of 1/16/23.
Review of Resident 30's Order Summary Report showed a physician's order dated 1/29/23, to administer Xanax 0.25 mg one tablet by mouth every eight hours as needed for anxiety manifested by verbalization of anxiousness.
Review of Resident 30's medical record failed to show the physician's documentation to extend the PRN Xanax use beyond 14 days and for the PRN Xanax order dated 1/29/23, without a stop date. The facility was unable to provide the physician's documentation.
On 2/9/23 at 1309 hours, an interview was conducted with the DON. When asked regarding the PRN antianxiety medications, the DON stated the PRN antianxiety medications should only be used for 14 days and the physician should have supporting documentation if the PRN antianxiety medication was extended for more than 14 days.
2. Review of Resident 21's medical record was initiated on 2/8/23. Resident 21 was admitted to the facility on [DATE], and readmitted to the facility on [DATE].
Review of Resident 21's Order Summary Report showed the following:
- a physician's order dated 11/30/22, to administer alprazolam (Xanax) 0.25 mg one tablet by mouth on time a day for anxiety manifested by inconsolable screaming, yelling, constant request for attention;
- a physician's order dated 12/8/22, to administer escitalopram oxalate five mg one tablet by mouth one time a day for depression manifested by verbalization of sadness; and
- a physician's order dated 1/17/23, to administer mirtazapine 15 mg one tablet at bedtime for depression manifested by poor oral intake less than 50%.
a. Medical record review of Resident 21's MAR for January 2023 showed for the use of escitalopram medication, to monitor for episodes of depression manifested by verbalization of sadness every shift. Resident 21 had one episode depression on 1/24/23, evening shift.
Medical record review of Resident 21's MAR for January 2023 showed for the use of Xanax medication, to monitor for episodes of anxiety manifested by inconsolable screaming, yelling, constant request for attention, calling out inconsolable repetitive every shift. Resident 21 had the following anxiety episodes:
- one episode on 1/10/23, evening shift;
- one episode on 1/11/23, evening shift;
- one episode on 1/12/23, morning shift;
- three episodes on 1/28/23, morning shift; and
- five episodes on 1/31/23, morning shift.
Review of Resident 21's MAR for January 2023 showed the monitoring for the % (percentage) of poor oral intake three times a day for breakfast, lunch, and dinner for the use of Remeron (mirtazapine) medication. Resident 21 had the following intakes:
- 10% for dinner on 1/17/23;
- zero % for breakfast and 25% for dinner on 1/18/23;
- 25% for breakfast and 25% for lunch on 1/20/23;
- 25% for breakfast, lunch, and dinner on 1/22/23;
- 25% for breakfast, lunch, and dinner on 1/23/23;
- 25% for breakfast, lunch, and dinner on 1/24/23; and
- 25% for breakfast, lunch, and dinner on 1/25/23.
Review of Resident 21's MAR for February 2023 showed for the use of Xanax medication, to monitor for episodes of anxiety manifested by inconsolable screaming, yelling, constant request for attention, calling out, inconsolable repetitive every shift. Resident 21 had the following anxiety episodes:
:
- six episodes in the morning shift and one episode in the evening shift on 2/4/23, and
- five episodes in the morning shift on 2/6/23.
Review of Resident 21's MAR for February 2023 showed to monitor for poor oral intake three times a day breakfast-lunch-dinner for the use of Remeron (mirtazapine). The document showed the following:
- 20% for lunch on 2/1/23,
- 25% for breakfast on 2/3/23, and
- 25% for breakfast on 2/5/23.
Review of Resident 21's medical record did not show documentation of the non-pharmacological interventions for Resident 21's anxiety, depression, and poor intake to minimize the use of alprazolam, escitalopram, and mirtazapine medications.
On 2/9/23 at 1226 hours, a concurrent interview and medical record review was conducted with LVN 2. When asked if the non-pharmacological interventions were provided for Resident 21's anxiety, depression, and poor intake, LVN 2 stated there were no documentation of non-pharmacological interventions provided for Resident 21's anxiety, depression, and poor intake.
b. Medical record review of Resident 21's Order Summary Report showed a physician's order dated 1/17/23, to monitor Resident 21 for poor oral intake three times a day for breakfast, lunch, and dinner for the use of mirtazapine.
Medical record review of Resident 21's MAR for January 2023 showed the monitoring for poor oral intake three times a day for breakfast, lunch, and dinner for the use of Remeron (mirtazapine). The MAR showed the resident's poor intake episodes as follows:
- one episode on 1/17/23,
- two episodes on 1/18/23,
- two episodes on 1/20/23,
- three times on 1/22/23,
- three times on 1/23/23,
- three times on 1/24/23, and
- three times on 1/25/23.
Medical record review of Resident 21's Psychotropic Tracking Record showed a behavior of poor oral intake less than 50% of each meal. The behavior tracking showed a total of zero episode in January.
On 2/9/23 at 1240 hours, a concurrent interview and medical record review was conducted with the ADON. When asked if the non-pharmacological interventions were provided for Resident 21's poor intake, the ADON stated no documentation of non-pharmacological interventions for the resident's poor intake. The ADON acknowledged Resident 21's MAR for monitoring of episodes of meal intake less than 50% and Psychotropic Tracking Record for January 2023 did not match.
3. Review of Resident 2's medical record was initiated on 2/9/23. Resident 2 was admitted to the facility on [DATE], and readmitted on [DATE].
Review of Resident 2's Order Summary Report showed a physician's order dated 12/2/22, to administer citalopram 10 mg one tablet by mouth one time a day for depression manifested by withdrawal from social activities.
Review of Resident 2's medical record did not show the non-pharmacological interventions was provided for the resident's depression to minimize the use of citalopram medication.
On 2/9/23 at 1530 hours, a concurrent interview and record review of Resident 2's medical record was conducted with LVN 2. LVN 2 verified there was no documentation of non-pharmacological interventions for the use of Resident 2's citalopram medication.
4. Review of Resident 537's medical record was initiated on 2/7/23. Resident 537 was admitted to the facility on [DATE], with a diagnosis of major depressive disorder among others.
Review of the Order Summary Report showed an order for mirtazapine tablet 15 mg one tablet by mouth at bedtime for depression manifested by poor oral intake. Further review of the medical record showed to monitor episodes of depression as evidenced by eating less than 50% of meals served every shift.
Review of Resident 537's eMAR for the month of February 2023, showed the monitoring of the behavior every shift. Further review of the medical record showed the dates from 2/1/23 to 2/2/23, were marked 0.
Review of Resident 537's medical record titled Follow Up Question Report from 2/1/23 to 2/9/23, showed Resident 537's intakes on 2/2/23 at 0905 hours, 2/2/23 at 1926 hours, 2/6/23 at 1410 hours, 2/7/23 at 1043 hours, and 2/7/23 at 1943 hours, were 26% - 50%.
On 2/9/23 at 0946 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 stated Resident 537 was on antidepressant medication for consuming less than 50% meal intake and Resident 537 had episodes of less than 50% meal intake when first admitted to the facility. When asked what the 0 documentation in eMAR for Resident 537's mirtazapine behavior monitoring meant, LVN 3 stated Resident 537 ate more than 50% of his meals. LVN 3 was informed of the above findings and further stated the documentation should be the same in the eMAR and meal intake record.
On 2/9/23 at 1005 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified and acknowledged the above findings. The DON further stated the documentation should be accurate for to provide proper interventions for Resident 537.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility's P&P titled Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles dated Apr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the facility's P&P titled Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles dated April 2022 showed the facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by the residents and visitors.
On 2/7/23 at 1222 hours, two packets of A&D ointment (a moisturizer to treat or prevent dry, rough, scaly, itchy skin and minor skin irritations) were observed on the base of the hand sanitizer dispenser located in the hallway next to Resident 736's room. One of the two packets was opened and the other was sealed.
On 2/7/23 at 1236 hours, a concurrent observation and interview was conducted with CNA 1. CNA 1 verified the above findings. CNA 1 stated it was not the right place to store the A&D ointment, and the A&D packets should not have been placed on the hand sanitizer dispenser. CNA 1 stated the A&D ointment was supposed to be kept with the treatment nurse.
On 2/8/23 at 0853 hours, an interview was conducted with RN 1. RN 1 stated the A&D ointment was to be stored in the treatment cart. RN 1 stated the staff were not allowed to leave medications in the hallways.
On 2/10/23 at 0924 hours, an interview was conducted with the DON. When asked where the treatment ointments and supplies should be kept, the DON stated they should be kept in the treatment cart.
Based on observation, interview, medical record review, and facility P&P review, the facility failed to store the medication and supplies according to the manufacturer's recommendations.
* Medication Cart 2 had Resident 16's Novolin R FlexPen insulin injection (medication used to lower blood sugar) with an opened date of 12/29/22, and labeled to expire on 1/27/23. This failure had the potential for the administration of deteriorated medication.
* Medication Cart 3 had the expired IV supplies. This had the potential for use of expired supplies.
* The facility failed to store the A&D ointment securely and inaccessible by the residents and visitors. This had the potential for unauthorized access to the medication.
Findings:
Review of the facility's P&P titled Storge and Expiration of Medications, Biologicals, Syringes and Needles revised 4/1/22, showed the facility should ensure that medications and biologicals for expired or discharged residents are store separately, away from use, until destroyed or returned to provider and facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with pharmacy return/destruction guidelines and other applicable law.
1. On 2/7/23 at 1206 hours, a medication administration observation for Resident 16 was conducted with LVN 2. LVN 2 checked Resident 16's blood sugar prior to giving insulin. LVN 2 checked Resident 16's physician's order and stated Resident 16 needed seven units of insulin medication. LVN 2 found Resident 16's Novolin R FlexPen insulin was expired in Medication Cart 2 while preparing Resident 16's insulin medication. LVN 2 verified Resident 16's Novolin R FlexPen was opened on 12/29/22, and labeled to expire 1/27/23. LVN 2 stated Resident 16 expired Novolin R FlexPen medication will be placed in Medication room [ROOM NUMBER] for disposal.
Review of Lexicomp (clinical drug resource) guide updated 12/12/22, showed to store Novolin R FlexPen unopened (not in use) pens in the refrigerator between two degrees Celsius and eight degrees Celsius (36 degrees Fahrenheit to 40 degrees Fahrenheit) until product expiration date or at room temperature (less than 30 degrees Celsius (less than 86 degrees Fahrenheit) for less than or equal to 28 days; store in use (opened) pens at room temperature (less than 30 degrees Celsius (less than 86 degrees Fahrenheit) for less than or equal to 28 days.
Review of Resident 16's medical record was initiated on 2/7/23. Resident 16 was admitted to the facility on [DATE] and readmitted on [DATE].
Review of Resident 16's Order Summary Report showed a physician's order dated 1/13/22, showed to administer Novolin R solution 100 units per ml inject subcutaneously (between the skin and muscle) per sliding scale (a dose of insulin based on blood sugar level before meal).
On 2/9/23 at 1309 hours, an interview was conducted with the DON. When asked regarding the expired medication in the medication cart, the DON stated the expired medications should be disposed and reordered from the pharmacy.
2. On 2/7/23 at 1506 hours, Medication Cart 3 inspection was conducted with RN 1. Medication 3 Cart had the following expired IV supplies:
- 11 pieces of SafetyGlide Needles (needle used to access a vein) had expired on 1/21,
- one piece of Integra syringe with needle had expired on 6/17,
- four pieces of Max Plus needleless connector (plastic cap used to access an IV) had expired on 1/19/23,
- one piece of Max Plus needleless connector had expired on 1/22/23,
- one piece of Max Plus needless connector had expired on 2/6/23,
- one piece of SorbaView Shield (type of dressing) had expired on 4/22,
- one piece of Tagaderm (type of dressing) had expired on 9/19,
- one piece of Flexigrid Opsite (type of dressing) had expired on 5/21,
- 6 packs of IV start kits had expired on 8/10/22,
- 23 packs of IV start kits had expired on 1/15/23, and
- one pack of IV start kit had expired on 1/5/23.
RN 1 verified the above expired IV supplies in Medication Cart 3. When asked if the above supplies should be in the medication cart, RN 1 stated the supplies should be discarded when expired.
On 2/9/23 at 1309 hours, an interview was conducted with the DON. When asked if the expired supplies should be in the medication cart, the DON stated the expired supplies in the medication cart should be disposed and reordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0825
(Tag F0825)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to provide the rehabilitation services for one of 14 final sam...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to provide the rehabilitation services for one of 14 final sampled residents (Resident 30).
* The facility failed to ensure Resident 30 was provided RNA services for ambulation when Resident 30 was in isolation for Covid-19. This failure had the potential for Resident 30 to decline in the resident's range of motion and mobility.
Findings:
On 2/7/23 at 1124 hours, during the initial tour of the facility, an interview was conducted with Resident 30. Resident 30 stated she was supposed to walk, but it was stopped while she was in isolation for Covid-19. Resident 30 stated she was out of the isolation for Covid-19 on Thursday, and the staff started to walk her again. Resident 30 stated she felt she was relearning to walk again.
Medical record review for Resident 30 was initiated on 2/7/23. Resident 30 was readmitted to the facility on [DATE].
Review of the MDS dated [DATE], showed Resident 30 was cognitively intact and required extensive assistance of one person for walking.
Review of Resident 30's Order Summary Report showed the following physician's orders dated:
- On 1/4/23, RNA ambulation with FWW (front-wheeled walker) five times per week daily as tolerated; and
- On 1/23/23, to hold RNA ambulation for duration of Covid isolation, and the resident to ambulate with RCA (resident care ambassador, CNA) as tolerated.
Review of Resident 30's RNA Monthly Report for January and February 2023 showed Resident 30 was documented as hold from 1/23 to 2/2/23.
Review of Resident 30's Documentation Survey Report v2 for January and February 2023, under the section for walk in room showed Resident 30 was documented as 97 which meant not applicable from 1/22 to 2/3/23.
Review of the Resident 30's Progress Notes showed a health status note dated 1/23/23, showing Resident 30 was tested positive for Covid-19 and was transferred to another room. Further review of the progress notes showed Resident 30 was afebrile and had no cough, no congestion, nor shortness of breath.
Review of Resident 30's Medication Administration Record showed Resident 30 was administered Safe Tussin DM (cough medication) on 1/27/23 at 1330 hours.
On 2/9/23 at 1050 hours, an interview and concurrent medical record review was conducted with RNA 2. When asked about RNA services provided for Resident 30, RNA 2 stated Resident 30 had an order for ambulation with RNA; however, the RNA services were put on hold because she was in isolation for Covid-19. RNA 2 stated they documented this in the RNA Monthly Report form.
On 2/9/23 at 1453 hours, an interview and concurrent medical record review was conducted with the MDS/Case Management Director. The MDS/Case Management Director verified the above findings. The MDS/Case Management Director stated he was in charge of the RNA program. When asked about RNA services provided for Resident 30, the MDS/Case Management Director stated the RNA services for ambulation was not provided to Resident 30 because of the resident's COVID-19 positive status, and isolation from 1/23 to 2/3/23. When asked why RNA services were on hold when Resident 30 was in isolation for Covid-19, the MDS/Case Management Director stated Resident 30 was coughing and could not tolerate the RNA services. However, the MDS/Case Management Director could not find documentation showing Resident 30 could not tolerate RNA services while in isolation for Covid-19. The MDS/Case Management Director showed the MAR showing Resident 30 was given a one dose of cough medication on 1/27/23. When asked for documentation when he spoke with the physician regarding holding the RNA services for the residents on isolation for Covid-19, the MDS/Case Management Director could not find any documentation.
On 2/10/23 at 0831 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified the above findings. When asked why RNA services were on hold when Resident 30 was in isolation for Covid-19, the DON stated the RNA services should not have stopped even if the resident was in isolation for Covid-19 unless the resident could not tolerate the ambulation. The DON stated the RNA services for ambulation was supposed to be done by the CNA while Resident 30 was in isolation for Covid-19. The DON could not find documentation the CNA ambulated Resident 30 while in isolation for Covid-19.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen.
* The facility failed to ensure the expired food items in th...
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Based on observation, interview, and facility P&P review, the facility failed to ensure the sanitary requirements were met in the kitchen.
* The facility failed to ensure the expired food items in the walk-in refrigerator and dry storage area were discarded.
* The facility failed to ensure the labeling and dating of foods in the kitchen and refrigerator used for the residents' food brought in by the visitors were proper.
* The facility failed to ensure the kitchen equipment was clean.
* The facility failed to ensure the resident dishware and utensils had a smooth cleanable surface.
* The facility failed to ensure the sanitizer test strips had not expired.
* The facility failed to ensure the backflow prevention of one air gap was properly maintained.
These failures had the potential to cause the foodborne illnesses in a medically vulnerable resident population who consumed food prepared in the kitchen.
Findings:
Review of the CMS 672 Resident Census and Conditions of Residents completed by the facility dated 2/7/23, showed 32 of 32 residents in the facility received food prepared in the kitchen.
1. Review of the facility's P&P titled Food Storage revised 11/1/14, showed the food items should be stored, thawed, and prepared in accordance with good sanitary practice. Any expired or outdated food products should be discarded.
a. On 2/7/23 at 0839 hours, during the initial tour of the main kitchen, an opened bottle of Hershey's chocolate sauce with a use-by-date of 2/6/23, was observed inside the refrigerator. [NAME] 1 verified the finding.
b. On 2/7/23 at 0854 hours, a bin containing breadcrumbs with a use-by-date of 1/10/23, was observed inside the dry storage area of the main kitchen. [NAME] 2 verified the finding.
c. On 2/7/23 at 0900 hours, an opened bottle of Tajin with a use-by-date of 2/6/23 was observed on the kitchen counter in the main kitchen, and a bin containing white onions with a use-by-date of 2/6/23, was observed below the kitchen preparation table counter in the main kitchen. The Production Chef verified the findings.
2.a. Review of the facility's P&P titled Food Storage revised 11/1/14, showed all products should be dated upon receipt and when they are prepared; and use use by dates on all food stored in refrigerators.
On 2/7/23 at 0839 hours, during the initial tour of the main kitchen. The following was observed:
- five opened bags of bread with no opened dates and use-by dates were stored in the bread storage rack;
- an opened bottle of Butter-it Creamy Soybean Liquid butter alternative with no opened date and use-by-date
- an opened bottle of vegetable oil with no opened date and use-by-date;
- an opened can of griddle and cooking spray with no opened date and use-by-date;
- two opened bottle with yellow liquid sauce with no label, opened date and use-by-date; and
- an opened bottle with pale yellow liquid with no label, opened date and use-by-date;
Cook 2 verified the above findings.
b. On 2/7/23 at 0900 hours, the following was observed in the main kitchen:
- a half of a cut onion wrapped in a cling wrap with no preparation date and use-by-date in a bin of onions; and
- a half of a cut potato wrapped in a cling wrap with no preparation date and use-by-date in a bin of potatoes.
The Production Chef verified the above findings. The Production Chef stated the sliced onion and potato should have been labeled with the preparation date and use-by-date and should have been stored inside the refrigerator.
c. Review of the facility's document titled Resident's Refrigerator (undated) showed to ensure the food items are properly stored/covered and labeled with the following information: the resident's name, resident's room number, and date stored. Items will be discarded 72 hours after date stored.
On 2/8/23 at 0820 hours, an observation of the residents' refrigerator located in the staff lounge was conducted with the DSS. An opened bottle of soda with no label was observed inside the residents' refrigerator. The DSS verified the findings.
3. According to the USDA Food Code 2017, 4-602.13, Non-Contact Surfaces, nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues.
a. On 2/8/23 at 0819 hours, a storage rack storing bowls was observed with dried black particles. The DSS verified the findings and stated the storage rack should have been properly cleaned before storing the bowls.
b. On 2/8/23 at 1555 hours, the heated plate lowerator (a spring-activated device which heats and raises stacks of plates to service level position) was observed with dried black particles. The DSS verified the findings and stated she would ask the maintenance to clean the plate lowerator.
4. According to the USDA Food Code 2017, Section 4-101.11, Multiuse, Characteristics, materials that are used in the construction of utensils and food contact surfaces of equipment may not allow the migration of deleterious substances or impart colors, odors, or tastes to food and under normal use conditions shall be durable, corrosion-resistant, nonabsorbent, finished to have a smooth, easily cleanable surface, and resistant to pitting, chipping, crazing, scratching, scoring, distortion, and decomposition.
a. On 2/8/23 at 0819 hours, a spatula with chipped handle was observed inside a bin with scoops. The DSS verified the findings.
b. On 2/8/23 at 1600 hours, the plate domes and bottom plates were observed on the shelf near the tray line area. Several plate domes and bottom plates were observed with chipped edges. The Director of Dietary Services verified the findings.
5. According to the USDA Food Code 2017, 4-701.10, Food Contact Surfaces and Utensils, effective sanitization procedures destroy organisms of public health importance that may be present on wiping cloths, food equipment, or utensils after cleaning, or which have been introduced into the rinse solution.
Review of the manufacturer's safety information on the sanitizer test strips (undated), underTesting Use Solution Concentration, showed the shelf-life for the sanitizer test strips is two years.
On 2/9/23 at 1330 hours, an observation of the sanitization solution test was conducted with the Dietary Aide. The Dietary Aide checked the concentration of the sanitizer using a paper test strip taken from a bottle of sanitizer test strips. The sanitizer test strip container had an expiration date of 09/2022.
On 12/9/22 at 0858 hours, an interview was conducted with the Dietary Services Director. The Director of Dietary Services verified the sanitizer test paper had expired.
6. According to the USDA Food Code 2017, 5-202.13, Backflow prevention, Air Gap, an air gap between the water supply inlet and flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm.
On 2/8/23 at 1110 hours, an observation in the main kitchen area was conducted. Two metal pipes and three hoses were observed below the flood level and into the drainage inlet. [NAME] 2 verified the findings and stated the maintenance department was responsible for the drainpipes in the kitchen.
On 2/9/23 at 1402 hours, an observation in the main kitchen area and concurrent interview was conducted with the Director of Maintenance and Maintenance Supervisor. The two drainpipes were observed above the flood level of the drainage inlet; however, the three hoses were observed below the flood level and into the drainage inlet. The Director of Maintenance and Maintenance Supervisor verified the findings. The Director of Maintenance stated the two drainpipes and two hoses were connected to the steamer, and one hose was connected to the water filtration system.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Handwashing/Hand Hygiene revised [DATE], showed all personnel shall follow the hand washi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's P&P titled Handwashing/Hand Hygiene revised [DATE], showed all personnel shall follow the hand washing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.
Review of the facility's P&P titled Infection Prevention and Control Guidelines revised [DATE], showed employees must wash their hands, scrubbing for twenty seconds using soap and water under the following conditions: before and after direct contact with residents; after contact with blood, body fluids, secretions, mucous membranes, or non-intact skin; and after removing gloves.
Review of the facility's P&P titled Wound Care/Change of dressing revised [DATE], showed the following:
- Wash hands (alcohol-based hand rub may be used at this point). Apply clean gloves.
- Remove of dressing and discard in the appropriate disposal bag.
- Remove gloves. Wash hands (alcohol-based hand rub may be used at this point). Apply clean gloves.
- Cleanse wound with solution ordered. Do not directly touch any item that will come in contact with the wound. Wash from the center of the wound to the periphery. Always wash from the area of least contamination to the area of most contamination.
- Observe the wound for size, color, drainage, appearance, and amount of drainage. Measure the area before any medication is applied.
- Remove gloves. Wash hands (alcohol-based hand rub may be used at this point). Apply clean gloves.
- Apply ointment, cream, or any medication ordered and dress the wound.
- Discard soiled materials in plastic bag.
- Remove gloves and wash hands.
Medical Record review for Resident 17 was initiated on [DATE]. Resident 17 was admitted on [DATE].
Review of Resident 17's plan of care showed a care plan problem dated [DATE], addressing pressure injury to the: coccyx, with the interventions including to observe good infection control when dealing with ulcer (an injury to the skin and underlying tissue resulting from prolonged pressure on the skin).
On [DATE] at 1408 hours, a wound care observation and concurrent interview was conducted with RN 1. RN 1 donned new gloves, entered Resident 17's room to greet Resident 17 and CNA 1, then went back to the treatment cart to gather supplies. RN 1 discarded his used gloves. RN 1 then donned new gloves and started with Resident 17's wound treatment. RN 1 positioned Resident 17 on her left side. RN 1 proceeded to remove Resident 17's sacrococcyx wound dressing, discarded the wound dressing in a trash bin next to the bed, then cleansed the wound with a new normal saline soaked gauze. RN 1 then removed his gloves and went to the treatment cart to gather more supplies. RN 1 put on new gloves; however, RN 1 did not perform hand hygiene. RN 1 then dressed the wound with a new dressing. Afterwards, RN 1 prepared a new dressing for Resident 17's right nephrostomy tube (a thin plastic tube passed from the back, thrugh the skin and then through the kidney, to the point where the urine collects to temporarily drain the urine that is blocked) without changing his gloves or performing hand hygiene. RN 1 then removed the old nephrostomy tube dressing and placed the new dressing at the site. Resident 17 was then repositioned on her back by CNA 1 and RN 1. RN 1did not perform hand hygiene or change his gloves. RN 1 proceeded to change the dressing on Resident 17's abdominal wound. RN 1 removed and discarded the old dressing, cleansed the wound with a normal saline soaked gauze, and placed a new dressing on Resident 17s' abdominal wound. RN 1 then removed his used gloves and went back to the treatment cart for more supplies. RN 1 did not perform hand hygiene but put on new gloves. Resident 17 was then turned to her right side by CNA 1. RN 1 removed and discarded Resident 17's old left nephrostomy tube dressing, then placed a new dressing to the tube site. RN 1 did not perform hand hygiene or change gloves prior to, during, or after the wound care was performed. When asked what the expectation was regarding hand washing during wound care, RN 1 stated he was expected to change his gloves and wash his hands in between wound care. When asked why he did not change his gloves or wash his hands when working with Resident 17's different wound sites, RN 1 stated he forgot.
On [DATE] at 0924 hours, an interview was conducted with the DON. The DON stated the staff should be washing their hands before putting on gloves. The DON further stated the staff should be performing hand hygiene and changing gloves in between different wound sites.
Based on observation, interview, medical record review, facility P&P review, and facility document review, the facility failed to maintain the infection control program designed to provide the safe environment and reduce the risk of development of illnesses and transmission of diseases.
* The facility failed to show documentation of the Legionella (a bacteria that can cause a serious type of lung infection) facility risk assessment and testing protocols.
* The facility failed to implement proper hand hygiene and changing gloves during wound care.
* The facility failed to ensure a confirmed COVID-19 case was assessed every four hours for respiratory rates, temperatures, and oxygen saturation levels as per the facility's P&P for Resident 25.
* LVN 2 failed to disinfect the self-sealing stopper top of the insulin (medication to lower blood sugar) vial prior to withdrawing the medication. This posed a risk for increased infection.
These failures had the potential to result in the transmission of infection to a vulnerable population of residents in the facility.
Findings:
1. According to the CMS QSO 17-30 titled Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaire's Disease dated [DATE], the facilities must develop and adhere to policies and procedures that inhibit microbial growth in building water systems that reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. These facilities must have water management plans and documentation to ensure each facility:
- Conducts a facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens (e.g. Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria, and fungi) could grow and spread in the facility water system.
- Specifies testing protocols and acceptable ranges for control measures and documents the results of testing and corrective actions when control limits are not maintained.
Review of the facility's P&P titled Water Management revised [DATE] showed the facility supports the prevention, detection, and control of water-borne containments, including Legionella. Further review of the policy showed it did not include methods to identify or test for waterborne pathogens.
Review of the Facility Assessment revised [DATE], showed no risk assessments or methods listed to identify and test for Legionella and waterborne pathogens in the water management program.
On [DATE] at 1110 hours, an interview was conducted with the DSD/IP. The DSD/IP acknowledged there was no water management program policy for Legionella in the Infection Control binder.
On [DATE] at 1124 hours, an interview was conducted with the Maintenance Supervisor. The Maintenance Supervisor stated the water was routinely checked for leaking and spills; however, it was not tested.
On [DATE] at 1237 hours, an interview was conducted with the Administrator and DON. The Administrator and DON verified there was a P&P for Water Management; however, the policy did not include the risk assessment or testing methods to identify and test for Legionella. The Administrator and DON acknowledged the facility should have had a documented risk assessment and testing methods in the water management plan.
4. On [DATE] at 1206 hours, a medication administration observation for Resident 16 was conducted with LVN 2. LVN 2 was observed to find Resident 16's Novolin R FlexPen in Medication Cart 2 had expired. LVN 2 obtained a new vial of Novolin R insulin medication from the facility's emergency kit. LVN 2 was observed removing the plastic top of the insulin vial, withdrawing the medication from the vial, and administering the insulin to Resident 16 via subcutaneous injection. LVN 2 did not disinfect the self-sealing stopper top of the insulin vial with an antimicrobial swab prior to withdrawing the insulin.
On [DATE] at 1229 hours, an interview was conducted with LVN 2. When asked if LVN 2 disinfected the top of the insulin vial, LVN 2 acknowledge the above findings.
On [DATE] at 1309 hours, an interview was conducted with the DON. When asked if the nurse was supposed to disinfect the top of the vial after opening, the DON stated the nurse was supposed to wipe the top of the vial with alcohol.
Cross reference to F761, example #1.
3. Review of the facility's P&P titled Isolating Residents During COVID-19 (undated) showed it is the facility's policy to maintain procedures for isolating COVID-19 positive residents. Further review of the facility's P&P showed the resident in a COVID-19 positive room will be assessed by a licensed nurse every four hours documenting Resident respiratory rates, temperatures, and oxygen saturation levels.
Review of Resident 25's medical record was initiated on [DATE]. Resident 25 was admitted to the facility on [DATE].
Review of the facility's document titled COVID-19 SNF Resident Surveillance Test as of [DATE] showed Resident 25 was tested positive for COVID-19.
Review of the Order Summary Report for [DATE] failed to show an order to monitor Resident 25'srespiratory rates, temperatures, and oxygen saturation levels every four hours.
Review of Resident 25's eMAR for [DATE], failed to show Resident 25's monitoring forrespiratory rates, temperatures, and oxygen saturation levels every four hours as per the facility's P&P.
On [DATE] at 0914 hours, an interview and concurrent medical record review was conducted with LVN 3. LVN 3 was informed and verified the above findings. LVN 3 stated it should have been monitored every four hours as per the facility's policy and to evaluate the resident's condition.
On [DATE] at 0932 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified and acknowledged the above findings. The DON further stated it should be monitored to provide proper care for the resident.
Aug 2019
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the Pharmacy Consultant identified and reported any ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the Pharmacy Consultant identified and reported any irregularities to the attending physician and facility for one of 12 final sampled residents (Resident 11). There was no documentation to show the Pharmacy Consultant reevaluated and followed up on the monitoring for the use of divalproex sodium as a seizure medication for Resident 11. This posed the risk for Resident 11 to have adverse consequences from the medication.
Findings:
Review of Lexicomp (an online drug reference) showed valproic acid is an anticonvulsant used as both mono and adjunctive therapy primarily in the treatment of epilepsy. To maintain a therapeutic window and prevent toxicity, serial monitoring is recommended.
Medical record review for Resident 11 was initiated on 8/20/19. Resident 11 was admitted to the facility on [DATE].
Review of the Order Summary Report showed a physician's order dated 12/13/18, for divalproex sodium capsule delayed release sprinkle 125 mg one capsule by mouth three times a day for seizure prophylaxis.
Review of the medical record failed to show Resident 11 was monitored for seizure activity/episodes nor for medication side effects.
Review of the medical record failed to show Resident 11's valproic acid level was checked since 12/13/18.
Review of the Pharmacy Consultant's monthly medication regimen review failed to show recommendations related to the use of divalproex sodium.
On 8/23/19 at 1046 hours, a telephone interview was conducted with the Pharmacy Consultant. When asked if a baseline valproic acid level was necessary upon initiation of the divalproex sodium to Resident 11, the Pharmacy Consultant stated yes. When asked if she was aware there was no monitoring for seizure episodes, the Pharmacy Consultant stated she thought the divalproex acid was used for Resident 11's behavior; however, the Pharmacy Consultant verified she failed to address these on her monthly medication regimen review. Cross reference to F757, example #1.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure two of 12 final sampled residents (Residents 5 and 1...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure two of 12 final sampled residents (Residents 5 and 11) were free from unnecessary drugs.
* Residents 5 was receiving the blood pressure medications without blood pressure parameters when to hold or administer the medication.
* Resident 11 was receiving divalproex sodium capsule (brand name is valproic acid, a medication for seizure) since 12/13/18. The facility failed to ensure Resident 11's valproic acid level was checked and seizure activity was being monitored.
These failures had the potential for the residents to receive unnecessary medications and developing significant side effects.
Findings:
1. Medical record review for Resident 11 was initiated on 8/20/19. Resident 11 was admitted to the facility on [DATE].
Review of the Order Summary Report showed a physician's order dated 12/13/18, for divalproex sodium capsule delayed release sprinkle 125 mg one capsule by mouth three times a day for seizure prophylaxis.
Review of the plan of care showed a care plan problem to address the risk for seizure was initiated on 12/16/18. The interventions included to administer divalproex as ordered and monitor/document for the effectiveness and side effects.
Review of the medical record failed to show documentation Resident 11 was monitored for the seizure activity/episodes nor the medication side effects. In addition, there was no documentation to show Resident 11's valproic acid level was checked since 12/13/18.
On 8/23/19 at 1009 hours, an interview and concurrent medical record review for Resident 11 was conducted with LVN 1. LVN 1 reviewed the medical record and verified there was no valproic acid level monitoring done for Resident 11 since 12/13/18. LVN 1 also verified Resident 11 was not monitored for seizure activity/episodes and side effects. [Cross reference to F756]
2. Review of Lexicomp (an online drug reference) showed concurrent drug therapy issues related to the use of antihypertensives and levodopa-containing products included drug to drug interactions that may enhance the hypotensive (low blood pressure) effect of the medications, requiring additional monitoring.
Medical record review for Resident 5 was initiated on 8/20/19. Resident 5 was admitted to the facility on [DATE].
Review of the Order Summary Report showed the following physician's orders dated 11/22/18:
- losartan potassium (blood pressure medication) 50 mg one tablet by mouth at bedtime for hypertension;
- triamterene-hydrochlorothiazide (blood pressure medication) 37.5-25 mg one tablet by mouth once a day for hypertension; and
- carbidopa-levodopa (medication used to treat Parkinson's disease) 25-100 mg one tablet by mouth three times a day.
There were no parameters when to give or hold the blood pressure medications.
On 8/21/19 at 1505 hours, an interview and concurrent medical record review for Resident 5 was conducted with RN 1. RN 1 reviewed the medical record and verified there was no parameter ordered when to give or hold the blood pressure medications. RN 1 stated they were supposed to check the blood pressure before administering a blood pressure medication to the resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to ensure the food items were labeled and dated properly in the dietary kitchen. This had the potential to result in expired food being served a...
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Based on observation and interview, the facility failed to ensure the food items were labeled and dated properly in the dietary kitchen. This had the potential to result in expired food being served and cause foodborne illnesses in the highly susceptible resident population.
Findings:
Review of the CMS 672 completed by the DON dated 8/20/19, showed 34 residents received food prepared in the kitchen.
According to the Federal Food Code (2017), the refrigerated foods kept longer than 24 hours are to have a date to identify when it is to be used or discarded.
On 8/20/19 at 1137 hours, an initial tour of the kitchen was conducted with the Chef Assistant. The following items were observed in the produce walk in refrigerator:
- Ten packages of corn tortillas were observed were not labeled or dated.
- Five packages of flour tortillas were observed were not labeled or dated.
- One box of peeled carrot was observed used by dated 8/17/19.
- One bag of six baguettes was observed was not labeled or dated.
The Chef Assistant and the RD verified the above findings.
On 8/20/19 at 1604 hours, an observation of the walk-in freezer was conducted with the Chef Assistant. Two clear plastic bags of fish were observed without the name of the type of food, received date, and open date. The Chef Assistant verified the findings.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected most or all residents
Based on observation, interview, and facility P&P review, the facility failed to maintain the essential equipment in proper working order. The temperature of the walk-in freezer in the main kitchen an...
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Based on observation, interview, and facility P&P review, the facility failed to maintain the essential equipment in proper working order. The temperature of the walk-in freezer in the main kitchen and freezer in the satellite kitchen were both too warm. This failure caused food to not be stored at the proper tempature.
Findings:
Review of the CMS 672 completed by the DON dated 8/20/19, showed 34 residents received food prepared in the facility's kitchen.
Review of the facility's P&P dated 11/1/14, titled Food Storage showed frozen meat, poultry, and foods are to be store promptly at 0 degree Fahrenheit or less or at a temperature that maintains the food frozen.
1. On 8/20/19 at 1137 hours, an observation and concurrent interview was conducted with the Chef Assistant. Observation of the walk-in freezer showed the digital thermometer registered 24 degrees Fahrenheit, and a thermometer hanging inside this freezer on a food rack registered 30 degrees Fahrenheit. At this time, a dietary staff member was observed arranging boxes of food in the walk-in freezer. The Chef Assistant acknowledged the reading of freezer temperature was too warm. The Chef Assistant stated the freezer might be warmer than normal due to it being in defrost mode, the staff were putting away a delivery of food, and there was more staff traffic due to lunchtime food preparation.
On 8/20/19 at 1604 hours, the walk-in freezer showed the digital thermometer was observed to registered 24 degree Fahrenheit and contained items that were either expired or not labeled. For example:
- 10 trays of cake dated as prepared on 8/4 and 8/9/19
- two bags of lemon creams
- one bag of cream puffs
- two trays chicken and beef which were soft to touch
The Chef Assistant stated two trays of chicken and beef were placed in the walk-in freezer earlier that day. The Chef Assistant acknowledged the freezer temperature was warm and got another thermometer from the outside to check the freezer temperature. After waiting for 20 minutes, the thermometer registered 25 degree Fahrenheit.
On 8/21/19 0748 hours, an observation and concurrent interview was conducted with the RD, the DON and the DSD. Observation of the walk-in freezer showed water dripping from the ceiling and from a sprinkler located in the middle of the ceiling. The DSD stated the technician was working the on the top of the freezer now. The DON and the DSD verified there was no documented temperature log of the freezer from last night. The RD and Chef Assistant verified the following food products were starting to thaw and becoming soft: one box of liver, one box of hamburger patties, one box of lamb, one box of turkey hot dogs and one box of beef hot dogs. The staff were observed to discard all of these boxes. The remaining meat products remained frozen and hard. The RD stated she would monitor these meat products.
Review of the Record of Freezer Temperature log hanging on the wall outside the walk-in freezer showed a posting to the staff which read: Refrigerator: not greater than 41 degrees; Freezer: not greater than 41 degrees. The RD verified the finding and stated the freezer range was supposed to be less than 0 degree Fahrenheit.
On 8/21/19 at 0833 hours, an interview was conducted with an outside company freezer technician. The Freezer Technician stated he replaced the defrost timer the previous night. He stated the normal cycle of the freezer is for it to go through defrost mode four times a day, every six hours for 30 minutes. The Freezer Technician stated when he arrived that morning at 0615 hours, the temperature of the walk-in freezer was 25 degree Fahrenheit.
On 8/21/19 at 1015 hours, an observation and concurrent was conducted with the RD and the DON. Observation of the walk-in freezer showed thermometer registered 28 degree Fahrenheit, and the thermometer hanging on the rack register 30 degree Fahrenheit. Inside the freezer was one box of green beans, one box of chicken, three box of fish, three boxes of bacon, one box of cut apples, two boxes of frozen berries, and 17 bottles of juices (cranberries and orange). All of the items were beginning to thaw. The RD stated she would dispose all the meat products from the freezer. The DON stated the facility was in the process of renting a mobile freezer.
Review of the outside company's Service Order Invoice dated 8/22/19, showed the walk-in freezer had too many cracks and air leaks and the system would not go down to 0 degree. Recommend to replace freezer box.
2. On 8/22/19 1415 hours, observation of the satellite kitchen and concurrent interview was conducted with the Director of Dietary. The thermometer outside of the freezer was observed showing defrost. The thermometer inside the freezer showed the temperature registered 30 degrees Fahrenheit. The Director of Dietary acknowledged the findings and stated the freezer was defrosted mode. However, observation of the ice cream and magic cups sitting on four trays inside the freezer were observed to be melted or very soft. The dietician was notified. The RD stated these items may have been taken out for the residents' lunch meal, not consumed and returned to the freezer but had not had time to refreeze. However, further inspection of the freezer showed eleven boxes of ice cream, magic cup, and sherbet were all found to be very soft and melted. The RD stated she would dispose all of box of the ice cream, sherbet, and magic cups in this freezer.
MINOR
(B)
Minor Issue - procedural, no safety impact
Resident Rights
(Tag F0550)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the dignity and respect were maintained for one nons...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the dignity and respect were maintained for one nonsampled resident (Resident 380). This resulted in the resident feeling unhappy, upset, and had the potential to lower Resident 380's self-esteem.
Findings:
On 8/21/19 at 1040 hours, an interview was conducted with Resident 380 who stated he had to wait more than 15 minutes for a CNA to respond to their call light during the evening shift (1500-2300). Resident 380 stated he needed assistance to the bathroom; however, by the time, the CNA 3 arrived, it was too late and he had already wet the bed. Resident 380 stated this made him feel upset.
On 8/21/19 at 1444 hours, an interview was conducted with CNA 1 who reported Resident 380 was not on a toilet training program because he was alert and able to make his needs known. CNA 1 stated Resident 380 was continent of bowel and bladder. CNA 1 stated Resident 380 used his call light when he needed assistance to the bathroom.
On 8/22/19 at 0754 hours, a follow-up interview was conducted with Resident 380. Resident 380 stated facility staff recommended he wear briefs (diaper) while in this facility. Resident 380 stated he had never worn diapers before.
Resident 380 stated he felt uncomfortable and embarrassed wearing the diapers and would prefer not to wear them.
On 8/22/19 at 1043 hours, medical record review was initiated for Resident 380. Review of the MDS dated [DATE], showed Resident 380 was alert, oriented, and able to make his needs known. He was assessed to need one person's extensive assistance with the use of the walker and wheelchair, and was continent of both bowel and bladder.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most California facilities.
- • 38% turnover. Below California's 48% average. Good staff retention means consistent care.
Concerns
- • 44 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 60/100. Visit in person and ask pointed questions.
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About This Facility
What is Freedom Village Healthcare Center's CMS Rating?
CMS assigns FREEDOM VILLAGE HEALTHCARE CENTER an overall rating of 3 out of 5 stars, which is considered average nationally. Within California, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Freedom Village Healthcare Center Staffed?
CMS rates FREEDOM VILLAGE HEALTHCARE CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 38%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Freedom Village Healthcare Center?
State health inspectors documented 44 deficiencies at FREEDOM VILLAGE HEALTHCARE CENTER during 2019 to 2025. These included: 40 with potential for harm and 4 minor or isolated issues.
Who Owns and Operates Freedom Village Healthcare Center?
FREEDOM VILLAGE HEALTHCARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by FREEDOM MANAGEMENT COMPANY, a chain that manages multiple nursing homes. With 52 certified beds and approximately 39 residents (about 75% occupancy), it is a smaller facility located in LAKE FOREST, California.
How Does Freedom Village Healthcare Center Compare to Other California Nursing Homes?
Compared to the 100 nursing homes in California, FREEDOM VILLAGE HEALTHCARE CENTER's overall rating (3 stars) is below the state average of 3.1, staff turnover (38%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Freedom Village Healthcare Center?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Freedom Village Healthcare Center Safe?
Based on CMS inspection data, FREEDOM VILLAGE HEALTHCARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in California. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Freedom Village Healthcare Center Stick Around?
FREEDOM VILLAGE HEALTHCARE CENTER has a staff turnover rate of 38%, which is about average for California nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Freedom Village Healthcare Center Ever Fined?
FREEDOM VILLAGE HEALTHCARE CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Freedom Village Healthcare Center on Any Federal Watch List?
FREEDOM VILLAGE HEALTHCARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.