Does MIRAGE POST ACUTE have any serious inspection findings?

Yes, MIRAGE POST ACUTE has 3 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 247 total deficiencies from recent inspections.

What are the staffing levels at MIRAGE POST ACUTE?

MIRAGE POST ACUTE has a four-star staffing rating from CMS with 0.33 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is MIRAGE POST ACUTE located?

MIRAGE POST ACUTE is located in LANCASTER, CA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does MIRAGE POST ACUTE have?

MIRAGE POST ACUTE has 299 certified beds.

Who owns MIRAGE POST ACUTE?

MIRAGE POST ACUTE is a for profit - partnership facility and is part of the PACS GROUP chain.

What questions should families ask when visiting MIRAGE POST ACUTE?

Families visiting MIRAGE POST ACUTE should ask about what corrective actions were taken after fines, how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does MIRAGE POST ACUTE compare to other nursing homes?

MIRAGE POST ACUTE has a 1-star overall rating, which is below average compared to other nursing homes in CA. Families should carefully review inspection findings and consider alternatives.

MIRAGE POST ACUTE

Name: MIRAGE POST ACUTE
Address: 44445 15TH ST W, LANCASTER, CA, 93534, US
Telephone: (661) 948-7501
Rating: 1.0

44445 15TH ST W, LANCASTER, CA 93534 · (661) 948-7501

For profit - Partnership 299 Beds PACS GROUP Data: November 2025 3 Immediate Jeopardy citations

Trust Grade

0/100

#1067 of 1155 in CA

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Last Inspection: January 2025

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

Overview

Mirage Post Acute in Lancaster, California, has a Trust Grade of F, indicating significant concerns regarding care quality. Ranked #1067 out of 1155 facilities in California, it falls in the bottom half of all nursing homes in the state, and at #322 out of 369 in Los Angeles County, only a few local options are worse. Despite a trend of improvement in overall issues, with a reduction from 101 in 2024 to 80 in 2025, the facility still faces serious challenges, including $134,479 in fines, which is concerning as it exceeds the fines of 80% of California facilities. Staffing is rated at 4 out of 5 stars, showing a strength in this area with a turnover of 45%, which is average for California, but RN coverage is below average, being less than 91% of other facilities. Specific incidents of concern include a failure to notify a physician about a resident's dangerously low blood pressure and high heart rate, leading to life-threatening respiratory distress, and neglect in addressing the resident's critical condition, highlighting both serious deficiencies in care and areas that need urgent attention.

Trust Score: F
In California: #1067/1155
Safety Record: High Risk
Inspections: Getting Better
Staff Stability: 45% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: $134,479 in fines. Lower than most California facilities. Relatively clean record.
Skilled Nurses: Each resident gets only 20 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 247 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★★★☆

4.0

Staff Levels

★☆☆☆☆

1.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 101 issues

2025: 80 issues

The Good

4-Star Staffing Rating · Above-average nurse staffing levels
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in staffing levels, fire safety.

The Bad

1-Star Overall Rating

Below California average (3.1)

Significant quality concerns identified by CMS

Staff Turnover: 45%

Near California avg (46%)

Higher turnover may affect care consistency

Federal Fines: $134,479

Well above median ($33,413)

Significant penalties indicating serious issues

Chain: PACS GROUP

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 247 deficiencies on record

3 life-threatening 1 actual harm

Sept 2025 5 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure a nasal spray (delivers a fine mist of medicine directly into your nose) was not left at a resident's bedside table and the resident was assessed for self-administration of medication for one of three sampled residents (Resident 5). This deficient practice had the potential to place the other residents at risk to misuse the medication.Findings: During a review of Resident 5's admission Record, the admission Record indicated the facility admitted Resident 5 on 8/22/2025 with diagnoses including diabetes mellitus (a chronic condition where the body has trouble regulating blood sugar (glucose) levels) and hypertension (high blood pressure).During a review of Resident 5's Minimum Data Set (MDS - a resident assessment tool), dated 8/28/2025, the MDS indicated Resident 5's thought process was intact and required supervision from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a concurrent observation and interview on 9/3/2025 at 12:40 p.m. with Resident 5 inside Resident 5's room, observed a bottle of nasal spray on the top of Resident 5's bedside table. Resident 5 stated she last used it this morning and Resident 5's daughters were the ones who brought the medication to her for her nose.During a concurrent observation and interview on 9/3/2025 at 12:45 p.m. with Certified Nursing Assistant (CNA) 10, CNA 10 stated that a bottle of nasal spray was on top of Resident 5's bedside table.During a concurrent observation and interview on 9/3/2025 at 12:59 p.m. with License Vocational Nurse (LVN) 4, observed a bottle of nasal spray on top of Resident 5's bedside table. LVN 4 stated that she was not aware that Resident 5 had a bottle of nasal spray at the bedside table. LVN 4 stated that Resident 5 should not keep a medication at bedside table because other residents could take it and it is possible for other residents to have an adverse reaction that could lead to death from the medication.During an interview on 9/5/2025 at 1:30 p.m. with the Director of Nursing (DON). The DON stated that it was important the Resident 5 must be assessed first before allowing Resident 5 to self-administer her own medication. The DON stated there is a potential it could cause an accident because other residents could access the medication from Resident 5's bedside table. The DON stated the medication must be stored in a secure location.During a review of the facility's policy and procedure titled, Self- Administration of Medications, last review date of 4/29/2025, the policy and procedure indicated, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Self- administered medications are stored in a safe and secure place, which is not accessible by other residents.

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer an antibiotic as ordered by the physician for one of three sample residents (Resident 1). This deficient practice had the potential for Resident 1's health condition to be untreated that can lead to physical harm. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility initially admitted Resident 1 on 2/12/2025 and readmitted on [DATE] with diagnoses including an encounter for attention to gastrostomy (a surgically created opening into the stomach) and chronic obstructive pulmonary disease (a permanent lung condition that makes it progressively harder to breathe because airways and air sacs in the lungs are damaged and narrowed). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 8/21/2025, the MDS indicated Resident 1 was severely impaired with thought process and required dependent assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 1's General Acute Care Hospital (GACH) Discharge Summary Order, dated 8/27/2025, the GACH Discharge Summary Order indicated Resident 1 to start taking fluconazole (a medication that treats infections caused by fungus or yeast) 200 milligrams (mg - metric unit of weight) 1 tablet daily for seven days. During a review of Resident 1's Order Summary, with order date of 8/28/2025, the Order Summary indicated to give one tablet of fluconazole 200 mg one time a day for sepsis (when your body has an extreme, life-threatening reaction to an infection that causes widespread inflammation and can lead to organs failing) for seven days, with indicated start date of 8/29/2025. During a review of Resident 1's Nursing Admission/readmission Evaluation/Assessment, dated 8/28/2025 at 9 a.m., the Nursing Admission/readmission Evaluation/Assessment indicated that Resident 1 was transferred to the facility via ambulance from GACH 1. During a review of Resident 1's Situation Background Appearance Review (SBAR) Communication Form, dated 8/28/2025 at 4 p.m., the SBAR Communication Form indicated at 4:30 p.m. Resident 1 was noted with blood pressure of 210/99 millimeter of Mercury (mmHg - unit of measurement) and pulse rate of 99 and Resident 1 was sent out to GACH 1 via ambulance after calling 911 (the number to call for emergency services) at 4:36 p.m. for further evaluation. During a concurrent interview and record review on 9/4/2025 at 1:55 p.m. with Registered Nurse (RN) 1, Resident 1's Nursing Admission/readmission Evaluation/Assessment, dated 8/28/2025, Medication Administration Record dated 8/2025, GACH Discharge summary dated [DATE], and Order Summary dated 8/28/2025 were reviewed. RN 1 stated Resident 1 got readmitted in the facility on 8/28/2025 at 9 a.m. RN 1 stated that Resident 1 did not receive fluconazole on 8/28/2025. RN 1 stated that the GACH Discharge Summary indicated to give fluconazole 200 mg one tablet daily for seven days. RN 1 stated that Order Summary dated 8/28/2025 to give one tablet of fluconazole 200 mg one time a day for Sepsis for seven days, indicated a start date of 8/29/2025. RN 1 stated that fluconazole antibiotic order must be given and carried out within four hours after receiving the order and should not start the next day due to the possibility that Resident 1's condition could decline, and Resident 1's sepsis could recur and could make Resident 1's condition worst. During a concurrent interview and record review on 9/5/2025 at 12:04 p.m. with RN 2, Resident 1's fluconazole order dated 8/28/2025 and Discharge Documentation dated 8/27/2025 were reviewed. RN 2 stated RN 2 was the one who carried out the Fluconazole order with a start date of 8/29/2025 at 9 a.m. under the assumption that the first dose was given from the hospital. During a concurrent interview and record review on 9/5/2025 at 12:31 p.m. with RN 2 and the Director of Nursing (DON), Resident 1's GACH Discharge summary dated [DATE] was reviewed. The DON stated that the antibiotic fluconazole can be started the next day if the staff received an endorsement from GACH that the first dose was already given from GACH 1. During a concurrent interview and record review on 9/5/2025 at 1 p.m. with RN 1, RN 2 and the Director of Nursing (DON), Resident 1's GACH Discharge summary dated [DATE] was reviewed. RN 1 stated that GACH 1 did not give any report and Resident 1 just showed up in the facility with Resident 1's admission packet. RN 1 stated she (RN 1) just depended on the discharge packet given by GACH 1. RN 1 stated that antibiotic order must be carried out within four hours after receiving the order since the antibiotic was available in an emergency kit. RN 2 stated that the antibiotic of Resident 1 must be given and carried out within four to six hours. RN 1 stated Resident 1 stayed in the facility for eight hours before discharging back to GACH 1. RN 2 stated that the facility failed to follow the physician's order due to miscommunication, failure to clarify the order from GACH 1 if first dose of antibiotic was already given. During an interview on 9/5/2025 at 1:30 p.m. with the DON, the DON stated that this was a documentation error because Resident 1's medication was supposed to be scheduled the same day (8/28/2025) of the readmission of Resident 1. The DON stated RN 2 needed to call GACH 1 to clarify if the first dose of the ordered antibiotic was given in GACH 1. During a review of the facility's policy and procedure titled, Physician's Medication and Treatment Orders, last review date of 4/29/2025, the policy and procedure indicated, Orders not specifying the number of doses, or duration of medication, shall be subject to automatic stop orders. One day prior to the date the stop order is to become effective, the nurse supervisor/charge nurse on duty must contact the prescriber or attending physician to determine if the medication is to be continued. During a review of the facility's policy and procedure titled, Reconciliation of Medications on Admission, last review date 4/29/2025, the policy and procedure indicated, The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. Gather the information needed to reconcile the medication list most recent medication administration record (MAR), if this is a readmission. Medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs have been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. If a medication history has not been obtained from the resident or family, complete this first. Information from the medication history should include dose, route, frequency and last dose taken for all items.

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 F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to ensure that one of nine sample resident's (Resident 2) call light was working properly.This deficient practice had the potential to place Resident 2 at risk for an accident like a fall due to not being able to call for help/assistance.Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 8/26/2025 with a diagnosis of hypertension (high blood pressure) and history of falling.During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 9/1/2025, the MDS indicated Resident 2 had intact thought process and required moderate assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a concurrent observation and interview on 9/3/2025 at 11:40 a.m. with Resident 2 inside Resident 2's room, Resident 2 stated that her call light was not working since she got admitted and was using her roommate's call light for Resident 2 to call for help. Resident 2 demonstrated to use her call light and observed that after pressing the call light button the call light was not turning on outside Resident 2's room.During a concurrent observation and interview on 9/3/2025 at 11:47 a.m. with License Vocational Nurse (LVN) 1, observed LVN 1 tried to use Resident 2's call light and observed that the light was not turning on. LVN 1 stated that Resident 2's call light did not turn on outside Resident 2's room. LVN 1 stated that it was important that the call light was working all the time to be able to attend to Resident 2's needs right away and if not, there was a risk of Resident 2's decline that could lead to injury. During an interview on 9/5/2025 at 1:30 p.m. with the Director of Nursing (DON), the DON stated that it was important that the call light was working all the time and this could potentially have a lapse in communication between staff and residents. The DON stated that the staff might not be able to meet the residents' needs immediately.During a review of the facility policy and procedure titled, Call System, Resident, last review date of 4/29/2025, the policy and procedure indicated, The resident call system remains functional at all times. If audible communication is used, the volume is maintained at an audible level that can be easily heard. If visual communication is used, the lights remain functional. The resident call system is routinely maintained and tested by maintenance department.

CONCERN (D) 📢 Someone Reported This

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

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

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain a written authorization or approval from the Department of Healthcare Access and Information (HCAI, previously known as the Office of Statewide Health Planning and Development of OSHPD) prior to the use of portable air-conditioning (AC- a machine that forces cool air into a building) unit. HCAI is the state agency that reviews and approves plans for construction, repairs, renovations, and remodeling made in healthcare facilities to comply with State Building Codes. In addition, the facility failed to notify the Department (Licensing/Certification), within five days of the commencement of any construction/alterations to the skilled nursing facility.This deficient practice placed residents at risk for any safety issues related to the unauthorized use of the portable AC unit. Findings: During an observation on 9/4/2025, at 10:18 a.m., observed room [ROOM NUMBER] with a portable air conditioner (AC) unit actively operating. Observed the portable AC units' ducts (tubes or pipes that carry air in and out of the building) going through the window to the exterior of the building. During a concurrent observation and interview on 9/4/2025 at 10:20 a.m., with Maintenance Assistant (MA), in room [ROOM NUMBER], the MA stated there was a portable AC unit installed with vent attached to the wall secured to window paneling with duct tape.During an interview on 9/4/2025 at 10:28 a.m. with Maintenance Supervisor (MS), the MS stated that per Administrator there was no permit from HCAI, and the Heating, Ventilation, and Air Conditioning (HVAC - refers to the integrated system of equipment that controls the temperature and quality of air within a building) was installed temporarily due to the hot weather. The MS stated that there were 9 units of HVACs in the whole building. The MS stated that the facility did not have any problem with the AC but was just blowing low air and they will just need to check the duct. The MA stated that there was only one portable AC installed in the whole facility. The MA also stated that the AC of the facility was working and has no problem. The MA stated the portable AC was installed due to resident request. During an interview on 9/4/2025 at 12:07 p.m., with the Administrator and Operation Assistant 1, the Administrator stated that HVAC had no permit from HCAI and did not contact HCAI. The Administrator stated he did not know what HCAI was and who was HCAI. The Administrator stated that the facility started using the HVAC on 4/22/2025 after receiving the heat advisory. During an interview on 9/4/2025 at 2:57 p.m., the Administrator stated that around 12 p.m. he contacted HCAI and spoke to HCAI Staff 1 who informed him (Administrator) that if the HVAC was only in a temporary use the facility does not need a HVAC permit from HCAI. The Administrator stated there was no documented evidence that HCAI stated that the facility does not permit HVAC use due to temporary use only of the HVAC.During a review of a facility-provided policy and procedure titled, Use of Portable HVACS, last revised on 4/24/2025, indicated potable HVAC systems should only be considered during power outages as outlined in the emergency preparedness plan or extreme weather conditions.During a review of a facility-provided policy and procedure titled, Maintenance Service, last revised on 4/24/2025, indicated maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned.

CONCERN (E) 📢 Someone Reported This

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

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

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to provide dignity for one of nine sample resident (Resident 7) by failing to ensure that the staff (Licensed Vocational Nurse 5) address Resident 7 by name and not being called honey and to ensure four staff ( three Certified Nursing Assistants and 1 Occupational Therapist) were talking in English all the time in the hallways. These deficient practices had the potential to affect residents' sense of self-worth and self-esteem. A. During a review of Resident 7's admission Record, the admission Record indicated the facility admitted Resident 7 on 9/3/2025 with diagnoses of hypertension (high blood pressure) and difficulty of walking. During a review of Resident 7's Minimum Data Set (MDS - a resident assessment tool), dated 9/9/2025, the MDS indicated Resident 7 had intact thought process and required moderate assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During an observation on 9/4/2025 at 10 a.m. outside Resident 7's room, observed and heard that Licensed Vocational Nurse (LVN) 5 called Resident 7 honey when Resident 7 was asking for his medication. During a concurrent observation and interview on 9/4/2025 at 10:05 a.m., observed and heard LVN 5 called Resident 7 honey again. LVN 5 stated LVN 5 did call Resident 7 honey, and his name is Resident 7 not honey when ask what LVN 7 called Resident 7. During an interview on 9/4/2025 at 10:35 a.m. with LVN 5, LVN 5 stated that LVN 5 should not call nicknames to any residents unless it was care planned and resident's preference. LVN 5 stated Resident 7 might not like it and may feel disrespected. During an interview on 9/5/2025 at 1:30 p.m. with the Director of Nursing (DON), the DON stated that LVN 5 should not call Resident 7 honey because that was a dignity issue and all the staff needs to respect residents by always addressing them by their names. During a review of the facility policy and procedure titled, Dignity, last review date of 4/24/2025, the policy and procedure indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Residents are treated with dignity and respect at all times. Staff speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs. B. During a concurrent observation and interview on 9/5/2025 at 2:47 p.m. with Certified Nursing Assistant (CNA) 6, observed in the hallway outside residents' room that CNA 6 was talking to a staff member walking in the hallway in a different dialect. CNA 6 stated that she responded to the staff with her own dialect because the staff was talking to CNA 6 in their own dialect. CNA 6 stated that CNA 6 should always talk in English all the time because not all the residents can speak their dialect. CNA 6 stated they do not want the residents to feel that staff are talking about them. During a concurrent observation and interview on 9/5/2025 at 2:50 p.m. with CNA 7 and CNA 8 in the hallway outside residents' room, observed CNA 7 and CNA 8 talking in their own dialect while CNA 7 was charting outside residents' room. CNA 8 stated they should not talk in the hallway with our dialect because not all the resident speaks their dialect and they do not want them (residents) to feel that staff were talking about them.During an interview on 9/5/2025 at 1:30 p.m. with the DON, the DON stated the staff should talk in English all the time when around residents' area as a courtesy and respect to the residents.During a review of the facility's policy and procedure titled, Courtesy, last review date of 4/24/2025, the policy and procedure indicated, Communication courtesy is required at all times. Establish and follow first language communication policy to follow at all times.

Aug 2025 4 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to report an allegation of an employee-to-resident abuse within two hours to the State Survey Agency (SSA- the agency that inspects long-term care facilities for the purposes of survey and certification), the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), and local law enforcement (police) as per its policies on abuse for one of three sampled residents (Resident 1).This failure had the potential to place Resident 1 at risk for further abuse.Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 8/11/2023, with diagnoses including Parkinson Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (a condition characterized by weakness on one side of the body, affecting the arm, leg, hand, and or face) following cerebral infarction (a condition where brain tissue dies due to a lack of blood supply).During a review of Resident 1's Situation Background Assessment Recommendation (SBAR, technique that provides a framework for communication between members of the health care team about a resident's condition) Communication Form, dated 4/11/2025, the SBAR indicated on 4/11/2025, at 9:40 p.m., Resident 1 reported to Licensed Vocational Nurse 3 (LVN 3) that he (Resident 1) was being hit by Certified Nursing Assistant 2 (CNA 2). The SBAR indicated LVN 3 notified Registered Nurse 2 (RN 2) and the physician, and the physician ordered to monitor Resident 1 and to have two staff present when providing care.During a review of Resident 1's Progress Notes, dated 4/11/2025, the Progress Notes indicated RN 2 assessed Resident 1 after Resident 1 claimed that CNA 2 hit Resident 1. The Progress Notes indicated no pain, no new wounds or discoloration, and vital signs (including body temperature, heart rate, breathing rate, and blood pressure. These measurements help assess overall health and can indicate potential health issues) was stable.During a review of Resident 1's History and Physical (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 6/24/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 6/30/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 1 required maximum assistance from staff for toileting, showering and dressing. During an interview on 8/7/2025, at 1:29 p.m., with the Director of Nursing (DON), the DON stated Resident 1's allegation that he (Resident 1) was hit by CNA 2 was not reported to SSA, Ombudsman and police.During an interview on 8/7/2025, at 2:11 p.m., with the Administrator (ADM), the ADM stated he (ADM) started as ADM in the facility on 4/11/2025 and was not informed of Resident 1's allegation. The ADM stated if Resident 1 claimed something occurred then it is reportable. The ADM stated allegation of hitting is an allegation of abuse and needed to be reported to SSA, Ombudsman and police. The ADM stated if allegation of abuse was not reported to SSA, Ombudsman and police, Resident 1 could be exposed to further potential abuse.During an interview on 8/7/2025, at 2:39 p.m., with the Assistant to the Administrator (AADM), the AADM stated the facility had two hours to report allegation of abuse to SSA, Ombudsman and police. The AADM stated if he (AADM) was informed he (AADM) would report it within two hours.During a concurrent interview, and record review with the ADM, facility's policy and procedure (P&P), titled, Abuse, Neglect (failing to properly care for someone or something, leading to potential harm), Exploitation (the action or fact of treating someone unfairly) or Misappropriation-Reporting and Investigating, undated and last reviewed on 4/24/2025, the P&P indicated, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The Administrator or the individual making the allegation immediately reports his or her suspicion to the following person or agencies:A. State licensing/certification agency responsible for surveying/licensing the facility.B. The local or state OmbudsmanC. The resident representative.D. Adult Protective ServiceE. Law enforcement officialsF. The resident attending physicianG. The facility's medical director.Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. The ADM stated the facility's policy was to report allegations if it involves abuse within two hours and if it does not involve abuse within 24 hours.During an interview on 8/7/2025, at 3:10 p.m. with the Assistant Director of Nursing (ADON), the ADON stated she (ADON) was not informed of Resident 1's allegation of abuse. The ADON stated the facility's process after an allegation of abuse was to report to the RN, DON, ADM and to the physician. The ADON stated the facility had two hours to report the allegation of abuse to SSA, Ombudsman and police.During an interview on 8/7/2025, at 3:35 p.m., the DON stated the facility failed to report allegation of abuse on 4/11/2025. The DON stated she (DON) was just notified today 8/7/2025, four months after Resident 1 reported an allegation of abuse.

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 F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to provide an ongoing activity program that is resident-centered for one of three sampled residents (Resident 2).This failure had the potential to affect the Resident 2's sense of self-worth and psychosocial (the interaction between an individual's mental and emotional state [psychological] and their social environment) well-being.Findings:During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 3/14/2012, with diagnoses including gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and Alzheimer's Disease (a disease characterized by a progressive decline in mental abilities).During a review of Resident 2's Care Plan, dated 8/27/2024, about Resident 2's risk for social isolation (a state of reduced social interaction and contact with others, often leading to feelings of loneliness and disconnection) due to decreased mobility and inability to verbalize needs, wants and preferences, the Care Plan indicated the following intervention1. assist with in-room activities such as nail grooming, aroma therapy, lotion rub, sensory and religious music.2. Room visits one on one (a direct encounter between two persons) for socialization.During a review of Resident 2's Physician Order, dated 11/21/2024, the Physician Order indicated Resident 2 may participate in activities as desired and/or as condition warrants.During a review of Resident 2's History and Physical (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 11/29/2024, the H&P indicated Resident 2 did not have the capacity to understand and make decisions.During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 6/30/2025, the MDS indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 2 was dependent on staff for activities of daily living (ADL- activities such as bathing, dressing and toileting a person performs daily). The MDS indicated Resident 2 had a urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) and was always incontinent (unable to control) for bowel. During a review of Resident 2's Activity Participation Review, dated 7/29/2025, the Activity Participation Review indicated Resident 2 was bed-bound and did not attend group activities. The Activity Participation Review indicated Resident 2 likes to have her (Resident 2)'s nails done, listens to gospel music, bible readings and aroma therapy.During a review of Resident 2's Documentation Survey Report, dated 7/2025, the Documentation Survey Report indicated 18 days of 7/2025 was left blank for one-on-one activity visit, on the following days: 7/3/2025, 7/5/2025, 7/6/2025, 7/8/2025, 7/12/2025 to 7/16/2025, 7/18/2025 to 7/20/2025, 7/22/2025, 7/24/2025, 7/26/2205 to 7/29/2025 and 7/31/2025.During a concurrent interview, and record review on 8/7/2025, at 12:38 p.m., with the Activity Director (AD), Resident 2's Documentation Survey Report dated 7/2025, was reviewed. The AD stated Documentation Survey Report is Resident 2's activity attendance. The AD stated there were multiple days that were left blank. The AD stated if left blank, it means activity was not provided. The AD stated activity should be offered at least three times weekly. The AD stated if activity was not provided Resident 2 can feel isolated.During an interview on 8/7/2025, at 12:49 p.m., with Activity Assistant (AA), AA stated activity was provided to Resident 2 five times a week and activity provided is documented in Resident 2's medical chart. AA stated the days the activity was left blank was because sometimes she (AA) gets busy with other residents and does not have time to return to her (Resident 2). AA stated sometimes she (AA) only says hi and good morning and if Resident 2 looks asleep, she (AA) moves on to the next resident.During an interview on 8/7/2025, at 1:08 p.m., with the AD, the AD stated saying hi and good morning is not an activity. The AD stated Resident 2 needed assigned and in-depth room visit. The AD stated AA should follow the activity planned for Resident 2 and document if unable. The AD stated in dept activity room visits includes:a. Lotion rubs (hand rubs)b. Music appreciationc. Visual cues (television, flowers)d. Scented synthetic flowerse. Reading stories to residentf. Talking to resident (one sided conversation)g. Bible StoriesDuring an interview on 8/7/2025, at 1:29 p.m., with the Director of Nursing (DON), the DON stated providing activity is a daily thing and should be provided to residents unless refused. The DON stated not offering and not providing activity for five consecutive days (7/12/2025 to 7/16/2025) was not good. The DON stated Resident 2's social and emotional interaction could be affected by not providing activity. The DON stated Resident 2 could develop social isolation.During a review of facility's policy and procedure (P&P), titled, Activity Programs, dated 7/24/2025, was reviewed. The P&P indicated, Activity programs are designed to meet the interests of and support the physical, mental and psychosocial wellbeing of each resident.2. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident.3. The activities program is ongoing and includes facility-organized group activities, independent individual activities and assisted individual activities.6. Activities are scheduled 7 (seven) days a week and residents are given an opportunity to contribute to the planning, preparation, conducting, cleanup and critique of the programs.7. Our activity programs consist of individual, small group and large group activities that are designed to meet the needs and interests of each resident. Activity programs include activities that promote:a. self-esteem;b. comfort;c. pleasure;d. education;e. creativity;f. success; andg. independence.9. All activities are documented in the resident's medical record.

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure the residents received care consistent with professional standards of practice for one of three sampled residents (Resident 1) by failing to obtain a physician order for oxygen (air we breathe and is used by our bodies to produce energy) use before oxygen administration.This failure had the potential to place Resident 1 at risk of receiving more oxygen than required and could negatively impact Resident 1's well-being. Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility initially admitted Resident 1 on 8/11/2023, with diagnoses including Parkinson Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), difficulty in walking and shortness of breath.During a review of Resident 1's History and Physical (H&P- a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 6/24/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 6/30/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 1 required maximum assistance from staff for toileting, showering and dressing. During a review of Resident 1's Physician Order, dated 7/27 /2025, the Physician's Order indicated no order for oxygen use.During a review of Resident 1's Weights and Vitals Summary, dated 7/28/2025 to 8/7/2025, the Weights and Vitals Summary indicated Residen1 was on daily oxygen from 7/28/2025 to 8/7/2025.During a review of Resident 1's Care Plan on Oxygen Therapy, dated and revised on 8/5/2025, the Care Plan indicated an intervention to give medications as ordered by the physician.During a concurrent observation, and interview on 8/7/2025, at 9:13 a.m., with Resident 1 inside Resident 1's room. Observed Resident 1's oxygen at two liters per minute and the nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) was not connected to Resident 1. Resident 1 stated he (Resident 1) used oxygen but just does not need it at this time.During a concurrent observation, and interview on 8/7/2025, at 9:20 a.m., with Certified Nursing Assistant 1 (CNA 1), inside Resident 1's room. CNA 1 stated Resident 1 uses oxygen but takes it off at times.During a concurrent interview, and record review on 8/7/2025, at 9:22 a.m., with the Unit Manager (UM), Resident 1's current Physician's Orders, and Weights and Vitals Summary, dated 7/27/2025, to 8/7/2025 was reviewed. The UM stated Resident 1 was in General Acute Care Hospital (GACH) from 7/23/2025, to 7/27/2025. The UM stated there were no physician orders for the use of oxygen from 7/27/2025, when Resident 1 was readmitted back to the facility.During an interview on 8/7/2025, at 10:40 a.m., with Registered Nurse 1 (RN 1), RN 1 stated use of oxygen needed a physician order. RN 1 stated nurses should have checked the physician order for oxygen use before providing oxygen to Resident 1. RN 1 stated without a physician order, nurses would not be able to know how many liters, and in what way oxygen should be delivered to Resident 1 and for how long oxygen will be used. RN 1 stated Resident 1 could experience over oxygenation (also known as oxygen toxicity, occurs when the body's tissues are exposed to excessively high levels of oxygen. While oxygen is essential for life, too much of it can become harmful and even toxic).During an interview on 8/7/2025, at 10:56 a.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated she (LVN 2) was the assigned nurse for Resident 1. LVN 2 stated Resident 1 was on oxygen this morning beginning of her (LVN 2) shift at 7 a.m.During a concurrent interview, and record review on 8/7/2025, at 1:29 p.m., with the Director of Nursing (DON), facility's policy and procedure (P&P), titled, Physician's Medication and Treatment Orders, dated and revised on 7/24/2025, was reviewed. The P&P indicated, Orders for medication and treatments will be consistent with principles of safe and effective order writing. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. Drug (medications) and biological orders must be recorded on the physician order sheet in the resident's chart. The DON stated the nurses failed to obtain a physician order for Resident 1's use of oxygen. The DON stated nurses could not administer oxygen without a physician order. The DON stated oxygen is a medication that needed a physician order before use. The DON stated Resident 1 could be overwhelmed and get agitated with the use of oxygen without a physician order.

CONCERN (D) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to implement its infection control measures for one of three sampled residents (Resident 3) who was on enhanced barrier precaution (EBP- wearing a protective gown and gloves whenever you are doing close-contact care with a patient who might be carrying these germs) by failing to ensure Certified Nursing Assistant 3 (CNA 3) wore protective gown while proving care.This failure had the potential for cross contamination (unintentional transfer of bacteria or germs or other contaminants from one surface to another) of infection among residents and staff.Findings:During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 7/5/2025, with diagnoses including unspecified (unconfirmed) organism sepsis (a life-threatening blood infection), urinary tract infection (UTI- an infection in the bladder/urinary tract), and stage three pressure ulcer (Full-thickness loss of skin. Dead and black tissue may be visible) of the buttocks.During a review of Resident 3's History and Physical (H&P a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 7/8/2025, the H&P indicated Resident 3 had fluctuating capacity to understand and make decisions.During a review of Resident 3's Minimum Data Set (MDS-a resident assessment tool), dated 7/11/2025, the MDS indicated Resident 3's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 3 was dependent on staff for toileting, showering, dressing and personal hygiene.During a review of Resident 3's Physician Order, dated 8/7/2025, the Physician Order indicated enhanced barrier precaution during high contact resident care activities secondary to wound management every shift.During a review of Resident 3's Care Plan on enhanced barrier precaution, dated 8/7/2025, the Care Plan indicated an intervention to use personal protective equipment (PPE wearable equipment that is intended to protect healthcare personnel and the public from exposure to or contact with infectious agents-like gown, gloves and face-shield as indicated) during high-contact resident care activities like dressing, bathing, showering, transferring, hygiene, linen changes, brief changes, toileting assistance, device care or wound care.During a concurrent observation, and interview on 8/7/2025, at 9:02 a.m., with Licensed Vocational Nurse 4 (LVN 4), inside Resident 3's room. Observed an EBP signage posted by the door with isolation gown and gloves on an isolation organizer hanging by Resident 3's door. LVN 4 stated Resident 3 was on EBP due to pressure ulcer wounds.During a concurrent observation, and interview on 8/7/2025, at 9:38 a.m., with Certified Nursing Assistant 3 (CNA 3) inside Resident 3's room. Observed CNA 3 repositioned Resident 3's head to the left side wearing gloves. CNA 3 stated on 8/7/2025, at 7:30 a.m. she (CNA 3) had provided and changed Resident 3's incontinent brief wearing only gloves and not wearing a gown. CNA 3 stated she (CNA 3) was not aware that Resident 3 was on EBP. CNA 3 stated she (CNA 3) did not pay attention and did not see the EBP signage by Resident 3's door. CNA 3 stated Licensed Vocational Nurse 4 did not inform her (CNA 3) that Resident 3 was on EBP. CNA 3 stated if she (CNA 3) was informed she (CNA 3) would use gloves and gown when providing care for residents on EBP.During an interview on 8/7/2025, at 10:15 a.m. with the Treatment Nurse (TN), the TN stated Resident 3 had stage four (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) sacral wound and right heel necrotic (dead or dying tissue) wound. The TN stated Resident 3 was on EBP and staff providing care should wear gowns and gloves.During an interview on 8/7/2025, at 11:08 a.m., with Infection Preventionist 2 (IP 2), IP 2 stated residents with indwelling catheter (a tube inserted into the bladder to drain urine) or with chronic (persisting for a long time or constantly recurring) wounds that needed dressing change are on EBP. IP 2 stated the facility posted the EBP signage on the resident's door and an orange circle sticker by resident's name to remind staff that resident is on EBP. IP 2 stated CNA 3 should have worn the gloves and gown when providing incontinent care to prevent transmission of infection.During an interview on 8/7/2025, at 12:08 p.m., with the Director of Staff Development (DSD), the DSD stated CNA 3 should be aware of who was on EBP to prevent spread of infection.During an interview on 8/7/2025, at 1:29 p.m., with the Director of Nursing (DON), the DON stated CNA 3 should wear a gown and gloves when providing direct care like changing incontinent brief to prevent spread of infection.During a review of facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions, dated 2001, and last reviewed on 4/24/2025, the P&P indicated, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDRO- a germ that is resistant to many antibiotics) to residents.2. Enhanced barrier precautions apply when: .b. A resident is not known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained; .7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply.a. Gloves and gowns are applied prior to performing the high contact resident care activity (as opposed to before entering the room).b. Personal protective equipment (PPE) is changed before caring for another resident.c. Face protection may be used if there is also a risk of splash or spray.8. Examples of high-contact resident care activities requiring the use of gowns and gloves for EBPs include:a. dressing;b. bathing/showering;c. providing hygiene or grooming;d. changing briefs or assisting with toileting;e. transferring;f. providing bed mobility;g. changing linens;h. prolonged, high contact with items in the resident's room, with resident's equipment, or with resident's clothing or skin (example in the shower room, therapy gym, or during restorative care);i. device care or use (central line [a thin, flexible tube inserted into a large vein and threaded near the heart], urinary catheter, feeding tube, tracheostomy [a surgical procedure that creates an opening in the trachea to help with breathing]); andj. wound care (any skin opening requiring a dressing) .17. Signs are posted on the door or wall outside the residents' rooms which communicate the type of precautions and PPE required.

Jul 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed:1. To supervise the student nurse while providing direct care to one out of three sample residents (Resident 1) during the student's clinical hours.This deficient practice resulted in Resident 1 assisted fall on 6/29/2025 when Student Nurse (SN) 1 assisted Resident 1 on the floor without the facilities knowledge.2. To document and assess Resident 1 after receiving a report from Clinical Instructor Registered Nurse (CIRN) 1 that Resident 1 was assisted in the floor by SN 1. Findings:Findings:During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/30/2025 with a diagnosis of end stage renal failure (when the kidneys are so damaged that they can no longer filter waste from the blood effectively) and hypertension (high blood pressure).During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 5/8/2025, the MDS indicated Resident 1 was intact with thought process and required moderate assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily).During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 5/10/2024 with a diagnosis of hypertension and intracerebral hemorrhage (bleeding inside the brain).During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was intact with thought process and required substantial assistance from staff to complete ADLs.During an interview on 7/16/2025 at 11:50 a.m. with Resident 2, Resident 2 stated that there was no facility staff present when the two students and one clinical instructor assisted Resident 1.During an interview on 7/16/2025 at 1:53 p.m. with SN 1, SN 1 stated that she was transferring Resident 1 from chair to bed with her classmate SN 2 and there was no staff present during the transfer of Resident 1 from chair to bed. SN 1 stated Resident 1's clothes were soaked and needed to change Resident 1's bed sheets. SN 1 stated that during Resident 1's transfer from chair to bed Resident 1's knees weakened, and SN 1 decided to return Resident 1 to her chair because SN 1 was not able to carry Resident 1 weight, but SN 1 observed that Resident 1 started to slide down from her chair. SN 1 stated she started to assist Resident 1 slowly down to the floor in a sitting position. SN 1 stated she asked SN 2 to call Clinical Instructor Registered Nurse (CIRN) 1.During an interview on 7/16/2025 at 3:48 p.m. with CIRN 1, CIRN 1 stated she was called by SN 2 in Resident 1's room. CIRN 1 stated SN 1 informed CIRN 1 stated Resident 1 knees started to weaken, and SN 1 was unable to carry Resident 1 weight so SN 1 assisted Resident 1 slowly down to the floor in a sitting position. CIRN 1 stated that CIRN 1 reported to License Vocational Nurse (LVN) 1 that Resident 1 knees were weakened and SN 1 assisted Resident 1 down in the floor in sitting position. CIRN 1 stated that LVN 1 said that he (LVN 1) will check on Resident 1.During an interview on 7/22/2025 at 9:34 a.m. with SN 2 stated that during the transfer of Resident 1, SN 2 was behind the chair holding to stabilize the chair and witnessed SN 1 assisted Resident 1 slowly to the floor. SN 2 stated there were no facility staff present during Resident 1's transfer. SN 2 stated only SN 1, SN 2 and the clinical instructors were present. SN 2 stated there was no need for the facility staff to be present during transfer.During a concurrent interview and record review on 7/22/2025 at 10:30 a.m. with the Director of Nursing (DON), the facility and school contract titled, Educational Affiliation Agreement, dated 9/7/2023, was reviewed. The DON stated the facility and school contract titled, Educational Affiliation Agreement, indicated the entity shall be under the supervision of the facility representative during clinical hours. The DON stated it was important to follow the contract between the facility and school to prevent any issues and concerns in the facility and to also provide smooth teaching to the students.During a review of the facility policy and procedure titled, Nursing Schools/Nursing Students, last review of date 4/24/2025, the policy and procedure indicated, The facility is committed to supporting clinical education for nursing students while ensuring that all resident care activities conducted by nursing students are in full compliance with California state regulations, CMS Conditions of Participation, and facility policies. Nursing students may provide care only under the supervision of a licensed nurse and in accordance with approved clinical education agreements.During a review of the facility and school contract titled, Educational Affiliation Agreement, dated 9/7/2023, the facility and school contract indicated, Supervision the entity shall be under the supervision of the facility representative during clinical hours.

Jul 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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) received medication as prescribed.This deficient practice had the potential for Resident 1 to be negatively affected.Findings:During a review of Resident 1's admission Record (AD), the AD indicated the facility admitted Resident 1 on 6/11/2025 with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), anemia (a condition where the body does not have enough healthy red blood cells), and essential (primary) hypertension (HTN-high blood pressure).During a review of Resident 1 Physician Orders, dated 6/13/2025 the Physician Orders indicated Miralax (an over-the-counter medication used to relieve occasional constipation) oral powder 17 grams (g- a unit of measurement) give 1 scoop by mouth one time a day for bowel management mix well with optimal amounts of fluid until dissolved. Hold for loose stool.During a review of Resident 1's Bowel Continence for 6/2025, the Bowel Continence indicated the following:- 6/14/2025 11-7 a.m. shift Resident 1 had a bowel movement (BM), incontinent, loose/diarrhea, small.- 6/21/2025 3-11 p.m. shift Resident 1 had a BM, incontinent, loose/diarrhea, and large.- 6/22/2025 7-3 p.m. shift Resident 1 had BM, incontinent, loose/diarrhea, and medium.- 6/22/2025 3-11 p.m. shift Resident 1 had BM, incontinent, loose/diarrhea, and large.- 6/22/2025 11-7 a.m. shift Resident 1 had BM, incontinent, loose/diarrhea, and large.- 6/23/2025 3-11 p.m. shift Resident 1 had two BM, incontinent, loose/diarrhea, and large.- 6/25/2025 11-7 a.m. shift Resident 1 had BM, incontinent, loose/diarrhea, and large.During a review of Resident 1's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for 6/2025, the MAR indicated Resident 1 order for Miralax 17 g 1 scoop by mouth one time a day for bowel management mix well with optimal amounts of fluid until dissolved. Hold for loose stool. The MAR indicated Resident 1 received Miralax 17 g daily from 6/13/2025 until 6/26/2025.During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 6/17/2025, the MDS indicated Resident 1 understood and was understood. The MDS indicated Resident 1 was dependent (helper does all the effort) with oral hygiene, toileting, showering, upper and lower body dressing, putting on and taking off footwear and personal hygiene and required substantial to maximal assistance (the helper does more than half the effort) with eating. The MDS further indicated Resident 1 always incontinent (not being able to control when you pee or poop) with urine and bowel.During a review of Resident 1's Change in Condition (COC) Evaluation, dated 6/26/2025 at 12:56 p.m., the COC Evaluation indicated Resident 1 had weight loss of 8.9 pounds (lbs.- a unit of measurement) in one (1) week. Resident 1 verbalized she has had episodes of loose stool for four (4) days, Miralax routine changed to as needed.During a review of Resident 1's COC Evaluation dated 6/28/2025 at 1:12 p.m., the COC Evaluation indicated Resident 1 called 911 on self. Resident 1 on monitoring for loose stool, Resident 1 had scheduled transportation to General Acute Care Hospital (GACH) 1, following morning at 11 a.m., Resident 1 made aware prior to night shift however resident called 911 to be treated earlier. Resident 1 transferred to GACH 2, Family Member and Medical Doctor (MD), notified at this time.During a review of Resident 1's GACH 2 Emergency Documentation dated 6/28/2025, the GACH 2 Emergency Documentation indicated Resident 1 complained of diarrhea for two days with abdominal pain, occurring about ten (10) times per day. GACH 2's medical decision making indicated Resident 1 diagnosed with infectious colitis.During an interview on 7/14/2025 at 11:45 a.m. with Resident 1, Resident 1 stated she called 911 herself because she (Resident 1) had diarrhea for more than 7 days. Resident 1 stated she was told she had some type of infection in the hospital.During a concurrent interview and record review of Resident 1's MAR for June 2025 and Bowel Continence for 6/2025, on 7/15/2025 at 10:23 a.m. with the Director of Nursing (DON), the DON stated when nurses need to know if residents had a bowel movement it is endorsed during the change of shift, and by the CNAs if the residents have had any loose BMs. The DON stated Resident 1 is alert and the nurse could ask Resident 1 if she had diarrhea or loose stool prior to administering the medication Miralax. The DON stated it is the nurses' job to communicate with the residents to find out if the resident has had a bowel movement or not. The DON reviewed Resident 1's MAR and Bowel Continence for 6/2025, the DON stated Resident 1 was administered Miralax even though she did have loose and or diarrhea, Miralax should not have been given. The DON stated Resident 1 will continue to have loose stool and diarrhea, can lead to colitis, could lead to electrolytes being imbalanced.During a review of the facility's policy and procedure (P&P) titled, Administering Medications, last reviewed on 4/24/2025, the P&P indicated medications are administered in a safe and timely manner, and as prescribed.4. Medications are administered in accordance with prescriber orders, including any required time frames.

Jul 2025 4 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure the residents received services with reasonable accommodation of the resident needs for one of four sampled residents (Residents 4). Resident 4, who was at risk for falls, did not have the call light (an alerting device for residents to call for assistance) within the resident's reach.This deficient practice had the potential for not meeting Residents 4's needs for assistance.Findings: During a review of Resident 4's admission Record (undated), the admission Record indicated the facility admitted Resident 4 on 6/24/2011 with diagnoses including multiple sclerosis (a chronic disease where the body's immune system attacks the protective covering of nerve fibers in the brain and spinal cord), chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 4's Care Plan on injury and falls, initiated on 3/1/2020, the Care Plan indicated the resident had the potential for injury and falls. The Care Plan Interventions indicated to instruct use of call light whenever in need of assistance. place call light within reach. During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 6/23/2025, the MDS indicated Resident 4's cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was moderately impaired. The MDS indicated Resident 4 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) on rolling to the right and left side, eating, and personal hygiene. During a review of Resident 3's Fall Risk Assessment, dated 6/23/2025, the Fall Risk Assessment indicated the resident had a total score of 18. A total score above 16 to 42 represented a high risk for falls. During a concurrent observation and interview on 7/9/2025 at 3:28 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 4's call light was observed at the right side of the resident's bed, on the floor. LVN 2 stated a resident's call light was required for resident safety. LVN 2 stated Resident 4's call light was not within the resident's reach. LVN 2 stated Resident 4's needs had the potential not to be met if the call light was not within the resident's reach. During an interview on 7/9/2025 at 5 p.m. with the Director of Nursing (DON), the DON stated Resident 4's call light should be within the resident's reach. The DON stated Resident 4's call light not within the resident's reach had the potential to cause delay in Resident 4's care. The DON stated the facility failed to ensure the call light was within Resident 4's reach. During a review of the facility's policy and procedure (PnP) titled, Call System, Residents, last reviewed on 4/24/2025, indicated each resident is provided with a means to call staff directly for assistance from his or her bed . The PnP indicated . to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation.

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 F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure resident's pain was managed as indicated in the facility's Pain Assessment and Management policy for one of four sampled residents (Resident 2) by failing to ensure Resident 2's pain medication, ibuprofen (medication used to treat moderate pain) 400 milligrams (mg - unit of measurement), scheduled every six hours as needed, was administered according to the physician order. This deficient practice had the potential for Resident 2's unnecessary pain experienced during daily activities and had the potential to lead to a decline in Resident 2's quality of life.Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 1/22/2024 with diagnoses including osteoarthritis (condition that causes the joints to become very painful and stiff) left hip, anemia (condition in which the body does not get enough oxygen-rich blood), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). During a review of Resident 2's Physician Orders, dated 1/22/2024, the Physician Orders indicated acetaminophen 650 mg tablet every four hours as needed for mild pain (one to three on the numeric pain scale). During a review of Resident 2's Care Plan on pain or discomfort, initiated on 1/22/2024, the Care Plan indicated the resident was at risk for pain and discomfort. The Care Plan Interventions indicated to administer medication and treatment as ordered. During a review of Resident 2's Physician Orders, dated 2/5/2024, the Physician Orders indicated ibuprofen 400 mg every six hours as needed for moderate pain (four to six on the numeric pain scale). During a review of Resident 2's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 4/30/2025, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 2 received as needed pain medications for the resident's occasional pain. The MDS indicated Resident 2 received non-medication intervention for pain. During an interview on 7/9/2025 at 2:14 p.m. and concurrent review of Resident 2 Medication Administration Record (MAR), dated 6/1/2025 to 6/30/2025 and 7/1/2025 to 7/31/2025, reviewed with Registered Nurse (RN) 2, RN 2 stated Resident 2's MAR indicated the following: a. On 6/3/2025 at 11:32 a.m., Resident 2 had two out of ten on the numeric pain scale. RN 2 stated Resident 2 received ibuprofen 400 mg instead of the acetaminophen 650 mg.b. On 6/5/2025 at 8:57 a.m., Resident 2 had two out of ten on the numeric pain scale. RN 2 stated Resident 2 received ibuprofen 400 mg instead of the acetaminophen 650 mg.c. On 6/25/2025 at 10:27 a.m. and 6:02 p.m. Resident 2 had three out of ten on the numeric pain scale. RN 2 stated Resident 2 received ibuprofen 400 mg instead of the acetaminophen 650 mg.d. On 6/29/2025 at 9:15 a.m., Resident 2 had three out of ten on the numeric pain scale. RN 2 stated Resident 2 received ibuprofen 400 mg instead of the acetaminophen 650 mg.e. On 7/5/2025 at 9:56 a.m., Resident 2 had three out of ten on the numeric pain scale. RN 2 stated Resident 2 received ibuprofen 400 mg instead of the acetaminophen 650 mg.f. On 7/7/2025 at 8:57 a.m., Resident 2 had two out of ten on the numeric pain scale. RN 2 stated Resident 2 received ibuprofen 400 mg instead of the acetaminophen 650 mg.RN 2 stated Resident 2 received the pain medication that was not appropriate for the resident's pain level. RN 2 stated Resident 2 received a pain medication that was not according to the Physician Order. RN 2 stated Resident 2's pain had the potential not to be managed. During an interview on 7/9/2025 at 5 p.m. with the Director of Nursing (DON), the DON stated Resident 2 received a pain medication that was not appropriate for the resident's pain level. The DON stated Resident 2 had the potential for inaccurate pain assessment. The DON stated the facility failed to follow the Physician Order on Resident 2's pain management. During a review of the facility's policy and procedure (PnP) titled, Administering Medications, last reviewed on 4/24/2025, the PnP indicated medications are administered in accordance with prescriber orders, including any required time frame. During a review of the facility's PnP titled, Administering Pain Medications, last reviewed on 4/24/2025, the PnP defined pain management as .the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. The PnP indicated administer pain medications as ordered.

CONCERN (E) 📢 Someone Reported This

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

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to provide necessary respiratory care and services for one of three sampled residents (Resident 4) by failing to:1. Ensure Resident 4's oxygen tubing and oxygen humidifier (a device that adds moisture to the oxygen a person is breathing in during oxygen therapy) was dated when it was changed.2. Ensure Resident 4's oxygen humidifier bottle had water in it while in use.3. Ensure Resident 4 had an oxygen supplies bag for the oxygen tubing to be kept inside when not in use.4. Ensure Resident 4 had a physician order for oxygen therapy (O2 therapy - a treatment that provides a person with supplemental or extra oxygen) before Resident 4 was provided with oxygen. These deficient practices had the potential for Resident 4 to develop respiratory (organs and structures in the body that allow a person to breathe) diseases or infections. These deficient practices had the potential to create confusion in the delivery of care and services to Resident 4.Findings: During a review of Resident 4's admission Record (undated), the admission Record indicated the facility admitted Resident 4 on 6/24/2011 with diagnoses including multiple sclerosis (a chronic disease where the body's immune system attacks the protective covering of nerve fibers in the brain and spinal cord), chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a review of Resident 4's Care Plan on COPD, initiated on 1/23/2025 and revised on 6/24/2025, the Care Plan indicated the resident was at risk for complications with the respiratory system. The Care Plan Interventions indicated to follow infection control protocol for universal or standard precautions. The Care Plan Interventions indicated oxygen therapy as ordered. During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 6/23/2025, the MDS indicated Resident 4's cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was moderately impaired. During a concurrent observation and interview on 7/9/2025 at 3:28 p.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 4 was observed with oxygen therapy at two liters (L - unit of measurement) per nasal cannula (a device used to deliver supplemental oxygen thru the nostril [nose])), connected to an oxygen concentrator (a device that provides extra oxygen). LVN 2 stated Resident 4's oxygen cannula was not dated. LVN 2 stated Resident 4's oxygen humidifier bottle was empty and was dated 6/28/2025. LVN 2 stated Resident 4 did not have an oxygen supplies bag in the resident's room. LVN 2 stated Resident 4's oxygen therapy supplies should be dated and changed every 7 days. During an interview on 7/9/2025 at 5 p.m. and concurrent record review of Resident 4's Physician Orders, dated 7/9/2025, reviewed with the Director of Nursing (DON), the DON stated Resident 4's Physician Order did not indicate an order for oxygen therapy. The DON stated Resident 4's oxygen cannula, oxygen humidifier bottle, and oxygen supplies bag should be dated and changed. The DON stated Resident 4 should have an oxygen therapy order before the resident received oxygen. The DON stated Resident 4 had the potential to experience shortness of breath, dryness of the nasal area, and respiratory infection. The DON stated the facility failed to ensure there was a physician's order for oxygen therapy before Resident 4 was provided with oxygen. The DON stated the facility failed to ensure Resident 4's oxygen therapy supplies were dated and changed. During a review of the facility's policy and procedure (PnP) titled, Oxygen Administration, last reviewed on 5/24/2025, the PnP indicated the purpose .to provide guidelines for safe oxygen administration. The PnP indicated to verify that there was a physician order for the procedure. The Steps in the Procedure section of the PnP indicated 12.be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through.14. Periodically re-check water level in humidifying jar. During a review of the facility's PnP titled, Departmental (Respiratory Therapy) - Prevention of Infection, last reviewed on 5/24/2025, the PnP indicated the purpose .to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff. The PnP indicated .7. Store the circuit in plastic bag, marked with date and resident's name, between uses.9. Discard administration set-up every seven (7) days.

CONCERN (E) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to ensure the medical records of one of four sampled residents (Resident 1) were maintained in accordance with accepted professional standards and practice, complete, and accurately documented by failing to:1. Ensure Licensed Vocational Nurse (LVN) 4 documented Resident 1's Change in Condition (CIC) monitoring indicating the correct date.2. Ensure Certified Nursing Assistants (CNAs) documented Residents 1's percentage (% - per one hundred) of food eaten every meal (breakfast, lunch, and dinner).3. Ensure CNAs accurately documented Resident 1's bladder (a hallow organ that stores urine in the body) continence. These deficient practices resulted in inaccurate information on Residents 1's medical records and had the potential for delayed and inaccurate medical interventions.Findings: During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted the resident on 1/14/2021, with diagnoses including Guillain-Barre syndrome (a condition in which the body's immune system attacks the nerves), age-related osteoporosis (a condition where bones become weaker and more brittle with age), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 4/15/2025, the MDS indicated Resident 1's cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. During a review of Resident 1's Progress Notes, dated 6/19/2025, the Progress Notes indicated on 6/19/2025 at 11:01 a.m., Resident 1 had a CIC. Resident 1's Progress Notes indicated LVN 4 documented a 72-hour monitoring on 6/19/2025 at 1:43 a.m., 9 hours and 18 mins before the resident's CIC. During an interview on 7/9/2025 at 12:39 p.m. and concurrent record review of Resident 1's Bladder Continence Task and Nutritional Task, dated 6/11/2025 to 7/9/2025, reviewed with Registered Nurse (RN) 1, RN 1 stated the Bladder Continence Task section indicated the following:a. On 6/13/2025, 6/16/2025, and 7/6/2025, the 3 p.m. to 11 p.m. shift did not document Resident 1's bladder continence status. b. On 6/14/2025 and 6/19/2025, the 7 a.m. to 3 p.m. shift did not document Resident 1's bladder continence status. c. On 7/3/2025, the 11 p.m. to 7 a.m. shift did not document Resident 1's bladder continence status. RN 1 stated Resident 1's Nutritional Task indicated the following: a. On 6/13/2025 and 6/16/2025, Resident 1 did not have a documented dinner meal intake.b. On 6/14/2025 and 6/19/2025, Resident 1 did not have a documented lunch meal intake.c. On 6/19/2025, Resident 1 did not have a documented breakfast meal intake.d. On 7/1/2025, Resident 1's documented breakfast and lunch meal intake were 51% to 75%, both at 1:15 p.m.e. On 7/5/2025, Resident 1's documented breakfast and lunch meal intake were 76% to 100%, both at 1:23 p.m.f. On 7/7/2025, Resident 1's documented breakfast and lunch meal intake were 76% to 100%, both at 12:58 p.m.RN 1 stated Resident 1's bladder continence should be documented every shift. RN 1 stated Resident 1's documented Bladder Continence Task and Nutritional Task were inaccurate and incomplete. During an interview on 7/9/2025 at 5 p.m. with the Director of Nursing (DON), the DON stated documentation in Resident 1's medical records should be accurate and complete. The DON stated incomplete and inaccurate documentation had the potential for residents' inaccurate plan of care and treatment. The DON stated the facility failed to ensure complete and timely documentation on the residents' medical records. During a review of the facility's policy and procedure (PnP) titled, Charting and Documentation, last reviewed on 4/24/2025, the PnP indicated the following information is to be documented in the resident medical record: a. objective observations.f. progress toward or changes in the care plan goals and objectives.

Jun 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs and preferences to two of four sampled residents (Resident 3 and 4) by failing to ensure: 1. The call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) was within reach for Resident 3. 2. The call light was functional for Resident 4. These failures had the potential to result in the inability of Residents 3 and 4 to call for facility staff assistance and delay in the provision of necessary care and services that could negatively affect the residents' well-being. Findings: a. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted on [DATE] with diagnoses of dementia (a progressive state of decline in mental abilities), cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), repeated falls, and diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 3's History and Physical (H&P), dated 2/21/2025, the H&P indicated Resident 3 had fluctuating capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS-a resident assessment tool), dated 2/27/2025, the MDS indicated Resident 3 had severely impaired cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS also indicated Resident 3 was dependent on staff for toileting hygiene, personal hygiene, upper and lower body dressing. During a review of Resident 3's Care Plan (CP), last revised on 4/23/2025, the CP indicated Resident 3 had an Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) self-care performance deficit related to activity intolerance, dementia, limited mobility. The CP interventions indicated encouraging the Resident to use call light for assistance. During a concurrent observation and interview on 6/4/2025 at 9:30a.m. with Licensed Vocational nurse (LVN) 1in Resident 3's room, Resident 3's call light was observed under the bed mattress. LVN 1 stated Resident 3 would not be able to reach the call light under the mattress. LVN 1 stated the call light should have been placed within Resident 3's reach to prevent accidents and maintain safety. b. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted on [DATE] with diagnoses of paraplegia (loss of movement and/or sensation, to some degree, of the legs), hypertension (high blood pressure), and chronic pain syndrome (a condition where persistent pain, lasting longer than 3 months, significantly impacts a resident's life, affecting their physical, mental, and emotional well-being). During a review of Resident 4's H&P, dated 4/30/2024, the H&P indicated Resident 4 had the capacity to understand and make decisions. During a review of Resident 4's CP, last revised on 5/19/2025, the CP indicated Resident 4 was at risk for ADL and mobility decline related to paraplegia and required assistance related to pain and vision problems. The CP indicated to encourage Resident to use call light for assistance. During a review of Resident 4's MDS, dated [DATE], the MDS indicated Resident 4's cognitive functioning was moderately impaired. The MDS also indicated Resident 4 required maximal assistance with toileting hygiene, lower body dressing, and moderate assistance with upper body dressing. During a concurrent observation and interview on 6/5/2025 at 11:36a.m. with LVN 2 in Resident 4's room, Resident 4 was observed pressing the call light without the call light indicator near the room entrance turning on to indicate the call light was functioning. LVN 2 stated Resident 4's call light was not working. LVN 2 stated call light should be functioning and within Resident 4's reach for the resident to communicate with staff and prevent accidents such as falls. During an interview on 6/5/2025 at 2:45p.m. with the Director of Nursing (DON), the DON stated call lights should be functional and within residents' reach. The DON stated the failure had the potential to delay necessary assistance and care to residents. During a review of the facility-provided policy and procedure (P&P) titled, Call System, Residents, last reviewed on 4/24/2025, the P&P indicated, 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor . 4. The resident call system remains functional at all times . If visual communication is used, the lights remain functional. Any malfunction or issues with the call light, staff is to notify supervisor/Maintenance/DON/Administrator for immediate resolution and provide alternatives such as call bell, etc.

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial (relating to the interrelation of social factors and individual thoughts and behavior) needs for one of four sampled residents (Resident 1), by failing to administer medications and treatments as ordered by the physician. These deficient practices had the potential to place Resident 1 at risk for unrelieved shortness of breath, respiratory complications, and negatively affect Resident 1's well-being. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE], with diagnoses of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), CHF ( a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in buildup of fluid in the lungs), and anxiety disorder (feeling of anxiousness that affects daily life). During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 3/12/2025, the MDS indicated Resident 1 had intact cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). During a review of Resident 1's Care Plan (CP) for CHF, last revised on 10/15/2024, the CP indicated Resident 1 had CHF and would be given cardiac medications as ordered. During a review of Resident 1's Respiratory CP, last revised on 2/18/2025, the CP indicated Resident 1 was at risk for respiratory complications. CP interventions indicated to administer medications as ordered. During a review of Resident 1's Order Summary Report, the report indicated the following physician's order: -10/14/2025: Trelegy Ellipta Inhalation Aerosol Powder Breath Activated (Fluticasone-Umeclidinium-Vilanterol- medication used to reduce inflammation, relax muscles around the airway, and open the airways to help improve breathing, prevent symptoms such as cough and shortens of breath) 100-62.5-25 microgram /ACT (MCG/ACT-unit of measurement) 1 inhalation inhale orally one time a day for COPD. Rinse mouth out with water after each use. -10/14/2025: Bumex (Bumetanide-medication used to get rid of excess water and salt by increasing the amount of urine produced by the kidneys, used to treat conditions like heart failure) Oral Tablet 1 milligram (mg - unit of measurement). Give 1 mg by mouth one time a day for CHF. During a concurrent interview and record review on 6/4/2025 at 12:30p.m. with Registered Nurse (RN) 1, Resident 1's Medication Administration Record (MAR), dated 5/2025, was reviewed. The MAR indicated on 5/10/2025 and 5/13/2025 for 9 a.m. administration time, there were no licensed staff initials in the box for Resident 1's Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG/ACT, to demonstrate the medication was administered. The MAR also indicated on 5/10/2025 and 5/13/2025 for 9 a.m. administration times, there were no licensed staff initials in the box for Resident 1's Bumex Oral Tablet 1 mg, to demonstrate the medication was administered. RN 1 stated there was no documentation on the MAR dated 5/2025 that indicated Resident 1 received LV1's Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG/ACT on 5/10/2023 9 a.m. and 5/13/2025 at 9 a.m. RN 1 also stated there was no documentation on the MAR dated 5/2025 that indicated Resident 1 received Bumex Oral Table 1 mg on 5/10/2025 at 9 a.m. and 5/13/2025 at 9 a.m. RN 1 stated the failure to administer medications as ordered could have caused shortness of breath. During an interview on 6/4/2025 at 3:30 p.m. with the Director of Nursing (DON), the DON stated the facility failed to administer Resident 1's medications and treatments as ordered by the physician. The DON stated failure to follow physicians' medication and treatment orders had the potential for Resident 1 to experience adverse effects (an undesirrable or harmful consequence that accurs as a result of a treatment, medication), exacerbation (worsening of a pre-existing medical condition) of the condition the medication is used for, respiratory complications such as shortness of breath and worsening of COPD. During a review of the facility-provided policy and procedure (P&P) titled, Administering Medications, last reviewed on 4/24/2025, the P&P indicated, 6. Medications are administered in accordance with prescriber order, including any required time frame 23. As required or indicated for a medication, the individual administering the medication records I the resident's medical record: a. the date and time the medication was administered g. the signature and title of the person administering the drug.

May 2025 4 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure a resident's open area on the right buttocks was assessed comprehensively to include the size and healing progress of wound for one of three sampled residents (Resident 2). This deficient practice could result in Resident 2 not receiving proper treatment. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 2/12/2025 with diagnoses including Huntington disease (nerve cells in the brain gradually break down and die) and anemia (blood is not carrying enough oxygen to your body's tissues). During a review of Resident 2's History and Physical Report, dated 1/24/2025, the report indicated that Resident 2 was severely impaired with thought process. During a record review of Change of Condition (COC) Evaluation, dated 4/15/2025, the COC Evaluation indicated the COC started in the afternoon of 4/15/2025 regarding Resident 2's skin wound or ulcer. The COC Evaluation indicated Resident 2 had an open area on the right buttock with no secretions, foul odor, heat to touch, or edema, no curled edges, and no signs and symptoms of infection. During a concurrent interview and record review on 5/16/2025 at 9:16 a.m., with License Vocational Nurse (LVN) 3, Resident 2's Weekly Skin Assessment was reviewed. LVN 3 stated there was no weekly skin assessments done for Resident 2, and Resident 2 must have weekly skin assessments due to Resident 2's wound. LVN 3 stated weekly skin assessments must be done to see Resident 2's wound progress and assess Resident 2's wound properly. LVN 3 stated if there were no weekly skin assessments, Resident 2's wound could get worse unnoticed. During an interview on 5/16/2025 at 12:07 p.m., with the Director of Nursing (DON), the DON stated weekly skin assessments must be done when a resident has a wound because it describes in the assessment how the wound looks like and progress of the wound healing. During a review of the current facility-provided policy and procedure titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, reviewed on 4/24/2025, the policy and procedure indicated the . the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active diagnoses. During a review of the current facility-provided policy and procedure titled, Pressure Ulcers/Skin Breakdown, reviewed on 4/24/2025, the policy and procedure indicated the . the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active diagnoses.

CONCERN (D) 📢 Someone Reported This

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

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 2) was using pressure-reducing mattress every shift to prevent wound development or promote wound healing. This deficient practice had the potential for Resident 2 to develop or worsen wound if the pressure-reducing mattress was not used. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 2/12/2025 with diagnoses including Huntington disease (nerve cells in the brain gradually break down and die) and anemia (blood is not carrying enough oxygen to your body's tissues). During a review of Resident 2's History and Physical Report, dated 1/24/2025, the report indicated that Resident 2 was severely impaired with thought process. During a record review of Change of Condition (COC) Evaluation, dated 4/15/2025, the COC Evaluation indicated the COC started in the afternoon of 4/15/2025 regarding Resident 2's skin wound or ulcer. The COC Evaluation indicated Resident 2 had an open area on the right buttock with no secretions, foul odor, heat to touch, or edema, no curled edges, and no signs and symptoms of infection. During a record review of Resident 2's Order Summary Report, dated 2/13/2025, indicated to provide pressure-reducing mattress to Resident 2. During a record review of Resident 2's care plan titled, Skin: Resident is at risk for skin breakdown, initiated on 2/12/2025, the care plan indicated an intervention to provide pressure reduction cushion to Resident 2. During a concurrent interview and record review on 5/16/2025 at 12:47 p.m., with License Vocational Nurse (LVN) 4, reviewed Resident 2's physician order, dated 2/13/2025. The physician order indicated to provide pressure reducing mattress, and reviewed medication administration dated 5/1/2025 to 5/31/2025 indicated cross marks and no signature of the nurse. LVN 4 stated the pressure reducing mattress order for Resident 2 should show in the treatment administration record and should not be in the medication administration record, because treatment nurse was the one who was assigned to check the settings of the pressure reducing mattress every shift to make sure that it was in the right settings and needs to sign for it after checking. LVN 4 stated if it was not signed it means it was not done. LVN 4 stated it was important to make sure that pressure reducing mattress setting was checked every shift to make sure it was in the right settings. During a review of the facility policy and procedure titled, Charting and Documentation, last reviewed on 4/24/2025, the policy and procedure indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychological condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

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 F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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Based on interviews and record review, the facility failed to properly manage pain for one of three sampled residents (Resident 1) who was assessed at a higher pain score and pain medication was not administered for treatment. This deficient practice had the potential to ineffectively manage Resident 1's pain. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/26/2025 with diagnoses including fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing (fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing) and hypertension (high blood pressure - the force of your blood pushing against your artery walls is consistently too high) During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/1/2025, the MDS indicated Resident 1 was severely impaired with thought process and required moderate assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 1's care plan on pain, dated 3/27/2025, indicated a goal that Resident 1 will express pain relief after alternative comfort measures and/or administration of medication as needed. The care plan indicated an intervention to administer medications as ordered. During a review of Resident 1's Physician's Order, dated 3/26/2025, indicated to give as follows: - Give acetaminophen tablet 650 milligram (mg - unit of measurement) by mouth every four hours as needed for mild pain one to three out of 10 using the numeric rating scale (a scale, typically from 0 to 10, where 0 represents no pain and 10 represents the worst possible pain). - Give Hydrocodone-Acetaminophen Tablet 5-325 mg one tablet by mouth every six hours as needed for severe pain seven out of 10 in the pain scale. During an interview on 5/14/2025 at 12:47 p.m., with License Vocational Nurse (LVN) 2, LVN 2 stated Resident 1's pain level was 7 of 10 and was not given any pain medication. LVN 2 stated she called pharmacy to use emergency kit pain medication and pharmacy did not allow her due to physician did not sign the authorization yet at that time. LVN 2 further stated it was important to provide pain medication for Resident 1's pain level of 7 of 10 because if not Resident 1's blood pressure could possibly go up, could have emotional distress, respiratory rate could increase, could not function with her ADLs, and will not participate in her therapy due to pain. During a concurrent interview and record review on 5/14/2025 at 2:25 p.m. with the Director of Nursing (DON), Resident 1's pain assessment was reviewed. The pain assessment indicated on 5/7/2025 at 8:52 a.m., Resident 1 had a pain level of 7 of 10. The DON stated that Resident 1 received an acetaminophen at 4 p.m. 7 hours after Resident 1's pain level of 7 of 10 at 8:52 a.m. The DON stated that LVN 2 should have told her (DON) so she (DON) can follow up with the physician and pharmacy. During a review of the facility policy and procedure titled, Pain Assessment and Management, last reviewed date of 4/24/2025, the policy and procedure indicated, The purpose of this procedure are to help the staff identify pain in the resident, develop interventions consistent with the resident's goals and needs, and address the underlying causes of pain. The medication regiment is implemented as ordered.

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to order pain medication and follow up with the physician to sign the narcotic (type of drug that can dull pain) authorization for one of three sample residents (Resident 1). These deficient practices increased the risk that Resident 1 could have with delayed medication treatment leading to untreated pain. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/26/2025 with diagnoses including fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing (fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing) and hypertension (high blood pressure - the force of your blood pushing against your artery walls is consistently too high) During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 3/1/2025, the MDS indicated Resident 1 was severely impaired with thought process and required moderate assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 1's care plan on pain, dated 3/27/2025, indicated goal that Resident 1 will express pain relief after alternative comfort measures and/or administration of medication as needed. The care plan indicated an intervention to administer medications as ordered. During a review of Physician's Order, dated 3/26/2025, the order indicated to give as follows: - Give acetaminophen tablet 650 milligram (mg - unit of measurement) by mouth every four hours as needed for mild pain one to three out of 10 using the numeric rating scale (a scale, typically from 0 to 10, where 0 represents no pain and 10 represents the worst possible pain). - Give Hydrocodone-Acetaminophen Tablet 5-325 mg one tablet by mouth every six hours as needed for severe pain seven out of 10 using the pain scale. During an interview on 5/14/2025 at 12:47 p.m., with License Vocational Nurse (LVN) 2, LVN 2 stated Resident 1's pain level was 7 of 10 and was not given any pain medication. LVN 2 stated she called pharmacy to use emergency kit pain medication and pharmacy did not allow her due to physician did not sign the authorization yet at this time. LVN 2 stated it was important to provide pain medication for Resident 1's pain level of 7 of 10 because if not Resident 1's blood pressure could possibly go up, could have emotional distress, respiratory rate could increase, could not function with her ADLs, and will not participate in her therapy due to pain. During a concurrent interview and record review on 5/14/2025 at 2:25 p.m. with the Director of Nursing (DON), Resident 1's pain assessment was reviewed. The pain assessment indicated on 5/7/2025 at 8:52 a.m., Resident 1 had a pain level of 7 of 10. The DON stated that Resident 1 received an acetaminophen at 4 p.m. seven hours after Resident 1's pain level of 7 of 10 at 8:52 a.m. The DON stated that LVN 2 should have told her (DON) so she (DON) can follow up with the physician and pharmacy. During a concurrent interview and record review on 5/15/2025 at 3:42 p.m., with the DON, reviewed a document titled, Quality Assurance Action Plan Template Change in Pharmacy, dated 4/9/2025. The document indicated the following: Systems Changes: - Update internal protocols for medication ordering and communication with pharmacy. - Integrate new pharmacy's electronic systems with facility EMR (if applicable). - Develop a step-by-step transition guide. Monitoring: - Daily medication delivery and administration audits for the first 2 weeks post-transition. - Monitor resident outcomes and incident reports related to medications. - Weekly pharmacy service feedback meeting with staff and administration for 1 month. - Any findings or concerns will be discussed by the Director of Nursing or designee to ensure long-term sustainability of new pharmacy service monthly for three months then quarterly after for a year. The DON stated that the infection preventionist helped her to check the carts to check for the missing narcotic, make rounds and ask the nurses if they have missing medication. The DON stated that she does not know why staff missed Resident 1's medications. The DON stated the license nurse was in charge in ordering and following up the medication from the pharmacy, and license nurses know that they should order it as soon as they only have five pills left. The DON further stated that the facility policy and procedures did not indicate how many pills were left before requesting a new refill, but that was the usual practice. During a review of the current facility-provided undated policy and procedure titled, Medication Orders, the policy and procedure indicated, Before a controlled drug can be dispensed, the pharmacy must be in receipt of a prescription from a person lawfully authorized to prescribe. A chart order is not equivalent to a prescription for controlled drugs. Therefore, the prescriber issuing the chart order must also provide the pharmacist with a valid prescription to ensure delivery of medication.

Apr 2025 6 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain a safe, clean, homelike environment for two of three sampled residents (Residents 2 and 3). This failure had the potential for unsafe and unclean resident's (Residents 2 and 3) environment with the potential for the spread of infection and place the residents at risk for physical discomfort. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 7/8/2024, with diagnoses that included metabolic encephalopathy (a disorder that affects brain function), end stage renal disease (ESRD- irreversible kidney failure), and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). During a review of Resident 2's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 7/9/2024, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 1/14/2025, the MDS indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 2 needed maximum assistance from staff for showering, dressing, and personal hygiene. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 1/22/2024, with diagnoses that included hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body, often affecting the arm, leg, and potentially the face) following cerebral infarction( a condition where blood flow to the brain is blocked, leading to brain tissue damage), essential hypertension (a condition characterized by persistently high blood pressure without an identifiable underlying cause), and prediabetes (a condition where blood sugar levels are higher than normal but not yet high enough to be diagnosed as diabetes). During a review of Resident 3's H&P, dated 9/7/2024, the H&P indicated Resident 3 had fluctuating capacity (situation where a person's decision-making ability varies) to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3's cognitive skills for daily decisions were intact. During an observation on 4/2/2025, at 2:53 pm., at Resident 2's bedside. Observed Resident 2's left side of the bed against the wall. During an interview on 4/3/2025, at 8:45 a.m., with Complainant 1 (Comp 1), Comp 1 stated on 4/1/2025, observed dried feces on the wall next to Resident 2. During an interview on 4/3/2025 at 9:51 a.m., with Resident 3, Resident 3 stated she (Resident 3) had seen feces on the wall of Resident 2 and last time she (Resident 3) had observed it was last night (4/2/2025). Resident 3 stated she (Resident 3) had noticed it whenever she (Resident 3) had to use the bathroom which is by Resident 2's side. Resident 3 stated nurses comes in the room at night but have never looked around. During an interview on 4/3/2025, at 9:59 a.m., with Registered Nurse 1 (RN 1), RN 1 stated on 4/1/2025, there was a dark stain on the wall. RN 1 stated it was from Resident 2 picking on her (Resident 2)'s nose. RN 1 stated he (RN 1) thought Resident 2 had gastrointestinal bleeding (bleeding in your digestive tract, which can range from the mouth to the rectum) but later on found out it was from Resident 2's nosebleed. RN 1 stated Licensed Vocational Nurse 1 (LVN 1) cleaned the stain from Resident 2's wall after the paramedics (persons trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) left. During an interview on 4/3/2025, at 10:12 a.m. with the Director of Nursing (DON), the DON stated if staff observed dirty environment, staff should have called the housekeeping to clean. The DON stated the importance of a clean environment was for infection control. The DON stated the facility's policy for physical environment was to maintain a clean and sanitary environment. During a review of facility's policy and procedure (P&P) titled, Homelike Environment undated and last reviewed on 4/18/2024, the P&P indicated, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include a. clean, sanitary and orderly environment .

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for one of three sampled residents (Resident 1) by failing to ensure a care plan was developed on Resident 1's refusal of his ordered medications. This failure had the potential for complications related to Resident 1 not receiving his ordered medications. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 7/3/2024, with diagnoses that included chronic congestive heart failure (CHF- condition where the heart muscle is weakened and cannot pump blood effectively, leading to fluid buildup in the body), pressure induced deep tissue damage (a type of soft tissue injury that affects the underlying layers of skin, muscle, and other tissues) of sacral region (above the tailbone) and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 7/5/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 1/9/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 needed maximum assistance from staff for toileting, showering, and personal hygiene. During a review of Resident 1's Physician Order, dated 2/12/2025, the Physician Order indicated the following orders. 1. Eliquis (medication used to prevent blood clot) tablet five milligram (mg- metric unit of measurement, used for medication dosage and or amount), give five mg by mouth two times a day for atrial fibrillation (irregular heartbeat). 2. Flomax (medication used to treat symptoms of enlarge prostate [male gland that is involved in reproduction]) oral capsule 0.4 mg, give 0.4 mg by mouth one time a day for benign prostatic hyperplasia (BPH-when the prostate and surrounding tissue expands). 3. Multivitamins with minerals (medication supplement containing a range of vitamins and minerals to help individuals meet their daily nutritional needs), give one tablet by mouth one time a day for wound healing. 4. Vitamin C (a water-soluble vitamin essential for various bodily functions, including wound healing), oral tablet 500 mg, give 500 mg by mouth two times a day for supplement. During a review of Resident 1's Physician Order, dated 2/13/2025, the Physician Order indicated Zinc Sulfate (medication used in wound care for its potential to enhance healing) tablet 220 mg, by mouth one time a day for wound management. During a review of Resident 1's Physician Order, dated 2/26/2025, the Physician Order indicated the following orders: 1. Metoprolol tartrate (medication used to treat high blood pressure) 100 mg, give one tablet by mouth two times a day for hypertension (HTN- high blood pressure). 2. Lisinopril (medication used to treat high blood pressure) oral tablet 2.5 mg, give one tablet by mouth one time a day for HTN. 3. Furosemide (medication used to treat fluid retention) 40 mg, give one tablet by mouth one time a day for edema (swelling caused by fluid trapped in your body's tissues). During a concurrent interview and record review on 4/3/2025, at 9:18 a.m., with Assistant Director of Nursing (ADON), Resident 1's Medication Administration Record (MAR-a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) dated 3/2025 and Care Plans were reviewed. The MAR on 3/6/2025, at 9 a.m. indicated Resident 1 had refused Flomax, furosemide, lisinopril, multivitamin, zinc sulfate, Eliquis, metoprolol and vitamin C. The ADON stated Resident 1 was here in the facility on 3/6/2025. The ADON stated there was no care plan developed for Resident 1's refusal to take ordered medication. The ADON stated nurses should have develop a care plan for medication refusal. The ADON stated the importance of a care plan was it identifies residents' problem, preference of care and interventions on how to take care of residents. During an interview on 4/3/2025, at 10:12 a.m., with the Director of Nursing (DON), the DON stated nurses should have developed a care plan for Resident 1's medication refusal and notify the physician. The DON stated a care plan guides the nurses on what to do when a problem arise like when Resident 1 refused his medication. During a review of facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Plans, undated and last reviewed on 4/18/2025, the P&P indicated, 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes. b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. c. Describe services that would otherwise be provided for the above but are not provided due to the resident exercising his or her rights, including the right to refuse treatment. d. Describe any specialized services to be provided as a result of PASARR recommendations. e. Include the resident's stated goals upon admission and desired outcomes. f. Include the resident's stated preference and potential for future discharge, including his or her desire to return to the community and any referrals made to local agencies or other entities to support such a desire. g. Incorporate identified problem areas. h. Incorporate risk factors associated with identified problems. i. Build on the resident's strengths. 15. The resident has the right to refuse to participate in the development of his/her care plan and medical and nursing treatments. Such refusals will be documented in the resident's clinical record in accordance with established policies.

CONCERN (D) 📢 Someone Reported This

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

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure that one of the three sampled residents (Resident 2), who was unable to carry out activities of daily living (ADLs-such as personal hygiene, bathing, bed mobility, dressing and transfers) received the necessary services to maintain good grooming and personal hygiene. This failure had the potential to negatively affect Resident 2' s self-esteem and wellbeing and also placed Resident 2 at risk for infection. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 7/8/2024, with diagnoses that included metabolic encephalopathy (a disorder that affects brain function), end stage renal disease (ESRD- irreversible kidney failure) and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). During a review of Resident 2's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 7/9/2024, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 1/14/2025, the MDS indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 2 needed maximum assistance from staff for showering, dressing, and personal hygiene. During an observation on 4/2/2025, at 2:53 p.m., inside Resident 2's room. Observed Resident 2 had black dirt under her (Resident 2)'s long fingernails. During an interview on 4/2/2025, at 3:12 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Certified Nursing Assistant (CNA) are in charge of cleaning residents' fingernails. During an interview on 4/2/2025, at 3:26 p.m. with CNA 1, CNA 1 stated she (CNA 1) had provided bed bath to Resident 2 this morning. CNA 1 stated nail hygiene was part of the bed bath. CNA 1 stated she (CNA 1) did not clean Resident 2's fingernails during the bed bath. CNA 1 stated she (CNA 1) should have cleaned Resident 2's fingernails as Resident 2 always scratches herself (Resident 2). CNA 1 stated the importance of nail hygiene was to prevent infection and prevent injury. During an interview on 4/2/2025, at 4:19 p.m., with the Director of Staff Development (DSD), the DSD stated CNAs are in charge of cleaning residents' fingernails. The DSD stated CNAs trims the fingernails if residents are not diabetic (high blood sugar) and if diabetic LVN's are in charge of trimming the fingernails. The DSD state nail care were part of hygiene. The DSD stated the importance of nail care was to prevent injury or skin breakdown when resident scratches or to prevent infection when residents uses their hands when eating. During an interview on 4/2/2025, at 4:24 p.m. with the Director of Nursing (DON), the DON stated CNAs should clean Resident 2's fingernails. The DON stated CNAs should trim Residents 2's fingernails because Resident 2 had a behavior of scratching herself (Resident 2) to prevent injury and for infection prevention. During a review of facility's policy and procedure (P&P) titled, Care of Fingernails/Toenails, undated and last reviewed on 4/18/2024, the P&P indicated, The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. General Guidelines: 1. Nail care includes daily cleaning and regular trimming. 2. Proper nail care can aid in the prevention of skin problems around the nail bed.4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin. Steps in the Procedure: 4. Allow the first hand or foot to soak in the warm soapy water for approximately five minutes. Encourage the resident to exercise his or her fingers or toes while they are soaking. 6. Rinse the hand or foot that has been in the soapy water with clear, warm water. 7. Dry the hand or foot with the towel. 9. Place the second hand or foot in the soak basin. 10. Gently, remove the dirt from around and under each nail with an orange stick. 11. Wipe the dirt from the orange stick with a paper towel. Discard the paper towel into the trash receptacle. 12. Do not trim nails below the skin line or cut the skin. 13. Trim fingernails in an oval shape and toenails straight across. 14. Smooth the nails with a nail file or emery board. Apply lotion as permitted. 15. Repeat the procedure for the second hand or foot.

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure the residents received care consistent with professional standards of practice for one of three sampled residents (Resident 2) by failing to ensure Resident 2's blood pressure was monitored every hour as per physician's order after Resident 2 had a change in condition on 4/1/2025 at 8:58 p.m. This failure had the potential for a delay in care in services and unidentified change in condition. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 7/8/2024, with diagnoses that included metabolic encephalopathy (a disorder that affects brain function), end stage renal disease (ESRD- irreversible kidney failure) and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). During a review of Resident 2's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 7/9/2024, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 1/14/2025, the MDS indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 2 needed maximum assistance from staff for showering, dressing and personal hygiene. During a review of Resident 2's Change in Condition (CIC) dated 4/1/2025, the CIC indicated Resident 2 had abnormal vital signs (your body's basic functions, like heart rate, breathing, temperature, and blood pressure, are outside of what's considered healthy or typical). The CIC indicated on 4/1/2025, at 8:58 p.m., Resident 2's blood pressure was 70/60 millimeters of mercury (mmHg - unit of pressure measurement). The CIC indicated physician was notified and ordered to transfer Resident 2 to the General Acute Care Hospital (GACH) via 911 (number to call for emergency medical response) and place intravenous (medical procedure or treatment that involves administering fluids, medications, or nutrients directly into a vein) for bolus (a single, large dose of medicine or fluid). During a review of Resident 2's Progress Notes dated 4/1/2025, at 9:22 p.m., the Progress Notes indicated the following on 4/1/2025. 9:02 p.m., Resident 2's blood pressure was 60/40 mmHg. 9:06 p.m., Physician was notified with order to call 911 (the number to call for emergency services). 9:07 p.m. Paramedics (persons trained to give emergency medical care to people who are injured or ill, typically in a setting outside of a hospital) called. 9:15 p.m.- Paramedics arrived. 9:25 p.m., Resident 2's blood pressure improved, and Resident 2 refused to be transferred to GACH. The paramedics left without taking Resident 2. The physician was notified with order for intravenous fluid bolus but Resident 2 had refused. The physician ordered to monitor Resident 2's blood pressure every hour for 72 hours. During a review of Resident 2's Order Recap Report, dated 4/1/2025, the Order Recap Report indicated to monitor blood pressure every hour for hypotension (low blood pressure) for three days. During a review of Resident 2's Medication Administration Record (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 4/2025, the MAR indicated Resident 2's blood pressure was documented from 4/2/2025 at 2 p.m. During a concurrent interview and record review on 4/2/2025, at 4:07 p.m., with Registered Nurse 2 (RN 2), Resident 2's CIC dated 4/1/2025, Physician Order dated 4/1/20245 and Weight Log dated 4/2025 were reviewed. The Weight log indicated on 4/1/2025, at 9:02 p.m. blood pressure was 70/60 mmHg. The Weight Log indicated on 4/2/2025, at 3:35 a.m., Resident 2's blood pressure was 98/75 mmHg. RN 2 stated the physician's order on 4/1/2025, at 9:25 p.m., was to check Resident 2's blood pressure every hour. RN 2 stated there were no documented blood pressure checks from 4/1/2025, 10:30 p.m. to 4/2/2025, at 1:30 a.m. RN 2 stated there were missing four hours of blood pressure checks. RN 2 stated she (RN 2) had check Resident 2's blood pressure and obtained 96/50 mmHg but did not remember the exact time it was taken. RN 2 stated she (RN 2) had notified RN 1 and thought RN 1 would document the blood pressure reading. During an interview on 4/2/2025, at 4:24 p.m., with the Director of Nursing (DON), the DON stated Resident 2's blood pressure was not monitored and documented as per physician's order. The DON stated nurses should follow the physician order. The DON stated if physician order was not followed Resident 2's blood pressure can decrease and cause hypotensive shock (a life-threatening condition caused by a significant loss of blood or fluid, leading to inadequate blood flow to the body's tissues and organs, potentially causing organ failure and death if untreated) that could endanger Resident 2's life. During an interview on 4/3/2025, at 9:59 a.m., with RN 1, RN 1 stated he (RN 1) obtained the physician's order for Resident 2's blood pressure monitoring every hour. RN 1 stated the nurses may not be monitoring Resident 2's blood pressure. RN 1 stated if Resident 2's blood pressure was not monitored, nurses would not be able to know if Resident 2's blood pressure was improving or not. RN 1 stated Resident 2 can experience complications like hypotension (low blood pressure) and hypovolemic shock. During a review of facility's policy and procedure (P&P) titled, Quality of Care undated and last reviewed on 4/18/2024, the P&P indicated, Facility is required to maintain quality of care to meet certain quality indicators and standards set by federal and state laws which include measures related to resident care, staffing levels, health and safety, infection control and more. Facility has quality improvement programs to continuously monitor and enhance the quality of care. provided to residents. This includes but not limited to tracking outcomes, conducting regular assessments, and implementing best practices. During a review of facility's P&P titled, Change in a Resident's Condition or Status, undated and last reviewed on 4/18/2024, the P&P indicated, The nurse will record in the resident's medical record information relative to changes in the resident's medical or mental condition or status.

CONCERN (D) 📢 Someone Reported This

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

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure the residents received care consistent with professional standards of practice to prevent pressure ulcers (PU-a localized injury to the skin and or underlying tissue usually over a bony prominences as a result of pressure or pressure in combination with shear) for one of three sampled residents (Resident 2) by failing to provide treatment to Resident 2 on 3/2025. This failure had placed Resident 2 at risk for development of pressure ulcers. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 7/8/2024, with diagnoses that included metabolic encephalopathy (a disorder that affects brain function), end stage renal disease (ESRD- irreversible kidney failure), chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), and muscle weakness. During a review of Resident 2's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 7/9/2024, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set (MDS-a resident assessment tool), dated 1/14/2025, the MDS indicated Resident 2's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 2 needed maximum assistance from staff for showering, dressing and personal hygiene. During a review of Resident 2's Physician Order, dated 11/8/2024, the Physician Order indicated to wash sacrococcyx (tailbone) extending to right and left buttocks with soap and water, pat dry and apply zinc oxide (medication used to treat and prevent diaper rash or protect skin from irritation) and cover with foam dressing daily or as needed for prevention. During a review of Resident 2's Braden Scale for Predicting Pressure Sore, dated 1/14/2025, the Braden Scale for Predicting Pressure Sore indicated Resident 2 was at risk for pressure sore. During a review of Resident 2's Treatment Administration Record (TAR-a daily documentation record used by a licensed nurse to document treatments given to a resident), dated 3/2025, the TAR indicated on 3/2/2025, 3/3/2025, 3/5/2025, 3/6/2025, 3/10/2025 and 3/29/2025, treatments for sacrococcyx extending to right and left buttocks with zinc oxide were left blank. During a concurrent interview and record review on 4/3/2025, at 8:58 a.m., with the Treatment Nurse 1 (TN 1), Resident 2's TAR dated 3/2025 was reviewed. TN 1 stated there were six days of treatments were not done for Resident 2. TN 1 stated the physician ordered the zinc oxide daily and as needed to prevent pressure injury. TN 1 stated if treatment not done, Resident 2's pressure injury could reopen. TN 1 stated nothing should be blank in TAR. TN 1 stated if Resident 2 goes out to dialysis (treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney have failed), treatment should be done when Resident 2 comes back in the facility. During an interview on 4/3/2025, at 10:12 a.m., with the Director of Nursing (DON), the DON stated treatment should be done as per physician's order. The DON stated the TAR should not be left blank. The DON stated blank means treatment was not done. The DON stated treatment was necessary to prevent skin breakdown or pressure injury. During a review of facility's policy and procedure (P&P) titled, Prevention of Pressure Injuries, undated and last reviewed on 4/18/2024, the P&P indicated, Prevention: Skin care 1. Keep the skin clean and hydrated. 2. Clean promptly after episodes of incontinence. 3. Avoid alkaline soaps and cleansers. 4. Use a barrier product to protect skin from moisture. 5. Use incontinence products with high absorbency. 6. Do not rub or otherwise cause friction on skin that is at risk of pressure injuries. 7. Use facility-approved protective dressings for at risk individuals. During a review of facility's P&P titled, Administering Medication, undated and last reviewed on 4/18/2025, the P&P indicated, Medications are administered in accordance with prescriber orders, including any required time frame. Topical medications used in treatments are recorded on the resident's treatment record (TAR).

CONCERN (E) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for two of three sampled residents (Resident 1 and 2) by failing to ensure the physician's order was followed. 1. Failed to ensure Licensed Vocational Nurse 3 (LVN 3) administered acetaminophen (medication used to treat pain and fever) to Resident 1 on 3/6/2025, with a pain level of four despite physician order to use acetaminophen for pain level between one to three. 2. Failed to ensure clobetasol cream (medication used to treat itching) was administered to Resident 1 as per physician order. 3. Failed to ensure LVN 4 administered amlodipine (medication used to treat high blood pressure) to Resident 2 on 3/5/2025, with a blood pressure of 109/70 millimeters of mercury (mmHg - a unit of pressure measurement) despite a physician's order to hold amlodipine for systolic blood pressure (sbp- pressure in the arteries when the heart beats) below 110. 4. Failed to ensure LVN 4 administered acetaminophen to Resident 2 on 3/10/2025, with a pain level of six despite physician order to use acetaminophen for pain level between one to three. These failures had the potential to result in medication error, decrease in blood pressure, can cause unmanageable pain and discomfort. Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 7/3/2024, with diagnoses that included chronic congestive heart failure (CHF- condition where the heart muscle is weakened and cannot pump blood effectively, leading to fluid buildup in the body), pressure induced deep tissue damage (a type of soft tissue injury that affects the underlying layers of skin, muscle, and other tissues) of sacral region (above the tailbone) and chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing). During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 1/9/2025, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 needed maximum assistance from staff for toileting, showering, and personal hygiene. During a review of Resident 1's History and Physical (H&P-a medical examination that involves a doctor taking a patient's medical history, performing a physical exam, and documenting their findings), dated 7/5/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Physician Order, dated 2/12/2025, the Physician Order indicated acetaminophen tablet, give 650 milligram (mg-metric unit of measurement, used for medication dosage and/or amount) every four hours as needed for mild pain between pain level one to three. During a review of Resident 1's Medication Administration Record (MAR-a daily documentation record used by a licensed nurse to document medications and treatments given to a resident), dated 3/2025, the MAR indicated LVN 3 administered acetaminophen 650 mg to Resident 1 on 3/6/2025, at 9:40 p.m., and 3/17/2025, at 9:43 a.m. with a pain level of four. During a concurrent interview and record review on 4/3/2025, at 9:18 a.m., with the Assistant Director of Nursing (ADON), Resident 1's Physician Order dated 2/12/2025, and MAR dated 3/2025, were reviewed. The ADON stated physician's order for acetaminophen was only for pain level of one to three. The ADON stated LVN 3 should have checked Resident 1's physician order for other pain medication that would match Resident 1's pain. The ADON stated if there were no physician's order for pain level four and above, LVN 3 should have called and notified the physician. The ADON stated if it was Resident 1's preference to only take acetaminophen for pain, LVN 3 still had to notify the physician to adjust pain scale to match resident's request. The ADON stated Resident 1's pain and discomfort will not be treated. b. During a concurrent interview and record review on 4/3/2025, at 8:58 a.m., with Treatment Nurse 1 (TN 1), Resident 1's Physician Order dated 3/14/2025, and Treatment Administration Record (TAR-a daily documentation record used by a licensed nurse to document treatments given to a resident) dated 3/2025 were reviewed. The Physician Order indicated clobetasol propionate cream 0.05 percent (%- per one hunderd) to apply throughout the body topically (used on the outside of the body) two times a day for rash (a skin irritation or inflammation that can appear as redness, bumps, blisters, or other changes to the skin). The TAR indicated on 3/16/2025, and 3/17/2025, at 5 p.m., clobetasol was left blank. TN 1 stated blank means treatment was not done. TN 1 stated LVNs are responsible for clobetasol administration to treat rash at 5 p.m. and in the morning TNs administers it. TN 1 stated if clobetasol was not applied to Resident 1, rashes would not be treated. During an interview on 4/3/2025, at 10:12 a.m. with the Director of Nursing (DON), the DON stated treatment should be applied as per physician's order. The DON stated nurses should apply clobetasol to Resident 1 for rashes. The DON stated rashes can worsen and cause discomfort if not treated. c. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 7/8/2024, with diagnoses that included metabolic encephalopathy (a disorder that affects brain function), end stage renal disease (ESRD- irreversible kidney failure) and COPD. During a review of Resident 2's H&P, dated 7/9/2024, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decisions was intact. The MDS indicated Resident 2 needed maximum assistance from staff for showering, dressing and personal hygiene. During a review of Resident 2's Physician Order, dated 7/8/2024, the Physician Order indicated the amlodipine besylate tablet five mg, give five mg by mouth two times a day for hypertension (HTN-high blood pressure), hold for sbp less than 110 or pulse less than 60. During a review of Resident 2's MAR, dated 3/2025, the MAR indicated on 3/5/2025, LVN 4 administered amlodipine5 mg to Resident 2 with a blood pressure of 109/70 mmHg. During a concurrent interview and record review on 4/3/2025, at 9:18 a.m., with the ADON, Resident 2's Physician Order dated 7/8/2024, and MAR dated 3/2025 were reviewed. The ADON stated Resident 2's MAR indicated LVN 4 administered amlodipine to Resident 2 on 3/5/2025, with a blood pressure of 109/70 mmHg. The ADON stated physician order indicated to hold the amlodipine for sbp below 110. The ADON stated LVN 4 should have held the amlodipine as per physician's order. The ADON stated Resident 2's blood pressure can potentially decrease as a result of the blood pressure medication administration. d. During a review of Resident 2's Physician Order, dated 7/8/2024, the Physician Order indicated acetaminophen tablet 650 mg by mouth every four hours as needed for mild pain level of one to three. During a review of Resident 2's MAR, dated 3/2025, the MAR indicated on 3/10/2025 at 9 a.m., LVN 4 administered acetaminophen 650 mg to Resident 2 for pain level of six. During a concurrent interview and record review on 4/3/2025, at 9:18 a.m., with the ADON, Resident 2's Physician Order dated 7/8/2024, and MAR dated 3/2025 were reviewed. The ADON stated Resident 2's MAR indicated LVN 4 administered acetaminophen to Resident 2 on 3/10/2024, at 9 a.m., with a pain level of six. The ADON stated physician order for acetaminophen was only for pain level between one to three. The ADON stated LVN 4 should have checked the physician's order for other medications that matches Resident 2's pain and if there were nothing, to call and notify the physician and obtain an order. The ADON stated LVN 4 did not follow the physician's order. The ADON stated Resident 2's pain will not be controlled. During an interview on 4/3/2025, at 10:12 a.m., with the Director of Nursing (DON), the DON stated nurses should follow physician's orders or call the physician to adjust blood pressure or change the pain scale order. The DON stated if residents were administered with blood pressure medication and resident had already low blood pressure, it can result to hypotension (low blood pressure). The DON stated if a resident with moderate to severe pain was administered pain medication for mild pain it would not be enough to treat the pain. During a review of facility's policy and procedure (P&P) titled, Administering Medications, undated and last reviewed on 4/18/2024, the P&P indicated, Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. During a review of facility's P&P titled, Pain Assessment and Management, dated 2001, and last reviewed on 4/18/2024, the P&P indicated, The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Pain management interventions reflect the sources, type and severity of pain. Pain management interventions shall address the underlying causes of the resident's pain. For those situations where the cause of the resident's pain has not been or cannot be determined, current standards of practice for managing pain are followed to help determine appropriate options. Implementing Pain management Strategies: 1. Establish a treatment regimen that is specific to the resident based on consideration of the following: a. The resident's medical condition. b. Current medication regimen. c. History of addiction or opioid use disorder. d. Nature, severity and cause of the pain. e. Course of the illness; and f. Treatment goals.

Mar 2025 4 deficiencies 3 IJ

CRITICAL (J) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Notification of Changes (Tag F0580)

Someone could have died · This affected 1 resident

Based on interview and record review, the facility failed to notify the physician of a change of condition (COC – a major decline in a resident ' s status) for one of nine sampled residents (Res...

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Based on interview and record review, the facility failed to notify the physician of a change of condition (COC – a major decline in a resident ' s status) for one of nine sampled residents (Resident 1) when on 3/12/2025 at approximately 5 p.m., Resident 1 had a low blood pressure (BP – measurement of the pressure or force of blood inside your arteries [the elastic, muscular tubes or blood vessels responsible for carrying the blood away from the heart and distributing it to several other organs and tissues]) reading of 86/57 millimeters of mercury (mmHg – unit of measurement used to measure BP and is abnormal if less than 90/60 mmHg or greater than 139/89 mmHg) and increased heart rate (HR – the number of heartbeats per unit of time) of 111 beats per minute (bpm - considered abnormal if less than 60 bpm or greater than 100 bpm). As a result, Resident 1 experienced severe respiratory distress (a life-threatening condition characterized by difficult breathing, rapid breathing, and low oxygen levels, often requiring immediate medical intervention) was transferred to a General Acute Care Hospital (GACH) on 3/13/2025 at 12:37 a.m., and pronounced dead on 3/13/2025 at 4:27 p.m. On 3/26/2025 at 5:31 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ – a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility ' s failure to notify the physician regarding Resident 1 ' s COC on 3/12/2025 at approximately 5 p.m. On 3/28/2025 at 10:06 a.m., the ADM and DON provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings) for the facility ' s failure to notify the physician regarding Resident 1 ' s COC on 3/12/2025 at approximately 5 p.m. On 3/28/2025 at 7:28 p.m., while onsite at the facility, the SSA verified that the IJ situation was no longer present and confirmed the facility ' s full implementation of the IJ Removal Plan through observations, interviews, and record reviews, the SSA removed the IJ situation for the facility ' s failure to notify the physician regarding Resident 1 ' s COC on 3/12/2025 at approximately 5 p.m., in the presence of the ADM, DON, and Assistant Director of Nursing (ADON). The acceptable IJ Removal Plan included the following summarized actions: 1. On 3/26/2025 and 3/27/2025, the nursing staff, including Certified Nursing Assistants (CNAs), Licensed Vocational Nurses (LVNs), and Registered Nurses (RNs), obtained vital signs for 262 in-house residents to identify abnormal (out of range) vital signs (measurements of the body ' s most basic functions), including BP, HR or pulse rate (PR), respiratory rate (RR – refers to the number of breaths a person takes per minute), and body temperature (refers to the measurement of the heat generated by the human body). The facility defined parameters for abnormal vital signs are as follows: HR or PR is considered abnormal if less than 60 or greater than 100 beats per minute; RR is abnormal if less than 12 or greater than 25 breaths per minute; temperature is abnormal if less than 97.8 ° Fahrenheit (° F – unit of measurement) or greater than 99.0 °F; systolic BP (the upper number in the BP reading) is abnormal if less than 90 mmHg or greater than 139 mmHg; and diastolic BP (the lower number in the BP reading) is abnormal if less than 60 mmHg or greater than 89 mmHg. 2. On 3/26/2025, the LVNs and RNs reviewed the current in-house residents who were actively being monitored for COCs between 3/23/2025 to 3/26/2025. Out of 262 in-house residents, 45 residents were identified as having recent COCs. For these 45 residents with COCs, the physicians were promptly notified, and appropriate orders were obtained and implemented to address the identified changes. 3. On 3/26/2025, following the completion of the vital signs audit, the facility identified 23 out of the 45 residents with recent COCs were directly related to abnormal vital signs. For these 23 residents, COC evaluations were promptly completed, primary care physicians were notified by LVNs and RNs, and appropriate medical orders were obtained and implemented. 4. On 3/26/2025, the facility implemented a structured communication protocol (is a set of guidelines and procedures ensuring clear, consistent, and effective communication among staff, residents, and families, promoting resident safety, dignity, and positive results) for reporting findings of abnormal vital signs among CNAs, LVNs, RNs, and ultimately to the attending physician. This protocol was reviewed and approved by the Quality Assurance Committee (QAC – is a group that regularly reviews care quality, identifies issues, and develops plans to address deficiencies, ensuring residents receive safe and effective care) and serves as a standardized guideline for nursing staff to ensure timely and accurate escalation (an increase in the intensity or seriousness) of clinical concerns (health-related issues or problems that require medical attention): i. CNAs are to report abnormal vital signs to the charge nurse immediately. ii. Once abnormal vital signs are rechecked and verified by the charge nurse, the charge nurse will escalate to the RN Supervisor for further evaluation. iii. A COC evaluation using the eInteract tool (a tool used in healthcare that helps care teams prevent unnecessary hospitalizations and improve resident outcomes to alert staff to changes in a resident ' s condition) will be initiated when abnormal vital signs are identified as part of a resident's COC. This applies to residents with underlying clinical concerns, including but not limited to the following: a history of hypertension (high BP), hypotension (low BP), recent infection, cardiac (heart) conditions, respiratory compromise (a situation where a person ' s breathing is at risk of becoming severely impaired), or any other medical condition that may predispose (to make more likely or render susceptible) the resident to instability. iv. A paper log titled, Abnormal Vital Sign Log will be maintained by each charge nurse to document communication between nursing staff and, ultimately, with the physician regarding abnormal vital signs. v. Family members / responsible party will be notified by the LVNs or RNs of any change of condition unless the resident has indicated otherwise. The nurse must document all attempts made in the resident's medical record and the outcome of the family notification. vi. Vital signs will be monitored every shift for a minimum of 72 hours for residents identified with a COC, or longer if clinically indicated. 5. On 3/27/2025, the ADM and DON initiated a root cause analysis (a systematic approach to identify the underlying reasons for a problem or failure, rather than just addressing its immediate symptoms, to prevent recurrence) on the facility ' s failure to ensure any resident having abnormal vital signs was provided with necessary care and services, including notification of the physician, to address a COC. The facility identified the root causes included licensed nurses have a lack of supervision to ensure they (licensed nurses) follow protocols, that proactive audits (conducting internal reviews before potential problems arise to prevent future issues) or quality checks to identify gaps in care were not addressed timely, and adequate training during the hiring orientation process was provided to staff. 6. On 3/26/2025, the DON provided one-on-one in-service training (is a personalized, focused training method where a healthcare professional learns a specific skill or procedure from a more experienced colleague in a one-to-one setting) to LVN 1. The planned training focused on providing care and services to residents, with the focus on the critical importance of documenting identified COCs, and notifying the primary physician when a change in a resident's condition is identified. Abnormal vital signs are communicated between CNAs, LVNs, RNs, and ultimately to the attending physician. Residents with COCs are monitored, and interventions are provided to address the COCs. 7. On 3/26/2025, LVN 1 was suspended and is currently still on suspension. 8. On 3/27/2025, the DON implemented staff training focusing on providing care and services to residents, with focus on critical importance of documenting identified COCs, and notifying the primary physician when a change in a resident's condition is identified. Abnormal vital signs are communicated between CNAs, LVNs, RNs, and ultimately to the attending physician. Residents with COCs are monitored, and interventions are provided to address the COCs. 9. On 3/26/2025, the DON initiated competency skills checks (are assessments that ensure healthcare professionals possess the necessary knowledge, skills, and abilities to perform their roles safely and effectively, often using checklists and other methods to evaluate performance) for LVNs and RNs to ensure that the licensed staff are proficient (competent or skilled) in evaluating COCs and accurately/timely reporting abnormal vital signs. The skills check included core competencies such as recognizing COCs, identifying abnormal vital signs, taking immediate action, notifying physicians promptly, and ensuring follow-up and continuous monitoring of COCs. Each nursing staff member was evaluated using a structured scoring tool, with opportunities for return demonstrations (a teaching technique where a student, after being shown a skill or procedure, demonstrates their understanding by performing it themselves, allowing the instructor to assess their learning) as needed to confirm competency. 10. On 3/26/2025, the DON, in collaboration with the Director of Staff Development (DSD), initiated in-service trainings for nursing staff, including CNAs, LVNs, and RNs, with a focus on recognizing COCs. The training emphasized timely reporting and appropriate interventions (including physician notification), ongoing monitoring of residents identified with a COC, and accurate documentation of abnormal vital signs. For staff who were unable to attend the scheduled in-service trainings, in-service trainings will be provided prior to the start of their next scheduled shift and will not be allowed to report to the assigned unit until training is completed. Nursing staff on leave or on vacation will receive competency-based education upon return to work. 11. The DON/designee will review newly identified COCs daily, from Monday through Friday. During weekends, holidays, and after-hours when the DON is not available, the RN Supervisor on duty will assume the responsibility of reviewing COCs. This process will continue for the next three months to ensure that physicians are promptly notified, appropriate orders are obtained, and interventions are implemented in a timely manner to address the identified changes. Issues identified will be addressed immediately by the DON/designee/RN supervisor. If gaps in practice or knowledge are identified, the DON will initiate targeted in-service training to reinforce expectations and ensure staff competency in managing COCs. 12. Medical Records Director 1/designee will audit ongoing COCs daily (Monday to Friday) to ensure residents are monitored every shift for at least 72 hours or more if necessary. 13. Unit Managers will review Abnormal Vital Sign Logs daily (Monday to Friday) and RN Supervisors on weekends/holidays for the next 3 months to ensure communication of abnormal vital signs between nursing staff and ultimately to the physician. A COC/elnteract electronic medical record is initiated, and the physician/provider is notified immediately as applicable. 14. During annual competency skills evaluation, LVNs and RNs will be evaluated on core competencies addressing residents with COCs. As part of the new hire orientation process, newly-hire RNs and LVNs will undergo training on addressing COC communication protocol among nursing staff on abnormal vital signs, initiating COC/elnteract record for abnormal vital signs and COCs, and reporting abnormal vital signs to RN supervisor and, ultimately, to the physician. 15. LVNs and RNs will undergo at least yearly in-service/training on addressing COCs, communication protocol among nursing staff on abnormal vital signs, initiating COC/elnteract record for abnormal vital signs and COCs, and reporting abnormal vital signs to RN supervisor and, ultimately, to the physician. 16. CNAs will undergo yearly in-service/training on obtaining vital signs, reporting abnormal vital signs immediately to the charge nurse and utilization of the Abnormal Vital Sign log. 17. The DON, ADON, and DSD will re-inservice all nursing staff, which include CNAs, LVNs, and RNs, monthly for the next three months on key areas such as recognizing and responding to COCs, timely and accurate reporting of abnormal vital signs, appropriate clinical interventions, and adherence to the structured communication protocol for escalating clinical concerns to the RN Supervisor and the attending physician. Licensed nurses will undergo competency-based skills checks to evaluate their proficiency in initiating COC / elnteract electronic medical record, notifying physicians promptly, and ensuring follow-up and monitoring. Staff will be assessed using a structured scoring tool, with return demonstrations conducted as needed to confirm understanding. Participants will also be required to complete a five-question post-test (an assessment or test administered after a training) to assess comprehension (understanding) of the material. Any staff unable to attend the scheduled sessions will receive the re-inservice and competency validation (to confirm) prior to the start of their next scheduled shift to ensure complete participation and sustained compliance. Cross Reference F600 and F684. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 3/4/2025 with diagnoses including unspecified hypothyroidism (unidentified cause for thyroid gland to not produce thyroid hormone, causing weakness), essential hypertension (persistent elevated blood pressure), and occlusion and stenosis of left carotid artery (complete blockage and narrowing of carotid artery, a major blood vessel supplying the brain). During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool), dated 3/12/2025, the MDS indicated Resident 1 was severely impaired with thought process and required substantial assistance from staff to complete activities of daily living (ADLs – activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 1 ' s record titled, eInteract Change of Condition Evaluation, dated 3/12/2025 at 11:40 p.m., the evaluation indicated Resident 1 had a change of condition of Abnormal vital signs and altered mental status (a change in a resident ' s mental state, including changes in awareness, alertness, and mental function). The evaluation indicated on 3/12/2025 at 5 p.m., Resident 1 ' s BP on a sitting position taken on Resident 1 ' s right arm was 86/57 mmHg and HR of 111 beats per minute. The evaluation indicated there were no other BP and HR assessments collected for Resident 1 after 5 p.m. on 3/12/2025. During a review of the physician ' s Progress Notes for Resident 1, dated 3/13/2025 at 1:06 a.m., the physician ' s Progress Notes indicated Resident 1 ' s physician (MD 1) called RN 1 after multiple times before RN 1 answered. The physician Progress Notes indicated MD 1 instructed RN 1 to check and examine Resident 1, then to call back MD 1. The physician ' s Progress Notes indicated RN 1 called back and told MD 1 Resident 1 ' s BP was 86/57 mmHg and HR was 111 bpm (these vital signs were the same readings taken on 3/12/2025 at approximately 5 p.m.). The physician ' s Progress Notes indicated RN 1 told MD 1 that it was unclear if Resident 1 was responsive (able to respond or reply) or not, so MD 1 ordered Resident 1 to be transferred to the GACH. During a review of Resident 1 ' s Physician ' s Orders, dated 3/13/2025 at 6:48 a.m., the Physician ' s Orders indicated Resident 1 was sent out to the GACH for abnormal vital signs and for altered level of consciousness (a change in mental status not normal from baseline). During an interview on 3/25/2025 at 3:54 p.m. with CNA 1, CNA 1 stated she was working on 3/12/2025 during the 3 p.m. to 11 p.m. shift and was assigned to Resident 1. CNA 1 stated she checked Resident 1 ' s vital signs approximately four to five times using both arms, and the BP readings were consistently low. CNA 1 stated she informed LVN 1, who was assigned to Resident 1 about Resident 1 ' s low BP and increased HR. CNA 1 stated LVN 1 told her (CNA 1) that she (LVN 1) will recheck Resident 1 ' s vital signs. CNA 1 stated, to be honest, I don ' t know if she (LVN 1) checked since I went to my other residents During an interview on 3/26/2025 at 7:05 a.m., with RN 1, RN 1 stated on 3/12/2025, he arrived at the facility at approximately 11:35 p.m., for the 11 p.m. to 7 a.m. shift. RN 1 stated he received a call from Resident 1 ' s primary physician asking if RN 1 was the supervisor on duty, and for a report on Resident 1 ' s condition. RN 1 stated, upon observing Resident 1, I was stunned, like he (Resident 1) was dying or towards the end of life RN 1 stated the previous shift staff failed to act to save Resident 1. RN 1 stated the previous shift staff should have notified the RN on duty, or called a code blue (an emergency code typically indicating a resident experiencing a life-threatening medical emergency that requires immediate medical attention) for Resident 1. RN 1 stated, When I saw the resident (Resident 1), to me, it looked like he (Resident 1) was gone. RN 1 stated the previous shift staff failed to notify Resident 1 ' s physician about the decreased blood pressure, and failed to call emergency services sooner for Resident 1. During a concurrent interview and record review on 3/26/2025 at 7:47 a.m., with LVN 2, Resident 1 ' s COC, dated 3/12/2025 documented at 11:40 p.m., and progress notes were reviewed. LVN 2 stated she worked on 3/12/2025 for the 11 p.m. to 7 a.m. shift, and was assigned to Resident 1. LVN 2 stated she did not recall if Resident 1 was receiving any oxygen. LVN 2 stated LVNs were to notify the RN on duty first for any residents with a COC. LVN 2 stated, from what I saw, he (Resident 1) was in code blue status because of his shallow breathing. LVN 2 stated Resident 1 ' s COC, dated 3/12/2025 documented at 11:40 p.m., indicated Resident 1 ' s last assessed BP of 86/57 mmHg and HR of 111 beats/minute recorded at 5 p.m. LVN 2 stated, for his (Resident 1 ' s) blood pressure, it was very low. When the emergency personnel (paramedics - health professionals certified to perform advanced life support procedures) came, she (LVN 1) mentioned it was taken around 6 p.m. 7 hours from the last collected vital signs. Per progress notes, the LVN (LVN 1) failed to notify the RN as there were no RN notification, no doctor (physician) notification, no code blue announced, and no interventions done on records (Resident 1 ' s medical records). The LVN (LVN 1) stated to the emergency personnel that was the resident ' s (Resident 1 ' s) baseline. From what I saw, that was not the resident ' s (Resident 1) baseline. During an interview on 3/26/2025 at 2:16 p.m. with LVN 1, LVN 1 stated she was informed of Resident 1 ' s change in vital signs on 3/12/2025, at approximately at 5 p.m. LVN 1 stated she did not discuss Resident 1 ' s COC with the on duty RN (RN2), and did not notify Resident 1 ' s physician. LVN 1 stated she did not call emergency services for Resident 1 and the incoming night shift (11 pm. to 7 a.m.) staff (LVN 2) notified the emergency services for Resident 1 ' s COC. During a phone interview on 3/26/2025 at 4:20 p.m. with MD 1, MD 1 stated on 3/12/2025 approximately after 11:30 p.m., she called the facility to get an update on Resident 1. MD 1 stated no facility staff notified her (MD 1) earlier in the day. MD 1 stated she was concerned about Resident 1 ' s kidney function, so MD 1 called the facility for an update on Resident 1. MD 1 stated staff knew on 3/12/2025 at 5 p.m., Resident 1 ' s BP was 86/57 mmHg and HR of 111 beats per minute. MD 1 stated doctors (in general) should be made aware of this. MD 1 stated she spoke to an RN (RN 1) who told her The patient does not look good. MD 1 stated, I would expect the nurses in general, when the BP is that low, the RN should evaluate the resident (Resident 1). MD 1 stated she was not informed of Resident 1 ' s COC on 3/12/2025 at 5 p.m. and the facility should have informed her (MD 1). During an interview on 3/28/2025 at 10:15 a.m. with Unit Manager 1 (LVN), Unit Manager 1 stated Resident 1 had no nursing progress notes from the 3 p.m. to 11 p.m., shift, no documented interventions and no physician notifications. Unit Manager 1 stated, The vital signs provide an internal baseline or anything happening for the residents, like blood pressures dropping or an increase in temperature could be related to possible infection, so vital signs help notify us (nursing staff) an indication of how the resident is doing, or to identify if any changes need to be addressed. There was about six hours and 40 minutes from when the MD was informed of the resident ' s (Resident 1 ' s) condition. Unit Manager 1 stated, For this case, after finding the vital signs at 5 p.m., the LVN (LVN 1) failed to reassess the resident ' s (Resident 1 ' s) vital signs, failed to notify the RN to assess the resident, and failure to notify the doctor of the COC. He (Resident 1) had a care plan for hypertension initiated on 3/4/2025, on his admission date. The interventions by licensed nurses (LVNs and RNs) are to observe for signs and symptoms of abnormal blood pressure and complications related to hypertension, and notify the physician as needed. In this scenario, the LVN (LVN 1) failed to implement this (Resident 1) care plan ' s intervention. During a concurrent interview and record review with MD 1 on 3/28/2025 at 11:30 a.m., Resident 1 ' s eInteract Change of Condition Evaluation, dated 3/12/2025 at 11:40 p.m., was reviewed. MD 1 stated she called the facility on 3/12/2025 approximately 11:30 p.m. MD 1 stated she did not realize the vital signs provided to her (MD 1) over the phone were Resident 1 ' s BP of 86/57 mmHg and HR of 111 bpm were the same collected vital signs from 5 p.m., earlier in the day (3/12/2025). MD 1 stated, I ' m talking to them on the phone, so I didn ' t know they (RN 1) used the same vital signs from 5 p.m. I thought it was a recent set of vital signs. During a concurrent interview and record review with the DON on 3/28/2025 at 5:50 p.m., Resident 1 ' s paramedics ' report, dated 3/13/2025 at 12:19 a.m., and the facility ' s undated policy and procedure titled, Change in a Resident ' s Condition or Status, were reviewed. The DON stated on 3/12/2025, staff knowing the changes in vital signs for Resident 1 at 5 p.m., to the time the physician called the facility at approximately 11:40 p.m., was almost seven hours of no interventions. The DON stated the paramedics ' report indicated the paramedics were contacted on 3/13/2025 at 12:19 a.m., arrived at the facility by 12:28 a.m., at bedside with Resident 1 at 12:30 a.m., and left the facility with Resident 1 by 12:37 a.m. The DON stated the report described Resident 1 as having decreased breath sounds and the vital signs collected by the paramedics on 3/13/2025 at 12:30 a.m. were a BP of 74/50 mmHg, HR of 56 beats per RR of 4 breaths per minute, and oxygen saturation (percentage of oxygen to the blood measuring how well the lungs deliver oxygen to the body) of 74 percent (% - per one hundred). The DON stated the paramedics described Resident 1 as lying in bed with the current concern of respiratory failure (occurs when the lungs are unable to adequately perform their primary function: taking in oxygen and removing carbon dioxide [a colorless, odorless gas formed when people breathe out] from the blood). The DON stated the report indicated Resident 1 was found in severe respiratory distress and had a nasal cannula (a small plastic tube which fits into nostrils to provide supplemental oxygen) and staff were standing by with no interventions to Resident 1 ' s RR. The DON stated the report indicated Resident 1 was assisted by the paramedics with a bag valve mask (a handheld device used to deliver breaths to someone who cannot breathe on their own) and transported on advanced life support (ALS – a set of life-saving protocols and skills to provide urgent care during critical conditions) to the nearest GACH 1. The DON stated, This resident passed away on 3/13/2025. The facility ' s policy and procedure titled Change in a Resident ' s Condition or Status was also reviewed with the DON. The DON was asked to clarify what Promptly meant as indicated in the policy. The DON stated, For the notification of promptly, whatever the change of condition was from the resident ' s baseline, licensed staff (LVNs & RNs) need to assess and inform the attending physician. There is no time indicated, but for emergent needs, like for this case, the doctor should have been notified from the initial identification of the 5 p.m. decreased blood pressure of Resident 1. During a review of Resident 1 ' s GACH records titled, Discharge Summary, the GACH records indicated Resident 1 passed away on 3/13/2025 at 4:27 p.m., and the preliminary cause of Resident 1 ' s death was septic shock (a life-threatening condition that happens when the BP drops to a dangerously low level after an infection). The Discharge Summary also indicated additional pertinent diagnoses of acute respiratory failure with hypoxia (when the lungs fail to provide oxygen to the body ' s tissues, leading to low oxygen levels in the blood) and anoxic brain damage (brain injury caused by lack of oxygen to the brain). During a review of the current facility-provided undated policy and procedure titled, Change in Resident ' s Condition or Status, the policy and procedure indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident ' s medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The policy also indicated: 1. The nurse will notify the resident ' s attending physician or physician on call when there has been a (an): d. significant change in the resident ' s physical/emotional/mental condition; g. need to transfer the resident to a hospital/treatment center; 2. A Significant change of condition is a major decline or improvement in the resident ' s status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not Self-limiting); b. impacts more than one area of the resident ' s health status; c. requires interdisciplinary review and/or revision of the care plan

CRITICAL (J) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Free from Abuse/Neglect (Tag F0600)

Someone could have died · This affected 1 resident

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Based on interview and record review, the facility failed to ensure one of nine sampled residents (Resident 1) was free from neglect (the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress) when Resident 1 had a change of condition (COC – a major decline in a resident ' s status) on 3/12/2025 at approximately 5 p.m. when Resident 1 had a low blood pressure (BP – measurement of the pressure or force of blood inside your arteries [the elastic, muscular tubes or blood vessels responsible for carrying the blood away from the heart and distributing it to several other organs and tissues]) reading of 86/57 millimeters of mercury (mmHg – unit of measurement used to measure BP and is abnormal if less than 90/60 mmHg or greater than 139/89 mmHg) and increased heart rate (HR – the number of heartbeats per unit of time) of 111 beats per minute (bpm - considered abnormal if less than 60 bpm or greater than 100 bpm). As a result, Resident 1 experienced severe respiratory distress (a life-threatening condition characterized by difficult breathing, rapid breathing, and low oxygen levels, often requiring immediate medical intervention) was transferred to a General Acute Care Hospital (GACH) on 3/13/2025 at 12:37 a.m., and pronounced dead on 3/13/2025 at 4:27 p.m. On 3/26/2025 at 5:31 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ – a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility ' s neglect by failing to provide the necessary care and services when Resident 1 had a COC on 3/12/2025 at approximately 5 p.m. On 3/28/2025 at 10:06 a.m., the ADM and DON provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings) for the facility ' s neglect by failing to provide the necessary care and services when Resident 1 had a COC on 3/12/2025 at approximately 5 p.m. On 3/28/2025 at 7:28 p.m., while onsite at the facility, the SSA verified that the IJ situation was no longer present and confirmed the facility ' s full implementation of the IJ Removal Plan through observations, interviews, and record reviews, the SSA removed the IJ situation for the facility ' s neglect by failing to provide the necessary care and services when Resident 1 had a COC on 3/12/2025 at approximately 5 p.m., in the presence of the ADM, DON, and Assistant Director of Nursing (ADON). The acceptable IJ Removal Plan included the following summarized actions: 1. On 3/26/2025 and 3/27/2025, the nursing staff, including Certified Nursing Assistants (CNAs), Licensed Vocational Nurses (LVNs), and Registered Nurses (RNs), obtained vital signs for 262 in-house residents to identify abnormal (out of range) vital signs (measurements of the body ' s most basic functions), including BP, HR, pulse rate (PR), respiratory rate (RR – refers to the number of breaths a person takes per minute), and body temperature (refers to the measurement of the heat generated by the human body). The facility defined parameters for abnormal vital signs are as follows: HR or PR is considered abnormal if less than 60 or greater than 100 beats per minute; RR is abnormal if less than 12 or greater than 25 breaths per minute; temperature is abnormal if less than 97.8 ° Fahrenheit (° F – unit of measurement) or greater than 99.0 °F; systolic BP (the upper number in the BP reading) is abnormal if less than 90 mmHg or greater than 139 mmHg; and diastolic BP (the lower number in the BP reading) is abnormal if less than 60 mmHg or greater than 89 mmHg. 2. On 3/26/2025, the LVNs and RNs reviewed the current in-house residents who were actively being monitored for COCs between 3/23/2025 to 3/26/2025. Out of 262 in-house residents, 45 residents were identified as having recent COCs. For these 45 residents with COCs, the physicians were promptly notified, and appropriate orders were obtained and implemented to address the identified changes. 3. On 3/26/2025, following the completion of the vital signs audit, the facility identified 23 out of the 45 residents with recent COCs were directly related to abnormal vital signs. For these 23 residents, COC evaluations were promptly completed, primary care physicians were notified by LVNs and RNs, and appropriate medical orders were obtained and implemented. 4. On 3/26/2025, the facility implemented a structured communication protocol (is a set of guidelines and procedures ensuring clear, consistent, and effective communication among staff, residents, and families, promoting resident safety, dignity, and positive results) for reporting findings of abnormal vital signs among CNAs, LVNs, RNs, and ultimately to the attending physician. This protocol was reviewed and approved by the Quality Assurance Committee (QAC – is a group that regularly reviews care quality, identifies issues, and develops plans to address deficiencies, ensuring residents receive safe and effective care) and serves as a standardized guideline for nursing staff to ensure timely and accurate escalation (an increase in the intensity or seriousness) of clinical concerns (health-related issues or problems that require medical attention): i. CNAs are to report abnormal vital signs to the charge nurse immediately. ii. Once abnormal vital signs are rechecked and verified by the charge nurse, the charge nurse will escalate to the RN Supervisor for further evaluation. iii. A COC evaluation using the eInteract tool (a tool used in healthcare that helps care teams prevent unnecessary hospitalizations and improve resident outcomes to alert staff to changes in a resident ' s condition) will be initiated when abnormal vital signs are identified as part of a resident's COC. This applies to residents with underlying clinical concerns, including but not limited to the following: a history of hypertension (high BP), hypotension (low BP), recent infection, cardiac (heart) conditions, respiratory compromise (a situation where a person ' s breathing is at risk of becoming severely impaired), or any other medical condition that may predispose (to make more likely or render susceptible) the resident to instability. iv. A paper log titled, Abnormal Vital Sign Log will be maintained by each charge nurse to document communication between nursing staff and, ultimately, with the physician regarding abnormal vital signs. v. Family members / responsible party will be notified by the LVNs or RNs of any change of condition unless the resident has indicated otherwise. The nurse must document all attempts made in the resident's medical record and the outcome of the family notification. vi. Vital signs will be monitored every shift for a minimum of 72 hours for residents identified with a COC, or longer if clinically indicated. 5. On 3/27/2025, the ADM and DON initiated a root cause analysis (a systematic approach to identify the underlying reasons for a problem or failure, rather than just addressing its immediate symptoms, to prevent recurrence) on the facility ' s failure to ensure any resident having abnormal vital signs was provided with necessary care and services, including notification of the physician, to address a COC. The facility identified the root causes included licensed nurses have a lack of supervision to ensure they (licensed nurses) follow protocols, that proactive audits (conducting internal reviews before potential problems arise to prevent future issues) or quality checks to identify gaps in care were not addressed timely, and adequate training during the hiring orientation process was provided to staff. 6. On 3/26/2025, the DON provided one-on-one in-service training (is a personalized, focused training method where a healthcare professional learns a specific skill or procedure from a more experienced colleague in a one-to-one setting) to LVN 1. The planned training focused on providing care and services to residents, with the focus on the critical importance of documenting identified COCs, and notifying the primary physician when a change in a resident's condition is identified. Abnormal vital signs are communicated between CNAs, LVNs, RNs, and ultimately to the attending physician. Residents with COCs are monitored, and interventions are provided to address the COCs. 7. On 3/26/2025, LVN 1 was suspended and is currently still on suspension. 8. On 3/27/2025, the DON implemented staff training focusing on providing care and services to residents, with focus on critical importance of documenting identified COCs, and notifying the primary physician when a change in a resident's condition is identified. Abnormal vital signs are communicated between CNAs, LVNs, RNs, and ultimately to the attending physician. Residents with COCs are monitored, and interventions are provided to address the COCs. 9. On 3/26/2025, the DON initiated competency skills checks (are assessments that ensure healthcare professionals possess the necessary knowledge, skills, and abilities to perform their roles safely and effectively, often using checklists and other methods to evaluate performance) for LVNs and RNs to ensure that the licensed staff are proficient (competent or skilled) in evaluating COCs and accurately/timely reporting abnormal vital signs. The skills check included core competencies such as recognizing COCs, identifying abnormal vital signs, taking immediate action, notifying physicians promptly, and ensuring follow-up and continuous monitoring of COCs. Each nursing staff member was evaluated using a structured scoring tool, with opportunities for return demonstrations (a teaching technique where a student, after being shown a skill or procedure, demonstrates their understanding by performing it themselves, allowing the instructor to assess their learning) as needed to confirm competency. 10. On 3/26/2025, the DON, in collaboration with the Director of Staff Development (DSD), initiated in-service trainings for nursing staff, including CNAs, LVNs, and RNs, with a focus on recognizing COCs. The training emphasized timely reporting and appropriate interventions (including physician notification), ongoing monitoring of residents identified with a COC, and accurate documentation of abnormal vital signs. For staff who were unable to attend the scheduled in-service trainings, in-service trainings will be provided prior to the start of their next scheduled shift and will not be allowed to report to the assigned unit until training is completed. Nursing staff on leave or on vacation will receive competency-based education upon return to work. 11. The DON/designee will review newly identified COCs daily, from Monday through Friday. During weekends, holidays, and after-hours when the DON is not available, the RN Supervisor on duty will assume the responsibility of reviewing COCs. This process will continue for the next three months to ensure that physicians are promptly notified, appropriate orders are obtained, and interventions are implemented in a timely manner to address the identified changes. Issues identified will be addressed immediately by the DON/designee/RN supervisor. If gaps in practice or knowledge are identified, the DON will initiate targeted in-service training to reinforce expectations and ensure staff competency in managing COCs. 12. Medical Records Director 1/designee will audit ongoing COCs daily (Monday to Friday) to ensure residents are monitored every shift for at least 72 hours or more if necessary. 13. Unit Managers will review Abnormal Vital Sign Logs daily (Monday to Friday) and RN Supervisors on weekends/holidays for the next 3 months to ensure communication of abnormal vital signs between nursing staff and ultimately to the physician. A COC/elnteract electronic medical record is initiated, and the physician/provider is notified immediately as applicable. 14. During annual competency skills evaluation, LVNs and RNs will be evaluated on core competencies addressing residents with COCs. As part of the new hire orientation process, newly-hire RNs and LVNs will undergo training on addressing COC communication protocol among nursing staff on abnormal vital signs, initiating COC/elnteract record for abnormal vital signs and COCs, and reporting abnormal vital signs to RN supervisor and, ultimately, to the physician. 15. LVNs and RNs will undergo at least yearly in-service/training on addressing COCs, communication protocol among nursing staff on abnormal vital signs, initiating COC/elnteract record for abnormal vital signs and COCs, and reporting abnormal vital signs to RN supervisor and, ultimately, to the physician. 16. CNAs will undergo yearly in-service/training on obtaining vital signs, reporting abnormal vital signs immediately to the charge nurse and utilization of the Abnormal Vital Sign log. 17. The DON, ADON, and DSD will re-inservice all nursing staff, which include CNAs, LVNs, and RNs, monthly for the next three months on key areas such as recognizing and responding to COCs, timely and accurate reporting of abnormal vital signs, appropriate clinical interventions, and adherence to the structured communication protocol for escalating clinical concerns to the RN Supervisor and the attending physician. Licensed nurses will undergo competency-based skills checks to evaluate their proficiency in initiating COC / elnteract electronic medical record, notifying physicians promptly, and ensuring follow-up and monitoring. Staff will be assessed using a structured scoring tool, with return demonstrations conducted as needed to confirm understanding. Participants will also be required to complete a five-question post-test (an assessment or test administered after a training) to assess comprehension (understanding) of the material. Any staff unable to attend the scheduled sessions will receive the re-inservice and competency validation (to confirm) prior to the start of their next scheduled shift to ensure complete participation and sustained compliance. Cross Reference F600 and F684. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 3/4/2025 with diagnoses including unspecified hypothyroidism (unidentified cause for thyroid gland to not produce thyroid hormone, causing weakness), essential hypertension (persistent elevated blood pressure), and occlusion and stenosis of left carotid artery (complete blockage and narrowing of carotid artery, a major blood vessel supplying the brain). During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool), dated 3/12/2025, the MDS indicated Resident 1 was severely impaired with thought process and required substantial assistance from staff to complete activities of daily living (ADLs – activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 1 ' s record titled, eInteract Change of Condition Evaluation, dated 3/12/2025 at 11:40 p.m., the evaluation indicated Resident 1 had a change of condition of Abnormal vital signs and altered mental status (a change in a resident ' s mental state, including changes in awareness, alertness, and mental function). The evaluation indicated on 3/12/2025 at 5 p.m., Resident 1 ' s BP on a sitting position taken on Resident 1 ' s right arm was 86/57 mmHg and HR of 111 beats per minute. The evaluation indicated there were no other BP and HR assessments collected for Resident 1 after 5 p.m. on 3/12/2025. During a review of the physician ' s Progress Notes for Resident 1, dated 3/13/2025 at 1:06 a.m., the physician ' s Progress Notes indicated Resident 1 ' s physician (MD 1) called RN 1 after multiple times before RN 1 answered. The physician Progress Notes indicated MD 1 instructed RN 1 to check and examine Resident 1, then to call back MD 1. The physician ' s Progress Notes indicated RN 1 called back and told MD 1 Resident 1 ' s BP was 86/57 mmHg and HR was 111 bpm (these vital signs were the same readings taken on 3/12/2025 at approximately 5 p.m.). The physician ' s Progress Notes indicated RN 1 told MD 1 that it was unclear if Resident 1 was responsive (able to respond or reply) or not, so MD 1 ordered Resident 1 to be transferred to the GACH. During a review of Resident 1 ' s Physician ' s Orders, dated 3/13/2025 at 6:48 a.m., the Physician ' s Orders indicated Resident 1 was sent out to the GACH for abnormal vital signs and for altered level of consciousness (a change in mental status not normal from baseline). During an interview on 3/25/2025 at 3:54 p.m. with CNA 1, CNA 1 stated she was working on 3/12/2025 during the 3 p.m. to 11 p.m. shift and was assigned to Resident 1. CNA 1 stated she checked Resident 1 ' s vital signs approximately four to five times using both arms, and the BP readings were consistently low. CNA 1 stated she informed LVN 1, who was assigned to Resident 1 about Resident 1 ' s low BP and increased HR. CNA 1 stated LVN 1 told her (CNA 1) that she (LVN 1) will recheck Resident 1 ' s vital signs. CNA 1 stated, to be honest, I don ' t know if she (LVN 1) checked since I went to my other residents During an interview on 3/26/2025 at 7:05 a.m., with RN 1, RN 1 stated on 3/12/2025, he arrived at the facility at approximately 11:35 p.m., for the 11 p.m. to 7 a.m. shift. RN 1 stated he received a call from Resident 1 ' s primary physician asking if RN 1 was the supervisor on duty, and for a report on Resident 1 ' s condition. RN 1 stated, upon observing Resident 1, I was stunned, like he (Resident 1) was dying or towards the end of life RN 1 stated the previous shift staff failed to act to save Resident 1. RN 1 stated the previous shift staff should have notified the RN on duty, or called a code blue (an emergency code typically indicating a resident experiencing a life-threatening medical emergency that requires immediate medical attention) for Resident 1. RN 1 stated, When I saw the resident (Resident 1), to me, it looked like he (Resident 1) was gone. RN 1 stated the previous shift staff failed to notify Resident 1 ' s physician about the decreased blood pressure, and failed to call emergency services sooner for Resident 1. RN 1 stated, This was . negligence because the vital signs were known since 5 p.m. and the documents show the doctor was not notified until 11:40 p.m., that ' s almost 7 hours. During a concurrent interview and record review on 3/26/2025 at 7:47 a.m., with LVN 2, Resident 1 ' s COC, dated 3/12/2025 documented at 11:40 p.m., and progress notes were reviewed. LVN 2 stated she worked on 3/12/2025 for the 11 p.m. to 7 a.m. shift, and was assigned to Resident 1. LVN 2 stated she did not recall if Resident 1 was receiving any oxygen. LVN 2 stated LVNs were to notify the RN on duty first for any residents with a COC. LVN 2 stated, from what I saw, he (Resident 1) was in code blue status because of his shallow breathing. LVN 2 stated Resident 1 ' s COC, dated 3/12/2025 documented at 11:40 p.m., indicated Resident 1 ' s last assessed BP of 86/57 mmHg and HR of 111 beats/minute recorded at 5 p.m. LVN 2 stated, for his (Resident 1 ' s) blood pressure, it was very low. When the emergency personnel (paramedics - health professionals certified to perform advanced life support procedures) came, she (LVN 1) mentioned it was taken around 6 p.m. 7 hours from the last collected vital signs. Per progress notes, the LVN (LVN 1) failed to notify the RN as there were no RN notification, no doctor (physician) notification, no code blue announced, and no interventions done on records (Resident 1 ' s medical records). The LVN (LVN 1) stated to the emergency personnel that was the resident ' s (Resident 1 ' s) baseline. From what I saw, that was not the resident ' s (Resident 1) baseline. LVN 2 stated an example for neglect would be if a resident needed care and no care was provided for many hours. LVN 2 stated, The LVN (LVN 1) failed to notify the RN on duty, failed to notify the doctor of the change of condition, failed to call a code blue, and failed to (immediately) call (the) emergency first responders (paramedics). LVN 2 further stated, It was about seven hours from when LVN (LVN 1) knew of the COC, so I feel this was neglect. During an interview on 3/26/2025 at 2:16 p.m. with LVN 1, LVN 1 stated she was informed of Resident 1 ' s change in vital signs on 3/12/2025, at approximately at 5 p.m. LVN 1 stated she did not discuss Resident 1 ' s COC with the on duty RN (RN2), and did not notify Resident 1 ' s physician. LVN 1 stated she did not call emergency services for Resident 1 and the incoming night shift (11 pm. to 7 a.m.) staff (LVN 2) notified the emergency services for Resident 1 ' s COC. During a phone interview on 3/26/2025 at 4:20 p.m. with MD 1, MD 1 stated on 3/12/2025 approximately after 11:30 p.m., she called the facility to get an update on Resident 1. MD 1 stated no facility staff notified her (MD 1) earlier in the day. MD 1 stated she was concerned about Resident 1 ' s kidney function, so MD 1 called the facility for an update on Resident 1. MD 1 stated staff knew on 3/12/2025 at 5 p.m., Resident 1 ' s BP was 86/57 mmHg and HR of 111 beats per minute. MD 1 stated doctors (in general) should be made aware of this. MD 1 stated she spoke to an RN (RN 1) who told her The patient does not look good. MD 1 stated, I would expect the nurses in general, when the BP is that low, the RN should evaluate the resident (Resident 1). MD 1 stated she was not informed of Resident 1 ' s COC on 3/12/2025 at 5 p.m. and the facility should have informed her (MD 1). During an interview on 3/28/2025 at 10:15 a.m. with Unit Manager 1 (LVN), Unit Manager 1 stated Resident 1 had no nursing progress notes from the 3 p.m. to 11 p.m., shift, no documented interventions and no physician notifications. Unit Manager 1 stated, The vital signs provide an internal baseline or anything happening for the residents, like blood pressures dropping or an increase in temperature could be related to possible infection, so vital signs help notify us (nursing staff) an indication of how the resident is doing, or to identify if any changes need to be addressed. There was about six hours and 40 minutes from when the MD was informed of the resident ' s (Resident 1 ' s) condition. Unit Manager 1 stated, For this case, after finding the vital signs at 5 p.m., the LVN (LVN 1) failed to reassess the resident ' s (Resident 1 ' s) vital signs, failed to notify the RN to assess the resident, and failure to notify the doctor of the COC. He (Resident 1) had a care plan for hypertension initiated on 3/4/2025, on his admission date. The interventions by licensed nurses (LVNs and RNs) are to observe for signs and symptoms of abnormal blood pressure and complications related to hypertension, and notify the physician as needed. In this scenario, the LVN (LVN 1) failed to implement this (Resident 1) care plan ' s intervention. During a concurrent interview and record review with MD 1 on 3/28/2025 at 11:30 a.m., Resident 1 ' s eInteract Change of Condition Evaluation, dated 3/12/2025 at 11:40 p.m., was reviewed. MD 1 stated she called the facility on 3/12/2025 approximately 11:30 p.m. MD 1 stated she did not realize the vital signs provided to her (MD 1) over the phone were Resident 1 ' s BP of 86/57 mmHg and HR of 111 bpm were the same collected vital signs from 5 p.m., earlier in the day (3/12/2025). MD 1 stated, I ' m talking to them on the phone, so I didn ' t know they (RN 1) used the same vital signs from 5 p.m. I thought it was a recent set of vital signs. During a concurrent interview and record review with the DON on 3/28/2025 at 5:50 p.m., Resident 1 ' s paramedics ' report, dated 3/13/2025 at 12:19 a.m., and the facility ' s undated policy and procedure titled, Change in a Resident ' s Condition or Status, were reviewed. The DON stated on 3/12/2025, staff knowing the changes in vital signs for Resident 1 at 5 p.m., to the time the physician called the facility at approximately 11:40 p.m., was almost seven hours of no interventions. The DON stated the paramedics ' report indicated the paramedics were contacted on 3/13/2025 at 12:19 a.m., arrived at the facility by 12:28 a.m., at bedside with Resident 1 at 12:30 a.m., and left the facility with Resident 1 by 12:37 a.m. The DON stated the report described Resident 1 as having decreased breath sounds and the vital signs collected by the paramedics on 3/13/2025 at 12:30 a.m. were a BP of 74/50 mmHg, HR of 56 beats per minute, RR of 4 breaths per minute, and oxygen saturation (percentage of oxygen to the blood measuring how well the lungs deliver oxygen to the body) of 74 percent (% - per one hundred). The DON stated the paramedics described Resident 1 as lying in bed with the current concern of respiratory failure (occurs when the lungs are unable to adequately perform their primary function: taking in oxygen and removing carbon dioxide [a colorless, odorless gas formed when people breathe out] from the blood). The DON stated the report indicated Resident 1 was found in severe respiratory distress and had a nasal cannula (a small plastic tube which fits into nostrils to provide supplemental oxygen) and staff were standing by with no interventions to Resident 1 ' s decreased RR. The DON stated the report indicated Resident 1 was assisted by the paramedics with a bag valve mask (a handheld device used to deliver breaths to someone who cannot breathe on their own) and transported on advanced life support (ALS – a set of life-saving protocols and skills to provide urgent care during critical conditions) to the nearest GACH 1. The DON stated, This resident passed away on 3/13/2025. The facility ' s policy and procedure titled Change in a Resident ' s Condition or Status was also reviewed with the DON. The DON was asked to clarify what Promptly meant as indicated in the policy. The DON stated, For the notification of promptly, whatever the change of condition was from the resident ' s baseline, licensed staff (LVNs & RNs) need to assess and inform the attending physician. There is no time indicated, but for emergent needs, like for this case, the doctor should have been notified from the initial identification of the 5 p.m. decreased blood pressure of Resident 1. During a review of Resident 1 ' s GACH records titled, Discharge Summary, the GACH records indicated Resident 1 passed away on 3/13/2025 at 4:27 p.m., and the preliminary cause of Resident 1 ' s death was septic shock (a life-threatening condition that happens when the BP drops to a dangerously low level after an infection). The Discharge Summary also indicated additional pertinent diagnoses of acute respiratory failure with hypoxia (when the lungs fail to provide oxygen to the body ' s tissues, leading to low oxygen levels in the blood) and anoxic brain damage (brain injury caused by lack of oxygen to the brain). During a review of the current facility-provided undated policy and procedure titled, Identifying Types of Abuse, the policy and procedure indicated, Neglect/Deprivation of Goods and Services by Staff .: 1. Neglect is the failure of the facility, its employees or services providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. 2. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident requires but the facility fails to provide them and this has resulted in (or may result in) physical harm, pain, mental anguish, or emotional distress. 3. Neglect includes cases where the facility ' s indifference to or disregard for resident care, comfort, or safety results in (or could have resulted in) physical harm, pain, mental anguish, or emotional distress. 4. Neglect may be a pattern of failures or may be the result of one or more failures involving one resident and one staff person. During a review of the current facility-provided undated policy and procedure titled, Recognizing Signs and Symptoms of Abuse/Neglect, the policy and procedure indicated, All types of resident . neglect . are strictly prohibited. The policy indicated, Neglect is defined as failure to provide goods and services as necessary to avoid physical harm, mental anguish, and mental illness. During a review of the current facility-provided undated policy and procedure titled, Resident Rights, the policy and procedure indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to: c. be free from . neglect During a review of the current facility-provided undated policy and procedure titled, Change in Resident ' s Condition or Status, the policy and procedure indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident ' s medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The policy also indicated: 1. The nurse will notify the resident ' s attending physician or physician on call when there has been a (an): d. significant change in the resident ' s physical/emotional/mental condition; g. need to transfer the resident to a hospital/treatment center; 2. A Significant change of condition is a major decline or improvement in the resident ' s status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not Self-limiting); b. impacts more than one area of the resident ' s health status; c. requires interdisciplinary review and/or revision of the care plan

CRITICAL (J) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Quality of Care (Tag F0684)

Someone could have died · This affected 1 resident

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Based on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of nine sampled residents (Resident 1), who had a change of condition (COC – a major decline in a resident ' s status) on 3/12/2025 at approximately 5 p.m., when Resident 1 had a low blood pressure (BP – measurement of the pressure or force of blood inside your arteries [the elastic, muscular tubes or blood vessels responsible for carrying the blood away from the heart and distributing it to several other organs and tissues]) reading of 86/57 millimeters of mercury (mmHg – unit of measurement used to measure BP and is abnormal if less than 90/60 mmHg or greater than 139/89 mmHg) and increased heart rate (HR – the number of heartbeats per unit of time) of 111 beats per minute (bpm – considered abnormal if less than 60 bpm or greater than 100 bpm). The facility failed to address Resident 1 ' s COC (low BP of 86/57 mmHg and high HR of 111 bpm) by: 1. Failing to ensure Licensed Vocation Nurse (LVN) 1 rechecked and monitored Resident 1 ' s vital signs (measurements of the body ' s most basic functions including but not limited to BP and HR) after getting a report from Certified Nursing Assistant (CNA) 1 regarding Resident 1 ' s COC. 2. Failing to ensure LVN 1 reported Resident 1 ' s COC to Registered Nurse (RN) 2 who was the RN on duty during the 3 p.m. to 11 p.m. shift. As a result, on 3/13/2025 at 12:30 a.m., the paramedics (health professionals certified to perform advanced life support procedures) found Resident 1 in severe respiratory distress (a life-threatening condition characterized by difficult breathing, rapid breathing, and low oxygen levels, often requiring immediate medical intervention) and transferred Resident 1 to the nearest General Acute Care Hospital (GACH) on 3/13/2025 at 12:37 a.m. for emergency (a serious, unexpected, and often dangerous situation requiring immediate action) needs. On 3/13/2025 at 4:27 p.m., Resident 1 was pronounced dead at the GACH with the preliminary cause of death of septic shock (a life-threatening condition that happens when the BP drops to a dangerously low level after an infection). On 3/26/2025 at 5:31 p.m., while onsite at the facility, the State Survey Agency (SSA) called an Immediate Jeopardy (IJ – a situation in which the facility ' s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) in the presence of the Administrator (ADM) and the Director of Nursing (DON) due to the facility ' s failure to provide treatment and care in accordance with professional standards of practice when Resident 1 had a low BP of 86/57 mmHg and low HR of 111 bpm on 3/12/2025 at approximately 5 p.m. On 3/28/2025 at 10:06 a.m., the ADM and DON provided an acceptable IJ Removal Plan (a detailed plan to address the IJ findings) for the facility ' s failure to provide treatment and care in accordance with professional standards of practice when Resident 1 had a COC on 3/12/2025 at approximately 5 p.m. On 3/28/2025 at 7:28 p.m., while onsite at the facility, the SSA verified that the IJ situation was no longer present and confirmed the facility ' s full implementation of the IJ Removal Plan through observations, interviews, and record reviews, the SSA removed the IJ situation for the facility ' s failure to provide treatment and care in accordance with professional standards of practice when the IJ situation was no longer present in the presence of the ADM, DON, and Assistant Director of Nursing (ADON). The acceptable IJ Removal Plan included the following summarized actions: 1. On 3/26/2025 and 3/27/2025, the nursing staff, including CNAs, LVNs, and RNs, obtained vital signs for 262 in-house residents to identify abnormal (out of range) vital signs including BP, HR, pulse rate (PR), respiratory rate (RR – refers to the number of breaths a person takes per minute), and body temperature (refers to the measurement of the heat generated by the human body). The facility defined parameters for abnormal vital signs are as follows: HR or PR is considered abnormal if less than 60 or greater than 100 bpm; RR is abnormal if less than 12 or greater than 25 breaths per minute; temperature is abnormal if less than 97.8 ° Fahrenheit (° F – unit of measurement) or greater than 99.0 °F; systolic BP is abnormal if less than 90 mmHg or greater than 139 mmHg; and diastolic BP is abnormal if less than 60 mmHg or greater than 89 mmHg. 2. On 3/26/2025, the LVNs and RNs reviewed the current in-house residents who were actively being monitored for COCs between 3/23/2025 to 3/26/2025. Out of 262 in-house residents, 45 residents were identified as having recent COCs. For these 45 residents with COCs, the physicians were promptly notified, and appropriate orders were obtained and implemented to address the identified changes. 3. On 3/26/2025, following the completion of the vital signs audit, the facility identified 23 out of the 45 residents with recent COCs were directly related to abnormal vital signs. For these 23 residents, COC evaluations were promptly completed, primary care physicians were notified by LVNs and RNs, and appropriate medical orders were obtained and implemented. 4. On 3/26/2025, the facility implemented a structured communication protocol (is a set of guidelines and procedures ensuring clear, consistent, and effective communication among staff, residents, and families, promoting resident safety, dignity, and positive results) for reporting findings of abnormal vital signs among CNAs, LVNs, RNs, and ultimately to the attending physician. This protocol was reviewed and approved by the Quality Assurance Committee (QAC – is a group that regularly reviews care quality, identifies issues, and develops plans to address deficiencies, ensuring residents receive safe and effective care) and serves as a standardized guideline for nursing staff to ensure timely and accurate escalation (an increase in the intensity or seriousness) of clinical concerns (health-related issues or problems that require medical attention): i. CNAs are to report abnormal vital signs to the charge nurse immediately. ii. Once abnormal vital signs are rechecked and verified by the charge nurse, the charge nurse will escalate to the RN Supervisor for further evaluation. iii. A COC evaluation using the eInteract tool (a tool used in healthcare that helps care teams prevent unnecessary hospitalizations and improve resident outcomes to alert staff to changes in a resident ' s condition) will be initiated when abnormal vital signs are identified as part of a resident's COC. This applies to residents with underlying clinical concerns, including but not limited to the following: a history of hypertension (high BP), hypotension (low BP), recent infection, cardiac (heart) conditions, respiratory compromise (a situation where a person ' s breathing is at risk of becoming severely impaired), or any other medical condition that may predispose (to make more likely or render susceptible) the resident to instability. iv. A paper log titled, Abnormal Vital Sign Log will be maintained by each charge nurse to document communication between nursing staff and, ultimately, with the physician regarding abnormal vital signs. v. Vital signs will be monitored every shift for a minimum of 72 hours for residents identified with a COC, or longer if clinically indicated. 5. On 3/27/2025, the ADM and DON initiated a root cause analysis (a systematic approach to identify the underlying reasons for a problem or failure, rather than just addressing its immediate symptoms, to prevent recurrence) on the facility ' s failure to ensure any resident having abnormal vital signs was provided with necessary care and services, including notification of the physician, to address a COC. The facility identified the root causes included licensed nurses have a lack of supervision to ensure they (licensed nurses) follow protocols, that proactive audits (conducting internal reviews before potential problems arise to prevent future issues) or quality checks to identify gaps in care were not addressed timely, and adequate training during the hiring orientation process was provided to staff. 6. On 3/26/2025, the DON provided one-on-one in-service training (a personalized, focused training method where a healthcare professional learns a specific skill or procedure from a more experienced colleague in a one-to-one setting) to LVN 1. The planned training focused on providing care and services to residents, with the focus on the critical importance of documenting identified COCs, and notifying the primary physician when a change in a resident's condition is identified. Abnormal vital signs are communicated between CNAs, LVNs, RNs, and ultimately to the attending physician. Residents with COCs are monitored, and interventions are provided to address the COCs. 7. On 3/26/2025, LVN 1 was suspended and is currently still on suspension. 8. On 3/27/2025, the DON implemented staff training focusing on providing care and services to residents, with focus on critical importance of documenting identified COCs, and notifying the primary physician when a change in a resident's condition is identified. Abnormal vital signs are communicated between CNAs, LVNs, RNs, and ultimately to the attending physician. Residents with COCs are monitored, and interventions are provided to address the COCs. 9. On 3/26/2025, the DON initiated competency skills checks (are assessments that ensure healthcare professionals possess the necessary knowledge, skills, and abilities to perform their roles safely and effectively, often using checklists and other methods to evaluate performance) for LVNs and RNs to ensure that the licensed staff are proficient (competent or skilled) in evaluating COCs and accurately/timely reporting abnormal vital signs. The skills check included core competencies such as recognizing COCs, identifying abnormal vital signs, taking immediate action, notifying physicians promptly, and ensuring follow-up and continuous monitoring of COCs. Each nursing staff member was evaluated using a structured scoring tool, with opportunities for return demonstrations (a teaching technique where a student, after being shown a skill or procedure, demonstrates their understanding by performing it themselves, allowing the instructor to assess their learning) as needed to confirm competency. 10. On 3/26/2025, the DON, in collaboration with the Director of Staff Development (DSD), initiated in-service trainings for nursing staff, including CNAs, LVNs, and RNs, with a focus on recognizing COCs. The training emphasized timely reporting and appropriate interventions (including physician notification), ongoing monitoring of residents identified with a COC, and accurate documentation of abnormal vital signs. For staff who were unable to attend the scheduled in-service trainings, in-service trainings will be provided prior to the start of their next scheduled shift and will not be allowed to report to the assigned unit until training is completed. Nursing staff on leave or on vacation will receive competency-based education upon return to work. 11. The DON/designee will review newly identified COCs daily, from Monday through Friday. During weekends, holidays, and after-hours when the DON is not available, the RN Supervisor on duty will assume the responsibility of reviewing COCs. This process will continue for the next three months to ensure that physicians are promptly notified, appropriate orders are obtained, and interventions are implemented in a timely manner to address the identified changes. Issues identified will be addressed immediately by the DON/designee/RN supervisor. If gaps in practice or knowledge are identified, the DON will initiate targeted in-service training to reinforce expectations and ensure staff competency in managing COCs. 12. Medical Records Director 1/designee will audit ongoing COCs daily (Monday to Friday) to ensure residents are monitored every shift for at least 72 hours or more if necessary. 13. Unit Managers will review Abnormal Vital Sign Logs daily (Monday to Friday) and RN Supervisors on weekends/holidays for the next 3 months to ensure communication of abnormal vital signs between nursing staff and ultimately to the physician. A COC/elnteract electronic medical record is initiated, and the physician/provider is notified immediately as applicable. 14. During annual competency skills evaluation, LVNs and RNs will be evaluated on core competencies addressing residents with COCs. As part of the new hire orientation process, newly-hire RNs and LVNs will undergo training on addressing COC communication protocol among nursing staff on abnormal vital signs, initiating COC/elnteract record for abnormal vital signs and COCs, and reporting abnormal vital signs to RN supervisor and, ultimately, to the physician. 15. LVNs and RNs will undergo at least yearly in-service/training on addressing COCs, communication protocol among nursing staff on abnormal vital signs, initiating COC/elnteract record for abnormal vital signs and COCs, and reporting abnormal vital signs to RN supervisor and, ultimately, to the physician. 16. CNAs will undergo yearly in-service/training on obtaining vital signs, reporting abnormal vital signs immediately to the charge nurse and utilization of the Abnormal Vital Sign log. 17. The DON, ADON, and DSD will re-inservice all nursing staff, which include CNAs, LVNs, and RNs, monthly for the next three months on key areas such as recognizing and responding to COCs, timely and accurate reporting of abnormal vital signs, appropriate clinical interventions, and adherence to the structured communication protocol for escalating clinical concerns to the RN Supervisor and the attending physician. Licensed nurses will undergo competency-based skills checks to evaluate their proficiency in initiating COC / elnteract electronic medical record, notifying physicians promptly, and ensuring follow-up and monitoring. Staff will be assessed using a structured scoring tool, with return demonstrations conducted as needed to confirm understanding. Participants will also be required to complete a five-question post-test (an assessment or test administered after a training) to assess comprehension (understanding) of the material. Any staff unable to attend the scheduled sessions will receive the re-inservice and competency validation (to confirm) prior to the start of their next scheduled shift to ensure complete participation and sustained compliance. Cross Reference F580 and F600. Findings: During a review of Resident 1 ' s admission Record, undated, the admission Record indicated the facility admitted Resident 1 on 3/4/2025 with diagnoses including unspecified hypothyroidism (unidentified cause for thyroid gland [a large ductless gland in the neck] to not produce thyroid hormone [hormone regulating growth and development], causing weakness), essential hypertension (persistent elevated blood pressure), and occlusion and stenosis of left carotid artery (complete blockage and narrowing of carotid artery, a major blood vessel supplying the brain). During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool), dated 3/12/2025, the MDS indicated Resident 1 was severely impaired with thought process and required substantial assistance from staff to complete activities of daily living (ADLs – activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 1 ' s record titled, eInteract Change of Condition Evaluation, dated 3/12/2025 at 11:40 p.m., the evaluation indicated Resident 1 had a change of condition of Abnormal vital signs and altered mental status (a change in a resident ' s mental state, including changes in awareness, alertness, and mental function). The evaluation indicated on 3/12/2025 at 5 p.m., Resident 1 ' s BP on a sitting position taken on Resident 1 ' s right arm was 86/57 mmHg and HR of 111 bpm. The evaluation indicated there were no other BP and HR assessments collected for Resident 1 after 5 p.m. on 3/12/2025. During a review of the physician ' s Progress Notes (PN) for Resident 1, dated 3/13/2025 at 1:06 a.m., the PN indicated Resident 1 ' s Medical Doctor (MD) 1 called RN 1 after multiple times before RN 1 answered. The PN indicated MD 1 instructed RN 1 to check and examine Resident 1, then call back MD 1. The PN indicated RN 1 called back and told MD 1, Resident 1 ' s BP was 86/57 mmHg and HR was 111 bpm (these vital signs were the same readings taken on 3/12/2025 at approximately 5 p.m.). The PN indicated RN 1 told MD 1 that it was unclear if Resident 1 was responsive (able to respond or reply) or not, so MD 1 ordered Resident 1 to be transferred to a GACH. During a review of Resident 1 ' s Physician ' s Orders (PO), dated 3/13/2025 at 6:48 a.m., the PO indicated Resident 1 was sent out to the GACH for abnormal vital signs and for altered level of consciousness (a change in mental status not normal from baseline). During an interview on 3/25/2025 at 3:54 p.m. with CNA 1, CNA 1 stated she was working on 3/12/2025 during the 3 p.m. to 11 p.m. shift and was assigned to care for Resident 1. CNA 1 stated she checked Resident 1 ' s vital signs approximately four to five times on Resident 1 ' s both arms, and the BP readings were consistently low (did not state the other low BP readings). CNA 1 stated she informed LVN 1, who was assigned to Resident 1 about Resident 1 ' s vital sign readings of low BP and increased HR. CNA 1 stated LVN 1 told her (CNA 1) that she (LVN 1) will recheck Resident 1 ' s vital signs. CNA 1 stated, To be honest, I don ' t know if she (LVN 1) checked since I went to my other residents During an interview on 3/26/2025 at 7:05 a.m. with RN 1, RN 1 stated RN 1 was working on 3/12/2025 and arrived at the facility at approximately 11:35 p.m. for the 11 p.m. to 7 a.m. shift. RN 1 stated RN 1 received a call from MD 1 (on 3/12/2025 at approximately 11:40 p.m.). RN 1 stated he was being asked by MD 1 if RN 1 was the supervisor on duty, and to provide a report on Resident 1 ' s condition. RN 1 stated, upon observing Resident 1, I was stunned, like he (Resident 1) was dying or towards the end of life RN 1 stated the previous shift staff failed to act to save the resident (Resident 1). RN 1 stated the previous shift staff (LVN 1) should have notified the RN on duty (RN 2), or by calling a code blue. RN 1 stated, When I saw the resident (Resident 1), to me, it looked like he (Resident 1) was gone. RN 1 stated the previous shift staff failed to notify Resident 1 ' s physician about the decreased blood pressure, and that staff also failed to call emergency services (the paramedics) sooner for Resident 1. During a concurrent interview and record review on 3/26/2025 at 7:47 a.m. with LVN 2, Resident 1 ' s eInteract Change of Condition Evaluation, dated 3/12/2025 at 11:40 p.m., was reviewed. LVN 2 stated she worked on 3/12/2025 for the 11 p.m. to 7 a.m. shift and was assigned to care for Resident 1. LVN 2 stated she cannot recall if Resident 1 was receiving any oxygen. LVN 2 stated LVNs are to notify the RN on duty first for any residents with a COC. LVN 2 stated (on 3/12/25 at approximately after 11 p.m.) From what I saw, he (Resident 1) was in code blue (an emergency code typically indicating a resident experiencing a life-threatening medical emergency that requires immediate medical attention) status because of his shallow breathing. LVN 2 stated Resident 1 ' s COC, dated 3/12/2025 documented at 11:40 p.m., indicated Resident 1 ' s last assessed BP of 86/57 mmHg and HR of 111 bpm recorded at 5 p.m. LVN 2 stated, For his (Resident 1 ' s) blood pressure, it was very low. LVN 2 stated when the emergency personnel (paramedics) came to the facility (on 3/13/2025 at 12:28 a.m.), she (LVN 1) mentioned it (BP and HR) was taken around 6 p.m. LVN 2 stated the paramedics arrived after midnight (3/13/25, after 12 a.m.). LVN 2 stated that would be 7 hours from the last collected vital signs. LVN 2 stated per the nursing progress notes, LVN 1 failed to notify RN 2 regarding Resident 1 ' s COC. LVN 2 stated there were no RN notification, no doctor (physician) notification, no code blue announced, and no interventions done on records (Resident 1 ' s medical records). LVN 2 stated, The LVN (LVN 1) stated to the emergency personnel that it (the BP of 86/57 mmHg and HR of 111 bpm) was the resident ' s (Resident 1 ' s) baseline. From what I saw, that was not the resident ' s (Resident 1) baseline. LVN 2 stated, The LVN (LVN 1) failed to notify the RN on duty (RN 2) During an interview on 3/26/2025 at 2:16 p.m. with LVN 1, LVN 1 stated she was informed of Resident 1 ' s change in vital signs approximately at 5 p.m. on 3/12/2025. LVN 1 stated she did not discuss Resident 1 ' s COC with the on-duty RN (RN 2), and she (LVN 1) did not inform Resident 1 ' s physician of Resident 1 ' s low vital signs. LVN 1 stated she did not call emergency services for Resident 1 and that it was the incoming night shift (11 pm. to 7 a.m.) staff (LVN 2) that notified emergency services for Resident 1 ' s COC. During a phone interview on 3/26/2025 at 4:20 p.m. with MD 1, MD 1 stated MD 1 called the facility to get an update on Resident 1 on 3/12/2025 approximately after 11:30 p.m. MD 1 stated that no facility staff had reached out to MD 1 earlier in the day. MD 1 stated MD 1 was concerned about Resident 1 ' s kidney function, so MD 1 called the facility for an update on Resident 1. MD 1 stated staff knew of Resident 1 ' s vital signs recorded on 3/12/2025 at 5 p.m. were a BP of 86/57 mmHg and a HR of 111 bpm, but staff did not make MD 1 aware of Resident 1 ' s condition timely. MD 1 stated (on 3/12/25, at approximately 11:30 pm) MD 1 spoke to an RN (RN 1) who told MD 1 The patient does not look good. MD 1 stated, MD 1 expected the nurses in general, evaluate Resident 1 when Resident 1 ' s BP was that low (86/57 mmHg). During an interview on 3/28/2025 at 10:15 a.m. with Unit Manager 1 (LVN), Unit Manager 1 indicated Resident 1 had no nursing progress notes from the 3 p.m. to 11 p.m. shift, no documented interventions. Unit Manager 1 stated the vital signs provide an internal baseline or anything happening for the residents, like blood pressures dropping or an increase in temperature could be related to possible infection, so vital signs help notify nursing staff an indication of how the resident is doing, or to identify if any changes need to be addressed. Unit Manager stated there was about six hours and 40 minutes from when MD 1 was informed of the Resident 1 ' s condition. Unit Manager 1 stated, For this case, after finding the vital signs at 5 p.m., the LVN (LVN 1) failed to reassess the resident ' s (Resident 1 ' s) vital signs, failed to notify the RN to assess the resident, and failure to notify the doctor of the COC. Unit Manager 1 stated Resident 1 had a care plan for hypertension initiated on 3/4/2025, upon admission date. Unit Manager 1 stated the interventions by licensed nurses (LVNs and RNs) are to observe for signs and symptoms of abnormal blood pressure and complications related to hypertension, and notify physician as needed. Unit Manager 1 stated, In this scenario, the LVN (LVN 1) failed to implement this (Resident 1) care plan ' s intervention. During a concurrent interview and record review on 3/28/2025 at 11:30 a.m., Resident 1 ' s eInteract Change of Condition Evaluation, dated 3/12/2025 at 11:40 p.m., was reviewed with MD 1. MD 1 stated MD 1 called the facility on 3/12/2025 at approximately after 11:30 p.m. MD 1 stated MD 1 did not realize the vital signs provided to MD 1 over the phone were Resident 1 ' s BP of 86/57 mmHg and HR of 111 bpm per minute were the same collected vital signs from 5 p.m. earlier in the day (3/12/2025). MD 1 stated, I ' m talking to them on the phone, so I didn ' t know they (RN 1) used the same vital signs from 5 p.m. I thought it was a recent set of vital signs. During a concurrent interview and record review on 3/28/2025 at 5:50 p.m., Resident 1 ' s paramedics ' report, dated 3/13/2025 at 12:19 a.m., and the facility ' s policy titled, Change in a Resident ' s Condition or Status, were reviewed with the DON. The DON stated on 3/12/2025, for Resident 1, from staff knowing the changes in vital signs for Resident 1 at 5 p.m., to the time the physician called the facility at approximately 11:40 p.m., that was almost seven hours of no interventions. The DON stated the paramedics ' report indicated that the paramedics were contacted on 3/13/2025 at 12:19 a.m., arrived at the facility by 12:28 a.m., at bedside with the Resident 1 at 12:30 a.m., and left the facility with Resident 1 by 12:37 a.m. The DON stated the report described Resident 1 as having decreased breath sounds and the vital signs collected by the paramedics on 3/13/2025 at 12:30 a.m. were a BP of 74/50 mmHg, HR of 56 beats per minute, RR of 4 breaths per minute, and oxygen saturation (percentage of oxygen to the blood measuring how well the lungs deliver oxygen to the body) of 74 percent (% - per one hundred, typically ranges from 95% to 100%). The DON stated the paramedics described Resident 1 as lying in bed with the current concern of respiratory failure (occurs when the lungs are unable to adequately perform their primary function: taking in oxygen and removing carbon dioxide [a colorless, odorless gas formed when people breathe out] from the blood). The DON stated the report indicated Resident 1 was found in severe respiratory distress and had a nasal cannula (a small plastic tube which fits into nostrils to provide supplemental oxygen) and staff were standing by with no interventions to Resident 1 ' s decreased RR. The DON stated the report indicated Resident 1 was assisted by the paramedics with a bag valve mask (a handheld device used to deliver breaths to someone who cannot breathe on their own) and transported on advanced life support (ALS – a set of life-saving protocols and skills to provide urgent care during critical conditions) to the nearest GACH 1. The DON stated, This resident passed away on 3/13/2025. During further record review of the policy titled Change in a Resident ' s Condition or Status with the DON, the DON was asked to clarify what Promptly meant as stated in the policy. The DON stated, For the policy titled Change in a Resident ' s Condition or Status, there is no date on this policy. For the notification of promptly, whatever the change of condition was from the resident ' s baseline, licensed staff (LVNs & RNs) need to assess and inform the attending physician. During a review of Resident 1 ' s GACH records titled, Discharge Summary, reviewed on 3/28/2025, the GACH records indicated Resident 1 passed away on 3/13/2025 at 4:27 p.m. The preliminary cause of Resident 1 ' s death was septic shock. The Discharge Summary also indicated additional pertinent diagnoses of acute respiratory failure with hypoxia (when the lungs fail to provide oxygen to the body ' s tissues, leading to low oxygen levels in the blood) and anoxic brain damage (brain injury caused by lack of oxygen to the brain). During a review of the current facility-provided undated policy and procedure titled, Change in Resident ' s Condition or Status, the policy and procedure indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident ' s medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.). The policy also indicated: 1. The nurse will notify the resident ' s attending physician or physician on call when there has been a (an): d. significant change in the resident ' s physical/emotional/mental condition; g. need to transfer the resident to a hospital/treatment center; 2. A Significant change of condition is a major decline or improvement in the resident ' s status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not Self-limiting); b. impacts more than one area of the resident ' s health status; c. requires interdisciplinary review and/or revision of the care plan

CONCERN (D) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to maintain accurate clinical records in accordance with accepted professional standards and practices for one of nine sampled residents (Resident 1) when Licensed Vocational Nurse (LVN) 1 added documentation entries in Resident 1 ' s medical record to show that Resident 1 was doing a little bit better. Resident 1 had a change of condition (COC – a major decline in a resident ' s status) on 3/12/2025 at approximately 5 p.m. when Resident 1 had a low blood pressure (BP – measurement of the pressure or force of blood inside your arteries [the elastic, muscular tubes or blood vessels responsible for carrying the blood away from the heart and distributing it to several other organs and tissues]) reading of 86/57 millimeters of mercury (mmHg – unit of measurement used to measure BP and is abnormal if less than 90/60 mmHg or greater than 139/89 mmHg) and increased heart rate (HR – the number of heartbeats per unit of time) of 111 beats per minute (bpm - considered abnormal if less than 60 bpm or greater than 100 bpm). LVN 1 added on 3/26/2025 at 9:07 a.m. and 9:51 a.m. made-up (invented or not true) documentation entries in Resident 1 ' s medical record regarding Resident 1 ' s vital signs (measurements of the body ' s most basic functions), LVN 1 notifying Registered Nurse (RN) 1, and RN 1 notifying Resident 1 ' s Medical Doctor (MD) 1. As a result, Resident 1 ' s medical record had inaccurate documentation to misrepresent (give a false or misleading representation of usually with an intent to deceive) Resident 1 ' s vital signs to show his BP of 86/57 mmHg on 3/12/2025 at approximately 5 p.m. was better on 3/12/2025 at 9 p.m. with BP of 97/60 mmHg (considered within the normal range). Resident 1 experienced severe respiratory distress (a life-threatening condition characterized by difficult breathing, rapid breathing, and low oxygen levels, often requiring immediate medical intervention) was transferred to a General Acute Care Hospital (GACH) on 3/13/2025 at 12:37 a.m., and pronounced dead on 3/13/2025 at 4:27 p.m. Cross Reference F580, F600, and F684. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 3/4/2025 with diagnoses including unspecified hypothyroidism (unidentified cause for thyroid gland to not produce thyroid hormone, causing weakness), essential hypertension (persistent elevated blood pressure), and occlusion and stenosis of left carotid artery (complete blockage and narrowing of carotid artery, a major blood vessel supplying the brain). During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool), dated 3/12/2025, the MDS indicated Resident 1 was severely impaired with thought process and required substantial assistance from staff to complete activities of daily living (ADLs – activities such as bathing, dressing, and toileting a person performs daily). During a review of Resident 1 ' s record titled, eInteract (a tool used in healthcare that helps care teams prevent unnecessary hospitalizations and improve resident outcomes to alert staff to changes in a resident ' s condition) Change of Condition Evaluation, dated 3/12/2025 at 11:40 p.m., the evaluation indicated Resident 1 had a change of condition of Abnormal vital signs and altered mental status (a change in a resident ' s mental state, including changes in awareness, alertness, and mental function). The evaluation indicated on 3/12/2025 at 5 p.m., Resident 1 ' s BP on a sitting position taken on Resident 1 ' s right arm was 86/57 mmHg and HR of 111 beats per minute. The evaluation indicated LVN 1 added a documentation entry on 3/26/2025 at 9:51 a.m. that on 3/12/2025 LVN 1 assessed Resident 1 with BP of 97/60, PR of 99, RR of 16, and HR of 96 and that LVN 1 called RN on duty to assess Resident 1, and RN on duty called MD 1 who ordered to send out Resident 1 to the GACH. During a review of Resident 1 ' s Weights and Vitals Summary, dated 3/12/2025 at 9 p.m., Resident 1 ' s BP was 97/60 mmHg. The Summary indicated LVN 1 entered this documentation entry on 3/26/2025 at 9:07 a.m. During a review of Resident 1 ' s GACH records titled, Discharge Summary, the GACH records indicated Resident 1 passed away on 3/13/2025 at 4:27 p.m., and the preliminary cause of Resident 1 ' s death was septic shock (a life-threatening condition that happens when the BP drops to a dangerously low level after an infection). The Discharge Summary also indicated additional pertinent diagnoses of acute respiratory failure with hypoxia (when the lungs fail to provide oxygen to the body ' s tissues, leading to low oxygen levels in the blood) and anoxic brain damage (brain injury caused by lack of oxygen to the brain). During a phone interview on 3/26/2025 at 4:20 p.m. with MD 1, MD 1 stated on 3/12/2025 approximately after 11:30 p.m., she called the facility to get an update on Resident 1. MD 1 stated no facility staff notified her (MD 1) earlier in the day. MD 1 stated she was concerned about Resident 1 ' s kidney function, so MD 1 called the facility for an update on Resident 1. MD 1 stated staff knew on 3/12/2025 at 5 p.m., Resident 1 ' s BP was 86/57 mmHg and HR of 111 beats per minute. MD 1 stated doctors (in general) should be made aware of this. MD 1 stated she spoke to an RN (RN 1) who told her The patient does not look good. MD 1 stated, I would expect the nurses in general, when the BP is that low, the RN should evaluate the resident (Resident 1). MD 1 stated she was not informed of Resident 1 ' s COC on 3/12/2025 at 5 p.m. and the facility should have informed her (MD 1). During a phone interview on 3/27/2025 at 11:45 a.m. with LVN 1, LVN 1 stated the Director of Nursing (DON) asked her (LVN 1) to report to the facility to update the documentation for Resident 1. LVN 1 stated the vital signs she added for Resident 1 on 3/12/2025 at 9 p.m., per the DON ' s instruction, was made-up to show that Resident 1 was doing a little bit better. LVN 1 stated she tried calling RN 1 but RN 1 was busy and LVN 1 never called MD 1 regarding the condition of Resident 1 (the added documentation entry on 3/26/2025 at 9:51 p.m. indicated LVN 1 called RN 1 then RN 1 called MD 1). During an interview on 3/27/2025 at 4:01 p.m. with the Medical Records Director (MRD), the MRD stated that any late entry in the documentation of a resident ' s medical records can be added about 72 hours later. During a concurrent interview and record review with the DON on 3/28/2025 at 5:50 p.m., Resident 1 ' s paramedics ' report, dated 3/13/2025 at 12:19 a.m., was reviewed. The DON stated the paramedics ' report indicated the paramedics were contacted on 3/13/2025 at 12:19 a.m., arrived at the facility by 12:28 a.m., at bedside with Resident 1 at 12:30 a.m., and left the facility with Resident 1 by 12:37 a.m. The DON stated the report described Resident 1 as having decreased breath sounds and the vital signs collected by the paramedics on 3/13/2025 at 12:30 a.m. were a BP of 74/50 mmHg, HR of 56 beats per minute, RR of 4 breaths per minute, and oxygen saturation (percentage of oxygen to the blood measuring how well the lungs deliver oxygen to the body) of 74 percent (% - per one hundred). The DON stated the paramedics described Resident 1 as lying in bed with the current concern of respiratory failure (occurs when the lungs are unable to adequately perform their primary function: taking in oxygen and removing carbon dioxide [a colorless, odorless gas formed when people breathe out] from the blood). The DON stated the report indicated Resident 1 was found in severe respiratory distress and had a nasal cannula (a small plastic tube which fits into nostrils to provide supplemental oxygen) and staff were standing by with no interventions to Resident 1 ' s decreased RR. The DON stated the report indicated Resident 1 was assisted by the paramedics with a bag valve mask (a handheld device used to deliver breaths to someone who cannot breathe on their own) and transported on advanced life support (ALS – a set of life-saving protocols and skills to provide urgent care during critical conditions) to the nearest GACH 1. The DON stated, This resident passed away on 3/13/2025. During a review of the current facility-provided undated policy and procedure titled, Charting Errors and/or Omissions, the policy and procedure indicated, Accurate medical Records shall be maintained by this facility. During a review of the current facility-provided undated policy and procedure titled, Charting and Documentation, the policy and procedure indicated, 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 records. The medical record should facilitate communication between the interdisciplinary team regarding the resident ' s condition and response to care The following information is to be documented in the resident medical record: a. Objective observation; b. Medications administered; c. Treatments or services performed; d. Changes in the resident ' s condition 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Mar 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to follow its Policy and Procedures (P&P) titled, Grievances/Complaints, Filing, for one of three residents (Resident 1) when the facility failed to inform Family Member 1 (FM 1) verbally and in writing of the findings of the investigation and the actions that were taken to correct the identified problem. This deficient practice had the potential to violate the rights of Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/14/2012 and readmitted the resident on 10/13/2023 with diagnoses including type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), gastrostomy (GT - a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/30/2025, the MDS indicated Resident 1 rarely understood and was rarely understood. The MDS indicated Resident 1 was dependent (helper does all the effort) with eating, oral hygiene, toileting, showering, upper and lower body dressing, putting on and taking off footwear and personal hygiene. During a review of facility-provided email from FM 1, dated 2/14/2025, with a subject line of Avoiding inconsistency with nurses when regular nurse isn't on the schedule, indicated FM 1 stated, I was proactive in talking to the Director of Staff Development (DSD) to see if she (Resident 1) would have a nurse. Initially DSD said LVN 1. I (FM 1) reminded DSD that she (Resident 1) could not have LVN 1 and informed him (DSD) that he could call the Director of Nursing (DON) for clarification. During an interview on 3/12/2025 at 8:45 a.m., FM 1 stated having a lot of complaints and grievances but never gets any updates on what the facility does to resolve the problem. During a concurrent record review and interview on 3/12/2025 at 2:04 p.m. of FM 1's emails with Social Service Director (SSD), the SSD stated having two emails from FM 1 with recent concerns. The SSD stated did not create grievance for either of these concerns, therefore, there is no resolution for her concerns. During a concurrent record review and interview on 3/12/2025 at 4:45 p.m. of FM 1's email with the Director of Nursing (DON), the DON stated when FM 1 has a complaint the process is to open a grievance but not sure if the facility have opened one regarding Licensed Vocational Nurse (LVN) 1. The DON stated a grievance is created to ensure there is a resolution to the grievance. The DON reviewed FM 1's email and stated SSD should have created a grievance because it is her job. The DON stated that if a grievance was not created there is a potential for not addressing the issue then the family will be upset. During a review of the facility's P&P titled, Grievances/Complaints, Filing, last reviewed on 4/18/2024, the P&P indicated residents, and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. 12. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) received medication as prescribed. This deficient practice had the potential for Resident 1 to be negatively affected. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 3/14/2012 and readmitted the resident on 10/13/2023 with diagnoses including type 2 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), gastrostomy (GT-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 1/30/2025, the MDS indicated Resident 1 rarely understood and was rarely understood. The MDS indicated Resident 1 was dependent (helper does all the effort) with eating, oral hygiene, toileting, showering, upper and lower body dressing, putting on and taking off footwear and personal hygiene. During a review of Resident 1's Physician Orders, dated 11/21/2024, the orders indicated: - Chlorhexidine Gluconate Mouth/throat Solution 0.12 percent (% - one part in every hundred) give 15 milliliters (ml - a unit of measurement) by mouth two times a day for oral care swish and spit. Use swab and suction with yankauer (an oral suctioning tool used in medical procedures). - Diltiazem HCI oral tablet 60 milligrams (mg- a unit of measurement) give via g-tube three times a day for hypertension (HTN-high blood pressure) and hold for systolic blood pressure (SBP- the pressure in your arteries when your heart beats and pumps blood out) less than 110 or pulse less than 60. - Eliquis oral tablet 2.5 mg give 2.5 mg via g-tube two times a day for atrial fibrillation (an irregular and often very rapid heart rhythm). - Hiprex oral tablet 1 gram give 1 tablet via g-tube two times a day for urinary tract infection (UTI- an infection in the bladder/urinary tract) prophylaxis if another antibiotic is given, hiprex should be held and then restarted after finishing the other antibiotic course. - Hydralazine HCI oral tablet 50 mg give 50 mg via g-ube two times a day for HTN hold for SBP less than 110. - Latanoprost ophthalmic solution 0.005 % instill 1 drop in both eyes in the evening for glaucoma (a condition where the optic nerve, which connects the eye to the brain, is damaged, often due to increased pressure inside the eye, potentially leading to vision loss or blindness if left untreated). - Levetiracetam oral solution 100 mg/ml give 2.5 ml via g-tube two times a day for seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). - Metformin HCI oral tablet 500 mg via g-tube two times a day for diabetes. - Metoprolol tartrate oral tablet 25 mg give 25 mg via g-tube two times a day for HTN hold for SBP less than 110 or pulse less than 60. - Valproic acid oral solution 250 mg/ 5 ml give 5 ml via g-tube tow times a day for seizures. During a review of the facility's Administration History Report with a date range from 2/9/2025 to 2/11/2025, the report indicated: On 2/9/2025: - Chlorhexidine Gluconate mouth/throat solution 0.12% scheduled on 2/9/2025 at 5 p.m. and given at 2/10/2025 at 12:26 a.m. - Diltiazem HCI oral table 60 mg, scheduled at 2/9/2025 at 5 p.m. and given on 2/10/2025 at 1:01 a.m. - Eliquis oral tablet 2.5 mg scheduled on 2/9/2025 at 5 p.m. and given on 2/10/2025 at 1:01 a.m. - Hiprex oral tablet 1 gm scheduled on 2/9/2025 at 5 p.m. given on 2/10/2025 at 1:01 a.m. - Hydralazine HCI oral tablet 50 mg scheduled on 2/9/2025 at 5 p.m. and given on 2/10/2025 at 1:01 a.m. - Latanoprost ophthalmic solution 0.005% scheduled on 2/9/25 at 5 p.m. and given on 2/10/2025 at 12:26 a.m. - Levetiracetam oral solution 100 mg/ml scheduled on 2/9/2025 at 5 p.m. and given on 2/10/2025 at 1:01 a.m. - Metformin HCI oral tablet 500 mg scheduled on 2/9/2025 at 5 p.m. and given on 2/10/2025 at 1:01 a.m. - Valproic acid oral solution 250mg/5 ml scheduled on 2/9/2025 at 5 p.m. and given on 2/10/2025 at 1:01 a.m. On 2/10/2025: - Chlorhexidine Gluconate mouth/throat solution 0.12% scheduled on 2/10/2025 at 5 p.m. and given at 2/10/2025 at 11:40 p.m. - Diltiazem HCI oral table 60 mg, scheduled at 2/10/2025 at 5 p.m. and given on 2/10/2025 at 11:40 p.m. - Eliquis oral tablet 2.5 mg scheduled on 2/10/2025 at 5 p.m. and given on 2/10/2025 at 11:40 p.m. - Hiprex oral tablet 1 gm scheduled on 2/10/2025 at 5p.m. given on 2/10/2025 at 11:40 p.m. - Hydralazine HCI oral tablet 50 mg scheduled on 2/10/2025 at 5 p.m. and given on 2/10/2025 at 11:40 p.m. - Latanoprost ophthalmic solution 0.005% scheduled on 2/10/25 at 5 p.m. and given on 2/10/2025 at 11:40 p.m. - Levetiracetam oral solution 100 mg/ml scheduled on 2/10/2025 at 5 p.m. and given on 2/10/2025 at 11:40 p.m. - Metformin HCI oral tablet 500 mg scheduled on 2/10/2025 at 5 p.m. and given on 2/10/2025 at 11:40 p.m. - Metoprolol Tartrate Oral tablet 25 mg schedule on 2/10/2025 at 5 p.m. and given on 2/10/25 at 11:40 p.m. - Valproic acid oral solution 250mg/5 ml scheduled on 2/10/2025 at 5 p.m. and given on 2/10/2025 at 11:40 p.m. During a concurrent interview and record review on 3/12/2025 at 4:45 p.m. of Administration History Report with the Director of Nursing (DON), the DON stated medications should be given one hour before or one hour after scheduled times. The DON reviewed Resident 1's Administration History Report and stated medications were supposed to be given at 5 p.m. but were given at 11:40 p.m. and at 1 a.m. The DON stated the nurse should be giving the medications as scheduled and documenting them right away. The DON stated based on the Administration History Report the medications were given five to six hours late. The DON stated this can cause Resident 1 to have side effects for not receiving the medications. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, last reviewed on 4/18/2024, the P&P indicated medications are administered in a safe and timely manner, and as prescribed. 4. Medications are administered in accordance with prescriber orders, including any required time frames. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Mar 2025 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to provide wound care treatment to one of three sampled residents (Resident 4). This deficient practice could lead to worsening and infection of Resident 4's wound. Findings: During a review of Resident 4's Record of Admission, the Record of admission indicated the facility admitted the resident on 1/29/2025, with diagnoses including phantom limb syndrome (feeling of pain in a limb that's been amputated) with pain. During a review of Resident 4's History & Physical (H&P), dated 1/24/2025, the H&P indicated that the resident had fluctuating capacity to understand and make decisions. The H& P indicated Resident 4 had bilateral (both) knee amputation (a surgical procedure where the knee joint is removed, separating the lower leg from the upper leg at the knee). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 2/4/2025, the MDS indicated that resident's cognition (refers to the mental processes involved in acquiring knowledge and understanding through thinking, experience, and the senses) was intact (not broken). During a review of Resident 4's Treatment Administration Report (TAR), dated 3/2/2025, the TAR indicated a treatment to clean Resident 4's surgical incision on right bilateral knee amputation with sutures with soap and water, pat dry, apply moisturizer to the surrounding dry skin not the incision, dress with telfa (brand of non-adherent wound dressings), apply gauze and wrap with kerlix (gauze) once a day or as needed. During a concurrent interview and record review on 3/7/2025 at 2 p.m. with License Vocational Nurse (LVN) 4, Resident 4's TARs, dated 3/1/2025 to 3/31/2025, were reviewed. LVN 4 stated the TAR indicated that on 3/4/2025 and 3/6/2025, Resident 4 was out of the facility for dialysis and missed his wound treatments. LVN 4 further stated that it was important to prioritize and provide Resident 4 treatment before leaving the facility for dialysis because Resident 4's wound could get infected and will get worse. During an interview on 3/11/2025 at 11 a.m., Registered Nurse (RN) 1 stated staff must not miss giving wound treatments to Resident 4 and should prioritize giving his wound treatments first before leaving the facility. The DON stated staff has a list of residents who have appointments for the day and must prioritize those residents so that they will not miss their treatments. RN 1 stated Resident 4's wound could get worst if wound treatments were not provided. The facility was not able to provide a policy and procedure on missing wound care treatments.

CONCERN (D) 📢 Someone Reported This

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

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received care consistent with professional standards of practice to prevent pressure ulcers/injury (the breakdown of skin integrity due to pressure) by not having Resident 1 wear boots per physician's order. This deficient practice had the potential for Resident 1 to develop pressure ulcers/injuries. Findings: During a review of Resident 1's Record of Admission, the Record of admission indicated the facility admitted the resident on 12/14/2023, with diagnoses including Alzheimer's Disease (brain disorder that gradually destroys memory and thinking skills) During a review of Resident 1's History & Physical (H&P), dated 12/20/2023, the H&P indicated Resident 1 did not have capacity to make decisions. During a review of Resident 1's Order Summary Report, dated 12/5/2024, the report indicated Resident 1 to wear heel protector boots in place for prevention (of pressure ulcer), may remove (the boots) to provide care and assess skin integrity everyday shift for wound management. During a review of Resident 1's Braden Scale (is a clinically validated tool that scores a resident's level of risk for developing pressure ulcers) for Predicting Pressure Sore Risk, dated 12/202/2024, the Braden Scale indicated that Resident 1 was high risk for pressure sore. During a concurrent observation, interview, and record review on 3/6/2025 at 3 p.m., with License Vocational Nurse (LVN) 1, Resident 1 was observed and Resident 1's Order Summary Report, dated 12/5/2025, was reviewed. During an observation, Resident 1 was lying down in bed sleeping, wearing socks, and house slippers. LVN 1 stated Resident 1 was not wearing her boots. LVN 1 stated Resident 1 should wear her heel protector boots all the time per physician order to prevent development of pressure ulcer. During a concurrent interview and record review on 3/7/2025 at 8 a.m., with Registered Nurse (RN) 2, Resident 1's Order Summary Report, dated 12/5/2025, was reviewed. RN 2 stated Resident 1 must wear her boots all the time except for showers and during activities of daily living (ADL's) to prevent developing of pressure ulcer. During a review of the facility's policy and procedure titled, Prevention of Pressure Injuries, last reviewed on 4/18/2024, the policy and procedure indicated that this procedure is to provide information regarding identification of pressure injury factors and interventions for specific factors. Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable.

CONCERN (E) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (a written or electronic record containing all the information the resident needs to effectively manage their own health) for two of three sampled residents (Resident 1 and Resident 4) by: 1. Failing to ensure Resident 1 had a communication board due to hard of hearing according to Resident 1's care plan intervention. 2. Failing to ensure Resident 4 had a care plan regarding Resident 4's diet and food preferences. These deficient practices had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services. Findings: 1. During a review of Resident 1's Record of Admission, the Record of admission indicated the facility admitted the resident on 12/14/2023, with diagnoses including Alzheimer's Disease (brain disorder that gradually destroys memory and thinking skills). During a review of Resident 1's History & Physical (H&P), dated 12/20/2023, the H&P indicated Resident 1 did not have the capacity to make decisions. During a review of Resident 1's care plan titled, Hearing, dated 12/15/2023, the care plan indicated an intervention to use a communication device to assist with Resident 1's communication. During a concurrent observation and interview on 3/10/2025 on 2 p.m., inside Resident 1's room, Certified Nursing Assistant (CNA) 3 stated that a communication board was not in Resident 1's bedside drawer and closet. CNA 3 stated that Resident 1 should have a communication board due to Resident 1's hard of hearing so that Resident 1 could understand the nurses during conversations. CNA 3 stated that if there was no communication board this could lead to Resident 1 being frustrated. During a concurrent interview and record review on 3/11/2025 on 11 a.m. with Registered Nurse (RN) 1, Resident 1's care plan titled, Hearing, dated 12/15/2023, was reviewed. The care plan indicated to use a communication device to assist with communication. RN 1 stated Resident 1 should have a communication device like a white board and marker for the staff to use to communicate with Resident 1 as indicated in Resident 1's plan of care. RN 1 further stated that because Resident 1 had no communication device, this could lead to Resident 1's frustration and miscommunication between Resident 1 and staff. During a review of the facility policy and procedure titled, Care Plans, Comprehensive Person-Centered, last reviewed on 4/18/2024, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet residents' physical, psychosocial and functional needs and implemented for each resident. During a review of the facility policy and procedure titled, Sensory Impairments – Clinical Protocol, last reviewed on 4/18/2024, indicated the staff and physician will identify approaches to help the resident improve or compensate for sensory deficits. For the resident with impaired hearing, the staff should check for cerumen (ear wax), and may help the individual obtain a hearing evaluation, hearing aid, or employ written or other means to communicate with the individual. 2. During a review of Resident 4's Record of Admission, the Record of admission indicated the facility admitted the resident on 1/29/2025, with diagnoses including phantom limb syndrome (feeling of pain in a limb that's been amputated) with pain. During a review of Resident 4's H&P, dated 1/24/2025, the H&P indicated that the resident had fluctuating capacity to understand and make decisions. The H&P indicated Resident 4 had bilateral (both) knee amputation (a surgical procedure where the knee joint is removed, separating the lower leg from the upper leg at the knee). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 2/4/2025, the MDS indicated that Resident 4's cognition (refers to the mental processes involved in acquiring knowledge and understanding through thinking, experience, and the senses) was intact (not broken). During an interview on 3/7/2025 on 9 a.m., Resident 4 stated receiving high carbohydrate food and does not like it because of medical condition. During a concurrent interview and record review on 3/10/2025 on 3 p.m., with RN 3, Resident 4's care plans, dated 1/29/2025 to 3/10/2025, were reviewed. RN 3 stated Resident 4 had no care plan regarding diet according to his medical condition and food preference. RN 3 further stated that Resident 4 should have specific interventiosn for his diet according to Resident 4 medical condition. RN 3 stated there was potential that Resident 4 could just receive any food that was not good for Resident 4's medical condition and food preference. During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered, last reviewed on 4/18/2024, the policy and procedure indicated a comprehensive, person-centered care plan that includes measurable to objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Reflect the resident's expressed wishes regarding care and treatment goals.

Mar 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from verbal abuse (use of oral, written, or gestured communication, or sounds which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation) for one of three sampled residents (Resident 1). This had the potential to negatively affect Resident 1's psychosocial well-being (refers to a resident's overall mental, emotional, and social health, encompassing aspects like happiness, life satisfaction, self-esteem, social functioning, and a sense of purpose). Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/8/2024 with the following diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (feeling of anxiousness that affects daily life). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 12/4/2024, the MDS indicated the resident had the ability to make self understood and understand others. During a review of Resident 1's Care Plan (CP), dated 12/26/2024, the CP indicated Resident 1 preferred to spend time in the hallway alone observing others. During a review of Resident 1's History and Physical (H&P), dated 1/27/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. b. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/22/2024 with the following diagnoses including hypertension (high blood pressure), anemia (a condition where the body does not have enough healthy red blood cells), and low back pain. During a review of Resident 2's Care Plan (CP) for Psychosocial-Behavior, dated 2/16/2024, the CP indicated Resident 2 exhibited or was at risk to exhibit behaviors such as striking out, grabbing others, verbally or physically abusive. During a review of Resident 2's MDS, dated [DATE], the MDS indicated the resident had intact cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS also indicated Resident 2 had the ability to make self understood and understand others. During a review of Resident 2's Psychosocial Progress Note, dated 2/28/25, the Psychosocial Progress Note indicated on 2/26/25 an attempt was made to transfer Resident 2 to acute care hospital due to verbally aggressive behavior towards staff and others. During an interview on 3/7/2025 at 11:29 a.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 2 had frequent episodes of shouting, using inappropriate words with staff. CNA 1 also stated between period of 2/23/2025 to 3/1/2025 (CNA 1 could not indicate the exact date of the incident) while standing in the hallway near Resident 2's room, she heard Resident 2 shouting, cursing, and calling Resident 1 inappropriate names. CNA 1 stated she did not report the incident. During an interview on 3/7/25 at 11:45 a.m. with Resident 1, Resident 1 stated he does not feel safe in his room with Resident 2. Resident 1 also stated Resident 2 had frequent episodes of screaming and calling him inappropriate, insulting names. Resident 1 stated approximately one week ago, when Resident 1 was trying to enter the bathroom and passed by Resident 2's bed, Resident 2 screamed and addressed Resident 1 with inappropriate names. Resident 1 stated he spends most of his time outside of his room to avoid Resident 2. Resident 1 stated he is scared Resident 2 will become agitated and harm him physically. During an interview on 3/7/25 at 1:44 p.m. with Social Services Director (SSD), the SSD stated Resident 2 has a history of verbal aggression towards other residents. The SSD also stated the other resident, Resident 1, prefers to spend his time outside of his room, socializing with other residents. During an interview on 3/10/25 at 3:14 p.m. with the Director of Nursing (DON), the DON stated the incident of Resident 2 shouting and using inappropriate names towards Resident 1 is a type of verbal abuse. The DON stated incidents of verbal or physical abuse should be reported to the Administrator, DON or Registered Nurse Supervisor for investigation. During a review of the facility's policy and procedure (P&P) titled, Resident-to-Resident Altercations, last reviewed on 4/18/2024, the P&P indicated verbally aggressive behavior such as screaming, cursing, intimidating, should be promptly reported to the nurse supervisor, director of nursing services, and to the administrator. The P&P also indicated the Administrator will report the incident in accordance with the criteria established under Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigation.

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an incident of a verbal abuse (use of oral, written, or gestured communication, or sounds which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation) for one of three sampled residents (Resident 1). This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect Resident 1 from further abuse. Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/8/2024 with the following diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (feeling of anxiousness that affects daily life). During a review of Resident 1's Minimum Data Set (MDS, a resident assessment tool), dated 12/4/2024, the MDS indicated the resident had the ability to make self understood and understand others. During a review of Resident 1's Care Plan (CP), dated 12/26/2024, the CP indicated Resident 1 preferred to spend time in the hallway alone observing others. During a review of Resident 1's History and Physical (H&P), dated 1/27/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. b. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/22/2024 with the following diagnoses including hypertension (high blood pressure), anemia (a condition where the body does not have enough healthy red blood cells), and low back pain. During a review of Resident 2's Care Plan (CP) for Psychosocial-Behavior, dated 2/16/2024, the CP indicated Resident 2 exhibited or was at risk to exhibit behaviors such as striking out, grabbing others, verbally or physically abusive. During a review of Resident 2's MDS, dated [DATE], the MDS indicated the resident had intact cognitive functioning (mental processes that enable people to think, understand, make decisions, and complete tasks). The MDS also indicated Resident 2 had the ability to make self understood and understand others. During a review of Resident 2's Psychosocial Progress Note, dated 2/28/25, the Psychosocial Progress Note indicated on 2/26/25 an attempt was made to transfer Resident 2 to acute care hospital due to verbally aggressive behavior towards staff and others. During an interview on 3/7/2025 at 11:29 a.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 2 had frequent episodes of shouting, using inappropriate words with staff. CNA 1 also stated between period of 2/23/2025 to 3/1/2025 (CNA 1 could not indicate the exact date of the incident) while standing in the hallway near Resident 2's room, she heard Resident 2 shouting, cursing, and calling Resident 1 inappropriate names. CNA 1 stated she did not report the incident. During an interview on 3/7/25 at 11:45 a.m. with Resident 1, Resident 1 stated Resident 2 is his roommate and approximately one week ago, when Resident 1 was trying to enter the bathroom and passed by Resident 2's bed, Resident 2 screamed and addressed Resident 1 with inappropriate names. Resident 1 also stated he is afraid to stay in his room with Resident 2 During a follow up interview on 3/7/25 at 1:13 p.m. with CNA 1, CNA 1 stated the incident of Resident 2 shouting and calling Resident 1 inappropriate names is an episode of verbal abuse. CNA 1 also stated she should have reported the incident to the supervisor to prevent continuation of abuse of Resident 1 but she did not. During an interview on 3/10/25 at 3:14 p.m. with the Director of Nursing (DON), the DON stated the incident of Resident 2 shouting and using inappropriate names towards Resident 1 is a type of verbal abuse. The DON stated incidents of verbal or physical abuse should be reported to the Administrator, DON or Registered Nurse Supervisor for investigation. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, dated 9/2022, the P&P indicated, if resident abuse or neglect is suspected, the suspicion must be reported immediately to the administrator and to other officials according to the state law. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to the other officials according to sate law. During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation or Misappropriation Prevention Program, last reviewed on 4/18/2024, the P&P indicated all possible incidents of abuse will be identified and investigated. During a review of the facility's policy and procedure (P&P) titled, Resident-to-Resident Altercations, last reviewed on 4/18/2024, the P&P indicated verbally aggressive behavior such as screaming, cursing, intimidating, should be promptly reported to the nurse supervisor, director of nursing services, and to the administrator. The P&P also indicated the Administrator will report the incident in accordance with the criteria established under Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigation.

Feb 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 2) had the right to be free from physical abuse (willful infliction of injury resulting physical harm, pain, or mental anguish) on 2/16/2025 at 4:30 p.m. when Resident 1 pulled and hit Resident 2 on the back. This deficient practice resulted in Resident 2 being subjected to physical abuse by Resident 1 while under the care of the facility. Based on the Reasonable Person Concept (the usual behavior of an average person under the same circumstances), due to Residents 2 ' s severely impaired cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) and medical condition, an individual subjected to physical abuse may have physical pain, psychological (mental or emotional) effects including feelings of hopelessness (a feeling or state of despair or lack of hope), helplessness (the belief that there is nothing that anyone can do to improve a bad situation), and humiliation (the feeling of being ashamed or losing respect for own self). Findings: During a record review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted the resident on 2/7/2025 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), absence of left leg below the knee, and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). During a record review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool), dated 2/13/2025, the MDS indicated the resident ' s cognitive skills (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) were intact. During a record review of Resident 1 ' s Change in Condition (COC) Evaluation, dated 2/16/2025, the COC Evaluation indicated the resident had an altercation (a loud, heated argument or disagreement between people) with Resident 2 on 2/16/2025. During a record review of Resident 1 ' s Progress Notes, dated 2/16/2025, the Progress Notes indicated Resident 2 kicked Resident 1 on the left upper leg. The Progress Notes indicated Resident 1 hit Resident 2 on the back. There were no witnesses to the reported physical altercation between Resident 1 and Resident 2. The Progress Notes indicated Resident 1 was assessed and the Attending Physician 1 (MD 1) was notified. During a record review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted the resident on 1/17/2025 with diagnoses including metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and anxiety disorder (persistent and excessive worry that interferes with daily activities). During a record review of Resident 2 ' s MDS, dated [DATE], the MDS indicated the resident ' s cognitive skills were severely impaired. During a record review of Resident 2 ' s COC Evaluation, dated 2/16/2025, the COC Evaluation indicated the resident had an altercation with Resident 1 on 2/16/2025. The COC Evaluation indicated MD 1 was notified and ordered an x-ray (invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs) of the back for Resident 2. During an interview on 2/24/2025 at 1:10 p.m. with Resident 1, Resident 1 stated Resident 2 (Resident 1 ' s roommate) kicked his left leg. Resident 1 stated Resident 2 tried to run out of the room when Resident 1 grabbed Resident 2 ' s shirt with both hands and pulled back Resident 2. Resident 1 stated he (Resident 1) hit Resident 2 on the back. Resident 1 did not specify if the hand used to hit Resident 2 was open or closed. Resident 1 stated he pulled and hit Resident 2 on purpose. During an interview on 2/24/2025 at 1:29 p.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated two before Resident 1 and Resident 2 ' s altercation, Resident 1 informed LVN 1 that Resident 2 touched and took Resident 1 ' s personal items. LVN 1 stated Resident 1 did not want Resident 2 as a roommate. During an interview on 2/24/2025 at 1:39 p.m. with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated two weeks ago Resident 1 reported that Resident 2 took Resident 1 ' s food and other items from Resident 1 ' s table. CNA 3 stated she did not report Resident 1 ' s concerns to the licensed nurses. CNA 3 stated she should have reported Resident 1 ' s concerns to prevent the incident from escalating. During a concurrent observation and interview on 2/24/2025 at 2:19 p.m. with LVN 2, observed Resident 2 opened the closets of the other residents in Resident 2 ' s room. LVN 2 stated Resident 2 had a behavior of verbal aggression towards nursing staff. During an interview on 2/24/2025 at 3:22 p.m. with Registered Nurse 1 (RN 1), RN 1 stated Resident 1 and Resident had a physical altercation. RN 1 stated Resident 1 hit Resident 2 on the back with Resident 1 ' s hand (did not specify which hand). RN 1 stated that Resident 1 hitting Resident 2 on the back was considered a physical abuse. RN 1 stated Resident 1 ' s cognition was intact and acted in his own will. During an interview on 2/24/2025 at 4:22 p.m. and concurrent record review of Resident 1 and Resident 2 ' s MDSs were reviewed with the Assistant Director of Nursing (ADON). The ADON stated Resident 1 ' s cognition was intact and Resident 2 ' s cognition was severely impaired. The ADON stated Resident 2 had an aggressive behavior towards staff. The ADON stated Resident 1 hitting Resident 2 on the back was considered a physical abuse. The ADON stated Resident 1 ' s action was a willful act. The ADON stated Resident 1 hitting Resident 2 on the back had the potential to affect Resident 2 ' s psychosocial health (a person ' s thoughts, feelings, and behavior influenced by their social environment) that may lead to changes in mood, depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities) and isolation. The ADON stated the facility failed to identify the residents ' compatibility concerns. During an interview on 2/24/2025 at 5:30 p.m. with the Director of Nursing (DON), the DON stated Resident 1 willfully hit Resident 2 on the back was considered a physical abuse. The DON stated the facility failed to prevent the resident-to-resident physical abuse. During a record review of the facility ' s policy and procedure (PnP) titled, Recognizing Signs and Symptoms of Abuse and Neglect, last reviewed on 4/18/2024, the PnP indicated all types of resident abuse, neglect, exploitation, or misappropriation of resident property were strictly prohibited. The PnP indicated all personnel were expected to report any signs and symptoms of abuse or neglect to their supervisor or to the DON immediately. The PnP defined abuse as a willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. During a record review of the facility ' s PnP titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, last reviewed on 4/18/2024, the PnP indicated residents have the right to be free from abuse The PnP indicated the resident abuse, neglect, and exploitation prevention program objectives included to protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone including, but not limited to . b. other residents. During a record review of the facility ' s PnP titled, Resident-to-Resident Altercation, last reviewed on 4/18/2024, the PnP indicated all altercations, including those that may represent resident-to-resident abuse, were investigated and reported to the nursing supervisor, the DON and to the Administrator. The PnP indicated the facility staff monitor residents for aggressive behavior or inappropriate behaviors towards other residents, family members, visitors, or to the staff. The PnP indicated behaviors that may provoke a reaction by residents or others include a verbally aggressive behavior and taking, touching, or rummaging through other ' s property.

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 F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 3) was provided care and services to maintain good grooming and personal hygiene. Resident 3 was not provided a scheduled shower on 1/29/2025 and 2/22/2025. This deficient practice resulted on Resident 3 ' s feeling dirty and had the potential to result in a negative impact on Resident 3 ' s self-esteem and self-worth. Findings: During a record review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted the resident on 9/4/2024 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities), and paraplegia (inability to voluntarily move the lower parts of the body). During a record review or Resident 3 ' s Care Plan on Activities of Daily Living (ADLs - basic tasks that must be accomplished every day for an individual to thrive), initiated on 9/4/2024, the Care Plan indicated the resident was at risk for ADL decline and required assistance related to bed-bound status and weakness. The Care Plan indicated Resident 3 will meet personal goal. The Care Plan Intervention included to encourage to participate in ADLs to promote independence. During a record review of Resident 3 ' s Minimum Data Set (MDS – a resident assessment tool), dated 12/11/2024, the MDS indicated the resident ' s cognitive skills (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) were intact. The MDS indicated Resident 3 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort) on shower, bathing self, and toileting hygiene. During a record review of an undated facility-provided residents shower schedule for station 4 (the station Resident 3 was located), The shower schedule indicated Resident 3 ' s shower was scheduled every morning on Wednesday and Saturday. During an interview on 2/24/2025 at 2 p.m. with Resident 3, Resident 3 stated his shower schedule was every morning on Wednesdays and Saturdays. Resident 3 stated he did not get a shower on 2/22/2025. Resident 3 stated the Certified Nursing Assistant (CNA) told him shower will be given in the afternoon. Resident 3 stated he was not provided a shower on the afternoon of 2/22/2025. Resident 3 stated he requested a shower on Sunday, 2/23/2025. Resident 3 stated he was not provided a shower on 2/23/2025. Resident 3 stated he had not received a shower yet and was losing hope on getting a shower on 2/24/2025. Resident 3 stated he was uncomfortable and felt dirty. During an interview on 2/24/2025 at 4:50 p.m. and a concurrent record review of Resident 3 ' s Bathing Task, dated 1/25/2025 to 2/24/2025, with the Director of Staff Development (DSD), the Bathing Task indicated bathing was not applicable on Wednesday (1/29/2025) and Saturday (2/22/2025). The DSD stated the documented not applicable on the Bathing Task meant it was not Resident 3 ' s shower day. The DSD stated Resident 3 was not provided a shower on 1/29/2025 and 2/22/2025. The DSD stated these dates were Resident 3 ' s scheduled shower days. The DSD stated residents not getting showers had the potential to affect their hygiene and result to skin problems and irritation. The DSD stated the residents should be clean and showered on the scheduled shower days. The DSD stated the facility failed to provide Resident 3 ' s ADLs as scheduled and as requested by Resident 3. During an interview on 2/24/2025 at 5:45 p.m. with CNA 5, CNA 5 stated Resident 3 did not get a shower on 2/22/2025 and she did not inform the 3 p.m. to 11 p.m. shift CNA that took care of the resident. CNA 5 stated Resident 3 did not get a shower on 2/23/2025 and she did not inform the 3 p.m. to 11 p.m. shift CNA that took care of the resident. During an interview on 2/24/2025 at 5:58 p.m. with the Director of Nursing (DON), the DON stated Resident 3 did not get the resident ' s scheduled showers on 1/29/2025 and 2/22/2025. The DON stated Resident 3 did not get the requested shower on 2/23/2025. The DON stated Resident 3 had the potential for psychosocial health (a person ' s thoughts, feelings, and behavior influenced by their social environment) and infection control concerns. The DON stated the facility failed to provide ADL such as showers to Resident 3. During a record review of the facility ' s policy and procedure (PnP) titled, Shower and Tub Bath, last reviewed on 4/18/2024, the PnP indicated the purpose of this procedure were to promote cleanliness, provide comfort to the resident and to observe the condition of the resident ' s skin. The PnP indicated to report other information in accordance with facility policy and professional standards of practice.

Feb 2025 1 deficiency 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

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Based on interview and record review, the facility failed to protect a resident's right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for one of four sampled residents (Resident 1) when on 1/29/2025 at 10:55 a.m., Student Nurse 1 (SN 1) and Student Nurse 2 (SN 2) witnessed Certified Nurse Assistant 1 (CNA 1) hit Resident 1 in the back of the head three times with an open hand (did not indicate which hand). This deficient practice resulted in Resident 1 being subjected to physical abuse by CNA 1 while under the care of the facility. Resident 1 stated he (Resident 1) felt humiliated (ashamed), sad, and complained of pain to the back of the head. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 11/16/2023, with diagnoses that included hemiplegia (paralysis [inability to move] that affects only one side of the body) and hemiparesis (muscle weakness that affects one side of the body) following a cerebral infarction (a condition where blood flow to the brain is interrupted causing brain tissue to die) affecting right dominant side, difficulty walking, heart failure (when the heart does not pump blood as well as it should), and history of falling. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 11/5/2024, the MDS indicated Resident 1 had moderate impairment of cognition (ability to think and make decisions). The MDS indicated Resident 1 required moderate assistance with activities of daily living (ADL - routine tasks and or activities such as bathing, dressing, and toileting a person performs daily to care for themselves). During a review of Resident 1's document titled, Interact Change in Condition (COC - when there is a sudden change in a resident's health condition or behavior) Evaluation, dated 1/29/2025, the COC indicated that on 1/29/2025 at 10:55 a.m., SN 1 and SN 2 reported seeing CNA 1 in Resident 1's room, hitting the top of Resident 1's head three times. The COC further indicated that CNA 1 was immediately removed and a head-to-toe assessment (a comprehensive medical examination where a healthcare professional checks a resident's entire body from the top of their head to the tips of their toes, systematically evaluating each body system to assess their overall health and identify any potential problems) on Resident 1 was completed with no skin issues noted. The COC indicated that Resident 1 was interviewed and reported in Spanish that CNA 1 hit him (Resident 1) in the head three times. During a review of Resident 1's Plan of Care, dated 1/29/2025, the Plan of Care indicated Resident 1 had an incident of alleged abuse. The Plan of Care indicated a goal that Resident 1 will be free from abuse in the facility by encouraging to verbalize feelings and provide psychosocial (relating to the interrelation of social factors and individual thought and behavior) support. During a review of CNA 1's Employee Counseling and or Disciplinary Notice, dated 1/29/2025, the notice indicated CNA 1 was witnessed hitting Resident 1 on his (Resident 1) head. During a review of Resident 1's Psychiatric Evaluation follow up note, dated 2/3/2025, the Psychiatric Evaluation follow up note indicated that Resident 1 was seen for a follow-up visit after reporting an incident (abuse) to staff. The note indicated Resident 1 alleges that a nurse (referring to CNA 1) tapped Resident 1 on the back of Resident 1's head. During an interview with Resident 1 on 2/7/2025 at 9 a.m., Resident 1 stated that CNA 1 hit him (Resident 1) three times on the back of his head. Resident 1 stated he (Resident 1) had asked the staff (referring to CNA 1) for assistance. Resident 1 stated that CNA 1 did not want to help Resident 1, so CNA1 started hitting Resident 1. Resident 1 stated he (Resident 1) felt sad, ashamed, and had some pain to the back of the head because CNA 1 hit him (Resident 1) very hard. Resident 1 stated he (Resident 1) could not defend himself (referring to Resident 1) because he (Resident 1) was sick and felt very bad. During a review of SN 2's written statement, dated 1/29/2025, the written statement indicated that SN 2 witnessed CNA 1 hit Resident 1 on the head (did not indicated which part) three times. The written statement indicated Resident 1, and CNA 1 were previously arguing in the bathroom. The written statement indicated when CNA 1 hit Resident 1, Resident 1 yelled in Spanish (a type of language), The CNA (CNA 1) hit me, she hit me. SN 2's written statement indicated that CNA 1 verbalized hitting Resident 1 by stating I hit him (Resident 1). During an interview on 2/7/2025 at 10 a.m. with SN 1, SN 1 stated on 1/29/2025, she (SN 1) observed CNA 1 slapped the back of Resident 1's head. SN 1 stated CNA 1 had her palm (inner part of hand) open (did not indicate which palm) and slapped Resident 1 in the head three times very hard. SN 1 stated Resident 1 was yelling out that a CNA (referring to CNA 1) hit him. During an interview with the Clinical Instructor (CI) on 2/7/2025 at 11 a.m., the CI stated, on 1/29/2025, SN 1 and SN 2 came to her and reported witnessing CNA 1 hitting Resident 1 in the head. The CI stated they (SN 1, SN 2, and CI) went to report the incident (abuse) to the Director of Nurses (DON). During an interview on 2/7/2025 at 3:30 p.m. with the DON, the DON stated the incident that occurred on 1/29/2025 with Resident 1 and CNA 1 was considered abuse. The DON stated the facility does not allow any type of abuse to occur because there is zero tolerance (a strict policy that prohibits violence, bullying, and other harmful behaviors in the workplace) for abuse. The DON stated CNA 1 was removed from the facility staffing schedule. During a review of the current facility-provided policy and procedure (P & P) titled, Abuse, Neglect, Exploitation (the act of taking advantage of someone or something for personal gain) and Misappropriation (unauthorized, improper, or unlawful use) Prevention Program, dated 2021, the P & P indicated residents have the right to be free from abuse. This includes . physical abuse.

Feb 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure confidential personal information for one of four sampled residents (Resident 1) was protected. The clinical records of Resident 1 were left unattended on the nurse station 3 computer. This deficient practice had the potential to violate Resident 1's rights for privacy and confidentiality of personal and medical records. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 10/22/2024 with diagnoses including metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), systemic lupus erythematosus (a long-lasting autoimmune disease where the body's immune system attacks its own healthy tissues causing inflammation and potentially damage organs), and osteoporosis (a disease that cause bones to become brittle and more likely to break). During a concurrent observation and interview on 2/4/2025 at 3:10 p.m. with the Director of Staff Development (DSD), observed Resident 1's medical records on the computer at nurse station 3. The DSD stated Resident 1's medical records were visible to the people walking on station 3 hallway. The DSD stated the computers with residents' medical records should be minimized or closed when not in use. The DSD stated Resident 1's medical records left unattended had the potential for other people such as visitors and family members to have unapproved access to the resident's information. During an interview on 2/4/2025 at 3:19 p.m. with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated she left the computer open with Resident 1's medical records. LVN 2 stated she should have closed the computer before she left the desk and did not leave Resident 1's medical records unattended. LVN 2 stated resident medical records left unattended had the potential for unauthorized access. During an interview on 2/4/2025 at 5:10 p.m. with the Director of Nursing (DON), the DON stated Resident 1's medical records should not be left unattended. The DON stated facility staff not involved in Resident 1's care, other residents, and visitors had the potential for unauthorized access to Resident 1's medical records. The DON stated the facility failed to ensure private information in Resident 1's medical records were safe from unauthorized access. During a record review of the facility's policy and procedure (PnP) titled, Computer Terminals and Workstations, last reviewed on 4/18/2024, the PnP indicated computer terminals and workstations will be positioned and shielded to ensure that protected health information (PHI) and facility information was protected from public view or unauthorized access. The PnP indicated a user may not leave the workstation or terminal unattended unless the terminal screen is cleared and the user is logged off.

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to implement their policy and procedure on safeguarding of all prescribed medications for one of four sampled residents (Resident 4) by failing to ensure Resident 4's prescribed medication was stored in the medication cart of the nursing station where Resident 4 was located. This deficient practice had the potential for non-authorized access to Resident 4's medications. Findings: During a record review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 1/31/2025 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), insomnia (a sleep disorder that makes it hard to fall asleep, stay asleep, or get quality sleep), and depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities). During a record review of Resident 4's Physician Orders, the Physician Orders did not indicate that Resident 4 had an order for melatonin (a medication used to help people with insomnia fall asleep faster) five milligrams (mg - unit of measurement). During a concurrent observation and interview on 2/4/2025 at 3:10 p.m., observed a medication container on the nurse station 3's table labeled melatonin 5mg with Resident 4's name. There were no licensed nurses at nurse station 3. The Director of Staff Development (DSD) walked in nurse station 3 and saw the medication container on the table at nurse station 3. The DSD stated licensed nurses should not leave medication containers unattended. During a concurrent observation and interview on 2/4/2025 at 3:19 p.m. with Licensed Vocational Nurse 2 (LVN 2), observed a medication container on the table at nurse station 3 labeled melatonin 5mg with Resident 4's name. LVN 2 stated Resident 4's medication should be placed inside the locked medication cart. LVN 2 stated medications should not be left unattended. LVN 2 stated other residents may take the medication and had the potential to cause harm to the resident. During an interview on 2/4/2025 at 5:10 p.m. with the Director of Nursing (DON), the DON stated Resident 4's medication should not be left unattended for the safety of other residents. The DON stated resident medications should be inside the locked medication cart. The DON stated medications left unattended had the potential for other residents to take the medication and cause adverse effects (unwanted and undesirable effects of a medication). During a record review of the facility's policy and procedure (PnP) titled, Medication Labeling and Storage, last reviewed on 4/18/2024, the PnP indicated the facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. The PnP indicated compartments containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Jan 2025 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to follow its Policy and Procedures (P&P) titled, Grievances/Complaints, Filing, for one of three residents (Resident 2) when the facility failed to inform Family Member 1 (FM 1) verbally and in writing of the findings of the investigation and the actions that were taken to correct the identified problem. This deficient practice had the potential to violate the rights of Resident 2. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 9/6/2024 with diagnoses including respiratory disorders (conditions that affect the lungs and other parts of the respiratory system), muscle weakness (generalized), and adult failure to thrive (a syndrome that describes a decline in physical and mental health in adults). During a review of Resident 2's Order Summary Report, dated 9/7/2024, the report indicated the following: - Change indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) drain bag every week and as needed (PRN) if damaged, leakage or blockage/obstruction noted, or any further complications. - Change indwelling catheter every month as PRN for dislodgement or non-patency or further complications noted. During a review of Resident 2's care plan, created on 9/17/2024, for Resident 2's risk for complications with urinary system related to indwelling catheter secondary to urinary retention, the care plan indicated interventions that included to change foley catheter per facility's policy and physician order. During a review of Resident 2's Minimum Data Set (MDS – a resident assessment tool), dated 12/13/2024, the MDS indicated Resident 2 usually understood and was usually able to understand. During a review of Resident 2's Complaint/Grievance Form, dated 12/19/2024, the form indicated FM 1 had told nurses on several occasions that Resident 2 ' s catheter was dirty, and on scheduled doctor's appointment was told by doctor Resident 2 needed to go to hospital due to urinary tract infection (UTI - an infection in the bladder/urinary tract). The response to family and or responsible party was not dated or timed. During a review of Resident 2's Order Summary Report, dated 12/22/2024, the report indicated the folowing: - Indwelling catheter care per day shift and PRN - Indwelling catheter size 16 french 10 milliliters (ml - unit of measurement) During an interview on 1/28/2025 at 8:13 a.m., FM 1 stated had written a grievance regarding catheter and felt Resident 2 was not properly looked after. FM 1 stated was not told what the facility did to ensure there were no more issues with the catheter. During a concurrent interview and record review on 1/28/2025 at 3:49 p.m. of Resident 2's Complaint/Grievance form, dated 12/19 /2024, with Social Services Director (SSD), the SSD stated FM 1 wanted to write a grievance regarding Resident 2's catheter with FM 1 saying Resident 2 had a UTI. The SSD stated she made a copy of the grievance form and provided the copy to the Director of Nursing (DON). The SSD reviewed Complaint/Grievance form and stated did not date it because she wanted to follow up with FM 1 but never did. The SSD stated she follows up when she remembers and resolution should be done within 10 days. If she needs a longer time, she still needs to inform the family. The SSD stated that not informing family about the resolution can result in the family not knowing it was address and they (the family) will be worried. During an interview on 1/28/2025 at 4:32 p.m., the DON stated he believes the grievance of FM 1 regarding Resident 2 had been resolved. The DON stated they in-serviced the staff and wrote up the Licensed Vocational Nurse. The DON stated that for grievance, the SSD always has the same issue because she never follows up with family and/or the complainant. The DON stated the SSD should follow up, needs to give family the feedback that the facility ensured this problem will not continue. The DON stated it is for the peace of mind of the family or complainant and it is their right to know. During a review of the facility's P&P titled, Grievances/Complaints, Filing, last reviewed on 4/18/2024, the P&P indicated residents, and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. 12. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems.

CONCERN (D) 📢 Someone Reported This

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

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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Based on interview and record review the facility failed to ensure one of three residents (Resident 4), who was at risk for urinary tract infection (UTI- an infection in the bladder/urinary tract) received the care and services to prevent UTI. This deficient practice had the potential for Resident 4 to develop a UTI. Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 1/22/2021 and readmitted the resident on 12/26/2023 with diagnoses including neuromuscular dysfunction of bladder (a condition that occurs when the nerves and muscles that control the bladder do not work together properly.), type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and heart failure. During a review of Resident 4's care plan, created on 11/13/2023, for indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) size 16 with 10 millimeters (ml - unit of measurement), the care plan indicated interventions including to observe for signs of urinary retention such as bladder distension or complaints of lower abdominal pain and notify physician of signs and symptoms of UTI. During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 11/2/2024, the MDS indicated Resident 4 rarely understood and rarely was able to understand. During a review of Resident 4's Order Summary Report, dated 12/27/2023, the report indicated the following: - Change indwelling catheter drainage bag every week and as needed (PRN) if damaged, leaking or blockage/obstruction noted, or any further complications. - Change indwelling catheter every month and PRN for dislodgement or non-patency for further complications. During a review of Resident 4's Order Summary Report, dated 12/10/2024, the report indicated indwelling catheter size 14 with 10 ml and diagnosis of neuromuscular dysfunction of bladder. During an observation on 1/28/2025 at 10 a.m. with Resident 4, observed Resident 4's indwelling catheter bag with a date of 1/19. During a concurrent observation and interview on 1/28/2025 at 10:15 a.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 4's indwelling catheter bag is labeled with a date of 1/19, and bag had 900 ml of yellow urine. During an interview on 1/28/2025 at 2:33 p.m., Licensed Vocational Nurse 1 (LVN 1) stated indwelling catheter bags are changed every Sunday and LVN 1 will date the indwelling catheter bags. LVN 1 stated he worked on 1/26/2025 and was the one assigned to change the indwelling catheter bag for Resident 4 and all residents on station 3. LVN 1 stated if drain bag was dated 1/19 then the indwelling catheter bag was changed on 1/19/2025. LVN 1 stated indwelling catheter bags must be changed weekly. LVN 1 stated Resident 4's indwelling catheter bag should have been changed on 1/26/2025. LVN 1 stated that if not changed, this can be a risk for Resident 4 to develop an infection. During an interview on 1/28/2025 at 4:32 p.m., the Director of Nursing (DON) stated not sure how often indwelling catheter bags need to be changed but would assume it would be weekly. The DON stated indwelling catheter bags need to be changed weekly because it can be an issue for infection control if bacteria develop in the bag and ascends to the urethra. The DON stated if Resident 4's order indicates it needs to be changed weekly then it must be changed weekly. During a review of the facility's Policy and Procedures (P&P) titled, Catheter Care, Urinary, last reviewed on 4/18/2024, the P&P indicated the purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. 2. Change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. 3. Residents who form encrustations that can quickly lead to an obstruction need more frequent catheter changes at intervals specific to the individual resident.

CONCERN (D) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices for one of three sampled residents (Resident 4) when on 1/26/2025 Licensed Vocational Nurse 1 (LVN 1) inaccurately documented on the Treatment Administration Record (TAR- a report detailing the treatment administered to a patient by a healthcare professional across all types of healthcare facilities) that Resident 4's indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) drainage bag was changed. This deficient practice had the potential for Resident 4 to develop a urinary tract infection (UTI- an infection in the bladder/urinary tract). Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility admitted Resident 4 on 1/22/2021 and readmitted the resident on 12/26/2023 with diagnoses including neuromuscular dysfunction of bladder (a condition that occurs when the nerves and muscles that control the bladder do not work together properly.), type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and heart failure. During a review of Resident 4's care plan, created on 11/13/2023, for indwelling catheter (a hollow tube inserted into the bladder to drain or collect urine) size 16 with 10 millimeters (ml- unit of measurement), the care plan indicated interventions including to observe for signs of urinary retention such as bladder distension or complaints of lower abdominal pain and notify physician of signs and symptoms of UTI. During a review of Resident 4's Minimum Data Set (MDS – a resident assessment tool), dated 11/2/2024, the MDS indicated Resident 4 rarely understood and rarely was able to understand. During a review of Resident 4's Order Summary Report, dated 12/27/2023, the report indicated: - Change indwelling catheter drainage bag every week and as needed (PRN) if damaged, leaking or blockage/obstruction noted, or any further complications. - Change indwelling catheter every month and PRN for dislodgement or non-patency for further complications. During a review of Resident 4's Order Summary Report, dated 12/10/2024, the report indicated indwelling catheter size 14 with 10 ml and diagnosis of neuromuscular dysfunction of bladder. During an observation on 1/28/2025 at 10 a.m. with Resident 4 observed Resident 4's urinary bag with a date of 1/19. During a review of Resident 4's TAR for January 2024, the TAR indicated on 1/26/2025 that Resident 4's indwelling catheter bag was changed. During an observation on 1/28/2025 at 10 a.m. with Resident 4 observed Resident 4's indwelling catheter bag with a date of 1/19. During a concurrent observation and interview on 1/28/2025 at 10:15 a.m., Certified Nursing Assistant 1 (CNA 1) stated Resident 4's indwelling catheter bag is labeled with a date of 1/19, and bag had 900 ml of yellow urine. During an interview on 1/28/2025 at 2:33 p.m., Licensed Vocational Nurse 1 (LVN 1) stated urinary drain bags are changed every Sunday and LVN 1 will date the bags. LVN 1 stated he worked on 1/26/2025 and was the one assigned to change the urinary drain bag for Resident 4 and all residents on station 3. LVN 1 stated if drain bag is dated 1/19 then the drain bag was changed on 1/19/2025. LVN 1 stated drain bags must be changed weekly, should have been changed on 1/26/2025, can be a risk for Resident 4 to develop an infection. LVN 1 stated documenting that it was done 1/26/2025 when it was not done is inaccurate documentation and can also be a risk for infection because it would look like the indwelling bag was changed and staff would not know it has not been changed. The bag will not be changed and can cause an infection. During an interview on 1/28/2025 at 4:32 p.m., the Director of Nursing (DON) stated not sure how often urinary bags need to be changed but would assume it would be weekly. The DON stated urinary drain bags need to be changed weekly because it can be an issue for infection control if bacteria develop in the bag and ascends to the urethra. The DON stated if Resident 4's order indicates it needs to be changed weekly then it must be changed weekly. The DON stated for LVN 1 documenting that he had done the indwelling catheter bag change is inaccurate documentation. The DON stated if it is indicated that it was done but it was not done, it will not be changed and it is a risk for infection. During a review of the facility's Policy and Procedures (P&P) titled, Catheter Care, Urinary, last reviewed on 4/18/2024, the P&P indicated the purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. 2. Change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. 3. Residents who form encrustations that can quickly lead to an obstruction need more frequent catheter changes at intervals specific to the individual resident. During a review of the facility's Policy and Procedures (P&P) titled, Charting and Documentation, last reviewed on 4/18/2024, the P&P indicated documentation in the medical record will be objective, complete, and accurate.

Jan 2025 3 deficiencies

CONCERN (E) 📢 Someone Reported This

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

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

Staffing Information (Tag F0732)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to follow their policy and procedure of meeting the staff posting requirements. This deficient practice had the potential to keep residents and visitors unaware of the total number of staff and the actual hours worked by staff in the facility. Findings: During an observation and concurrent interview on 1/22/2025 at 11:55 a.m. with the Director of Nursing (DON), observed the projected Direct Care Service Hours Per Patient Day (DHPPD refers to the actual hours of work performed per patient day by a direct caregiver), dated 1/21/2025 and the actual DHPPD, dated 1/16/2025, were posted at the facility lobby. The DON stated the posted projected and actual DHPPD were not current. The DON stated the DHPPD were posted on all nurse stations. Observed the projected DHPPD, dated 1/21/2025, was posted at nurse station 1. There was no posted actual DHPPD at nurse station 1. During an observation and concurrent interview on 1/22/2025 at 11:57 a.m. with the Director of Nursing (DON), observed the projected DHPPD, dated 1/21/2025, was posted at nurse station 2. There was no posted actual DHPPD at nurse station 2. The DON stated the DHPPD should have been posted at the nurse station at the start of the shift. During an observation and concurrent interview on 1/22/2025 at 11:58 a.m. with the Director of Nursing (DON), observed the projected DHPPD, dated 1/21/2025, was posted at nurse station 3. There was no posted actual DHPPD at nurse station 3. The DON stated the DHPPD should have been posted at the nurse station at the start of the shift. During an observation and concurrent interview on 1/22/2025 at 11:59 a.m. with the Director of Nursing (DON), observed the projected DHPPD, dated 1/21/2025, was posted at nurse station 4. There was no posted actual DHPPD at nurse station 4. The DON stated the DHPPD should have been posted at the nurse station at the start of the shift. During an observation and concurrent interview on 1/22/2025 at 12 p.m. with the Director of Nursing (DON), The DON stated there was no posted projected and actual DHPPD at nurse station 5. The projected DHPPD, dated 1/22/2025 was found in the station 5 assignment folder. The DON stated the DHPPD should have been posted at the nurse station at the start of the shift. During an observation on 1/22/2025 at 12:03 p.m., observed the projected DHPPD, dated 1/22/2025, for station 3 and station 4 were in the stations' assignment folder. During an interview on 1/22/2025 at 12:05 p.m. with the DON, the DON stated the payroll staff, charge nurse, or the Director of Staff Development (DSD) should post the DHPPD every morning. The DON stated the DHPPD were posted to inform the residents and visitors that the facility was adequately staffed to provide resident care and services. During a record review of the facility's policy and procedure (PnP) titled, Posting Direct Care Daily Staffing Numbers, last reviewed on 4/18/2024, the PnP indicated within two hours of the beginning of each shift, the number of licensed nurses and the number of unlicensed nursing personnel directly responsible for resident care will be posted in a prominent location, accessible to residents and visitors, and in a clear and readable format.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of six sampled residents (Resident 1 and Resident 3) were free from significant medication errors by failing to ensure the physician orders were followed. The facility failed to: 1. Ensure Resident 3's brimonidine tartrate ophthalmic solution 0.2 percent (a medication used to lower pressure inside the eyes of people with glaucoma) and netarsudil dimesylate ophthalmic solution 0.02 percent (a medication used to treat glaucoma) were administered at the scheduled time on multiple dates. 2. Ensure Resident 1's gabapentin (a medication used to treat nerve pain and seizures) 600 milligrams (mg - unit of measurement) was administered at the scheduled time on multiple dates. These deficient practices placed Resident 3 at risk for inadequate glaucoma management which can cause vision loss. These deficient practices placed Resident 1 at risk for experiencing unnecessary pain. Findings: During a record review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 4/28/2024 with diagnoses including hemiplegia (inability to move one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting the left non-dominant side, type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and unspecified glaucoma (a condition in which increased pressure in the eye may lead to gradual loss of vision). During a record review of Resident 3's Physician Order, dated 4/30/2024, the Physician Order indicated the resident had an order for brimonidine tartrate ophthalmic solution 0.2 percent one drop in both eyes, three times a day for glaucoma. During a record review of Resident 3's Physician Order, dated 7/22/2024, the Physician Order indicated the resident had an order for netarsudil dimesylate ophthalmic solution 0.02 percent one drop in both eyes, one time a day for glaucoma. During a record review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 11/4/2024, the MDS indicated Resident 3's cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills for daily decision making were intact. During a record review of the Resident 3's Administration History on netarsudil dimesylate ophthalmic solution 0.02 percent, dated 1/1/2025 to 1/22/2025, the Administration History indicated the resident was scheduled to receive the medication at 9 a.m. every day. The Administration History indicated Resident 3 received the scheduled netarsudil dimesylate ophthalmic solution 0.02 percent late on the following dates and times: a. On 1/3/2025 at 1:14 p.m., three hours and 14 minutes after the allowed administration time. b. On 1/14/2025 at 11:33 a.m., one hour and 33 minutes after the allowed administration time. c. On 1/18/2025 at 11:11 a.m., one hour and 11 minutes after the allowed administration time. d. On 1/19/2025 at 11:09 a.m., one hour and nine minutes after the allowed administration time. e. On 1/20/2025 at 10:49 a.m., 49 minutes after the allowed administration time. During a record review of Resident 3's Progress Notes, dated 1/14/2025, the Progress Notes indicated that on 1/14/2025 at 4:15 p.m., Resident 3 informed Licensed Vocational Nurse 5 (LVN 5) that the resident's medication was not given on time. The Progress Notes indicated LVN 5 reassured Resident 3 that all medications were given on time. During a record review of Resident 3's Progress Notes, dated 1/15/2025, the Progress Notes indicated that on 1/15/2025 at 10:44 a.m., an interdisciplinary team (IDT, a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological and spiritual needs of the patient) meeting was held. The Progress Notes indicated Resident 3 was observed with behavior of confabulation (unintentional making up false memories) related to the resident's statement of not receiving the medication. The Intervention section indicated the licensed nurses checked Resident 3's administration record that indicated the medications were signed. During an interview on 1/22/2025 at 1:07 p.m. and concurrent record review of Resident 3's Administration History on brimonidine tartrate ophthalmic solution 0.2 percent, dated 1/1/2025 to 1/21/2025, reviewed with LVN 1, the Administration History indicated the resident was scheduled to receive the medication at 9 a.m., 2 p.m., and 9 p.m. everyday. The Administration History indicated Resident 3 received the scheduled brimonidine tartrate ophthalmic solution 0.2 percent late on the following dates and times: a. On 1/14/2025 at 10:42 a.m., 42 minutes after the allowed administration time. b. On 1/15/2025 at 10:53 p.m., 53 minutes after the allowed administration time. c. On 1/19/2025 at 11:10 a.m., one hour and ten minutes after the allowed administration time. d. On 1/20/2025 at 10:47 a.m., 47 minutes after the allowed administration time. Resident 3's 9 a.m. and 2 p.m. scheduled brimonidine tartrate ophthalmic solution 0.2 percent were both given at 1:14 p.m. on 1/3/2025. On 1/8/2025, Resident 3's brimonidine tartrate ophthalmic solution 0.2 percent was scheduled for 9 a.m. and 2 p.m. but were given at 12:53 p.m. and 12:54 p.m., one minute apart. On 1/14/2025, there was no documented evidence that Resident 3 received the scheduled 2 p.m. brimonidine tartrate ophthalmic solution 0.2 percent. Resident 3's 9 a.m. and 2 p.m. scheduled brimonidine tartrate ophthalmic solution 0.2 percent were both given at 3:06 p.m. on 1/18/2025. LVN 1 stated Resident 3's medications not given on time had the potential to cause the resident's glaucoma to worsen. During an interview on 1/22/2025 at 4:44 p.m. with the Director of Nursing (DON), the DON stated medications given timely were important to maintain or improve a resident's health status. The DON stated Resident 3's medications should be given according to the physician's order. The DON stated Resident 3's medications that were not given timely had the potential to cause the resident harm. The DON stated the facility failed to follow the physician orders as indicated in the policy and procedure (PnP). During a record review of the facility's PnP titled, Administering Medications, last reviewed on 4/18/2024, the PnP indicated medications were administered in a safe and timely manner and as prescribed. The PnP indicated medications are administered in accordance with prescriber orders, including any required time frame. The PnP indicated medication administration times were determined by resident need and benefit, not staff convenience, and factors that were considered included enhancing optimal therapeutic effect of the medication. The PnP indicated medications were administered within one hour of their prescribed time unless otherwise specified. The PnP indicated the individual administering the medication records in the resident's medical record the date and time the medication was administered. During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 11/11/2024 with diagnoses including Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), spinal stenosis (a condition where the space around the spinal cord in the lower back narrows, causing pressure on the nerves and resulting in pain, numbness, or weakness in the legs), and major depressive disorder (mental health condition that causes a persistently low or sad mood and a loss of interest in activities that once brought joy). During a record review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1's cognitive skills for daily decision making were intact. During a record review of Resident 1's Physician Order, dated 11/11/2024, the Physician Order indicated the resident had an order for gabapentin 600 mg three times a day for neuropathy (a nerve problem that causes pain, numbness, swelling, or muscle weakness in different parts of the body). During an interview on 1/22/2025 at 1:07 p.m. and concurrent record review of Resident 1's Administration History on gabapentin 600 mg, dated 1/1/2025 to 1/22/2025, reviewed with LVN 1, the Administration History indicated the resident was scheduled to receive the medication at 9 a.m., 1 p.m., and 5 p.m. everyday. The Administration History indicated Resident 1 received the scheduled gabapentin 600 mg late on the following dates and times: a. On 1/13/2025 at 2:27 p.m., 27 minutes after the allowed administration time. b. On 1/14/2025 at 10:23 a.m., 23 minutes after the allowed administration time. c. On 1/19/2025 at 2:06 p.m., 6 minutes after the allowed administration time. d. On 1/20/2025 at 10:40 a.m., 40 minutes after the allowed administration time. e. On 1/20/2025 at 2:23 p.m., 23 minutes after the allowed administration time. On 1/8/2025, Resident 1's gabapentin 600 mg was scheduled for 9 a.m. and 1 p.m. but were given at 2:03 p.m. and 2:04 p.m., one minute apart. LVN 1 stated Resident 1 had the potential to experience pain and discomfort due to the resident's medications not given timely. During an interview on 1/22/2025 at 4:44 p.m. with the Director of Nursing (DON), the DON stated medications given timely were important to maintain or improve a resident's health status. The DON stated Resident 1's medications should be given according to the physician's order. The DON stated Resident1's medications that were not given timely had the potential to cause the resident pain. The DON stated the facility failed to follow the physician orders as indicated in the policy and procedure (PnP). During a record review of the facility's PnP titled, Administering Medications, last reviewed on 4/18/2024, the PnP indicated medications were administered in a safe and timely manner and as prescribed. The PnP indicated medications are administered in accordance with prescriber orders, including any required time frame. The PnP indicated medication administration times were determined by resident need and benefit, not staff convenience, and factors that were considered included enhancing optimal therapeutic effect of the medication. The PnP indicated medications were administered within one hour of their prescribed time unless otherwise specified. The PnP indicated the individual administering the medication records in the resident's medical record the date and time the medication was administered.

CONCERN (E) 📢 Someone Reported This

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

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

Safe Environment (Tag F0921)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to provide safe and comfortable environment for residents, staff, and visitors, as indicated in the facility's policies and procedures by failing to maintain required water temperature range of 105 degrees Fahrenheit (°F - unit of measurement) to 120°F in six of six resident shower rooms (station 1 shower 1B room, station 2 shower 2A and 2B rooms, station 3 shower 4A room, station 4 shower 4 room, and station 5 shower 5 room) and five of five nurse station hand sinks (station 1, station 2, station 3, station 4, and station 5). These deficient practices had the potential for residents, staff, and visitors to be exposed to uncomfortable and unsafe water temperatures. Findings: During a concurrent observation and interview on 1/22/2025 at 9:47 a.m. with Licensed Vocational Nurse 1 (LVN 1), LVN 1 ran water in nurse station 1 hand sink for three minutes. A temperature probe was used to take the water temperature and LVN 1 stated the water temperature measured at 71.6°F. During a concurrent observation and interview on 1/22/2025 at 9:50 a.m. with Certified Nursing Assistant 1 (CNA 1) ran water in shower 1B for two minutes. A temperature probe was used to take the water temperature and CNA 1 stated the water temperature measured at 90.3°F. During a concurrent observation and interview on 1/22/2025 at 9:52 a.m. with CNA 1 ran water in nurse station 2 hand sink for two minutes. A temperature probe was used to take the water temperature and CNA 1 stated the water temperature measured at 70.7°F. During a concurrent observation and interview on 1/22/2025 at 9:55 a.m. with CNA 1 ran water in shower 2A for two minutes and ten seconds. A temperature probe was used to take the water temperature and CNA 1 stated the water temperature measured at 85.6°F. During a concurrent observation and interview on 1/22/2025 at 9:59 a.m. with CNA 1 ran water in shower 2B for two minutes. A temperature probe was used to take the water temperature and CNA 1 stated the water temperature measured at 86.2°F. During a concurrent observation and interview on 1/22/2025 at 10:25 a.m. with the Maintenance Supervisor (MS), the MS ran the water in shower 5 for two minutes. A temperature probe was used to take the water temperature and MS stated the water temperature measured at 93°F. During a concurrent observation and interview on 1/22/2025 at 10:29 a.m. with the MS, the MS ran the water in nurse station 3 hand sink for two minutes and eight seconds. A temperature probe was used to take the water temperature and MS stated the water temperature measured at 81.3°F. During an interview on 1/22/2025 at 11:07 a.m. with the MS, the MS stated the water temperature taken on all five stations did not meet the temperature of 105°F to 120°F per regulation. The MS stated residents had the potential to refuse showers due to the low water temperature which may lead to residents not feeling clean and comfortable. The MS stated the facility failed to ensure the facility's water temperatures were within normal range. During an interview on 1/22/2025 at 11:28 a.m. with Resident 3, Resident 3 stated there was no hot water in the resident's restroom sink. Resident 3 stated it was uncomfortable to use cold water for washing the resident's face and brush the resident's teeth. During an interview on 1/22/2025 at 11:42 a.m. with Resident 4, Resident 4 stated there was no hot water in the resident's restroom sink. Resident 4 stated it was uncomfortable and inconvenient to wash up with cold water. During an interview on 1/22/2025 at 12:23 p.m. with Resident 1, Resident 1 stated there was no hot water in the shower rooms. Resident 1 stated lukewarm water was used for the resident's shower. Resident 1 stated it was uncomfortable to shower with lukewarm water and sometimes the resident preferred not to shower at all. During a concurrent observation and interview on 1/22/2025 with the MS, MS was observed checking the water temperature in the nurse station hand sinks and shower rooms using a probe thermometer and the following readings were observed: a. At 3:51 p.m., the water temperature at nurse station 2 hand sink was 103.3°F. b. At 3:53 p.m., the water temperature at shower 2A was 102.8°F. c. At 3:56 p.m., the water temperature at shower 2B was 101°F. d. At 3:59 p.m., the water temperature at nurse station 3 hand sink was 95.2°F. e. At 4:05 p.m., the water temperature at shower 4A was 82°F. f. At 4:08 p.m., the water temperature at nurse station 4 hand sink was 97.5°F. g. At 4:10 p.m., the water temperature at shower 4 was 68.5°F. h. At 4:12 p.m., the water temperature at nurse station 5 hand sink was 95.4°F. i. At 4:15 p.m., the water temperature at shower 5 was 86.4°F. During an interview on 1/22/2025 at 4:44 p.m. with the Director of Nursing (DON), the DON stated residents exposed to cold water temperature had the potential for hypothermia (a medical emergency that occurs when the body's temperature drops too low). The DON stated the facility failed to provide a homelike environment for the residents. The DON stated the facility failed to maintain the facility's water temperature according to the policy and procedure necessary for resident care. During a follow up interview on 1/22/2025 at 5:10 p.m. and concurrent record review of the facility's Maintenance and Plant Operations, dated 12/28/2023, reviewed with the MS, indicated the purpose of maintenance of a safe and sanitary environment, ensures safety, affords protection, and enhances the well-being of the residents, public, and staff. The Water Supply, Plumbing, and Water Heating System section indicated the hot water temperature be maintained at not less than 105°F and not more than 120°F for all hot water used by residents. The MS stated there was no preventive maintenance monitoring done for the newly installed water heaters. The MS stated a third-party company will be called if a problem arises. During a record review of the facility's policy and procedures (PnP) titled, Safety of Water Temperatures, last reviewed on 4/18/2024, the PnP indicated maintenance staff were responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. During a record review of the facility's PnP titled, Homelike Environment, last reviewed on 4/18/2024, the PnP indicated staff provides person-centered care that emphasizes the resident's comfort, independence, and personal preferences.

Jan 2025 26 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

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Based on observation, interview, and record review, the facility failed to ensure medication self-administration was clinically appropriate and failed to honor the resident's right to self-administer medications for one of three sampled residents (Resident 179) reviewed under the General-Skin Conditions care area by failing to perform a medication self-administration assessment when staff had knowledge that the resident kept topical medication at the bed side for self-administration. This deficient practice violated the residents' right to self-administer medications and had the potential for the resident to experience adverse effects (an undesired effect of a drug or other type of treatment) of the medication. Cross-reference F689 Findings: During a review of Resident 179's admission Record, the admission Record indicated the facility admitted the resident on 8/28/2023 with diagnoses that included diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN-high blood pressure), and acquired absence of left toes. During a review of Resident 179's Minimum Data Set (MDS - resident assessment tool) dated 12/4/2024, the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident required partial/moderate assistance from staff for bathing and dressing, required supervision for toileting and personal hygiene, and required setup or clean up assistance for eating and oral hygiene. During a review of Resident 179's History and Physical (H&P), dated 12/3/2024, the H&P indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 179's Skin Rash Weekly Monitoring tool, dated 12/6/2024, the Skin Rash Weekly tool indicated the resident had a rash throughout the body. During a concurrent observation and interview, on 1/14/2025, at 9:34 a.m., inside Resident 179's room, Resident 179 sat in bed and the top of resident's bedside rolling table contained seven clear plastic medication cups containing ointment. Resident 179 stated the medications were left by the nurse for him to apply because he has a rash throughout his body. Resident 179's bilateral lower extremities, torso, and bilateral upper extremities had raised red pustules (small blisters or pimples on the skin containing pus) in various stages of healing. Resident 179 stated the nurse sometimes leaves the ointments for him to apply himself. During an interview, on 1/16/2025, at 11:28 a.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated Resident 179 had a body rash and the treatment nurses provide care for it. During an interview, on 1/16/2025, at 11:52 a.m., with the Wound Coordinator (WC), the WC stated Resident 179 has been seen by the dermatologist (a doctor who specializes in diagnosing and treating skin conditions) and has been previously treated for a rash that comes and goes and now the rash has returned. During an interview, on 1/16/2025, at 12:06 a.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated she worked on 1/14/2025 and cared for Resident 179. CNA 2 stated she did not see any medication cups with ointment left at the resident's bedside. CNA 2 stated maybe the resident hid the cups from her. CNA 2 stated Resident 179 had tubes of ointment sent by his family that he currently kept in his room in his nightstand. CNA 2 stated she did not know if the medication observed by the surveyor in the seven medication cups was left by the nurse or if it was the resident's own ointments. During a concurrent observation and interview, on 1/16/2025, at 1:44 p.m., with Treatment Nurse (TN) 1, TN 1 stated Resident 179 had a body rash and she and the evening nurses provide topical treatments for the resident. TN 1 stated the process for providing topical medication treatments is to take the medication to the resident and apply the medication. TN 1 stated Resident 179 was not care planned for medication self-administration, so she does not leave his medications for him to self-apply. TN 1 stated she did not know if the seven medications cups observed by the surveyor was medication left by nursing staff or if it was the resident's own medication that he placed in the cups. TN 1 stated Resident 179 had various tubes of ointments and creams in his room provided by his family. TN 1 entered Resident 179's room and stated there was a tube of hydrocortisone cream (medication used to treat skin conditions that cause swelling, redness, itching, and rashes) on Resident 179's bedside table. Resident 179 applied hydrocortisone cream to his left arm in the presence of TN 1. TN 1 exited Resident 179's room. TN 1 did not remove Resident 179's tube of hydrocortisone cream from the resident's room. During a concurrent observation and interview, on 1/16/2025, at 3:14 p.m., with Resident 179, the resident stated he had three tubes of creams that he applies himself that were provided by his family. Observed two tubes of hydrocortisone cream and a tube labeled Barmicil Compuesto (medication used to treat skin conditions that involve inflammation, infection, and itching). Resident 179 stated the facility staff knows that he applies the creams by himself and that he stores them in his room. During a concurrent interview and record review, on 1/16/2025, at 3:32 p.m., with the WC, the WC reviewed Resident 179's care plans, physician orders, and assessments. The WC stated it was a resident's right to self-administer medications but there was a process to follow and the physician must be aware of all medications the resident is using. The WC stated Resident 79 did not have a physician's order for hydrocortisone cream or Barmicil Compuesto and the resident should not be applying those medications. The WC stated Resident 179 was not assessed for the safe self-administration of any kind of medication whether it was provided by the staff or the resident's family. The WC stated if TN 1 and CNA 2 knew Resident 179 wanted to self-administer topical medications, staff should have notified the licensed nurse to ensure the physician was aware and agreed with the treatment and a self-administration assessment was completed. The WC stated if it was determined that the resident was safe for self-administration, then the resident should be supervised during administration of the topical medications, the administration should be documented in the Medication Administration Record, and medications should be kept in a locked and safe environment. The WC stated this process was not followed when CNA 2 and TN 1 allowed Resident 179 to self-administer topical medications unsupervised and to store medications at bedside. The WC stated if the resident was self-administering these medications, it may be a contributing factor as to why the resident's rash does not completely heal because the resident may be allergic to the ointments and creams he is self-administering. During a concurrent interview and record review, on 1/17/2025, at 12:10 p.m., with the Director of Nursing (DON), the DON reviewed the facility's policy and procedures regarding self-administration of medication. The DON stated medications should never be left at a resident's bedside, even if they are care planned for safe self-administration. The DON stated he was just made aware that Resident 179 was self-administering medications with staff knowledge. The DON stated Resident 179 was interviewed and the resident stated the medications were sent by his family member from another country. The DON stated CNA 2 and TN 1 should have notified the DON of the resident's desire to self-administer medication, but they did not. The DON stated the licensed nurses and physician need to be aware of all the medications a resident is taking, document the administration in the MAR, and keep the medication locked up so it isn't available to other residents. The DON stated the facility policy and procedure was not followed when CNA 2 and TN 1 allowed Resident 179 to self-administer medications and store the medication at the bedside. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, last reviewed 4/18/2024, the P&P indicated federal and state laws guarantee certain basic rights to all residents of the facility. The rights include the resident's right to self-administer medications, if the interdisciplinary care planning team determines it is safe. During a review of the facility's P&P titled, Self-Administration of Medications, last reviewed 4/18/2024, the P&P indicated residents have the right to self-administer medications if the interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of their residents) has determined that it is clinically appropriate and safe for the resident to do so. As part of the evaluation comprehensive assessment the IDT assess each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. The IDT considers the following factors when determining whether self-administration of medications is safe and appropriate for the resident: a. The medication is appropriate for self-administration. b. The resident is able to read and understand medication labels; c. The resident can follow directions and tell time to know when to take the medication. d. The resident comprehends the medication's purpose, proper dosage, timing, signs of side effects and when to report these to the staff; e. The resident has the physical capacity to open medication bottles, remove medications from a container and to ingest and swallow (or otherwise administer) the medication; and f. The resident is able to safely and securely store the medication. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is reassessed periodically based on changes in the resident's medical and/or decision-making status. If the team determines that a resident cannot safely self-administer medications, the nursing staff administer the resident's medications. The IDT evaluates options which allow residents to safely participate in the medication administration process if they wish to do so. Residents who are identified as being able to self-administer medications are asked whether they wish to do so. For self-administering residents, the nursing staff determines who is responsible (the resident or the nursing staff) for documenting that medications are taken. Self-administered medications are stored in a safe and secure place which is not accessible by other residents. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party.

CONCERN (D)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to provide a comfortable and homelike environment to one of two sampled residents (Resident 109) investigated under physical environment by failing to ensure the hot water temperature in the bathroom sink was within acceptable levels per the facility's policy and procedure. This deficient practice violated the resident's rights to a safe, clean, sanitary, and homelike environment. Findings: During a review of Resident 109's admission Record, the admission Record indicated the facility admitted the resident on 7/17/2024, with diagnoses including muscle weakness, depression (a mental health condition that involves persistent feelings of sadness, loss of interest, and difficulty with daily life), and history of falling. During a review of Resident 109's Minimum Data Set (MDS - a resident assessment tool), dated 10/23/2024, the MDS indicated the Resident 109 had the ability to make self-understood and understand others and had mild cognitive impairment (a condition that causes memory or thinking difficulties that are more severe than what's expected for a person's age). The MDS indicated Resident 109 required substantial to maximal assistance on showering and bathing. During a review of Resident 109's Care Plan (CP) titled Resident requires 24-hour care and will remain in facility long term under custodial care, initiated on 8/25/2024, the CP indicated an intervention to help create a home like environment. During a concurrent observation and interview, on 1/14/2025, at 8:41 a.m., with Resident 109, inside the resident's room, Resident 109 stated the water in their bathroom sink was cold and it takes time to warm up. The hot water faucet in the sink ran for five minutes and turned lukewarm. During a concurrent observation and interview, on 1/17/2025, at 8:55 a.m., with Maintenance Staff 1 (MS 1), inside Resident 109's room, MS 1 ran the hot water at the sink faucet for 5 minutes and measured the temperature of the water with a thermometer. MS 1 stated the temperature of the water was 85 to 86 degrees Fahrenheit (F, a temperature scale where water freezes at 32 degrees and boils at 212 degrees). MS 1 stated the hot water should be in between 105 to 120 degrees F to promote a comfortable temperature of water for residents to wash their face and body with. During an interview, on 1/17/2025, at 3:38 p.m., with the Director of Nursing (DON), the DON stated the hot water in the sink faucet should be within 105 to 120 degrees F to promote comfort when residents are washing their faces or having a bath. During a review of the facility's recent policy and procedure (P&P) titled, Water Temperatures, Safety of, last reviewed on 4/18/2024, the P&P indicated tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 105 degrees to 120 degrees F (45.9 degrees C), or maximum allowable temperature per state regulation.

CONCERN (D)

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

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to provide treatment and services to maintain or improve a resident's ability to carry out activities of daily living (ADL - activities such as bathing, dressing, grooming, oral care, mobility, elimination, dining, and communication) for one of one sampled resident (Resident 115) when Resident 115 was not provided nail trimming and cleaning to his fingernails. This deficient practice had the potential in Resident 115 having dirty fingernails, which could lead to scratching himself and cause skin tears or bleeding. Findings: During a review of Resident 115's admission Record, the admission Record indicated the facility originally admitted the resident on 2/1/2022 and readmitted the resident on 1/4/2025 with diagnoses including coronavirus disease (COVID-19 - a highly contagious respiratory illness capable of producing severe symptoms), chronic pulmonary edema (a long-term condition that occurs when fluid builds up in the lungs), and other cirrhosis of the liver (chronic disease that occurs when healthy liver tissue is replaced by scar tissue). During a review of Resident 115's Minimum Data Set (MDS-a resident assessment tool) dated 1/10/2025, the MDS indicated the resident was able to make self understood and was able to understand others. The MDS indicated the resident required assistance with ADLs including toileting hygiene, putting on/taking off footwear, and upper and lower body dressing. During a review of Resident 115's care plan addresing resident's assistance with ADLs, revised 11/11/2023, the care plan indicated the resident required one person extensive assistance with bathing/showers and personal hygiene. During an observation on 1/15/2025 at 8:58 a.m., at Resident 115's bedside, resident's fingernails were noted with black substance underneath his long fingernails. During a concurrent observation and interview on 1/17/2025 at 7:50 a.m., at Resident 115's bedside, with Certified Nursing Assistant 9 (CNA 9), CNA 9 stated she was the assigned CNA for Resident 115. CNA 9 stated Resident 115's fingernails were long and had dirt underneath his fingernails and needs trimming. CNA 9 stated any CNAs can trim the resident's nails as the task is part of the resident's morning care or as needed. CNA 9 stated if the fingernails are not trimmed, Resident 115 can accidentally scratch himself and can cause an infection. CNA 9 stated she will trim and clean the resident's nails. During an interview on 1/17/2025 at 4:11 p.m., with the Director of Nursing (DON), the DON stated the resident's fingernails are checked daily when CNAs are doing their daily care and Resident 115's nails should have been checked. The DON stated it is not acceptable that residents have long and dirty fingernails because for infection control and for the wellness of the resident. During a review of the facility's recent policy and procedure (P&P) titled Fingernails/Toenails, Care of, last reviewed on 4/18/2024, the P&P indicated the purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infections. The P&P indicated nail care includes daily cleaning and regular trimming and trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injury (the breakdown of skin integrity due to pressure) for one (1) out of two (2) sampled residents (Resident 66) investigated under pressure injury when Resident 66's low air loss mattress (LALM - a mattress that helps prevent and treat pressure wounds by circulating air and relieving pressure on the body) was not turned on and was set according to resident's Body Mass Index (BMI - a tool used to estimate the amount of body fat by using the height and weight measurements). This deficient practice had the potential for the resident's pressure injury to worsen. Findings: During a review of Resident 66's admission Record, the admission Record indicated the facility originally admitted the resident on 9/27/2024, and readmitted the resident on 12/18/2024, with diagnoses including type 2 diabetes mellitus (a chronic disease that occurs when the body does not produce enough insulin or does not use it properly) with foot ulcer, neuromuscular disorder of the bladder (lack bladder control due to a brain, spinal cord or nerve problem), and pressure ulcer (injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time) of left buttock. During a review of Resident 66's Minimum Data Set (MDS - a resident assessment tool), dated 12/24/2024, the MDS indicated the resident had severely impaired cognition (having the ability to think, learn, and remember clearly). The MDS indicated Resident 66 required substantial/maximal assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 66 had 1 Stage 2 (a partial thickness wound that exposes a layer of tissue that is moist and red or pink in color) and 1 Stage three (3) [a deep wound that affect the top 2 layers of skin as well as fatty tissue] pressure ulcers that were present on admission. During a review of Resident 66's Order Summary Report, the Order Summary Report indicated the following physician's order: - 1/3/2025: Air Pressure redistribution mattress for prevention. Monitor settings and function every shift. Set according to current BMI. BMI: 12-20 setting 1; BMI: 21-35 setting 2; BMI: 36-50 setting 3; BMI: 51-70 setting 4; BMI: 71-100 setting 5. Every day shift for wound management. During a review of Resident 66's care plan (CP) on risk for skin breakdown and/or slow wound healing due to decreased mobility, incontinence of bowel and G-tube feeding, initiated on 11/21/2024 and last revised on 1/2/2025, the CP indicated interventions including air pressure redistribution mattress for prevention, set according to current BMI, and monitor setting and functioning to help heal the ulcers without complications. During a review of Resident 66's Braden Scale for Predicting Pressure Sore Risk form (tool used to assess risk for pressure injury), dated 12/25/2024 and 1/3/2025, the Braden Scale for Predicting Pressure Sore Risk form indicated the resident was a moderate risk for developing pressure injury. During a review of Resident 66's Weights and Vitals Summary, dated 1/13/2025, the Weights and Vitals Summary indicated the resident's current height, weight, and BMI were as follows: - Weight: 212.4 pounds (lbs. - a unit of measurement) - Height: 72 inches - BMI: 28.7 During an observation, on 1/14/2025, at 9:50 a.m., inside Resident 66's room, Resident 66 appeared sunk in the bed and the LALM machine's power button indicator light was a light shade of orange. During a concurrent observation and interview, on 1/14/2025, at 9:57 a.m., inside Resident 66's room, with Treatment Nurse (TN) 1, TN 1 verified Resident 66 appeared sunk in the bed, the LALM machine was turned off and was unable to determine how long the machine had been turned off. When TN 1 pressed the On/Off button, green lights illuminated in the panel and setting was at number 3. TN 1 verified the label on the machine was pointing at number 2 setting. TN 1 stated licensed nurses, especially the treatment nurse assigned to resident, ensures proper functioning of the mattress and machine and that the setting was correct according to resident's BMI every day shift. TN 1 stated Resident 66's LALM machine should have been turned on at all times, and setting should be at number 2 as indicated in the label. TN 1 stated if the machine was turned off and the setting was not correct, it placed the resident at risk for worsening of pressure ulcer. During an interview, on 1/17/2025, at 5:15 p.m., with the Director of Nursing (DON), the DON stated the nurses should always makes sure the LALM was always turned on and setting should be correct according to resident's weight and BMI. The DON stated Resident 66's LALM should not have been turned off unless the resident was not in bed and should have been at the correct setting as indicated in the label on the machine and according to Resident 66's BMI as it placed the resident at risk for worsening of pressure ulcers. During a review of the facility's policy and procedure (P&P) titled, Beds, Special - Low Air Loss Therapy, last reviewed 4/18/2024, the P&P indicated: - Utilize low air loss therapy under the direction of the physician's order. - Always leave unit turned on when in use. - Pressure adjustments may be made by staff in accordance with resident condition and need. During a review of the facility provided manufacturer's guideline on LALM 1, undated, the manufacturer's guideline indicated the following: - Indication: LALM 1 models are intended for the prevention and treatment of pressure ulcers. Powered modes are intended for active wound treatment and may be indicated for use as a preventive tool against further complications associated with immobility. - On/Off: Plug power cord into wall outlet. On/Off indicator light will illuminate in amber, indicating that the unit is drawing current but not yet powered up. Press On/Off switch button to On. Indicator light will change to green, along with additional lights on control panel, indicating the unit is powered up. Unit will resume the settings it was in when last powered down. - Comfort Level: In powered mode, elevating the head of bed (HOB) may require adjusting comfort level to ensure appropriate support, especially if elevated beyond 30 degrees. With HOB elevated this way, caregivers may find the following BMI setting suggestions helpful in determining an ideal comfort setting: BMI: 12-20 setting 1; BMI: 21-35 setting 2; BMI: 36-50 setting 3; BMI: 51-70 setting 4; BMI: 71-100 setting 5.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. During a review of Resident 193's admission Record, the admission Record indicated the facility originally admitted the resident on 11/7/2023, and readmitted the resident in the facility on 7/28/2024, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebrovascular disease (stroke, loss of blow to a part of the brain) affecting right dominant side, type 2 diabetes mellitus (a chronic disease that occurs when the body does not produce enough insulin or does not use it properly) with foot ulcer, and generalized weakness. During a review of Resident 193's History and Physical (H&P) dated 7/28/2024, the H&P indicated Resident 193 had fluctuating capacity to understand and make decisions. During a review of Resident 193's MDS dated [DATE], the MDS indicated the resident had severely impaired cognition (having the ability to think, learn, and remember clearly). The MDS indicated Resident 193 required supervision or touching assistance with eating and oral hygiene; partial/moderate assistance with mobility, upper body dressing, and personal hygiene; total assistance with lower body dressing, tub and toilet transfers; substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 193's Order Summary Report, the Order Summary Report indicated a physician's order dated 7/28/2024: - Bedside safety mattress right and/or left side while resident in bed. Monitor for placement every shift and each opportunity that resident is observed in bed, and as needed. During a review of Resident 193's Fall Risk Assessments dated 7/28/2024, 8/15/2024, and 10/21/2024, the Fall Risk Assessments indicated Resident 193 was a high risk for falls. During a concurrent observation and interview on 1/15/2025 at 12:00 p.m. inside Resident 193's room with Licensed Vocational Nurse 15 (LVN 15), LVN verified Resident 193 did not have a bedside safety mattress on the left side of the bed. LVN 1 stated Resident 193 was a high risk for falls due to poor cognition and positioning in bed. LVN 15 stated she was not sure if Resident 193 had an order for a bedside safety mattress. LVN 15 stated staff should ensure the bedside safety mattress was always at the resident's bedside per physician's order to prevent injuries from falls and monitored for placement every shift. LVN 15 stated Resident 193's bedside safety mattress should have been at the bedside for safety and to prevent the resident from getting injured during a fall. During an interview and record review on 1/15/2025 at 12:10 p.m. with Licensed Vocational Nurse 14 (LVN 14), reviewed Resident 193's physician's order with LVN 14. LVN 14 verified Resident 193 had a physician's order for beside safety mattress dated 7/28/2024. LVN 14 stated Resident 193's bedside safety mattress should have been placed at the resident's bedside on the floor as it placed the resident at risk for incurring injury during a fall incident. During an interview on 1/17/2025 at 5:30 p.m. with the Director of Nursing (DON), the DON stated if the staff obtained an order from the physician to place a bedside safety mattress for safety during falls, the staff should place the safety mattress at the bedside on the floor and monitor placement every shift. The DON stated Resident 193's bedside safety mattress should have been placed at the bedside. The DON stated not placing the safety mattress at the bedside placed Resident 193 at risk for getting injured in the event of a fall incident. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, last reviewed 4/18/2024, the P&P indicated: - Individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. - Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff. b. Ensuring the interventions are implemented c. Documenting interventions - Monitoring the effectiveness of interventions shall include the following: a. Ensuring the interventions are implemented correctly and consistently. - Certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures which include bed safety and falls. 7. During a review of Resident 58's admission Record, the admission Record indicated the facility admitted the resident on 11/30/2019 with diagnoses including dementia (a progressive stated of decline in mental abilities), Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 58's History and Physical (H&P) dated 12/15/2024, the H&P indicated Resident 58 did not have the capacity to understand and make decisions. During a review of Resident 58's MDS dated [DATE], the MDS indicated the resident had severely impaired cognition (having the ability to think, learn, and remember clearly). The MDS indicated Resident 58 required partial/moderate assistance with eating and mobility; substantial/maximal assistance with oral hygiene and upper body dressing; total assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 58's Order Summary Report, the Order Summary Report indicated a physician's order dated 7/18/2022: - Bedside safety mat right and/or left side while resident in bed. Monitor for placement every shift and each opportunity that resident is observed in bed and as needed. During a review of Resident 58's Fall Risk Assessments dated 8/5/2024, 11/3/2024, and 11/29/2024, the fall risk assessments indicated Resident 58 was a high risk for falls. During a review of Resident 58's care plan on high risk for fall related to poor safety awareness, and behavioral problems initiated on 3/22/2023 and last revised on 11/6/2024 indicated bed safety mat right on the right and/or left while resident in bed and provide a safe environment, free of clutter, clear floors and adequate lighting as a few of the interventions to prevent falls. During a concurrent observation and interview on 1/14/2025 at 12:37 p.m., inside Resident 58's room with Wound Coordinator (WC), observed Resident 58 lying in bed asleep with the overbed table placed on top of the right floor mat. The WC stated she is not aware that the overbed table cannot be placed on top of the floor mat for a long period of time. The WC verified Resident 58's overbed table wheels left an indentation on the floor affecting the integrity of the floor mat affecting resident safety in the event a fall. During an interview on 1/17/2025 at 5:30 p.m. with the Director of Nursing (DON), the DON resident rooms should be free of clutter and the floor clear. The DON stated there should no equipment or furniture placed on top of the floor mat for a long period of time. The DON stated Resident 58's overbed table should have not been left on top of the floor mat as it can cause injury to the resident when they fall out of the bed and hit the table that was on the floor mat. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, last reviewed 4/18/2024, the P&P indicated: - Individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. - Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff. b. Ensuring the interventions are implemented c. Documenting interventions - Monitoring the effectiveness of interventions shall include the following ensuring the interventions are implemented correctly and consistently. - Certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures which include bed safety and falls. 8. During a review of Resident 19's admission Record, the admission Record indicated the facility admitted the resident on 11/27/2021 with diagnoses including Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), pain in unspecified joint, and generalized muscle weakness. During a review of Resident 19's History and Physical (H&P) dated 9/18/2024, the H&P indicated Resident 19 did not have the capacity to understand and make decisions. During a review of Resident 19's MDS dated [DATE], the MDS indicated the resident had severely impaired cognition (having the ability to think, learn, and remember clearly). The MDS indicated Resident 19 required supervision or touching assistance with eating; substantial/maximal assistance with showers, transfers, and lower body dressing; partial/moderate assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 19's Order Summary Report, the Order Summary Report indicated a physician's order dated 10/13/2024: - Bedside safety mat right and/or left side while resident in bed. Monitor for placement every shift and each opportunity that resident is observed in bed and as needed. During a review of Resident 19's Fall Risk Assessments dated 9/6/2024, 10/12/2024, and 12/5/2024, the fall risk assessments indicated Resident 19 was a high risk for falls. During a review of Resident 19's care plan (CP) indicated the following: 1. Potential for further injury/fall related to poor safety awareness, unsteady gait/balance, and weakness initiated on 11/28/2021 and last revised on 10/14/2024, the CP indicated bed safety mat right on the right and/or left while resident in bed and provide a safe environment, free of clutter, clear floors and adequate lighting as a few of the interventions to prevent falls. 2. Resident had an unwitnessed fall and is at risk for recurring falls, pain, and injury initiated on 10/14/2024, the CP indicated bed safety mat right on the right and/or left while resident in bed and monitor for placement every shift as on the interventions to prevent further falls. During an observation on 1/14/2025 at 12:37 p.m. inside Resident 19's room, observed Resident 19 lying in bed asleep, with oxygen concentrator (medical device that extracts oxygen from the surrounding air, concentrating it and delivering it to the patient) placed on top of the left floor mat and overbed table on top of the right floor mat. During a concurrent observation and interview on 1/15/2025 at 5:20 p.m. inside Resident 19's room with Licensed Vocational Nurse 9 (LVN 9), LVN 9 verified Resident 19's oxygen concentrator was placed on top of the left floor mat and the overbed table was placed on top of the right floor mat. LVN 9 stated she is not aware if there should be no equipment or furniture on top of the floor mat for long period of time. LVN 9 stated the overbed table can be unstable when moved and fall on the resident and cause injury. LVN 9 stated Resident 19 can get injured when the resident falls out of bed and hit the overbed table and oxygen concentrator. LVN 9 Resident 19's overbed table and oxygen concentrator should not have been placed on top of the floor mat for long period of time. During an interview on 1/17/2025 at 5:30 p.m. with the Director of Nursing (DON), the DON stated there should no equipment or furniture placed on top of the floor mat for a long period of time. The DON stated Resident 19's overbed table and oxygen concentrator should have not been placed on top of the floor mats as it can cause injury to the resident when they fall out of the bed and hit the table or oxygen concentrator that was on the floor mat. The DON stated a resident's environment should be clutter free and clear of any hazards. During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, last reviewed 4/18/2024, the P&P indicated: - Individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. - Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff. b. Ensuring the interventions are implemented c. Documenting interventions - Monitoring the effectiveness of interventions shall include the following ensuring the interventions are implemented correctly and consistently. - Certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures which include bed safety and falls. 9. During a review of Resident 129's admission Record, the admission Record indicated the facility originally admitted the resident on 8/3/2021 and readmitted the resident on 8/16/2021 with diagnoses including dysphagia (difficulty swallowing), unspecified intellectual disabilities (a lifelong condition that limits a person's mental functioning and skills), and difficulty in walking. During a review of Resident 129's History and Physical (H&P) dated 9/5/2024, the (H&P) indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 129's MDS dated [DATE], the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 129 required total assistance from staff with lower body dressing, partial/moderate assistance with bathing, toileting hygiene, upper body dressing, toilet transfer, and shower transfer, and substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 129's fall risk assessments dated 5/27/2024, 8/24/2024, and 11/23/2024, the fall risk assessments indicated the resident was a high risk for falls. During a review of Resident 129's care plan (CP) on potential for injury or falls due to unsteady gait or balance and poor safety awareness initiated 8/4/2021 and last revised on 8/25/2023, the CP indicated the following interventions to prevent falls: - Call light placed within reach. - Instruct use of call light whenever in need of assistance. Instruct use of safety. During a concurrent observation and interview on 1/14/2025 at 10:38 a.m. inside Resident 129's room with Licensed Vocational Nurse 12 (LVN 12), observed Resident 129's call light was coiled and hung on the wall plug with the black and white wires exposed. LVN 12 the maintenance department staff is responsible in ensuring the call lights are in proper working condition. LVN 12 stated she is not sure of how often and when the maintenance staff make their rounds to check on the rooms. LVN 12 stated Resident 129's call light should not have the black and white wires exposed as it placed the resident at risk for accidents such as electrocution due to exposed wires. During an interview on 1/17/2025 with the DON, the DON stated the maintenance department is responsible to do room rounds and check on any defective equipment in resident rooms and replace them as needed. The DON stated there should be no exposed electrical wiring at the resident's rooms. The DON stated Resident 129's call light should not have the black and white wires exposed as it can cause accidental injuries like electrocution. The DON stated it is the responsibility of all staff in the facility to report potential accidents in the facility to protect the residents. During a review of the facility's recent policy and procedure (P&P) titled Maintenance Service, last reviewed on 4/18/2024, the P&P indicated maintenance service shall be provided to all areas of the building, grounds, and equipment. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 10. During a review of Resident 179's admission Record, the admission Record indicated the facility admitted the resident on 8/28/2023 with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypertension (HTN-high blood pressure), and acquired absence of left toes. During a review of Resident 179's MDS dated [DATE], the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident required partial/moderate assistance from staff for bathing and dressing, required supervision for toileting and personal hygiene, and required setup or clean up assistance for eating and oral hygiene. During a review of Resident 179's History and Physical (H&P), dated 12/3/2024, the H&P indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 179's Skin Rash Weekly Monitoring tool, the tool indicated on 12/6/2024 the resident had a rash throughout the body. During a concurrent observation and interview on 1/14/2025 at 9:34 a.m., Resident 179 sat in bed, on the resident's bedside rolling table, observed seven clear plastic medication cups containing ointment. Resident 179 stated the medications were left by the nurse for him to apply because he has a rash throughout his body. Observe Resident 179 bilateral lower extremities, torso, and bilateral upper extremities with raised red pustules in various stages of healing. Resident 179 stated the nurse sometimes leaves the ointments for him to apply himself. During an interview on 1/16/2025 at 11:28 a.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated Resident 179 had a body rash and the treatment nurses provide care for it. During an interview on 1/16/2025 at 11:52 a.m., with the Wound Coordinator (WC), the WC stated Resident 179 has been seen by the dermatologist (a doctor who specializes in diagnosing and treating skin conditions) and has been previously treated for a rash that comes and goes and now the rash has returned. During an interview on 1/16/2025 at 12:06 a.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated she worked on 1/14/2025 and cared for Resident 179. CNA 2 stated she did not see any medication cups with ointment left at the resident's bedside. CNA 2 stated maybe the resident hid the cups from her. CNA 2 stated Resident 179 had tubes of ointment sent by his family that he currently kept in his room in his nightstand. CNA 2 stated she did not know if the medication observed by the surveyor in the seven medication cups was left by the nurse or if it was the resident's own ointments. During an observation and interview on 1/16/2025 at 1:44 p.m. with Treatment Nurse 1 (TN 1), TN 1 stated Resident 179 had a body rash and she and the evening nurses provide topical treatments for the resident. TN 1 stated the process for providing topical medication treatments is to take the medication to the resident and apply the medication. TN 1 stated Resident 179 was not care planned for medication self-administration so she does not leave his medications for him to self apply. TN 1 stated she did not know if the seven medications cups observed by the surveyor was medication left by nursing staff or if it was the resident's own medication that he placed in the cups. TN 1 stated Resident 179 had various tubes of ointments and creams in his room provided by his family. Observed TN 1 entered Resident 179's room and stated there was a tube of hydrocortisone cream on Resident 179's bedside table. ObservedO Resident 179 applied hydrocortisone cream to his left arm in the presence of TN 1. Observed TN 1 exited Resident 179's room. Observed TN 1 did not remove the tube of hydrocortisone cream. During a concurrent observation and interview on 1/16/2025 at 3:14 p.m. with Resident 179, the resident stated he had three tubes of creams that he applies himself that were provided by his family. Observed two tubes of hydrocortisone cream and tube labeled Barmicil Compuesto. Resident 179 stated the facility staff knows that he applies the creams by himself and that he stores them in his room. During a concurrent interview and record review on 1/16/2025 at 3:32 p.m. with the WC, the WC reviewed Resident 179's care plans, physician orders, and assessments. The WC stated it was a resident's right to self-administer medications but there was a process to follow and the physician must be aware of all medications the resident is using. The WC stated Resident 179 was not assessed for the safe self-administration of any kind of medication. The WC stated if TN 1 and CNA 2 knew Resident 179 wanted to self-administer topical medications, staff should have notified the licensed nurse to ensure the physician was aware and agreed with the treatment, a self-administration assessment was completed for the resident. The WC stated if it was determined that the resident was safe for self administration, then the resident should be supervised during administration of the topical medications, the administration should be documented in the Medication Administration Record, and medications should b- kept in a locked and safe environment. The WC stated this process was not followed when CNA 2 and TN 1 allowed Resident 179 to self-administer topical medications unsupervised and to store medications at bedside. The WC stated if the resident was self-administering these medications, it may be a contributing factor as to why the resident's rash does not completely heal because the resident may be allergic to the ointments and creams he is self-administering. The WC stated there was also a potential for Resident 179 to provide these medications to other residents for self-administration without staff knowledge leading to other residents having allergic reactions or overdosing on the medications. During a concurrent interview and record review with the Director of Nursing (DON) on 1/17/2025 at 12:10 p.m., the DON reviewed the facility policy and procedures regarding self-administration of medication and resident supervision. The DON stated medications should never be left at a resident's bedside, even if they are care planned for safe self-administration. The DON stated he was just made aware that Resident 179 was self-administering medications with staff knowledge. The DON stated Resident 179 was interviewed and the resident stated the medications were sent by his sister from Mexico. The DON stated CNA 2 and TN 1 should have notified the DON of the resident's desire to self -administer medication, but they did not. The DON stated the license nurses and physician need to be aware of all the medications a resident is taking, document the administration in the MAR, and keep the medication locked up so it isn't available to other residents. The DON stated the facility policy and procedure was not followed when CNA 2 and TN 1 allowed Resident 179 to self-administer medications and store them at bedside. During a review of the facility policy and procedure (P&P) titled, Resident Rights, last reviewed 4/18/2024, the P&P indicated federal and state laws guarantee certain basic rights to all residents of the facility. The rights include the resident's right to self-administer medications, if the interdisciplinary care planning team determines it is safe. During a review of the facility P&P titled, Self-Administration of Medications, last reviewed 4/18/2024, the P&P indicated residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. As part of the evaluation comprehensive assessment the IDT assess each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. The IDT considers the following factors when determining whether self-administration of medications is safe and appropriate for the resident: a. The medication is appropriate for self-administration; b. The resident is able to read and understand medication labels; c. The resident can follow directions and tell time to know when to take the medication; d. The resident comprehends the medication's purpose, proper dosage, timing, signs of side effects and when to report these to the staff; e. The resident has the physical capacity to open medication bottles, remove medications from a container and to ingest and swallow (or otherwise administer) the medication; and f. The resident is able to safely and securely store the medication. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. The decision that a resident can safely self-administer medications is reassessed periodically based on changes in the resident's medical and/or decision-making status. If the team determines that a resident cannot safely self-administer medications, the nursing staff administer the resident's medications. The IDT evaluates options which allow residents to safely participate in the medication administration process if they wish to do so. Residents who are identified as being able to self-administer medications arc asked whether they wish to do so. For self-administering residents, the nursing staff determines who is responsible(the resident or the nursing staff) for documenting that medications are taken. Sclf-administered medications are stored in a safe and secure place which is not accessible by other residents. Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. During a review of the facility P&P titled, Safety and Supervision of Residents, last reviewed 4/18/2024, the P&P indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents. 11. During a review of Resident 49's admission Record, the admission Record indicated the facility admitted the resident on 3/18/2016 and readmitted the resident on 12/3/2022 with diagnoses that included congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), dementia (a progressive state of decline in mental abilities), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), depression, psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), anxiety disorder (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear), and acquired absence of left and right legs below the knee. During a review of Resident 49's MDS dated [DATE], the MDS indicated the resident was usually able to understand others and usually was able to make himself understood. The MDS further indicated the resident required substantial/maximal assistance from staff for bathing, dressing, toileting, and personal hygiene. During a review of Resident 49's H&P, dated 2/16/2024, the H&P indicated the resident did not have the capacity make decisions. During a review of Resident 49's Order Summary Report, the order summary report indicated to apply a bed sensor alarm while in bed for fall management. Monitor for placement and functionality every shift and each opportunity that resident is observed in bed and as needed, dated 5/16/2023. During a review of Resident 49's Care Plan (CP) titled Falls: Resident had an incident of fall ., initiated on 11/14/2024, the CP indicated the resident slid from the bed trying to reach for stuff on the floor. The CP indicated an intervention to provide safety devices as ordered. During a review of Resident 49's CP titled (Resident 49) has potential for further falls ., initiated 9/26/2020 and last reviewed 1/14/2025, the CP indicated to apply the bed sensor alarm while in bed for fall management. During an observation on 1/14/2025 at 10:39 a.m., observed Resident 49 awake and lying in bed. Resident 49 did not respond to the surveyor. Observed no bed sensor alarm was present. During a concurrent interview and record review 1/14/2025 at 10:57 a.m., with Restorative Nursing Aid 1 (RNA 1), RNA 1 entered Resident 49's room and stated the resident did not have bed sensor alarm. RNA 1 exited Resident 49's room and stated the resident did not have bed sensor alarm because the resident breaks them. During an observation on 1/14/2025 at 12:57 p.m., observed Resident 49 lying in bed. Observed the resident was not provided a bed sensor alarm. During an observation on 1/16/2025 at 11 a.m., observed Resident 49 lying in bed. Observed the resident was not provided a bed sensor alarm. During an observation on 1/17/2025 at 9:50 a.m., observed Resident 49 lying in bed. Observed the resident was not provided a bed sensor alarm. During a concurrent observation, interview, and record review on 1/17/2025 at 10:10 a.m. the Wound Coordinator (WC), the WC reviewed Resident 49's physician orders. The WC entered Resident 49's room and stated the resident did not have a bed sensor alarm. The WC stated the resident had a physician's order for an alarm, but did not have one. During an interview on 1/17/2025 at 10:15 a.m. with Certified Nursing Assistant 5 (CNA 5), CNA 5 stated she was assigned to care for Resident 49 and he did not have a bed sensor alarm. CNA 5 stated she did not know if the resident needed a bed sensor alarm. CNA 5 stated Resident 49 was at risk for falls. CNA 5 stated the charge nurse is responsible for monitoring if the bed sensor alarm is in place and working. During a concurrent interview and record review on 1/17/2025 at 10:45 a.m. with Licensed Vocational Nurse 11 (LVN 11) and the WC, reviewed Resident 49's physician orders. LVN 11 stated the bed sensor alarm triggers staff to assist the resident when they are attempting to get out of the bed. LVN 11 stated Resident 49 is a high risk for falls and should have a [TRUNCATED]

CONCERN (D)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections (UTI, an infection in the bladder/urinary tract) for one of two sampled residents (Resident 481) being investigated under urinary catheters (a hollow tube inserted into the bladder to drain or collect urine) by failing to keep the urinary catheter tubing off the floor. The deficient practices had the potential for residents to develop catheter associated urinary tract infection (CAUTI, an infection of the urinary tract caused by a tube [urinary catheter] that has been placed to drain urine from the bladder [an organ inside the body that stores urine until it can be excreted]). Findings: During a review of Resident 481's admission Record, the admission Record indicated the facility admitted the resident on 7/20/2024, and readmitted the resident on 1/13/2025, with diagnoses including cellulitis (a bacterial infection that affects the skin and underlying tissue), benign prostatic hyperplasia (a non-cancerous condition that causes the prostate gland to enlarge) with lower urinary tract symptoms, and urinary tract infection. During a review of Resident 481's Minimum Data Set (MDS, a resident assessment tool), dated 7/26/2024, the MDS indicated the resident usually had the ability to make self-understood and understand others and had intact cognition (a person's mental abilities, like thinking, remembering, understanding, and reasoning, are fully functioning and not significantly impaired). The MDS indicated the resident had an indwelling urinary catheter. During a review of Resident 481's Order Summary Report, dated 7/22/2024, the Order Summary Report indicated an order of indwelling catheter size 16 French (FR)/10 cubic centimeter (cc, a commonly used unit of volume). Diagnosis (Dx): benign prostatic hyperplasia with lower urinary tract symptoms. During a concurrent observation and interview on 1/14/2025, at 12:28 p.m., with Registered Nurse 3 (RN 3), inside Resident 481's room, observed the urinary catheter of the resident hanging at the right side of the bed with the tubing touching the floor. RN 3 stated the urinary catheter tubing should not be touching the floor to prevent infection to the resident. RN 3 stated when the staff is doing their rounds on their residents, the staff should be proactively checking for infection control issues. During an interview on 1/17/2025, at 3:38 p.m., with the Director of Nursing (DON), the DON stated the staff should keep the urinary catheter tubing off the floor to prevent ascending infection to the resident such as UTI. During a review of the facility's recent policy and procedure (P&P) titled Catheter Care, Urinary, last reviewed on 4/18/2024, the P&P indicated the purpose of this procedure is to prevent catheter-associated complications, including urinary tract infections. Be sure the catheter tubing and drainage bag are kept off the floor.

CONCERN (D)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents receiving enteral feeding (EF - also known as tube feeding, a method of supplying nutrients directly into the stomach) received appropriate care and services to prevent complications of enteral feeding for one (1) of 1 sampled resident (Resident 66) investigated under the tube feeding care area when the EF bottle did not indicate in the label the resident's name, room number, administration rate, the date and time the bottle was started, and the initials of the nurse. This deficient practice had the potential to result in altered nutritional status such as dehydration and malnutrition and complications associated with enteral feeding such as gastrointestinal (GI) (relating to stomach and intestines) problems such as abdominal pain and diarrhea. Findings: During a review of Resident 66's admission Record, the admission Record indicated the facility originally admitted the resident on [DATE], and readmitted the resident on [DATE], with diagnoses including type 2 diabetes mellitus (a chronic disease that occurs when the body does not produce enough insulin or does not use it properly) with foot ulcer, neuromuscular disorder of the bladder (lack bladder control due to a brain, spinal cord or nerve problem), and pressure ulcer (injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time) of left buttock. During a review of Resident 66's Minimum Data Set (MDS, a resident assessment tool), dated [DATE], the MDS indicated the resident had severely impaired cognition (having the ability to think, learn, and remember clearly). The MDS indicated Resident 66 required substantial/maximal assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 66 had a diagnosis of gastrostomy status and received tube feeding. During a review of Resident 66's Order Summary Report, the Order Summary Report indicated the following physician's order dated [DATE]: - Every shift continuous gastrostomy tube (G-tube) feeding of Glucerna 1.2 formula at 75 milliliter per hour (ml/hr - a unit of measurement for 20 hours to provide 1500 ml per 1800 kilocalories (kcal - a unit of measurement). Pump to run from 1:00 p.m. to 9:00 a.m. or until dose limit is met. During a review of Resident 66's care plan (CP) on enteral nutrition related to swallowing problem initiated on [DATE] indicated the following interventions: - Enteral nutrition as ordered, monitor tolerance to enteral feeding. - Monitor for nausea or vomiting, abdominal distention, or discomfort with each feeding or as needed. During a concurrent observation and interview on [DATE] at 9:57 a.m. inside Resident 66's room with Licensed Vocational Nurse 12 (LVN 13), LVN 13 verified Resident 66's EF bottle did not indicate the resident's name, room number, administration rate, start date and time, and nurse initials on the label. LVN 13 stated when hanging a new EF bottle, the charge nurse is supposed to indicate in the label the resident's name, room number, administration rate, the date and time the bottle was started, and the initials of the nurse. LVN 13 stated, Resident 66's EF bottle should have indicated in the label the resident's name, room number, administration rate, the date and time the bottle was started, and the initials of the nurse for the staff to know when it was started and ensure the formula was not expired. During an interview on [DATE] at 5:30 p.m. with the Director of Nursing (DON), the DON stated the staff write in the formula bottle the resident's name, room number, administration, dated and time the formula was started, and the initials of the nurse. The DON stated charge nurse should have indicated in Resident 66's EF bottle the resident's name, room number, administration, dated and time the formula was started, and the initials of the nurse so the other nurse would be aware when the EF bottle was started and that it was not expired. The DON stated if the formula was expired it can lead to gastrointestinal complications such as intolerance of the formula, stomach pain, and diarrhea. During a review of the facility's policy and procedure (P&P) titled, Enteral Feedings - Safety Precautions, last reviewed [DATE], the P&P indicated a purpose to ensure safe administration of enteral nutrition. The P&P further indicated the following general guidelines on preventing errors in administration: - Check the enteral nutrition label against the order before administration. Check the following information: a. Resident name, ID, and room number b. Type of formula c. Date and time formula was prepared. d. Route of delivery g. Rate of administration (ml/hour). - On the formula label document initials, date and time the formula was hung, and initial that the label was checked against the order.

CONCERN (E)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. During a review of Resident 48's admission Record, the admission Record indicated the facility originally admitted the resident on 7/8/2024 and readmitted on [DATE] with diagnoses including type 2 diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcer (a small open sore or wound generally found in the stomach or on the skin), pneumonia (an infection/inflammation in the lungs), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 48's History and Physical (H&P), dated 7/10/2024, the H&P indicated the resident has the capacity to understand and make decisions. During a review of Resident 48's MDS, dated [DATE], the MDS indicated the resident was able to usually make self understood and was able to usually understand others. The MDS indicated the resident required partial/moderate assistance from staff with ADLs including toileting hygiene, personal hygiene, shower/bathe self, upper and lower body dressing, and putting on/taking off footwear. The MDS indicated the resident required assistance from staff with mobility including sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. During a review of Resident 48's Care Plan focus on at risk for falls, initiated 7/9/2024, the Care Plan indicated the resident with goals of minimizing risk for falls. The care plan indicated interventions of keeping call light within reach and to anticipate and meet the needs of the resident. During a review of Resident 48's Nursing-Fall Risk Observation/Assessment, dated 10/14/2024, the Nursing-Fall Risk Observation/Assessment indicated the resident was at moderate risk for falls. During a concurrent observation and interview, on 1/15/2025, at 8:50 a.m., at Resident 48's bedside, the call light was hanging on the right side of the resident's bed out of reach. Resident 48 stated she does not know where her call light is. Resident 48 stated she uses her call light to call for staff for assistance, but when she does no one comes. During a concurrent observation and interview, on 1/15/2025, at 8:52 a.m., at Resident 48's bedside, Certified Nursing Assistant (CNA) 1 stated the resident's call light was hanging on the right side of her bed. CNA 1 stated it should be within reach because the resident uses it to ask for assistance when they need something such to be changed or request for blankets. During an interview, on 1/17/2025, at 4:09 p.m., the DON stated call light are used for communication between resident and health team if resident has needs. The DON stated if a call light is not within reach, the ability to address the needs of the resident is affected, the resident's safety is at risk, and residents could fall if not within reach. During a review of the facility's recent P&P titled, Answering the Call Light, last reviewed on 4/18/2024, the P&P indicated the purpose of this procedure is to respond to the resident's requests and needs. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. e. During a review of Resident 129's admission Record, the admission Record indicated the facility originally admitted the resident on 8/3/2021 and readmitted the resident on 8/16/2021 with diagnoses including dysphagia (difficulty swallowing), unspecified intellectual disabilities (a lifelong condition that limits a person's mental functioning and skills), and difficulty in walking. During a review of Resident 129's H&P, dated 9/5/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 129's MDS, dated [DATE], the MDS indicated the resident had severely impaired cognition. The MDS indicated Resident 129 required total assistance from staff with lower body dressing, partial/moderate assistance with bathing, toileting hygiene, upper body dressing, toilet transfer, and shower transfer, and substantial/maximal assistance with all other ADLs. During a review of Resident 129's Fall Risk Assessments, dated 5/27/2024, 8/24/2024, and 11/23/2024, the Fall Risk Assessments indicated the resident was a high risk for falls. During a review of Resident 129's CP on potential for injury or falls due to unsteady gait or balance and poor safety awareness, initiated 8/4/2021 and last revised on 8/25/2023, the CP indicated the following interventions to prevent falls: - Call light placed within reach. - Instruct use of call light whenever in need of assistance. Instruct use of safety. During a concurrent observation and interview, on 1/14/2025, at 10:38 a.m., inside Resident 129's room, with LVN 12, Resident 129's call light coiled and hung on the wall plug outside of Resident 129's reach. LVN 12 stated staff should place all call lights within reach prior to leaving the room. LVN 12 stated the call light should have not been coiled and hung on the wall plug. LVN 12 stated the call light should have been placed within Resident 129's reach so the resident would be able to call for assistance when needed. LVN 12 stated if the call light was not within reach, Resident 129 may try to get out of bed unassisted and fall which may lead to injury. During an interview, on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the staff should always check the placement of the call light during their rounds to ensure the call lights were within reach. The DON stated the resident will not be able to ask for assistance or communicate their needs if the call light was not within reach. The DON stated Resident 129 may try to get out of bed and fall if the call light was not within reach and is unable to call for assistance. During a review of the facility's recent P&P titled, Answering the Call Light, last reviewed on 4/18/2024, the P&P indicated the purpose of this procedure is to respond to the resident's requests and needs. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. d. During a review of Resident 49's admission Record, the admission Record indicated the facility admitted the resident on 3/18/2016 and readmitted the resident on 12/3/2022 with diagnoses that included congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), dementia (a progressive state of decline in mental abilities), bipolar disorder, psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), anxiety disorder (a mental health condition that may result in restlessness, irritability, feelings of nervousness, panic, and fear), and acquired absence of left and right legs below the knee. During a review of Resident 49's MDS, dated [DATE], the MDS indicated the resident was usually able to understand others and usually was able to make himself understood. The MDS further indicated the resident required substantial/maximal assistance from staff for bathing, dressing, toileting, and personal hygiene. During a review of Resident 49's H&P, dated 2/16/2024, the H&P indicated the resident did not have the capacity to make decisions. During a review of Resident 49's CP titled, Falls: Resident had an incident of fall ., initiated on 11/14/2024, the CP indicated the resident slid from the bed trying to reach for items on the floor. The CP indicated an intervention to keep call light within reach and to provide safety devices as ordered. During a review of Resident 49's CP titled, (Resident 49) has potential for further falls ., initiated 9/26/2020 and last reviewed 1/14/2025, the CP indicated to apply the bed sensor alarm while in bed for fall management and to place the call light within reach. During an observation, on 1/14/2025, at 10:39 a.m., Resident 49 laid in bed, awake. Resident 49 did not respond to the surveyor. A metal call light plate on the wall behind Resident 49's bed had two call light cord adapter pieces plugged in with no call light cords attached. During a concurrent interview and record review, on 1/14/2025, at 10:57 a.m., with Restorative Nursing Aid (RNA) 1, RNA 1 entered Resident 49's room and stated the resident did not have a call light. RNA 1 exited Resident 49's room and stated the resident did not have a call light because he breaks the call lights. During an observation, on 1/14/2025, at 12:57 p.m., Resident 49 laid in bed. Resident 49 did not have a call light. During an observation, on 1/16/2025, at 11 a.m., Resident 49 laid in bed. Resident 49 did not have a call light. During a concurrent observation and interview, on 1/16/2025, at 11:07 a.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated call lights are a communication method between the resident and staff to ensure the needs of the resident are met and to attend to the resident in case of an emergency. LVN 4 stated all residents should have a call light and Resident 49 usually had a call light. LVN 4 stated Resident 49 had a history of breaking call lights, and they replace them as soon as possible. LVN 4 stated she was not made aware Resident 49 did not have a call light. LVN 4 entered Resident 49's room and stated the resident did not have a call light. LVN 4 stated she administered the resident's medications earlier that day and did not notice the resident did not have a call light. LVN 4 stated she assessed the resident but missed identifying the resident's missing call light. LVN 4 stated when residents are not provided a call light, the resident's safety is compromised because there may be delay in responding to the resident. LVN 4 stated if staff were aware Resident 49 did not have a call light, they should have notified the maintenance department to fix it. During a concurrent interview and record review, on 1/16/2025, at 11:16 a.m., with Maintenance Staff 2 (MS 2), MS 2 reviewed the Station 4 Maintenance Log and stated he was not aware of Resident 49's call light and it was not reported to the maintenance department that Resident 49 did not have and needed a call light. During an interview, on 1/16/2025, at 12:06 p.m., with CNA 2, CNA 2 stated she regularly cares for Resident 49 and the resident had not had a call light for months. CNA 2 stated all residents should have a call light in case they need anything. CNA 2 stated Resident 49 had a history of pulling the call light out of the wall. CNA 2 stated she did not know who removed Resident 49's call light but she had reported it to the charge nurses because it concerned her that the resident may not get assistance. CNA 2 stated she did not remember which nurse she reported it to, but all the nurses knew the resident did not have a call light. During an interview, on 1/16/2025, at 2:10 p.m., with RNA 1, RNA 1 stated he did not notify anyone on 1/14/2025 that Resident 49 did not have a call light because he believed the maintenance department knew the resident did not have a call light. RNA 1 stated he believed Resident 49 had not had a call light for no longer that a week. During a concurrent interview and record review, on 1/17/2025, at 12:10 p.m., with the DON, the DON reviewed the facility policy and procedure regarding call lights. The DON stated he was made aware that Resident 49 was not provided a call light. The DON stated there was a communication disconnect between the staff regarding Resident 49's call light. The DON stated every resident requires a call light, no matter what their clinical condition is. The DON stated had he known the resident was not provided a call light, he would have taken action to ensure a call light was provided. The DON stated the importance of the call light is for a resident's dignity and safety. The DON stated if a resident is breaking the call light, then there should be an interdisciplinary meeting to ensure the resident has a way to communicate with staff, but there was no meeting. The DON stated when a resident is not provided a call light, it can potentially result in the resident not having a way to communicate with the care team in the event of emergency. The DON stated the facility policy regarding call lights was not followed when Resident 49 was not provided a call light or way to communicate with staff. During a review of the facility P&P titled, Answering the Call Light, last reviewed 4/18/2024, the P&P indicated the purpose of the procedure is to respond to the resident's requests and needs. Be sure the call light is plugged in at all times. When the resident is in bed be sure the call light is within easy reach of the resident. Report all defective call lights to the nurse supervisor promptly. During a review of the facility's P&P titled, Resident Rights, the P&P indicated federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to communication with and access to people and services, both inside and outside of the facility. Based on observation, interview, and record review the facility failed to provide reasonable accommodation of resident needs and preferences by failing to provide a call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) to five of nine sampled residents (Resident 249, 159, 48, 49, and 129) reviewed under the Environment task. This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to summon health care workers. Findings: a. During a review of Resident 249's admission Record, the admission Record indicated the facility admitted the resident on 11/3/2024, with diagnoses including pathological fracture (a broken bone caused by diseases, rather than an injury) of the right ankle, other symptoms and signs involving the musculoskeletal system (the body's system of bones, muscle, tendons, ligaments, and cartilage that gives the body structure, movement, and stability), and muscle weakness. During a review of Resident 249's Minimum Data Set (MDS - a resident assessment tool), dated 11/13/2024, the MDS indicated the resident had the ability to make self-understood and understand others, with intact cognition (a person's mental abilities like thinking, remembering, reasoning, and understanding, are fully functioning and not significantly impaired). The MDS indicated the resident was dependent to requiring partial assistance on mobility and activities of daily living (ADLs - activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 249's Fall Risk Observation/Assessment, dated 11/3/2024, the Fall Risk Observation/Assessment indicated the resident was high risk for falls. During a review of Resident 249's Care Plan (CP) titled, Falls: Resident is at risk for falls with or without injury related to altered balance while standing and/or walking ., initiated on 11/2/2024, the CP indicated an intervention to keep call light within reach. During a concurrent observation and interview, on 1/14/2025, at 9:59 a.m., with the Assistant Director of Staff Development (ADSD), inside Resident 249's room, observed Resident 249's call light at the left side of the bed near the trashcan. The ADSD stated the resident will not be able to reach the call light and can fall while reaching for it. The ADSD stated the staff should ensure the call light is within reach to prevent accidents to the resident. During an interview, on 1/17/2025, at 3:38 p.m., with the Director of Nursing (DON), the DON stated the staff should always check the placement of the call light during their rounds to ensure the call lights are within reach. The DON stated the resident will not be able to ask for help or communicate their needs if the call light was unreachable. The DON stated the resident can fall while reaching for the call light. During a review of the facility's recent policy and procedure (P&P) titled, Answering the Call Light, last reviewed on 4/18/2024, the P&P indicated the purpose of this procedure is to respond to the resident's requests and needs. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. b. During a review of Resident 159's admission Record, the admission Record indicated the facility admitted the resident on 11/23/2024, with diagnoses of collapsed vertebra (one of the bones that make up the spinal column), muscle weakness, and other symptoms and signs involving the musculoskeletal system. During a review of Resident 159's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition. The MDS indicated the resident required substantial to partial assistance on mobility and ADLs. During a review of Resident 159's Fall Risk Observation/Assessment, dated 11/23/2024, the Fall Risk Observation/Assessment indicated the resident was high risk for falls. During a review of Resident 159's CP titled, Falls: Resident is at risk for falls with or without injury, last revised on 11/24/2024, the CP indicated an intervention to keep call light within reach. During a concurrent observation and interview, on 1/14/2025, at 9:59 a.m., with the ADSD, inside Resident 159's room, observed the call light at the right side of the bed near the trashcan. The ADSD stated the resident will not be able to reach the call light and can fall while reaching for them. The ADSD stated the staff should ensure the call light is within reach to prevent accidents to the resident. During an interview, on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the staff should always check the placement of the call light during their rounds to ensure the call lights are within reach. The DON stated the resident will not be able to ask for help or communicate their needs if the call light was unreachable. The DON stated the resident can fall while reaching for the call light. During a review of the facility's recent P&P titled, Answering the Call Light, last reviewed on 4/18/2024, the P&P indicated the purpose of this procedure is to respond to the resident's requests and needs. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

CONCERN (E)

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

Deficiency F0604 (Tag F0604)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. During a review of Resident 193's admission Record, the admission Record indicated the facility originally admitted the resident on 11/7/2023, and readmitted the resident in the facility on 7/28/2024, with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following cerebrovascular disease (stroke, loss of blow to a part of the brain) affecting right dominant side, type 2 diabetes mellitus (a chronic disease that occurs when the body does not produce enough insulin or does not use it properly) with foot ulcer, and generalized weakness. During a review of Resident 193's History and Physical (H&P) dated 7/28/2024, the H&P indicated Resident 193 had fluctuating capacity to understand and make decisions. During a review of Resident 193's MDS dated [DATE], the MDS indicated the resident had severely impaired cognition (having the ability to think, learn, and remember clearly). The MDS indicated Resident 193 required supervision or touching assistance with eating and oral hygiene; partial/moderate assistance with mobility, upper body dressing, and personal hygiene; total assistance with lower body dressing, tub and toilet transfers; substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 193's Order Summary Report, the Order Summary Report indicated a physician's order dated 10/29/2024 that resident and family wanted to place the bed against the wall for comfort. During a review of Resident 193's Fall Risk Assessments dated 7/28/2024, 8/15/2024, and 10/21/2024, the Fall Risk Assessments indicated Resident 193 was a high risk for falls. During a concurrent observation and interview on 1/14/2025, at 11:31 a.m., inside Resident 193's room with Treatment Nurse 1 (TN 1), observed Resident 193's bed was placed against the wall on the right side. TN 1 verified the bed was placed against the wall and that it was a family preference. During a concurrent interview and record review on 1/14/2025 at 11:45 a.m. inside Resident 193's room with Licensed Vocational Nurse 12(LVN 12), LVN 12 verified Resident 193's bed was placed against the wall on the right side as he was a high risk for fall, and it can be considered a form of restraint as it was preventing the resident's movement from the other side of the bed. During a concurrent interview and record review on 1/16/2025, at 5:30 p.m. with Licensed Vocational Nurse 10 (LVN 10), reviewed Resident 193's physician's orders, informed consent, restraint assessment, fall risk assessment, and care plan with LVN 10. LVN 10 verified there was no restraint assessment, and informed consent on the use of bed against the wall in Resident 193's medical record. LVN 10 stated it was important to have a a restraint assessment and care plan on the use of bed placed against the wall to ensure appropriateness of the use of restraint and the staff aware of the resident plan of care. During an interview on 1/17/2025, at 3:31 p.m., with the DON, the DON stated the staff prior to use of any type of restraints, there should be a physician's order, obtain informed consent from the resident or resident representative, complete a restraint assessment, and develop and implement a care plan. The DON stated the restraint assessment should have been completed and informed consent should have been obtained from Resident 193 and/or representative so the resident and/or representative would be aware of the risks and benefits of having a bed placed against the wall. During a review of the facility's recent policy and procedure (P&P) titled Use of Restraints, last reviewed 4/18/2024, the P&P indicated physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period of time for the use of the restraint. Care plans shall also include the measurable takes to systematically reduce or eliminate the need for restraint use. 6. During a review of Resident 82's admission Record, the admission Record indicated the facility originally admitted the resident on 6/25/20218 and readmitted the resident in the facility on 6/21/2019 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on one side of the body) following intracerebral hemorrhage (a sudden bleeding into the tissues of the brain) affecting right dominant side, and generalized muscle weakness. During a review of Resident 82's H&P dated 3/22/2024, the (H&P) indicated the resident had the capacity to understand and make decisions. During a review of Resident 82's MDS dated [DATE], the MDS indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 82 required partial/moderate assistance with eating; total assistance from staff with lower body dressing, personal hygiene, and shower transfers; substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 82's fall risk assessments dated 7/3/2024, 10/3/2024, and 1/3/2025, the fall risk assessments indicated the resident was a high risk for falls. During a concurrent observation and interview on 1/5/2025 at 8:00 a.m. inside Resident 82's room, observed Resident 82 lying in bed eating breakfast and the bed remained placed against the wall. Resident 82 stated his bed had always been against the wall on the left side. Resident 82 stated his weak side is on the right side and with the bed against the wall on the left side, Resident 82 verified he would be unable to get out of bed from the left side. During a concurrent observation and interview on 1/16/2025 at 5:20 p.m. inside Resident 82's room with Licensed Vocational Nurse 9 (LVN 9), LVN 9 verified Resident 82's bed was placed against the wall on the left side and the resident has weakness and paralysis on the right side of the body. LVN 9 stated the bed against the wall on the left side can be considered a restraint as it was restricting Resident 82 to be able to get out of bed on the left side. During a concurrent interview and record review on 1/16/2025, at 5:30 p.m. with Licensed Vocational Nurse 10 (LVN 10), reviewed Resident 82's physician's orders, informed consent, restraint assessment, fall risk assessment, and care plan with LVN 10. LVN 10 verified there was no restraint assessment, and informed consent on the use of bed against the wall in Resident 82's medical record. LVN 10 stated it was important to have a restraint assessment and care plan on the use of bed placed against the wall to ensure appropriateness of the use of restraint and for the staff to be aware of the resident's plan of care. During an interview on 1/17/2025, at 3:31 p.m., with the DON, the DON stated the staff prior to use of any type of restraints, there should be a physician's order, obtain informed consent from the resident or resident representative, complete a restraint assessment, and develop and implement a care plan. The DON stated the restraint assessment should have been completed and informed consent should have been obtained from Resident 82 and/or representative so the resident and/or representative would be aware of the risks and benefits of having a bed placed against the wall. During a review of the facility's recent policy and procedure (P&P) titled Use of Restraints, last reviewed 4/18/2024, the P&P indicated physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period of time for the use of the restraint. Care plans shall also include the measurable takes to systematically reduce or eliminate the need for restraint use. 7. During a review of Resident 129's admission Record, the admission Record indicated the facility originally admitted the resident on 8/3/2021 and readmitted the resident on 8/16/2021 with diagnoses including dysphagia (difficulty swallowing), unspecified intellectual disabilities (a lifelong condition that limits a person's mental functioning and skills), and difficulty in walking. During a review of Resident 129's History and Physical (H&P) dated 9/5/2024, the (H&P) indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 129's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 11/24/2024, the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 129 required total assistance from staff with lower body dressing, partial/moderate assistance with bathing, toileting hygiene, upper body dressing, toilet transfer, and shower transfer, and substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 129's fall risk assessments dated 5/27/2024, 8/24/2024, and 11/23/2024, the fall risk assessments indicated the resident was a high risk for falls. During a concurrent observation and interview on 1/14/2025 at 10:38 a.m. inside Resident 129's room with Licensed Vocational Nurse 12 (LVN 12), observed Resident 129's bed was placed against the wall on the right side as he was a high risk for fall, and it can be considered a form of restraint as it was preventing the resident's movement from the other side of the bed. During a concurrent interview and record review on 1/16/2025, at 5:30 p.m. with Licensed Vocational Nurse 10 (LVN 10), reviewed Resident 129's physician's orders, informed consent, restraint assessment, fall risk assessment, and care plan with LVN 10. LVN 10 verified there was no physician's order, restraint assessment, informed consent, and care plan on the use of bed against the wall in Resident 129's medical record. LVN 10 stated it was important to have a physician's order, informed consent, restraint assessment, and care plan on the use of bed placed against the wall to ensure appropriateness of the use of restraint and for the staff to be aware of the resident's plan of care. During an interview on 1/17/2025, at 3:31 p.m., with the Director of Nursing (DON), the DON stated the staff prior to use of any type of restraints, there should be a physician's order, obtain informed consent from the resident or resident representative, complete a restraint assessment, and develop and implement a care plan. The DON stated the restraint assessment should have been completed and informed consent should have been obtained from Resident 193 and/or representative so the resident and/or representative would be aware of the risks and benefits of having a bed placed against the wall. During a review of the facility's recent policy and procedure (P&P) titled Use of Restraints, last reviewed 4/18/2024, the P&P indicated physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period of time for the use of the restraint. Care plans shall also include the measurable takes to systematically reduce or eliminate the need for restraint use. 8. During a review of Resident 165's admission Record, the admission Record indicated the facility originally admitted the resident on 6/18/2023 and readmitted the resident in the facility on 9/17/2024 with diagnoses including major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (persistent and excessive worry that interferes with daily activities), chronic osteomyelitis (a bone infection caused by injuries and blood circulation disorders) of the left ankle and foot. During a review of Resident 165's H&P dated 12/19/2024, the (H&P) indicated the resident had the capacity to understand and make decisions. During a review of Resident 165's MDS dated [DATE], the MDS indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 165 required set up assistance with eating; supervision with oral hygiene and mobiity; substantial/maximal assistance with lower body dressing; partial/moderate assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 165's fall risk assessments dated 9/17/2024, 9/30/2024, 12/4/2024, and 12/31/2024, the fall risk assessments indicated the resident was a high risk for falls. During a concurrent observation and interview on 1/14/2025 at 10:11 a.m. inside Resident 165's room with Licensed Vocational Nurse 12 (LVN 12), observed Resident 165's bed was placed against the wall on the left side and verified he was a high risk for fall, and it can be considered a form of restraint as it was preventing the resident's movement from the other side of the bed. During a concurrent interview and record review on 1/16/2025, at 5:30 p.m. with Licensed Vocational Nurse 10 (LVN 10), reviewed Resident 165's physician's orders, informed consent, restraint assessment, fall risk assessment, and care plan with LVN 10. LVN 10 verified there was no restraint assessment, and care plan on the use of bed against the wall in Resident 165's medical record. LVN 10 stated it was important to have a restraint assessment, and care plan on the use of bed placed against the wall to ensure appropriateness of the use of restraint and for the staff to be aware of the resident's plan of care. During an interview on 1/17/2025, at 3:31 p.m., with the DON, the DON stated the staff prior to use of any type of restraints, there should be a physician's order, obtain informed consent from the resident or resident representative, complete a restraint assessment, and develop and implement a care plan. The DON stated the restraint assessment should have been completed and informed consent should have been obtained from Resident 165 and/or representative so the resident and/or representative would be aware of the risks and benefits of having a bed placed against the wall. During a review of the facility's recent policy and procedure (P&P) titled Use of Restraints, last reviewed 4/18/2024, the P&P indicated physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period of time for the use of the restraint. Care plans shall also include the measurable takes to systematically reduce or eliminate the need for restraint use. 9. During a review of Resident 160's admission Record, the admission Record indicated the facility originally admitted the resident on 6/27/2023 and readmitted the resident in the facility on 8/3/2023 with diagnoses including nontraumatic intracranial hemorrhage (a sudden bleeding into the tissues of the brain), seizures (a sudden uncontrolled electrical disturbance on the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), and abnormalities of gait and mobility. During a review of Resident 160's H&P dated 8/10/2024, the (H&P) indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 160's MDS dated [DATE], the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 160 required partial/moderate assistance with eating, oral hygiene, and mobility; supervision with oral hygiene and mobility; total assistance with shower transfers and lower body dressing; substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 160's fall risk assessments dated 8/3/2024, 11/10/2024, 12/19/2024, and 12/19/2024, the fall risk assessments indicated the resident was a high risk for falls. During a concurrent observation and interview on 1/15/2025 at 12:00 p.m. inside Resident 160's room with Licensed Vocational Nurse 15 (LVN 15), observed Resident 160's beside safety mattress was placed on its side on the left side of the bed with the upper part of the mattress wedged between the bedside table and the resident's bed preventing resident 160 from getting out of bed. LVN 15 stated bedside safety mattresses should be laying flat on the floor for resident safety when they try to get out of bed unassisted. LVN 15 stated Resident 160 was unable to remove the bedside safety mattress and should have been lying flat on the floor instead of placing on its side restricting Resident 160 from getting out of bed freely and can be considered a restraint. LVN 15 verified Resident 160 always gets out of bed from the left side. During an interview on 1/17/2025, at 3:31 p.m., with the DON, the DON stated the staff prior to use of any type of restraints, there should be a physician's order, obtain informed consent from the resident or resident representative, complete a restraint assessment, and develop and implement a care plan. The DON stated the staff are not supposed to block the resident's ability to get out of bed freely such as placing a bedside safety mattress on its side blocking the resident's pathway. The DON stated bedside safety mattresses are a least restrictive form of intervention to prevent the resident from getting injured in the event of a fall incident. The DON stated the staff should not have placed Resident 160's bedside safety mattress on its side instead of laying on the floor as it restricted the resident to get out of bed freely. The DON stated Resident 160 would be unable to remove the safety mattress if the upper part was wedged between the bedside table and the resident's bed. The DON stated it can be considered a restraint as it was used for staff convenience. During a review of the facility's recent policy and procedure (P&P) titled Use of Restraints, last reviewed 4/18/2024, the P&P indicated: - Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried successfully. - Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls. - When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary, and the ongoing re-evaluation for the need of restraints will be documented. - If a resident cannot remove a device in the same way staff applied it given that resident's physical condition, and this restricts his/her typical ability to change position of place, that device is considered a restraint. 10. During a review of Resident 39's admission Record, the admission Record indicated the facility admitted the resident on 6/4/2024 with diagnoses that included osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of vertebra (bones of spine), sacral and sacrococcygeal region (base of spine at the tailbone), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body) following cerebral infarction (CVA-stroke, loss of blood flow to a part of the brain) affecting the right dominant side, cognitive communication deficit (trouble communicating due to problems with thinking skills), and depression. During a review of Resident 39's Minimum Data Set (MDS - resident assessment tool) dated 12/11/2024, the MDS indicated the resident was able to understand others and was able to make herself understood. The MDS further indicated the resident required partial/moderate assistance from staff for toileting and required substantial/maximal assistance for bathing, dressing, personal hygiene, and mobility while in bed. During a review of Resident 39's History and Physical (H&P), dated 6/7/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 39's Order Summary Report, the report indicated an order for two, top quarter SRs up for mobility/enabler (safety), every shift, dated 6/4/2024. During a review of Resident 39's Nursing Bed Rail Observation Assessment, dated 6/4/2024, the assessment indicated informed consent was received by the resident's representative after a discussion regarding the risk and benefits of the use of the recommended left and right upper SRs that did not impede the resident's freedom of movement. During a concurrent observation and interview on 1/14/2025 at 12:14 p.m., with Resident 39, Resident 39 lay in bed with four SRs (bilateral upper and bilateral lower) in the raised position. Observed Certified Nursing Assistant 6 (CNA 6) entered the resident's room, spoke to the resident, and then exited. Resident 39 stated the staff puts the SRs up and she cannot remove them. During an interview on 1/14/2025 at 12:22 p.m. with CNA 6, CNA 6 stated Resident 39 must have four SRs up to prevent her from falling out of the bed because the resident leans to the left and moves her feet. During an observation on 1/15/2025 at 7:45 a.m., observe Resident 39 in bed with fours SRs in the raised position. During a concurrent observation, interview, and record review on 1/16/2025 at 9:19 a.m., with CNA 6 and Licensed Vocational Nurse 13 (LVN 13), LVN 13 reviewed Resident 39's physician orders. Observed LVN 13 at Resident 39's room entry. Observed Resident 39 with four SRs in the raised position. LVN 13 stated she did not know why Resident 39 had four SRs raised because the resident had a physician's order for only two SRs. LVN 13 stated CNA 6 was also caring for Resident 39 and CNA 6 did not mention the resident needed four SRs. CNA 6 approached LVN 13 and stated Resident 39 requested to have the four SRs in the raised position to prevent falls. LVN 13 stated SRs should not be used as a fall prevention strategy. LVN 13 stated Resident 39's four SRs in the raised position is considered a restraint because it restricts the resident's freedom to exit the bed. LVN 13 stated there was no need for Resident 39 to have four SRs in the raised position. LVN 13 stated CNA 6 should have communicated that Resident 39 requested to have the four SRs up because there is a process to follow. LVN 13 stated if the resident requested four SRs up, the physician should be notified and the resident should be assessed for safety. During a concurrent interview and record review on 1/16/2025 at 9:48 a.m., with Licensed Vocational Nurse 14 (LVN 14), LVN 14 reviewed Resident 39's physician orders, Care Plans, and Nursing Bed Rail Observation Assessment, dated 6/4/2024. LVN 14 stated Resident 39 had an order, was care planned, and assessed and consented for the use of two upper SRs only. LVN 14 stated there was no documentation to indicate the resident requested to have four SRs. LVN 14 stated if Resident 39 requested for four SRs, then the resident needed to be re-evaluated. LVN 14 stated the importance of the safety evaluation is to make sure the resident would not become confined or trapped in the SRs. LVN 14 stated the use of four SRs is considered a restraint because a resident cannot remove the SRs and it restricts their ability to exit the bed. LVN 14 stated when a restraint is used alternatives to the restraint must be attempted first. LVN 14 stated a bolster mattress (designed to prevent residents from falling out of bed) could be used to provide a feeling of security for the resident instead of using four SRs that pose more of a risk. LVN 14 stated when CNA 6 placed Resident 39's four SRs in the raised position there was a potential that the resident's limbs could become wedged between the mattress and SRs causing bruising or injury. During a follow up interview on 1/16/2024 at 12:27 p.m. with LVN 14, LVN 14 stated Resident 39 did not have the capacity to consent for the use of four SR's so the resident's representative was called. LVN 14 stated the representative did not consent to the use of four SRs. During a concurrent interview and record review on 1/17/2025 at 12:10 p.m. with the Director of Nursing (DON), the DON reviewed the facility policy and procedures regarding SRs and restraints. The DON stated some beds in the facility have lower SRs that cannot be removed from the bed. The DON stated CNA 6 saw the lower SRs and placed them up for Resident 39. The DON stated placing four SRs up is considered a restraint because it limits the free movement of the resident. The DON stated there is a process for the use of SRs that includes an interdisciplinary meeting to determine the safety of SR use and to explain the risk and benefits of the SRs to the resident and representative. The DON stated this process was not followed by CNA 6 for Resident 39 and could have potentially resulted in entrapment and injury of the resident. The DON stated the facility policy for SRs and restraints was not followed. During a review of the facility policy and procedure (P&P) titled, Use of Restraints, last reviewed 4/18/2024, the P&P indicated restraints shall only be used for the safety and well being of the residents and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms and never for discipline or staff convenience, or for the prevention of falls. When the use of restraints is indicated, the least restrictive alternative will be used for the least amount of time necessary. Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted including using bedrails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed. Prior to placing a resident in a restraint, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident or representative. Should the resident not be capable of making a decision, the surrogate or sponsor may exercise the right of the use or non-use of a restraint. During a review of the facility P&P titled, Bed Safety and Bed Rails, last reviewed 4/18/2024, the P&P indicated resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bed rails is prohibited unless the criteria for use of bed rails have been met. The resident's sleeping environment is evaluated by the interdisciplinary team. Consideration is given to the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family. Bed rails are adjustable metal or rigid plastic bars that attach to the bed. The use of bed rails or SRs is prohibited unless the criteria for the use of bed rails have been met, including attempting alternatives, interdisciplinary evaluation, resident assessment, and informed consent. Prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted. Alternatives may include roll guards, foam bumpers, lowering the bed, and the use of a concave mattress to reduce rolling off the bed. Based on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity including the right to be free from physical restraints (any manual method, physical or mechanical device, material or equipment that is attached or adjacent to the resident's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body) for 10 of 10 sampled residents (Residents 264, 109, 96, 481, 165, 82, 193, 129, 160, 39) investigated during review of physical restraints care area by failing to ensure: 1. Resident 264 had a physician's order, an informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered), a restraint assessment, and a care plan for restraint wedge pillow (a triangular pillow that raises the top half of your body, usually made of foam) tucked under the sheet. 2. Residents 109, 96, 193, 82, and 165 had restraint assessments and informed consents (the act of agreeing to allow something to happen, or to do something, with a full understanding of all risks and available alternatives) obtained from the residents and/or their representatives on the use of bed placed against the wall. 3. Residents 481 and 129 had a physician's order, an informed consent, a restraint assessment, and a care plan on the use of restraint bed placed against the wall. 4. Resident 160's bedside safety mattress was not placed on its side preventing the resident from getting out of bed freely. 5. Side rails (SR, adjustable rigid bars attached to the bed that may be positioned in various locations on the[TRUNCATED]

CONCERN (E)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for three of 10 sampled residents (Resident 249, 109, and 481) during initial sampling of residents by failing to develop and implement a care plan on: 1. Resident 249's use of Trazadone (a drug used to treat depression [a mental health condition that involves a persistent feeling of sadness and a loss of interest in activities]) and Buspirone (a medication that treats anxiety). 2. Resident 109's use of Zoloft (also known as sertraline, medication that can help treat depression and other mental health conditions). 3. Resident 481's use of indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine). 4. Resident 481's use of restraint (the use of a manual hold to restrict freedom of movement of all or part of a person's body, or to restrict normal access to the person's body) bed placed against the wall. These deficient practices had the potential for residents to not receive necessary care and treatment. Findings: 1. During a review of Resident 249's admission Record, the admission Record indicated the facility admitted the resident on 11/3/2024, with diagnoses including anxiety disorder (a mental health condition that involves excessive and persistent feelings of fear, worry, and dread), major depressive disorder (a serious mental illness that causes a persistent low mood and loss of interest in activities), and psychosis (a mental health condition that causes a person to lose touch with reality). During a review of Resident 249's Minimum Data Set (MDS - a resident assessment tool), dated 11/13/2024, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (having the ability to think, learn, and remember clearly). The MDS further indicated the resident was on a high-risk drug class antianxiety (something that reduces or prevents anxiety) and antidepressant (a type of medicine used to treat clinical depression) medications. During a review of Resident 249's Order Summary Report, dated 11/3/2024, the Order Summary Report indicated an order for: Trazadone HCl Oral Tablet (Trazadone HCl). Give 200 milligrams (mg - a unit of measurement of mass in the metric system equal to a thousandth of a gram) by mouth at bedtime for depression monitor behavior (m/b) inability to sleep at night. Risks and benefits explained. Physician obtained informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered). Buspirone HCl Oral Tablet 15 mg (Buspirone HCl). Give 15 mg by mouth three times a day for anxiety m/b overly concern about health risks and benefits explained. Physician obtained informed consent. During a concurrent interview and record review, on 1/16/2025, at 3:51 p.m., with Licensed Vocational Nurse (LVN) 5, Resident 249's Order Summary Report, dated 11/3/2024, and Resident 249's Care Plans were reviewed. LVN 5 stated there was no care plan developed and implemented on the use of Trazadone and Buspirone. LVN 5 stated it was important to have care plan on the use of psychotropic medications (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) Trazadone and Buspirone to ensure safe use of the medication. LVN 5 stated care plans sets the goal of therapy and the interventions to meet the needs of the resident. During an interview, on 1/17/2025, at 3:38 p.m., with the Director of Nursing (DON), the DON stated the staff should have developed and implemented a care plan on the use of Trazadone and Buspirone to ensure the medications were appropriately used. The DON stated the care plan serves as a communication tool to the healthcare team and the family members. The DON stated the care plan standardizes the care that is being provided to the resident. During a review of the facility's recent policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, last reviewed on 4/18/2024, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). 2. During a review of Resident 109's admission Record, the admission Record indicated the facility admitted the resident on 7/17/2024, with a diagnosis of depression. During a review of Resident 109's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had mild cognitive impairment (a condition that causes memory or thinking difficulties that are more severe than normal aging). The MDS also indicated the resident was on a high-risk drug class antidepressant (a type of medicine used to treat clinical depression) medication. During a review of Resident 109's Order Summary Report, dated 7/17/2024, the Order Summary Report indicated an order for Zoloft oral tablet 25 mg, give 25 mg by mouth one time a day for depression m/b verbalization of sadness. During a concurrent interview and record review, on 1/16/2025, at 5:03 p.m., with LVN 5, Resident 109's Order Summary Report, dated 7/17/2024, and Resident 109's Care Plans were reviewed. LVN 5 stated there was no care plan developed and implemented on the use of Zoloft. LVN 5 stated it was important to have care plan on the use of psychotropic medications Zoloft to ensure safe use of the medication. LVN 5 stated care plans sets the goal of therapy and the interventions to meet the needs of the resident. During an interview, on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the staff should have developed and implemented a care plan on the use of Zoloft to ensure the medications were appropriately used. The DON stated the care plan serves as a communication tool to the healthcare team and the family members. The DON stated the care plan standardizes the care that is being provided to the resident. During a review of the facility's recent P&P titled, Care Plans, Comprehensive Person-Centered, last reviewed on 4/18/2024, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS). 3. During a review of Resident 481's admission Record, the admission Record indicated the facility admitted the resident on 7/20/2024, and readmitted the resident on 1/13/2025, with diagnoses including repeated falls, benign prostatic hyperplasia (a noncancerous condition that causes the prostate gland to enlarge), and urinary tract infection (UTI - an infection in the bladder/urinary tract). During a review of Resident 481's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and understand others and had intact cognition. The MDS indicated the resident requires supervision on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and had an indwelling urinary catheter. During a review of Resident 481's Order Summary Report, dated 7/22/2024, the Order Summary Report indicated an order of indwelling catheter size 16 French (FR - a unit of measurement for catheters)/10 cubic centimeter (cc, a unit of volume in the metric system that measures the amount of space a three-dimensional object occupies). Diagnosis (Dx): Benign prostatic hyperplasia with lower urinary tract symptoms. During a concurrent observation and interview, on 1/15/2024, at 4:59 p.m., with the Assistant Director of Staff Development (ADSD), the left side of Resident 481's bed was against the wall. The ADSD stated placing the bed against the wall was a form of physical restraint. During a concurrent interview and record review, on 1/15/2025, at 6:05 p.m., with LVN 5, Resident 481's Care Plans were reviewed. LVN 5 stated there was no care plan on placing Resident 481's bed against the wall as a form of restraint. LVN 5 stated it was important to have care plan on the use of restraint bed placed against the wall to ensure safe use of the restraint. LVN 5 stated care plans sets the goal of therapy and the interventions to meet the needs of the resident. During a concurrent interview and record review, on 1/17/2025, at 10:49 a.m., with LVN 5, Resident 481's Order Summary Report, dated 7/22/2024, and Resident 481's Care Plans were reviewed. LVN 5 stated there was no care plan on the use of urinary catheter on the resident's medical record. LVN 5 stated it was important to have care plan on the use of urinary catheter to ensure its safe use. LVN 5 stated care plans sets the goal of therapy and the interventions to meet the needs of the resident. During an interview, on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the staff should have developed and implemented a care plan on the use of restraint bed placed against the wall and indwelling urinary catheter to ensure safe and appropriate use of the device. The DON stated the care plan serves as a communication tool to the healthcare team and the family members. The DON stated the care plan standardizes the care that is being provided to the resident. During a review of the facility's recent P&P titled, Care Plans, Comprehensive Person-Centered, last reviewed on 4/18/2024, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS).

CONCERN (E)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards to seven (7) out of 7 sampled residents (Residents 64, 66, 73, 64, 111, 213, 96, 73, and 220) investigated under insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) and anticoagulant (blood thinner - that stops the blood from forming blood clots or making them bigger) use by: 1. Failing to rotate (a method to ensure repeated injections are not administered in the same area) the insulin administration sites for Residents 64 and 66. 2. Failing to rotate subcutaneous (beneath the skin) insulin and heparin administration sites for Residents 111, 213, 96, 73, and 220. These deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin and heparin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross-reference F760 Findings: 1.a. During a review of Resident 64's admission Record, the admission Record indicated the facility originally admitted the resident on 1/22/2021, and readmitted the resident on 12/26/2023, with diagnoses including type 2 diabetes mellitus (DM 2 - a chronic disease that occurs when the body does not produce enough insulin or does not use it properly) without complications, gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 64's Minimum Data Set (MDS - a resident assessment tool), dated 11/2/2024, the MDS indicated the resident had severely impaired cognition (having the ability to think, learn, and remember clearly). The MDS indicated Resident 64 required substantial/maximal assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 64 had a diagnosis of DM 2 and received insulin. During a review of Resident 64's History and Physical (H&P), dated 12/27/2024, the H&P indicated the resident did not have the capacity to make decisions. During a review of Resident 64's Order Summary Report, the Order Summary Report indicated the following physician's orders dated 12/26/2023: - Insulin NPH (a long-acting insulin) subcutaneous suspension 100 unit per milliliter (unit/ml - a unit of measurement). Inject 20 units subcutaneously two times a day for DM 2. Rotate Injection Sites. Give with meals. - Insulin regular human solution (a short-acting insulin) 100 unit/ml. Inject subcutaneously before meals and at bedtime for DM 2. Give 12 units if blood sugar (BS) is more than (>) 350 and notify physician (MD). Inject as per sliding scale (increasing administration of the pre?meal insulin dose based on the blood sugar level before the meal): if 70 - 149 = 0, if BS less than (<)70 give orange juice via gastrostomy tube if responsive and notify MD.; 150 - 199 = 1; 200 - 249 = 3; 250 - 299 = 5; 300 - 349 = 7; 350+ = 8. Give 12 units if BS is >350 and notify MD. During a concurrent interview and record review, on 1/16/2025, at 2:30 p.m., with Licensed Vocational Nurse (LVN) 9, Resident 64's Order Summary Report, dated 12/26/2023, Resident 64's Medication Administration Record (MAR - a daily documentation records used by a licensed nurse to document medications and treatments given to a resident), and Resident 64's Location of Administration Report, dated between 11/2024 to 1/2025, was reviewed and LVN 9 verified Resident 64 had a physician's order for NPH and regular insulin and were administered as follows: - Insulin regular human solution 100 unit/ml: 12/22/24 5::19 p.m. subcutaneously Abdomen - right upper quadrant (RUQ) 12/23/24 5:18 p.m. subcutaneously Abdomen - RUQ 12/27/24 8:27 a.m. subcutaneously Arm - left 12/29/24 3:58 p.m. subcutaneously Arm - left 1/06/25 4:12 p.m. subcutaneously Abdomen -RUQ 1/07/25 5:10 p.m. subcutaneously Abdomen - RUQ - Insulin NPH suspension 100 unit/ml: 11/26/24 7:56 a.m. subcutaneously Abdomen - left upper quadrant (LUQ) 11/26/24 8:55 p.m. subcutaneously Abdomen - LUQ 12/21/24 5:58 a.m. subcutaneously Abdomen - right lower quadrant (RLQ) 12/21/24 8:53 p.m. subcutaneously Abdomen - RLQ 12/27/24 8:29 a.m. subcutaneously Abdomen -LUQ 12/27/24 7:53 p.m. subcutaneously Abdomen - LUQ LVN 9 stated insulin administration sites should be rotated per standards of practice, manufacturer's guidelines, and according to physician's orders. LVN 9 verified Resident 64's MAR indicated the insulin administration sites were not rotated and that there was a physician's order to rotate injection sites. LVN 9 stated the insulin administration sites should have been rotated as ordered by the physician to prevent pain, redness, irritation, lipodystrophy, and denting of the resident's skin. During an interview, on 1/17/2025, at 3:38 p.m., with the Director of Nursing (DON), the DON stated the administration sites of insulin should be rotated to prevent complications such as bruising, and lipodystrophy. During a review of the facility's policy and procedure (P&P) titled, Insulin Administration, last reviewed on 4/18/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. The P&P further indicated: a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided manufacturer's guideline on, Humulin R Regular Insulin Huma Injection, undated, the manufacturer's guideline indicated Humulin R may be administered by subcutaneous injection in the abdominal wall, the thigh, the gluteal region, or in the upper arm. The manufacturer's guideline further indicated injection sites should be rotated within the same region and the following common side effects: - Skin thickening or pits at the injection site (lipodystrophy). Change (rotated) where to inject the insulin to help prevent lipodystrophy from happening. Do not inject into the exact spot for each injection. - Injection site reactions (local allergic reaction). Symptoms may include redness, swelling and itching at the injection site. During a review of the facility provided manufacturer's guideline on Humulin N Pen NPH Human Insulin, undated, the manufacturer's guideline indicated side effects include injection site reactions such as pian, redness, and irritation. The manufacturer's guideline further indicated adverse reactions include lipodystrophy and localized cutaneous amyloidosis. 1.b. During a review of Resident 66's admission Record, the admission Record indicated the facility originally admitted the resident on 9/27/2024, and readmitted the resident on 12/18/2024, with diagnoses including DM 2 with foot ulcer, neuromuscular disorder of the bladder (lack bladder control due to a brain, spinal cord or nerve problem), and pressure ulcer (injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time) of left buttock. During a review of Resident 66's MDS, dated [DATE], the MDS indicated the resident had severely impaired cognition (having the ability to think, learn, and remember clearly). The MDS indicated Resident 66 required substantial/maximal assistance from staff with all ADLs. The MDS indicated Resident 66 had a diagnosis of DM 2 and received insulin. During a review of Resident 66's Order Summary Report, the Order Summary Report indicated the following physician's orders: - 9/8/2024: Humalog solution (a fast-acting insulin) 100 unit per milliliter (unit/ml - a unit of measurement) (insulin lispro). Inject as per sliding scale (increasing administration of the pre?meal insulin dose based on the blood sugar level before the meal): if 0 - 150 = 0 units; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units, subcutaneously before meals and at bedtime for DM 2. - 12/28/2024: Humalog injection solution 100 unit/ml (insulin lispro). Inject subcutaneously before meals and at bedtime for DM 2 Rotate injection sites. Inject as per sliding scale: if 70 - 149 = 0 units. Notify physician (MD) if blood sugar (BS) is less than 70. Give orange juice if alert, responsive, and able to swallow; 150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 7 units; 300 - 349 = 10 units; 350+ = 12 units. Give 12 units if BS is greater than 401 and notify MD, subcutaneously before meals and at bedtime. During a concurrent interview and record review, on 1/16/2025, at 2:45 p.m., with LVN 9, Resident 66's Order Summary Report, dated 9/8/2024 and 12/28/2024, and Resident 66's MAR and Location of Administration Report, dated between 11/2024 to 1/2025, were reviewed and LVN 9 verified Resident 66 had a physician's order for Humalog insulin and were administered as follows: 11/19/24 9:40 p.m. subcutaneously Abdomen - left lower quadrant (LLQ) 11/20/24 6:30 a.m. subcutaneously Abdomen - LLQ 11/25/24 11:28 a.m. subcutaneously Abdomen -RLQ 11/25/24 10:20 p.m. subcutaneously Abdomen - RLQ 11/27/24 9:33 p.m. subcutaneously Abdomen - LLQ 11/28/24 5:20 a.m. subcutaneously Abdomen - LLQ 11/29/24 8:48 p.m. subcutaneously Abdomen - LLQ 12/02/24 4:42 p.m. subcutaneously Abdomen - LLQ 12/02/24 9:32 p.m. subcutaneously Abdomen - LLQ 12/07/24 2:17 p.m. subcutaneously Abdomen - LLQ 12/07/24 5:47 p.m. subcutaneously Abdomen - LLQ 12/07/24 10:45 p.m. subcutaneously Abdomen - LLQ 12/28/24 11:29 a.m. subcutaneously Abdomen - LLQ 12/29/24 11:36 a.m. subcutaneously Abdomen - LLQ 12/30/24 12:27 p.m. subcutaneously Abdomen - LLQ 12/31/24 11:41 a.m. subcutaneously Abdomen - LLQ 01/03/25 12:20 p.m. subcutaneously Abdomen - LLQ 01/04/25 4:23 a.m. subcutaneously Abdomen - LLQ 01/09/25 12:26 p.m. subcutaneously Abdomen - LLQ 01/10/25 11:14 a.m. subcutaneously Abdomen - LLQ LVN 9 stated insulin administration sites should be rotated per standards of practice, manufacturer's guidelines, and according to physician's orders. LVN 9 verified Resident 66's MAR indicated the insulin administration sites were not rotated and that there was a physician's order to rotate injection sites. LVN 9 stated the insulin administration sites should have been rotated as ordered by the physician to prevent pain, redness, irritation, lipodystrophy, and denting of the resident's skin. During an interview on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the administration sites of insulin should be rotated to prevent complications such as bruising, and lipodystrophy. During a review of the facility's P&P titled, Insulin Administration, last reviewed on 4/18/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. The P&P further indicated: a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately two inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided manufacturer's guideline on insulin Aspart (Humalog), undated, the manufacturer's guideline indicated to change (rotate) injection site within the chosen area such as stomach or upper arm with each dose and do not inject into the exact same sport for each injection. The manufacturer's guideline further indicated the following side effects: - Reactions at the injection site such as redness, swelling, and itching. - Skin thickens or pits at the injection site (lipodystrophy). Change (rotate) the injection site to help prevent lipodystrophy from happening. 2.a. During a review of Resident 111's admission Record, the admission Record indicated the facility admitted the resident on 1/18/2023, and readmitted the resident on 12/14/2024, with diagnoses including DM 2 with foot ulcer and DM 2 with diabetic neuropathy (nerve damage caused by diabetes). During a review of Resident 111's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had an intact cognition (having the ability to think, learn, and remember clearly). The MDS indicated the resident was on a high-risk drug class hypoglycemic medication (drugs that lower blood sugar levels and are used to treat diabetes). During a review of Resident 111's Order Summary Report, the Order Summary Report indicated an order of: 12/15/2024 Insulin Aspart Injection Solution 100 unit (a standard measurement of the insulin's biological activity, essentially representing the amount of insulin needed to produce a specific effect on blood sugar levels)/ milliliters (ml, a unit used to measure capacity) (Insulin Aspart). Inject as per sliding scale (the increasing administration of the pre?meal insulin dose based on the blood sugar level before the meal): if 70 - 149 = 0 Units If blood sugar (BS) is less than (<)70 Give orange juice (OJ) if responsive and notify MD.; 150 - 199 = 1 Unit; 200 - 249 = 3 Units; 250 - 299 = 5 Units; 300 - 349 = 7 Units; 350+ = 8 Units If BS is greater than (>)350+ Give 8 Units and notify MD., subcutaneously before meals and at bedtime for Diabetes. Rotate injection sites. 12/15/2024 Lantus (a long-acting insulin) Subcutaneous Solution 100 unit/ml (Insulin Glargine). Inject 10 unit subcutaneously two times a day for type 2 DM. Give with meals. During a review of Resident 111's Location of Administration Report for Insulin, dated between 12/2024 to 1/2025, the Location of Administration Report for Insulin indicated: 1. Lantus Subcutaneous Solution 100 unit/ml was given subcutaneously on: 12/17/2024 at 7:49 p.m. on the Abdomen - RLQ 12/18/2024 at 11:13 a.m. on the Abdomen - RLQ 2. Aspart Injection Solution 100 unit/ml was given subcutaneously on: 1/1/2025 at 8:54 p.m. on the Abdomen - LLQ 1/1/2025 at 10:36 p.m. on the Abdomen - LLQ 1/3/2025 at 11:52 a.m. on the Abdomen - RUQ 1/3/2025 at 4:32 p.m. on the Abdomen - RUQ 1/12/2025 at 5:09 p.m. on the Abdomen - LLQ 1/12/2025 at 9:01 p.m. on the Abdomen - LLQ During a concurrent interview and record review, on 1/16/2025, at 3:58 p.m., with LVN 5, Resident 111's Order Summary Report, dated 12/15/2024, Resident 111's Location of Administration of Insulin, dated between 12/2024 to 1/2025, MAR, dated between 12/2024 to 1/2025, and Care Plans were reviewed. LVN 5 stated there were multiple instances that insulin administrations were not rotated on the resident. LVN 5 stated the administration sites of insulin should be rotated to prevent bruising, lipodystrophy, and denting of the resident's skin. During an interview, on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the administration sites of insulin should be rotated to prevent complications such as deep vein thrombosis (DVT, a blood clot that forms in a deep vein in the body), bruising, and lipodystrophy. During a review of the facility's recent P&P titled, Insulin Administration, last reviewed on 4/18/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility-provided Highlights of Prescribing Information on the use of Lantus (insulin glargine) injection, for subcutaneous use, with initial U.S. approval in 2000, the highlights of prescribing information indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. 2.b. During a review of Resident 213's admission Record, the admission Record indicated the facility admitted the resident on 4/16/2024, with diagnoses including DM 2, dementia (a progressive state of decline in mental abilities), and atrial fibrillation (a condition where the heart's upper chambers beat irregularly and often too fast). During a review of Resident 213's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and understand others and had severe cognitive impairment (a condition that makes it difficult for a person to think, learn, remember, and make decisions). The MDS indicated the resident was on a high-risk drug class hypoglycemic medication (drugs that lower blood sugar levels and are used to treat diabetes). During a review of Resident 213's Order Summary Report, dated 4/16/2024, the Order Summary Report indicated an order for: - Humulin R Injection Solution 100 unit/ml (Insulin Regular [Human]). Inject as per sliding scale: if 70 - 149 = 0 units Notify MD if BS is <70. Give OJ if responsive.; 150 - 199 = 1 unit; 200 - 249 = 2 units; 250 - 299 = 3 units; 300 - 349 = 4 units; 350+ = 5 units Give 5 units if BS is >350. Notify MD., subcutaneously before meals and at bedtime for Diabetes. Rotate injection sites. - Lantus Subcutaneous Solution 100 unit/ml (Insulin Glargine). Inject 10 unit subcutaneously every 12 hours for Diabetes. Rotate injection sites. During a review of Resident 213's Location of Administration Report for Insulin, dated between 11/2024 to 1/2025, the Location of Administration Report for Insulin indicated: 1. Lantus subcutaneous solution 100 unit/ml was administered on: 11/7/2024 at 8:58 a.m. on the Abdomen - LLQ 11/7/2024 at 9:23 p.m. on the Abdomen - LLQ 2. Humulin R Injection Solution 100 unit/ml was administered on: 11/5/2024 at 9:37 p.m. on the Arm - right 11/6/2024 at 5:10 p.m. on the Arm - right 11/12/2024 at 9:15 p.m. on the Abdomen - LUQ 11/15/2024 at 9:37 p.m. on the Abdomen - LUQ 11/20/2024 at 6:55 p.m. on the Abdomen - LLQ 11/20/2024 at 8:20 p.m. on the Abdomen - LLQ 11/28/2024 at 4:14 p.m. on the Arm - right 11/28/2024 at 12:14 a.m. on the Arm - right During a concurrent interview and record review, on 1/16/2025, at 3:58 p.m., with LVN 5, Resident 213's Order Summary Report, dated 4/16/2024, Resident 213's Location of Administration of Insulin, dated between 11/2024 to 1/2025, Resident 213's MAR, dated between 11/2024 too 1/2025, and Care Plans were reviewed. LVN 5 stated there were multiple instances that insulin administrations were not rotated on the resident. LVN 5 stated the administration sites of insulin should be rotated to prevent bruising, lipodystrophy, and denting of the resident's skin. During an interview, on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the administration sites of insulin should be rotated to prevent complications such as DVT, bruising, and lipodystrophy. During a review of the facility's recent P&P titled, Insulin Administration, last reviewed on 4/18/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility-provided Highlights of Prescribing Information on the use of Lantus (insulin glargine) injection, for subcutaneous use, with initial U.S. approval in 2000, the highlights of prescribing information indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. During a review of the facility-provided Information for the Physician on the use of Humulin R, Regular Insulin Human Injection, USP (rDNA origin) 100 units per ml (U-100), issued March 2011, the information for the Physician indicated Humulin R U-100 may be administered by subcutaneous injection in the abdominal wall, the thigh, the gluteal region or in the upper arm. Injection sites should be rotated within the same region. 2.c. During a review of Resident 96's admission Record, the admission Record indicated the facility admitted the resident on 8/28/2019, and readmitted the resident on 11/7/2019, with diagnoses including DM 2 with diabetic neuropathy, and DM 2 with diabetic chronic kidney disease (a kidney disease that develops in people with diabetes). During a review of Resident 96's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and understand others and had severe cognitive impairment. The MDS indicated the resident was on a high-risk drug class hypoglycemic medication. During a review of Resident 96's Order Summary Report, the Order Summary Report indicated an order for: - 1/26/2023 Humulin R Injection Solution 100 unit/ml (Insulin Regular [Human]). Inject as per sliding scale: if 70-140= 0 units. Notify MD if BS is <70. Give OJ if responsive; 141-200= 4 units; 201-250= 6 units; 251-300= 8 units; 301-350= 10 units; 351-400=12 units; 401+= 14 units. Give 14 units if BS>400. Notify MD, subcutaneously before meals and at bedtime for Diabetes. Rotate injection sites. - 4/11/2024 Humulin N Subcutaneous Suspension 100 unit/ml (Insulin NPH (Human) (Isophane)). Inject 30 unit subcutaneously two times a day for Diabetes. Hold for BS <100. Rotate injection sites. - 5/10/2024 Lantus Subcutaneous Solution 100 unit/ml (Insulin Glargine). Inject 5 unit subcutaneously at bedtime for Diabetes. Hold for BS <100. Rotate injection sites. During a review of Resident 96's Location of Administration Report for Insulin for 12/2024, the Location of Administration Report for Insulin indicated- 1. Lantus Subcutaneous Solution 100 unit/ml was administered on: 12/17/2024 at 9:18 p.m. on the Arm - left 12/18/2024 at 9:05 p.m. on the Arm - left 2. Humulin N Subcutaneous Suspension 100 unit/ml was administered on: 12/08/2024 at 4:14 p.m. on the Abdomen - LLQ 12/09/2024 at 4:05 p.m. on the Abdomen - LLQ 12/23/2024 at 5:02 p.m. on the Abdomen - LUQ 12/24/2024 at 6:32 a.m. on the Abdomen - LUQ 12/25/2024 at 6:30 a.m. on the Abdomen - LUQ 3. Humulin R Injection Solution 100 unit/ml was administered on: 12/2/2024 at 4:30 p.m. on the Arm - right 12/3/2024 at 6:32 a.m. on the Arm - right 12/4/2024 at 10:48 p.m. on the Arm - left 12/6/2024 at 11:41 a.m. on the Arm - left 12/21/2024 at 9:33 p.m. on the Abdomen - LUQ 12/22/2024 at 6:30 a.m. on the Abdomen - LUQ During a concurrent interview and record review, on 1/16/2025, at 3:58 p.m., with LVN 5, Resident 96's Order Summary Report, dated 1/26/2023, 4/11/2024, and 5/10/2024, Resident 96's Location of Administration of Insulin, dated 12/2024, MAR, dated 12/2024, and Care Plans were reviewed. LVN 5 stated there were multiple instances that insulin administrations were not rotated on the resident. LVN 5 stated the administration sites of insulin should be rotated to prevent bruising, lipodystrophy, and denting of the resident's skin. During an interview, on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the administration sites of insulin should be rotated to prevent complications such as DVT, bruising, and lipodystrophy. During a review of the facility's recent P&P titled, Insulin Administration, last reviewed on 4/18/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility-provided Information for the Patient 10 ml Vial (1000 Units per vial) Humulin N NPH Human Insulin (rDNA Origin) Isophane Suspension 100 Units per ml (U-100), copyright 1997, the information for patient indicated to avoid tissue damage, choose a site for each injection that is at least 1/2 inch from the previous injection site. The usual sites of injection are abdomen, thighs, and arms. During a review of the facility-provided Highlights of Prescribing Information on the use of Lantus (insulin glargine) injection, for subcutaneous use, with initial U.S. approval in 2000, the highlights of prescribing information indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. During a review of the facility-provided Information for the Physician on the use of Humulin R, Regular Insulin Human Injection, USP (rDNA origin) 100 units per ml (U-100), issued March 2011, the information for the Physician indicated Humulin R U-100 may be administered by subcutaneous injection in the abdominal wall, the thigh, the gluteal region or in the upper arm. Injection sites should be rotated within the same region. 2.d. During a review of Resident 73's admission Record, the admission Record indicated the facility admitted the resident on 10/2/2024, with diagnoses including DM 2 with diabetic polyneuropathy (a complication of diabetes that damages nerves in the hands, feet, legs, and arms), anemia, and displaced intertrochanteric fracture (a break in the bone where the broken bone has shifted or separated) of right femur (he thigh bone on the right side of the body). During a review of Resident 73's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition. The MDS indicated the resident was on a high-risk drug class hypoglycemic medication. During a review of Resident 73's Order Summary Report, dated 10/2/2024, the Order Summary Report indicated an order for: - Humulin R Injection Solution 100 unit/ml (Insulin Regular (Human)). Inject as per sliding scale: if 70 - 149 = 0 units Notify MD if BS is <70. Give OJ if responsive.; 150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 7 units; 300 - 349 = 10 units; 350+ = 12 units Give 12 units if BS is >350. Notify MD., subcutaneously before meals and at bedtime for Diabetes Rotate injection sites. - Humulin R Injection Solution 100 unit/ml (Insulin Regular (Human)). Inject as per sliding scale: if 70 - 149 = 0 units Notify MD if BS is <70. Give OJ if responsive.; 150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 7 units; 300 - 349 = 10 units; 350+ = 12 units Give 12 units if BS is >350. Notify MD., subcutaneously before meals and at bedtime for Diabetes Rotate injection sites. - Heparin Sodium (Porcine) Injection Solution 5000 unit/ml (Heparin Sodium [Porcine]). Inject 1 ml subcutaneously every 12 hours for DVT prophylaxis (reduces the risk of developing deep vein thrombosis through medications, compression stockings, and devices). Rotate injection sites. During a review of Resident 73's Location of Administration Report for Insulin and Heparin for 11/2024 to 1/2025, the Location of Administration Report for Insulin and Heparin indicated- 1. Heparin Sodium (Porcine) Injection Solution 5000 unit/ml was administered on: 11/19/2024 at 11:03 p.m. on the Abdomen - LLQ 11/20/2024 at 11:03 p.m. on the Abdomen - LLQ 11/22/2024 at 2:23 p.m. on the Abdomen - LUQ 11/22/2024 at 8:44 p.m. on the Abdomen - LUQ 12/19/2024 at 8:22 a.m. on the Abdomen - RUQ 12/19/2024 at 8:28 p.m. on the Abdomen - RUQ 2. Humulin R Injection Solution 100 unit/ml was administered on: 12/1/2024 at 11:26 a.m. on the Arm - right 12/2/2024 at 9 p.m. on the Arm - right 12/3/2024 at 4:53 p.m. on the Arm - right 12/3/2024 at 8:57 p.m. on the Arm - right 12/19/2024 at 9:07 p.m. on the Arm - left 12/22/2024 at 12:29 p.m. on the Arm - left 12/22/2024 at 9:10 p.m. on the Abdomen - LUQ 12/23/2024 at 7:47 a.m. on the Abdomen - LUQ 3. Humulin 70/30 Subcutaneous Suspension (70-30) 100 unit/ml was administered on: 1/6/2025 at 6:07 a.m. on the Abdomen - LLQ 1/6/2025 at 4:53 p.m. on the Abdomen - LLQ During a concurrent interview and record review, on 1/16/2025, at 3:58 p.m., with LVN 5, Resident 73's Order Summary Report, dated 10/2/2024, Resident 73's Location of Administration of Insulin, dated between 11/2024 to 1/2025, Resident 73's MAR, dated between 11/2024 to 1/2025, and Care Plans were reviewed. LVN 5 stated there were multiple instances that insulin and heparin administrations were not rotated on the resident. LVN 5 stated the administration sites of insulin and heparin should be rotated to prevent bruising, lipodystrophy, and denting of the resident's skin. During an interview on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the administration sites of insulin and heparin should be rotated to prevent complications such as DVT, bruising, and lipodystrophy. During a review of the facility's recent P&P titled, Insulin Administration, last reviewed on 4/18/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility-provided Manufacturer's Specification on the use of Heparin Sodium Injection, USP, undated, the manufacturer's specification indicated a different side should be used for each injection to prevent the development of massive hematoma. During a review of the facility-provided Information for the Physician on the use of Humulin R, Regular Insulin Human Injection, USP (rDNA origin) 100 units per ml (U-100), issued March 2011, the information for the Physician indicated Humulin R U-100 may be administered by subcutaneous injection in the abdominal wall, the thigh, the gluteal re[TRUNCATED]

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0694 (Tag F0694)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure parenteral fluids (are liquids that are administered intravenously or by injection to bypass the digestive system) were administered consistent with professional standards of practice: 1. For one (1) out of 1 sampled resident (Resident 55) investigated during a random observation when Resident 55's intravenous fluid (IVF) did not indicate the date and time it was started and the licensed nurse's initials on the label. This deficient practice had the potential to place Resident 452 at risk for developing complications such as inflammation of the vein and infection. 2. For 1 of 1 sampled resident (Resident 111) investigated under peripheral intravenous catheter (PIVC, a thin, flexible tube that is inserted into a vein through the skin to administer fluids, medications, or blood products) by failing to: a. Clarify with the primary physician if the midline catheter (a long, thin, flexible tube inserted into a vein in the upper arm) was still needed in the facility. b. Change the dressing of the midline catheter of the resident, dated 1/6/2024 on the day of observation. c. Flush the 2 infusion ports (a small medical device that allows healthcare providers to access a vein and give fluids and medications) of the midline catheter with normal saline routinely and after accessing the infusion ports. These deficient practices had the potential to result in Resident 111's midline catheter site to develop an infection. Findings: a. During a review of Resident 55's admission Record, the admission Record indicated the facility admitted the resident on 7/29/2022 with diagnoses including type 2 diabetes mellitus (a chronic disease that occurs when the body does not produce enough insulin or does not use it properly), hypertension (HTN - high blood pressure), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 55's History and Physical (H&P) dated 7/19/2024, the (H&P) indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 55's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 11/5/2024, the MDS indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 55 required set up or clean up assistance with eating, partial/moderate assistance with bathing, upper and lower body dressing, and ambulation; supervision or touching assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 55's Order Summary Report, the Order Summary Report indicated a physician's order dated 1/14/2025: - Sodium Chloride Intravenous Solution 0.9% (NS - a solution often used to restore blood volume and provide hydration in cases of dehydration, low blood volume, or fluid loss due to bleeding or burns). Use 75 milliliter per hour (ml/hr) intravenously every shift for electrolyte imbalance (a condition that occurs when certain mineral levels in the blood get too high or too low when a person lose a large amount of body fluids such as sweating or vomiting) for 1 liter only. During a concurrent observation and interview on 1/15/2024 at 9:13 a.m. inside Resident 55's room with Registered Nurse 3 (RN 3), observed a bag of Sodium Chloride Intravenous Solution infusing at 75 ml/hr via pump and did not indicate on the label the start date and time and initials of the licensed nurse. RN 3 stated licensed nurses are supposed to indicate in the label the date and time the infusion was started and the initials of the licensed nurse who started it. RN 3 stated he was the one who started Resident 55's infusion. RN 3 stated he should have indicated in the label the date and time he started the infusion and his initials. RN 3 stated the purpose of indicating the date and time and initials of the licensed nurse is so all the staff would be aware of when it was started which can lead to complications. During an interview on 1/17/2025, at 3:38 p.m., with the Director of Nursing (DON), the DON stated when administering intravenous solutions, the licensed nurses should indicate in the label the date and time the bad was started and indicate the initials of the licensed nurse. The DON stated the licensed nurse who started the infusion should have indicated in Resident 55's intravenous solution bag the date and time it was started and the licensed nurse's initials to ensure all staff are aware of when the IV was started to prevent complications and to ensure the infusion was accurate. During a review of the facility's policy and procedure (P&P) titled, Peripheral I.V.: Continuous Infusion, last reviewed 4/18/2024, the P&P indicated a purpose to infuse liquids and electrolytes through a cannula directly in the vein to replace water and electrolyte losses from the body and provide a vehicle for the administration of medications. The P&P further indicated to label the administration set and container with time, date, and initials of the nurse. b. During a review of Resident 111's admission Record, the admission Record indicated the facility admitted the resident on 1/18/2023, and readmitted the resident on 12/14/2024, with diagnoses including cellulitis (a bacterial infection that affects the skin and underlying tissue) of left lower limb and peripheral vascular disease (PVD, a slow and progressive disorder of the blood vessels). During a review of Resident 111's MDS dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (a participant who has sufficient judgment, planning, organization, self-control, and the persistence needed to manage the normal demands of the participant's environment). The MDS indicated the resident had intravenous (IV, within a vein) medications. During a review of Resident 111's Order Summary Report, the Order Summary Report indicated an order for: 12/16/2024 Flush each lumen (infusion ports) with 3 cubic centimeters (cc, a unit of measurement for volume) of 0.9% sodium chloride (NaCl, mixture of water and salt) before and after each meds. 1/16/2025 Central Line Care- change transparent dressing and injection cap/extension every 7 days and if needed (PRN) if integrity is compromised as needed and every day and evening shift every 7 day(s). During a review of Resident 111's Care Plan (CP) titled Vascular Access: Resident is at risk for complications due to the presence of a midline for treatment if long term IV antibiotic therapy, last revised on 12/16/2024, the CP indicated an intervention to flush IV access per physician orders and keep IV site dressing dry and intact. During a concurrent observation and interview on 1/14/2025, at 12:20 p.m., with the Registered Nurse 4 (RN 4), inside Resident 11's room, observed Resident's midline catheter with transparent dressing dated 1/6/2025, soaked with bloody drainage and the infusion ports had bloody backflow. RN 4 stated the dressing should be changed every 7 days and PRN. RN 4 stated the dressing should have been changed on 1/13/2025. RN 4 also stated the infusion ports should be flushed routinely and before and after medications were administered on the ports. RN 4 stated it was important to keep the dressing clean and dry, ports flushed without blood backflow to prevent infection and to keep the line patent and intact. During an interview on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the dressing of the midline catheter should be changed every 7 days or PRN when soiled to prevent infection and the infusion ports should be flushed routinely, before and after administering medications to prevent clogging of the line. During a review of the facility's recent policy and procedure (P&P) titled, Guidelines for Preventing Intravenous Catheter -Related Infections, last reviewed 4/18/2024, the P&P indicated the purpose of this procedure is to maximally reduce the risk of infection associated with indwelling intravenous (IV) catheters. Change TSM dressings on CVADs every 5-7 days or PRN if damp, loosened, or visibly soiled. This does not require a physician's order. Replace transparent dressings on tunneled or implanted CVCs every 5-7 days unless the dressing is loose or soiled.

CONCERN (E)

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

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review the facility failed to ensure the safe and appropriate use of side rails (SR, adjustable rigid plastic or metal bars attached to the bed that may be positioned in various locations on the bed; upper or lower, either or both sides) for one of nine sampled residents (Resident 39) reviewed under the Restraints care area by failing to: 1. Attempt to use appropriate alternatives prior to installing bilateral lower (at the leg area) SRs. 2. Conduct an assessment including the risk for entrapment (occurs when a resident is caught between the mattress and bed rail or within the bed rail itself) from bilateral lower SRs use. 3. Review the risk and benefits of bilateral lower SRs with the resident or resident representative and obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered). These deficient practices had the potential to result in psychosocial harm, physical harm from entrapment and death of residents. Findings: During a review of Resident 39's admission Record, the admission Record indicated the facility admitted the resident on 6/4/2024 with diagnoses that included osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of vertebra (bones of spine), sacral and sacrococcygeal region (base of spine at the tailbone), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (partial paralysis or weakness on one side of the body) following cerebral infarction (CVA-stroke, loss of blood flow to a part of the brain) affecting the right dominant side, cognitive communication deficit (trouble communicating due to problems with thinking skills), and depression. During a review of Resident 39's Minimum Data Set (MDS - resident assessment tool) dated 12/11/2024, the MDS indicated the resident was able to understand others and was able to make herself understood. The MDS further indicated the resident required partial/moderate assistance from staff for toileting and required substantial/maximal assistance for bathing, dressing, personal hygiene, and mobility while in bed. During a review of Resident 39's History and Physical (H&P), dated 6/7/2024, the H&P indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 39's Order Summary Report, the report indicated an order for two, top quarter SRs up for mobility/enabler (safety), every shift, dated 6/4/2024. During a review of Resident 39's Nursing Bed Rail Observation Assessment, dated 6/4/2024, the assessment indicated informed consent was received by the resident's representative after a discussion regarding the risk and benefits of the use of the recommended left and right upper SRs that did not impede the resident's freedom of movement. During a concurrent observation and interview on 1/14/2025 at 12:14 p.m., with Resident 39, Resident 39 lay in bed with four SRs (bilateral upper and bilateral lower) in the raised position. Observed Certified Nursing Assistant 6 (CNA 6) entered the resident's room, spoke to the resident, and then exited. Resident 39 stated the staff puts the SRs up and she cannot remove them. During an interview on 1/14/2025 at 12:22 p.m. with CNA 6, CNA 6 stated Resident 39 must have four SRs up to prevent her from falling out of the bed because the resident leans to the left and moves her feet. During an observation on 1/15/2025 at 7:45 a.m., observe Resident 39 in bed with fours SRs in the raised position. During a concurrent observation, interview, and record review on 1/16/2025 at 9:19 a.m., with CNA 6 and Licensed Vocational Nurse 13 (LVN 13), LVN 13 reviewed Resident 39's physician orders. Observed LVN 13 at Resident 39's room entry. Observed Resident 39 with four SRs in the raised position. LVN 13 stated she did not know why Resident 39 had four SRs up because the resident had a physician's order for only two SRs. LVN 13 stated CNA 6 was also caring for Resident 39 and CNA 6 did not mention the resident needed four SRs. CNA 6 approached LVN 13 and stated Resident 39 requested to have the four SRs in the raised position to prevent falls. LVN 13 stated SRs should not be used as a fall prevention strategy. LVN 13 stated there was no need for Resident 39 to have four SRs in the raised position. LVN 13 stated CNA 6 should have communicated that Resident 39 requested to have the four SRs up because there is a process to follow for the use of SRs. LVN 13 stated if the resident requested four SRs, the physician should be notified and the resident should be assessed for safety. During a concurrent interview and record review on 1/16/2025 at 9:48 a.m., with Licensed Vocational Nurse 14 (LVN 14), LVN 14 reviewed Resident 39's physician orders, Care Plans, and Nursing Bed Rail Observation Assessment, dated 6/4/2024. LVN 14 stated Resident 39 had an order, was care planned, and assessed and consented for the use of two upper SRs only. LVN 14 stated there was no documentation to indicate the resident requested to have four SRs. LVN 14 stated if Resident 39 requested for four SRs, then the resident needed to be re-evaluated. LVN 14 stated the importance of the safety evaluation is to make sure the resident would not become confined or trapped in the SRs. LVN 14 stated a bolster mattress (designed to prevent residents from falling out of bed) could be used to provide a feeling of security for the resident instead of using four SRs that pose more of a risk. LVN 14 stated when CNA 6 placed Resident 39's four SRs in the raised position there was a potential that the resident's limbs could become wedged between the mattress and SRs causing bruising or injury. During a follow up interview on 1/16/2024 at 12:27 p.m. with LVN 14, LVN 14 stated Resident 39 did not have the capacity to consent for the use of four SR's so the resident's representative was called. LVN 14 stated the representative did not consent to the use of four SRs. During a concurrent interview and record review on 1/17/2025 at 12:10 p.m. with the Director of Nursing (DON), the DON reviewed the facility policy and procedures regarding SRs. The DON stated some beds in the facility have lower SRs that cannot be removed from the bed. The DON stated CNA 6 saw the lower SRs and placed them up for Resident 39. The DON stated there is a process for the use of SRs that includes an interdisciplinary meeting to determine the safety of SR use and to explain the risk and benefits of the SRs to the resident and representative. The DON stated this process was not followed by CNA 6 for Resident 39 and could have potentially resulted in entrapment and injury of the resident. The DON stated the facility policy for SRs was not followed. During a review of the facility P&P titled, Bed Safety and Bed Rails, last reviewed 4/18/2024, the P&P indicated resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. The use of bed rails is prohibited unless the criteria for use of bed rails have been met. The resident's sleeping environment is evaluated by the interdisciplinary team. Consideration is given to the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family. Bed rails are adjustable metal or rigid plastic bars that attach to the bed. The use of bed rails or SRs is prohibited unless the criteria for the use of bed rails have been met, including attempting alternatives, interdisciplinary evaluation, resident assessment, and informed consent. Prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted. Alternatives may include roll guards, foam bumpers, lowering the bed, and the use of a concave mattress to reduce rolling off the bed.

CONCERN (E) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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Based on observation interview, and record review, the facility failed provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of one sampled resident (Resident 37) and one of three medication carts (Station 1 Cart B) investigated under the Medication Storage and Labeling task by: 1. Failing to administer Resident 37's Jardiance (hypoglycemic medication-lowers blood sugar levels) and metformin (hypoglycemic medication) medications as ordered by the physician. This deficient practice placed Resident 37 at risk for causing complications and delay in the necessary care and services the resident needs. 2. Failing to ensure licensed nurses completed the incoming and outgoing Floor Narcotic (opioid [a class of drug to reduce moderate to severe pain]) Release (a form signed by the incoming and outgoing licensed nurse after reconciling narcotic medications) on 1/14/2025 for Station 1 Cart B. This deficient practice had the potential to result in increase opportunity for medication diversion (the transfer of a medication from a lawful to an unlawful channel of distribution or use). Findings: During a review of Resident 37's admission Record, the admission Record indicated the facility admitted the resident on 6/23/2015 with diagnoses including type II diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), multiple sclerosis (MS-a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), and rheumatoid arthritis (a chronic progressive disease-causing inflammation in the joints and resulting in painful deformity and immobility). During a review of Resident 37's Minimum Data Set (MDS-a resident assessment tool), dated 10/11/2024, the MDS indicated the resident had the ability to make self understood and had the ability to understand others. The MDS indicated the resident is taking a hypoglycemic one of the high-risk drug classes. During a review of Resident 37's Order Summary Report, the Order Summary Report indicated: - Jardiance (empagliflozin) oral tablet 10 milligram (mg-a unit of measurement) give (1) tablet by mouth in the morning for diabetes, dated 12/8/2024. - Metformin hydrochloride (HCl) tablet 1000 mg, give 1000 mg by mouth in the morning related to type 2 diabetes mellitus without complications with meal, dated 1/4/2023. - Metformin HCl tablet 500 mg, give 500 mg by mouth in the evening related to type 2 diabetes mellitus without complications, dated 1/4/2023. During a review of Resident 37's care plan focusing on medication-hypoglycemic, initiated date 1/16/2025, the care plan indicated the goals of no sign/symptoms of hyperglycemia: flushed skin, dry skin, drowsiness, nausea, vomiting, abdominal pain, and increased respirations. The care plan indicated to administer medications as ordered which included Jardiance oral tablet daily and metformin HCl tablet 1000 mg in the morning and 500 mg in the evening. During an interview of Resident 137 pm 1/15/2025 at 9:28 a.m., Resident 37 stated during the 3 p.m. to 11 p.m. shift on 1/14/2025 her medication nurse could not find her metformin medication and she complained about it and later they were able to find it and gave her metformin. During a concurrent observation and interview on 1/16/2025 at 6:40 a.m., inspected Station 1 Cart B with Licensed Vocational Nurse 1 (LVN 1). LVN 1 stated she has completed medication administration for Resident 37 for medications scheduled at 6:30 a.m. LVN 1 stated she did not administer Jardiance because it was not available. LVN 1 stated Resident 37 last received Jardiance on 1/12/2025 and she submitted the refill request on 1/15/2025 and has not been delivered yet. LVN 1 stated Resident 37's metformin is in the cart, and she administered it 1/16/2025 and 1/15/2025. LVN 1 stated she did not administer metformin on 1/13/2025 and 1/14/2025. LVN 1 stated Resident 37 requested for her supervisor and Registered Nurse 1 (RN 1) spoke to the resident about her 6:30 a.m. scheduled medications. During an interview with LVN 1 on 1/16/2025 at 7:38 a.m., LVN 1 stated she was told by RN 1 that their pharmacy has ran out of Jardiance and that Resident 37's Jardiance medication would not be delivered until 1/20/2025. During an interview on 1/16/2025 at 10 a.m., Resident 37 stated she had problems with her medications again that morning when the medication nurse would not give her (Resident 37) medication, Jardiance. Resident 37 she complained about it and she spoke to RN 1. RN 1 was able to find the resident's Jardiance and administered to Resident 37. Resident 37 stated it was an ongoing issue with her medications and the facility is not doing anything about it. During a concurrent observation and interview on 1/16/2025 at 10:20 a.m., re-inspected Station 1 Cart B, with LVN 15. LVN 15 stated she completed medication administration for Resident 37. Requested to see the bubble packs (packaging that have a preformed plastic pocket or shell where a product sits securely in place) scheduled during the morning medications. LVN 15 stated Jardiance bubble pack was in her drawer, but she did not administer it because it is scheduled for 6:30 a.m. and not during her shift, 7 a.m. to 3 p.m. shift. LVN 15 stated she did not put it there and it should be placed in the 11 p.m. to 7 a.m. drawer. During an interview on 1/16/2025 at 1:23 p.m., with Registered Nurse 2 (RN 2), RN 2 stated she did not receive report from RN 1 about Resident 37's medication concerns that morning. RN 2 stated if the resident's medication needed follow-up, she would follow-up with pharmacy and ensure the resident's medication be delivered on time. During a concurrent interview and record review of Resident 37's Medication Administration Record (MAR) 1/2025, on 1/16/2025 at 1:36 p.m., with RN 2, RN 2 stated Resident 37's Jardiance and metformin did not have initials on 1/6/2025 and 1/14/2025. RN 2 stated there were no documentation in the nursing progress/narrative notes about the metformin and Jardiance on 1/6/2025, 1/13/2025, and 1/14/2025 of any explanation why the doses were not administered. RN 2 stated medications should be administered on time and as ordered. RN 2 stated when Resident 37's hypoglycemic medications are not administered as scheduled and as ordered, resident could potentially experience hyperglycemia symptoms such as cold, clammy skin, frequent urination, and/or altered level of consciousness. During a concurrent interview and record review of Resident 37's MAR for 1/2025, on 1/17/2025 at 7:01 a.m., with RN 1, RN 1 stated Resident 37 likes things done a certain way, and he (RN 1) administered Jardiance on 1/16/2025 and 1/14/2025. RN 1 stated he also administered Resident 37's metformin on 1/14/2025 but he did not sign the MAR. RN 1 stated he has access to the electronic MAR and he should have charted (documented) the MAR after he administered the medications to Resident 37. RN 1 stated the purpose of documentation is to make sure the resident is receiving the proper care including the medications. During an interview on 1/17/2025 at 4:19 p.m., with the Director of Nursing (DON), the DON stated medications are administered as ordered by the physician because it is part of the six patient rights. The DON stated when residents do not receive their medication, the resident could have an adverse effect and is a medication error. The DON stated when the licensed nurse does not document on the resident's MAR when the medication was given, then it was not done, and the medication was not given. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, last reviewed on 4/18/2024, the P&P indicated medications are administered in a safe and timely manner, and as prescribed. The P&P indicated medications are administered in accordance with prescriber orders, including any required time frame. The P&P indicated as required or indicated for a medication, the individual administering the medication records in the resident's medical record the signature and title of the person administering the drug. b. During a concurrent interview and record review of the facility's Floor Narcotic Release form 1/2025, on 1/16/2025 at 6:51 a.m., with LVN 1, LVN 1 stated there were no signatures on 1/14/2025 for retiring nurses for 7 a.m. - 3 p.m. shift and 3 p.m. - 11 p.m. shift. LVN 1 stated they are supposed to sign after they counted the narcotic medication. LVN 1 stated she does not know why it was not signed. LVN 1 stated they sign after the end of their shift and after counting the medications. During an interview on 1/16/2025 at 2:12 p.m., with RN 2, RN 2 stated the incoming and outgoing licensed nurses would count the narcotics and both licensed nurses would sign the Floor Narcotic Release form accepting the actual number on their shift for all residents that are receiving narcotic medications. RN 2 stated when the licensed nurses do not sign the Floor Narcotic Release form on their shift, it means the licensed nurse did not do the counting. RN 2 stated once the counting is done, they would sign right after they counted the narcotic medications. During a review of the facility's P&P titled, Controlled Substances, last reviewed on 4/18/2024, the P&P indicated controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. The P&P indicated nursing staff count controlled medication inventory at the end of each shift, using theses records to reconcile the inventory count.

CONCERN (E)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to unsure psychotropic drugs (a drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) were given to treat a specific condition as diagnosed and documented in the clinical record to one of 5 sampled residents (Resident 213) investigated under unnecessary medications by failing to act upon the pharmacy consultant's request from the physician to indicate the rationale for contraindication for gradual dose reduction (GDR, stepwise tapering of a dose) of Buspar (a medication that treats anxiety) and Zoloft (an antidepressant ). This deficient practice had the potential for residents receiving unnecessary medication and adverse reactions (undesirable effect). Findings: During a review of Resident 213's admission Record, the admission Record indicated the facility admitted the resident on 4/16/2024, with diagnoses including dementia (a progressive state of decline in mental abilities), major depressive disorder (a serious mental illness that causes a persistent low mood and loss of interest in activities), and generalized anxiety disorder (a mental health condition where a person experiences excessive and persistent worry about everyday things, often finding it difficult to control this anxiety, which can significantly impact their daily life). During a review of Resident 213's Minimum Data Set (MDS, a resident assessment tool), dated 10/23/2024, the MDS indicated the resident usually had the ability to make self-understood and understand others and had severe cognitive impairment (a condition that makes it difficult for a person to think, learn, remember, and make decisions). The MDS also indicated the resident was taking a high-risk drug class antianxiety (medications that treat or prevent anxiety symptoms) and antidepressant medications ( type of medicine used to treat clinical depression). During a review of Resident 213's Order Summary Report, the Order Summary Report indicated an order of: 4/25/204 Buspirone HCl Oral Tablet 5 milligrams (mg, a unit of weight) (Buspirone HCl). Give5 mg by mouth two times a day for anxiety: Inability to relax. 4/19/2024 Zoloft oral Tablet 25 mg (Sertraline HCl). Give 25 mg by mouth one time a day for depression: Verbalization of hopelessness. During a review of Resident 213's Consultant Pharmacist's Medication Regimen Review, created between 9/1/2024 and 9/24/2024, the Consultant Pharmacist's Medication Regimen Review indicated resident has not been on Buspar 5 mg twice a day (BID). Behaviors have not been seen. Recommend reduction in dose at this time. During a review of Resident 213's Psychotropic & Sedative/Hypnotic Utilization By Resident, updated between 10/1/2024 and 10/24/2204, the Psychotropic & Sedative/Hypnotic Utilization By Resident indicated the Last GDR for Buspirone Hydrochloride (Buspirone HCl tab 5 mg) and Zoloft (Sertraline HCl tab 25 mg) was last done on 9/7/2024 and it indicated contraindicated. During a concurrent interview and record review on 1/17/2025, at 3:18 p.m., with Licensed Vocational Nurse 5 (LVN 5), reviewed Resident 213's Order Summary Report, Psychiatric Notes, and Progress Notes. LVN 5 stated there was no documentation of why a GDR was not indicated on Resident 213's Zoloft and Buspar on the physical chart and on the electronic healthcare record. During a concurrent interview and record review on 1/17/2025, at 3:20 p.m., with the Director of Nursing (DON), reviewed Resident 213's Order Summary Report, Psychiatric Notes, Progress Notes, Consultant Pharmacist's Medication Regimen Review, and Psychotropic & Sedative/Hypnotic Utilization By Resident. The DON stated there was no GDR done for the resident regarding the use of Buspar and Zoloft. During a concurrent interview and record review on 1/17/2025, at 3:21 p.m., with the Assistant Administrator (AADM), the AADM found Resident 213's Consultant Pharmacist's Medication Regimen Review, created between 9/1/2024 and 9/24/2024, the Consultant Pharmacist's Medication Regimen Review indicated resident has not been on Buspar 5 mg BID. Behaviors have not been seen. Recommend reduction in dose at this time. The AADM stated the physician did not act upon the recommendation of the consultant pharmacist. During an interview on 1/17/2025, at 3:38 p.m., with the DON stated it was important to address the pharmacy consultant's recommendation for medication regimen review to prevent unnecessary medications to residents and to prevent adverse effects on the use of psychotropic medications. During a review of the facility's recent policy and procedure (P&P) titled Medication Regimen Reviews, last reviewed on 4/18/2024, the P&P indicated within 24 hours of the MMR, the Consultant Pharmacist provides a written report to the attending physicians for each resident identified as having a non-life-threatening medication irregularity. The report contains: a. The resident's name; b. The name of the medication; c. The identified irregularity; and d. The pharmacist's recommendation. The attending physician documents in the medical record that the irregularity has been reviewed and what (if any) action was taken to address it.

CONCERN (E)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free of any significant medication errors to seven (7) out of 7 sampled residents (Residents 64, 66, 73, 64, 111, 213, 96, 73, and 220) investigated under insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) and anticoagulant (blood thinner - that stops the blood from forming blood clots or making them bigger) use by: 1. Failing to rotate (a method to ensure repeated injections are not administered in the same area) the insulin administration sites for Residents 64 and 66. 2. Failing to rotate subcutaneous (beneath the skin) insulin and heparin administration sites for Residents 111, 213, 96, 73, and 220. These deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin such as excessive bruising, lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin). Cross-reference F658 Findings: 1.a. During a review of Resident 64's admission Record, the admission Record indicated the facility originally admitted the resident on 1/22/2021, and readmitted the resident on 12/26/2023, with diagnoses including type 2 diabetes mellitus (DM 2 - a chronic disease that occurs when the body does not produce enough insulin or does not use it properly) without complications, gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), and anemia (a condition where the body does not have enough healthy red blood cells). During a review of Resident 64's Minimum Data Set (MDS, a resident assessment tool), dated 11/2/2024, the MDS indicated the resident had severely impaired cognition (having the ability to think, learn, and remember clearly). The MDS indicated Resident 64 required substantial/maximal assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 64 had a diagnosis of DM 2 and received insulin. During a re view of Resident 64's History and Physical (H&P) dated 12/27/2024, the H&P indicated the resident did not have the capacity to make decisions. During a review of Resident 64's Order Summary Report, the Order Summary Report indicated the following physician's orders dated 12/26/2023: - Insulin NPH (a long-acting insulin) subcutaneous suspension 100 unit per milliliter (unit/ml - a unit of measurement). Inject 20 units subcutaneously two times a day for DM 2. Rotate Injection Sites. Give with meals. - Insulin regular human solution (a short-acting insulin) 100 unit/ml. Inject subcutaneously before meals and at bedtime for DM 2. Give 12 units if blood sugar (BS) is more than (>) 350 and notify physician (MD). Inject as per sliding scale (increasing administration of the pre?meal insulin dose based on the blood sugar level before the meal): if 70 - 149 = 0, if BS less than (<)70 give orange juice via gastrostomy tube if responsive and notify MD.; 150 - 199 = 1; 200 - 249 = 3; 250 - 299 = 5; 300 - 349 = 7; 350+ = 8. Give 12 units if BS is >350 and notify MD. During a concurrent interview and record review, on 1/16/2025, at 2:30 p.m., with Licensed Vocational Nurse (LVN) 9, Resident 64's Order Summary Report, dated 12/26/2023, Resident 64's Medication Administration Record (MAR - a daily documentation records used by a licensed nurse to document medications and treatments given to a resident), and Resident 64's Location of Administration Report, dated between 11/2024 to 1/2025, was reviewed and LVN 9 verified Resident 64 had a physician's order for NPH and regular insulin and were administered as follows: - Insulin regular human solution 100 unit/ml: 12/22/24 5:19 p.m. subcutaneously Abdomen - right upper quadrant (RUQ) 12/23/24 5:18 p.m. subcutaneously Abdomen - RUQ 12/27/24 8:27 a.m. subcutaneously Arm - left 12/29/24 3:58 p.m. subcutaneously Arm - left 1/06/25 4:12 p.m. subcutaneously Abdomen -RUQ 1/07/25 5:10 p.m. subcutaneously Abdomen - RUQ - Insulin NPH suspension 100 unit/ml: 11/26/24 7:56 a.m. subcutaneously Abdomen - left upper quadrant (LUQ) 11/26/24 8:55 p.m. subcutaneously Abdomen - LUQ 12/21/24 5:58 a.m. subcutaneously Abdomen - right lower quadrant (RLQ) 12/21/24 8:53 p.m. subcutaneously Abdomen - RLQ 12/27/24 8:29 a.m. subcutaneously Abdomen -LUQ 12/27/24 7:53 p.m. subcutaneously Abdomen - LUQ LVN 9 stated insulin administration sites should be rotated per standards of practice, manufacturer's guidelines, and according to physician's orders. LVN 9 verified Resident 64's MAR indicated the insulin administration sites were not rotated and that there was a physician's order to rotate injection sites. LVN 9 stated the insulin administration sites should have been rotated as ordered by the physician to prevent pain, redness, irritation, lipodystrophy, and denting of the resident's skin. LVN 9 stated not rotating insulin administration sites is considered a medication error due to not following physician's order, manufacturer's recommendation, and standards of practice. During an interview, on 1/17/2025, at 3:38 p.m., with the Director of Nursing (DON), the DON stated the administration sites of insulin should be rotated to prevent complications such as bruising, and lipodystrophy. The DON stated not rotating insulin administration sites is considered a medication error due to not following physician's order, manufacturer's recommendation, and standards of practice. During a review of the facility's recent policy and procedure (P&P) titled, Medication Errors and Adverse Consequences, last reviewed on 4/18/2024, the P&P indicated a medication error is defines as the preparation or administration of drugs and biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility's P&P titled, Insulin Administration, last reviewed on 4/18/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. The P&P further indicated: a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided manufacturer's guideline on, Humulin R Regular Insulin Huma Injection, undated, the manufacturer's guideline indicated Humulin R may be administered by subcutaneous injection in the abdominal wall, the thigh, the gluteal region, or in the upper arm. The manufacturer's guideline further indicated injection sites should be rotated within the same region and the following common side effects: - Skin thickening or pits at the injection site (lipodystrophy). Change (rotated) where to inject the insulin to help prevent lipodystrophy from happening. Do not inject into the exact spot for each injection. - Injection site reactions (local allergic reaction). Symptoms may include redness, swelling and itching at the injection site. During a review of the facility provided manufacturer's guideline on Humulin N Pen NPH Human Insulin, undated, the manufacturer's guideline indicated side effects include injection site reactions such as pian, redness, and irritation. The manufacturer's guideline further indicated adverse reactions include lipodystrophy and localized cutaneous amyloidosis. 1.b. During a review of Resident 66's admission Record, the admission Record indicated the facility originally admitted the resident on 9/27/2024, and readmitted the resident on 12/18/2024, with diagnoses including DM 2 with foot ulcer, neuromuscular disorder of the bladder (lack bladder control due to a brain, spinal cord or nerve problem), and pressure ulcer (injuries to the skin and the tissue below the skin that are due to pressure on the skin for a long time) of left buttock. During a review of Resident 66's Minimum Data Set (MDS, a resident assessment tool) , dated 12/24/2024, the MDS indicated the resident had severely impaired cognition (having the ability to think, learn, and remember clearly). The MDS indicated Resident 66 required substantial/maximal assistance from staff with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 66 had a diagnosis of DM 2 and received insulin. During a review of Resident 66's MDS, dated [DATE], the MDS indicated the resident had severely impaired cognition (having the ability to think, learn, and remember clearly). The MDS indicated Resident 66 required substantial/maximal assistance from staff with all ADLs. The MDS indicated Resident 66 had a diagnosis of DM 2 and received insulin. During a review of Resident 66's Order Summary Report, the Order Summary Report indicated the following physician's orders: - 9/8/2024: Humalog solution (a fast-acting insulin) 100 unit per milliliter (unit/ml - a unit of measurement) (insulin lispro). Inject as per sliding scale (increasing administration of the pre?meal insulin dose based on the blood sugar level before the meal): if 0 - 150 = 0 units; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351 - 400 = 10 units, subcutaneously before meals and at bedtime for DM 2. - 12/28/2024: Humalog injection solution 100 unit/ml (insulin lispro). Inject subcutaneously before meals and at bedtime for DM 2 Rotate injection sites. Inject as per sliding scale: if 70 - 149 = 0 units. Notify physician (MD) if blood sugar (BS) is less than 70. Give orange juice if alert, responsive, and able to swallow; 150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 7 units; 300 - 349 = 10 units; 350+ = 12 units. Give 12 units if BS is greater than 401 and notify MD, subcutaneously before meals and at bedtime. During a concurrent interview and record review, on 1/16/2025, at 2:45 p.m., with LVN 9, Resident 66's Order Summary Report, dated 9/8/2024 and 12/28/2024, and Resident 66's MAR and Location of Administration Report, dated between 11/2024 to 1/2025, were reviewed and LVN 9 verified Resident 66 had a physician's order for Humalog insulin and were administered as follows: 11/19/24 9:40 p.m. subcutaneously Abdomen - left lower quadrant (LLQ) 11/20/24 6:30 a.m. subcutaneously Abdomen - LLQ 11/25/24 11:28 a.m. subcutaneously Abdomen -RLQ 11/25/24 10:20 p.m. subcutaneously Abdomen - RLQ 11/27/24 9:33 p.m. subcutaneously Abdomen - LLQ 11/28/24 5:20 a.m. subcutaneously Abdomen - LLQ 11/29/24 8:48 p.m. subcutaneously Abdomen - LLQ 12/02/24 4:42 p.m. subcutaneously Abdomen - LLQ 12/02/24 9:32 p.m. subcutaneously Abdomen - LLQ 12/07/24 2:17 p.m. subcutaneously Abdomen - LLQ 12/07/24 5:47 p.m. subcutaneously Abdomen - LLQ 12/07/24 10:45 p.m. subcutaneously Abdomen - LLQ 12/28/24 11:29 a.m. subcutaneously Abdomen - LLQ 12/29/24 11:36 a.m. subcutaneously Abdomen - LLQ 12/30/24 12:27 p.m. subcutaneously Abdomen - LLQ 12/31/24 11:41 a.m. subcutaneously Abdomen - LLQ 01/03/25 12:20 p.m. subcutaneously Abdomen - LLQ 01/04/25 4:23 a.m. subcutaneously Abdomen - LLQ 01/09/25 12:26 p.m. subcutaneously Abdomen - LLQ 01/10/25 11:14 a.m. subcutaneously Abdomen - LLQ LVN 9 stated insulin administration sites should be rotated per standards of practice, manufacturer's guidelines, and according to physician's orders. LVN 9 verified Resident 66's MAR indicated the insulin administration sites were not rotated and that there was a physician's order to rotate injection sites. LVN 9 stated the insulin administration sites should have been rotated as ordered by the physician to prevent pain, redness, irritation, lipodystrophy, and denting of the resident's skin. LVN 9 stated not rotating insulin administration sites is considered a medication error due to not following physician's order, manufacturer's recommendation, and standards of practice. During a review of the facility's recent P&P titled, Medication Errors and Adverse Consequences, last reviewed on 4/18/2024, the P&P indicated a medication error is defines as the preparation or administration of drugs and biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility's recent P&P titled, Insulin Administration, last reviewed on 4/18/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility provided manufacturer's guideline on insulin Aspart (Humalog - a fast-acting insulin), undated, the manufacturer's guideline indicated to change (rotate) injection site within the chosen area such as stomach or upper arm with each dose and do not inject into the exact same sport for each injection. The manufacturer's guideline further indicated the following side effects: - Reactions at the injection site such as redness, swelling, and itching. - Skin thickens or pits at the injection site (lipodystrophy). Change (rotate) the injection site to help prevent lipodystrophy from happening. 2.a. During a review of Resident 111's admission Record, the admission Record indicated the facility admitted the resident on 1/18/2023, and readmitted the resident on 12/14/2024, with diagnoses including DM 2 with foot ulcer and DM 2 with diabetic neuropathy (nerve damage caused by diabetes). During a review of Resident 111's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had an intact cognition (having the ability to think, learn, and remember clearly). The MDS indicated the resident was on a high-risk drug class hypoglycemic medication (drugs that lower blood sugar levels and are used to treat diabetes). During a review of Resident 111's Order Summary Report, the Order Summary Report indicated an order of: 12/15/2024 Insulin Aspart Injection Solution 100 unit (a standard measurement of the insulin's biological activity, essentially representing the amount of insulin needed to produce a specific effect on blood sugar levels)/ milliliters (ml, a unit used to measure capacity) (Insulin Aspart). Inject as per sliding scale (the increasing administration of the pre?meal insulin dose based on the blood sugar level before the meal): if 70 - 149 = 0 Units If blood sugar (BS) is less than (<)70 Give orange juice (OJ) if responsive and notify MD.; 150 - 199 = 1 Unit; 200 - 249 = 3 Units; 250 - 299 = 5 Units; 300 - 349 = 7 Units; 350+ = 8 Units If BS is greater than (>)350+ Give 8 Units and notify MD., subcutaneously before meals and at bedtime for Diabetes. Rotate injection sites. 12/15/2024 Lantus (a long-acting insulin) Subcutaneous Solution 100 unit/ml (Insulin Glargine). Inject 10 unit subcutaneously two times a day for type 2 DM. Give with meals. During a review of Resident 111's Location of Administration Report for Insulin, dated between 12/2024 to 1/2025, the Location of Administration Report for Insulin indicated: 1. Lantus Subcutaneous Solution 100 unit/ml was given subcutaneously on: 12/17/2024 at 7:49 p.m. on the Abdomen - RLQ 12/18/2024 at 11:13 a.m. on the Abdomen - RLQ 2. Aspart Injection Solution 100 unit/ml was given subcutaneously on: 1/1/2025 at 8:54 p.m. on the Abdomen - LLQ 1/1/2025 at 10:36 p.m. on the Abdomen - LLQ 1/3/2025 at 11:52 a.m. on the Abdomen - RUQ 1/3/2025 at 4:32 p.m. on the Abdomen - RUQ 1/12/2025 at 5:09 p.m. on the Abdomen - LLQ 1/12/2025 at 9:01 p.m. on the Abdomen - LLQ During a concurrent interview and record review, on 1/16/2025, at 3:58 p.m., with LVN 5, Resident 111's Order Summary Report, dated 12/15/2024, Resident 111's Location of Administration of Insulin, dated between 12/2024 to 1/2025, MAR, dated between 12/2024 to 1/2025, and Care Plans were reviewed. LVN 5 stated there were multiple instances that insulin administrations were not rotated on the resident. LVN 5 stated the administration sites of insulin should be rotated to prevent bruising, lipodystrophy, and denting of the resident's skin. LVN 5 stated not rotating insulin administration sites is considered a medication error. During an interview, on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the administration sites of insulin should be rotated to prevent complications such as deep vein thrombosis (DVT, a blood clot that forms in a deep vein in the body), bruising, and lipodystrophy. The DON stated not rotating insulin administration sites is considered a medication error. During a review of the facility's recent P&P, titled Medication Errors and Adverse Consequences, last reviewed on 4/18/2024, the P&P indicated a medication error is defines as the preparation or administration of drugs and biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility's recent P&P titled, Insulin Administration, last reviewed on 4/18/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). 2.b. During a review of Resident 213's admission Record, the admission Record indicated the facility admitted the resident on 4/16/2024, with diagnoses including DM 2, dementia (a progressive state of decline in mental abilities), and atrial fibrillation (a condition where the heart's upper chambers beat irregularly and often too fast). During a review of Resident 213's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and understand others and had severe cognitive impairment (a condition that makes it difficult for a person to think, learn, remember, and make decisions). The MDS indicated the resident was on a high-risk drug class hypoglycemic medication (drugs that lower blood sugar levels and are used to treat diabetes). During a review of Resident 213's Order Summary Report, dated 4/16/2024, the Order Summary Report indicated an order for: - Humulin R Injection Solution 100 unit/ml (Insulin Regular [Human]). Inject as per sliding scale: if 70 - 149 = 0 units Notify MD if BS is <70. Give OJ if responsive.; 150 - 199 = 1 unit; 200 - 249 = 2 units; 250 - 299 = 3 units; 300 - 349 = 4 units; 350+ = 5 units Give 5 units if BS is >350. Notify MD., subcutaneously before meals and at bedtime for Diabetes. Rotate injection sites. - Lantus Subcutaneous Solution 100 unit/ml (Insulin Glargine). Inject 10 unit subcutaneously every 12 hours for Diabetes. Rotate injection sites. During a review of Resident 213's Location of Administration Report for Insulin, dated between 11/2024 to 1/2025, the Location of Administration Report for Insulin indicated: 1. Lantus subcutaneous solution 100 unit/ml was administered on: 11/7/2024 at 8:58 a.m. on the Abdomen - LLQ 11/7/2024 at 9:23 p.m. on the Abdomen - LLQ 2. Humulin R Injection Solution 100 unit/ml was administered on: 11/5/2024 at 9:37 p.m. on the Arm - right 11/6/2024 at 5:10 p.m. on the Arm - right 11/12/2024 at 9:15 p.m. on the Abdomen - LUQ 11/15/2024 at 9:37 p.m. on the Abdomen - LUQ 11/20/2024 at 6:55 p.m. on the Abdomen - LLQ 11/20/2024 at 8:20 p.m. on the Abdomen - LLQ 11/28/2024 at 4:14 p.m. on the Arm - right 11/28/2024 at 12:14 a.m. on the Arm - right During a concurrent interview and record review, on 1/16/2025, at 3:58 p.m., with LVN 5, Resident 213's Order Summary Report, dated 4/16/2024, Resident 213's Location of Administration of Insulin, dated between 11/2024 to 1/2025, Resident 213's MAR, dated between 11/2024 to 1/2025, and Care Plans were reviewed. LVN 5 stated there were multiple instances that insulin administrations were not rotated on the resident. LVN 5 stated the administration sites of insulin should be rotated to prevent bruising, lipodystrophy, and denting of the resident's skin. LVN 5 stated not rotating insulin administration sites is considered a medication error. During an interview, on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the administration sites of insulin should be rotated to prevent complications such as DVT, bruising, and lipodystrophy. The DON stated not rotating insulin administration sites is considered a medication error. During a review of the facility's recent P&P titled, Medication Errors and Adverse Consequences, last reviewed on 4/18/2024, the P&P indicated a medication error is defines as the preparation or administration of drugs and biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility's recent P&P, titled Insulin Administration, last reviewed on 4/18/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility-provided Highlights of Prescribing Information on the use of Lantus (insulin glargine) injection, for subcutaneous use, with initial U.S. approval in 2000, the highlights of prescribing information indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. During a review of the facility-provided Information for the Physician on the use of Humulin R, Regular Insulin Human Injection, USP (rDNA origin) 100 units per ml (U-100), issued March 2011, the information for the Physician indicated Humulin R U-100 may be administered by subcutaneous injection in the abdominal wall, the thigh, the gluteal region or in the upper arm. Injection sites should be rotated within the same region. 2.c. During a review of Resident 96's admission Record, the admission Record indicated the facility admitted the resident on 8/28/2019, and readmitted the resident on 11/7/2019, with diagnoses including DM 2 with diabetic neuropathy, and DM 2 with diabetic chronic kidney disease (a kidney disease that develops in people with diabetes). During a review of Resident 96's MDS, dated [DATE], the MDS indicated the resident usually had the ability to make self-understood and understand others and had severe cognitive impairment. The MDS indicated the resident was on a high-risk drug class hypoglycemic medication. During a review of Resident 96's Order Summary Report, the Order Summary Report indicated an order for: - 1/26/2023 Humulin R Injection Solution 100 unit/ml (Insulin Regular [Human]). Inject as per sliding scale: if 70-140= 0 units. Notify MD if BS is <70. Give OJ if responsive; 141-200= 4 units; 201-250= 6 units; 251-300= 8 units; 301-350= 10 units; 351-400=12 units; 401+= 14 units. Give 14 units if BS>400. Notify MD, subcutaneously before meals and at bedtime for Diabetes. Rotate injection sites. - 4/11/2024 Humulin N Subcutaneous Suspension 100 unit/ml (Insulin NPH (Human) (Isophane)). Inject 30 unit subcutaneously two times a day for Diabetes. Hold for BS <100. Rotate injection sites. - 5/10/2024 Lantus Subcutaneous Solution 100 unit/ml (Insulin Glargine). Inject 5 unit subcutaneously at bedtime for Diabetes. Hold for BS <100. Rotate injection sites. During a review of Resident 96's Location of Administration Report for Insulin for 12/2024, the Location of Administration Report for Insulin indicated- 1. Lantus Subcutaneous Solution 100 unit/ml was administered on: 12/17/2024 at 9:18 p.m. on the Arm - left 12/18/2024 at 9:05 p.m. on the Arm - left 2. Humulin N Subcutaneous Suspension 100 unit/ml was administered on: 12/08/2024 at 4:14 p.m. on the Abdomen - LLQ 12/09/2024 at 4:05 p.m. on the Abdomen - LLQ 12/23/2024 at 5:02 p.m. on the Abdomen - LUQ 12/24/2024 at 6:32 a.m. on the Abdomen - LUQ 12/25/2024 at 6:30 a.m. on the Abdomen - LUQ 3. Humulin R Injection Solution 100 unit/ml was administered on: 12/2/2024 at 4:30 p.m. on the Arm - right 12/3/2024 at 6:32 a.m. on the Arm - right 12/4/2024 at 10:48 p.m. on the Arm - left 12/6/2024 at 11:41 a.m. on the Arm - left 12/21/2024 at 9:33 p.m. on the Abdomen - LUQ 12/22/2024 at 6:30 a.m. on the Abdomen - LUQ During a concurrent interview and record review, on 1/16/2025, at 3:58 p.m., with LVN 5, Resident 96's Order Summary Report, dated 1/26/2023, 4/11/2024, and 5/10/2024, Resident 96's Location of Administration of Insulin, dated 12/2024, MAR, dated 12/2024, and Care Plans were reviewed. LVN 5 stated there were multiple instances that insulin administrations were not rotated on the resident. LVN 5 stated the administration sites of insulin should be rotated to prevent bruising, lipodystrophy, and denting of the resident's skin. LVN 5 stated not rotating insulin administration sites is considered a medication error. During an interview, on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the administration sites of insulin should be rotated to prevent complications such as DVT, bruising, and lipodystrophy. The DON stated not rotating insulin administration sites is considered a medication error. During a review of the facility's recent P&P titled, Medication Errors and Adverse Consequences, last reviewed on 4/18/2024, the P&P indicated a medication error is defines as the preparation or administration of drugs and biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services. During a review of the facility's recent P&P titled, Insulin Administration, last reviewed on 4/18/2024, the P&P indicated to provide guidelines for the safe administration of insulin to residents with diabetes. Select an injection site. a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of the thighs and abdomen. Avoid the area approximately 2 inches around the navel. b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh, upper arm). During a review of the facility-provided Information for the Patient 10 ml Vial (1000 Units per vial) Humulin N NPH Human Insulin (rDNA Origin) Isophane Suspension 100 Units per ml (U-100), copyright 1997, the information for patient indicated to avoid tissue damage, choose a site for each injection that is at least 1/2 inch from the previous injection site. The usual sites of injection are abdomen, thighs, and arms. During a review of the facility-provided Highlights of Prescribing Information on the use of Lantus (insulin glargine) injection, for subcutaneous use, with initial U.S. approval in 2000, the highlights of prescribing information indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis. During a review of the facility-provided Information for the Physician on the use of Humulin R, Regular Insulin Human Injection, USP (rDNA origin) 100 units per ml (U-100), issued March 2011, the information for the Physician indicated Humulin R U-100 may be administered by subcutaneous injection in the abdominal wall, the thigh, the gluteal region or in the upper arm. Injection sites should be rotated within the same region. 2.d. During a review of Resident 73's admission Record, the admission Record indicated the facility admitted the resident on 10/2/2024, with diagnoses including DM 2 with diabetic polyneuropathy (a complication of diabetes that damages nerves in the hands, feet, legs, and arms), anemia, and displaced intertrochanteric fracture (a break in the bone where the broken bone has shifted or separated) of right femur (he thigh bone on the right side of the body). During a review of Resident 73's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition. The MDS indicated the resident was on a high-risk drug class hypoglycemic medication. During a review of Resident 73's Order Summary Report, dated 10/2/2024, the Order Summary Report indicated an order for: - Humulin R Injection Solution 100 unit/ml (Insulin Regular (Human)). Inject as per sliding scale: if 70 - 149 = 0 units Notify MD if BS is <70. Give OJ if responsive.; 150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 7 units; 300 - 349 = 10 units; 350+ = 12 units Give 12 units if BS is >350. Notify MD., subcutaneously before meals and at bedtime for Diabetes Rotate injection sites. - Humulin R Injection Solution 100 unit/ml (Insulin Regular (Human)). Inject as per sliding scale: if 70 - 149 = 0 units Notify MD if BS is <70. Give OJ if responsive.; 150 - 199 = 2 units; 200 - 249 = 4 units; 250 - 299 = 7 units; 300 - 349 = 10 units; 350+ = 12 units Give 12 units if BS is >350. Notify MD., subcutaneously before meals and at bedtime for Diabetes Rotate injection sites. - Heparin Sodium (Porcine) Injection Solution 5000 unit/ml (Heparin Sodium [Porcine]). Inject 1 ml subcutaneously every 12 hours for DVT prophylaxis (reduces the risk of developing deep vein thrombosis through medications, compression stockings, and devices). Rotate injection sites. During a rev[TRUNCATED]

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to: 1. Remove Resident 271's discontinued insulin (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) lispro (fast-acting type of insulin) from the medication cart in one of three inspected medication carts (Station 1 Cart B). 2. Dispose Resident 10's hydrocodone-acetaminophen (medication used to relieve severe pain) when the bubble pack (packaging that have a preformed plastic pocket or shell where a product sits securely in place) slot #17 was found with a non-intact seal and covered with tape in one of three inspected medication carts (Station 1 Cart B). 3. Dispose Resident 37's hydrocodone-acetaminophen when the bubble pack slot #15 was found with a non-intact seal and covered with tape in one of three inspected medication carts (Station 1 Cart B). 4. Maintain residents' medication bubble packs in an orderly manner when Resident 37's Jardiance scheduled during the 11 p.m. to 7 a.m. shift was observed in the 7 a.m. to 3 p.m. shift's medication drawer in one of three inspected medication carts (Station 1 Cart B). 5. Discard Resident 43's insulin glargine with no open date and with printed date of 5/23/2024 observed in one of three sampled medication carts (Station 3 Cart B). The deficient practices of failing to store and label medications per the manufacturers' requirements and remove expired medications from the medication carts may cause the medications to become ineffective or toxic due to improper storage which can possibly lead to health complications resulting in hospitalization or death. 6. Maintain safe and proper temperatures for all medications stored in the medication refrigerator when it was observed out of range at 32 degrees Fahrenheit (F-a unit of measurement) during an observation on 1/17/2025 in one of three medication storage rooms (Medication Storage 1). 7. Ensure the medication refrigerator temperature log (a record-keeping tool used to monitor the storage temperature of medications) was checked and completed when there were no temperatures recorded on 1/15/2025, 1/16/2025, and 1/17/2025. These deficient practices had the potential to result in degradation or alteration of the medications, rendering them ineffective or even potentially harmful. Findings: 1. During a concurrent observation and interview on 1/16/2025 at 6:50 a.m., inspected Station 1 Cart B with Licensed Vocational Nurse 1 (LVN 1). LVN 1 stated Resident 271's insulin lispro 100 unit/ml, dated 12/6/2024, filled 12/6/2024. LVN 1 stated Resident 271's insulin was good for 30 days and should have been removed from the medication cart on 1/15/2025. During an interview with the Director of Nursing (DON) on 1/17/2025 at 4:25 p.m., the DON stated when residents are transferred or discharged , the licensed nurse is expected to remove the medication and place it on the medication bin inside the medication storage room. The DON stated after three (3) days when the resident is discharged home with a physician order, the medications will be release, to the resident. The DON stated if the discontinued and/or expired medications are not removed from the medication cart, there is a potential to cause confusion to some nurses and could give it to another resident. 2 & 3. During a concurrent observation and interview on 1/16/2025 at 6:53 a.m., inspected Station 1 Cart B with LVN 1. LVN 1 stated Resident 10's hydrocodone-acetaminophen 5-325 mg tablet, bubble pack slot #17 had a non-intact seal and was covered with tape. LVN 1 stated for narcotics when the tablets are popped accidentally or not given, the licensed nurse should put it in a plastic pill cover and staple it date and time and hand it over to the DON for disposal. LVN 1 stated Resident 10's hydrocodone-acetaminophen should not have been taped. LVN 1 stated Resident 37's hydrocodone-acetaminophen 10-325 mg tablet, bubble pack slot #15 had a non-intact seal and was covered with tape. LVN 1 stated she never checked the back of the bubble packs, so she never noticed there was a tape and the seal non-intact. During an interview on 1/17/2025 at 4:23 p.m., with the DON, the DON stated controlled medications with non-intact seal is a medication error. The DON stated the practice is ensure the seal is not broken and if it is, the licensed nurses are expected to waste the medication. 4. During a concurrent observation and interview on 1/16/2025 at 10:20 a.m., inspected Station 1 Cart B, with LVN 15. LVN 15 stated she completed medication administration for Resident 37. Requested to see the bubble packs scheduled during the morning medications. LVN 15 stated Jardiance bubble pack was in her drawer, but she did not administer it because it is scheduled for 6:30 a.m. and not during her shift, 7 a.m. to 3 p.m. shift. LVN 15 stated she did not put it there and it should be placed in the 11 p.m. to 7 a.m. drawer. During an interview on 1/16/2025 at 2:20 p.m.,with Registered Nurse 2 (RN 2 ), RN 2 stated licensed nurses can check in their medication cart in the other drawers depending on the reason what medications they are looking for. RN 2 stated medications inside the medication carts should be organized. During an interview on 1/17/2025 at 7:01 a.m., with RN 1, RN 1 stated he placed the Jardiance back in the wrong drawer on 1/16/2025 that was why it was in the morning shift drawer. 5. During a concurrent observation and interview on 1/16/2025 at 7:56 a.m., inspected Station 3 Cart B with LVN 16. LVN 16 stated Resident 43's insulin glargine does not have an open date, so she is going to throw it away. LVN 16 stated there should be a date on it. LVN 16 stated there is a printed date 5/23/2024 but she does not know how long it has been in the cart so she would dispose it. During an interview on 1/17/2025 at 4:28 p.m., the DON stated Resident 43's insulin glargine should have been removed from the medication cart. The DON stated this is to make sure the potency of medications administered to the residents are effective and the manufacturer's guidelines are followed. 6. During a concurrent observation and interview on 1/17/2025 at 8:17 a.m., inside Station 1 Medication Room (Med Storage 1), the Infection Preventionist (IP) stated the medication refrigerator temperature reading was at 32 F. 7. During a concurrent interview and record review of the facility's Temperature Log, on 1/17/2025 at 8:25 a.m., with the IP, the IP stated temperature log indicated for 1/2025 and refrigerator temperature daily 36 to 46 F daily. The IP stated there were no temperatures and initials recorded on the following dates and shifts: - 1/15/2025, 3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. - 1/16/2025 all three shifts - 1/17/2025, 7 a.m. to 3 p.m. The IP stated when the licensed nurses checked the medication room, they should initial that they checked the temperatures and document on the temperature log. During an interview on 1/17/2025 at 4:29 p.m., with the DON, the DON stated the medication refrigerator temperature is between 36 to 46 F. The DON stated this is done to ensure and maintain the potency and effectiveness of refrigerated medications. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, last reviewed on 4/18/2024, the P&P indicated the expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. During a review of the facility's P&P titled, Storage of Medications, last reviewed on 4/18/2024, the P&P indicated the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. The P&P indicated discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. During a review of the facility's P&P titled, Discarding and Destroying Medications, last reviewed on 4/18/2024, the P&P indicated schedule II, III, and IV (non-hazardous) controlled substances are disposed of in accordance with state regulations and federal guidelines regarding disposition of non-hazardous controlled medications. During a review of the facility's P&P titled, Controlled Substances, last reviewed on 4/18/2024, the P&P indicated controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. The P&P indicated nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. The P&P indicated unless otherwise instructed by the director of nursing services, when a resident refuses a non-unit dose medication (or it is not given), or a resident receives partial tablets or single dose ampules (or it is not given) the medication is destroyed and may not be returned to the container. During a review of the facility's P&P titled, Medication Labeling and Storage, last reviewed on 4/18/2024, the P&P indicated medications stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. The P&P indicated each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents. During a review of the facility's P&P titled, Insulin Administration, last reviewed on 4/18/2024, the P&P indicated to check expirations date and follow manufacturer recommendations for expiration after opening. During a review of the facility's P&P titled, Medication Storage in the Facility, last reviewed on 4/18/2024, the P&P indicated medications requiring refrigeration temperatures between 36F to 46F are kept in a refrigerator with a thermometer to allow temperature monitoring. The P&P indicated medication storage conditions are monitored on a regular basis and corrective action taken if problems are identified.

CONCERN (E)

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

Deficiency F0802 (Tag F0802)

Could have caused harm · This affected multiple residents

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Based on observation, interview and record review, the facility failed to ensure kitchen staff were routinely trained and evaluated for competency skills when staff: a. Unable to verbalize the process of three (3) compartment sink dishwashing and quaternary ammonium compound (QUAT, a chemical that disinfect) sanitizer concentration testing for the red buckets. b. Unable to verbalize which type of dishwashing machine they were using and the process of testing the chlorine solution of the dishwashing machine. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 271 of 279 medically compromised residents who received food and ice from the kitchen. Findings: a. During a concurrent demonstration and interview on 1/15/2024 at 2:44 p.m. with Dietary Aide 1 (DA 1) and Dietary Supervisor (DS), DA 1 stated they used Quat sanitizer in the three-compartment sink to sanitize the dishes. DA 1 stated the concentration of the Quat sanitizer should be at 150-400 parts per million (ppm, strength of chemical concentration) however, the poster indicated 200 ppm is the acceptable concentration. DA 1 dipped the test strip for 17 seconds while agitating it. DA 1 stated the color of the test strips should match the color chart and it was 400 ppm. DA 1 stated, he dipped the test strip in the testing solution for one (1) to two (2) minutes. DA 1 stated he also test the first compartment sink. DA 1 stated the first compartment sink is for soaking the dishes with soap or detergent. DA 1 pulled a test strip and tested the first compartment sink while agitating the strip and stated the concentration was 200 ppm. During an interview on 1/15/2025 at 3:00 p.m. with the DS, the DS stated they are not supposed to test the first compartment sink with the test strip as it was for soap. The DS stated, DA 1 should not be agitating the test strips during testing, the temperature of the testing solution was not temped, and the test strip was dipped too long in the sanitizer testing solution. The DS stated dipping the test strip too long while agitating it could affect the reading of the solution concentration. The DS stated the sanitizer reading would not be accurate affecting the cleanliness of the dishes leading to unsanitized dishes. The DS stated unsanitized dishes could lead to food borne illnesses to residents. The DS stated it was always important to follow manufacturer's guidelines. During a review of the facility's policies and procedures (P&P) titled, Three Compartment Procedure for Manual Dishwashing, dated 4/18/2024, the P&P indicated, Procedure: Three compartment sink washing procedures are to be initiated when the dishwasher is inoperable, the dishmachine registers low water temperature, the machine detergent or sanitizer is not available or other emergencies. Immediately begin using disposable dishes. The first compartment is for washing. Fill the first compartment with detergent per manufacturer's instructions and hot water (110-120°F). Record temperature log. Replace water when it becomes cloudy or dirty, the suds are gone, or when temperature falls below 110°F. During a review of the test strips manufacturer's guidelines titled Hydrion Quat Test Paper undated, the guidelines indicated Hydrion sanitizer test papers have been trusted worldwide for nearly 40 years to test the concentration of quaternary ammonium-based sanitizer solutions. QT 40 is for 4-chain quats, 0-500ppm. During a review of the test strips manufacturer's guidelines titled Hydrion QT-40 Instructions Lot 213024 undated, the guidelines indicated, Immerse for 10 seconds. Compare when wet. 1. Dip paper in Quat solution. Not foal surface for 10 seconds. Do not shake. Compare colors at once. 2. Testing solution should be between 65-75°F. 3. Testing solution should have a neutral pH. 4. Follow manufacturer's dilution instructions carefully. During a review of the facility's job description titled Job Description: Dietary Aide dated and signed by DA 1, on 11/30/2024 the document indicated Essential duties included: to leave the kitchen in a clean and sanitary manner and be of assistance when called upon by the cook or dietary supervisor. During a review of the facility's competency checklist titled Job Description and Performance Standards, dated 11/29/2023, the checklist indicated, DA 1 rarely meets standards when assisting in the proper care, use and cleaning of kitchen equipment and there was no action indicated. The checklist further indicated, DA 1 is usually meeting standards in performing all duties assigned in an effective, timely and professional manner but there was no action indicated to train DA 1 to always meet these standards. b. During an interview on 1/16/2025 at 3:12 p.m. with Dietary Aide 3 (DA 3) in the dishmachine area, DA 3 stated he has been working as a dishwasher for a month, but nobody told him that he needed to check the temperature of the dishmachine and log it, and nobody trained him. During an interview on 1/16/2025 at 3:14 p.m. with Dietary Aide 4 (DA 4), DA 4 stated they used a high temperature dishmachine and the acceptable temperatures are as follows: - Wash 130-140°F - Rinse 130°F - Final Rinse 130-140°F. During a concurrent observation and interview on 1/16/2025 at 3:22 p.m. of the dishwashing process with DA 4, DA 4 stated the wash gauge was reading 130°F and the rinse temperature was reading 130°F. DA 4 demonstrated the testing of chlorine by pulling a test strip and agitated the strips while dipping it in the solution and blotted it dry with a paper towel. DA 4 compared the test strip in the color chart and stated it was 25ppm and it was not an acceptable range. DA 4 stated the dishes would not be disinfected with this chlorine concentration at 25ppm. During an interview on 1/16/2025 at 3:29 p.m. with the DS, the DS stated they used a low temperature dishmachine and the minimum temperature should be at 120°F and the maximum acceptable temperature is at 150°F. The DS stated the acceptable chlorine concentration is 150-200ppm. The DS stated the concentration of the chlorine was at 50ppm and it was not acceptable. The DS stated the poster on the wall indicated wash temperature should be at 140-160°F and final rinse was at 180-190°F. The DS stated he needed to call the dishmachine vendor to clarify if they used a high temperature dishmachine or low temperature dishmachine. The DS stated it was important to know what kind of dishmachine they were using to ensure dishes were properly cleaned and sanitized to prevent cross-contamination. During an interview on 1/16/2025 at 3:29 p.m. with the DS, the DS stated their vendor said they are using low temperature dishmachine and the poster needed to be taken down and updated. The DS stated he will update the poster in the dishmachine area to prevent confusion. During a review of the facility's P&P titled Dishwashing dated 4/18/2024, the P&P indicated, All dishes will be properly sanitized through the dishwasher. (8) A temperature log (and chlorine log for low temperature machines) will be kept and maintained by dishwashers to assure that the dishmachine is working correctly. This log will be completed each meal prior to any dishwashing. Low temperature dishmachine: If you do not have the manufacturer's recommendations, use the machine range of 120-140°F. The chlorine should read 50-100ppm on dish surface in final rinse. The proper chlorine level is crucial in sanitizing dishes. If you do not achieve the proper temperature or chlorine level, resort to manual method of dishwashing. During a review of the facility's job description titled Job Description: Dietary Aide dated and signed by DA 3, on 10/10/2024 the document indicated Essential duties included: - Check and record chlorine concentration and water temperature of dishwashing machine at the beginning of shift. - Observe the water temperature of dishwasher during dishwashing cycles. - Operate dishwasher. During a review of the facility's competency checklist titled Job Description and Performance Standards, dated 11/16/2021, the checklist indicated DA 3 did not meet standards for the following job task: - Assist in the proper care, use and cleaning of kitchen equipment - Perform all duties assigned in an effective, timely and professional manner. The checklist further indicated no actions were done for DA 3 to reach needed competencies to work in the kitchen. During a review of the facility's job description titled Job Description: Dietary Aide dated and signed by DA 4 on 11/17/2021, the document indicated Essential duties included: - Check and record chlorine concentration and water temperature of dishwashing machine at the beginning of shift. - Observe the water temperature of dishwasher during dishwashing cycles. - Operate dishwasher. During a review of the facility's competency checklist titled Job Description and Performance Standards, dated 11/16/2021, the checklist indicated, DA 4 rarely meets standards for the following task: - Assist in the proper care, use and cleaning of kitchen equipment - Perform all duties assigned in an effective, timely and professional manner. The checklist further indicated no actions were done for DA 4 to reach needed competencies to work in the kitchen.

CONCERN (E)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to follow the menu and did not meet nutritional needs of 108 of 109 residents on soft mechanical diet (diet consisting of soft, and chopped foods), seven of 46 residents on fortified diet (addition of food to increase calories and proteins in the diet), and three of 14 residents on large portions (doubling portion size of foods to increase calories and protein in the diet) diet when: 1. Residents on soft mechanical diet did not receive toasted garlic bread without hard crust. 2. Residents on fortified diet did not receive additional cheese on their pasta. 3. Residents on large portion diets did not receive eight (8) ounces ([oz], a unit of measurement) of milk as indicated on the menu spreadsheet (a sheet that contains each diet and what food and portions each diet would get). These failures had the potential to result in difficulty in swallowing, chewing, decreased in food and nutrient intake resulting to unintended weight loss and choking (when food gets stuck in your airway, blocking the flow of air to your lungs). Cross reference F808 Findings: 1. During a review of the facility's cook's spreadsheet titled Winter Menus, dated 1/14/2025, the spreadsheet indicated residents on soft mechanical diet would include the following foods in the tray: - Italian Lasagna 3x3 1/3 inches = 1 square - Soft seasoned broccoli ½ cup ([c], household measurement) - Parsley flakes garnish- yes - Soft garlic bread, no hard crusts - Peanut butter cup pudding #12 scoop (1/3 c) - Milk 4 oz. During a review of Resident 35's admission Record, the admission Record indicated the facility admitted Resident 35 on 6/9/2021 with diagnoses including dementia (a progressive state of decline in mental abilities), peptic ulcer (open sores on the inner lining of the stomach and upper part of the small intestines) and anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). During a review of Resident 35's Minimum Data Set (MDS - a resident assessment tool), dated 12/18/2024, the MDS indicated Resident 35 usually made self understood and understand others. The MDS further indicated Resident 35 required set up and clean up assistance with eating. The MDS further indicated Resident 35 had mechanically altered diet (food texture that is intended to be safe and easy to swallow) while being a resident of the facility and within the last seven days. During a review of Resident 35's Order Summary Report, dated 4/10/2024, the Order Summary Report indicated a physician's order for regular, soft mechanical texture, thin liquid consistency, chopped meat and vegetables. During a review of Resident 35's Care Plan titled, [Resident 35] has nutritional problems and potential for nutritional problems related to (wanting) meat to be chopped, be mechanically altered diet due to visual loss to both eyes, last revised on 7/10/2023, the care plan indicated interventions including providing and serving diet, monitor intake and record every meal of regular soft chopped texture. During an observation on 1/14/2025 at 11:59 a.m. of the trayline (an area where foods were assembled on the trays), Resident 35 got two (2) slices of garlic bread with hard crust on the tray. During a review of Resident 134's admission Record, the admission Record indicated the facility admitted Resident 134 on 8/24/2023 with diagnoses including mild protein-calorie malnutrition (a nutritional status in which reduced ability of nutrients leads to changes in body composition and function), hypothyroidism (a condition where the thyroid gland does not make enough thyroid hormones, leading to symptoms like fatigue, weight again, and feeling cold), and essential hypertension ([HTN], high blood pressure). During a review of Resident 134's MDS, dated [DATE], the MDS indicated Resident 134 did not make self understood and did not understand others. The MDS further indicated Resident 134 required set up and clean up assistance with eating. The MDS further indicated Resident 134 had mechanically altered diet while a resident of the facility and within the last seven days. During a review of Resident 134's Order Summary Report, dated 10/9/2023, the Order Summary Report indicated a physician's order for fortified, no added salt (NAS, no salt packet on the tray), mechanical soft with chopped meat texture, and thin liquid consistency diet. During a review of Resident 134's care plan titled, [Resident 134] was at risk for or potential for nutritional problems related to diet modification and or restrictions with diet of regular diet, mechanical soft with chopped meat texture and thin liquid consistency, last revised on 8/24/2023, the care plan indicated interventions including ensuring dental appliances are in good repair and in place for meals and activities to promote intake. During an observation on 1/14/2025 at 12:02 p.m. of Resident 134's tray, Resident 134 got two slices of garlic bread with hard crust on the tray. During a review of Resident 32's admission Record, the admission Record indicated the facility originally admitted Resident 32 on 1/18/2023 and readmitted on [DATE] and 12/14/2024 with diagnoses including type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor would healing), mild protein-calorie malnutrition, and dysphagia, oropharyngeal phase (difficulty swallowing occurring in mouth or in the throat). During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32 did not make self-understood and did not understand others. During a review of Resident 32's Order Summary Report, dated 12/14/2024, the Order Summary Report indicated a physician's order for CCHO, NAS diet, mechanical soft texture, thin liquids consistency. During a review of Resident 32's care plan titled, [Resident 32] was at risk for or potential for nutritional problems related to diet modification and or restrictions with diet of regular diet, mechanical soft with chopped meat texture and thin liquid consistency, last revised on 8/24/2023, the care plan indicated interventions including ensuring dental appliances are in good repair and in place for meals and activities to promote intake. During an observation on 1/14/2025 at 12:18 p.m. of Resident 32's tray, Resident 32 got two slices of garlic bread with hard crust on the tray. During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) observation and interview on 1/14/2025 at 2:22 p.m. with the Dietary Supervisor (DS), the DS stated the soft mechanical test tray had hard bread and crust. The DS stated the garlic bread must be soft with no hard crust as soft mechanical diets are used for residents with swallowing and chewing difficulties. The DS stated residents could potentially choke if the food they ate was not soft. During a review of the facility's policies and procedures (P&P) titled, Menu Planning, dated 4/18/2024, the P&P indicated, (1) Menu service which provides the seasonal menus with corresponding recipes. (2) Menus and cook's spreadsheets are to be dated and posted in the kitchen and on consumer bulletin board in the entrance of the facility by the FNS director two weeks in advance. (4). The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, physician's diet orders and, to the extent medically possible, in accordance to the most recent recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences. Menus are planned to consider: (f) texture and color of all foods in meals. Procedures: (1) The facilities' diet manual and diets ordered by the physician should mirror the nutritional care provided by the facility. During a review of the facility's diet manual titled, Regular Mechanical Soft Diet, dated 4/18/2024, the diet manual indicated, Description: The Mechanical Soft diet is designed for residents who experience chewing or swallowing limitations. The regular diet is modified texture to a soft, chopped or ground consistency as per foods below. Other textures may be included such as a mechanical soft diet with pureed meats if further texture reduction is required. During a review of the facility's recipe titled, Recipe: Garlic Bread, dated 4/18/2024, the recipe indicated, Mechanical soft: may use soft French bread, no hard crusts, or cut crust off. Keep soft. Can cut off crusts if they become hard or overdone. 2. During an observation on 1/14/2025 at 12:05 p.m. of residents' trays on fortified diet, there were seven (7) residents (Resident 104, Resident 96, Resident 213, Resident 145, Resident 135, Resident 129, and Resident 84) on fortified diet did not get extra cheese on their trays. During an interview on 1/14/2025 at 12:07 p.m. with Dietary Aide 5 (DA 5), DA 5 stated residents on fortified diets get extra cheese. The DS asked the staff to prepare grated cheese on containers and give the extra cheese on the following trays that have not been distributed yet. During an observation on 1/14/2025 at 12:21 p.m. of the trayline, observed staff started giving fortified diet trays with extra cheese. During an interview on 1/14/2025 at 1:35 p.m. with the DS, the DS stated there were residents on fortified diets who did not get extra shredded cheese on their meals and the trayline staff missed putting it in the tray. The DS stated fortifying food is adding extra gravy, sauces, butter, and cheese to help residents with weight loss. The DS stated the residents not given the one (1) oz grated cheeses were missing nutrition and calories affecting their diets and as a result, these residents would continue to lose weight as a potential outcome. During a review of the facility's P&P titled Food Preparation, dated 4/18/2024, the P&P indicated, (1) The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared. (2) Recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide. During a review of the facility' diet manual titled, Fortified Diet, dated 4/18/2024, the diet manual indicated, Description: The fortified diet is designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status. Nutritional breakdown: The goal is to increase the calorie density of foods commonly consumed by the resident. The amount of calorie increase should be approximately 300-400 per day. Examples of adding calories include: add cheese to soups, pasta or vegetables. Approximate calories of food used for fortifying diet: cheese- 1 Tablespoon = 55 calories. During a review of the facility's diet manual titled, Fortification of Food: Increasing Calories and/or Protein in the Diet, dated 4/18/2024, the diet manual indicated, The enrichment of food will be done on an individual basis for residents who cannot consume adequate amounts of calories and/or protein to sustain their weight or nutrition status. The goal is to increase the calorie and/or protein density of foods commonly consumed by the resident to promote improvement in their nutritional status. 3. During a review of the facility's cook's spreadsheet titled Winter Menus, dated 1/14/2025, the spreadsheet indicated residents on regular diet would include the following foods in the tray: - Italian Lasagna 3x3 1/3 inches = 1 square - Seasoned broccoli ½ c - Parsley granish- yes - Garlic bread- yes - Peanut butter cup pudding 1/3 c - Milk 4 oz. During a review of the facility's cook's spreadsheet titled, Winter Menus, dated 1/14/2025, the spreadsheet indicated residents on large portion diet would include the following foods in the tray: - Italian Lasagna 3x3 1/3 inches = 1 square - Seasoned broccoli ½ c - Parsley granish- yes - Garlic bread- yes - Peanut butter cup pudding 1/3 c - Milk 8 oz. During an interview on 1/14/2025 at 12:11 p.m. with DA 5, DA 5 stated large portion diets would get the same food as regular diet and it is only the double portion diets that they double the food. During an observation on 1/14/2025 at 12:18 p.m., of Resident 32's menu ticket, the menu ticket indicated, Resident 32 was on mechanical soft, chopped, fortified, large portions, consistent carbohydrate diet (CCHO, a diet to manage blood sugar levels containing the same amount of carbohydrates per meal), thin liquid. Observed Resident 32 did not get 8 oz of milk. During a concurrent observation and interview on 1/14/2025 at 12:32 p.m., of Resident 249's menu ticket with DA 5, the menu ticket indicated Resident 249 was on large portion diet. Observed Resident 249 did not get 8 oz of milk. DA 5 stated they gave four (4) oz of juice as that was the preference of the resident. During an interview on 1/14/2025 at 1:40 p.m. with the DS, the DS stated residents on large portion diets would get 8 oz of milk instead of 4 oz per the menu spreadsheet as long as it is not in the dislike list of the residents. The DS stated large portion diet was used for residents with weight loss and to cater to their food preferences. The DS stated, residents on large portions who did not get milk lose their nutrition and could potentially lose weight and for those who has it as food preference, they would get upset. The DS stated residents could have psychosocial harm as a potential outcome. During a review of the facility's diet manual titled, Regular Diet, dated 4/18/2025, the diet manual indicated, Large Portions: follow the regular diet. Increase calories by adding food from the dairy, protein, and grain groups. Addition of these foods will increase the sugars and fats in the diet. Calories will equal about 2500-2800 calories per day, 120-130 grams protein, and 295-315 grams carbohydrates. If a resident request larger portions than are specified on the menu, increase specific food the resident enjoys.

CONCERN (E)

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance for lunch when staff served mushy and overcooked broccoli, carrots, and peas. This failure had a potential to result in 137 of 279 residents, including Resident 188, facility residents on regular texture (no restriction) at risk of unplanned weight loss, a consequence of poor food intake, getting food from the kitchen. Findings: During a review of Resident 188's admission Record, the admission Record indicated the facility admitted Resident 188 on 10/24/2023 with diagnoses including acute and chronic respiratory failure (define), type 2 diabetes (a chronic condition where the body does not use insulin effectively or does not produce enough insulin) and chronic obstructive pulmonary disease (COPD, a condition involving constriction of the airways and difficulty or discomfort in breathing). During a review of Resident 188's Minimum Data Set (MDS- a resident assessment tool), dated 12/10/2024, the MDS indicated Resident 188 made self understood and can understand others. The MDS further indicated Resident 188 required set up and clean up assistance with eating while a resident of the facility and within the last seven days. During a review of Resident 188's Order Summary Report, dated 10/14/2024, the Order Summary Report indicated a physician's order for consistent carbohydrate diet (CCHO, diet used in management of blood sugar level by providing same amount of carbohydrates each meal), large portion (adding meat, carbohydrates and other food items on the tray to increase proteins and calories) regular thin texture (no restriction) consistency with meals. During an interview on 1/14/2025 at 10:06 a.m. with Resident 188, Resident 188 stated the food does not taste and quality of food was not good. During a review of the facility's cook's spreadsheet (a sheet that contains each diet and what food and portions each diet would get) titled, Winter Menus, dated 1/14/2025, the spreadsheet indicated residents on regular diet would include the following foods in the tray: - Italian Lasagna 3x3 1/3 inches = 1 square - Seasoned broccoli ½ cup ([c], household measurement) - Parsley garnish- yes - Garlic bread- yes - Peanut butter cup pudding #12 scoop (1/3 c) - Milk 4 ounces (oz - unit of measure) During an observation on 1/14/2025 at 11:38 a.m. in trayline (an area where foods were assembled on the trays), observed dark yellowish-green, overcooked, and mushy broccoli in the steamtable. During a test tray (a process of tasting, temping, and evaluating the quality of food) observation and interview on 1/14/2025 at 2:17 a.m. with the Dietary Supervisor (DS), the DS stated the broccoli was overcooked as it was supposed to be batch-cooked (cook small portions throughout the meal period and serve as needed) but it was not batch- cooked today. The DS stated batch cooking preserve color, quality, taste, and presentation of the food. The DS stated the green peas looked brown and the carrots were overcooked. The DS stated the broccoli, carrots and peas were mushy, tasted watery and lost their taste and nutrients after tasting it. The DS stated residents could lose weight for not getting vitamins and nutrients from overcooked vegetables. During a review of the facility's policies and procedures (P&P) titled, Food Preparation, dated 4/18/2024, the P&P indicated, POLICY: Food shall be prepared by methods that conserve nutritive value, flavor, and appearance. Procedure: 1. The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared. 2. Recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide. 3. Prepared food will be sampled. The Food and Nutrition Services employee who prepares the food will sample it to be sure the food has satisfactory flavor and consistency. Use a clean spoon or put a small portion of the food in a dish and taste from the dish. 4. Poorly prepared food will not be served. Such food is to either be improved, prepared again, or replaced with an appropriate substitution. May add increased amounts of herbs and spices (not salt) since potency of product may vary. 5. Prepare foods as close as possible to serving time in order to preserve nutrition, freshness and to prevent overcooking. 6. Process raw and uncooked foods in batches. Remove from refrigeration only the amount of product that can be processed within a 30-minute period. The P&P further indicated, Cook vegetables on small amount of water for a short amount of time. Serve vegetables promptly. Do not hold on to the steam table for long period of time. (Maximum-1 hour prior to serving). During a review of facility's recipe titled, Recipe: Seasoned Broccoli, dated 4/18/2024, the recipe indicated, Cooking Time: 10-20 minutes. Directions: (2) Boil or steam broccoli until tender. Drain well. Do not overcook, will turn brown and mushy. During a review of the facility's recipe titled, Seasoned Peas, dated 4/18/2024, the recipe indicated, Cooking time: 10-15 minutes. During a review of the facility's recipe titled, Seasoned Carrots, dated 4/18/2024, the recipe indicated, Cooking time: about 10-20 mins.

CONCERN (E)

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

Deficiency F0805 (Tag F0805)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prepare foods in a form designed to meet individual needs when: 1. Puree pasta was too sticky and did not pass the spoon tilt test (a test used to determine the stickiness of the food and the ability of the food to hold together) for residents on puree diet (foods that are smooth with pudding-like consistency)/International Dysphagia (difficulty swallowing) Diet Initiative ([IDDSI] a framework for categorizing food textures and drink thickness) level four (4). 2. Residents on soft mechanical diet (diet consisted of soft, chopped foods) received toasted garlic bread with hard crust. These failures had the potential to result in difficulty in swallowing, chewing, decreased in food intake and nutrient intake to 18 of 18 residents on puree diet and 108 of 109 residents on soft mechanical diet, resulting to unintended weight loss and choking (when food gets stuck in your airway, blocking the flow of air to your lungs). Findings: 1. During a review of the facility's cook's spreadsheet (a sheet that contains each diet and what food and portions each diet would get) titled, Winter Menus, dated 1/14/2025, the spreadsheet indicated residents on puree/IDDSI level 4 would include the following foods in the tray: a. Puree Italian Lasagna one (1) cup ([c], household measurement). b. Puree seasoned broccoli #12 scoop (1/3 c) c. Parsley flakes garnish - yes d. Puree garlic bread #16 (1/4 c) e. Peanut butter cup pudding 1/3 c f. Milk 4 ounces (oz - unit of measurement) During an observation on 1/14/2025 at 11:38 a.m. of the puree Italian lasagna in a trayline (an area where foods were assembled on the trays) set up, observed the puree garlic bread looked sticky. During a concurrent test tray (a process of tasting, temping, and evaluating the quality of food) observation and interview with the Dietary Supervisor (DS), the DS stated he has never seen puree/IDDSI level 4 but always followed the recipe book. The DS stated puree diets are used for residents with swallowing problems and the puree food should not be too shiny, pudding thick, mixed well with thickener, and a consistency of baby food. The DS performed the spoon tilt test and stated the puree Italian pasta did not pass the spoon tilt test because it was too sticky, and the food did not fall off the spoon when tilted. The DS stated the cook might have put too much food thickener. The DS stated the food with too much thickener would not taste good resulting to residents refusing the tray and sticky food could cause choking to residents with difficulty in swallowing. During a review of the facility's policy and procedure (P&P) titled, Food Preparation, dated 4/18/2024, the P&P indicated, The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared. Recipes are specific as to portions, yield, methods of preparation, amounts of ingredients, and time and temperature guide. During a review of the facility's diet manual titled, Regular Pureed Diet, dated 4/18/2024, the diet manual indicated, The pureed diet is a regular diet that has been designed for residents who have difficulty chewing and/or swallowing. The texture of the food should be of a smooth and moist consistency and able to hold its shape. All foods are prepared in a food processor or blender, with the exception of foods which are normally in a soft and smooth state such as pudding, ice cream, applesauce, mashed potatoes. During a review of the facility's recipe titled, Recipe: Italian Lasagna, dated 4/18/2024, the recipe indicated, Pureed/Dysphagia: can layer also with puree ingredients. Make one pan. Or puree: 1 cup/serving, small #6. Cut off any hard noodles before pureeing. Puree following the pureed recipes in the Food Safety/Misc. section of Book 1. During a review of the facility's recipe titled, Recipe: Pureed (IDDSI LEVEL 4) Casserole, dated 4/18/2024, the recipe indicated, (5) The finished pureed item should be smooth and free of lumps, hold its shape, while not being too firm or sticky, and should not weep. The finished pureed items must pass IDDSI level 4 testing requirements (i.e., the fork drip, fork pressure, and spoon tilt test). During a review of the IDDSI guideline from the website titled, IDDSI, dated 7/2019, the IDSSI website indicated, Level 4 Pureed is usually eaten with spoon, falls off spoon in a single spoonful when tilted and continues to hold shape on the plate, no lumps, not sticky, and liquid must not separate from solid. Food testing method: Spoon tilt test and Fork drip test). 2. During a review of the facility's cook's spreadsheet titled, Winter Menus, dated 1/14/2025, the spreadsheet indicated residents on soft mechanical diet would include the following foods in the tray: a. Italian Lasagna 3x3 1/3 inches = 1 square b. Soft seasoned broccoli ½ c. c. Parsley flakes garnish- yes d. Soft-garlic bread, no hard crusts e. Peanut butter cup pudding 1/3 c. f. Milk 4 oz. During a review of Resident 35's admission Record, the admission Record indicated the facility admitted Resident 35 on 6/9/2021 with diagnoses including dementia (a progressive state of decline in mental abilities), peptic ulcer (open sores on the inner lining of the stomach and upper part of the small intestines) and anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). During a review of Resident 35's Minimum Data Set (MDS - a resident assessment tool), dated 12/18/2024, the MDS indicated Resident 35 usually made self understood and can understand others. The MDS further indicated Resident 35 required set up and clean up assistance with eating. The MDS further indicated Resident 35 had mechanically altered diet (food texture that is intended to be safe and easy to swallow) while a resident of the facility and within the last seven days. During a review of Resident 35's Order Summary Report, dated 4/10/2024, the Order Summary Report indicated a physician's order for regular, soft mechanical texture, thin liquid consistency, chopped meat and vegetables. During a review of Resident 35's care plan titled, [Resident 35] has nutritional problems and potential for nutritional problems related to (wanting) meat to be chopped, to be mechanically altered diet due to visual loss to both eyes, last revised on 7/10/2023, the care plan indicated interventions including providing and serving diet, monitor intake and record every meal of regular soft chopped texture. During an observation on 1/14/2025 at 11:59 a.m. of the trayline, Resident 35 got two (2) slices of garlic bread with hard crust on the tray. During a review of Resident 134's admission Record, the admission Record indicated the facility admitted Resident 134 on 8/24/2023 with diagnoses including mild protein-calorie malnutrition (a nutritional status in which reduced ability of nutrients leads to changes in body composition and function), hypothyroidism (a condition where thyroid gland does not make enough thyroid hormones, leading to symptoms like fatigue, weight gain and feeling cold), and essential hypertension ([HTN], high blood pressure). During a review of Resident 134's MDS, dated [DATE], the MDS indicated Resident 134 did not make self understood and did not understand others. The MDS further indicated Resident 134 required set up and clean up assistance with eating. The MDS further indicated Resident 134 had mechanically altered diet while a resident of the facility and within the last seven days. During a review of Resident 134's Order Summary Report, dated 10/9/2023, the Order Summary Report indicated a physician's order for fortified (food with nutrients added to them), no added salt (NAS, no salt packet on the tray), mechanical soft with chopped meat texture, and thin liquid consistency. During a review of Resident 134's care plan titled, [Resident 134] was at risk for or potential for nutritional problems related to diet modification and/or restrictions with diet of regular diet, mechanical soft with chopped meat texture and thin liquid consistency, last revised on 8/24/2023, the care plan indicated interventions including ensuring dental appliances are in good repair and in place for meals and activities to promote intake. During an observation on 1/14/2025 at 12:02 p.m. of Resident 134's tray, Resident 134 got 2 slices of garlic bread with hard crust on the tray. During a review of Resident 32's admission Record, the admission Record indicated the facility originally admitted Resident 32 on 1/18/2023 and readmitted on [DATE] and 12/14/2024 with diagnoses including type 2 diabetes (DM, a disorder characterized by difficulty in blood sugar control and poor would healing), mild protein-calorie malnutrition, and dysphagia, oropharyngeal phase (difficulty swallowing occurring in mouth or in the throat). During a review of Resident 32's MDS, dated [DATE], the MDS indicated Resident 32 did not make self understood and did not understand others. During a review of Resident 32's Order Summary Report, dated 12/14/2024, the Order Summary Report indicated a physician's order for consistent carbohydrate diet (CCHO, a diet used to manage blood sugar by serving the same amount of carbohydrates each meal), NAS diet, mechanical soft texture, thin liquids consistency. During a review of Resident 32's care plan titled, [Resident 32] was at risk for or potential for nutritional problems related to diet modification and/or restrictions with diet of regular diet, mechanical soft with chopped meat texture and thin liquid consistency, last revised on 8/24/2023, the care plan indicated interventions including ensuring dental appliances are in good repair and in place for meals and activities to promote intake. During an observation on 1/14/2025 at 12:18 p.m. of Resident 32's tray, Resident 32 got 2 slices of garlic bread with hard crust on the tray. During a concurrent test tray observation and interview on 1/14/2025 at 2:22 p.m. with the Dietary Supervisor (DS), the DS stated the soft mechanical test tray had hard bread and crust. The DS stated the garlic bread must be soft with no hard crust as soft mechanical diets are used for residents with swallowing and chewing difficulties. The DS stated residents could potentially choke if the food they ate was not soft. During a review of the facility's P&P titled, Menu Planning, dated 4/18/2024, the P&P indicated, (1) Menu service which provides the seasonal menus with corresponding recipes. (2) Menus and cook's spreadsheets are to be dated and posted in the kitchen and on consumer bulletin board in the entrance of the facility by the FNS director two weeks in advance. (4). The menus are planned to meet nutritional needs of residents in accordance with established national guidelines, physician's diet orders and, to the extent medically possible, in accordance to the most recent recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences. Menus are planned to consider: (f) texture and color of all foods in meals. Procedures: (1) The facility's diet manual and diets ordered by the physician should mirror the nutritional care provided by the facility. During a review of the facility's diet manual titled, Regular Mechanical Soft Diet, dated 4/18/2024, the diet manual indicated, Description: The Mechanical Soft diet is designed for residents who experience chewing or swallowing limitations. The regular diet is modified texture to a soft, chopped or ground consistency as per foods below. Other textures may be included such as a mechanical soft diet with pureed meats if further texture reduction is required. During a review of the facility's recipe titled, Recipe: Garlic Bread, dated 4/18/2024, the recipe indicated, Mechanical soft: may use soft French bread, no hard crusts, or cut crust off. Keep soft. Can cut off crusts if they become hard or overdone.

CONCERN (E)

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

Deficiency F0808 (Tag F0808)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents receive and consume foods in the appropriate nutritive content as prescribed by a physician for regular fortified diet (addition of food to increase calories and proteins in the diet) when staff did not add cheese for seven of 46 sampled residents (Resident 135, Resident 213, Resident 104, Resident 96, Resident 129, Resident 145, and Resident 84) on fortified diet during lunch on 1/14/2025. This deficient practice had the potential to cause weight loss for residents on fortified diets. Cross reference F803 Findings: 1. During a review of the facility's cook's spreadsheet (a sheet that contains each diet and what food and portions each diet would get) titled, Winter Menus, dated 1/14/2025, the spreadsheet indicated residents on regular diet would include the following foods in the tray: a. Italian Lasagna 3x3 1/3 inches = 1 square b. Seasoned broccoli ½ cup ([c], household measurement) c. Parsley garnish- yes d. Garlic bread- yes e. Peanut butter cup pudding #12 scoop (1/3 c) f. Milk 4 ounces (oz - unit of measurement) During an observation on 1/14/2025 at 12:05 p.m. of residents' tray on fortified diet, there were seven residents (Resident 104, Resident 96, Resident 213, Resident 145, Resident 135, Resident 129, and Resident 84) on fortified diet who did not get extra cheese on their trays. During a review of Resident 135's admission Record, the admission Record indicated the facility admitted Resident 135 on 11/30/2021 with diagnoses including atrial fibrillation (irregular heart rhythm), essential hypertension (HTN, high blood pressure) and anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). During a review of Resident 135's Minimum Data Set (MDS- a resident assessment tool), dated 12/8/2024, the MDS indicated Resident 135 usually made self understood and can understand others. The MDS further indicated Resident 135 required set up and clean up assistance with eating. The MDS further indicated Resident 35 had mechanically altered diet (food texture that is intended to be safe and easy to swallow) while a resident of the facility and within the last seven days. During a review of Resident 135's Order Summary Report, dated 7/18/2024, the Order Summary Report indicated a physician's order for fortified, no added salt (NAS, no salt packet on the trays), regular texture, thin liquid consistency diet. During a review of Resident 135's care plan titled, [Resident 135] has nutritional problems and potential for nutritional problems related to therapeutic diet, last revised on 7/10/2023, the Care Plan indicated interventions including monitoring, recording, and reporting to MD significant weight loss and gain, provide and serve diet of regular, NAS, fortified, and health shakes with meal. During a review of Resident's 135's Nutritional Risk Assessment, dated 12/10/2024, the Nutritional Risk Assessment indicated Resident 135 had inadequate food intake and the Registered Dietitian recommended to continue with fortified diet for weight gain goals. During a trayline observation on 1/14/2025 at 12:05 a.m., of Resident 135's tray, observed Resident 135 did not get additional cheese on the tray. During a review of Resident 213's admission Record, the admission Record indicated the facility admitted Resident 213 on 4/16/2024 with diagnoses including atrial fibrillation, type 2 diabetes (a chronic condition that affects the way the body processes blood sugar) and anxiety disorder. During a review of Resident 213's MDS, dated [DATE], the MDS indicated Resident 213 usually made self understood and can understand others. The MDS further indicated Resident 213 required assistance with supervision or touching assistance with eating. During a review of Resident 213's Order Summary Report, dated 7/9/2024, the Order Summary Report indicated a physician's order for fortified, mechanical soft texture, thin liquid consistency diet. During a review of Resident 213's care plan titled, [Resident 213] was at risk for malnutrition (lack of nutrition in the body) due to dementia, diabetes and fracture, last revised on 4/16/2023, the care plan indicated interventions including encourage adequate nutrition and hydration and intake monitoring. During a review of Resident's 213's Nutritional Risk Assessment, dated 10/13/2024, the Nutritional Risk Assessment indicated Resident 213 had weight loss due to inadequate food intake and the Registered Dietitian recommended to continue with fortified diet for weight maintenance goals. During a trayline observation on 1/14/2025 at 12:05 a.m., of Resident 213's tray, observed Resident 213 did not get additional cheese on the tray. During an interview on 1/14/2025 at 12:07 p.m. with Dietary Aide 5 (DA 5), DA 5 stated residents on fortified diets get extra cheese. The DS asked the staff to prepare grated cheese on containers and give the extra cheese for the rest of the trays that have not been distributed yet. During an observation on 1/14/2025 at 12:21 p.m. of the trayline, observed staff started giving fortified diet trays extra cheese. During an interview on 1/14/2025 at 1:35 p.m. with the DS, the DS stated there were residents on fortified diets who did not get extra shredded cheese on their meal and the trayline staff missed putting it on the trays. The DS stated fortifying food is adding extra gravy, sauces, butter, and cheese to help residents with weight loss. The DS stated the residents not given the one (1) oz grated cheese were missing nutrition and calories affecting their diets and as a result, these residents would continue to lose weight as a potential outcome. During a review of the facility's P&P titled, Food Preparation, dated 4/18/2024, the P&P indicated, (1) The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared. (2) Recipes are specific as to portion yield, method of preparation, amounts of ingredients, and time and temperature guide. During a review of the facility' diet manual titled, Fortified Diet, dated 4/18/2024, the diet manual indicated, Description: The fortified diet is designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status. Nutritional breakdown: The goal is to increase the calorie density of foods commonly consumed by the resident. The amount of calorie increase should be approximately 300-400 per day. Examples of adding calories include add cheese to soups, pasta or vegetables. Approximate calories of food used for fortifying diet: cheese- 1 Tablespoon = 55 calories. During a review of the facility's diet manual titled, Fortification of Food: Increasing Calories and/or Protein in the Diet, dated 4/18/2024, the diet manual indicated, The enrichment of food will be done on an individual basis for residents who cannot consume adequate amounts of calories and/or protein to sustain their weight or nutrition status. The goal is to increase the calorie and/or protein density of foods commonly consumed by the resident to promote improvement in their nutritional status.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Kitchen equipment and areas were not cleaned and sanitized. a. There was an ice, dirt buildup and dirt debris in the chest freezer. Walk-in freezer roof had ice buildup. b. Walk-in refrigerator floors had dirt buildup and food debris. c. Reach-in refrigerator vents had dust buildup and shelves had dirt and food debris. d. Dry storage room floor had dirt and food debris. e. Ice machine internal parts had reddish dirt and mineral buildup. The ice machine filter was dirty to touch. f. Mixer guard, agitator shaft had dried up food and splatters. g. Residents' refrigerator had dirt buildup. 2. Kitchen equipment and utensils were not smooth, had scratches and cracks. a. Seven (7) of 7 racks had rust, dirt, chips, and cracks in the walk-in refrigerator. b. Can opener blade have had chips (a small piece of something removed while opening cans). c. [NAME] chopping board had brown liquid splatters stored in the clean area. 3. One (1) rack in the walk-in freezer was not six (6) inches from the floor. 4. Food boxes were stored in the floor in the walk-in freezer. 5. Five (5) dented cans were stored with non-dented cans. 6. Pots and pans were stacked wet. 7. Two (2) of 2 cooks had beards sticking out of their mask and hair restraint while serving and preparing food. 8. Staff failed to label a resident's food (fiery chicken vindaloo, cheese, cottage cheese and butter) with the name in the residents' refrigerator and burrito had no received date. 9. Residents' freezer did not have a thermometer, and staff were not monitoring freezer temperatures. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or chemicals) in 271 of 279 medically compromised residents who received food and ice from the kitchen. Findings: 1. a. During an observation on 1/14/2025 at 8:42 a.m., observed dirt debris at the bottom shelves of the chest freezer and ice buildup. During an observation on 1/14/2025 at 8:58 a.m., observed an ice buildup on the freezer roof. During a concurrent observation and interview on 1/14/2025 at 9:09 a.m. with the Dietary Supervisor (DS), the DS stated the dirt on the bottom shelves of the chest in freezer was coming from the food boxes and it was not okay because of physical contamination to the food. The DS stated the ice buildup in the chest freezer was not okay as it affects the temperature of the freezer causing poor quality of the food product like freezer burn. The DS stated hot air could be coming inside the freezer and it affects food temperature causing food borne illnesses as a potential outcome to the residents. b. During an observation on 1/14/2025 at 8:46 a.m., observed food debris and dirt buildup on the floor in the Walk-in Refrigerator 1. During a concurrent observation and interview on 1/14/2025 at 9:12 a.m. with the DS, the DS stated there was dirt buildup and food debris on the floor in the Walk-in Refrigerator 1. The DS stated the staff sweep and mop the floor daily to prevent rodents, mice, and insects but it was not done. The DS stated this could cause cross-contamination to food. During a review of the facility's policies and procedures (P&P) titled, Refrigerator and Freezer, dated 4/18/2024, the P&P indicated, Maintaining a clean refrigerator and freezer can improve the safety and quality of your foods. (1) Refrigerator and freezer should be on a weekly cleaning schedule. (2) wipe spills immediately (6) Remove all items and clean shelves. Wipe with sanitizer. (7) Sweep freezer floor and mop with a freezer cleaner product obtained from your chemical company. c. During an observation on 1/14/2025 at 9:05 a.m., observed dirt debris on the shelves and dust buildup on the vent in the reach-in refrigerator near the kitchen entrance. During a concurrent observation and interview on 1/14/2025 at 9:16 a.m. of the reach-in refrigerator with the DS, the DS stated the dirt on the shelves and the dust buildup were not okay as it could caused food contamination. During an interview on 1/14/2025 at 9:36 a.m. with the DS, the DS stated the vent in the reach-in refrigerator was dusty to touch. The DS stated they needed to keep the dust and debris away from the vent so it would not contaminate the food. d. During an observation on 1/14/2025 at 9:39 a.m., of the dry storage area, observed the dry storage area floors had food and dirt debris. During an interview on 1/14/2025 at 9:58 a.m., the DS stated the floor had dirt debris, hairnet and food debris and it was not acceptable as it could attract pest resulting to contamination of food. During a review of the facility's P&P titled, Storage of Food and Supplies, dated 4/18/2025, the P&P indicated, Food and supplies will be stored properly and in a safe manner. (1) The storeroom should be well-lighted, well-ventilated, cool, dry, and clean at all times. (4) All shelves and storage racks or platforms should be in accordance with state and federal regulations to facilitate air circulation and promote easy and regular cleaning. All food and food containers are to be stored 6 inches off the floor and on clean surfaces in a manner that protects it from contamination. e. During an observation on 1/15/2025 at 10:00 a.m., of the ice machine, observed the vent of the ice machine had dust and the internal parts had reddish residues coming off when wiped with a paper towel. During an interview on 1/15/2025 at 10:09 a.m., the DS stated the internal part of the ice machine was last cleaned on 1/10/2025 per their log. The DS stated the filter was dusty to touch and it would be the maintenance staff's responsibility. The DS stated the internal part of the ice machine had reddish dirt and it was not supposed to be dirty due to infection control as they used their ice for resident's tea and lemonade. During an interview on 1/15/2025 at 10:19 a.m. with the Maintenance Supervisor (MS), the MS stated they empty the ice machine bin and clean it with bleach once a week. The MS stated they were getting a quote from an outside company to clean it and the Administrator (ADM) must approve it. The MS stated there was dust on the vent and the internal part had reddish mineral buildup. The MS stated they needed to maintain the cleanliness of the ice machine for infection control for the residents. During a review of the facility's P&P titled, Ice Machine Cleaning Procedures, dated 4/18/2025, the P&P indicated, The ice machine needs to be cleaned and sanitized monthly. (3) Clean inside of the ice machine with a sanitizing agent per the manufacturer's instructions. f. During a concurrent observation and interview on 1/15/2025 at 10:30 a.m., of the mixer with [NAME] 1, observed the mixer guard and agitator shaft had dried up food debris and whipped cream splatters. [NAME] 1 stated the mixer was not used this morning, but it needed to be cleaned after every use to prevent bacterial growth. [NAME] 1 stated if there is bacterial growth in the food, the residents could get sick. During an interview on 1/15/2025 at 10:56 a.m. with the DS, the DS stated the mixer must be cleaned after every use and the last time it was used was Sunday as they prepared biscuit, peanut butter cups and cake mix. The DS stated the staff in the pots and pans did not clean it. The DS stated not cleaning the mixer could cause cross-contamination resulting to the residents potentially getting sick. During a review of the facility's P&P titled, Electrical Food Machines, dated 4/18/2025, the P&P indicated, Keep and maintain all food machines in good operating, sanitary condition. This includes mixers, grinders, slices, and toasters. (3) Clean the beater shaft and body of the machine with warm water and detergent following manufacturer's instructions. g. During a concurrent observation and interview on 1/16/2025 at 9:50 a.m., of the Residents' refrigerator with Registered Nurse 2 (RN 2), observed dirt debris on the refrigerator shelves. RN 2 stated dirty refrigerator for the residents was not acceptable as bacteria could grow and could contaminate food resulting to food poisoning to the residents as a potential outcome. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-601.11 (A) Equipment Food Contact Surfaces and utensils shall be cleaned: (1) Except as specified in (B) of this section, before use with a different type of raw animal food such as beef, fish, lamb, pork or poultry; (2) Each time there is a change from working with raw foods to working with ready-to-eat food; (3) Between uses with raw fruits and vegetables and with time/temperature control for safety food. (4) Before using or storing a food temperature measuring device, and (5) At the time during the operation when contamination may have occurred. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated,4-602.13 Nonfood-Contact Surfaces. Nonfood-contact surfaces of equipment shall be cleaned at a frequency necessary to preclude accumulation of soil residues. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-602.12 Cooking and Baking Equipment. (A) The food contact surfaces of cooking and baking equipment shall be cleaned at least every 24 hours. This section does not apply to hot oil cooking and filtering equipment if it is cleaned as specified subparagraph 4-602.11 (D)(6). During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-307.11 Miscellaneous Sources of Contamination. Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301-3-306. 2. a. During an observation on 1/14/2025 at 8:46 a.m. observed seven (7) of 7 racks were chipped and had amber discoloration in the walk-in refrigerator. During a concurrent observation and interview on 1/14/2025 at 9:22 a.m. with the DS, the DS stated the racks were bad, old, and needed to be replaced. The DS stated the racks were rusty and had chips that could fall to the food causing cross-contamination. During a review of the facility's P&P titled, Refrigerator and Freezer, dated 4/18/2024, the P&P indicated, 9). Periodically inspect shelves and replace if coating is chipped away exposing metal shelves. b. During an observation on 1/15/2025 at 10:38 a.m., of the can opener, observed the can opener blade had chips. During a concurrent observation and interview on 1/15/2025 at 10:59 p.m. with the DS, the DS stated the can opener blade was corroded and chipped. The DS stated the can opener would be hard to clean and it could grow bacteria. The DS stated chipped can opener could cause physical contamination to food and residents could get sick as a potential outcome. During a review of the facility's P&P titled, Can Opener and Base, dated 4/18/2025, the P&P indicated, Proper sanitation and maintenance of the can opener and base is important to sanitary of food preparation. Metal shavings and shredding can result from dull cutting blade and work out cogwheel. (6) Replace blade on can opener as needed. c. During an observation on 1/15/2025 at 10:41 a.m., of the clean area where chopping boards are stored, observed green and white chopping board had scratches and brown liquid splatters. During a concurrent observation and interview on 1/15/2025 at 10:43 a.m., of the white chopping board with Dietary Aide 2 (DA 2) in the preparation area, DA 2 stated the chopping board had scratches and it was not okay as the dirt could go in between the scratches and bacteria could grow it in. DA 2 stated the area would be hard to clean if its was not smooth and could contaminate the food causing residents to get sick. During a concurrent observation an interview on 1/15/2025 at 11:02 a.m. with the DS, DS stated the chopping board had cut and knife marks making it hard to clean. The DS stated the chopping board could harbor bacteria and could contaminate food resulting to residents getting food borne illnesses. During an interview on 1/15/2025 at 11:06 a.m. with the DS, the DS stated the white chopping board had a dirt spill and we did not know if that was from the raw meat. The DS stated the residents could get sick due to cross-contamination. The DS stated the green chopping board needed replacement as it was scratched, and the white chopping board had plenty of dents from chopping. During a review of the facility's P&P titled, Sanitation, dated 4/18/2025, the P&P indicated, All equipment shall be maintained as necessary and kept in working order. (9) All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosion, open seam, cracks, and chipped areas. (10) Plastic ware, china and glassware that becomes unsightly, unsanitary, or hazardous because of chips, cracks or loss of glaze shall be discarded. (17) Separate chopping boards are to be used for preparing meats and vegetables. After each use, chopping boards shall be thoroughly cleaned and sanitized. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be (1) Smooth (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections. (3) Free of sharp internal angles, corners, and crevices, (4) Finished to have smooth welds and joints. 3. During an observation on 1/14/2025 at 8:58 a.m., observed one rack was not six (6) inches elevated from the floor. During a concurrent observation and interview on 1/14/2025 at 9:32 a.m. with the DS, the DS stated a rack was not 6 inches above the ground and it should be. The DS stated it was important that the racks are elevated 6 inches or more so that they could have access to clean the floor for potential dirt build up and rodents that could cause cross-contamination to food. During a review of the facility's P&P titled, Storage of Food and Supplies, dated 4/18/2025, the P&P indicated, (4) All shelves and storage racks or platforms should be in accordance with state and federal regulations to facilitate air circulation and promote easy and regular cleaning. All food and food containers are to be stored 6 inches off the floor and on clean surfaces in a manner that protects it from contamination. A review of Food Code 2022, dated 1/18/2023, the Food Code indicated, 3-305.11 Food Storage (A) Except as specified in (B) and (C) of this section, food shall be protected from contamination by storing the food: (3) at least 15 cm (6 inches) above the floor. 4. During an observation on 1/14/2025 at 8:58 a.m., observed boxes of food stored on the floor inside the walk-in freezer. During an interview on 1/14/2025 at 9:33 a.m. with the DS, the DS stated he placed the food boxes on the floor in the walk-in freezer because if he placed it in the cart, it would block the walkway. The DS stated, he would figure it out as it was not okay to store food on the floor due to physical contamination. 5. During an observation on 1/14/2025 at 9:39 a.m., of the dry storage area rack, observed three (3) dented cans were stored with non-dented cans. 6. During an interview on 1/14/2025 at 9:51 a.m. with the DS, the DS stated there were five (5) dented cans stored with non-dented cans. The DS stated they needed to place all the dented cans to a designated area as they need to bring it back to the vendor for credit and it needed to be separated because they could not use them. The DS stated residents could get ill and die from botulism (a rare but serious illness caused by a toxin that attacks the body's nerves from consuming food from dented cans) from consuming food from dented cans as a potential outcome. During a review of the facility's P&P titled, Storage of Food and Supplies, dated 4/18/2025, the P&P indicated, 15). Food in unlabeled rusty, leaking, broken containers or cans with side seam dents, rim dents or swells shall not be retained or used. During a review of the facility's P&P titled, Food Storage-Dented Cans, dated 4/18/2025, the P&P indicated, POLICY: Food in unlabeled, rusty, leaking, broken containers or cans with side seam dents, rim dent or swells shall not be retained or use by the facility. PROCEDURE: All dented cans (defined as side seam or rim dents) and rusty cans are to be separated from remaining stock and placed in a specified labeled area for return to purveyor for refund. All leaking cans are to be disposed immediately. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-101.11 Safe Unadulterated, and Honestly Presented. Food shall be safe, unadulterated, and, as specified under 3-601.12, honestly presented. 3-201.11 Compliance with Food Law. A primary line of defense ensuring that food meets the requirements of §3-101.11 is to obtain food from approved sources, the implications of which are discussed below. However, it is also critical to monitor food products to ensure that, after harvesting, processing, they do not fail victim to conditions that endanger their safety, make them adulterated, or compromise their honest presentation. The regulatory community, industry, and consumers should exercise vigilance in controlling the conditions to which foods are subjected and be alert to signs of abuse. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted, and pitted or dented cans may also present a serious potential hazard. 7. During an observation on 1/15/2025 at 10:41 a.m., of the drying rack, observed the pans were stacked wet. During an interview on 1/15/2025 at 11:04 a.m. with the DS, the DS stated the pots and pans needed to be air dried first before putting it away so there would no moist and mildew that would spread to pots and pans and could go to the food. The DS stated cross-contamination would be the potential outcome for stacking the pots and pans wet. During an interview on 1/15/2025 at 2:44 p.m. with Dietary Aide 1 (DA 1) stated their process of pots and pans washing in the three-compartment sink were as follows: - Wash - Rinse - Sanitize - Air dry DA 1 stated air dry was the last process, and he would know if the pots and pans we completely dry if there was no water dripping from the pots and pans. DA 1 stated the if the pans were stacked wet, it could spread germs for the residents. During a review of the facility's P&P titled, Three Compartment Procedure for Manual Dishwashing, dated 4/18/2025, the P&P indicated, Step 6: All items are air-dried, which means no water droplets are present. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 4-901.11 Equipment and Utensils, air-drying required. After cleaning and sanitizing equipment and utensils: (A) Shall be air-dried or used after adequate draining as specified in the first paragraph of 40 CFR 180.940 tolerance exemptions for active and inert ingredients for use in antimicrobial formulations (food-contact surface sanitizing solutions), before contact with food and; (B) May not be cloth dried except that utensils that have been air-dried may be polished with cloths that are maintained clean and dry. 8. During an observation on 12/14/2025 at 12:43 p.m. of the trayline, observed Dietary Aide 5 (DA 5), was at the end of trayline checking the trays with his beard sticking out of his mask. During an observation on 12/14/2025 at 12:45 p.m., of the food preparation by [NAME] 2, [NAME] 2 was preparing food at the grill and his beard was not fully covered with a hair restraint. During a concurrent observation and interview on 12/14/2025 at 1:31 p.m. with the DS, the DS stated facial hair should all be covered because hair could go to the food causing cross-contamination. The DS stated they needed to have hair restraints to prevent hair from falling off to the food. During a review of the facility's P&P titled, Dress Code dated 4/18/2024, the P&P indicated, 8. Beards and mustaches (any facial hair) must wear beard restraint. During a review of Food Code 2022, the Food Code 2022 indicated 2-402 Hair Restraints. 2-402.11 Effectiveness (A) except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens, and unwrapped single-service and single use article. 9. During an observation an interview on 1/16/2025 at 9:38 a.m. of the Resident's refrigerator with RN 2, the following food were not labeled with resident's name: i. Fiery chicken vindaloo ii. Cheese iii. Cottage cheese iv. Butter RN 2 stated they would not know which food belong to the residents and other residents could accidentally consume the food and they could get allergic reaction if they are allergic to certain foods. RN 2 stated a burrito for a resident did not have a received date so they would not know if its safe for the resident to consume or if it is expired. RN 2 stated they keep food for only 72 hours hence it was important to label it with received date to prevent potential food poisoning from eating expired food. During a review of the facility's P&P titled, Food Brought by Family/Visitors, dated 4/18/2024, the P&P indicated, (6) Perishable foods must be stored in re-sealable containers such as zip lock or tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the items, and the use by date. (7) The nursing staff is responsible for discarding perishable foods on or before the use by date. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 3-501.17 Commercially processed food, open and hold cold, (B) except specified in (E) - (G) of this section, refrigerated, ready-to-eat time/temperature control for food safety food prepared and packed by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacture's use-by- date if the manufacturer determined the use-by date based on food safety. 10. During an observation and interview on 1/16/2025 at 9:50 a.m. of the Residents' freezer with RN 2, observed that there was no thermometer inside the freezer and the ice cream sneaker and hot packet in it were not completely frozen. RN 2 stated there was no thermometer in the freezer and the freezer should be at 0 degree Fahrenheit (°F, a scale of temperature on which water freezes). RN 2 stated if there was no thermometer in the freezer, they would not know what temperature the freezer was maintaining and if the food was in their proper temperature. RN 2 stated residents could get food poisoning as bacteria grows on food if they are not in their proper temperatures. During a review of Food Code 2022, dated 1/18/2023, the Food Code indicated 4-204.112 Temperature Measuring Devices. (A) In a mechanically refrigerated or hot FOOD storage unit, the sensor of a TEMPERATURE MEASURING DEVICE shall be located to measure the air temperature or a simulated product temperature in the warmest part of a mechanically refrigerated unit and in the coolest part of a hot FOOD storage unit. (B) Except as specified in (C) of this section, cold or hot holding EQUIPMENT used for TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be designed to include and shall be equipped with at least one integral or permanently affixed TEMPERATURE MEASURING DEVICE that is located to allow easy viewing of the device's temperature display.

CONCERN (E)

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

Garbage Disposal (Tag F0814)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to dispose garbage and refuse (broad, overarching term that applies to anything that is leftover after it is used) properly when the dumpster (large trash container designed to be emptied into a truck) surroundings had liquid and food juices spills on the ground since Monday, 1/13/2025. This failure had a potential to result to attracting birds, flies, insects, pest and possibly spread infection to 266 of 274 facility residents. Findings: During a concurrent observation and interview on 1/15/2025 at 11:28 a.m. with the Dietary Supervisor (DS), the dumper surrounding had liquid spills on the ground. The DS stated there were a lot of juices and liquid spills from the trash on the ground and needed to be cleaned everyday as it could attract pests. The DS stated they prevent pests in the facility due to infection control. During a concurrent observation and interview on 1/15/2025 at 11:36 a.m. with the Maintenance Supervisor (MS) near the dumpster area, the MS stated the trash pickup came late last Monday, and the trash was too full that they had to put the trash on the floor causing a lot of spills on the ground from the trash. The MS stated the dumpster area was not cleaned yesterday and it was important to maintain its cleanliness for it not to attract flies, pests, and mice. The MS stated the pests could go inside the facility and could spread bacteria and diseases to the residents as a potential outcome of the trash area not being cleaned. During a review of the facility's policies and procedures (P&P) titled, Trash Collection Area, dated 4/18/2024, indicated The trash collection area is a potential feeding ground for vermin and rodents and must be kept clean. (1) The area must be swept and washed down by maintenance with a detergent on a regular basis. If a commercial rubbish service is used, arrangements must be made for periodic exchange of trash bins. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.113 Covering Receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered: (A) Inside food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and 174 (B) With tight-fitting lids or doors if kept outside the food establishment. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, 5-501.116 Cleaning Receptacles. Proper storage and disposal of garbage and refused are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage of breeding place for insects and rodents, and prevent the soiling of food preparation and food service areas. Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be possible source of contamination of food, equipment, and utensils. Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents. Proper equipment and supplies must be made available to accomplish thorough and proper cleaning of garbage storage areas and receptacles so that unsanitary conditions can be eliminated. During a review of Food Code 2022, dated 1/18/2023, the Food Code 2022 indicated, A review of Food Code 2017, indicated, 5-501.15 Outside receptacles. (A) Receptacles and waste handling units for REFUSE, recyclables, and returnable used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During a review of Resident 129's admission Record, the admission Record indicated the facility originally admitted the resident on 8/3/2021 and readmitted the resident on 8/16/2021 with diagnoses including dysphagia (difficulty swallowing), unspecified intellectual disabilities (a lifelong condition that limits a person's mental functioning and skills), and difficulty in walking. During a review of Resident 129's History and Physical (H&P) dated 9/5/2024, the (H&P) indicated the resident did not have the capacity to understand and make decisions. During a review of Resident 129's MDS dated [DATE], the MDS indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 129 required total assistance from staff with lower body dressing, partial/moderate assistance with bathing, toileting hygiene, upper body dressing, toilet transfer, and shower transfer, and substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 129's Order Summary Report, the Order Summary Report indicated a physician's order dated 10/25/2024 for humidified oxygen at two (2) liter per minute (liters/min - a unit of measurement) to five (5) liters/min via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) as needed for shortness of breath. During a concurrent observation and interview on 1/14/2025 at 10:38 a.m. inside Resident 129's room with Licensed Vocational Nurse 12 (LVN 12), observed Resident 129's oxygen nasal cannula tubing was placed on top of personal belongings at the bedside table and did not indicate the date of when it was last changed. LVN 12 stated oxygen tubing are changed every Sunday and should be labeled with the date. LVN 12 stated the oxygen tubing should be placed inside a plastic bag when not in use. LVN 12 stated Resident 129's oxygen tubing should have been labeled when it was last changed so staff would be aware when it was last changed. LVN 12 stated the oxygen tubing should have been placed inside the plastic storage bag when not in use, so it does not get contaminated. LVN 12 stated not indicating the date on the tubing and not placing in a plastic storage bag placed the resident at risk for acquiring infection due to contaminated tubing. During an interview on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the licensed staff should label the tubing with the date it was last changed to prevent the growth of microorganisms on the tubing that can cause infection to the resident. The DON stated the oxygen tubing should be changed every 7 days and as needed if soiled. The DON stated Resident 129 oxygen tubing should have been labeled with the date it was last changed to prevent the resident from acquiring infection due to contaminated tubing. During a review of the facility provided policy and procedure (P&P) titled Oxygen Administration, last reviewed on 4/18/2024, the P&P indicated a purpose of providing guidelines for safe oxygen administration. The P&P further indicated to replace oxygen supplies/tubing typically every 7-14 days or per manufacturer's guidelines. 4. During a review of Resident 72's admission Record, the admission Record indicated the facility admitted the resident on 8/23/2018 with diagnoses including chronic respiratory failure with hypoxia (a condition that occurs when the is not enough oxygen in the blood), chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), and dependence on supplemental oxygen. During a review of Resident 72's History and Physical (H&P) dated 12/8/2024, the (H&P) indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 72's MDS dated [DATE], the MDS indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 73 required set up or clean up assistance with eating; supervision or touching assistance with oral hygiene; partial/moderate assistance with mobility; substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 72's Order Summary Report, the Order Summary Report indicated a physician's order dated 1/22/2024: - Oxygen at 2 - four (4) liters/min via nasal cannula to maintain oxygen saturation (O2 Sat - a measurement of how much oxygen the blood is carrying as a percentage) above 90 percent (% - a unit of measurement) every shift. During a concurrent observation and interview on 1/14/2025 at 11:41 a.m. inside Resident 72's room with Licensed Vocational Nurse 116 (LVN 16), observed Resident 72's oxygen nasal cannula tubing did not indicate the date of when it was last changed. LVN 16 stated oxygen tubing are changed every week and should be labeled with the date it was last changed. LVN 16 stated Resident 72's oxygen tubing should have been labeled with the date of when it was last changed so staff would be aware when it was last changed and infection control. LVN 16 stated bacteria can grow in the tubing if not changed as scheduled. LVN 16 stated not indicating the date on the tubing placed the resident at risk for acquiring infection due to contaminated tubing. During an interview on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the licensed staff should label the tubing with the date it was last changed to prevent the growth of microorganisms on the tubing that can cause infection to the resident. The DON stated the oxygen tubing should be changed every 7 days and as needed if soiled. The DON stated Resident 129 oxygen should have been labeled with the date it was last changed to prevent the resident from acquiring infection due to contaminated tubing. During a review of the facility provided policy and procedure (P&P) titled Oxygen Administration, last reviewed on 4/18/2024, the P&P indicated a purpose of providing guidelines for safe oxygen administration. The P&P further indicated to replace oxygen supplies/tubing typically every 7-14 days or per manufacturer's guidelines. 5. During a review of Resident 225's admission Record, the admission Record indicated the facility admitted the resident on 8/23/2018 with diagnoses including hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body) and hemiparesis (weakness on the same side of the body) following cerebral infarction (stroke - loss of blood flow to a part of the body) affecting left dominant side, and chest pain. During a review of Resident 225's History and Physical (H&P) dated 10/24/2024, the (H&P) indicated the resident had fluctuating capacity to understand and make decisions. During a review of Resident 225's MDS dated [DATE], the MDS indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 225 required supervision or touching assistance with eating; substantial/maximal assistance with ambulation, toileting hygiene, bathing, upper body and lower body dressing; partial/moderate assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 225 was frequently incontinent of bowel and bladder. During a concurrent observation and interview on 1/14/2025 at 10:52 a.m., inside Resident 225's room with Licensed Vocational Nurse 13 (LVN 13), LVN 13 verified Resident 225's urine bottle on top of the overbed table and was not labeled with the resident's room number. LVN 13 stated urine bottles are labeled with at least the room number every time the staff changes the urine bottle. LVN 13 stated Resident 225's urine bottle should have been labeled with the room number of the resident to prevent switching with other residents that can cause cross contamination which may lead to infection. During an interview on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the urinal should be labeled with the name and room number of the resident to prevent cross-contamination (the transfer of harmful bacteria or other microorganisms from one object to another) among residents which may lead the residents to acquire infection. During a review of the facility's recent policy and procedure (P&P) titled Policies and Procedures- Infection Prevention and Control, last reviewed on 4/18/2024, the P&P indicated the facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. 6. During a review of Resident 13's admission Record, the admission Record indicated the facility admitted the resident on 5/16/2023 with diagnoses that included DM and hypertension (HTN-high blood pressure). During a review of Resident 13's MDS dated [DATE], the MDS indicated the resident was able to understand others and was able to make himself understood. The MDS further indicated the resident required insulin injections (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication) while a resident in the facility. During a review of Resident 13's Order Summary Report, the report indicated an order for insulin regular, inject subcutaneously (under the skin) per sliding scale (dosage of medication is determined by the resident's blood sugar) before meals and at bedtime, dated 9/5/2023. During a medication pass observation on 1/15/2025 at 5:15 p.m. with Licensed Vocational Nurse 8 (LVN 8) at Medication Cart 1A, LVN 8 stated he would check Resident 13's blood sugar. Observed LVN 8 remove a glucometer from Medication Cart 1A, walked into Resident 13's room, placed the glucometer on Resident 13's bedside rolling table, used a disposable lancet (sharp needle that's used to prick the skin to draw a small amount of blood) on the resident's finger, placed a test strip in the glucometer, and angled the glucometer at the resident's finger to test the blood. After the test was completed LVN 8 then removed and disposed of the used test strip, walked back to Medication Cart 1A and stated the resident did not require any insulin. LVN 8 stated he had no other residents that required a blood sugar check and then placed the glucometer back in Medication Cart 1A's top left drawer. Observed LVN 8 did not disinfect the glucometer prior to placing it back in the medication cart. LVN 8 then stated he did not clean Resident 13's bedside rolling table prior to placing the glucometer on top of it, and he did not clean the glucometer after testing Resident 13's blood sugar and placing the glucometer back in Medication Cart 1A. LVN 8 stated the facility process is to sanitize and clean the glucometer before putting it back in the medication cart, but he was using an unfamiliar medication cart and did not have sanitizing wipes on the cart as he usually did. LVN 8 stated it was important to sanitize for infection control purposes. During an interview on 1/15/2025 at 6:27 p.m. with the Infection Preventionist (IP), the IP stated glucometers are always cleaned between resident use and prior to placing back in the medication cart because there is a potential that the glucometer may be contaminated with bacteria or the resident's blood. The IP stated if the glucometer was not cleaned after resident use and prior to placing it in the medication cart it could result in the spread of infection between residents by cross contamination (the process by which bacteria, blood born pathogens, or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) The IP stated the glucometer and Medication Cart 1A would be disinfected. During a concurrent interview and record review on 1/17/2025 at 12:10 p.m., with the DON, the DON reviewed the facility policy and procedures on Infection Control and glucometer use. The DON stated he was made aware that LVN 8 did not disinfect the glucometer after use on a resident and prior to placing the glucometer back in the medication cart. The DON stated LVN 8 was using an unfamiliar medication cart and was very nervous. The DON stated the facility policy was not followed when the glucometer was not cleaned and could have potentially resulted in the cross contamination of blood borne pathogens and bacteria to residents. During a review of the facility policy and procedure (P&P) titled, Infection Control, last reviewed 4/18/2024, the P&P indicated the facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. All personell are trained on infection prevention and control policies and procedures upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. During a review of the facility P&P titled, Obtaining a Fingerstick Glucose Level, last reviewed 4/18/2024, the P&P indicated always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five of six sampled residents (Residents 73, 47, 129, 72, and 225) by failing to ensure: 1. The oxygen tubing was labeled with the date it was last changed for one of two sampled residents (Resident 73). 2. The urinal bottle (a container for collecting urine that is used by people who are unable to use a bathroom toilet) was labeled with the name and room number of the resident for one of one sampled resident (Resident 47). 3. Failing to ensure Residents 129's and 72's oxygen tubing were labeled with the date they were last changed. 4. Failing to ensure Resident 225's urine bottle was labeled with the resident's room number. 5. Licensed Vocational Nurse 8 (LVN 8) disinfected (cleanse of bacteria that may cause disease) the glucometer (blood glucose meter - device that measures the amount of glucose [sugar] in the blood of someone with diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) prior to placing the used glucometer in Medication Cart 1A for one five sampled residents (Resident 13) observed during the Medication Administration task. These deficient practices had the potential to spread infections and illnesses among residents. Findings: 1. During a review of Resident 73's admission Record, the admission Record indicated the facility admitted the resident on 10/2/2024, with diagnoses including displaced intertrochanteric fracture of right femur ( broken hip bone where the broken bone has shifted or separated) and anemia (a problem of not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues). During a review of Resident 73's Minimum Data Set (MDS, a resident assessment tool), dated 1/8/2025, the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (having the ability to think, learn, and remember clearly). During a review of Resident 73's Order Summary Report, dated 1/15/2025, the Order Summary Report indicated an order of oxygen at 2 liters per minute (LPM, a metric unit that measures the volume of a liquid or gas that flows in one minute) - 5 LPM via nasal cannula (a medical device that delivers oxygen to a patient through their nose) inhalation if needed (PRN) for shortness of breath (SOB) may use humidifier (a medical device that adds moisture to supplemental oxygen). As needed for shortness of breath monitor oxygen saturation (O2 sats, the percentage of oxygen currently bound to the hemoglobin in your blood) every (q) shift. During a concurrent observation and interview on 1/14/2025, at 11:25 a.m., with Certified Nursing Assistant 3 (CNA 3), inside Resident 73's room, observed Resident 73's oxygen tubing without any date of when it was last changed. CNA 3 stated the tubing was not dated and stated oxygen tubing should be changed every week and dated for the staff to know when to change them again. During an interview on 1/17/2025, at 3:38 p.m., with the Director of Nursing (DON), the DON stated the licensed staff should label the tubing with the date it was last changed to prevent the growth of microorganisms on the tubing that can cause infection to the resident. The DON stated the oxygen tubing should be changed every 7 days and PRN if soiled. During a review of the facility provided policy and procedure (P&P) titled Oxygen Administration, last reviewed on 4/18/2024, the P&P indicated the purpose of this procedure is to provide guidelines for safe oxygen administration. Replace oxygen supplies/tubings typically every 7-14 days or per manufacturer's guidelines. 2. During a review of Resident 47's admission Record, the admission Record indicated the facility admitted the resident on 4/9/2017, and readmitted the resident on 10/24/2024, with diagnoses including sepsis (a life-threatening condition that occurs when the body has an extreme response to an infection), personal history of other infections and parasitic diseases (an illness caused by organisms called parasites that live in or on another organism, known as the host). During a review of Resident 47's MDS, dated [DATE], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition. The MDS indicated the resident required substantial assistance on toileting and hygiene. During an observation and interview on 1/14/2025, at 10:15 a.m., with the Assistant Director of Staff Development (ADSD), observed Resident 47's two urinals hanging at bedside rail of the resident. The ADSD stated the urinal should be labeled with the name and the room number of the resident to prevent switching of urinals with other residents that can cause infection. During an interview on 1/17/2025, at 3:38 p.m., with the DON, the DON stated the urinal should be labeled with the name and room number of the resident to prevent cross-contamination (the transfer of harmful bacteria or other microorganisms from one object to another) among residents. During a review of the facility's recent policy and procedure (P&P) titled Policies and Procedures- Infection Prevention and Control, last reviewed on 4/18/2024, the P&P indicated the facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0645 (Tag F0645)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately code on one (1) of two (2) sampled residents (Resident 164) Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) when the PASARR prior to admission did not indicate Resident 103 had schizophrenia (a mental illness that is characterized by disturbances in thought). This deficient practice had the potential to result in the resident's medical and nursing care needs not being met. Findings: During a review of Resident 164's admission Record, the admission Record indicated the facility originally admitted the resident on 6/27/2024 and readmitted the resident on 9/1/2024, with diagnoses including schizophrenia, abnormalities of gait and mobility, and anxiety disorder (a mental health condition that causes excessive and persistent feelings of fear, dread, and worry). During a review of Resident 164's Minimum Data Set (MDS - a resident assessment tool), dated 12/19/2024, the MDS indicated Resident 164 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 164 required set up or cleanup assistance with eating and oral hygiene; supervision or touching assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During a review of Resident 164's History and Physical (H&P), dated 9/1/2024, the H&P indicated Resident 164 had fluctuating capacity to understand and make decisions. During a review of Resident 164's PASARR, date started 8/11/2024, the PASARR indicated that the resident did not have a diagnosed mental disorder. During a concurrent interview and record review, on 1/15/2025, at 12:53 p.m., with the Director of Admissions (DA), Resident 164's PASARR Level 1 Screening form (a preliminary assessment that determines if someone might have a mental illness or intellectual disability before being admitted to a nursing facility), dated 8/11/2024, and Resident 164's admission Record were reviewed. The DA verified she completed Resident 164's PASARR Level 1 Screening and the screening did not indicate the resident had a mental disorder. The DA stated the admission Record indicated Resident 164 had a diagnosis of schizophrenia upon original admission on [DATE]. The DA stated the PASARR Level 1 Screening was not completed accurately prior to admission to the facility. The DA stated prior to admission, the facility requests the general acute care hospital (GACH) to complete the PASARR Level 1 Screening and uploaded in the electronic health record. The DA stated she will complete the PASARR Level 1 Screening upon admission if the GACH did not complete prior to transferring the resident to the facility. The DA stated she should have checked Resident 164's admission Record and should have coded the PASARR Level 1 Screening accurately to reflect the resident's current medical condition such as diagnoses of behavioral issues, mental illness, or mood disorder to ensure Resident 164 received the proper care and services the resident needed. During an interview, on 1/17/2025, at 5:30 p.m., with the Director of Nursing (DON), the DON stated the PASARR Level 1 Screening is completed in the GACH prior to admission to the facility when they submit inquiry for bed availability in the facility. The DON stated the DA is responsible to make sure the GACH completed the Level 1 Screening prior to admission. The DON stated if not completed, then the DA will complete the Level 1 Screening. The DON stated the PASARR Level 1 Screening should be completed accurately to ensure resident placement in the facility is appropriate to receive the proper services the resident needs. The DON stated Resident 164's PASARR Level 1 Screening should have been completed accurately to reflect Resident 164's diagnosis of schizophrenia to ensure proper placement and avoid delay in the delivery of necessary care and services Resident 164 needs. During a review of the facility's policy and procedure (P&P) titled, PASARR, last reviewed 4/18/2024, the P&P indicated: - Before a [resident] can be transferred from a hospital, they must undergo a PASARR Level 1 Screening. This initial screening is to identify individuals who may have mental illness, intellectual disability, or related conditions. The goal is to determine whether they require further evaluation to assess the need for specialized services. - If the Level 1 screen indicates that the individual may meet the criteria for a mental disorder, intellectual disability, or related disorders, he or she is referred to the Stated PASARR representative for the Level II (evaluation and determination) screening process.

Jan 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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Resident 1) by not following the physician's orders. This deficient practice had the potential to result in Resident 1's increase in blood pressure (BP- pressure of circulating blood against the walls of blood vessels). Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 1/22/2024 with diagnoses that included stress hip fracture (a small, hairline crack in the bone of the hip, typically caused by repetitive stress from activities like running or jumping, rather than a single traumatic event), left hip osteoarthritis (a chronic disease that causes the breakdown of cartilage [a strong, flexible connective tissue that protects your joints and bones] and bone in joints, leading to pain, stiffness, and swelling) and essential hypertension (HTN- high blood pressure). During a record review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 10/30/2024, the MDS indicated Resident 1 had cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 1 needed moderate assistance from staff for bathing and personal hygiene. During a record review of Resident 1's Order Summary Report, dated 1/22/2024, the Order Summary Report indicated an order for amlodipine besylate (medication used to treat high blood pressure) 10 milligram (mg-metric unit of measurement, used for medication dosage and/or amount) tablet, give one tablet by mouth daily for HTN. During a record review of Resident 1's Medication Administration Record (MAR-record of medication received by the resident), dated 12/30/2024, the MAR indicated amlodipine was given at 9 a.m. with a blood pressure of 132/81. During a record review of Resident 1's Progress Notes (PN), dated 12/30/2024 timed at 4 p.m., the PN indicated Resident 1 refused blood pressure check at 9 a.m. During a record review of Resident 1's Care Plan about hypertension, dated 1/23/2024, the care plan indicated an intervention to administer medication as ordered. During an interview on 1/6/2025 at 9:51 a.m., Licensed Vocational Nurse 2 (LVN 2) stated Resident 1 takes amlodipine daily for high blood pressure scheduled at 9.a.m. LVN 2 stated nurses should check Resident 1's blood pressure first before giving amlodipine to prevent low blood pressure. LVN 2 stated medication should be given one hour before and one hour after schedule time. During an interview and record review on 1/7/2025 at 10:08 a.m., with Medical Records Director (MRD), Resident 1's Amlodipine Administration Details dated 12/30/2024 was reviewed. The Amlodipine Administration Details indicated LVN 1 administered amlodipine at 1:09 p.m., which was scheduled at 9 a.m. on 12/30/2024. The MRD stated amlodipine was given four hours after the scheduled time. During an interview on 1/7/2025 at 10:13 a.m., Resident 1 stated LVN 1 did not administer his blood pressure medication on the morning of 12/30/2024. Resident 1 stated he needed that medication to control his blood pressure. During an interview on 1/7/2025 at 10:19 a.m., with the Director of Nursing (DON), the DON stated amlodipine was scheduled at 9 a.m. and could be given one hour before and one hour after the scheduled time. The DON stated amlodipine could be given between 8 a.m. and 10 a.m. if ordered daily. The DON stated LVN 1 should have documented in the MAR that Resident 1 refused amlodipine at 9 a.m., and LVN 1 should have documented in the Progress Note that amlodipine was given late at 1:09 p.m. The DON stated it was a late medication administration. During a record review of facility's policy and procedure titled, Administering Medications dated 2001 and last reviewed on 4/18/2024, the PP indicated, Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. the date and time the medication was administered.

Jan 2025 4 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) for one of four sampled residents (Resident 4) by failing to: 1. Follow the Physician's Order to place Resident 4 on a Low Air Loss Mattress (LALM, a mattress composed of inflatable air cushions and used to relieve pressure). 2. Follow the manufacturer's instructions to set the firmness of the LALM based on Resident 4's weight. These deficient practices placed the residents at risk for the development and worsening of PUs. Findings: During a record review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 11/6/2024 with diagnoses including anemia (condition in which the body does not get enough oxygen-rich blood), depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). During a record review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 11/12/2024, the MDS indicated the resident's cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills were severely impaired. The MDS indicated Resident 4 was dependent on facility staff on rolling to the left and right. The MDS indicated Resident 4 had one PU that was present on admission. During a record review of Resident 4's Braden Scale For Predicting Pressure Sore Risk, dated 11/27/2024, the Braden Scale For Predicting Pressure Sore Risk indicated total score of 13. A Braden Score of 13 to 14 indicated moderate risk. During a record review of Resident 4's Skin and Wound Evaluation, date 12/19/2024, the Skin and Wound Evaluation indicated the resident had a stage 4 (full-thickness skin and tissue loss) PU on the sacral region (area at the base of the spine, near the hips). During a record review of Resident 4's Care Plan on skin, last revised on 1/3/2025, the Care Plan indicated Resident 4 had a stage 4 PU on the sacrum and was at risk for further breakdown and slow delayed healing related to decreased mobility. The Care Plan Interventions indicated air pressure redistribution mattress for wound management and to monitor settings and function every shift based on Resident 4's current Body Mass Index (BMI, a tool used to compare a person's weight to their height). During a concurrent observation and interview on 1/6/2025 at 12:15 p.m. with the Director of Nursing (DON), observed Resident 4's LALM was off. The DON turned the LALM on and observed the machine setting was on level 3, alternating pressure. The DON stated the LALM setting should be based on the resident's weight. During an observation and concurrent interview on 1/6/2025 at 12:30 p.m., with Licensed Vocational Nurse 1 (LVN 1), observed Resident 4's LALM machine setting was on level 3 alternating pressure. LVN 1 stated Resident 4's LALM should be on and set based on the resident's BMI. During a concurrent record review of Resident 4's medical records, the resident's Physician Orders, dated 12/13/2024, indicated air pressure redistribution mattress for wound management and to monitor settings and function every shift. Resident 4's Physician Order indicated the setting according to the resident's current BMI (setting 1 for BMI 12 to 20, setting 2 for BMI 21 to 35, setting 3 for BMI 36 to 50 .). Resident 4's Weekly Weight Nutrition Note, dated 1/1/2025, indicated the resident's BMI was 13.4. LVN 1 stated Resident 4's LALM setting should be on level 1. LVN 1 stated the LALM was used to relieve pressure from the body. LVN 1 stated a wrong LALM setting had the potential for Resident 4's PU to get worst. During a follow up interview on 1/6/2025 at 4:21 p.m. with the DON, the DON stated incorrect LALM setting had the potential for Resident 4's PU to get worst. The DON stated the facility failed to ensure Resident 4's LALM was on with the setting based on the resident's current BMI per physician order. During a record review of the facility's policy and procedure (PnP) titled, Support Surface Guidelines, last reviewed on 4/18/2024, the PnP indicated the purpose to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. The PnP indicated any individual at risk for developing PU should be placed on a redistribution support surface such as . alternating air or air-loss when lying on bed. During a record review of the facility-provided undated manufacturer's instructions titled, Pressure Guard Custom Care, the manufacturer's instructions indicated the BMI setting suggestions may be helpful in determining an ideal comfort setting. Based on observation, interview, and record review, the facility failed to ensure care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) for one of four sampled residents (Resident 4) by failing to: 1. Follow the Physician's Order to place Resident 4 on a Low Air Loss Mattress (LALM, a mattress composed of inflatable air cushions and used to relieve pressure). 2. Follow the manufacturer's instructions to set the firmness of the LALM based on Resident 4's weight. These deficient practices placed the residents at risk for the development and worsening of PUs. Findings: During a record review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 11/6/2024 with diagnoses including anemia (condition in which the body does not get enough oxygen-rich blood), depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). During a record review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 11/12/2024, the MDS indicated the resident's cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills were severely impaired. The MDS indicated Resident 4 was dependent on facility staff on rolling to the left and right. The MDS indicated Resident 4 had one PU that was present on admission. During a record review of Resident 4's Braden Scale For Predicting Pressure Sore Risk, dated 11/27/2024, the Braden Scale For Predicting Pressure Sore Risk indicated total score of 13. A Braden Score of 13 to 14 indicated moderate risk. During a record review of Resident 4's Skin and Wound Evaluation, date 12/19/2024, the Skin and Wound Evaluation indicated the resident had a stage 4 (full-thickness skin and tissue loss) PU on the sacral region (area at the base of the spine, near the hips). During a record review of Resident 4's Care Plan on skin, last revised on 1/3/2025, the Care Plan indicated Resident 4 had a stage 4 PU on the sacrum and was at risk for further breakdown and slow delayed healing related to decreased mobility. The Care Plan Interventions indicated air pressure redistribution mattress for wound management and to monitor settings and function every shift based on Resident 4's current Body Mass Index (BMI, a tool used to compare a person's weight to their height). During a concurrent observation and interview on 1/6/2025 at 12:15 p.m. with the Director of Nursing (DON), observed Resident 4's LALM was off. The DON turned the LALM on and observed the machine setting was on level 3, alternating pressure. The DON stated the LALM setting should be based on the resident's weight. During an observation and concurrent interview on 1/6/2025 at 12:30 p.m., with Licensed Vocational Nurse 1 (LVN 1), observed Resident 4's LALM machine setting was on level 3 alternating pressure. LVN 1 stated Resident 4's LALM should be on and set based on the resident's BMI. During a concurrent record review of Resident 4's medical records, the resident's Physician Orders, dated 12/13/2024, indicated air pressure redistribution mattress for wound management and to monitor settings and function every shift. Resident 4's Physician Order indicated the setting according to the resident's current BMI (setting 1 for BMI 12 to 20, setting 2 for BMI 21 to 35, setting 3 for BMI 36 to 50 .). Resident 4's Weekly Weight Nutrition Note, dated 1/1/2025, indicated the resident's BMI was 13.4. LVN 1 stated Resident 4's LALM setting should be on level 1. LVN 1 stated the LALM was used to relieve pressure from the body. LVN 1 stated a wrong LALM setting had the potential for Resident 4's PU to get worst. During a follow up interview on 1/6/2025 at 4:21 p.m. with the DON, the DON stated incorrect LALM setting had the potential for Resident 4's PU to get worst. The DON stated the facility failed to ensure Resident 4's LALM was on with the setting based on the resident's current BMI per physician order. During a record review of the facility's policy and procedure (PnP) titled, Support Surface Guidelines, last reviewed on 4/18/2024, the PnP indicated the purpose to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. The PnP indicated any individual at risk for developing PU should be placed on a redistribution support surface such as . alternating air or air-loss when lying on bed. During a record review of the facility-provided undated manufacturer's instructions titled, Pressure Guard Custom Care, the manufacturer's instructions indicated the BMI setting suggestions may be helpful in determining an ideal comfort setting.

CONCERN (D) 📢 Someone Reported This

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

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 4) had a physician order for oxygen therapy (O2 therapy - a treatment that provides a person with supplemental or extra oxygen) before Resident 4 was provided with oxygen. This deficient practice had the potential to create confusion in the delivery of care and services to Resident 4. Findings: During an observation and concurrent interview on 1/6/2025 at 12:30 p.m. with Licensed Vocational Nurse 1 (LVN 1), observed Resident 4's O2 nasal cannula (a device used to deliver supplemental oxygen thru the nostril [nose]) was on top of the resident's bed and was not connected to the resident's nostrils. LVN 1 stated Resident 4 should have the O2 per nasal cannula at four liters per minute (Lpm - unit of measurement). During a record review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 11/6/2024 with diagnoses including anemia (condition in which the body does not get enough oxygen-rich blood), depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). During a record review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 11/12/2024, the MDS indicated the resident's cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills were severely impaired. During a record review of Resident 4's Care Plan on oxygen, initiated on 1/1/2025, the Care Plan indicated Resident 4 required the use of intermittent oxygen related to episodes of shortness of breath and decreased O2 saturation (a measurement of how much oxygen was in a person's blood relative to the maximum amount it could carry). The Care Plan indicated Resident 4 required oxygen at two Lpm via nasal cannula as needed and may titrate to four LPM to maintain O2 saturation above 95%. The Care Plan Intervention indicated to educate the resident on the importance of keeping oxygen on and at the prescribed setting. During a record review of Resident 4's Weekly Summary Notes, dated 1/2/2025, the Weekly Summary Notes indicated Resident 4 was on O2 per nasal cannula. During a follow up interview on 1/6/2025 at 12:38 p.m. and concurrent record review of Resident 4's Physician Orders, reviewed with LVN 1, LVN 1 stated there was no Physician Order for Resident 4's O2 therapy. LVN 1 stated Resident 4 should have an oxygen therapy order before the resident received oxygen. LVN 1 stated Resident 4 had the potential to be over or under oxygenated. During an interview on 1/6/2025 at 3 p.m. and concurrent record review of Resident 4's Physician Orders, reviewed with the Infection Prevention Nurse (IPN), the IPN stated Resident 4's Physician Order for O2 therapy, dated 1/1/2025 indicated the O2 therapy order was entered in the resident's medical records but was not confirmed. The IPN stated Resident 4's unconfirmed order was not active and had the potential for the order to be missed. During an interview on 1/6/2025 at 4:21 p.m., the Director of Nursing (DON) stated Resident 4's medical records did not indicate an active O2 therapy order. The DON stated Resident 4 received O2, but the nasal cannula was not in the resident's nostrils. The DON stated Resident 4 had the potential to experience shortness of breath. The DON stated the facility failed to ensure there was a physician's order for O2 therapy before Resident 4 was provided with O2. The DON stated the facility failed to ensure Resident 4's O2 therapy per nasal cannula was in the resident's nostrils. During a record review of the facility's policy and procedure (PnP) titled, Oxygen Administration, last reviewed on 4/18/2024, the PnP indicated the purpose to provide guidelines for safe oxygen administration. The PnP indicated to verify that there was a physician order for the procedure. The General Guidelines section of the PnP indicated oxygen therapy was administered by way of an . nasal cannula. The PnP indicated to securely anchor the tubing so that it does not rub or irritate the resident's nose or behind the ears. During a record review of the facility's PnP titled, Medication and Treatment Orders, last reviewed on 4/18/2024, the PnP indicated orders for medications and treatments will be consistent with principles of safe and effective order writing. The PnP indicated medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. The PnP indicated drugs and biological orders must be recorded on the physician's order sheet in the resident's chart. Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 4) had a physician order for oxygen therapy (O2 therapy - a treatment that provides a person with supplemental or extra oxygen) before Resident 4 was provided with oxygen. This deficient practice had the potential to create confusion in the delivery of care and services to Resident 4. Findings: During an observation and concurrent interview on 1/6/2025 at 12:30 p.m. with Licensed Vocational Nurse 1 (LVN 1), observed Resident 4's O2 nasal cannula (a device used to deliver supplemental oxygen thru the nostril [nose]) was on top of the resident's bed and was not connected to the resident's nostrils. LVN 1 stated Resident 4 should have the O2 per nasal cannula at four liters per minute (Lpm – unit of measurement). During a record review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 11/6/2024 with diagnoses including anemia (condition in which the body does not get enough oxygen-rich blood), depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). During a record review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 11/12/2024, the MDS indicated the resident's cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills were severely impaired. During a record review of Resident 4's Care Plan on oxygen, initiated on 1/1/2025, the Care Plan indicated Resident 4 required the use of intermittent oxygen related to episodes of shortness of breath and decreased O2 saturation (a measurement of how much oxygen was in a person's blood relative to the maximum amount it could carry). The Care Plan indicated Resident 4 required oxygen at two Lpm via nasal cannula as needed and may titrate to four LPM to maintain O2 saturation above 95%. The Care Plan Intervention indicated to educate the resident on the importance of keeping oxygen on and at the prescribed setting. During a record review of Resident 4's Weekly Summary Notes, dated 1/2/2025, the Weekly Summary Notes indicated Resident 4 was on O2 per nasal cannula. During a follow up interview on 1/6/2025 at 12:38 p.m. and concurrent record review of Resident 4's Physician Orders, reviewed with LVN 1, LVN 1 stated there was no Physician Order for Resident 4's O2 therapy. LVN 1 stated Resident 4 should have an oxygen therapy order before the resident received oxygen. LVN 1 stated Resident 4 had the potential to be over or under oxygenated. During an interview on 1/6/2025 at 3 p.m. and concurrent record review of Resident 4's Physician Orders, reviewed with the Infection Prevention Nurse (IPN), the IPN stated Resident 4's Physician Order for O2 therapy, dated 1/1/2025 indicated the O2 therapy order was entered in the resident's medical records but was not confirmed. The IPN stated Resident 4's unconfirmed order was not active and had the potential for the order to be missed. During an interview on 1/6/2025 at 4:21 p.m., the Director of Nursing (DON) stated Resident 4's medical records did not indicate an active O2 therapy order. The DON stated Resident 4 received O2, but the nasal cannula was not in the resident's nostrils. The DON stated Resident 4 had the potential to experience shortness of breath. The DON stated the facility failed to ensure there was a physician's order for O2 therapy before Resident 4 was provided with O2. The DON stated the facility failed to ensure Resident 4's O2 therapy per nasal cannula was in the resident's nostrils. During a record review of the facility's policy and procedure (PnP) titled, Oxygen Administration, last reviewed on 4/18/2024, the PnP indicated the purpose to provide guidelines for safe oxygen administration. The PnP indicated to verify that there was a physician order for the procedure. The General Guidelines section of the PnP indicated oxygen therapy was administered by way of an . nasal cannula. The PnP indicated to securely anchor the tubing so that it does not rub or irritate the resident's nose or behind the ears. During a record review of the facility's PnP titled, Medication and Treatment Orders, last reviewed on 4/18/2024, the PnP indicated orders for medications and treatments will be consistent with principles of safe and effective order writing. The PnP indicated medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. The PnP indicated drugs and biological orders must be recorded on the physician's order sheet in the resident's chart.

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to implement policy and procedure on safeguarding of all prescribed medications including controlled medications (medications with a high potential for abuse) for one of four sampled residents (Resident 1) by failing to ensure Resident 1's prescribed controlled medications were stored in the medication cart of the nursing station where Resident 1 was located. This deficient practice had the potential for non-authorized access to the resident's medications. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 9/6/2024 with diagnoses including sepsis (the body's extreme response to an infection), adult failure to thrive (a state of gradual decline in a person's overall health making it difficult to maintain daily functions), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/13/2024, the MDS indicated the resident's cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills were severely impaired. During a record review of Resident 1's Physician Orders, dated 12/24/2024, the Physician Orders indicated lorazepam oral (mouth) concentrate (a medication used to treat anxiety) 2 milligrams (mg - unit of measurement) per milliliter (ml - unit of measurement), give 0.5 ml sublingually (under the tongue) every four hours as needed for anxiety (feeling of worry, nervousness, or restlessness [uneasiness]). During a record review of Resident 1's Physician Orders, dated 12/24/2024, the Physician Orders indicated morphine sulfate (a medication used to treat severe pain) oral solution 20 mg per ml, give 0.5 ml sublingually every two hours as needed for moderate to severe pain. During a record review of Resident 1's Physician Orders, dated 12/25/2024, the Physician Orders indicated fentanyl (a medication used in the management and treatment of chronic pain and cancer pain) transdermal patch (a patch attached to the skin and contains medication) 100 micrograms (mcg - unit of measurement) per hour apply one patch every three days. During a record review of Resident 1's Progress Notes, dated 12/25/2024, the Progress Notes indicated the pharmacy delivered Resident 1's medications on 12/24/2024 and were found on 12/25/2024 inside a medication cart. During an interview on 1/6/2025 at 1:43 p.m. with Registered Nurse 1 (RN 1), RN 1 stated the licensed nurse on nursing station 3 informed him that Resident 1's pharmacy-delivered controlled medications were not in station 3 medication cart. RN 1 stated he was informed that Resident 1's medications were delivered on 12/24/2024 (11 p.m. to 7 a.m. shift). RN 1 stated Resident 1's prescribed controlled medications were found on 12/25/2024 (3 p.m. to 11 p.m. shift) inside nursing station 1's medication cart. RN 1 stated the licensed nurse that received the medications should deliver the medications to the nursing unit where the resident was located. RN 1 stated it had the potential for Resident 1 to miss the medication and not have the full therapeutic effect. RN 1 stated the facility failed to store Resident 1's medications in the right station. During am interview on 1/6/2025 at 4:21 p.m. with the Director of Nursing (DON), the DON stated the licensed nurse that received the medications from the pharmacy was responsible to deliver the resident's medications to the nursing unit where the resident was located. The DON stated Resident 1's medications were misplaced on 12/24/2024 and were found on 12/25/2024. The DON stated misplaced medications had the potential to cause discomfort to the resident. The DON stated the facility failed to ensure Resident 1's medications were stored and accounted for upon delivery from the pharmacy. During a record review of the facility's policy and procedure (PnP) titled, Medication Labeling and Storage, last reviewed on 4/18/2024, the PnP indicated nursing staff was responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. The PnP indicated controlled substances and other drugs subject to abuse were separately locked in permanently affixed compartments. Based on interview and record review, the facility failed to implement policy and procedure on safeguarding of all prescribed medications including controlled medications (medications with a high potential for abuse) for one of four sampled residents (Resident 1) by failing to ensure Resident 1's prescribed controlled medications were stored in the medication cart of the nursing station where Resident 1 was located. This deficient practice had the potential for non-authorized access to the resident's medications. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 9/6/2024 with diagnoses including sepsis (the body's extreme response to an infection), adult failure to thrive (a state of gradual decline in a person's overall health making it difficult to maintain daily functions), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/13/2024, the MDS indicated the resident's cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills were severely impaired. During a record review of Resident 1's Physician Orders, dated 12/24/2024, the Physician Orders indicated lorazepam oral (mouth) concentrate (a medication used to treat anxiety) 2 milligrams (mg – unit of measurement) per milliliter (ml – unit of measurement), give 0.5 ml sublingually (under the tongue) every four hours as needed for anxiety (feeling of worry, nervousness, or restlessness [uneasiness]). During a record review of Resident 1's Physician Orders, dated 12/24/2024, the Physician Orders indicated morphine sulfate (a medication used to treat severe pain) oral solution 20 mg per ml, give 0.5 ml sublingually every two hours as needed for moderate to severe pain. During a record review of Resident 1's Physician Orders, dated 12/25/2024, the Physician Orders indicated fentanyl (a medication used in the management and treatment of chronic pain and cancer pain) transdermal patch (a patch attached to the skin and contains medication) 100 micrograms (mcg – unit of measurement) per hour apply one patch every three days. During a record review of Resident 1's Progress Notes, dated 12/25/2024, the Progress Notes indicated the pharmacy delivered Resident 1's medications on 12/24/2024 and were found on 12/25/2024 inside a medication cart. During an interview on 1/6/2025 at 1:43 p.m. with Registered Nurse 1 (RN 1), RN 1 stated the licensed nurse on nursing station 3 informed him that Resident 1's pharmacy-delivered controlled medications were not in station 3 medication cart. RN 1 stated he was informed that Resident 1's medications were delivered on 12/24/2024 (11 p.m. to 7 a.m. shift). RN 1 stated Resident 1's prescribed controlled medications were found on 12/25/2024 (3 p.m. to 11 p.m. shift) inside nursing station 1's medication cart. RN 1 stated the licensed nurse that received the medications should deliver the medications to the nursing unit where the resident was located. RN 1 stated it had the potential for Resident 1 to miss the medication and not have the full therapeutic effect. RN 1 stated the facility failed to store Resident 1's medications in the right station. During am interview on 1/6/2025 at 4:21 p.m. with the Director of Nursing (DON), the DON stated the licensed nurse that received the medications from the pharmacy was responsible to deliver the resident's medications to the nursing unit where the resident was located. The DON stated Resident 1's medications were misplaced on 12/24/2024 and were found on 12/25/2024. The DON stated misplaced medications had the potential to cause discomfort to the resident. The DON stated the facility failed to ensure Resident 1's medications were stored and accounted for upon delivery from the pharmacy. During a record review of the facility's policy and procedure (PnP) titled, Medication Labeling and Storage, last reviewed on 4/18/2024, the PnP indicated nursing staff was responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. The PnP indicated controlled substances and other drugs subject to abuse were separately locked in permanently affixed compartments.

CONCERN (E) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to follow infection control procedures for one of four sampled residents (Resident 4) by failing to: 1. Ensure Resident 4, who was on enhanced barrier precaution (EBP - an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities), had EBP signage outside the resident's door. 2. Ensure personal protective equipments (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) were available to use for Resident 4's care. 3. Ensure Licensed Vocational Nurse 1's (LVN 1) PPE was worn before entering the EBP room. LVN 1 did not wear gloves before touching Resident 4's oxygen nasal cannula (a device used to deliver supplemental oxygen thru the nostril [nose]). 4. Ensure unused PPE supplies were kept clean. Resident 4 had a box of opened unused gloves on the resident's bed. LVN 1 took a pair of gloves from the box and used the gloves to put the nasal cannula on Resident 4. LVN 1 placed the box of gloved from Resident 4's bed on top of the treatment cart. These deficient practices placed Resident 4 at risk for exposure and contracting infections. Findings: During a record review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 11/6/2024 with diagnoses including anemia (condition in which the body does not get enough oxygen-rich blood), depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). During a record review of Resident 4's Care Plan on EBP, initiated on 11/7/2024, the Care Plan indicated the resident required EBP during high-contact resident care activities due to the presence of indwelling device (a medical device that is inserted inside the body). The Care Plan Goal indicated EBP will be utilized to reduce the risk of transmission of multidrug-resistant organisms (bacteria that had become resistant to certain antibiotics) during high-contact resident care activities. The Care Plan Interventions indicated to ensure items for following EBP were in place and to place EBP notification signage near Resident 4's room doorway to alert staff and visitors of precautions. The Care Plan Interventions indicated to utilize PPE during high-contact resident care activities such as .device care. During a record review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 11/12/2024, the MDS indicated the resident's cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills were severely impaired. The MDS indicated Resident 4 was dependent on facility staff on rolling to the left and right. The MDS indicated Resident 4 had one pressure ulcer (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) that was present on admission. During a record review of Resident 4's Skin and Wound Evaluation, date 12/19/2024, the Skin and Wound Evaluation indicated the resident had a stage 4 (full-thickness skin and tissue loss) PU on the sacral region (area at the base of the spine, near the hips). During a record review of Resident 4's Weekly Summary Notes, dated 1/2/2025, the Weekly Summary Notes indicated Resident 4 had an enteral feeding tube (g-tube, a way of delivering nutrition directly to the stomach or small intestine) and was on oxygen per nasal cannula. During an observation and concurrent interview on 1/6/2025 at 12:30 p.m. with LVN 1, observed LVN 1 touch Resident 4's oxygen nasal cannula without wearing gloves. Observed LVN 1 take a pair of gloves from an opened box of gloves located on top of Resident 4's bed. Observed LVN 1 wore the gloves without washing her hands or using a hand sanitizer. Observed LVN 1 place Resident 4's oxygen nasal cannula on the resident's nostrils. LVN 1 stated the box of gloves should not be on Resident 4's bed. LVN 1 stated she should perform hand washing or used a hand sanitizer before she wore the gloves and before she touched Resident 4's oxygen nasal cannula. LVN 1 stated it had the potential to cause cross contamination (the transfer of bacteria or other microorganisms from one substance to another). During an observation and a follow up interview on 1/6/2025 at 12:38 p.m. with LVN 1, Observed LVN 1 placed the box of gloves taken from Resident 4's bed on top of the clean treatment cart. observed Resident 4 did not have an EBP sign on the door. Observed there were no PPE supplies at the entrance of Resident 4's room. LVN 1 stated Resident 4 was on EBP because of the resident's g-tube and PU. LVN 1 stated no EBP sign and no easily accessible PPE supplies for Resident 4's care had the potential for staff confusion on the precautions to be used on the resident. LVN stated Resident 4 had the potential for infection. During an interview on 1/6/2025 at 4:04 p.m. with the Infection Preventionist Nurse (IPN), the IPN stated Resident 4's oxygen cannula should be in the oxygen bag when not in use. The IPN stated LVN 1 should use hand sanitizer before she wore gloves and touched Resident 4's oxygen nasal cannula. The IPN stated the clean box of gloves should be on the glove's holder and not on Resident 4's bed. The IPN stated the box of gloves that was on top of Resident 4's bed should not be placed on top of the clean treatment cart. The IPN stated the EBP signs should be on Resident 4's door and the PPE supplies should be on the PPE supplies cart. The IPN stated the EBP was to decrease cross contamination and decrease the spread of infection. The IPN stated these practices had the potential for cross contamination that may lead to Resident 4's infection. The IPN stated the facility failed to follow the facility's infection prevention policies. During a record review of the facility's policy and procedure (PnP) titled, Infection Prevention and Control Program, last reviewed on 4/18/2024, the PnP indicated an infection prevention and control program was established and maintained to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. During a record review of the facility's PnP titled, Enhanced Barrier Precautions,, last reviewed on 4/18/2024, the PnP indicated EBP were utilized to reduce the transmission of multi-drug resistant organisms to residents. The PnP indicated gloves and gown were applied prior to performing the high-contact resident care activity. The PnP indicated the high-contact resident care activities required the use of gown and gloves for EBP included .g. device care or use. The PnP indicated EBP were indicated for residents with wounds or indwelling medical devices. The PnP indicated signs were posted in the door or wall outside the resident room indicating the type of precautions and PPE required. The PnP indicated PPE were available outside of the resident rooms. During a record review of the facility's PnP titled, Standard Precautions,, last reviewed on 4/18/2024, the PnP indicated standard precautions apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious disease. The PnP indicated hand hygiene was performed with alcohol-based hand rub or soap and water . 1. before and after contact with the resident . 4. after contact with item in the resident's room. The PnP indicated resident-care equipment soiled with blood, body fluids, secretions, and excretions were handled in a manner that prevents skin and mucous membrane exposure, contamination of clothing, and transfer of microorganisms to other residents and environments. Based on observation, interview, and record review, the facility failed to follow infection control procedures for one of four sampled residents (Resident 4) by failing to: 1. Ensure Resident 4, who was on enhanced barrier precaution (EBP – an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities), had EBP signage outside the resident's door. 2. Ensure personal protective equipments (PPE – equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) were available to use for Resident 4's care. 3. Ensure Licensed Vocational Nurse 1's (LVN 1) PPE was worn before entering the EBP room. LVN 1 did not wear gloves before touching Resident 4's oxygen nasal cannula (a device used to deliver supplemental oxygen thru the nostril [nose]). 4. Ensure unused PPE supplies were kept clean. Resident 4 had a box of opened unused gloves on the resident's bed. LVN 1 took a pair of gloves from the box and used the gloves to put the nasal cannula on Resident 4. LVN 1 placed the box of gloved from Resident 4's bed on top of the treatment cart. These deficient practices placed Resident 4 at risk for exposure and contracting infections. Findings: During a record review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 11/6/2024 with diagnoses including anemia (condition in which the body does not get enough oxygen-rich blood), depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). During a record review of Resident 4's Care Plan on EBP, initiated on 11/7/2024, the Care Plan indicated the resident required EBP during high-contact resident care activities due to the presence of indwelling device (a medical device that is inserted inside the body). The Care Plan Goal indicated EBP will be utilized to reduce the risk of transmission of multidrug-resistant organisms (bacteria that had become resistant to certain antibiotics) during high-contact resident care activities. The Care Plan Interventions indicated to ensure items for following EBP were in place and to place EBP notification signage near Resident 4's room doorway to alert staff and visitors of precautions. The Care Plan Interventions indicated to utilize PPE during high-contact resident care activities such as .device care. During a record review of Resident 4's Minimum Data Set (MDS - a resident assessment tool), dated 11/12/2024, the MDS indicated the resident's cognitive (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) skills were severely impaired. The MDS indicated Resident 4 was dependent on facility staff on rolling to the left and right. The MDS indicated Resident 4 had one pressure ulcer (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) that was present on admission. During a record review of Resident 4's Skin and Wound Evaluation, date 12/19/2024, the Skin and Wound Evaluation indicated the resident had a stage 4 (full-thickness skin and tissue loss) PU on the sacral region (area at the base of the spine, near the hips). During a record review of Resident 4's Weekly Summary Notes, dated 1/2/2025, the Weekly Summary Notes indicated Resident 4 had an enteral feeding tube (g-tube, a way of delivering nutrition directly to the stomach or small intestine) and was on oxygen per nasal cannula. During an observation and concurrent interview on 1/6/2025 at 12:30 p.m. with LVN 1, observed LVN 1 touch Resident 4's oxygen nasal cannula without wearing gloves. Observed LVN 1 take a pair of gloves from an opened box of gloves located on top of Resident 4's bed. Observed LVN 1 wore the gloves without washing her hands or using a hand sanitizer. Observed LVN 1 place Resident 4's oxygen nasal cannula on the resident's nostrils. LVN 1 stated the box of gloves should not be on Resident 4's bed. LVN 1 stated she should perform hand washing or used a hand sanitizer before she wore the gloves and before she touched Resident 4's oxygen nasal cannula. LVN 1 stated it had the potential to cause cross contamination (the transfer of bacteria or other microorganisms from one substance to another). During an observation and a follow up interview on 1/6/2025 at 12:38 p.m. with LVN 1, Observed LVN 1 placed the box of gloves taken from Resident 4's bed on top of the clean treatment cart. observed Resident 4 did not have an EBP sign on the door. Observed there were no PPE supplies at the entrance of Resident 4's room. LVN 1 stated Resident 4 was on EBP because of the resident's g-tube and PU. LVN 1 stated no EBP sign and no easily accessible PPE supplies for Resident 4's care had the potential for staff confusion on the precautions to be used on the resident. LVN stated Resident 4 had the potential for infection. During an interview on 1/6/2025 at 4:04 p.m. with the Infection Preventionist Nurse (IPN), the IPN stated Resident 4's oxygen cannula should be in the oxygen bag when not in use. The IPN stated LVN 1 should use hand sanitizer before she wore gloves and touched Resident 4's oxygen nasal cannula. The IPN stated the clean box of gloves should be on the glove's holder and not on Resident 4's bed. The IPN stated the box of gloves that was on top of Resident 4's bed should not be placed on top of the clean treatment cart. The IPN stated the EBP signs should be on Resident 4's door and the PPE supplies should be on the PPE supplies cart. The IPN stated the EBP was to decrease cross contamination and decrease the spread of infection. The IPN stated these practices had the potential for cross contamination that may lead to Resident 4's infection. The IPN stated the facility failed to follow the facility's infection prevention policies. During a record review of the facility's policy and procedure (PnP) titled, Infection Prevention and Control Program, last reviewed on 4/18/2024, the PnP indicated an infection prevention and control program was established and maintained to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections. During a record review of the facility's PnP titled, Enhanced Barrier Precautions, , last reviewed on 4/18/2024, the PnP indicated EBP were utilized to reduce the transmission of multi-drug resistant organisms to residents. The PnP indicated gloves and gown were applied prior to performing the high-contact resident care activity. The PnP indicated the high-contact resident care activities required the use of gown and gloves for EBP included .g. device care or use. The PnP indicated EBP were indicated for residents with wounds or indwelling medical devices. The PnP indicated signs were posted in the door or wall outside the resident room indicating the type of precautions and PPE required. The PnP indicated PPE were available outside of the resident rooms. During a record review of the facility's PnP titled, Standard Precautions, , last reviewed on 4/18/2024, the PnP indicated standard precautions apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious disease. The PnP indicated hand hygiene was performed with alcohol-based hand rub or soap and water . 1. before and after contact with the resident . 4. after contact with item in the resident's room. The PnP indicated resident-care equipment soiled with blood, body fluids, secretions, and excretions were handled in a manner that prevents skin and mucous membrane exposure, contamination of clothing, and transfer of microorganisms to other residents and environments.

Dec 2024 4 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the physician order of one of five residents (Resident 3) matched the Physician Order for Life-Sustaining Treatment (POLST - a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life). This deficient practice had the potential for Resident 3's wishes regarding their health care to be violated. Findings: During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on [DATE] and readmitted the resident on [DATE] with diagnoses that included chronic pain syndrome (a long-term pain condition that persists for more than three months, or longer than the usual recovery time), benign neoplasm (a noncancerous abnormal mass of cells that does not spread to other parts of the body) of pituitary gland (a pea-sized gland located at the base of the brain that produces hormones that control many bodily functions), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 3's Order Summary Report, dated [DATE], the report indicated do not resuscitate (DNR - a medical order written by a doctor to instruct health care providers NOT to do cardiopulmonary resuscitation (CPR-an emergency procedure that involves chest compressions and rescue breathing to restart a person's breathing and heartbeat) if breathing stops or the heart stops beating). During a review of Resident 3's History and Physical (H&P- a medical assessment that involves a patient interview, physical exam, and documentation of findings), dated [DATE], the H&P indicated Resident 3 had fluctuating capacity to understand and make decisions. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated [DATE], the MDS indicated Resident 3 had the ability to usually understand and usually be understood. During a review of Resident 3's POLST, dated [DATE], the POLST indicated to do CPR to Resident 3 as attempt to resuscitate and indicated full treatment for medical interventions. During an interview on [DATE] at 1:24 p.m. with Family Member 1 (FM 1), FM 1 stated that the Intermediate Social Services Director (ISSD) had Resident 3 sign a POLST after FM 1 had already given them a POLST. FM 1 stated ISSD cannot do that. During a concurrent interview and record review on Resident 3's POLST and Physician Order dated [DATE], on [DATE] at 3:31 p.m., the Social Services Director (SSD) stated she reviewed Resident 3's Physician Order and SSD stated it indicated Resident 3 was DNR. The SSD stated if there was an emergency staff would follow POLST. The SSD stated if order says DNR, staff may not do full code. The SSD stated this would not be respecting Resident 3's rights. During a concurrent interview and record review on [DATE] at 4:30 p.m. with the Director of Nursing (DON), Resident 3's POLST and Physician Order dated [DATE] were reviewed. Resident 3's POLST, dated [DATE] indicated Resident 3 was full code. Resident 3's Physician Order, dated [DATE], indicated Resident 3 was DNR. The DON stated based on the POLST, Resident 3 was a full code which was different from the physician order indicating Resident 3 was a DNR. The DON stated if Resident 3 has a significant Change in Condition (COC), facility staff would not be able to provide the proper treatment basing on the correct code status. During a review of the facility's policy and procedure (P&P) titled, Dignity, last reviewed [DATE], the P&P indicated the facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs. Individual needs and preferences of the resident are identified through the assessment process. Resident may exercise their rights without interference, coercion, discrimination or reprisal from any person or entity associated with 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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to provide a safe, comfortable, and homelike environment for one of five sampled residents (Resident 1) when Resident 1's toilet was observed on 12/19/2024 at 11:29 a.m. overflowing into Resident 1's room. This deficient practice resulted in Resident 1 being unable to use the toilet and placed Resident 1 at risk for fall. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 12/6/2024 with diagnoses that included displaced subtrochanteric fracture of right femur (a break in the upper part of the thigh bone, or femur, that occurs within 5 centimeters of the lesser trochanter [a small, bony projection on the femur that serves as an attachment site for muscles]), muscle weakness (general), and history of falling. During a review of Resident 1's Fall Risk Observation Assessment, dated 12/6/2024, the assessment indicated Resident 1 had a fall risk score of 18 (a score of 16 to 42 indicated a high risk for fall). During a review of Resident 1's Care Plan, created on 12/7/2024, for risk of falls with or without injury with interventions, indicated to keep Resident 1 within supervised view as much as possible and monitor for changes in condition affecting risk for falls and notify physician if observed. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 12/12/2024, the MDS indicated Resident 1 had the ability to understand and be understood. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort) with lower body dressing, and putting on and taking off footwear, and required partial assistance (helper does less than half the effort) with toileting, showering, and upper body dressing. The MDS further indicated Resident was continent of bowel and occasionally continent with urine. During a review of the facility's Maintenance Work Order, dated 12/18/2024, indicated Resident 1's toilet (inside Resident 1's room) was not working. During an interview on 12/19/2024 at 11:29 a.m., Resident 1 stated his toilet was overflowing and his roommate almost fell. Resident 1 stated toilet had been clogged for about two to three days. Resident 1 stated with the toilet overflowing there were concerns for diseases like E-coli (a type of bacteria that can cause diarrhea, vomiting, and kidney failure), the toilet overflows and spills onto the floor, there was poop on the floor, and also the wet floor can cause someone to slip and fall. Resident 1 stated he tried to not use the restroom because he did not want to get hurt, and it smells awful. During a concurrent observation and interview on 12/19/2024 at 112:45 a.m., the Maintenance Supervisor (MS) stated he was made aware of Resident 1's toilet being clogged yesterday. The MS stated Resident 1's room had water on the floor from the toilet. The MS stated they must shut off water to prevent the water from overflowing while we get the right part or plumber to come to fix it. The MS stated residents should not be using the restroom. The MS stated the water on the floor was a risk for fall and there was a need to coordinate with nursing staff for residents to use another restroom. During an interview on 12/19/2024 at 4:30 p.m., the Director of Nursing (DON) stated he was not aware of Resident 1's toilet overflowing. The DON stated for Resident 1 there should have been a notice not to use the toilet. The DON stated there is a risk due to water overflowing that can be a risk for staff and residents to fall. The DON stated if water was overflowing with feces, it can be a risk for infection control and it is not a home like environment. During a review of the facility's policy and procedure (P&P) titled, Quality of Life- Homelike Environment, last reviewed 4/18/2024, the P&P indicated residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. a. Cleanliness and order e. pleasant, neutral scents

CONCERN (D) 📢 Someone Reported This

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

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse (the act of harassing, labeling, insulting, scolding, rebuking, or excessive yelling towards an individual) for one of five sampled residents (Resident 5), when on 12/14/2024, Resident 4 called Resident 5 a derogatory word. This deficient practice resulted in Resident 5 being subjected to verbal abuse while under the care of the facility. Residents who are subjected to verbal abuse are at increased risk for low self-esteem (when someone lacks confidence in themselves and their abilities), anxiety (a feeling of fear, dread, and uneasiness), depression (mood disorder that causes a persistent feeling of sadness and loss of interest in activities for long periods of time) and social isolation (when someone has few or no social connections or support, and lacks relationships with others). Findings: a. During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included psychoactive substance abuse (A drug or other substance that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior), osteomyelitis (a bone infection that causes inflammation and swelling in the bone), and paraplegia (loss of movement and/or sensation, to some degree, of the legs). During a review of Resident 4's Social History Assessment, dated 12/10/2024, the assessment indicated Resident 4 had intact cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering). During a review of Resident 4's Situational, Background, Assessment, and Recommendation (SBAR- a structured communication tool that healthcare teams use to share information about a patient's condition) Communication Form, dated 12/14/2024, the SBAR indicated Resident 4 claimed he was trying to go against medical advice and came back to facility and went to his old room and cursing at Resident 5 trying to make him (Resident 4) calm but snapped at Resident 4 in a threatening and abusive manner. During a review of the facility's Incident Narrative Report, dated 12/14/2024, written by Certified Nursing Assistant 2 (CNA2), the report indicated that on 12/14/2024 at 7:28 a.m. Resident 4 was gathering his things to leave the room. As Resident 4 left he told Resident 5 to come outside, I have been to prison, and I'm about that life, (derogatory word was used). At 12:15 p.m., Resident 4 entered Resident 5's room and threatened Resident 5. b. During a review of Resident 5's admission Record indicated Resident 5 was admitted on [DATE] with diagnose that included paraplegia (loss of movement and/or sensation, to some degree, of the legs), depression (a mental health condition that involves a persistent low mood and loss of interest in activities for a prolonged period), and anxiety (feelings of fear, dread, and uneasiness that may occur as a reaction to stress). During a review of Resident 5's Minimum Data Set (MDS resident assessment tool), dated 11/11/2024, the MDS indicated Resident 5 had the ability to understand and be understood. During an interview on 12/19/2024 at 11:10 a.m., Resident 5 stated that on the morning of 12/14/2024 he told Resident 4 to keep it down, then Resident 4 began to bump Resident 5's bed. Resident 5 stated Resident 4 was in his wheelchair and began to bump his wheelchair towards Resident 5's bed. Resident 5 stated Resident 4 was cussing at him but cannot recall what Resident 4 said. Resident 5 stated staff came in and took Resident 4 out of the room. Resident 5 stated about two hours later, Resident 4 came back with a male companion (name not indicated). Resident 5 stated the companion was not a resident in the facility. Resident 5 stated Resident 4 then began to bump Resident 5's bed again and said he wanted to fight Resident 5. Resident 5 stated it was abuse. Resident 5 stated Resident 4 did not hit me but was bumping my bed and woke me up. During an interview on 12/19/2024 at 2:50 p.m., Certified Nursing Assistant 3 (CNA 3) stated was present when Resident 4 and Resident 5 had verbal cursing. CNA stated cannot recall date, but it was around 11 a.m. CNA 3 stated Resident 4 had an argument with Resident 5 and overheard yelling. CNA 3 stated Resident 4 was in wheelchair at the end of Resident 5's bed and Resident 5 was in bed lying. CNA 3 stated heard Resident 4 cussing at Resident 5 calling him (Resident 5) a derogatory name. During an interview on 12/19/2024 at 3 p.m., the Intermediate Social Services Director (ISSD) stated on 12/14/2024 was informed by CNA 3 that Resident 4 and Resident 5 had a verbal altercation. The ISSD stated Resident 4 was cursing and threatening to hit Resident 5. The ISSD stated Resident 4 wheeled himself out of the facility and then 30 minutes later Resident 4 came in back into the facility with a friend. The ISSD stated maybe Resident 4 went into Resident 5's room but ISSD did not see that. The ISSD stated must keep residents separate at all times after alleged abuse. During an interview on 12/19/2024 at 4:30 p.m., the Director of Nursing (DON) stated he heard that Resident 4 was frustrated and was cursing. The DON stated Resident 5 told Resident 4 to calm down and Resident 4 reacted in a manner that was not okay. The DON stated Resident 4 was cursing at Resident 5. The DON stated Resident 4 left then came back with a friend, returned into Resident 5's room and cursed at Resident 5. The DON stated Resident 4 used a derogatory word and is considered as abuse because it is a racial slur. During a review of the facility`s policy and procedure (P&P) titled, Preventing Resident Abuse, last revised on 4/18/2024, the P&P indicated our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training program, system to assist in preventing resident abuse. The facilities goal is to achieve and maintain an abuse free environment.

CONCERN (E) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 3/31/2023 and readmitted on [DATE] with diagnoses that included chronic pain syndrome (a long-term pain condition that persists for more than three months, or longer than the usual recovery time), benign neoplasm (a noncancerous abnormal mass of cells that does not spread to other parts of the body) of pituitary gland (a pea-sized gland located at the base of the brain that produces hormones that control many bodily functions), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 3's Care Plan, created on 3/31/2023, for potential for further fall related to resident preference, the Care Plan indicated Resident 3 to perform task independently with interventions to provide safe environment, free of clutter, clear floors, and adequate lighting. During a review of Resident 3's Minimum Data Set (MDS - a resident assessment tool), dated 11/30/2024, the MDS indicated Resident 3 had the ability to usually understand and usually be understood. The MDS indicated Resident 3 required supervision (helper provides verbal cues and or touching, steadying and or contact guard assistance as resident completes activity) with showering, lower body dressing, putting on and taking off shoes and personal hygiene and requires set up or clean up assistance with eating, oral hygiene, toileting, and upper body dressing. During a review of Resident 3's Fall Risk Observation and Assessment, dated 11/30/2024, the assessment indicated Resident 3 had a fall risk of 10 (A score of 9-15 indicates a moderate risk for a fall). During a review of Resident 3's Situation, Background, Assessment, and Recommendation (SBAR- is a structured communication framework that can help teams share information about the condition of a patient), dated 12/14/2024, the SBAR indicated Resident 3 was noted on the floor and Resident 3 stated, I woke up to go bathroom and I lost balance and I fell. During a review of Resident 3's Fall Risk Observation and Assessment, dated 12/14/2024, the assessment indicated Resident 3 had a fall risk of 4 (A score of 0-8 indicates a low risk for a fall). During a concurrent record review and interview on 12/19/2024 at 4:30 p.m., the Director of Nursing (DON) stated a fall assessment is done upon admission then quarterly and annually. The DON stated if resident has another fall, another fall assessment must be done. The DON reviewed Resident 3's fall assessment, dated 11/30/2024, and the DON stated the score was 10 and post fall, 12/14/2024, indicated a score of 4. The DON stated the score should increase or stay the same. The DON stated the score should not be lower. The DON stated it can be a risk for not having accurate interventions to prevent resident from falling. During a review of the facility's policy and procedure (P&P) titled, Dignity, last reviewed on 4/18/2024, the P&P indicated to provide each resident with appropriate assessment and intervention to prevent falls and to minimize complications if a fall occurs. Based on observation, interview, and record review, the facility failed the following: 1) Failed to supervise and identify one of six sampled residents (Resident 1's) whereabouts inside and outside of the facility and failed to follow Resident 1's Care Plans (a summary of a person's health condition and current treatment interventions associated with care needs). Resident 1 was found on the floor of the facility's parking lot unattended to and without staff supervision. These deficient practices increased the risks for injuries, pain, and or psychosocial despair to Resident 1 who was dependent on staff for care. 2. Failed to ensure the Fall Risk Evaluation (used to find out if you have a low, moderate, or high risk of falling) was accurate to reflect the correct fall risk score of one of five sampled residents (Resident 3). This deficient practice had the potential to negatively affect Resident 3's plan of care and delivery of necessary care and services. Findings: 1. A review of Resident 1's admission Record indicated an admit date of 3/29/2024 with the diagnoses of paraplegia (loss of muscle function to the lower half of the body), end-stage renal disease (irreversible kidney failure), and difficulty in walking. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 10/5/2024, indicated that Resident 1 was fully alert and capable of answering questions. The MDS further indicated that Resident 1 required supervision (helper provides verbal cues and/or touching/steadying and/or contact guard assistance) for distances greater than one hundred and fifty (150) feet (measurement of distance). A review of Resident 1's Elopement and Wandering Risk Observation/Assessment, dated 10/10/2024, indicated Resident 1 was identified as At Risk for Wandering or Elopement. On 12/18/2024 at 11:20 a.m., during an observation, prior to start of investigation, Resident 1 was observed resting on a wall separating the garden from the facility's parking lot. No staff present with Resident 1 at this time. On 12/18/2024 at 11:50 a.m., during an observation, Resident 1 was now observed resting on parked cars to keep balance. Resident 1 was noted without shoes or sandals, no assistive walking device nearby, or staff present to supervise Resident 1. On 12/18/2024 at 11:55 a.m., during an observation, the Administrator (Adm) came out to observe the situation and identified the individual as Resident 1. Resident 1 was now found laying on the floor of the facility's parking lot. On 12/12/2024 at 12:05 p.m., during an interview with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated not knowing that Resident 1 was outside of the facility alone and that Resident 1 had issues in the past of just leaving the facility without telling staff. LVN stated for accidents, Anything can happen out there. The resident can have a fall or can be hit by a moving car. On 12/19/2024 at 4 p.m., during an interview with Registered Nurse 1 (RN 1), RN 1 stated it was important for staff to know where the residents are for safety reasons. RN 1 added that other things that can happen outside of the facility include strangers attacking the facility's residents or accidents like a vehicle hitting Resident 1 leading to fractures (a broken bones) and the possibility of death. A review of Resident 1's care plans with the focus on Falls, dated of 3/31/2024, indicated the intervention of Keep within supervised view as much as possible. A review of the facility provided policy and procedure titled Falls and Fall Risk Management with last revised date of 6/2018 indicated, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. A review of the facility provided policy and procedure titled Safety and Supervision of Residents with last revised date of 7/2017 stated, Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The policy also added, Individualized, Resident-Centered Approach to Safety 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. 3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 4. Implementing interventions to reduce accident risks and hazards shall include the following: a. Communicating specific interventions to all relevant staff; b. Assigning responsibility for carrying out interventions; c. Providing training, as necessary; d. Ensuring interventions are implemented; and e. Documenting interventions.

Dec 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to implement its abuse prevention policy for one of four sampled residents (Resident 2) by failing to ensure an allegation of sexual abuse (any sexual activity that occurs without consent [permission]) was reported immediately, but not later than two hours after the allegation was made, to the State Survey Agency (SSA). This deficient practice had the potential to result in an unidentified abuse in the facility and had the potential for Resident 2 to experience further abuse. Findings: During a review of Resident 2's Record of Admission, the Record of admission indicated the facility admitted the resident on 6/8/2024, with diagnoses including urinary tract infection (bacterial infection that can occur in any part of the urinary tract, which includes the bladder, kidneys, ureters, and urethra). During a review of Resident 2's Minimum Data Set (MDS, a resident assessment tool), dated 9/14/2024, indicated that resident's cognition (the mental process of acquiring knowledge and understanding through the senses, experience, and though) was intact. The MDS indicated Resident 2 needed maximal assistance (helper does more than half the effort) during shower, lower and upper body dressing, putting on/off footwear, personal hygiene. During a review of Resident 2's Change of Condition (COC - significant change of resident's status) Evaluation, dated 12/3/2024, the COC indicated Resident 2's verbalization that a staff was touching her inappropriately. During an interview on 12/12/2024 at 12:15 p.m. the Administrator (Admin) stated the facility did not report it to the SSA, Ombudsman (an advocate for residents of nursing homes), and law enforcement agency because the facility determined it was not abuse and Resident 2's statement was not consistent. During an interview on 12/12/2024 at 12:46 p.m., the Social Service Director (SSD) stated Resident 2 reported the incident on 12/3/2024 at 10:45 a.m. The SSD interviewed Resident 2 and did not feel that it was an abuse because of Resident 2's statement was not consistent. The SSD stated the facility did not report to the local agency or law enforcement agency. During an interview on 12/12/2024, at 1:50 p.m., the Admin stated the sexual abuse allegation was reported to him (Admin) by the SSD. The Admin stated it should have been reported immediately after receiving the report from Resident 2. The Admin stated that he (Admin) was a mandated reporter. The Admin stated that if the sexual abuse was not reported, the resident will not receive the services they need and will not be heard. During a review of the facility policy and procedure titled, Elder Justice Act, last reviewed date of 4/18/2024, indicated that if the event involves abuse or results in serious bodily injury, the suspicion will be reported immediately but no later than two hours after forming the suspicion. During a review of the facility policy and procedure titled, Reporting Abuse to State Agencies and Other Entities/Individuals, last reviewed date of 4/18/2024, indicated all suspected violations and all substantiated incidents of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law.

Dec 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of resident-to-resident abuse within two hours to the State Survey Agency (SSA) as per its policy on abuse for two of three sampled residents (Resident 1 and Resident 2). This deficient practice had the potential to place Resident 1 and Resident 2 at risk for further abuse. Findings: a. During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 10/17/2024, with diagnoses that included cellulitis (a skin infection that causes swelling and redness), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and osteomyelitis (inflammation of bone or bone marrow, usually due to infection). The admission Record indicated Resident 1 was discharged on 11/2/2024. During a record review of Resident 1's History and Physical (H&P), dated 10/19/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 10/24/2024, the MDS indicated Resident 1's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 1 required moderate assistance from staff for all activities of daily living (ADL-toileting, showering and personal hygiene). During a record review of Resident 1's Progress Notes, dated 10/26/2024 timed at 12:52 a.m., the Progress Notes indicated Resident 1 claimed that Resident 2 went into Resident 1's room and tried to get physical at him (Resident 1). The Progress Notes indicated staff were alerted and separated Resident 1 and Resident 2. During a record review of Resident 1's Progress Notes dated 10/26/2024 timed at 1:22 a.m., the Progress Notes indicated, Registered Nurse 1 (RN 1) notified the physician, the Family Member 1 (FM 1), the Ombudsman and local sheriff. b. During a record review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 10/25/2024 with diagnoses that included chronic (a disease continuing for a long time) osteomyelitis, DM, and unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities). The admission Record indicated Resident 2 was discharged on 11/10/2024. During a record review of Resident 2's History and Physical (H&P), dated 10/26/2024, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a record review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decisions were severely impaired. During a record review of Resident 2's Progress Notes, dated 10/26/2024 timed at 2:35 a.m., the Progress Notes indicated Resident 2 was found in Resident 1's room and allegedly physically abused Resident 1. The Progress Note indicated RN 1 notified the physician, and FM 2. During an interview on 12/6/2024 at 9:11 a.m., RN 2 stated Resident 1 was already discharged on 11/2/2024 and Resident 2 was discharged on 11/10/2024. During a concurrent interview and record review on 12/6/2024 at 9:29 a.m., with the Administrator Assistant (AA), facility's Abuse Report to Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities), dated 10/26/2024 was reviewed. The facility's Abuse Report to Ombudsman was dated 10/26/2024 with a fax confirmation dated 11/21/2024 at 12:21 p.m. The AA stated he (the AA) reviewed Resident 1 and Resident 2's abuse report and did not see the confirmation faxed to SSA, so he (the AA) faxed it again on 11/26/2024. The AA stated RN 1 did not received a fax confirmation from SSA on 10/26/2024. The AA stated RN 1 should make sure that the abuse report goes through to SSA and Ombudsman and keep the confirmation receipts as proof. The AA stated reporting of abuse should be within two hours for timely investigation. During an interview on 12/5/2024 at 10:23 a.m. the AA stated they do not have any documentary evidence that abuse report was faxed to SSA and Ombudsman on 10/26/2024. The AA stated RN 1 should have made a follow up call to SSA to confirm receipt. During a concurrent interview and record review on 12/5/2024 at 10:43 a.m., with the Administrator (the ADM), the facility's policy and procedure (PP) titled, Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating, dated 2001 was reviewed. The PP indicated, Reporting Allegations to the Administrator and Authorities: 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility. b. The local/state ombudsman. c. The resident's representative. d. Adult protective services (where state law provides jurisdiction in long-term care). e. Law enforcement officials. f. The resident's attending physician; and g. The facility medical director. 3. Immediately'' is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 4. Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone. The ADM stated the PP was last reviewed on 10/2024. The ADM stated RN 1 called and reported to him (the ADM) the incident between Resident 1 and Resident 2 on 10/26/2024 and he had informed RN 1 to follow the protocol for reporting allegation of abuse, which is to report within two hours to SSA, Ombudsman and police. The ADM stated not having a documented evidence that the allegation of abuse was reported on 10/26/2024. The ADM stated an allegation of abuse should be reported within two hours as indicated in their policy.

Nov 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe and comfortable environment for one of three sampled residents (Resident 2) by failing to ensure Resident 2's room was comfortable and free from malodor. Resident 1's wound had a malodor (bad odor). This deficient practice had the potential for Resident 2 to be uncomfortable and loss of appetite. Findings: During a record review of Resident 2's admission Record, the admission Record indicated the facility admitted the resident on 8/3/2021 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), asthma (a disease that affects the lungs), and depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities). During a record review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 8/22/2024, the MDS indicated the resident's cognitive (problems with a person's ability to think, learn, remember, use judgement, and make decisions) skills were intact. During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 10/7/2024 with diagnoses including malignant neoplasm (an abnormal growth of cells that can spread to other parts of the body and considered dangerous) of the skin, depression, and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). During a record review of Resident 1's MDS, dated [DATE], the MDS indicated the resident's cognitive skills were moderately impaired. During a record review of Resident 1's Wound Assessment, dated 11/20/2024, the Wound Assessment indicated the resident had wound on the scalp with heavy wound drainage (fluid that leaks out of a wound). The Wound Assessment indicated Resident 1's wound had increasing malodor. During an observation and concurrent interview on 11/25/2024 at 1:56 p.m., Resident 1 was observed with malodor coming from the wound on the right scalp. Licensed Vocational Nurse 2 (LVN 2) stated Resident 1's wound dressing (materials applied to wounds to promote healing) was changed every day and as needed because of the wound drainage and malodor from the wound. During an interview on 11/25/2024 at 2:07 p.m. with Resident 2, Resident 2 stated the smell that came from Resident 1's wound was bad. Resident 2 stated the malodor caused the residents in the room to lose appetite. Resident 2 stated the malodor was present all day and had affected the resident's sleep. During a follow up interview on 11/25/2024 at 2:37 p.m. with LVN 2, LVN 2 stated Resident 1's wound had a malodor and wound drainage. LVN 2 stated Resident 1's wound malodor had the potential to negatively affect the resident's roommates such as loss of appetite and uncomfortable stay in the residents' room. During an interview ion 11/25/2024 at 4:56 p.m. with the Director of Nursing (DON), the DON stated Resident 1's wound malodor had the potential to cause Resident 2's loss of appetite, anxiety (feeling of worry, nervousness, or restlessness [uneasiness]), anger towards facility staff, and Resident 2's uncomfortable stay in the room. The DON stated the facility failed to ensure Resident 2 had a homelike environment. During a record review of the facility's policy and procedures (PnP) titled, Quality of Life - Homelike Environment, last reviewed on 4/18/2024, the PnP indicated residents were provided with safe, clean, comfortable, and homelike environment. The PnP indicated the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting including pleasant neutral scents.

CONCERN (D) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to follow infection control procedures for one of three sampled residents (Resident 1) by failing to ensure Resident 1, who had open wounds, was not exposed to the presence of fruit flies. This deficient practice placed Resident 1 at risk for exposure and contracting infections. Findings: During a record review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 10/7/2024 with diagnoses including Malignant neoplasm (an abnormal growth of cells that can spread to other parts of the body and considered dangerous) of the skin, depression (a constant feeling of sadness and loss of interest, which stops the individual from doing normal activities), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). During a record review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/13/2024, the MDS indicated the resident's cognitive (problems with a person's ability to think, learn, remember, use judgement, and make decisions) skills were moderately impaired. During a record review of Resident 1's Progress Notes, dated 11/21/2024, the Progress Notes indicated Resident 1 was noted with tumor (an abnormal mass of tissue that form in the body) on the resident's right scalp. The Progress Notes indicated Resident 1's wound had serous drainage (a clear yellow fluid that leaks out of a wound) with foul smell. During an observation and concurrent interview on 11/25/2024 at 2:07 p.m., Resident 2's bedside table was observed with flying fruit flies. LVN 2 stated the flying fruit flies had the potential to carry bacteria into Resident 1's open wound and cause the Resident 1's wound to be infected. During an interview on 11/25/2024 at 2:54 p.m. with the Infection Prevention Nurse (IPN), the IPN stated fruit flies carry organisms that had the potential for cross contamination (the transfer of harmful bacteria from one substance to another). The IPN stated the fruit flies carrying the organisms had the potential to infect Resident 1's open wound. During an interview on 11/25/2024 at 4:56 p.m. with the Director of Nursing (DON), the DON stated the fruit flies may carry organisms that had the potential to cause diseases. The DON stated the fruit flies from Resident 2's bedside table had the potential to go on Resident 1's open wound and cause infection. The DON stated the facility failed to ensure the resident's environment was free from fruit flies that had the potential to cause diseases and infections to other residents. The DON stated the presence of fruit flies in a resident's room was an infection control and prevention concern. During a record review of the facility's policy and procedures (PnP) titled, Infection Prevention and Control, last reviewed on 4/18/2024, the PnP indicated the facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of disease and infections.

CONCERN (E) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure medical records were complete and accurately documented for three of five sampled residents (Resident 9, Resident 10, and Resident 11) by failing to ensure licensed nurses documented the level of care provided to Resident 9, Resident 10, and Resident 11 after the residents were exposed to invasive group A streptococcal disease (iGAS - a severe and sometimes life-threatening infection). This deficient practice resulted in inaccurate information on Resident 9, Resident 10, and Resident 11's clinical records and had the potential for delayed and inaccurate medical interventions. Findings: During a record review of the facility-provided Prospective Surveillance for Group A Streptococcus (GAS - a type of bacteria commonly found in the throat and on the skin), dated 11/6/2024, the Prospective Surveillance for GAS indicated Resident 9, Resident 10, and Resident 11 were assessed for sore throat, increased cough, increased wound drainage, and shortness of breath. Resident 9, Resident 10, and Resident 11 refused culture collection (a test to identify whether a person had a bacterial infection) on 11/7/2024. a. During a record review of Resident 9's admission Record, the admission Record indicated the facility admitted the resident on 6/10/2022 with diagnoses including multiple sclerosis (MS - a chronic, progressive disease involving damage to the nerve cells in the brain and spinal cord), muscle weakness, and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). During a record review of Resident 9's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 10/16/2024, the MDS indicated the resident's cognitive (problems with a person's ability to think, learn, remember, use judgment, and make decisions) skills were intact. During a record review of Resident 9's Care Plan on iGAS, initiated on 11/7/2024, the Care Plan indicated the resident was exposed to iGAS. The Care Plan Interventions indicated to monitor for signs and symptoms of complications of infection and worsening of infection. During a record review of Resident 9's Medication Administration Record (MAR), dated 11/1/2024 to 11/30/2024, the MAR indicated on 11/22/2024, 16 days after the resident was identified as exposed to iGAS, the resident was monitored for sign and symptoms on iGAS. During an interview on 11/25/2024 at 2:54 p.m. and concurrent record review of Resident 10's medical records, reviewed with the Infection Prevention Nurse (IPN), the IPN stated Resident 9's refusal to be tested for iGAS on 11/7/2024 was not documented in the resident's medical records. The IPN stated Resident 9's iGAS screening was documented in the facility's Prospective Surveillance for GAS form but not in the resident's medical records. Resident 9's Progress Notes did not indicate documented evidence of the resident's screening for iGAS. The IPN stated Resident 9's refusal to be tested for iGAS and the resident's screening should be documented in the resident's medical records. The IPN stated documentation in residents' medical records should be complete, timely and accurate. The IPN stated incomplete and untimely documentation had the potential for facility staff to miss Resident 9's symptoms and not be treated appropriately and timely. The IPN stated the facility failed to ensure Resident 9 was provided with timely treatment and to ensure screenings and refusals were documented in the resident's medical records. During an interview on 11/25/2024 at 4:56 p.m., with the Director of Nursing (DON), the DON stated documentation should be complete and accurate. The DON stated there was no documented evidence of Resident 's refusal to be tested for iGAS and the resident's screening. The DON stated the facility failed to document Resident 9's iGAS screening and refusal to be tested in the resident's medical records. During a record review of the facility's policy and procedure (PnP) titled, Charting and Documentation, last reviewed on 4/18/2024, the PnP indicated 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 PnP indicated documentation in the medical record will be objective, complete, and accurate. b. During a record review of Resident 10's admission Record, the admission Record indicated the facility admitted the resident on 5/28/2022 with diagnoses including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), chronic obstructive pulmonary disease (COPD - a lung disease characterized by long term poor airflow), and anxiety disorder (persistent and excessive worry that interferes with daily activities). During a record review of Resident 10's MDS, dated [DATE], the MDS indicated the resident's cognitive skills were moderately impaired. During a record review of Resident 10's Care Plan on iGAS, initiated on 11/7/2024, the Care Plan indicated the resident was exposed to iGAS. The Care Plan indicated the interventions were initiated on 11/26/2024, 19 days after the care plan was initiated. During a record review of Resident 10's Physician Order, dated 11/22/2024, the Physician Order indicated to monitor Resident 10 for signs and symptoms of iGAS such as fever, chills, sore throat, and skin infection. During a record review of Resident 10's MAR, dated 11/1/2024 to 11/30/2024, the MAR indicated on 11/22/2024, 16 days after the resident was identified as exposed to iGAS, the resident was monitored for sign and symptoms on iGAS. During an interview on 11/25/2024 at 2:54 p.m. and concurrent record review of Resident 10's medical records, reviewed with the IPN, the IPN stated Resident 10's refusal to be tested for iGAS on 11/7/2024 was not documented in the resident's medical records. The IPN stated Resident 10's iGAS screening was documented in the facility's Prospective Surveillance for GAS form but not in the resident's medical records. Resident 10's Progress Notes did not indicate documented evidence of the resident's screening for iGAS. The IPN stated Resident 10's refusal to be tested for iGAS and the resident's screening should be documented in the resident's medical records. The IPN stated documentation in residents' medical records should be complete, timely and accurate. The IPN stated incomplete and untimely documentation had the potential for facility staff to miss Resident 10's symptoms and not be treated appropriately and timely. The IPN stated the facility failed to ensure Resident 10 was provided with timely treatment and to ensure screenings and refusals were documented in the resident's medical records. During an interview on 11/25/2024 at 4:56 p.m., with the DON, the DON stated documentation should be complete and accurate. The DON stated there was no documented evidence of Resident 's refusal to be tested for iGAS and the resident's screening. The DON stated the facility failed to document Resident 10's iGAS screening and refusal to be tested in the resident's medical records. During a record review of the facility's PnP titled, Charting and Documentation, last reviewed on 4/18/2024, the PnP indicated 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 PnP indicated documentation in the medical record will be objective, complete, and accurate. c. During a record review of Resident 11's admission Record, the admission Record indicated the facility admitted the resident on 8/28/2019 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and asthma (a disease that affects the lungs). During a record review of Resident 11's MDS, dated [DATE], the MDS indicated the resident's cognitive skills were severely impaired. During a record review of Resident 11's Care Plan on iGAS, initiated on 11/7/2024, the Care Plan indicated the resident was exposed to iGAS. The Care Plan Interventions indicated to monitor for signs and symptoms of complications of infection and worsening of infection. During a record review of Resident 11's Physician Order, dated 11/22/2024, the Physician Order indicated to monitor Resident 11 for signs and symptoms of iGAS such as fever, chills, sore throat, and skin infection. During an interview on 11/25/2024 at 2:54 p.m. and concurrent record review of Resident 10's medical records, reviewed with the IPN, the IPN stated Resident 11's refusal to be tested for iGAS on 11/7/2024 was not documented in the resident's medical records. The IPN stated Resident 10's iGAS screening was documented in the facility's Prospective Surveillance for GAS form but not in the resident's medical records. Resident 11's Progress Notes did not indicate documented evidence of the resident's screening for iGAS. The IPN stated Resident 11's refusal to be tested for iGAS and the resident's screening should be documented in the resident's medical records. The IPN stated documentation in residents' medical records should be complete, timely and accurate. The IPN stated incomplete and untimely documentation had the potential for facility staff to miss Resident 11's symptoms and not be treated appropriately and timely. The IPN stated the facility failed to ensure Resident 11 was provided with timely treatment and to ensure screenings and refusals were documented in the resident's medical records. During an interview on 11/25/2024 at 4:56 p.m., with the DON, the DON stated documentation should be complete and accurate. The DON stated there was no documented evidence of Resident 's refusal to be tested for iGAS and the resident's screening. The DON stated the facility failed to document Resident 11's iGAS screening and refusal to be tested in the resident's medical records. During a record review of the facility's policy and procedure (PnP) titled, Charting and Documentation, last reviewed on 4/18/2024, the PnP indicated 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 PnP indicated documentation in the medical record will be objective, complete, and accurate.

Nov 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to timely follow its policy and procedure titled, Change in a Resident's Condition of Status, which indicated the facility will notify the resident's attending physician (MD) when there was a significant change (a change in the resident's physical, mental, or psychosocial status that causes either life-threatening conditions or clinical complications) in the resident's condition for one of three sampled residents (Resident 1). Resident 1 had a Change of Condition (COC- a major decline in a resident's status) that started on 7/25/2024 when Resident 1's intake was less than 50 % for three (3) consecutive meals. This deficient practice resulted in a delay of care in Resident 1's nutritional status. Resident 1 lost 20.6 pounds (lbs - a unit of measurement) in a month. Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 7/5/2024 with diagnoses that included hemiplegia (inability to move the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, depriving brain cells of oxygen and nutrients) affecting left non-dominant side, type 2 diabetes mellitus (a chronic disease that occurs when the body does not produce enough insulin [hormone that lowers the level of sugar in the blood] or does not use it properly, resulting in high blood sugar levels), kidney transplant (a surgical procedure that replaces a patient's diseased or failed kidneys with a healthy kidney from a donor), and mild protein-calorie malnutrition (occurs when someone does not consume enough protein and calories to meet their nutritional needs). During a review of Resident 1's Weight Summary, dated 7/8/2024, the Weight Summary indicated the resident weighed 137 lbs. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/9/2024, the MDS indicated Resident 1 had the ability to be understood and had the ability to understand. The MDS further indicated Resident 1 was dependent (helper does all the effort) with showering, lower body dressing, and putting on and taking off footwear. The MDS also indicated Resident 1 requires partial assistance (helper does less than half the effort) with eating and oral (by mouth) hygiene. The MDS indicated Resident 1 coughed or choked during meals or when swallowing medications. During a review of Resident 1's Care Plan for risk for malnutrition, developed on 7/12/2024, the Care Plan indicated to observe for signs or symptoms of malnutrition emaciation (extreme, dangerous thinness), refusing meals, significant weight loss, significant abnormal laboratory (lab) values, signs and symptoms of dehydration (a condition that occurs when the body loses more fluids than it takes in) and report to physician as needed. The Care Plan also indicated to check Resident 1's weight weekly for four (4) weeks upon admission and then monthly if stable, and to encourage adequate nutrition and hydration. During a review Resident 1's Physician's Order, dated 7/15/2024, the Physician's Order indicated constant carbohydrate (a diet that involves eating the same amount of carbohydrates every day to help keep blood sugar levels stable), no added salt, renal diet (a diet that limits the amount of certain foods and nutrients to help reduce the amount of waste in the blood and improve kidney function), mechanical soft texture (a soft, moist texture that's easy to eat without chewing or biting), thin liquids consistency (flows like water from a faucet). During a review of Resident 1's progress notes, with effective date of 7/23/2024 at 12:21 p.m. and with creation date of 8/2/2024 at 12:22 p.m., the progress notes indicated a late entry (documentation that is typically recorded more than 24-48 hours after providing care to capture information that was missed or not written down in a timely manner) regarding Resident 1's refusal to be weighed. The progress notes indicated the staff offered three times to weigh the resident but Resident 1 refused. The progress notes indicated the resident's MD was made aware. During a review of Resident 1's Task for Amount Eaten (indicates the percent [%] of food consumed) for July 2024, the Task for Amount Eaten indicated the following: - 7/25/2024 9 a.m. ate 26-50%, 1p.m. ate 0-25%, 6 p.m. blank. - 7/26/2024 9 a.m. ate 26-50%, 1 p.m. ate 0-25%, 6 p.m. 26-50%. - 7/27/2024 9 a.m. ate 0-25%, 1 p.m. ate 0-25%, 6 p.m. 26-50%. - 7/28/2024 9 a.m. ate 0-25%, 1 p.m. 26-50%, 6 p.m. 0-25%. - 7/29/2024 9 a.m. ate 0-25%, 1 p.m. 51-75%, 6 p.m. 0-25%. - 7/30/2024 9 a.m. 51-75%, 1p.m. resident refused (RR), 6 p.m. 76-100%. - 7/31/2024 9 a.m. 51-75%, 1 p.m. 0-25%, 6 p.m. 26-50%. During a review of Resident 1's Task for Amount Eaten for August 2024, the Task for Amount Eaten indicated the following: - 8/1/2024 9 a.m. RR, 1 p.m. RR, 6 p.m. 0-25%. - 8/2/2024 9 a.m. 0-25%, 1 p.m. RR, 6 p.m. 0-25%. - 8/3/2024 9 a.m. 0-25%, 1 p.m. 26-50%, 6 p.m. 76-100%. - 8/4/2024 9 a.m. 0-25%, 1 p.m. 0-25%, 6 p.m. RR. - 8/5/2024 9 a.m. RR, 1 p.m. RR, 6 p.m. RR. - 8/6/2024 9 a.m. RR, 1 p.m. RR, 6 p.m. RR. - 8/7/2024 9 a.m. RR, 1 p.m. 0-25%, 6 p.m. RR. During a review of Resident 1's Weight Summary, dated 8/2/2024, the Weight Summary indicated the resident weighed 116.4 lbs. During a review of Resident 1's COC Evaluation, dated 8/2/2024 at 2:22 p.m., the COC Evaluation indicated Resident 1 was noted with weight loss of 20 lbs. in four (4) weeks and the MD was notified with orders for Restorative Nursing Assistant (RNA) dining room program, provide supplement 8 ounces (oz - unit of measurement) three times a day, and check weekly weights. During a review Resident 1's Physician's Order, dated 8/2/2024, the Physician's Order indicated: - Megestrol acetate (a medication used to treat loss of appetite and weight loss) oral suspension 400 milligrams (mg- a unit of measurement) give 10 milliliters (ml-unit of measurement) by mouth two (2) times a day for poor intake. - Glucerna (brand of nutritional supplement) three (3) times a day for risk for malnutrition, offer eight (8) oz of Glucerna. - Assist the resident with all meals. If the resident eats less than 50%, offer supplement and notify MD. During a review of Resident 1's Medication Administration Records (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for August 2024, the resident's intake of Glucerna three times a day (9 a.m., 2 p.m., and 9 p.m.) indicated the following: - 8/2/2024 from 2 p.m. until 8/5/2024, consumed 100% - 8/6/2024 at 9 p.m. consumed 50% - 8/7/2024 9 a.m. consumed 100% - 8/7/2024 2p.m. consumed 50% During a review of Resident 1's COC Evaluation, dated 8/3/2024 at 7:09 a.m., the COC Evaluation indicated Resident 1 was noted with poor intake and weakness and that the MD was notified on 8/3/2024 at 6:35 a.m. During a review of Resident 1's progress notes, dated 8/6/24 at 9:38 p.m., the progress notes indicated Resident 1's daughter requested for Mirtazapine (drug used to treat depression [constant feeling of sadness and loss of interest]) for Resident 1 and the MD approved. During a review of Resident 1's Physician's Orders, dated 8/7/2024, the Physician's Orders indicated: - Mirtazapine give 15 mg by mouth at bedtime for depression and poor oral intake. - Monitor behavior for poor oral intake and record number of episodes every shift. During a review of Resident 1's MAR for August 2024, the MAR indicated there were zero (0) episodes of poor oral intake on 8/7/2024. During an interview on 11/14/2024 at 2:56 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated working regularly with Resident 1. CNA 2 reported Resident 1 did not eat much, maybe 25% and if Resident 1 did not eat well, she would give Glucerna. CNA 2 stated he/she would communicate with the charge nurse to let them know that Resident 1 was not eating, and the charge nurses would give the CNAs Glucerna to give to Resident 1. During an interview on 11/14/2024 at 3:07 p.m., with CNA 3, CNA 3 stated Resident 1 required assistance with feeding because the resident would not eat on her own, and when the resident started losing weight, she (Resident 1) was placed on feeding program. During an interview on 11/14/2024 at 4:04 p.m., with the Director of Nursing (DON), the DON stated less than 50% of amount eaten by a resident need to be reported to a Licensed Vocational Nurse (LVN). During a concurrent interview and record review on 11/15/2024 at 9:57 a.m., with the Registered Dietitian (RD), the RD stated Resident 1 initially weighed 137 lbs., but on 8/2/2024 Resident 1 weighed 116.4 lbs. which was a significant amount of weight loss. The RD stated Resident 1's 20.6 lbs. significant weight loss is a 15% change in the resident's weight. During a concurrent interview and record review on 11/15/2024 at 2:30 p.m., with the Assistant Director of Nursing (ADON), the ADON reviewed Resident 1's Task Amount Eaten for July 2024. The ADON stated a poor intake of less than 50% needs to be reported to the charge nurse. The ADON stated they would need to do a COC evaluation if a resident has had three (3) episodes of poor intake (of less than 50%) consecutively. The ADON stated based on the July 2024 amount eaten by Resident 1, the COC evaluation should have been created on 7/25/2024 because Resident 1 ate less than 50 % for three (3) consecutive meals. The ADON stated the COC evaluation is needed to notify the MD and to start interventions. The ADON stated if there is a delay in interventions, there can be a delay in care and the resident's condition can worsen. During a concurrent interview and record review on 11/15/2024 at 3 p.m. with the DON, the DON reviewed Resident 1's Task Amount Eaten for July 2024. The DON stated the resident's intake on 7/25/2024 was concerning because Resident 1 ate less than 50% of her meals, and that a COC evaluation should have been started that day. The DON stated a COC is a change in the resident's baseline including food intake. The DON stated COC evaluation is a communication between the MD and the resident's family. During a review of the facility's policy and procedures (PnP) titled, Change in a Resident's Condition or Status, last revised on 11/2015, the PnP indicated they facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical and or mental condition and or status. 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: d. a significant change in the resident's physical/emotional/mental condition. f. refusal of treatment or medications (i.e. two (2) or more consecutive times). 2. A significant change of condition is a decline or improvement in the resident's status. During a review of the facility's PnP titled, Weight Assessment and Intervention, last revised in March 2022, the PnP indicated resident weights are monitored for desirable or unintended wight loss or gain. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month- 5% weight loss is significant, greater than 5% is severe.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0694 (Tag F0694)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to administer dextrose (sugar) five (5) percent (%) in water (D5W - a solution of 5% sugar [dextrose]) mixed in water, given when patients need fluids and a small amount of sugar to replenish their body) as prescribed for intravenous (IV - given directly into the blood stream) hydration for one of three sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to develop dehydration (a condition that occurs when the body loses more fluids than it takes in). Findings: During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 7/5/2024 with diagnoses that included hemiplegia (inability to move the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, depriving brain cells of oxygen and nutrients) affecting left non-dominant side, type 2 diabetes mellitus (a chronic disease that occurs when the body does not produce enough insulin [hormone that lowers the level of sugar in the blood] or does not use it properly, resulting in high blood sugar levels), kidney transplant (a surgical procedure that replaces a patient's diseased or failed kidneys with a healthy kidney from a donor), and mild protein-calorie malnutrition (occurs when someone does not consume enough protein and calories to meet their nutritional needs). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/9/2024, the MDS indicated Resident 1 had the ability to be understood and had the ability to understand. The MDS further indicated Resident 1 was dependent (helper does all the effort) with showering, lower body dressing, and putting on and taking off footwear. The MDS also indicated Resident 1 requires partial assistance (helper does less than half the effort) with eating and oral (by mouth) hygiene. The MDS indicated Resident 1 coughed or choked during meals or when swallowing medications. During a review of Resident 1's Care Plan on risk for dehydration or electrolyte imbalance, developed on 7/12/2024, the Care Plan interventions included evaluating the need for assistance with eating and drinking as needed, monitoring laboratory test results (labs) when available, and reporting significant changes (a change in the resident's physical, mental, or psychosocial status that causes either life-threatening conditions or clinical complications) to the physician (MD). During a review of Resident 1's Change of Condition (COC- a major decline in a resident's status) Evaluation, dated 8/3/2024, the COC Evaluation indicated Resident 1 was noted with poor intake and weakness and the MD was notified with new orders. During a review of Resident 1's Physician Orders, dated 8/3/2024, the Physician Orders indicated to administer dextrose 5% in water at 100 milliliters (ml-unit of measurement) an hour IV every shift for hydration, ordered from 8/3/2024 until 8/5/2024 at 11:59 p.m. for three (3 liters). During a review of Resident 1's Lab Results Report, dated 8/3/2024 at 9:32 p.m., the Lab Results Report indicated the following: - blood urea nitrogen (BUN- measures the amount of urea nitrogen [a waste product that forms as the body breaks down proteins) test was 47 milligrams per decilitre (mg/dL- unit of measurement; normal level is within 7-25 mg/dL) - creatinine (measures how well your kidneys are working) test was 2.7 mg/dL (normal level is within 0.6-1.2 mg/dL). During a review of Resident 1's Lab Results Report dated 8/7/2024 at 4:03 a.m., the Lab Results Report indicated the following: - BUN was 65 mg/dL - creatinine was 2.8 mg/dL During a review of Resident 1's Lab Results Report dated 8/8/2024 at 5:04 a.m., the Lab Results Report indicated the following: - BUN was 84 mg/dL - creatinine was 3.6 mg/dL During a review of Resident 1's Medication Administration Records (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for August 2024, the MAR indicated D5W 100 ml an hour IV every shift for hydration until 8/5/2024 at 11:59 p.m. indicated not given on 8/3/2024 at night and on 8/5/2024 at night. During a concurrent interview and record review of Resident 1's MAR for August 2024, on 11/15/2024 at 2:11 p.m with the Director of Nursing (DON), the DON stated Resident 1's IV fluid per MD order should have been given per shift. The DON stated the licensed nurse failed to administer the IV fluid placing Resident 1 a risk for further dehydration. During a review of the facility's policy and procedures (PnP) titled, Charting and Documentation, last revised in 2001, the PnP indicated all services provided to the resident, progress toward the care plan goal, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record.

CONCERN (D) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices for one of three sampled residents (Resident 1) when: 1. The facility failed to accurately document Resident 1's intake (the amount that you eat, drink, or breathe in). 2. The facility failed to accurately document Resident 1's behavior for poor oral intake. These deficient practices resulted in Resident 1 losing 20.6 pounds (lbs.- a unit of measurement) in a month. Findings: a. During a review of Resident 1's admission Record, the admission Record indicated the facility admitted the resident on 7/5/2024 with diagnoses that included hemiplegia (inability to move the arm, leg, and trunk on the same side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (a serious condition that occurs when blood flow to the brain is blocked, depriving brain cells of oxygen and nutrients) affecting left non-dominant side, type 2 diabetes mellitus (a chronic disease that occurs when the body does not produce enough insulin [hormone that lowers the level of sugar in the blood] or does not use it properly, resulting in high blood sugar levels), kidney transplant (a surgical procedure that replaces a patient's diseased or failed kidneys with a healthy kidney from a donor), and mild protein-calorie malnutrition (occurs when someone does not consume enough protein and calories to meet their nutritional needs). During a review of Resident 1's Weight Summary, dated 7/8/2024, the Weight Summary indicated the resident weighed 137 lbs. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/9/2024, the MDS indicated Resident 1 had the ability to be understood and had the ability to understand. The MDS further indicated Resident 1 was dependent (helper does all the effort) with showering, lower body dressing, and putting on and taking off footwear. The MDS also indicated Resident 1 requires partial assistance (helper does less than half the effort) with eating and oral (by mouth) hygiene. The MDS indicated Resident 1 coughed or choked during meals or when swallowing medications. During a review of Resident 1's Care Plan for risk for malnutrition, developed on 7/12/2024, the Care Plan indicated to observe for signs or symptoms of malnutrition emaciation (extreme, dangerous thinness), refusing meals, significant weight loss, significant abnormal laboratory (lab) values, signs and symptoms of dehydration (a condition that occurs when the body loses more fluids than it takes in) and report to physician as needed. The Care Plan also indicated to check Resident 1's weight weekly for four (4) weeks upon admission and then monthly if stable, and to encourage adequate nutrition and hydration. During a review Resident 1's Physician's Order, dated 7/15/2024, the Physician's Order indicated constant carbohydrate (a diet that involves eating the same amount of carbohydrates every day to help keep blood sugar levels stable), no added salt, renal diet (a diet that limits the amount of certain foods and nutrients to help reduce the amount of waste in the blood and improve kidney function), mechanical soft texture (a soft, moist texture that's easy to eat without chewing or biting), thin liquids consistency (flows like water from a faucet). During a review of Resident 1's progress notes, with effective date of 7/23/2024 at 12:21 p.m. and with creation date of 8/2/2024 at 12:22 p.m., the progress notes indicated a late entry (documentation that is typically recorded more than 24-48 hours after providing care to capture information that was missed or not written down in a timely manner) regarding Resident 1's refusal to be weighed. The progress notes indicated the staff offered three times to weigh the resident but Resident 1 refused. The progress notes indicated the resident's MD was made aware. During a review of Resident 1's Task for Amount Eaten (indicates the percent [%] of food consumed) for July 2024, the Task for Amount Eaten indicated the following: - 7/25/2024 9 a.m. ate 26-50%, 1p.m. ate 0-25%, 6 p.m. blank. - 7/26/2024 9 a.m. ate 26-50%, 1 p.m. ate 0-25%, 6 p.m. 26-50%. - 7/27/2024 9 a.m. ate 0-25%, 1 p.m. ate 0-25%, 6 p.m. 26-50%. - 7/28/2024 9 a.m. ate 0-25%, 1 p.m. 26-50%, 6 p.m. 0-25%. - 7/29/2024 9 a.m. ate 0-25%, 1 p.m. 51-75%, 6 p.m. 0-25%. - 7/30/2024 9 a.m. 51-75%, 1p.m. resident refused (RR), 6 p.m. 76-100%. - 7/31/2024 9 a.m. 51-75%, 1 p.m. 0-25%, 6 p.m. 26-50%. During a review of Resident 1's Task for Amount Eaten for August 2024, the Task for Amount Eaten indicated the following: - 8/1/2024 9 a.m. RR, 1 p.m. RR, 6 p.m. 0-25%. - 8/2/2024 9 a.m. 0-25%, 1 p.m. RR, 6 p.m. 0-25%. - 8/3/2024 9 a.m. 0-25%, 1 p.m. 26-50%, 6 p.m. 76-100%. - 8/4/2024 9 a.m. 0-25%, 1 p.m. 0-25%, 6 p.m. RR. - 8/5/2024 9 a.m. RR, 1 p.m. RR, 6 p.m. RR. - 8/6/2024 9 a.m. RR, 1 p.m. RR, 6 p.m. RR. - 8/7/2024 9 a.m. RR, 1 p.m. 0-25%, 6 p.m. RR. During a review of Resident 1's Weight Summary, dated 8/2/2024, the Weight Summary indicated the resident weighed 116.4 lbs. During a review of Resident 1's COC Evaluation, dated 8/2/2024 at 2:22 p.m., the COC Evaluation indicated Resident 1 was noted with weight loss of 20 lbs. in four (4) weeks and the MD was notified with orders for Restorative Nursing Assistant (RNA) dining room program, provide supplement 8 ounces (oz - unit of measurement) three times a day, and check weekly weights. During a review Resident 1's Physician's Order, dated 8/2/2024, the Physician's Order indicated: - Megestrol acetate (a medication used to treat loss of appetite and weight loss) oral suspension 400 milligrams (mg- a unit of measurement) give 10 milliliters (ml-unit of measurement) by mouth two (2) times a day for poor intake. - Glucerna (brand of nutritional supplement) three (3) times a day for risk for malnutrition, offer eight (8) oz of Glucerna. - Assist the resident with all meals. If the resident eats less than 50%, offer supplement and notify MD. During a review of Resident 1's Medication Administration Records (MAR- a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for August 2024, the resident's intake of Glucerna three times a day (9 a.m., 2 p.m., and 9 p.m.) indicated the following: - 8/2/2024 from 2 p.m. until 8/5/2024, consumed 100% - 8/6/2024 at 9 p.m. consumed 50% - 8/7/2024 9 a.m. consumed 100% - 8/7/2024 2p.m. consumed 50% During a review of Resident 1's COC Evaluation, dated 8/3/2024 at 7:09 a.m., the COC Evaluation indicated Resident 1 was noted with poor intake and weakness and that the MD was notified on 8/3/2024 at 6:35 a.m. During a review of Resident 1's progress notes, dated 8/6/24 at 9:38 p.m., the progress notes indicated Resident 1's daughter requested for Mirtazapine (drug used to treat depression [constant feeling of sadness and loss of interest]) for Resident 1 and the MD approved. During a review of Resident 1's Physician's Orders, dated 8/7/2024, the Physician's Orders indicated: - Mirtazapine give 15 mg by mouth at bedtime for depression and poor oral intake. - Monitor behavior for poor oral intake and record number of episodes every shift. During a review of Resident 1's MAR for August 2024, the MAR indicated there were zero (0) episodes of poor oral intake on 8/7/2024. During an interview on 11/14/2024 at 2:56 p.m. with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated working regularly with Resident 1. CNA 2 reported Resident 1 did not eat much, maybe 25% and if Resident 1 did not eat well, she would give Glucerna. CNA 2 stated he/she would communicate with the charge nurse to let them know that Resident 1 was not eating, and the charge nurses would give the CNAs Glucerna to give to Resident 1. During an interview on 11/14/2024 at 3:07 p.m., with CNA 3, CNA 3 stated Resident 1 required assistance with feeding because the resident would not eat on her own, and when the resident started losing weight, she (Resident 1) was placed on feeding program. During an interview on 11/14/2024 at 4:04 p.m., with the Director of Nursing (DON), the DON stated less than 50% of amount eaten by a resident need to be reported to a Licensed Vocational Nurse (LVN). During a concurrent interview and record review on 11/15/2024 at 9:57 a.m., with the Registered Dietitian (RD), the RD stated Resident 1 initially weighed 137 lbs., but on 8/2/2024 Resident 1 weighed 116.4 lbs. which was a significant amount of weight loss. The RD stated Resident 1's 20.6 lbs. significant weight loss is a 15% change in the resident's weight. During an interview on 11/15/2024 at 12:39 p.m., the Certified Nursing Assistant 4 (CNA 4) stated initially the food was regular and Resident 1 would cough and spit up the food then it was changed to puree, and she was able to eat it. CNA 4 stated it was noted that Resident 1 started refusing to eat. CNA 4 stated if resident eats less than 50% that is when they notify the charge nurse. CNA 4 stated for about two to three weeks Resident 1 refused to eat or ate very little. CNA 4 stated that at that point Resident 1 declined and Resident 1 stopped speaking and looked different. CNA 4 stated not sure who her charge nurse was at that time, but CNA 4 stated she reported to the charge nurse regularly. During a concurrent interview and record review on 11/15/2024 at 2:30 p.m., with the Assistant Director of Nursing (ADON), the ADON reviewed Resident 1's Task Amount Eaten for July 2024. The ADON stated a poor intake of less than 50% needs to be reported to the charge nurse. The ADON stated they would need to do a COC evaluation if a resident has had three (3) episodes of poor intake (of less than 50%) consecutively. The ADON stated based on the July 2024 amount eaten by Resident 1, the COC evaluation should have been created on 7/25/2024 because Resident 1 ate less than 50 % for three (3) consecutive meals. The ADON stated the COC evaluation is needed to notify the MD and to start interventions. The ADON stated if there is a delay in interventions, there can be a delay in care and the resident's condition can worsen. During a concurrent interview and record review on 11/15/2024 at 3 p.m. with the DON, the DON reviewed Resident 1's Task Amount Eaten for July 2024. The DON stated the resident's intake on 7/25/2024 was concerning because Resident 1 ate less than 50% of her meals, and that a COC evaluation should have been started that day. The DON stated the monitoring should reflect the amount eaten. The DON stated a COC is a change in the resident's baseline including food intake. The DON stated COC evaluation is a communication between the MD and the resident's family. A review of the facility's policy and procedures (PnP) titled, Change in a Resident's Condition or Status, last revised on 11/2015 indicated our facility shall promptly notify the resident, his or her Attending Physician, and representative of changes in the resident's medical and or mental condition and or status. 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician when there has been: d. a significant change in the resident's physical/emotional/mental condition. f. refusal of treatment or medications (i.e. two (2) or more consecutive times). 2. A significant change of condition is a decline or improvement in the resident's status. A review of the facility's policy and procedures (PnP) titled, Weight Assessment and Intervention, last revised in March 2022 indicated resident weights are monitored for desirable or unintended wight loss or gain. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month- 5% weight loss is significant, greater than 5% is sever. A review of the facility's policy and procedures (PnP) titled, Charting and Documentation, last revised in 2001 indicated all services provided to the resident, progress toward the care plan goal, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary tea, regarding the resident's condition and response to care. A review of the facility's policy and procedures (PnP) titled, Weight Assessment and Intervention, last revised in March 2022 indicated resident weights are monitored for desirable or unintended wight loss or gain. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: b. 1 month- 5% weight loss is significant, greater than 5% is sever. A review of the facility's policy and procedures (PnP) titled, Charting and Documentation, last revised in 2001 indicated all services provided to the resident, progress toward the care plan goal, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary tea, regarding the resident's condition and response to care.

Nov 2024 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to: 1. Implement Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO, microorganisms, mainly bacteria, that are resistant to one or more classes of antibiotics] that uses targeted gown and glove use during high contact resident care activities) when Licensed Vocational Nurse 2 (LVN 2) did not don (put on) a gown while providing gastrostomy (GT, a surgical opening fitted with a device to allow feedings to be administered directly to the stomach, common for people with swallowing problems) care for one of seven sampled residents (Resident 5). 2. Implement Enhanced Barrier Precautions when Certified Nurse Assistant 6 (CNA 6) and CNA 7 did not don a gown while changing bed linen of Resident 6 that has foley catheter (flexible tube that's inserted into the urethra [the tube that carries urine from your bladder {the organ that stores urine} to the outside of your body] and left in the bladder to drain urine) for one of seven sampled residents (Resident 6). These deficient practices had the potential to spread infections and illnesses among residents and staff. Findings: 1. During a review of Resident 5's Record of Admission, the Record of admission indicated the facility admitted the resident on 1/11/2024 with a diagnosis of acute combined systolic and diastolic heart failure (a sudden severe condition where the heart is not pumping blood effectively due to both problems with contracting and relaxing properly). During a review of Resident 5's History & Physical (H&P), dated 1/3/2024, the H&P indicated Resident 5 had fluctuating capacity to understand and make decisions. During a review of Resident 5's Order Summary Report, dated 5/14/2024, the report indicated an order for EBP during wound care and GT placement. During a concurrent observation and interview on 11/14/2024, at 6:15 a.m., with LVN 2, observed LVN 2 manipulating the gastrostomy tube of Resident 5 without wearing a gown. LVN 2 stated the importance of wearing a gown when providing care to a resident with a GT is to prevent the spread of infection. During an interview on 11/14/2024, at 10:35 a.m., the Director of Nursing (DON) stated that LVN 2 should wear a gown when providing care to Resident 5's gastrostomy tube to prevent the spread of infection. 2. During a review of Resident 6's Record of Admission, the Record of admission indicated the facility initially admitted the resident on 9/29/2017 and readmitted on [DATE], with a diagnosis of type 2 diabetes mellitus with ketoacidosis without coma (the body does not have enough insulin to move sugar into cells for energy, so it breaks down fat instead). During a review of Resident 6's History & Physical (H&P), dated 4/18/2024, indicated that resident had fluctuating capacity to understand and make decisions. During a review of Resident 6's Order Summary Report, dated 11/6/2024, indicate to insert Indwelling Catheter Size: FR (French size- indicate the size of the catheter based on its outer diameter) 16 CC (cubic centimeter) 10. DX Urinary retention. Order in place for Urology Consult. During an observation and interview on 11/14/2024 at 6:45 a.m., with CNA 6 and CNA 7, observed that CNA 6 and CNA 7 inside Resident 6's room and was not wearing gown while changing Resident 6 bed linen and observed that resident has foley catheter. CNA 6 stated staff must wear gown due to infection control when taking care of Resident 6. During an interview on 11/14/2024, at 10:35 a.m., the Director of Nursing (DON) stated that CNA 6 and CNA 7 should wear a gown when providing care to Resident 6's to prevent the spread of infection. During a review of the facility's undated policy and procedure titled, Enhanced Barrier Precautions, indicated: · EBPs employ targeted gown and gloves use in a addition to standard precautions during high contract resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity. · Examples of high-contract resident care activities requiring the use of gown and gloves for EBPs include: a. Changing linens. b. Device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.) · Indwelling medical devices include central lines, urinary catheters, feeding tubes and tracheostomies.

Nov 2024 5 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure the physician was notified timely for one of three sampled residents (Resident 4) when Resident 4 eloped from the facility on 11/9/2024. This deficient practice resulted in delay of obtaining appropriate instructions from the physician for proper management. Findings: During a record review of Resident 4 ' s admission Record, the admission Record indicated the facility admitted Resident 4 on 10/25/2024, with diagnoses that included other chronic osteomyelitis (a bone infection that lasts longer than six months), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities) and unspecified psychosis (a collection of symptoms that cause a person to lose touch with reality and have difficulty distinguishing what's real and what's not). During a record review of Resident 4 ' s History and Physical (H&P), dated 10/26/2024, the H&P indicated Resident 4 had no capacity to understand and make decisions. The H&P indicated Resident 4 was found wandering the halls in the middle of the night and entered another resident ' s room in a Skilled Nursing Facility (SNF) and was provided a sitter (healthcare worker who provides care and supervision to patients who need close monitoring). During a record review of Resident 4 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 10/31/2024, the MDS indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 4 required moderate assistance from staff for activities of daily living (ADL - toileting, showering, dressing and personal hygiene). The MDS indicated Resident 4 needed supervision with walking and used a walker (a device that gives support to maintain balance or stability while walking) and wheelchair (a chair with wheels that helps people with mobility impairments move around) for mobility. During a record review of Resident 4 ' s Progress Notes, dated 11/9/2024, timed at 6:02 p.m., the Progress Notes indicated Family Member 1 (FM 1) and FM 2 was at the facility to pick up Resident 4 but Resident 4 was not in the room. The Progress Notes indicated the facility overhead paged (a message broadcast throughout the facility) Code (system of signals or symbols for communication) M (Missing Resident) and searched for Resident 4. During an interview on 11/12/2024, at 9:22 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated on 11/9/2024, at 1:30 p.m., Certified Nursing Assistant 1 (CNA 1) informed her (LVN 1) that Resident 4 was missing. LVN 1 stated she (LVN 1) reported to the Director of Nursing (DON). During a concurrent interview and record review on 11/12/2024, at 11:31 a.m., with the DON. Resident 4 ' s Progress Notes dated 11/9/2024, was reviewed. The DON stated Resident 4 ' s medical record did not have any documentary evidence that physician was notified. The DON stated nurses should have documented that physician was notified when Resident 4 eloped. During a concurrent interview and record review on 11/13/2024, at 12:08 p.m., with the Assistant Director of Nursing (ADON), facility ' s policy and procedure (PP) titled, Change in a Resident ' s Condition or Status dated 2001 and last reviewed on 4/18/2024, the PP indicated, The nurse will notify the resident's attending physician or physician on call when there has been a (an): a. accident or incident involving the resident. b. discovery of injuries of an unknown source. c. adverse reaction to medication. d. significant change in the resident's physical, emotional, mental condition. The ADON stated it is important to notify the physician of any incident related to the resident to obtain new orders. During a record review of facility ' s PP, titled, Wandering and Elopements dated 2001 and last reviewed on 4/18/2024, the PP indicated, If the resident is not located, notify the administrator and the director of nursing services, the resident's legal representative, the attending physician, law enforcement officials, and as necessary volunteer agencies (emergency management, rescue squads, etcetera). 4 When the resident returns to the facility, the director of nursing services or charge nurse shall: a. examine the resident for injuries. b. contact the attending physician and report findings and conditions of the resident;

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to develop a comprehensive care plan on wandering (to walk around slowly in a relaxed way or without any clear purpose or direction) and elopement (leaves a healthcare facility without supervision or detection), for one of five sampled residents (Resident 4) when resident eloped from the facility on 11/9/2024. This deficient practice can potentially place Resident 1 at risk for injury. Findings: During a record review of Resident 4 ' s admission Record, the admission Record indicated the facility admitted Resident 4 on 10/25/2024, with diagnoses that included other chronic osteomyelitis (a bone infection that lasts longer than six months), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities) and unspecified psychosis (a collection of symptoms that cause a person to lose touch with reality and have difficulty distinguishing what's real and what's not). During a record review of Resident 4 ' s History and Physical (H&P), dated 10/26/2024, the H&P indicated Resident 4 had no capacity to understand and make decisions. The H&P indicated Resident 4 was found wandering the halls in the middle of the night and entered another resident ' s room in a Skilled Nursing Facility (SNF) and was provided a sitter (healthcare worker who provides care and supervision to patients who need close monitoring). During a record review of Resident 4 ' s Progress Notes dated 10/26/2024, the Progress Notes indicated Resident 4 was found very confused in Room C (Resident 4 was in Room A). During a record review of Resident 4 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 10/31/2024, the MDS indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 4 required moderate assistance from staff for activities of daily living (ADL-toileting, showering, dressing and personal hygiene). The MDS indicated Resident 4 needed supervision with walking and used a walker (a device that gives support to maintain balance or stability while walking) and wheelchair (a chair with wheels that helps people with mobility impairments move around) for mobility. During a record review of Resident 4 ' s Progress Notes dated 11/9/2024, timed at 6:02 p.m., the Progress Notes indicated Family Member 1 (FM 1) and FM 2 was at the facility to pick up Resident 4 but Resident 4 was not in the room. The Progress Notes indicated the facility overhead paged (a message broadcast throughout the facility) Code (system of signals or symbols for communication) M (Missing Resident) and searched for Resident 4. During a record review of Resident 4 ' s Progress Notes dated 11/9/2024, timed at 7:21 p.m., Resident 4 was seated in the wheelchair with FM 1 and FM 2 at bedside. During a concurrent interview and record review on 11/13/2024, at 12:08 p.m., with the Assistant Director of Nursing (ADON), Resident 4 ' s Care Plans was reviewed. The ADON stated there were no Care Plan developed for wandering and elopement. The ADON stated individualized care plan should have been developed to address residents concern and plan intervention to address elopement. The ADON stated possible effects of not developing a care plan are risk for elopement, fall and injury. During a concurrent interview and record review on 11/13/2024, at 12:43 p.m., with the Director of Nursing (DON), facility ' s policy and procedure (PP) titled, Comprehensive Care Pans dated 12/2009 and last reviewed on 4/18/2024, the PP indicated, The comprehensive care plan is based on a thorough assessment that includes but is not limited to the MDS. Assessment of residents are ongoing and care plans are revised as information about the resident and the residents condition change. The Care Planning or Interdisciplinary Team (IDT- a coordinated group of experts from several different fields who work together) is responsible for the periodic review and updating the care plans. The DON stated care plan should have been developed on actual elopement on 11/9/2024. During a record review of facility ' s PP titled, Wandering and Elopements dated 2001 and last reviewed on 4/18/2024, the PP indicated, 1.If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.

CONCERN (D) 📢 Someone Reported This

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

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure that one of the three sampled residents (Resident 3), who was unable to carry out activities of daily living (ADLs-such as personal hygiene, bathing, bed mobility, dressing and transfers) received the necessary services to maintain good grooming and personal hygiene. This deficient practice had the potential to negatively affect Resident 3's self-esteem and wellbeing and placed Resident 3 at risk of infection. Findings: During a record review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted Resident 3 on 8/2/2024, with diagnoses that included cerebral ischemia (a condition that occurs when there isn't enough blood flow to the brain), unspecified (unconfirmed) sepsis (the body's extreme response to an infection that can lead to tissue damage, organ failure, or death if not treated right away) and unspecified pneumonia (lung infection). During a record review of Resident 3 ' s History and Physical (H&P), dated 10/22/2024, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a record review of Resident 3 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 10/24/2024, the MDS indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 3 required maximum assistance from staff for activities of daily living (ADL-toileting, showering and dressing). The MDS indicated Resident 3 was always incontinent (unable to control) of bowel and bladder functions. During an interview on 11/12/2024, at 11:01 a.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated Certified Nursing Assistant 4 (CNA 4) had a habit of leaving the floor for more than 30 minutes and LVN 3 had to look for her. LVN 3 stated on 10/27/2024, Family Member 3 (FM 3) was at Resident 3 ' s bedside and had ask to change the incontinent brief of Resident 3 but she (LVN 3) cannot find CNA 4. LVN 3 stated she reported the incident to Registered Nurse 1 (RN 1). During an interview on 11/12/2024, at 11:31 a.m., with the Director of Nursing (DON), the DON stated CNA 4 was written up (a formal written document that informs employees that they have violated the company's internal processes and regulations) and was suspended. During an interview on 11/12/2024, at 11:53 a.m., with the Director of Staff Development (DSD), the DSD stated RN 1 notified him (DSD) on 10/27/2024 about an issue with Resident 3 ' s care. The DSD stated RN 1 reported that Resident 3 was not changed, was soaking wet and FM 3 was upset. The DSD stated CNA 4 was sent home that night for not performing her (CNA 4) duty to care for Resident 3. The DSD stated the importance of incontinent care was to prevent skin breakdown. During an interview on 11/13/2024, at 11:30 a.m., with RN 1, RN 1 stated on 10/27/2024, they (RN 1 and LVN 3) looked and overhead paged (a communication system that broadcasts messages to entire facilities) CNA 4, but CNA 4 was missing from 10:30 a.m. to 12 noon. RN 1 stated FM 3 requested a CNA to do an incontinent care to Resident 3 and he (RN 1) had asked another staff to change Resident 3 because CNA 4 was missing. RN 1 stated Resident 3 validated that she (Resident 3) was soaking wet that time and FM 3 was upset. RN 1 stated CNA 4 failed to respond to call light and failed to attend to Resident 3 ' s needs. RN 1 stated the importance of answering the call light and changing the resident was to provide care and prevent pressure ulcer (localized, pressure-related damage to the skin and or underlying tissue usually over a bony prominence). During a concurrent interview and record review on 11/13/2024, at 12:08 p.m., with the Assistant Director of Nursing (ADON), facility ' s policy and procedure (PP) titled, Supporting Activities of Daily Living, dated 2001 and last reviewed on 4/18/2024, the PP indicated, 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care). The ADON stated it is their policy to provide hygiene to prevent skin issues.

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who was a high risk for fall, had history of dementia (a progressive state of decline in mental abilities) and had wandering behavior (to walk around slowly in a relaxed way or without any clear purpose or direction) was provided adequate supervision to prevent an elopement (the act of leaving a facility unsupervised and without prior authorization) for one of three sampled residents (Resident 4). This deficient practice potentially placed Resident 4 at risk for injury. Findings: During a record review of Resident 4 ' s admission Record, the admission Record indicated the facility admitted Resident 4 on 10/25/2024, with diagnoses that included other chronic osteomyelitis (a bone infection that lasts longer than six months), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified (unconfirmed) dementia and unspecified psychosis (a collection of symptoms that cause a person to lose touch with reality and have difficulty distinguishing what's real and what's not). During a record review of Resident 4 ' s Nursing Fall Risk Observation Assessment (FRA), dated 10/25/2024, the FRA indicated Resident 4 was a high risk for fall. During a record review of Resident 4 ' s Progress Notes, dated 10/25/2024, timed at 7:30 p.m., the Progress notes indicated Resident 4 was ambulatory. During a record review of Resident 4 ' s History and Physical (H&P), dated 10/26/2024, the H&P indicated Resident 4 had no capacity to understand and make decisions. The H&P indicated Resident 4 was found wandering the halls in the middle of the night and entered another resident ' s room in a Skilled Nursing Facility (SNF) and was provided a sitter (healthcare worker who provides care and supervision to patients who need close monitoring). During a record review of Resident 4 ' s Progress Notes, dated 10/26/2024, timed at 2:35 a.m., the Progress Notes indicated Resident 4 was found very confused in Room C (Resident 4 was in Room A) allegedly had physically abused Resident 6 and one on one sitter was provided. During a record review of Resident 4 ' s Progress Notes, dated 10/26/2024, timed at 9:29 a.m., the Progress Notes indicated, Resident 4 was, confuse, wanderer and walked around the station. The Progress Note indicated physician was notified and recommended one on one sitter for safety. During a record review of Resident 4 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 10/31/2024, the MDS indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 4 required moderate assistance from staff for activities of daily living (ADL-toileting, showering, dressing and personal hygiene). The MDS indicated Resident 4 needed supervision with walking and used a walker (a device that gives support to maintain balance or stability while walking) and wheelchair (a chair with wheels that helps people with mobility impairments move around) for mobility. During a record review of Resident 4 ' s Progress Notes, dated 11/9/2024, timed at 6:02 p.m., the Progress Notes indicated Family Member 1 (FM 1) and FM 2 was at the facility to pick up Resident 4 but Resident 4 was not in the room. The Progress Notes indicated the facility overhead paged (a message broadcast throughout the facility) Code (system of signals or symbols for communication) M (Missing Resident) and searched for Resident 4. During a record review of Resident 4 ' s Progress Notes, dated 11/9/2024, timed at 7:21 p.m., the Progress Notes indicated Resident 4 was back at the facility with family at bedside. During an interview on 11/12/2024, at 9:22 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 4 was for discharge that day on 11/9/2024. LVN 1 stated she (LVN 1) last saw Resident 4 on 11/9/2024, between 11:50 a.m., to 12 noon. LVN 1 stated at 2 p.m. Family Member 1 (FM 1) and FM 2 arrived to pick up Resident 4 but Resident 4 was missing. LVN 1 stated she (LVN 1) notified the Director of Nursing (DON). LVN 1 stated Resident 4 walked out from the front entrance at 12:57 p.m., on 11/9/2024, and left the wheelchair in the lobby. LVN 1 stated she (LVN 1) had never seen Resident 4 walked but Resident 4 can transfer from bed to wheelchair and was always in the wheelchair. LVN 1 stated FM 1 and FM 2 found Resident 4 in the smoke shop. During an interview on 11/12/2024, at 9:49 a.m. with the Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 4 walks to the bathroom and only uses the wheelchair to go around in the hallway. CNA 1 stated she (CNA 1) last saw Resident 4 on 11/9/2024, between 11:30 a.m. to 12:30 p.m., and at 1 p.m. lunch tray came, and Resident 4 was not in his room. CNA 1 stated she (CNA 1) had informed LVN 1 at 1 p.m., while she (CNA 1) had looked inside and outside the facility. CNA 1 stated she had seen the facility video surveillance and Resident 4 left the front entrance of the facility on 11/9/2024, at 12:57 p.m. CNA 1 stated Resident 4 walked wobbly (unsteady gait) and was at risk for fall. During an interview on 11/12/2024, at 11:31 with the Director of Nursing (DON), the DON stated Resident 4 eloped on 11/9/2024, and was missing from 1 p.m. and he (DON) came to help with the search. The DON stated FM 1 and FM 2 were here to pick up Resident 4. The DON stated 911 (a phone number used to contact the emergency services) and law enforcement was called but did not respond. The DON stated the Receptionist (RCP) did not notice Resident 4 left. The DON stated the smoke shop two blocks away from the facility called FM 1 and FM 1 picked up Resident 4 and Resident 4 was brought back to the facility. The DON stated Resident 4 who eloped on 11/9/2024, can fall and be in danger outside of the facility. During a concurrent interview and record review on 11/13/2024, at 12:08 p.m., with the Assistant Director of Nursing (ADON), Resident 4 ' s Wandering and Elopement assessment dated [DATE], Nursing Fall Risk Observation assessment dated [DATE], and MDS dated [DATE], was reviewed. The ADON stated Resident 4 was a high risk for fall and had moderately impaired cognition. The ADON stated Resident 4 who eloped can fall and may be expose to car accident-causing injury outside of the facility. During an interview on 11/13/2024, at 12:24 p.m., with the Administrator (ADM), the ADM stated Resident 4 left the front entrance on 11/9/2024, at 12:57 p.m., and was found at 6:20 p.m., when the smoke shop owner two blocks away from the facility called FM 1. During a concurrent interview and record review on 11/13/2024, at 12:43 p.m., with the DON, facility ' s policy and procedure (PP) titled, Accidents and Incidents-Investigating and Reporting dated 2001 and last reviewed on 4/18/2024, the PP indicated, 1. The nurse supervisor/charge nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 5. The nurse supervisor charge nurse and/or the department director or supervisor shall complete a Report of Incident Accident form and submit the original to the director of nursing services within 24 hours of the incident or accident. Incident accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities. The DON stated the policy was not followed. The DON stated Resident 4 ' s elopement can result to fall and accident. During a record review of facility ' s policy and procedure (PP) titled, Wandering and Elopements dated 2001 and last reviewed on 4/18/2024, the PP indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.

CONCERN (D) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the failed to maintain accurate and complete medical record for two of three sampled residents (Resident 3 and Resident 4). This deficient practice had the potential to cause confusion in care and the medical records containing inaccurate documentation and can result in the delay of delivery of care. Findings: a. During a record review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted Resident 3 on 8/2/2024, with diagnoses that included cerebral ischemia (a condition that occurs when there isn't enough blood flow to the brain), unspecified (unconfirmed) sepsis (the body's extreme response to an infection that can lead to tissue damage, organ failure, or death if not treated right away) and unspecified pneumonia (lung infection). During a record review of Resident 3 ' s History and Physical (H&P), dated 10/22/2024, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a record review of Resident 3 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 10/24/2024, the MDS indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 3 required maximum assistance from staff for activities of daily living (ADL-toileting, showering and dressing). The MDS indicated Resident 3 was always incontinent (unable to control) of bowel and bladder functions. During an interview on 11/12/2024, at 11:01 a.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated on 10/27/2024, Family Member 3 (FM 3) was at Resident 3 ' s bedside and had ask to change the incontinent brief of Resident 3 but she (LVN 3) cannot find Certified Nursing Assistant 4 (CNA 4) assigned to Resident 3. LVN 3 stated CNA 4 was missing for more than 30 minutes. LVN 3 stated she (LVN 3) notified Registered Nurse 1 (RN 1). During a concurrent interview and record review on 11/12/2024, at 11:10 a.m., with the Assistant Director of Nursing (ADON), Resident 3 ' s Progress Notes were reviewed. The ADON stated there were no documented notes on 10/27/2024. The ADON stated nurses should have documented the incident in Resident 3 ' s medical records. During an interview on 11/12/2024, at 11:53 a.m., with the Director of Staff Development (DSD), the DSD stated RN 1 notified him (DSD) on 10/27/2024, about an issue with Resident 3 ' s care. The DSD stated RN 1 reported that Resident 3 was not changed, was soaking wet and FM 3 was upset. The DSD stated CNA 4 was sent home that night for not performing her (CNA 4) duty to care for Resident 3. During an interview on 11/13/2024, at 11:30 a.m., with RN 1, RN 1 stated on 10/27/2024, they (RN 1 and LVN 3) looked and overhead paged (a communication system that broadcasts messages to entire facilities) CNA 4, but CNA 4 was missing from 10:30 a.m. to 12 noon. RN 1 stated FM 3 requested a CNA to do an incontinent care to Resident 3 and he (RN 1) had asked another CNA to change Resident 3 because CNA 4 was missing. RN 1 stated Resident 3 validated that she (Resident 3) was soaking wet that time and FM 3 was upset. RN 1 stated CNA 4 failed to respond to call light and failed to attend to Resident 3 ' s needs. RN 1 stated the importance of answering the call light and changing the resident was to provide care and prevent pressure ulcer (localized, pressure-related damage to the skin and or underlying tissue usually over a bony prominence). b. During a record review of Resident 4 ' s admission Record, the admission Record indicated the facility admitted Resident 4 on 10/25/2024, with diagnoses that included other chronic osteomyelitis (a bone infection that lasts longer than six months), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), unspecified (unconfirmed) dementia (a progressive state of decline in mental abilities) and unspecified psychosis (a collection of symptoms that cause a person to lose touch with reality and have difficulty distinguishing what's real and what's not). During a record review of Resident 4 ' s History and Physical (H&P) dated 10/26/2024, the H&P indicated Resident 4 had no capacity to understand and make decisions. During a record review of Resident 4 ' s MDS, dated [DATE], the MDS indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 4 required moderate assistance from staff for activities of daily living (ADL-toileting, showering, dressing and personal hygiene). The MDS indicated Resident 4 needed supervision with walking and used a walker (a device that gives support to maintain balance or stability while walking) and wheelchair (a chair with wheels that helps people with mobility impairments move around) for mobility. During a record review of Resident 4 ' s Progress Notes, dated 11/9/2024, timed at 6:02 p.m., the Progress Notes indicated FM 1 and FM 2 was at the facility to pick up Resident 4 but Resident 4 was not in the room. The Progress Notes indicated the facility overhead paged code M (Missing Resident) and searched for Resident 4. During a record review of Resident 4 ' s Progress Notes, dated 11/9/2024, timed at 7:21 p.m., the Progress Notes indicated Resident 4 was back at the facility with family at bedside. During an interview on 11/12/2024, at 9:22 a.m., with LVN 1, LVN 1 stated Resident 4 was for discharge that day on 11/9/2024. LVN 1 stated she (LVN 1) last saw Resident 4 on 11/9/2024, between 11:50 a.m., to 12 noon. LVN 1 stated at 2 p.m. FM 1 and FM 2 arrived to pick up Resident 4 but Resident 4 was missing. LVN 1 stated she (LVN 1) notified the Director of Nursing (DON). LVN 1 stated Resident 4 walked out from the front entrance on 11/9/2024, at 12:57 p.m. and left the wheelchair in the lobby. LVN 1 stated FM 1 and FM 2 found Resident 4 in the smoke shop, outside of the facility. During an interview on 11/12/2024 at 9:49 a.m. with the CNA 1, CNA 1 stated she (CNA 1) last saw Resident 4 on 11/9/2024, between 11:30 a.m. to 12:30 p.m., and at 1 p.m., lunch tray arrived, and Resident 4 was not in his room. CNA 1 stated she (CNA 1) had informed LVN 1 at 1 p.m., while she (CNA 1) had looked inside and outside the facility. CNA 1 stated she had seen the facility video surveillance and Resident 4 left the front entrance of the facility on 11/9/2024, at 12:57 p.m. During a concurrent interview and record review on 11/12/2024, at 11:10 a.m., with the ADON, Resident 4 ' s Progress Notes dated 11/9/2024, were reviewed. The ADON stated there were no documentation of when Resident 4 left the facility and when Resident 4 was found. The ADON stated staff should have documented and notified the physician of Resident 4 ' s elopement. The ADON stated the importance of documentation is their way of communication and for accurate medical records. During a concurrent interview and record review on 11/12/2024, at 11:31 a.m., with the DON, Resident 4 ' s Progress Notes dated 11/9/2024 were reviewed. The DON stated Resident 4 eloped on 11/9/2024 and was missing from 1 p.m. and he (DON) came to help with the search. The DON stated FM 1 and FM 2 were at the facility to pick up Resident 4. The DON stated 911 (a phone number used to contact the emergency services) and law enforcement was called but did not respond. The DON stated the Receptionist (RCP) did not notice Resident 4 left. The DON stated the smoke shop two blocks away from the facility called FM 1 and picked up Resident 4 and Resident 4 was brought back to the facility. The DON stated RN 2 ' s documentation was incomplete and LVN 1 did not document. The DON stated the importance of complete and accurate documentation, indicates what intervention was done when Resident 4 was missing and after Resident 4 was found. During a concurrent interview and record review on 11/13/2024, at 12:08 p.m., with the ADON, facility ' s policy and procedure titled, Charting and Documentation, dated 2001 and last reviewed on 4/18/2024, indicated, 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 medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. 2. The following information is to be documented in the resident medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition; e. Events, incidents or accidents involving the resident; and f. Progress toward or changes in the care plan goals and objectives. 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. The ADON stated it is their policy to document accurately in resident ' s medical records. During an interview on 11/13/2024, at 12:24 p.m., with the Administrator (ADM), the ADM stated Resident 4 left the front entrance on 11/9/2024, at 12:57 p.m., and was found at 6:20 p.m., when the smoke shop owner two blocks away from the facility called FM 1.

Oct 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure that one of the three sampled residents (Resident 2), who was unable to carry out activities of daily living (ADLs-such as personal hygiene, bathing, bed mobility, dressing and transfers) received the necessary services to maintain good grooming and personal hygiene as indicated in Resident 2 ' s care plan. This deficient practice had the potential to negatively affect Resident 2's self-esteem and wellbeing and placed Resident 2 at risk of infection. Findings: During a record review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted Resident 2 on 3/19/2024, with diagnoses that included other seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition) and dysphagia (difficulty in swallowing). During a record review of Resident 2 ' s History and Physical (H&P), dated 3/20/2024, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions. During a record review of Resident 2 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 9/25/2024, the MDS indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 2 was dependent to staff for personal hygiene. During a concurrent observation and interview on 10/8/2024, at 9:32 a.m., with the Assistant Director of Staff Development (ADSD), inside Resident 2 ' s room. Observed Resident 2 ' s fingernails long with black material under Resident 2 ' s right thumbnail. The ADSD stated Resident 2 ' s fingernails were long and dirty. During an interview on 10/8/2024, at 10:31 a.m., with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated CNAs are assigned to cut residents' fingernails. During a concurrent interview and record review on 10/8/2024, at 11:30 a.m., with Licensed Vocational Nurse 6 (LVN 6), Resident 2 ' s Care Plan on at risk for ADL decline dated 3/20/2024 and Documentation Survey Report for Bathing dated 10/2024, were reviewed. The Care Plan on at risk for ADL decline indicated an intervention to trim nails with bathing schedule. The Documentation Survey Report for Bathing indicated on 10/7/2024, a bed bath was provided. LVN 6 stated CNA should have trimmed and cleaned the nails after the bed bath. During an interview on 10/8/2024, at 11:54 a.m., with the ADSD, the ADSD stated the importance of proving nail or hand hygiene is to prevent infection. During a concurrent interview and record review on 10/8/2024, at 12:45 p.m., with the Director of Nursing (DON), facility ' s policy and procedure titled, Supporting Activities of Daily Living dated 2001 and reviewed on 4/18/2024, indicated, Appropriate care and services will be provided for residents who are unable to carry out ADL ' s independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming and oral care. The DON stated if part of resident ' s care plan, CNAs should have trimmed and clean the nails. The DON stated it is important to provide nail care to prevent skin breakdown when resident scratches themselves and for infection control.

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 F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to provide an ongoing activity program that is resident centered for one of three sampled residents (Resident 2). This deficient practice had the potential to affect the Resident 2's sense of self-worth and psychosocial well-being. Findings: During a record review of Resident 2 ' s admission Record, the admission Record indicated the facility admitted Resident 2 on 3/19/2024, with diagnoses that included other seizures (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness), essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition), and dysphagia (difficulty in swallowing). During a record review of Resident 2 ' s History and Physical (H&P), dated 3/20/2024, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions. During a record review of Resident 2 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 9/25/2024, the MDS indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 2 was dependent to staff for personal hygiene. During a concurrent interview and record review on 10/8/2024, at 12:10 p.m., with the Activity Director (AD), Resident 2 ' s Activity Participation Review dated 9/20/2024, and Documentation Survey Report for one-on-one visits dated 9/2024, was reviewed. The Activity Participation Review indicated Resident 2 responds well to one-to-one visits and would hold a conversation with staff. The Documentation Survey Report indicated three, one to one visits were conducted on 9/2024, dated 9/14/2024, 9/19/2024, and 9/30/2024. The AD stated on 9/2024, Resident 2 was provided with one-on-one visits three times only on 9/2024. The AD stated three times for the month was not enough. The AD stated activity or one to one visits should be provided daily. During a concurrent interview and record review on 10/8/2024, at 12:45 p.m. with the Director of Nursing (DON), facility ' s policy and procedure (PnP) titled, Department Duty Hours undated, was reviewed on 4/18/2024, indicated, The Activity department has established work hours to provide an ongoing program of activities to meet the interests and the physical, mental and psychosocial wellbeing of each resident. Activities shall be provided seven days per week. The DON stated the facility ' s PnP indicated activity should be provided daily. The DON stated if not documented it was not done.

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for one of three sampled residents (Resident 1) by failing to follow the physician ' s order. This deficient practice placed Resident 1 at risk of developing dangerous low blood pressure levels and medication error. Findings During a record review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted Resident 1 on 8/23/2018, with diagnoses that included unspecified (unconfirmed) chronic respiratory failure (condition in which not enough oxygen passes the lungs into your blood), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and hypertensive (HTN-high blood pressure) heart disease with heart failure (a serious condition that occurs when the heart is unable to pump enough blood and oxygen to the body's organs). During a record review of Resident 1 ' s History and Physical (H&P), dated 12/8/2023, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions. During a record review of Resident 1 ' s Physician Order dated 12/9/2023, the Physician Order indicated metoprolol tartrate (medication used to treat high blood pressure) oral tablet 25 milligrams (mg-metric unit of measurement, used for medication dosage and or amount), give one tablet by mouth two times a day for hypertension. Hold for systolic blood pressure (sbp-the pressure in your arteries [muscular, tube-shaped blood vessels that transport oxygen-rich blood from the heart to the body's organs and tissues] when your heart contracts and pumps blood) less than 110 or pulse rate less than 60. During a record review of Resident 1 ' s Minimum Data Set (MDS-a federally mandated resident assessment tool), dated 9/3/2024, the MDS indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making was intact. During a concurrent interview and record review on 10/8/2024, at 12:21 p.m., with the Director of Staff Development (DSD), Resident 1 ' s Medication Administration Record (MAR) dated 9/2024 was reviewed. The MAR indicated metoprolol had a check mark at 5 p.m., on the following dates with blood pressure of: 1. 9/7/2024 blood pressure- 103/57 2. 9/8/2024 blood pressure -100/60 3. 9/22/2024 blood pressure- 105/73 The DSD stated Licensed Vocational Nurse 1 (LVN 1), LVN2 and LVN 3 should have held the medication as per physician ' s order to prevent hypotension (low blood pressure). During a concurrent interview and record review on 10/8/2024, at 12:45 p.m., with the Director of Nursing (DON), facility ' s policy and procedure (PnP) titled, Administering Medications dated 2001 and reviewed on 4/18/2024. The PnP indicated, Medications are administered in accordance with prescribers ' orders, including required time frame. The DON stated check mark in MAR indicated medications were given. The DON stated LVN 1, LVN 2 and LVN 3 should have held the metoprolol because of the parameter ordered by the physician. The DON stated nurses should follow the physician ' s order to prevent adverse effects (undesired effect of a drug) and further hypotension.

Oct 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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to follow its policy and procedure titled, Change in a Resident ' s Condition or Status, which indicated the facility to promptly notify the resident ' s attending physician (MD) and the resident representative of a change in the resident ' s medical and or mental condition and or status for one of five sampled residents (Resident 2). This deficient practice had a potential to delay the care of Resident 2. Findings: A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 3/14/2012 and readmitted the resident on 10/13/2023 with diagnoses including gastrostomy (a surgical procedure used to insert a tube, often referred to as a G-tube [GT], through the abdomen and into the stomach), dysphagia (swallowing difficulties), and gastro-esophageal reflux (GERD- is a common condition in which the stomach contents move up into the esophagus). A review Resident 2 ' s Physician Orders, dated 8/2/2024, indicated the following orders: - elevate head of bed 30 to 40 degrees at all times during feeding and for at least 30 to 40 minutes after feeding stopped every shift. - Monitor for signs and symptoms of GT feeding aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident) i.e. presence of formulate in mouth, dyspnea, decreased oxygen saturation and new onset audible rhonchi and wheezes per shift. Document NO if no signs or symptoms of GT feeding aspiration observed. Document Y for YES of any sign or symptoms of GT feeding aspiration was observed. Notify doctor. A review of Resident 2 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/12/2024, indicated Resident 2 rarely understood and was rarely understood. The MDS indicated Resident 2 was dependent (helper does all the effort) for eating, oral hygiene, toileting, showering, upper and lower body dressing, putting on and taking off footwear and with personal hygiene. A review Resident 2 ' s Physician Orders, dated 9/24/2024, indicated enteral feed orders every shift continuous GT feeding of 1.5 Glucerna formula at 45 millimeters (ml- unit of measurement) for 20 hours to provide 900 and or 1350 kilocalorie (kcal-a unit of measurement) pump to run from 1 p.m. to 9 a.m. or until dose limit met. A review of Resident 2 ' s Situational Background Assessment Recommendation form (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents), dated 9/30/2024, indicated Resident 2 regurgitated (to vomit forth [partially digested food]) when CNA 6 was trying to reposition and or change Resident 2. Emesis was light brown medium size. Resident 2 was then suctioned and cleaned and or changed vital signs (reflect essential body functions, including your heartbeat, breathing rate, temperature, and blood pressure [the force of blood pushing against the walls of your arteries as your heart pumps blood throughout your body]) were stable, resident tolerated, no signs of distress or aspiration. Doctor and daughter notified. Doctor notified on 10/1/2024 at 12 a.m. and Family Member 1 (FM 1) notified on 10/1/2024 at 11:30 a.m. A review of Resident 2 ' s progress note, dated 9/30/2024 at 10 p.m., by Registered Nurse 1 (RN 1) indicated late entry. Note text indicated received call from CNA 6 that Resident 2 had vomited once. CNA 6 had just changed Resident 2 and CNA 6 reported that she turned the tube feeding (enteral feeding pump) off to be able to change Resident 2 but Resident 2 was laying down while being changed. Resident 2 was immediately placed at 90-degree angle and suctioned to prevent aspiration. Upon assessment Resident 2 is neurologically at baseline, no residual noted, lung sound are clear, vital signs stable, no signs or symptoms of respiratory distress. A review of Resident 2 ' s progress note, dated 10/1/2024 at 4:39 p.m., indicated grievance was received from the Social Services Director (SSD) that FM 1 was upset that nobody informed her Resident 2 vomited last night. During an interview on 10/2/2024 at 3:38 p.m., FM 1 stated on 9/30/2024 Resident 2 threw up and FM 1 was not notified. FM 1 stated Resident 2 has a GT and there is a concern for Resident 2 to aspirate. FM 1 stated when Resident throws up the doctor will request for the feeding to be turned off and labs, then she (FM 1) will be called but that did not occur. FM 1 stated yesterday (10/1/2024) RN 1 called FM 1 to explain what occurred the previous night (9/30/2024). FM 1 stated she informed RN 1 if there is any change in condition RN 1 needs to call the doctor. During a concurrent record review and interview of Resident 2 ' s progress notes on 10/3/2024 at 4 p.m., RN 1 stated worked during the 3 p.m. to 11 p.m. shift on 9/30/2024 and around 10 p.m. CNA 6 stated Resident 2 regurgitated. RN 1 stated went into Resident 2 ' s room and saw the feeding was off and Resident 2 was on her back flat. RN 1 stated did not notify the MD or family. RN 1 stated did not do any progress notes pertaining to the situation on 9/30/2024. RN 1 reviewed progress notes via point click care (a cloud-based software platform that helps healthcare providers connect and collaborate to improve care outcomes) and stated notes dated 9/30/2024 at 10 p.m. indicate late entry with creation date of 10/3/2024 at 11:20 a.m. RN 1 stated did not document on 9/30/2024 because she was busy. RN 1 stated documentation should be done right away but did not do that for Resident 2. During a concurrent record review and interview of Resident 2 ' s physician orders on 10/3/2024 at 4:22 p.m., the Director of Nursing (DON) stated that for Resident 2's regurgitation RN 1 should have created a change of condition (SBAR). The DON stated there is an order to hold feeding if Resident 2 throws up but during a concurrent record review of Resident 2's physician order summary, the DON was not able to provide documented evidence that there was a physian order to hold feedind if Resdient 2 throws up. During a concurrent record review and interview of Resident 2 ' s physician orders on 10/3/2024 at 4:44 p.m., the DON and Assistant Director of Nursing (ADON) stated they found the order for holding feeding if Resident 2 vomits but it was discontinued on 8/2/2024. The DON stated in that case RN 1 should have initiated a COC, need to communicate to family and doctor. The DON stated not doing a COC can lead to a delay in care and there would be no communication with the family and or MD. The DON stated documentation should be done as soon as possible. The DON stated if we miss the documentation, we might miss the incident and unable to address the incident. A review of the facility ' s P&P titled, Change in a Resident ' s Condition or Status, revised on 2/2021, indicated our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident ' s medical and or mental condition and or status. 1. The nurse will notify the resident ' s attending physician or physician on call when there has been a: d. significant change in the resident ' s physical, emotional, mental condition. i. specific instruction to notify the physician of changes in the resident ' s condition. 4. Unless otherwise instructed by the resident, a nurse will notify the resident ' s representative when: b. significant change in the resident ' s physical, mental, or psychosocial status. 8. The nurse will record in the resident ' s medical record information relative to changes in the resident ' s medical and or mental condition or status.

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to follow its policy and procedure when on 9/30/2024 at 10 p.m. a Certified Nursing Assistant 6 (CNA 6) turned off the enteral feeding pump (a device that delivers nutrient fluids into a patient's stomach, at a controlled rate) for one of five sampled residents (Resident 2). This deficient practice placed Resident 2 at risk for complications. Findings: A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 3/14/2012 and readmitted the resident on 10/13/2023 with diagnoses including gastrostomy (a surgical procedure used to insert a tube, often referred to as a G-tube [GT], through the abdomen and into the stomach), dysphagia (swallowing difficulties), and gastro-esophageal reflux (GERD- is a common condition in which the stomach contents move up into the esophagus). A review Resident 2 ' s Physician Orders, dated 8/2/2024, indicated the following orders: - elevate head of bed 30 to 40 degrees at all times during feeding and for at least 30 to 40 minutes after feeding stopped every shift. - Monitor for signs and symptoms of GT feeding aspiration (when food, liquid, or other material enters a person's airway and eventually the lungs by accident) i.e. presence of formulate in mouth, dyspnea, decreased oxygen saturation and new onset audible rhonchi and wheezes per shift. Document NO if no signs or symptoms of GT feeding aspiration observed. Document Y for YES of any sign or symptoms of GT feeding aspiration was observed. Notify doctor. A review of Resident 2 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/12/2024, indicated Resident 2 rarely understood and was rarely understood. The MDS indicated Resident 2 was dependent (helper does all the effort) for eating, oral hygiene, toileting, showering, upper and lower body dressing, putting on and taking off footwear and with personal hygiene. A review Resident 2 ' s Physician Orders, dated 9/24/2024, indicated enteral feed orders every shift continuous GT feeding of 1.5 Glucerna formula at 45 millimeters (ml- unit of measurement) for 20 hours to provide 900 and or 1350 kilocalorie (kcal-a unit of measurement) pump to run from 1 p.m. to 9 a.m. or until dose limit met. A review of Resident 2 ' s Situational Background Assessment Recommendation form (SBAR- a communication tool used by healthcare workers when there is a change of condition among the residents), dated 9/30/2024, indicated Resident 2 regurgitated (to vomit forth [partially digested food]) when CNA 6 was trying to reposition and or change Resident 2. Emesis was light brown medium size. Resident 2 was then suctioned and cleaned and or changed vital signs (reflect essential body functions, including your heartbeat, breathing rate, temperature, and blood pressure [the force of blood pushing against the walls of your arteries as your heart pumps blood throughout your body]) were stable, resident tolerated, no signs of distress or aspiration. Doctor and daughter notified. Doctor notified on 10/1/2024 at 12 a.m. and Family Member 1 (FM 1) notified on 10/1/2024 at 11:30 a.m. A review of Resident 2 ' s progress note, dated 9/30/2024 at 10 p.m., by Registered Nurse 1 (RN 1) indicated late entry. Note text indicated received call from CNA 6 that Resident 2 had vomited once. CNA 6 had just changed Resident 2 and CNA 6 reported that she turned the tube feeding (enteral feeding pump) off to be able to change Resident 2 but Resident 2 was laying down while being changed. Resident 2 was immediately placed at 90-degree angle and suctioned to prevent aspiration. Upon assessment Resident 2 is neurologically at baseline, no residual noted, lung sound are clear, vital signs stable, no signs or symptoms of respiratory distress. A review of Resident 2 ' s progress note, dated 10/1/2024 at 4:39 p.m., indicated grievance was received from the Social Services Director (SSD) that FM 1 was upset that nobody informed her Resident 2 vomited last night. During an interview on 10/2/2024 at 3:38 p.m., FM 1 stated on 9/30/2024 Resident 2 threw up and FM 1 was not notified. FM 1 stated Resident 2 has a GT and there is a concern for Resident 2 to aspirate. FM 1 stated when Resident throws up the doctor will request for the feeding to be turned off and labs, then she (FM 1) will be called but that did not occur. FM 1 stated yesterday (10/1/2024) RN 1 called FM 1 to explain what occurred the previous night (9/30/2024). FM 1 stated she informed RN 1 if there is any change in condition RN 1 needs to call the doctor. During a concurrent record review and interview of Resident 2 ' s progress notes on 10/3/2024 at 4 p.m., RN 1 stated worked during the 3 p.m. to 11 p.m. shift on 9/30/2024 and around 10 p.m. CNA 6 stated Resident 2 regurgitated. RN 1 stated went into Resident 2 ' s room and saw the feeding was off and Resident 2 was on her back flat. RN 1 stated did not notify the MD or family. RN 1 stated did not do any progress notes pertaining to the situation on 9/30/2024. RN 1 reviewed progress notes via point click care (a cloud-based software platform that helps healthcare providers connect and collaborate to improve care outcomes) and stated notes dated 9/30/2024 at 10 p.m. indicate late entry with creation date of 10/3/2024 at 11:20 a.m. RN 1 stated did not document on 9/30/2024 because she was busy. RN 1 stated documentation should be done right away but did not do that for Resident 2. During a concurrent record review and interview of Resident 2 ' s physician orders on 10/3/2024 at 4:22 p.m., the Director of Nursing (DON) stated that for Resident 2's regurgitation RN 1 should have created a change of condition (SBAR). The DON stated there is an order to hold feeding if Resident 2 throws up but during a concurrent record review of Resident 2's physician order summary, the DON was not able to provide documented evidence that there was a physian order to hold feedind if Resdient 2 throws up. The Director of Nursing (DON) stated that for the enteral tube feeding the nurses are the ones to turn off the enteral tube feeding. The DON stated the CNA must call the licensed nurse to turn the enteral tube feeding off. The DON stated it is not standard of care for CNAs to turn off the enteral tube feeding. The DON stated if a CNA is turning off a resident's tube feeding it can affect the amount of tube feeding ordered to the resident. During a concurrent record review and interview of Resident 2 ' s physician orders on 10/3/2024 at 4:44 p.m., the DON and Assistant Director of Nursing (ADON) stated they found the order for holding feeding if Resident 2 vomits but it was discontinued on 8/2/2024. The DON stated in that case RN 1 should have initiated a COC, need to communicate to family and doctor. The DON stated not doing a COC can lead to a delay in care and there would be no communication with the family and or MD. The DON stated documentation should be done as soon as possible. The DON stated if we miss the documentation, we might miss the incident and unable to address the incident. A review of the facility ' s undated P&P titled, Enteral Nutrition, indicated only licensed nurse can turn on and off the feeding. A review of the facility ' s P&P titled, Change in a Resident ' s Condition or Status, revised on 2/2021, indicated our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident ' s medical and or mental condition and or status. 1. The nurse will notify the resident ' s attending physician or physician on call when there has been a: d. significant change in the resident ' s physical, emotional, mental condition. i. specific instruction to notify the physician of changes in the resident ' s condition. 4. Unless otherwise instructed by the resident, a nurse will notify the resident ' s representative when: b. significant change in the resident ' s physical, mental, or psychosocial status. 8. The nurse will record in the resident ' s medical record information relative to changes in the resident ' s medical and or mental condition or status.

Sept 2024 12 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to ensure one of 14 sampled residents (Resident 3) was provided dignity when Resident 3 ' s gown was pulled up to her chest, exposing the resident in view of other residents and staff. This deficient practice had the potential to negatively affect the resident ' s psychosocial wellbeing and loss of dignity. Findings: During a review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted the resident on 3/14/2012 with diagnoses including Alzheimer ' s disease (a brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out the simplest tasks), dementia (a progressive state of decline in mental abilities) and aphasia (a language disorder that affects a person's ability to communicate). During a review of Resident 3 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/12/2024, the MDS indicated the resident ' s cognitive skills was severely impaired. The Functional Limitation in Range of Motion section of the MDS indicated Resident 3 had impairment on both sides of the upper extremities (shoulder, elbow, wrist, and hand) and the lower extremities (hip, knee, ankle, and foot). The MDS indicated Resident 3 was dependent on facility staff on oral, toileting, and personal hygiene. The MDS indicated Resident 3 was incontinent (involuntary loss of urine or the inability to control the bowels [a long tube in the body which digested food passes from the stomach to the anus]) of both bladder (a hallow organ that stores urine in the body) and bowel. During a review of Resident 3 ' s Comprehensive Skin Evaluation/Assessment, dated 8/3/2024, the Comprehensive Skin Evaluation/Assessment form indicated the resident had a gastrostomy tube (g-tube, also called as gastric tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach) on the mid-abdomen (middle of the abdomen). The Comprehensive Skin Evaluation/Assessment form indicated Resident 3 had a suprapubic indwelling catheter (a flexible plastic tube [a catheter] inserted into the bladder [a hallow organ that stores urine] through a hole in the abdomen to provide continuous urinary drainage). During an observation and a concurrent interview on 9/24/2024 at 8:45 a.m. with the Infection Preventionist Nurse (IPN) inside Resident 3 ' s room, the IPN pulled the resident ' s gown up and pulled the blanket down toward the resident ' s knees. Resident 3 ' s privacy curtain was pulled back and the door was open, exposing the resident ' s abdomen, g-tube, suprapubic indwelling catheter, and the resident ' s disposable brief in view to residents and staff passing by the resident ' s room. The IPN stated the privacy curtain should be fully drawn during resident care to provide Resident 3 with privacy and dignity. During a review of the facility ' s policy and procedure (PnP) titled, Quality of Life – Dignity, dated 4/18/2024, the PnP indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. The PnP indicated residents shall be treated with dignity and respect at all times. The PnP indicated staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. During a review of the facility ' s PnP titled, Resident Rights, dated 4/18/2024, the PnP indicated employees shall treat all residents with kindness, respect, and dignity.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to ensure the call light device (also known as a call bell or nurse call button, is a device typically found near a patient's bed or within reach. consists of a button that, when pressed, sends a signal to the nursing station or a centralized system, alerting healthcare providers that assistance is required in the room) was within reach for one of three sampled residents (Resident 14). This deficient practice had the potential to result in the delay of care and services and possible injury to residents when they are unable to call for assistance. Findings: During a record review of Resident 14 ' s admission Record, the admission Record indicated the facility admitted Resident 14 on 11/9/2020, with diagnoses that included displaced intertrochanteric fracture (type of broken hip) of left femur (thigh bone), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and acute respiratory failure (condition in which not enough oxygen passes the lungs into your blood). During a record review of Resident 14 ' s History and Physical (H&P) dated 7/20/2021, the H&P indicated Resident 14 had fluctuating capacity to understand and make decisions. During a record review of Resident 14 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 6/26/2024, the MDS indicated the resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. During a record review of Resident 14 ' s care plan on at risk for fall dated 7/20/2024, the care plan indicated an intervention to keep call light within reach. During a concurrent observation and interview on 9/27/2024, at 3:38 p.m., with Certified Nursing Assistant 6 (CNA 6), inside Resident 14 ' s room, observed Resident 14 ' s call light on the floor. CNA 6 stated she (CNA 6) did not notice that the resident's call light was on the floor when she (CNA 6) came inside the room. CNA 6 stated Resident 14 cannot reach the call light because it it on the floor. During an interview on 9/27/2024, at 4:33 p.m., with the Director of Staff Development (DSD), the DSD stated the call light device should be within the residents' reach so they (residents) can call for assistance and staff will be able to attend to the residents' needs. During an interview on 9/27/2024, at 5 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the call light device should be within the residents' reach. During a concurrent interview and record review on 9/28/2024, at 8:48 a.m., with Registered Nurse 2 (RN 2), the facility ' s policy and procedure (PnP) titled Call Lights dated 3/2017 was reviewed. The PnP indicated, Assure that the call light is within the residents reach when in their room or on the toilet. RN 2 stated it is their policy to make sure the residents can reach their call lights and for staff to attend to the resident ' s needs.

CONCERN (D) 📢 Someone Reported This

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

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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to notify the resident and the resident's responsible party (RP) of the result of the investigation and resolution of the grievance and failed to document the result of the grievance in the complaint and grievance form for one of three sampled residents (Resident 3). This deficient practice had the potential to violate residents' rights to have grievances addressed. Findings: During a record review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 3/14/2012, with diagnoses that included encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). During a record review of Resident 3's History and Physical (H&P) dated 8/5/2024, the H&P indicated Resident 3 had no capacity to understand and make decisions. During a record review of Resident 3's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 9/12/2024, the MDS indicated resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. During an interview on 9/26/2024 at 9:29 a.m., with Family Member 1 (FM 1), FM 1 stated, she (FM 1) had filed a grievance on 8/8/2024 and 9/6/2024 to the facility but was not informed of result of the grievance. During a record review of the facility's Complaint and Grievance Form dated 8/8/2024, the Complaint and Grievance Form indicated on 8/9/2024 the time, name of person notified and name of staff that notified RP was left blank. During a concurrent interview and record review on 9/27/2024 at 3:27 p.m., with the Assistant Director of Nursing (ADON), the facility's Concern and Grievance Log dated 9/2024, was reviewed. The Concern and Grievance Log indicated FM 1 filed grievance twice on 9/6/2024. There was no documentation that indicated FM 1 was informed of the findings and the disposition of the complaint. The ADON stated grievance should have been resolved and FM 1 should have been notified of the findings as soon as the investigation was completed. During a concurrent interview and record review on 9/27/2024 at 4:33 p.m., with the Director of Staff Development (DSD), the facility's Complaint and Grievance Log dated 8/2024 and Complaint Grievance Form dated 8/8/2024 was reviewed. The DSD stated on 8/8/2024 the Complaint Grievance Form indicated the grievance was resolved but the time, the person informed and the staff who informed was left blank. The DSD stated Social Service should follow up and complete the form. During an interview on 9/27/2024 at 4:53 p.m., with the Social Service Director (SSD), the SSD stated she (SSD) is responsible for notifying the family or the resident of the result of a grievance. The SSD stated it is important to document the results of the grievance and notify the resident or their representative, so they are aware of the actions taken by the facility to resolve the issues. During a concurrent interview and record review on 9/28/2024 at 8:48 a.m., with Registered Nurse 2 (RN 2), the facility's policy and procedure (PnP) titled, Grievance Procedure dated 11/1/2016 was reviewed. The PnP indicated, If the person who expressed the grievance is not satisfied with the investigation results or method of resolution, the Social Service Designee should suggest a formal meeting to attempt to resolve the issues with the complainant and the administrator, social service designee, other appropriate employee(s). Once resolution is reached, the social services designee should follow-up with the complainant in person or by phone to ensure continued satisfaction and determine if there are any additional concerns. Investigation and resolution of grievances shall be completed in a timely manner, within five working days of receipt of the Grievance/Concern form. The resolution will be communicated to the person who submitted the complaint. The social worker will monitor for timeliness of the process and as needed, will follow-up with the resident or family for effectiveness of the action taken. RN 2 stated grievance should be resolve within two days but according to the facility's PnP, the PnP indicated grievance should be resolved within five working days and Social Service are responsible for notifying the family.

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan (contains relevant information about a resident ' s health conditions, goals of treatment, specific actions that must be performed, and a plan for evaluation) with measurable objectives and interventions for one of 14 sampled residents (Resident 1) by failing to develop a care plan addressing Resident 1 ' s discharge plans. This deficient practice placed the resident at risk for not receiving the necessary care and services related to the resident ' s discharge goals and needs. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted the resident on 2/23/2024 with diagnoses including diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and anxiety disorder (persistent and excessive worry that interferes with daily activities). During a review of Resident 1 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/31/2024, the MDS indicated the resident ' s cognitive (problems with a person ' s ability to think, learn, remember, use judgement, and make decisions) skills was moderately impaired. The MDS indicated Resident 1 required setup or clean up assistance (helper assists only prior to or following the activity; the resident completes activity) on sitting to lying, walking 50 feet with two turns, and walking 150 feet. The MDS indicated Resident 1 required supervision (helper provides verbal cues and/or touching or steadying as resident completes activity) on sit-to-stand and transfers. During a concurrent interview and record review on 9/20/2024 at 1:11 p.m., with the Assistant Director of Nursing (ADON), Resident 1's care plans were reviewed. The facility was not able to provide documented evidence that a discharge care plan was created and implemented for Resident 1. The ADON stated Resident 1 ' s discharge planning process should have started upon admission and is ongoing until the resident is discharged from the facility. The ADON stated the facility failed to develop and implement an individualized discharge care plan to ensure a safe discharge for Resident 1. During a review of the facility ' s policy and procedure (PnP) titled, Comprehensive Person-Centered Care Plans, dated 4/18/2024, the PnP indicated the interdisciplinary team (IDT, a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological and spiritual needs of the patient), in conjunction with the resident develops and implements a comprehensive, person-centered care plan for each resident.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0679 (Tag F0679)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to provide an ongoing activity program that is resident centered for one of three sampled residents (Resident 3). This deficient practice had the potential to affect the resident's sense of self-worth and psychosocial well-being. During a review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted the resident on 3/14/2012 with diagnoses including Alzheimer ' s disease (a brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out the simplest tasks), dementia, and aphasia (a language disorder that affects a person's ability to communicate). During a review of Resident 3 ' s Minimum Data Set (MDS -a federally mandated resident assessment tool), dated 9/12/2024, the MDS indicated the resident ' s cognitive skills was severely impaired. The Functional Limitation in Range of Motion section of the MDS indicated Resident 3 had impairment on both sides of the upper extremities (shoulder, elbow, wrist, and hand) and the lower extremities (hip, knee, ankle, and foot). The MDS indicated Resident 3 was dependent on facility staff on oral, toileting, and personal hygiene. During a review of Resident 3 ' s care plan on activities, last revised on 8/27/2024, the care plan indicated the resident was at risk for social isolation. The care plan Interventions included to assist Resident 3 with in-room activities as needed and one on one room visits for socialization. During an interview and concurrent record review with the Activity Director (AD) on 9/25/2024 at 12:37 p.m., Resident 3 ' s Activity Tasks and One on One Visits were reviewed. The AD stated Resident 3 had sensory and auditory activities in the dining room or resident ' s room. The One-on-One Visits, dated 7/2024, indicated Resident 3 was provided one on one visits on 7/7/2024 and 7/20/2024. The One-on-One Visits, for 8/2024, indicated Resident 3 was provided one on one visits on 8/26/2024 to 8/28/2024 and on 8/31/2024. The Activity Task, for 9/2024, indicated Resident 3 was provided activities on 9/18/2024 and 9/21/2024. The AD stated Resident 3 received fewer sessions of activities than expected for the past three months. The AD stated Resident 3 should be provided activities at least three times a week. The AD stated residents that do not receive activities had the potential to feel isolated and depressed (feeling of sadness that will not go away). The AD stated the facility failed to provide Resident 3 with activities as indicated in the resident ' s care plan. During a review of the facility ' s policy and procedure (PnP) titled Room Visit Program, dated 4/18/2024, indicated the purpose to assure all residents receive an opportunity for socialization and stimulation. The PnP indicated residents will be visited on a regular scheduled basis. The PnP indicated resident who cannot or choose not to leave their rooms will be seen three times per week, more frequently if time allows.

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to follow professional standards of practice for one of four sampled residents (Resident 3) by failing to: a. Ensure Resident 3 was assessed and monitored after the resident had a change of condition (COC) on 9/16/2024. b. Ensure Resident 3 ' s Attending Physician 1 (MD 1) and resident representative (FM 1) were notified about the resident's COC timely. These deficient practices had the potential to result in inaccurate assessment that can lead to the resident not receiving timely medical interventions. Findings: During a review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 3/14/2012 with diagnoses including Alzheimer ' s disease (a brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out the simplest tasks), dementia, and aphasia (a language disorder that affects a person's ability to communicate). During a review of Resident 3's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/12/2024, the MDS indicated the resident ' s cognitive skills was severely impaired. The Functional Limitation in Range of Motion section of the MDS indicated Resident 3 had impairment on both sides of the upper extremities (shoulder, elbow, wrist, and hand) and the lower extremities (hip, knee, ankle, and foot). The MDS indicated Resident 3 was dependent on facility staff on oral, toileting, and personal hygiene. The MDS indicated Resident 3 was incontinent (involuntary loss of urine or the inability to control the bowels [a long tube in the body which digested food passes from the stomach to the anus]) of both bladder (a hallow organ that stores urine in the body) and bowel. During a review of Resident 3's History and Physical (H&P), dated 8/5/2024, the H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a telephone interview on 9/25/2024 at 11:12 a.m., with Licensed Vocational Nurse 13 (LVN 13), LVN 13 stated on 9/16/2024 at 10:30 p.m., she went to Resident 3 ' s room and saw vomit on the right side of the resident ' s shirt. LVN 13 stated Resident 3 had a large amount of liquid stool (also known as feces, the material in the bowel movement) that overflowed out of the resident ' s disposable brief. LVN 13 stated she did not document Resident 3 ' s COC on the SBAR Communication Form and did not notify MD 1 and FM 1 regarding Resident 3 ' s COC. LVN 13 stated Resident 3 had the potential for dehydration due to vomitting and diarrhea. During a review of Resident 3's SBAR (Situation Background, Appearance Review and Notify) Communication Form, dated 9/17/2024, the SBAR Communication Form indicated the resident had diarrhea (loose, watery stools), nausea and vomiting. Resident 3 ' s MD 1 was notified at 8:57 p.m. on 9/17/2024. Resident 3 ' s FM 1 was notified at 10:57 p.m. on 9/17/2024. During a review of Resident 3's Physician Orders, dated 8/3/2024, the Physician Orders indicated metochlopramide hydrochloride (a medication to treat nausea and vomiting) 5 mg every eight hours as needed for nausea and vomiting. During a review of Resident 3 ' s Medication Administration Record (MAR), dated 9/1/2024 to 9/30/2024, the MAR indicated Resident 3 did not receive the ondansetron hydrochloride 4 mg or the metochlopramide hydrochloride 5 mg on 9/16/2024. During an interview and concurrent record review on 9/25/2024 at 11:36 a.m., with the Assistant Director of Nursing (ADON), Resident 3 ' s clinical records inlcuding progress notes SBAR forms were reviewed. The ADON stated the SBAR for Resident 3 ' s COC was not done at 10:30 p.m. on 9/16/2024. The ADON stated Resident 3 ' s COC was documented on 9/17/2024 at 8:57 p.m., 22 hours and 27 minutes after Resident 3 ' s COC. The facility was not able to provide documented evidence that Resident 3 was assessed and monitored after the resident ' s COC on 9/16/2024. The ADON stated Resident 3 ' s medications for nausea and vomiting were not given to the resident after the resident ' s COC. The ADON stated late documentation and late notification of MD had the potential for a delay in resident care. The ADON stated the facility failed to provide interventions for Resident 3 ' s COC. The ADON stated the facility failed to ensure MD 1 and FM 1 were notified immediately regarding Resident 3 ' s COC. During a review of the facility ' s policy and procedure (PnP) titled Change in a Resident ' s Condition or Status, dated 4/18/2024, indicated the nurse supervisor or charge nurse will promptly notify the resident ' s attending physician, or on-call physician when there has been . d. significant change in the resident ' s physical, emotional, and mental condition. The PnP indicated the nurse supervisor or charge nurse will notify the resident ' s family or representative when there is a significant change in the resident ' s physical, mental, or psychosocial status. The PnP indicated the nurse supervisor or charge nurse will record in the resident ' s medical record information relative to changes in the resident ' s medical and mental condition or status. The PnP indicated if a significant change in the resident ' s physical or mental condition occurs, a comprehensive assessment of the resident ' s condition will be conducted.

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure residents who are receiving enteral feeding (also known as tube feeding, a method of supplying nutrients directly into the gastrointestinal tract) received appropriate treatment and services for one of three sampled residents (Resident 3) by: 1. Failing to ensure the physician was notified timely when Resident 3 ' s gastrostomy tube (GT-a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) malfunctioned (fail to operate). 2. Failing to ensure GT residual (the amount of liquid drained from a stomach following administration of enteral feed) was checked and documented before administration of medications, flushing and formula every shift. This deficient practices had the potential to result in Resident 3 not receiving the volume of tube feeding formula ordered and placed Resident 3 at risk for unplanned, progressive weight loss and or fluid overload. Findings: a. During a record review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted Resident 3 on 3/14/2012, with diagnoses that included encounter for attention to gastrostomy, diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and Alzheimer ' s disease (a disease characterized by a progressive decline in mental abilities). During a record review of Resident 3 ' s History and Physical (H&P) dated 8/5/2024, the H&P indicated Resident 3 had no capacity to understand and make decisions. During a record review of Resident 3 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 9/12/2024, the MDS indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 3 was on feeding tube. During a record review of Resident 3 ' s Situation Background Assessment Recommendation (SBAR, technique that provides a framework for communication between members of the health care team about a resident ' s condition) Communication Form dated 8/7/2024, the SBAR indicated on 8/7/2024 Resident 3 had blockage and displaced GT. The SBAR indicated GT was torn at y-port (there are three ports at the end of the tube, a large clear port for feedings, a small clear port for medications, and a numbered (white) port which is the balloon port, y-port is between feeding and balloon port) and LVN 7 could not administer medication and feeding due to leakage. The SBAR indicated the physician was notified at 6:44 p.m. and ordered to transfer Resident 3 to General Acute Care Hospital (GACH) for GT reinsertion. During an interview on 9/26/2024, at 9:29 a.m., with the Family Member 1 (FM 1), FM 1 stated on 8/7/2024, FM 1 visited Resident 3 and saw Licensed Vocational Nurse 7 (LVN 7) flushed Resident 3 ' s GT. FM 1 stated there was a clear tape wrapped around the GT and LVN 7 had a hard time flushing. FM 1 stated there was a cut on the GT when LVN 7 removed the clear tape. During an interview on 9/28/2024, at 10:14 a.m., with the Director of Nursing (DON), the DON stated he (DON) was informed that there was a clear tape applied on Resident 3 ' s GT. The DON stated Treatment Nurse 1 (TxN 1) and LVN 7 saw the clear tape on the resident ' s GT. The DON stated staff should not have taped the GT but document a change in condition and call the physician to get an order for transfer to GACH for GT reinsertion to prevent delay in providing feeding and medication to the resident The DON stated applying tape on GT is not acceptable. During an interview on 9/28/2024, at 10:35 a.m., with Treatment Nurse 1 (TxN1), TxN1 stated she (TxN 1) did morning rounds on 8/7/2024 with the Wound Doctor, checked Resident 3 ' s GT stoma (a small opening in the abdomen) and changed the GT dressing. TxN 1 stated she (TxN 1) did not notice the clear tape on the GT when she was changing the stoma dressing. During an interview on 9/28/2024, at 11:04 a.m., with LVN 7, LVN 7 stated on 8/7/2024 she worked from 7 a.m., until 11 p.m. LVN 7 stated she (LVN 7) noticed the clear tape on the GT during the 3 p.m. to 11 p.m. shift. LVN 7 stated she was unable to flush the GT because it was clogged. LVN 7 if the GT was clogged or leaking, staff should have reported it to the physician so the GT can be replaced at the hospital. During a record review of Resident 3 ' s GACH ' s Emergency Department Physician Record dated 8/7/2024, the Emergency Department Physician Record indicated Resident 3 was seen at 7:47 p.m., with a cut in the port of the GT and reinsertion of GT was performed at 9:17 p.m. During a record review of facility ' s policy and procedure (PnP) titled Enteral Feeding dated 5/2014, the PnP indicated, When a gastrostomy tube is present, follow physicians order for replacement of tube as needed or when it becomes permanently clogged, damaged, dislodged, ceases to work properly or accidentally pulled out. A foley catheter (a thin, flexible tube that drains urine) may be used to keep the stoma open. Formula, medications and water may not be administered with a foley catheter. If GT cannot be reinserted, Physician may order insertion of nasogastric tube (NGT is a thin, soft tube made of plastic or rubber that is passed through the nose, down through the throat, and into the stomach) until GT is reinserted. b. During a record review of Resident 3 ' s Progress Notes dated 9/2024, the Progress Notes did not indicate there was documentation that Resident 3 ' s GT residual was checked. During a concurrent interview and record review on 9/27/2024, at 5 p.m., with the Assistant Director of Nursing (ADON), Resident 3 ' s Physician order dated 8/2/2024, and Medication Administration Record (MAR) dated 9/2024, were reviewed. The physician ' s order indicated to check and record residuals before administration of medications, flushing and formula every shift. The MAR did not indicate licensed nurses were documenting the amount of residuals. The ADON stated staff should have checked the GT residual and document the amount in the Progress Notes so staff would know if Resident 3 was retaining fluid. During a record review of facility ' s policy and procedure (PnP) titled, Administering Medications through an Enteral Tube dated 9/2014, the PnP indicated Check gastric residual volume to assess for tolerance of enteral feeding. During a record review of facility ' s policy and procedure (PnP) titled, Enteral Feeding dated 5/2014, the PnP indicated The dose completion time will vary depending on the amount of time the feeding will be held for care. Residual parameters and unforeseen circumstances related to resident ' s condition. During a record review of facility ' s policy and procedure titled, Charting and Documentation dated 7/2017, the PnP indicated Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 9), who was receiving Lovenox (an anticoagulant that helps prevent the formation of blood clots) was monitored for the side effects of bleeding. This deficient practice had the potential to place Resident 9 at increased risk for side effects including bleeding and bruising. Findings: During a record review of Resident 9 ' s admission Record, the admission Record indicated the facility admitted Resident 9 on 1/2/2024, with diagnoses that included Parkinson ' s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), history of fall, and essential hypertension (persistently raised blood pressure with no secondary cause identified). During a record review of Resident 9 ' s History and Physical (H&P) dated 1/21/2024, the H&P indicated Resident 9 had fluctuating capacity to understand and made decisions. During a record review of Resident 9 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 7/10/2024, the MDS indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. During a record review of Resident 9 ' s Physician's Order dated 1/2/2024, the Physician's Order indicated Lovenox injection (the act of putting a liquid, especially a drug, into a person's body using a needle and a syringe) solution prefilled syringe (a single dose of medication to which a needle has been fixed by the manufacturer) 40 milligram (mg- unit of measurement) per 4 milliliter (ml- unit of measurement), inject 0.4 ml subcutaneously (beneath, or under, all the layers of the skin) one time a day for deep vein thrombosis (DVT-occurs when a blood clot forms in one or more of the deep veins in the body, usually in the legs) prophylaxis (an attempt to prevent disease). During a record review of Resident 9 ' s Physician's Order dated 1/2/2024, the Physician's Order indicated to monitor for anticoagulant medication side effects of discolored urine (urine color changes), black tarry (a sticky consistency) stools, sudden severe headache, nausea, vomiting, diarrhea, muscle joint pain, lethargy (condition marked by drowsiness and an unusual lack of energy and mental alertness), brushing, sudden changes in mental status, shortness of breath, and nose bleeds every shift. During a record review of Resident 9 ' s Care Plan addressikng the risk for potential bleeding and bruising due to anticoagulant therapy dated 1/2/2024, the Care Plan indicated the following interventions: -assess for signs signifying blood loss (petechia [a minute reddish or purplish spot containing blood that appears in skin or mucous membrane as a result of localized bleeding], bruises, dark colored stools) and notify the physician. -monitor for blood in the urine or stool and report abnormal findings to the physician. -monitor for bruising or bleeding and report abnormal findings to the physician. During a record review of Resident 9 ' s Medication Administration Record (MAR) dated 9/2024, the MAR indicated Lovenox was given daily at 9 a.m. During a record review of Resident 9 ' s MAR dated 9/2024, the MAR indicated anticoagulant medication side effects monitoring was left blank on 9/7/2024, 9/17/2024, 9/18/2024, 9/19/2024, 9/21/2024 and 9/22/2024 at night shift (a period of time during the night such as from 11 p.m. to 7 a.m.) During a concurrent interview and record review on 9/26/2024, at 10:25 a.m., with the Director of Staff Development (DSD), Resident 9 ' s Physician's Order dated 1/2/2024 and MAR dated 9/2024 were reviewed. The DSD stated the anticoagulant monitoring was left blank on 9/7/2024, 9/17/2024, 9/18/2024, 9/19/2024, 9/21/2024 and 9/22/2024 at night shift). During an interview on 9/27/2024, at 5 p.m., the Assistant Director of Nursing (ADON) stated nurses should assess Resident 9 for the side effect of bleeding because of the anticoagulant use. The ADON stated nurses should monitor and document as per physician's order for signs of bleeding. During a record review of facility ' s policy and procedure (PnP) titled, Administering Medications, dated 4/2019, was reviewed. The PnP indicated medications are administered in accordance with prescribers ' orders, including any required time frame. During a record review of facility ' s PnP titled, Administering Oral Medications, dated 10/2010, the PnP indicated, Perform any pre-administration assessment.

CONCERN (D) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement infection control procedures for two of six sampled residents (Resident 3 and Resident 11) by: a. Failing to ensure Certified Nursing Assistant 7 (CNA 7) wore gloves while performing oral care (cleaning of the teeth, oral cavity [mouth], and dentures). Resident 3 was on enhanced barrier precaution (EBP – an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities). b. Failing to ensure Resident 11 ' s oxygen tubing was not touching the floor. These deficient practices had the potential for cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) of the resident ' s care equipment and placed the residents at risk for infection. Findings: a. During a record review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted the resident on 3/14/2012 with diagnoses including Alzheimer ' s disease (a brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out the simplest tasks), dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and aphasia (a language disorder that affects a person's ability to communicate). During a record review of Resident 3 ' s Care Plan on EBP, initiated on 5/14/2024 and revised on 7/17/2024, the Care Plan indicated the resident required EBP during high-contact resident care activities. Resident 3 ' s Care Plan Goal indicated EBP will be followed during high-contact resident care activities. The Care Plan Interventions included hand hygiene utilizing alcohol-based hand rub and to utilize personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) during high-contact resident care activities such as hygiene. During a record review of Resident 3 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/12/2024, the MDS indicated the resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills was severely impaired. The MDS indicated Resident 3 was dependent on facility staff on oral, toileting, and personal hygiene. The MDS indicated Resident 3 was incontinent (involuntary loss of urine or the inability to control the bowels [a long tube in the body which digested food passes from the stomach to the anus]) of both bladder (a hallow organ that stores urine in the body) and bowel. During an observation and concurrent interview on 9/24/2024 at 9:14 a.m. with CNA 7, CNA 7 was observed inside Resident 3 ' s room wearing a disposable gown holding a cup and mouth sponges. CNA 7 was not wearing gloves on both hands. CNA 7 touched Resident 3 ' s bedside drawers and personal belongings located at the bedside. CNA 7 poured Resident 3 ' s mouthwash in the cup and placed the mouth sponges in the cup with her ungloved hands. CNA 7 used the mouth sponges to clean Resident 3 ' s teeth and mouth, touching the resident ' s lips with her ungloved hands. CNA 7 stated she was looking for Resident 3 ' s lip moisturizer and proceeded to touch the resident ' s bedside drawers with her ungloved hands. CNA 7 wiped Resident 3 ' s lips with a white towel that was over the resident ' s chest. CNA 7 took a pair of gloves from the box without performing hand hygiene (hand washing with soap and water and use of alcohol-based hand sanitizer). CNA 7 stated she forgot to wear gloves during Resident 3 ' s oral care. CNA 7 stated not wearing gloves and not using the hand sanitizer had the potential to spread infection to Resident 3 and other residents. During an interview on 9/24/2024 at 10:34 a.m. with the Infection Preventionist Nurse (IPN), the IPN stated Resident 3 was on EBP because of the resident ' s suprapubic indwelling urinary catheter (a flexible plastic tube [a catheter] inserted into the bladder [a hallow organ that stores urine] through a hole in the abdomen to provide continuous urinary drainage) and a gastrostomy tube (g-tube, also called as gastric tube, a tube inserted through the abdomen that delivers nutrition directly to the stomach). The IPN stated the facility failed to ensure facility staff perform hand hygiene and use PPE during high-contact resident care activities. During a review of the facility ' s policy and procedure (PnP) titled, Infection Prevention and Control, dated 4/18/2024, the PnP indicated the facility adopted infection prevention and control policies and procedures are intended to help maintain a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The PnP indicated infection prevention and control PnP apply to all personnel, consultants, contractors, residents, visitors, and volunteers. During a record review of the facility ' s PnP titled, Categories of Transmission-Based Precautions, dated 4/18/2024, the EBP section of the PnP indicated to wear gown and gloves while performing the following high-contact tasks associated with the greatest risk for multidrug resistant organisms (MDRO, bacteria that became resistant to certain antibiotics [medicines that fight bacterial infections]) contamination of staff hands, clothes, and the environment. During a record review of the facility ' s PnP titled, Handwashing/Hand Hygiene, dated 4/18/2024, the PnP indicated all personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. The PnP indicated hand hygiene is indicated immediately before and after touching a resident, after contact with blood, body fluids, or contaminated surfaces, and after touching the resident ' s environment. During a record review of the facility ' s PnP titled, Gloves, dated 4/18/2024, the PnP indicated all employees must wear gloves when touching blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin. The PnP indicated to wash hands after removing gloves. b. During a record review of Resident 11 ' s admission Record, the admission Record indicated the resident was admitted on [DATE], with diagnoses that included acute (rapid onset of new or worsening signs and symptoms) combined congestive heart failure (a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control), bronchitis (a condition that develops when the airways in the lungs become inflamed and cause coughing, often with mucus production). During a record review of Resident 11 ' s MDS dated [DATE], the MDS indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were intact. The MDS indicated Resident 11 required maximum assistance from staff for all activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a record review of Resident 11 ' s Physician's Order dated 9/25/2024, the Physician's Order indicated oxygen at two liters per minute via nasal cannula (device that delivers extra oxygen through a tube and into your nose). May titrate (adjusting the dose for the maximum benefit) up to four liters per minute as needed. During a concurrent interview and record review on 9/27/2024 at 3:38 p.m., with Certified Nursing Assistant 6 (CNA 6), inside Resident 11 ' s room, observed Resident 11 ' s oxygen tubing touching the floor. CNA 6 stated Resident 11 ' s oxygen tubing should not touch the floor. During an interview on 9/27/2024 at 4:33 p.m., the Director of Staff Development (DSD) stated oxygen tubing should not touch the floor for infection control. During an interview on 9/27/2024 at 5 p.m., the Assistant Director of Nursing (ADON) stated oxygen tubing should not touch the floor for infection control. The ADON stated if the resident was on low bed, the staff should roll the oxygen tubing and place it in a bag to prevent the tubing from touching the floor. During a record review of the facility ' s policy and procedure (PnP) titled Departmental (Respiratory Therapy)-Prevention of Infection dated 4/2012, the PnP indicated, The purpose of this procedure is to guide prevention of infection associated with respiratory therapy task and equipment, including ventilators, among residents and staff.

CONCERN (E) 📢 Someone Reported This

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

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of seven sampled residents (Resident 2, Resident 3, and Resident 9) received care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) by failing to: a. Ensure Resident 3's low air-loss mattress (LALM - a mattress composed of inflatable air cushions that is used to relieve pressure on body parts) was set at the appropriate setting per facility policy. b. Ensure treatment was provided to Resident 9 as per physician's order. c. Ensure staff use a single draw sheet on Resident 2's LALM as indicated in the facility's policy. These deficient practices placed Resident 2, 3, and 9 at risk for the development and worsening of pressure ulcers. Findings: a. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted the resident on 3/14/2012, with diagnoses including Alzheimer's disease (a brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out the simplest tasks), dementia, and aphasia (a language disorder that affects a person's ability to communicate). During a review of Resident 3's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 9/12/2024, the MDS indicated the resident's cognitive (mental action or process of acquiring knowledge and understanding) skills was severely impaired. The Functional Limitation in Range of Motion section of the MDS indicated Resident 3 had impairment on both sides of the upper extremities (shoulder, elbow, wrist, and hand) and the lower extremities (hip, knee, ankle, and foot). The MDS indicated Resident 3 was dependent on facility staff on oral, toileting, and personal hygiene. The MDS indicated Resident 3 was incontinent (involuntary loss of urine or the inability to control the bowels [a long tube in the body which digested food passes from the stomach to the anus]) of both bladder (a hallow organ that stores urine in the body) and bowel. During a review of Resident 3's Braden Scale for Predicting Sore Risk (BSPSR), dated 9/12/2024, the BSPSR indicated the score of 9. The score of 9 indicated Resident 3 had a very high risk for developing pressure ulcers. During a review of Resident 3's Physician Orders, dated 8/2/2024, the Physician Orders indicated an order for pressure reducing mattress every shift. During a review of Resident 3's Comprehensive Skin Evaluation/Assessment, dated 8/3/2024, the Comprehensive Skin Evaluation/Assessment form indicated the resident had significant scar tissues on the sacrococcyx (fused sacral [a large triangle-shaped bone in the lower spine] and coccyx [a small bone at the bottom of the spine] bones) area extending to the left and right buttocks. During a review of Resident 3's Care Plan on skin problem, last revised on 8/13/2024, the Care Plan indicated the resident had potential for skin impairment and skin breakdown related to the risk factors including scar tissue to coccyx and bilateral buttocks, incontinence of bowel (a long tube in the body which digested food passes from the stomach to the anus), and decreased mobility. The Care Plan Intervention included pressure relieving devices in bed and in wheelchair. During an observation and concurrent interview on 9/24/2024 at 8:53 a.m., with the Wound Coordinator (WC), the WC stated Resident 3 had a high risk for developing a PU. Resident 3's LALM setting was observed to be set at level 5 (firm setting). The WC stated Resident 3's LALM setting should be set at level 3 based on the resident's Body Mass Index (BMI, the ratio of a person's height to weight to estimate the amount of body fat). The WC stated that a setting of level 5 was similar to lying on a regular mattress. During an interview and a concurrent record review of Resident 3's Physician Orders, the Physician Orders were reviewed on 9/24/2024 at 11:13 a.m. with Treatment Nurse 3 (TxN 3). TxN 3 stated the treatment nurses and charge nurses were responsible for checking and documenting the residents' LALM setting. TxN 3 stated Resident 3's BMI was 22.1 so the resident's LALM setting should be at level 2. TxN 3 stated she checked Resident 3's LALM and made sure it was on but did not change the setting because there was no physician's order. TxN 3 stated Resident 3's LALM setting was ordered on 9/24/2024 at 9:15 a.m., 22 minutes after Resident 3's LALM was observed with the WC. TxN 3 stated resident's with LALM on wrong settings had the potential for skin breakdown. During an interview on 9/25/2024 at 11:36 a.m. with the Assistant Director of Nursing (ADON), the ADON stated Resident 3 had a very high risk in developing PU. The ADON stated LALM set at level 5 had the potential for high-risk residents to develop PU. The ADON stated the facility failed to ensure Resident 3's LALM setting was correct. During a review of the facility's policy and procedure (PnP) titled, Mattress/Low Air Loss, dated 4/18/2024, the PnP indicated the purpose to decrease pressure from the resident's weight while lying on bed and to promote healing or prevention of pressure ulcers. The PnP indicated to .follow the manufacturer's directions for appropriate setting. During a review of the facility-provided manufacturer's guidelines (MG) titled, Pressure Guard Custom Care Convertible, the MG indicated to adjust for user comfort level using softer and firmer buttons. The MG indicated the BMI settings for determining an ideal comfort setting as follows: BMI 12 to 20 setting 1; BMI 21 to 35 setting 2; BMI 36 to 50 setting 3; BMI 51 to 70 setting 4; and BMI 71 to 100 setting 5. b. During a record review of Resident 9's admission Record, the admission Record indicated the facility admitted Resident 9 on 1/2/2024, with diagnoses that included Parkinson's Disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements) history of fall and essential hypertension (persistently raised blood pressure with no secondary cause identified). During a record review of Resident 9's History and Physical (H&P) dated 1/21/2024, the H&P indicated Resident 9 had fluctuating capacity to understand and made decisions. During a record review of Resident 9's MDS dated [DATE], the MDS indicated resident's cognitive skills for daily decisions were intact. The MDS indicated Resident 9 needed maximum assist from staff for shower and personal hygiene. The MDS indicated Resident 9 was incontinent of bowel and bladder functions. During a record review of Resident 9's Physician Order dated 3/9/2024, the Physicians' Order indicated the following: 1. Cleanse with normal saline (a saltwater solution), pat dry and apply triad paste (contains dimethicone to moisturize the skin and petrolatum and zinc oxide to reduce skin irritation) to excoriation (s scrape or scratch to the skin) on left buttocks two times a day. 2. Cleanse with normal saline, pat dry and apply triad paste to excoriation to right buttocks extending to inner thigh two times a day. During a record review of Resident 9's Physician Order dated 8/1/2024, the Physician's Order indicated cleanse excoriation on sacrum with normal saline, pat dry, apply triad paste and cover with foam dressing every day and as needed for excoriation. During a concurrent interview and record review on 9/27/2024 at 10:25 a.m., with the Director of Staff Development (DSD), Resident 9's Treatment Administration Record (TAR) dated 9/2024 was reviewed. The TAR indicated the following: 1. On 9/1/2024, 9/2/2024 and 9/14/2024, the treatment for sacrum was not signed by a licensed nurse. 2. On 9/1/2024, 9/2/2024 and 9/14/2024 at 9 a.m., treatment for left and right buttocks were not signed by the Licensed Nurse. 3. On 9/2/2024 and 9/7/2024 treatment for left and right buttocks was left blank at 5 p.m. The DSD stated treatments that were not signed off by the licensed nurses are considered not done. During an interview on 9/27/2024 at 2:35 p.m., with the DSD, the DSD stated on 9/1/2024 and 9/2/2024, there was no Treatment Nurse (TxN) assigned to do the resident's treatments. The DSD stated if the TXN was not available, the Licensed Vocational Nurse (LVN) should have provided the treatment to Resident 9. The DSD stated on 9/7/2024 and 9/14/2024, TxN 3, who was assigned to provide the treatment to Resident 9, should have done the treatment for the resident. The DSD the resident's skin problems can worsen if the treatments are not being provided. During an interview on 9/27/2024 at 5 p.m., with the ADON, the ADON stated wound treatments should have been done and documented for Resident 9 to prevent possible risk for infection and the development and worsening of pressure ulcers. During a concurrent interview and record review on 9/28/2024 at 8:48 a.m., with Registered Nurse 2 (RN 2), the facility's PnP titled, Pressure Ulcer prevention and Treatment dated 12/2018 was reviewed. The PnP indicated, Assessment and Treatment of pressure ulcers are done by the licensed nurses, wound consultants or physical therapist that have been trained in the assessment and treatment of pressure ulcers. Treatment is ordered by physician and documented on designated forms. RN 2 stated it is the facility's policy to provide treatment to help residents pressure ulcer to heal as per the physician order. c. During a record review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 1/22/2024 with diagnoses that included unspecified (unconfirmed) stress fracture (tiny cracks in a bone) hip, stage 3 (subcutaneous fat [just under your skin] may be visible, but bone, tendon, or muscle is not exposed) sacral (tail bone) pressure ulcer and other low back pain. During a record review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decisions making was intact. During a record review of Resident 2's Physician Order dated 1/31/2024, the Physician Order indicated an order for air pressure redistribution mattress (redistribute a patient's weight so as to relieve pressure points) for wound management. During a concurrent observation and interview on 9/27/2024 at 3:39 p.m., with Certified Nursing Assistant 6 (CNA 6), inside Resident 2's room, observed Resident 2 on a LALM with a fitted sheet on it. During an interview on 9/27/2024 at 4:33 p.m., with the DSD, the DSD stated LALMs should not have a fitted sheet on it; instead, it should have a flat sheet (a flat piece of material that can be used to cover the mattress base) to enable air circulation. During an interview on 9/27/2024 at 5 p.m., with the ADON, the ADON stated a flat sheet should be used on top of the LALM instead of a fitted sheet. During a record review of facility's PnP titled, Mattress/Low Air Loss dated 7/2012, the PnP indicated, A single cotton draw sheet may be used for turning and absorb incontinence.

CONCERN (E) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for three of five sampled residents (Resident 3, 9, and 10) by: 1. Failing to hold (not administer) Resident 3 ' s hydralazine (medication used to manage elevated blood pressure) for systolic blood pressure (SBP – measures the pressure the blood exerting against the artery walls when the heart beats) less than 110. At 5 p.m., on 8/12/2024, 8/13/2024, and 8/30/2024, Licensed Vocational Nurse 13 (LVN 13) administered hydralazine to Resident 3 when the resident ' s SBP levels were less than 110. 2. Failing to hold Resident 3 ' s diltiazem (medication used to manage elevated blood pressure) for SBP less than 110. On 8/12/2024 at 2 p.m. LVN 15 administered diltiazem, and at 9 p.m., LVN 13 administered diltiazem when Resident 3 ' s SBP levels were less than 110. 3. Failing to hold Resident 9 ' s losartan (medication used to manage elevated blood pressure) for SBP less than 110. On 9/17/2024 at 9 a.m., LVN 2 administered losartan to Resident 9 when Resident 9 ' s SBP was less than 110. 4. Failing to hold Resident 10 ' s amlodipine besylate (medication used to manage elevated blood pressure) for SBP less than 110. On 9/12/2024 at 5 p.m., LVN 3 administered amlodipine to Resident 10 when Resident 10 ' s SBP was less than 110. These deficient practices placed Residents 3, 9, and 10 at risk of developing dangerous low blood pressure levels with symptoms like fainting (sudden, temporary loss of consciousness), shock (cold and sweaty skin, rapid breathing, a blue skin tone, or a weak and rapid pulse), confusion, headaches, or rapid irregular heartbeats. Findings: a.1. During a record review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted the resident on 3/14/2012 with diagnoses that included encounter for attention to gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control), and Alzheimer ' s disease (a disease characterized by a progressive decline in mental abilities). During a record review of Resident 3 ' s History and Physical (H&P) dated 8/5/2024, the H&P indicated Resident 3 had no capacity to understand and make decisions. During a record review of Resident 3 ' s Minimum Data Set (MDS – a federally mandated resident assessment tool) dated 9/12/2024, the MDS indicated the resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. During a concurrent interview and record review on 9/27/2024, at 5 p.m., with the Assistant Director of Nursing (ADON), Resident 3 ' s Physician ' s Order dated 8/2/2024, and Resident 3 ' s Medication Administration Record (MAR) dated 9/2024 were reviewed. The Physician ' s Order indicated hydralazine hydrochloride (HCL) oral (by mouth) tablet 50 milligrams (mg- unit of measurement), give one tablet via gastrostomy tube (GT) two times a day for hypertension (HTN - uncontrolled elevated blood pressure) and hold for SBP less than 110 or heart rate less than 60. The MAR indicated LVN 13 administered hydralazine to Resident 3 at 5 p.m. on the following dates: 1. 8/12/2024 when Resident 3 ' s SBP was 106. 2. 8/13/2024 when Resident 3 ' s SBP was 109. 3. 8/30/2024 when Resident 3 ' s SBP was 109. The ADON stated LVN 13 should have held the medication to prevent further drop in Resident 3 ' s blood pressure. a.2. During a concurrent interview and record review on 9/27/2024, at 5 p.m., with the ADON, Resident 3 ' s Physician ' s Order dated 8/2/2024, and Resident 3 ' s Medication Administration Record (MAR) dated 8/2024, were reviewed. The Physician ' s Order indicated diltiazem HCL oral tablet 30 mg, give 60 mg via GT three times a day for HTN, hold for SBP less than 110 or heart rate less than 60. The MAR indicated LVN 15 administered diltiazem on 8/12/2024 at 2 p.m. when Resident 3 ' s SBP was 106; LVN 13 administered diltiazem at 9 p.m. when Resident 3 ' s SBP was 106. The ADON stated LVN 13 and LVN 15 should have held the medication as per physician ' s order to prevent further drop in Resident 3 ' s blood pressure. During a record review of the facility ' s policy and procedure (PnP) titled, Medication Administration, dated 3/2004, the PnP indicated, To assure that residents receive their medication as ordered by the physician. During a concurrent interview and record review, on 9/8/2024, at 8:48 a.m., with Registered Nurse 2 (RN 2), facility ' s PnP titled, Administering Medications, dated 4/2019, was reviewed. The PnP indicated, Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescribers ' orders, including any required time frame. The following information is checked or verified for each resident prior to administering medications: b. Vitals signs, if necessary. RN 2 stated staff should follow physicians order before medication administration to prevent medication error. b. During a record review of Resident 9 ' s admission Record, the admission Record indicated the facility admitted Resident 9 on 1/2/2024, with diagnoses that included Parkinson ' s disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), history of fall, and essential hypertension (persistently raised blood pressure with no secondary cause identified). During a record review of Resident 9 ' s History and Physical (H&P) dated 1/21/2024, the H&P indicated Resident 9 had fluctuating capacity to understand and made decisions. During a record review of Resident 9 ' s MDS dated [DATE], the MDS indicated Resident 9 ' s cognitive skills for daily decisions were intact. During a concurrent interview and record review on 9/26/2024, at 10:25 a.m., with the Director of Staff Development (DSD), Resident 9 ' s Physician ' s Order dated 1/2/2024, and the resident ' s MAR dated 9/2024, were reviewed. The Physician ' s Order indicated losartan potassium oral tablet, give 25 mg by mouth one a day for HTN, hold for SBP less than 110 or heart rate less than 60. The MAR indicated on 9/17/2024 at 9 a.m., LVN 2 administered losartan to Resident 9 when the resident ' s SBP was 102. The DSD stated LVN 2 should have held the medication as per physician ' s order to prevent hypotension (low blood pressure). During an interview on 9/27/2024, at 5 p.m., with the ADON, the ADON stated LVN 2 should have documented in Resident 9 ' s Progress Notes that the resident ' s blood pressure was rechecked before administering and held the losartan following the physician ' s order to prevent a drop in Resident 9 ' s blood pressure. During a record review of the facility ' s policy and procedure (PnP) titled, Medication Administration, dated 3/2004, the PnP indicated, To assure that residents receive their medication as ordered by the physician. During a concurrent interview and record review, on 9/8/2024, at 8:48 a.m., with Registered Nurse 2 (RN 2), facility ' s PnP titled, Administering Medications, dated 4/2019, was reviewed. The PnP indicated, Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescribers ' orders, including any required time frame. The following information is checked or verified for each resident prior to administering medications: b. Vitals signs, if necessary. RN 2 stated staff should follow physicians order before medication administration to prevent medication error. c. During a record review of Resident 10 ' s admission Record, the admission Record indicated the facility admitted Resident 10 on 7/8/2024, with diagnoses that included metabolic encephalopathy (a change in how your brain works due to an underlying condition. It can cause confusion, memory loss and loss of consciousness) and end stage renal disease (ESRD- irreversible kidney failure). During a record review of Resident 10 ' s History and Physical (H&P) dated 7/9/2024, the H&P indicated Resident 10 had the capacity to understand and make decisions. During a record review of Resident 10 ' s MDS dated [DATE], the MDS indicated Resident 10 ' s cognitive skills for daily decisions were intact. During a record review of Resident 10 ' s Physician ' s Order dated 7/8/2024, the Physician ' s Order indicated an order for amlodipine besylate oral tablet 5 mg., give 5 mg by mouth two times a day for HTN, hold for SBP less than 110 or heart rate less than 60. During a record review of Resident 10 ' s MAR dated 9/2024, the MAR indicated on 9/12/2024, at 5 p.m. LVN 3 administered amlodipine to Resident 10 when the resident ' s SBP was 99. During an interview on 9/27/2024, at 1:16 p.m. LVN 3 stated she (LVN 3) should have held the amlodipine. LVN 3 stated she (LVN 3) should have followed the physician ' s order to prevent further drop in Resident 10 ' s blood pressure. During an interview on 9/27/2024, at 5 p.m., with the ADON, the ADON stated LVN 3 should have rechecked Resident 10 ' s blood pressure and followed the physician ' s order to hold the amlodipine to prevent further hypotension. During a record review of the facility ' s policy and procedure (PnP) titled, Medication Administration, dated 3/2004, the PnP indicated, To assure that residents receive their medication as ordered by the physician. During a concurrent interview and record review, on 9/8/2024, at 8:48 a.m., with Registered Nurse 2 (RN 2), facility ' s PnP titled, Administering Medications, dated 4/2019, was reviewed. The PnP indicated, Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescribers ' orders, including any required time frame. The following information is checked or verified for each resident prior to administering medications: b. Vitals signs, if necessary. RN 2 stated staff should follow physicians order before medication administration to prevent medication error.

CONCERN (E) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure medical records were complete and accurately documented for two of 14 sampled residents (Resident 1 and Resident 3) by failing to: 1. Ensure Licensed Vocational Nurse 8 (LVN 8) and the Social Service Assistant (SSA) documented Resident 1 ' s condition in the resident ' s clinical records before and after the resident's discharge from the facility. 2. Ensure LVN 13 documented Resident 3 ' s Change of Condition (COC) timely in the resident ' s clinical record. Resident 3 had a COC on 9/16/2024 and the COC form was created on 9/17/2024. 3. Ensure facility staff documented the level of care provided to Resident 3 based on the resident ' s level of care assessment. These deficient practices resulted in inaccurate information on Resident 1 and Resident 3 ' s clinical record and had the potential for delayed and inaccurate medical interventions for Resident 3. Findings: 1. During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted the resident on 2/23/2024 with diagnoses including diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and anxiety disorder (persistent and excessive worry that interferes with daily activities). During a review of Resident 1 ' s Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 8/31/2024, the MDS indicated the resident ' s cognitive (problems with a person ' s ability to think, learn, remember, use judgement, and make decisions) skills were moderately impaired. The MDS indicated Resident 1 required set-up or clean-up assistance (helper assists only prior to or following the activity; the resident completes activity) on sitting to lying, walking 50 feet with two turns, and walking 150 feet. The MDS indicated Resident 1 required supervision (helper provides verbal cues and/or touching or steadying as resident completes activity) on sit-to-stand and transfers. During an interview on 9/20/2024 at 11:42 a.m. with the Social Service Co-director (SSC), the SSC stated that she did not document the mode of transportation Resident 1 left with on discharge from the facility. The SSC stated nursing staff was responsible for documenting Resident 1 ' s condition upon discharge. During an interview on 9/20/2024 at 12:22 p.m. with the SSA, the SSA stated she did not document Resident 1 ' s discharge notes. SSA stated she will document Resident 1 ' s discharge notes as a late entry on the resident ' s clinical records. During an interview on 9/20/2024 at 1:11 p.m. and a concurrent record review of Resident 1 ' s Progress Notes with the Assistant Director of Nursing (ADON), the Progress Notes did not indicate documentation of Resident 1 ' s condition upon discharge. The ADON stated LVN 8 should have documented Resident 1 ' s condition, time of discharge, and mode of transportation in the resident ' s clinical records to ensure the resident was stable upon leaving the facility. The ADON stated incomplete documentation had the potential for Resident 1 ' s inaccurate clinical records. During a review of the facility ' s policy and procedure (PnP) titled, Charting and Documentation, dated 4/18/2024, the PnP indicated 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 Medical record should facilitate communication between the interdisciplinary team (IDT, a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological, and spiritual needs of the patient) regarding the resident ' s condition and response to care. The policy indicated documentation in the medical record will be objective, complete, and accurate. During a review of the facility ' s PnP titled, Preparing a Resident for Transfer or Discharge, dated 4/18/2024, the PnP indicated nursing services is responsible for . h. completing discharge note in the medical record. 2. During a review of Resident 3 ' s admission Record, the admission Record indicated the facility admitted the resident on 3/14/2012 with diagnoses including Alzheimer ' s disease (a brain disorder that slowly destroys memory, thinking skills, and eventually the ability to carry out the simplest tasks), dementia, and aphasia (a language disorder that affects a person's ability to communicate). During a review of Resident 3 ' s MDS, dated [DATE], the MDS indicated the resident ' s cognitive skills was severely impaired. The Functional Limitation in Range of Motion section of the MDS indicated Resident 3 had impairment on both sides of the upper extremities (shoulder, elbow, wrist, and hand) and the lower extremities (hip, knee, ankle, and foot). The MDS indicated Resident 3 was dependent on facility staff on oral, toileting, and personal hygiene. The MDS indicated Resident 3 was incontinent (involuntary loss of urine or the inability to control the bowels [a long tube in the body which digested food passes from the stomach to the anus]) of both bladder (a hallow organ that stores urine in the body) and bowel. During a telephone interview on 9/25/2024 at 11:12 a.m. with LVN 13, LVN 13 stated she went in Resident 3 ' s room and saw Resident 3 had vomitus (matter that had been vomited) on the resident ' s clothes. LVN 13 stated she noted Resident 3 ' s stool was liquid in consistency and had come out of the resident ' s disposable brief. LVN 13 stated she documented Resident 3 ' s episode of vomiting and loose stool in the resident ' s clinical record but she did not check if the documentation was recorded. LVN 13 stated she did not document on the COC form. LVN 13 stated the Attending Physician 1 (MD1) and Resident 3 ' s Family Member 1 (FM 1) were not informed. During an interview on 9/25/2024 at 11:36 a.m. and a concurrent record review of Resident 3 ' s clinical records with the ADON, the ADON stated the resident ' s COC form was created on 9/17/2024 at 8:57 p.m., 22 and a half hours after Resident 3 ' s episode of vomiting and loose stool. The ADON stated the COC should be done immediately. The ADON stated late documentation of Resident 3 ' s COC had the potential for delay in care provided for the resident. During a review of Resident 3 ' s Bladder Continence Task, dated 9/2024, the Bladder Continence Task indicated the resident was continent on the following dates and shifts: a. 9/11/2024 (7 a.m. to 3 p.m. shift) b. 9/16/224 (3 p.m. to 11 p.m. shift) c. 9/17/2024 (3 p.m. to 11 p.m. shift) During a review of Resident 3 ' s Bladder Continence Task, dated 9/2024, the Bladder Continence Task indicated no documented data on the following dates and shifts: a. 9/2/2024 (11 p.m. to 7 a.m. shift) b. 9/5/2024 (11 p.m. to 7 a.m. shift) c. 9/11/2024 (3 p.m. to 11 p.m. shift) d. 9/12/2024 (3 p.m. to 11 p.m. and 11 p.m. to 7 a.m. shift) e. 9/17/2024 (11 p.m. to 7 a.m. shift) f. 9/19/2024 (7 a.m. to 3 p.m. shift) During a review of Resident 3 ' s Eating Task (the ability to use suitable utensils to bring food and /or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident), dated 9/2024, the Eating Task indicated the resident was independent on eating on the following dates: a. 9/10/2024 at 1:41 p.m. b. 9/11/2024 at 2:14 p.m. c. 9/13/2024 at 2:05 p.m. d. 9/15/2024 at 2:42 p.m. During a review of Resident 3 ' s Eating Task, dated 9/2024, the Eating Task indicated the resident required set-up or clean-up assistance on eating on the following dates: a. 9/4/2024 at 10:45 p.m. b. 9/10/2024 1:41 p.m. c. 9/13/2024 at 2:05 p.m. d. 9/19/2024 at 6 p.m. During a review of Resident 3 ' s Turn and Reposition Task, dated 9/2024, the Turn and Reposition Task indicated the resident self-repositioned on the following dates: a. 9/1/2024 (11 p.m. to 7 a.m. shift) b. 9/9/2024 (11 p.m. to 7 a.m. shift) c. 9/10/2024 (7 a.m. to 3 p.m. shift) d. 9/12/2024 and 9/13/2024 (7 a.m. to 3 p.m. shift) The ADON stated documentation in the residents ' clinical records should be accurate and timely. The ADON stated inaccurate documentation had the potential for miscommunication among the healthcare team and had the potential for Resident 3 to receive inappropriate care. The ADON stated the facility failed to document accurately and timely in Resident 3 ' s clinical records. During a review of the facility ' s PnP titled, Charting and Documentation, dated 4/18/2024, the PnP indicated 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 Medical record should facilitate communication between the interdisciplinary team regarding the resident ' s condition and response to care. The policy indicated documentation in the medical record will be objective, complete, and accurate. During a review of the facility ' s PnP titled, Change in the Resident ' s Condition or Status, dated 4/18/2024, the PnP indicated the nurse supervisor or charge nurse will record in the resident ' s medical record information relative to changes in the resident ' s medical or mental condition or status.

Sept 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to provide an environment free from accidents and hazards, ensure residents received adequate supervision, and implement and modify interventions to prevent accidents for one of three sampled residents (Resident 1) by failing to ensure Resident 1, who had repeated falls, was appropriately assessed by the interdisciplinary team (IDT, a group of health care professionals with various areas of expertise who work together toward the goals of the resident) after each fall incident. This deficient practice placed the resident at increased risk for falls resulting in injuries. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted the resident on 8/6/2024 and readmitted the resident on 8/19/2024, with diagnoses including traumatic amputation (surgical procedure to remove a part of the body) between elbow and wrist left arm and pneumothorax (occurs when air leaks into the space between the lung and chest wall, causing the lung to collapse). During a review of Resident 1 ' s History and Physical (H&P – a formal assessment of a patient and their problem), dated 8/6/2024, the H&P indicated Resident 1 has fluctuating capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS - standardized assessment and care planning tool), dated 8/12/2024, the MDS indicated Resident 1's cognition (mental processes) was intact (not altered). During a review of Resident 1's Care Plan (CP), initiated on 8/19/2024 and revised on 8/29/2024, the CP indicated Resident 1 had an incident of fall and is at risk for change in neurological status fear of falls. The following interventions were initiated on 8/19/2024: - Anticipate and meet needs. - Educate/remind resident to call for assistance. - Encourage activity as tolerated with rest periods between activities as needed. - Evaluation of medications for side effects that may increase fall risk. - Explain all procedures and provide reassurance during mobility tasks to alleviate the fear of falling. - Keep bed in low position with brakes locked. - Keep call light within reach. - Keep personal items frequently used within reach. - Medication regimen review as indicated. - Monitor for complications related to the fall and notify physician promptly if observed. - Obtain PT/OT consult as indicated. - Orient to new environment as indicated. - Provide proper, well-maintained footwear as indicated. - Provide verbal reminders/cues to ask for assistance as needed. - Safety devices as ordered. - Side rails up while in bed to aid in bed mobility, and repositioning. There were no new CP interventions implemented after Resident 1 had a fall on 8/23/2024 and 8/24/2024. During a review of Resident 1 ' s Change of Condition Evaluation dated on 8/18/2024, the change of condition evaluation indicated Resident 1 had an unwitnessed fall with a complaint of neck pain 7/10 (pain scale is a numeric pain rating sacle that measures pain levels from no pain (0) to the worst pain possible (10). The physiican gave an order to send Resident 1 to general acute care hospital (GACH) for further evaluation. During a review of Resident 1' Progress Notes dated 8/19/2024 and timed at 9:30 a.m., Resident 1 was readmitted from GACH. The progress notes indicated Resident 1was in stable condition with pain medication for generalized body pain. During a review of Resident 1 ' s Change of Condition Evaluation dated on 8/23/2024, the change of condition evaluation indicated Resident 1 was found on the floor facing down and complained of neck pain. The physician was notified, and gave an order to transfer the resident to GACH. The paramedics were called and when the paramedics arrived in the facility, the resident refused to be transfered to GACH. The paramedics transfered the resident back in bed. During a review of Resident 1 ' s Change of Condition Evaluation dated on 8/24/2024, the change of condition evaluation indicated Resident 1 had a fall. The evaluation indicated the resident's fall was associated with no injury or minor injury. The evaluation indicated the resident had a behavior of attempting to perform task independently. During a review of Resident 1 ' s Fall Risk Observation assessment dated on 8/18/2024, the fall risk observation assessment indicated that resident had one to two falls in last 90 days, and resident was at moderate risk for fall. During a review of Resident 1 ' s Fall Risk Observation assessment dated on 8/23/2024, the fall risk observation assessment indicated that resident had one to two falls in last 90 days, and resident was at moderate risk for fall. During a review of Resident 1 ' s Fall Risk Observation assessment dated on 8/24/2024, the fall risk observation assessment indicated that resident had three or more falls in last 90 days, and resident was at high risk for fall. During a concurrent interview and record review on 9/3/2024 at 1:43 p.m., with the Assistant Director of Nursing (DON), reviewed Resident 1's change of condition evaluation dated 8/18/2024, 8/23/2024 and 8/24/2024 that indicated Resident had fall incidents. The ADON stated there was no IDT meeting done after each fall incident. The ADON stated the IDT meeting must be done the next day after the fall to identify and discuss the root cause of the fall and discuss any additional interventions to prevent Resident 1 from falling. During a review of the facility ' s policy and procedure (P&P) titled, Falls and Fall Risk, Managing, last revised date on 4/18/2024, the P&P indicated if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls.

Aug 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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to fully inform the Responsible Party (RP- a person delegated to make medical decisions for the resident in the event they are unable to do so) for one of four sampled residents (Resident 1) when heparin (an anticoagulant medication; substance that is used to prevent and treat blood clots in blood vessels and the heart) a new medication to Resident 1 was prescribed on 6/25/2024. This deficient practice violated Resident 1's right to be informed of and participate in the resident's treatment. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 3/14/2012 and readmitted the resident on 10/13/2023 with diagnoses including hypertensive hear disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure, cardiomegaly (an enlarged heart seen on any imaging test, including a chest radiography [X-ray- is the imaging of body structures, or parts of the body]), chronic embolism (an obstruction or blockage in a blood vessel) and thrombosis (a blood clot within blood vessels that limits the flow of blood). A review of Resident 1's care plan, developed on 12/14/2020 and revised on 6/26/2024, for Resident 1's potential for poor circulation, irregular pulse, leg pain and or edema secondary to chronic embolism and thrombosis. The interventions included heparin sodium injection and to check extremities for peripheral pulses, color, coolness and swelling. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 6/13/2024, indicated Resident 1 cognitive skills were severely impaired (never made decisions). The MDS indicated Resident 1 was dependent (helper does all the effort) with eating, oral hygiene, toileting, showering, upper and lower body dressing, and personal hygiene. A review of Resident 1's Order Summary, dated 6/25/2024, indicated heparin sodium injection solution 5000 units per milliliter (ml- unit of measurement) subcutaneously (beneath the skin) inject 1 ml subcutaneously two times a day for deep vein thrombosis (DVT- formation of one or more blood clots) prophylaxis (an attempt to prevent disease) rotate injection sites. A review of Resident 1's admission and readmission Evaluation Assessment written by Licensed Vocational Nurse 5 (LVN 5), dated 6/25/2024, indicated Resident 1's daughter (C1) was the RP. Doctor notified and made aware of Resident 1's admission and discharge orders; orders verified and clarified to continue. During an interview on 7/22/2024 at 10:55 a.m. with C1 stated she found out Resident 1 was on a blood thinner sometime in July. C1 stated the facility used to inform her when Resident 1 had a change in condition or had a new medication but not anymore. C1 stated it is her right to know what medications Resident 1 is receiving as she it the RP to Resident 1. During an interview on 7/22/2024 at 4:05 p.m., the Director of Nursing (DON) stated must inform family about new medications to answer all questions and ensure they are educated on the medication, and it is their right to know the care given to the resident. The DON can be at risk for not being notified and not having the right to have a say in the resident care. During an interview on 7/22/2024 at 4:25 p.m., LVN 5 stated did admission for Resident 1. LVN 5 stated called doctor and verified medications and the doctor wanted to continue with medications. LVN 5 stated RP must be notified, so they are aware of the plan of care, if gone for more than 72hrs must treat the resident like a new resident, go over new medications. LVN 5 stated has no documentation indicting the RP was notified of the new order for heparin. LVN 5 stated must inform RP to discuss the risk and benefit, and it is the RP right to know and be informed, can be a risk would not be updated on the plan of care and their rights will be violated. A review of the facility's policies and procedures, titled Notifying Resident, Attending Physician, and Resident Representative, with no date indicated facility promptly notified the resident, his or her attending physician, and or the resident representative of changes in the resident's medical/mental condition and/or status (e.g changes in level of care, billing/payments, resident rights, new medications). Regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatment including new medications.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free of any significant medication error when: 1. Licensed Vocational Nurse 4 (LVN 4) failed to administer diltiazem (a calcium channel blocker [type of drug that keeps calcium from entering the muscle cells of the heart and blood vessels] that treats high blood pressure and angina [chest pain]) and hydralazine (medication that relaxes the blood vessels and increasing the supply of blood and oxygen to the heart while reducing its workload) to Resident 1 as prescribed. This deficient practice had the potential for Resident 1's blood pressure to go down. 2. Licensed Vocational Nurse 1 (LVN 1) and Licensed Vocational Nurse 3 (LVN 3) failed to administer heparin (an anticoagulant medication; substance that is used to prevent and treat blood clots in blood vessels and the heart) to Resident 1, as prescribed. This deficient practice had the potential for Resident 1 to develop lipohypertrophy (a lump of fatty tissue under your skin caused by repeated injections in the same place) and could have affected the ability for Resident 1 to absorb the medication properly. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 3/14/2012 and readmitted the resident on 10/13/2023 with diagnoses including hypertensive hear disease (heart problems that occur because of high blood pressure that is present over a long time) with heart failure, cardiomegaly (an enlarged heart seen on any imaging test, including a chest radiography [X-ray- is the imaging of body structures, or parts of the body]), chronic embolism (an obstruction or blockage in a blood vessel) and thrombosis (a blood clot within blood vessels that limits the flow of blood). A review of Resident 1's care plan developed on 12/14/2020 and revised on 6/26/2024 for Resident 1's potential for poor circulation, irregular pulse, leg pain and or edema secondary to chronic embolism and thrombosis. The interventions included heparin sodium injection and to check extremities for peripheral pulses, color, coolness and swelling. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 6/13/2024 indicated Resident 1 cognitive skills were severely impaired (never made decisions). The MDS indicated Resident 1 was dependent (helper does all the effort) with eating, oral hygiene, toileting, showering, upper and lower body dressing, and personal hygiene. A review of Resident 1's Order Summary dated 6/25/2024 indicated: - diltiazem 30 milligrams (mg- a unit of measurement) give 30 mg via gastrostomy tube (g-tube- tube inserted through the wall of the abdomen directly into the stomach to be used to give drugs and liquids) two times a day for hypertension hold for systolic blood pressure (SBP- the pressure in the arteries when the heart beats) under 110. - Hydralazine 50 mg via g-tube two times a day for hypertension hold for SBP under 110. - Heparin sodium injection solution 5000 units per milliliter (ml- unit of measurement) subcutaneously (beneath the skin) inject 1 ml subcutaneously two times a day for deep vein thrombosis (DVT- formation of one or more blood clots) prophylaxis (an attempt to prevent disease) rotate injection sites. A review of Resident 1's Medication Administration Record (MAR- is a report detailing the drugs administered to a patient by a healthcare professional at a treatment facility) for July 2024 indicated: - diltiazem 30 mg via g-tube two times a day for hypertension hold for SBP under 110, was given for 5 p.m. dose on 7/3/2024, with a blood pressure of 108/56. - Hydralazine 50 mg via g-tube two times a day for hypertension hold for SBP under 110, was given for 5 p.m. dose on 7/3/2024, with a blood pressure of 108/56. - Heparin sodium 5000 unit/ml inject 1 ml subcutaneously two times a day for DVT prophylaxis rotate injection sites, was given from 7/1/2024 to 7/19/2024. A review of Resident 1's Location of Administration Report for the use of heparin sodium injection solution 5000 unit/ml indicated: - 7/5/2024 at 7:29 p.m. was administered on Resident 1's lower left quadrant of abdomen. - 7/6/2024 at 8:41 a.m. was administered on Resident 1's lower left quadrant of abdomen. - 7/10/2024 at 7:14 p.m. was administered on Resident 1's left arm. - 7/11/2024 at 8:06 a.m. was administered on Resident 1's left arm. - 7/11/2024 at 6:28 p.m. was administered on Resident 1's left arm. During a concurrent record review and interview on 7/22/2024 at 2:10 p.m. of Resident 1's MAR, LVN 1 stated when administering heparin must rotate sites, if heparin is given in arm the next dose would be given in the abdomen. LVN 1 reviewed Resident 1 MAR and stated on 7/11/2024 administered heparin the same site and previously administered. LVN 1 stated must rotate sites because it can cause the tissue to become necrotic. During a concurrent record review and interview on 7/22/2024 at 2:59 p.m. of Resident 1's MAR, LVN 3 stated when administering heparin must check previous site it was administered on, must rotate site, if there is discoloration stop and let the doctor know. LVN 3 reviewed Resident 1's MAR and stated on 7/6/2024 administered heparin on same site but should have rotated the site, can be a risk for inaccurate administration of the medication. During an interview on 7/22/2024 at 3:47 p.m., LVN 4 stated all medications are given on time within parameters. LVN 4 stated must follow the parameters so the residents blood pressure does not drop, can be a risk for the resident to go into shock, should follow doctors' orders. During an interview on 7/22/2024 at 4:05 p.m., the Director of Nursing (DON) stated medications with parameters must be followed can be a risk for hypotension or hypertension if the parameters are not followed. The DON stated aware of blood pressure medication given when Resident 1's blood pressure was not within parameters when the pharmacist reviewed the MAR. The DON stated for heparin since it is a subcutaneous medication must rotate the sites to avoid complications, the skin can thicken causing lipohypertrophy and the absorption rate will not be accurate. A review of the facility's policies and procedures, titled Medication- Administration, with no revision date, indicated medications are administered in accordance with the written orders of the attending physician. A review of the facility's policies and procedures, titled Subcutaneous injections, last revised in 2021, indicated follow the medication administration guideline in the policy entitled Administering Medications. A review of the manufacture's guidelines for heparin sodium 5000 unit/ml vial indicated if you are injecting heparin under the skin, clean the injection site with rubbing alcohol. Change the injection site each time to lesson injury under the skin.

Jul 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure medical records are complete, accurately documented, readily accessible, and systematically organized for two of nine sampled residents (Resident 1 and Resident 2) by failing to document the resident ' s condition upon leaving the facility and the time the residents were transferred to the General Acute Care Hospital (GACH) emergency room (ER). This deficient practice had the potential for delayed medical interventions for Resident 1 and Resident 2. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 10/21/2023, with diagnoses including fibromyalgia (a chronic widespread pain throughout the body or in multiple areas), dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and essential hypertension (high blood pressure that is not due to another medical condition). A review of Resident 1 ' s History and Physical (H&P), dated 10/29/2023, indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 4/28/2024, indicated the resident ' s cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was moderately impaired. The MDS indicated Resident 1 required maximal assistance (helper lifts or holds trunk or limbs and provides more than half the effort on toileting. The MDS indicated Resident 1 was dependent on facility staff on shower and bath. The Bladder (a hallow organ that stores urine in the body) and Bowel (a long tube in the body which digested food passes from the stomach to the anus) section indicated Resident 1 was frequently incontinent (involuntary loss of urine or the inability to control the bowels). A review of Resident 1 Situation Background Assessment Recommendation (SBAR) Communication Form, dated 6/26/2024, indicated the resident had shortness of breath and was sent to the GACH ER. The SBAR Communication Form indicated Resident 1 ' s family members were present at the time the resident was taken to the ER. A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 4/3/2024, with diagnoses including, pain due to genitourinary (urinary and genital organs) prosthetic devices (artificial replacement body part), dementia, and essential hypertension. A review of Resident 2 ' s H&P, dated 4/4/2024, indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 2 ' s MDS, dated [DATE], indicated the resident ' s cognition was moderately impaired. The MDS indicated Resident 2 was dependent on facility staff on toileting, shower, and bath. The Bladder and Bowel section indicated Resident 2 had an indwelling catheter (a flexible plastic tube [a catheter] inserted into the bladder to provide continuous urinary drainage) and was incontinent of bowels. A review of Resident 2 SBAR Communication Form, dated 7/2/2024, indicated the resident had fever with a body temperate of 104.7 degrees Fahrenheit (°F – unit of measurement). Resident 1 was sent to the GACH ER. There was no documented evidence of the time Resident 2 was sent to the GACH ER. On 7/11/2024 at 4:41 p.m., during a concurrent interview and record review, Resident 1 ' s Progress Notes, dated 6/26/2024, and Resident 2 ' s Progress Notes, dated 7/2/2024, were reviewed with the Assistant Director of Nurses (ADON). The ADON stated Resident 1 and Resident 2 ' s Progress Notes were incomplete and did not indicate the time the residents were sent to the ER. The ADON stated Resident 1 and Resident 2 ' s Progress Notes did not indicate the residents ' condition upon leaving the facility to be transferred to the GACH ER. The ADON stated licensed nurses should document accurately and timely with the timeline events that led to the residents ' transfer to ER. The ADON stated that incomplete documentation had the potential for delay of care to be provided to Resident 1 and Resident 2. The ADON stated that the facility failed to ensure proper documentation was done on Resident 1 and Resident 2 ' s medical condition. A review of the facility ' s policy and procedure titled, Charting and Documentation, dated 4/18/2024, indicated 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 indicated documentation in the medical record will be objective, complete, and accurate.

May 2024 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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Based on interview and record review the facility failed to ensure one of four sampled residents (Resident 1) was treated with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of their quality of life by failing to ensure only a female Certified Nursing Assistant will be assigned to the resident. On 5/1/2024 Resident 1 was assisted by a male CNA, Certified Nursing Assistant 1 (CNA 1) with perineal care (washing the genital and rectal areas of the body). This deficient practice had the potential to affect the residents ' self-worth and self-esteem. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 12/30/2023 with diagnoses that included abnormalities of gait and mobility, lack of coordination, and type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high). A review of Resident 1 ' s Minimum Data Set (MDS – a standardized assessment and care screening tool), dated 4/6/2024 indicated Resident 1 cognition was intact and able to make decisions. The MDS indicated Resident 1 required moderate assistance with toileting, bathing, upper and lower body dressing, taking and putting on footwear, and with personal hygiene. A review of Resident 1 ' s Situational Background Assessment and Recommendation (SBAR- a structured communication framework that can help teams share information about the condition of a patient or team member or about another issue your team needs to address) dated 5/1/2024 indicated Resident 1 had an issue with a male CNA (CNA 1) regarding care. A review of Resident 1 ' s Care Plan developed on 5/1/2024 indicated Resident 1 had issues being provided care by a male CNA. The care plan indicated an intervention that no male CNA will be assigned to resident. During an interview on 5/3/2024 at 11:42 a.m. with Resident 1, Resident 1 stated on 5/1/2024 a male CNA (CNA 1) was assigned to the resident. Resident 1 stated she informed Licensed Vocational Nurse 2 (LVN 2) around 1 p.m. that she (Resident 1) did not want a male CNA. Resident 1 stated LVN 2 then informed Licensed Vocational Nurse 1 (LVN 1) regarding the resident ' s request and LVN 1 reassigned Certified Nursing Assistant 2 (CNA 2), a female staff to Resident 1. Resident 1 stated she had to use the restroom and waited for CNA 2 for 15 minutes, but CNA 2 was was unavailable to assist the resident. Resident 1 stated she was frustrated with waiting and asked CNA 1 to assist her to the toilet. Resident 1 stated she felt uncomfortable while CNA 1 was providing care because CNA 1 saw her private parts. During an interview on 5/3/2024 at 1:25 p.m. with LVN 1 stated on 5/1/2024 at around 12 p.m. Resident 1 stated she did not a male CNA. LVN 1 stated she reassigned CNA 2 a female CNA, to Resident 1. LVN 1 stated she then informed CNA 1 and CNA 2 of the reassignment. During an interview on 5/3/2024 at 2:22 p.m. with CNA 2 stated around 12-12:30 p.m. was notified by LVN 1 that Resident 1 requested a female CNA, and that she (CNA 2) would be taking over for CNA 1 to assist Resident 1. CNA 2 stated when she went to see Resident 1, CNA 1 had already assisted Resident 1. During an interview on 5/6/2024 at 10:16 a.m. with CNA 1, CNA 1 stated that on 5/1/2024 at around 12 p.m. CNA 1 was told by an LVN (cannot recall name), to not take care for Resident 1 because Resident 1 wanted a female CNA. CNA 1 stated around 12-1 p.m. he was helping Resident 1 ' s roommate in the toilet when Resident 1 asked CNA 1 to take Resident 1 to the toilet. CNA 1 stated he then assisted Resident 1 to the toilet and assisted the resident with cleaning her buttocks after a bowel movement using a washcloth. CNA 1 stated he only cleaned the part of Resident 1 ' s anal area that had feces and stated he did not do anything inappropriately to Resident 1. During an interview on 5/6/2024 at 2:24 p.m. with the Director of Nursing (DON), the DON stated Resident 1 did not want to have a male CNA. The DON stated it is the resident ' s right to have a female staff provide care for them if this is what they requested, and if the resident did not feel respected the resident will feel like they are being violated of their rights. During an interview on 5/6/2024 at 3:31 p.m. with the Assistant Administrator (AA) stated Resident 1 ' s preference for a female CNA should have been acknowledged and respected. The AA stated not respecting the rights can lead to violating the resident ' s rights. A review of the facility ' s Policy and Procedures titled, Dignity, last revised on 2/2021 indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feeling of self -worth and self-esteem. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs. Resident may exercise their rights without interference, coercion, discrimination or reprisal from any person or entity associated with this 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

Abuse Prevention Policies (Tag F0607)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to implement its Abuse Prevention and Prohibition Policy and Procedures by failing to conduct pre-employment screening prior to hiring of employees for four out of five sampled staff (CNA 1, 3, 4, and 5). This deficient practice had the potential to place the residents at risk for abuse. Findings: During a concurrent interview and record review on 5/6/2024 at 1:41p.m. with the Assistant Director of Staff Development (ASDS), reviewed Certified Nursing Assistant 1, 3, and 5 ' s (CNA 1, 3, and 5) employee file. The ASDS stated CNA 1 ' s employee file indicated CNA 1 was hired on 1/10/2024 and CNA 1's pre-employment background was completed on 1/14/2024. The ASDS stated CNA 1 was assigned to take care of three residents on 1/13/2024, prior to completion of pre-employment screening. The ADSD stated CNA 3 ' s employee file indicated CNA 3 was hired on 2/7/2024 and CNA 3 ' s pre-employment screening was completed on 2/12/2024. The ADSD stated CNA 3 was assigned to take care of three residents on 2/10/2024, prior to completion of pre-employment screening. The ADSD stated CNA 5 ' s employee file indicated CNA 5 was hired on 4/10/2024 and CNA 5 ' s pre-employment screening was completed on 4/16/2024. The ADSD stated CNA 5 was assigned 3 residents on 4/13/2024 prior to completion of pre-employment screening. During a concurrent interview and record review on 5/6/2024 at 2:59 p.m. with the ADSD, Certified Nursing Assistant 4 ' s (CNA 4) employee file indicated CNA 4 was hired on 3/29/2024. The ADSD stated there was no pre-employment screening done prior to CNA 4 being hired. The ADSD stated CNA 4 has been working in the facility since 4/7/2024. During an interview on 5/6/2024 at 2:24 p.m. with the Director of Nursing (DON), the DON stated pre-empoyment screening for all staff must be completed prior to hiring. The DON stated the reason for conducting pre-employment screening is to ensure the staff does not have any criminal background or history of abuse. The DON stated not conducting a pre-empoyment screening of staff prior to hiring places the resident at risk for abuse. During an interview on 5/6/2024 at 3:31 p.m. with the Assistant Administrator (AA), the AA stated pre-employment screening should be done prior the staff being hired to ensure the staff has a clear record and does not have a history of abuse. The AA stated not conducting pre-employment screening prior to hiring placed the residents ' safety at risk. A review of the facility ' s Policy and Procedures titled, Background Screening Investigation, last revised on 3/2019 indicated the facility conducts employment background screening checks, reference checks and criminal conviction investigation checks on all applicants for positions with direct access to residents. Background and criminal checks are initiated within 2 days of an offer of employment or contract agreement and completed prior to employment.

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 F0728 (Tag F0728)

Could have caused harm · This affected 1 resident

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Based on interview and record review the facility failed to ensure a Certified Nursing Assistant has a current certification for one of five Certified Nursing Assistant reviewed for certifications (CNA 4). CNA 4 was hired on 4/7/2024. This deficient practice placed the residents at risk for receiving care from CNAs who are not competent and proficient. Findings: During a concurrent interview and record review on 5/6/2024 at 1:41 p.m. with the Assistant Director of Staff Development (ADSD), CNA 4 ' s employee file was reviewed. The ADSD stated there is no proof of a CNA certificate in the employee file. The ADSD stated CNA 4 had been working in the facility since 4/7/2024. The ADSD stated she is unable to verify CNA 4's certificate on the State website. During an interview on 5/6/2024 at 2:59 p.m. with the ADSD, the ADSD stated CNA 4 had proof of passing to work as a CNA but it was given to the previous Director of Staff Development (DSD) but the facility was unable to provide documentation. During an interview on 5/6/2024 at 3:31 p.m. with the Assistant Administrator (AA), the AA stated if the CNA does not have proof of being certified then the CNA needed to be taken off the schedule. A review of the facility ' s undated Job Description and Performance Standards for CNA indicated qualification included active Nursing Assistant Certification in the State of California or Proof of Passing Competency Exam.

May 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a resident centered care plan addressing oxygen use for one of three sampled residents (Resident 2). This deficient practice had the potential to result in inappropriate care and treatment. Findings: A review of Resident 2 ' s admission Record indicated the resident was admitted on [DATE] with medical history including hemiplegia (a condition that causes paralysis or weakness on one side of the body), and hemiparesis (muscle weakness on one side of the body), hyperlipidemia ( elevated cholesterol), pressure ulcer of sacral region (injury to skin and underlying tissue resulting from prolonged pressure on the skin), hyperlipidemia (elevated cholesterol), dementia (memory loss), sepsis (a life-threatening complications of an infection), calculus of kidney (a small, hard deposit that forms in the kidney). A review of Resident 2 ' s Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool) dated 4/7/2024, indicated the resident ' s cognition was moderately impaired. The MDS indicated the resident required moderate assistance with toileting and oral hygiene. A review of Resident 2 ' s Physician Order dated 2/6/2024, indicated an order for oxygen two liters/minute via nasal cannula (a device that delivers extra oxygen through a tube and into the nose) PRN (as needed) for shortness of breath and/or respiratory distress. During an interview and record review with the Assistant Director of Nurses (ADON) on 4/30/2024 at 2:50 p.m., the ADON stated she could not locate a care plan indicating the resident needed 2 liters (a metric unit of capacity) of oxygen vial nasal cannula as needed for shortness of breath. The ADON stated, the resident had a general care plan indicating oxygen therapy, however the care pan needs to be specific to the resident and the physician's order. During an interview with the Director of Nurses (DON) on 4/30/2024 at 3:00 p.m., the DON stated the care plans need to be resident centered so that the nurses will be aware on how to treat the resident appropriately and according to the physician ' s order. A review of the facility ' s policy and procedure titled, Care Plan, Comprehensive Person-Centered dated March, 2022, indicated a comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs.

CONCERN (D) 📢 Someone Reported This

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

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to: 1. Limit the use of PRN (as needed) Alprazolam (a medication used to treat the inability to sleep) to 14 days in one of five sampled residents (Resident 1). 2. Define and monitor for specific target behaviors tied to the use of psychotropic medications (medications that affect brain activities associated with mental processes and behavior) in one of three sampled residents (Resident 1). These deficient practices increased the risk that Resident 1 may have experienced adverse effects of psychotropic medication therapy leading to an overall negative impact on their physical, mental, and psychosocial well-being. Findings: A review of Resident 1 ' s admission Record, indicated the facility admitted the resident on 6/16/2023 with medical history including type 2 diabetes (body ' s inability to process sugar), dysphagia (inability to swallow), obesity, depression (mood disorder characterized by sadness), hyperlipidemia (elevated cholesterol), hypertension (hypertension), generalized anxiety disorder (excessive worry), acute respiratory infection (respiratory tract infection that affects breathing), shortness of breath, tachypnea (rapid breathing), and otitis media (ear infection) . A review of Resident 1 ' s Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool dated 3/24/2024, indicated the resident ' s cognition (the mental action or process of acquiring knowledge and understanding) was moderately impaired. Resident 1 required supervision with personal hygiene, and requires set up assistance with eating, and oral hygiene. A review of Resident 1 ' s Physician Orders dated 4/29/2024, indicated an order for Alprazolam (medication used to treat anxiety disorders by calming down the nervous system) Oral Tablet 1 mg (milligram- a unit of measurement of mass in the metric system equal to a thousandth of a gram) by mouth every 12 hours as needed for increased restlessness leading to crying episodes. A review of Resident 1 ' s Care Plan dated 8/23/2023 with a target date 6/22/2024, indicated Resident 1 required anti-anxiety medication: Xanax (a brand of Alprazolam). The care plan did not indicate which behavior the resident was exhibiting. The intervention included to observe and record the effectiveness of the medication. During an interview with the Assistant Director of Nursing (ADON) on 4/30/2023 at 2:30 p.m., the ADON stated, Alprazolam is a psychotropic medication, and the order needs to specify the duration of the PRN order. The ADON stated the order needs to state 14 days as per the facility policy. The ADON stated, the medication order should specify the behavior that the resident is experiencing so that the nurses can assess the resident and administer the medication appropriately. The ADON stated, the care plan needs to be updated with new date that the medication was prescribed and specify which behavior the resident is experiencing. During an interview with the Director of Nurses (DON) on 4/30/2023 at 3:00 p.m., the DON stated, PRN orders for psychotropic medications should be limited to 14 days. The DON stated, this is important to reduce the overuse of psychotropic medications, especially if they are not needed. The DON stated, the facility must follow their policy of prescribing PRN psychotropic medications for 14 days as well as specify the resident ' s specific behavior. A review of the facility ' s Policy and Procedure titled, Antipsychotic Medication Use dated July 2022, indicated residents will not receive medications that are not clinically indicated to treat a specific condition. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. 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. Residents will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record. PRN orders for psychotropic medication will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication and documented the rationale for continues use. The duration of the PRN order will be indicated in the order.

Apr 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to create a comprehensive person-centered care plan for one of three sampled residents (Resident 1) by failing to address Resident 1's refusal for Restorative Nursing Assistant (RNA- provide residents routine restorative nursing care and assist residents with exercises to improve or maintain mobility and independence) Program. This deficient practice had the potential for delayed provision of necessary care and services. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 6/23/2015 with diagnoses that included Multiple Sclerosis (MS-a long-lasting [chronic] disease of the central nervous system thought to be an autoimmune disorder [ a condition in which the body attacks itself by mistake] that affects people differently. Some people with MS may have only mild symptoms but others may lose their ability to see clearly, write, speak, or walk when communication between the brain and other parts of the body becomes disrupted), unspecified (unconfirmed) rheumatoid arthritis (an autoimmune and inflammatory disease, which means that your immune system attacks healthy cells in your body by mistake, causing inflammation [painful swelling] in the affected parts of the body) and severe obesity (having a weight that is 80 to 100 pounds over what is considered your ideal body weight). A review of Resident 1's Physician Order, dated 7/12/2021, indicated an order for Restorative Nursing Assistant (RNA- provide residents routine restorative nursing care and assist residents with exercises to improve or maintain mobility and independence) to sit and stand Resident 1 daily five times a week as tolerated. A review of Resident 1's Physician Order, dated 12/5/2022, indicated an order for RNA to dorsiflex (the backward bending of your hand or foot) and plantar flexion (a movement in which the top of your foot points away from your leg) using large rubber band to bilateral lower extremity daily, five times a week as tolerated. A review of Resident 1's History and Physical, dated 10/21/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 4/2/2024, indicated Resident 1 had intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 1 needed maximum assistance from staff for toileting, dressing, and transfers. During a concurrent interview and record review on 4/16/2024 at 9:45 a.m. with Licensed Vocational Nurse 1 (LVN 1), Resident 1's RNA documentation and care plan were reviewed. The RNA Task dated 4/2024 indicated Resident 1 refused RNA on 4/5/2024 and 4/12/2024. LVN 1 stated she cannot find a care plan for RNA refusal. During a concurrent interview and record review on 4/16/2024 at 10:44 a.m., with the Assistant Director of Nursing (ADON), Resident 1's Documentation Survey Reported dated 3/2024 and 4/2024 were reviewed. The Documentation Survey Report dated 3/2024 indicated Resident 1 refused RNA on 3/5/2024, 3/7/2024, 3/25/2024 and 3/29/2024. The Documentation Survey Report, dated 4/2024, indicated Resident 1 refused RNA on 4/5/2024 and 4/12/2024. The ADON stated there were no care plan created for Resident 1's RNA refusal. The ADON stated care plan is important for nurses to be aware of the refusal and for nurses to list the intervention and resident's preference to address the RNA refusal. A review of facility's policy and procedure titled, Comprehensive Person-Centered Care Plans, dated 3/2022 and reviewed on 12/28/2023, indicated, A comprehensive, person-centered care plan should include measurable objectives, and timetables to meet the resident's physical, psychological and functional needs. 6. The comprehensive, person-centered care plan should: b. Describe the services that are to be furnished in an attempt to assist the resident attain or maintain that level of physical, mental, and psychosocial wellbeing that the resident desires or that is possible, including services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights (including the right to refuse treatments), 7. When possible, interventions should address the underlying source (s) of the problem.

Mar 2024 9 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure one of 18 sampled residents (Resident 18) was provided a safe and homelike environment. The facility failed to ensure the ceiling in Resident 18 ' s room was free from water leak and water stains. This deficient practice resulted in Resident 18 not having a homelike comfortable and safe environment. Findings: A review of Resident 18 ' s admission Record indicated the facility admitted the resident on 12/30/2023 with diagnoses including lymphedema (tissue swelling caused by an accumulation of protein-rich fluid that is usually drained through the body ' s lymphatic system), type 2 diabetes mellitus (occurs when the blood sugar is too high), and abnormalities of gait (a manner of walking or moving on foot) and mobility. A review of Resident 18 ' s History and Physical, dated 12/30/2023, indicated that the resident had fluctuating capacity to understand and make decisions. A review of Resident 18 ' s Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 1/5/2024, indicated the resident ' s cognition was intact. Resident 18 required maximal assistance (helper lifts or holds the trunk or limbs and provides more than half the effort) on chair or bed to chair transfer, toilet transfer, and walking 10 to 50 feet. On 3/7/2024 at 12:25 p.m., during a concurrent observation and interview, Resident 18 stated that the resident room ' s ceiling was leaking when it rained. Resident 18 stated that there was a lot of water on the floor outside the bathroom when it rained on 3/6/2024. Resident 18 stated that it was unsafe for the people walking in and out of the room. Resident 18 ' s ceiling was observed with discolored brown water stains on the ceiling. On 3/7/2024 at 1:45 p.m., during a concurrent interview and record review, the Maintenance Supervisor (MS) provided his meeting notes, dated 2/27/2024, indicating that there was a ceiling leak in Resident 18 ' s room. The MS stated that he was not made aware that materials needed was not available and that the ceiling was not fixed. The MS stated that materials were ordered and would be fixed immediately. The MS stated that there should be a better communication in the department. The MS stated that leak on the ceiling was not safe for the residents and staff. The MS stated that it had the potential to cause accidents. A review of the facility ' s policy and procedure titled, Homelike Environment, dated 12/28/2023, indicated that residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. The policy indicated that staff provides person-centered care that emphasizes the residents ' comfort, independence, and personal needs and preferences. The policy indicated that the facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting including . a. clean, sanitary, and orderly environment. A review of the facility ' s Maintenance and Plant Operations, dated 12/28/2023, indicated the purpose of maintenance of a safe and sanitary environment, ensures safety, affords protection, and enhances the well-being of the residents, public, and staff. The purpose indicated the maintenance activities included providing a functional, sanitary, and comfortable environment and ensuring that all equipment, buildings, spaces, and fixtures are kept in operable condition.

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 4) was provided transportation to the facility timely after a medical appointment. On 2/14/2024 at 6 a.m., Resident 4 was transported to Outpatient Rehab Center 1 (ORC 1) for an appointment at 8:40 a.m. Resident 4 did not return to Skilled Nursing Facility 1 (SNF 1) on 2/14/2024. Resident 4 was found in a parking lot near ORC 1 and transferred to General Acute Care Hospital 1 (GACH 1) on 2/16/2024. This deficient practice placed Resident 4 at risk for accidents and injuries. Findings: A review of Resident 4's admission Record indicated the facility admitted the resident on 12/12/2023 and readmitted the resident on 1/8/2024 with diagnoses that included paraplegia (paralysis that affects your legs, but not your arms), muscle weakness, and chronic pain syndrome (pain that lasts for over three months). A review of Resident 4's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 12/18/2023, indicated the resident was able to understand and be understood. Resident 4 ambulated (to move from place to place) with wheelchair and required substantial to maximal assistance with toileting, bathing, and lower body dressing and required partial to moderate assistance with upper body dressing and personal hygiene. A review of Resident 4's Care plan, developed on 12/13/2023, for Activities of Daily Living (ADL)/Mobility Resident 4 is at risk for ADL/mobility decline and requires assistance. The interventions included assist with ambulation, bathing, bed mobility, dressing, transfer, and toileting. A review of Resident 4's Fall Risk Assessment, dated 1/9/2024, indicated Resident 4 had a score of 16 (a score of 16 to 42 means the resident should be considered a high risk for potential falls). A review of Resident 4's Elopement Risk, dated 1/9/2024, indicated Resident 4 had a score of 4 (a total score of 10 or greater means the resident would be at risk for elopement). A review of the Transportation Request for Resident 4, dated 1/29/2024, indicated Resident 4 appointment on 2/14/24 time 8:40 a.m. with pick up time of 6 a.m. and return at 12 p.m. A review of the Physician's Orders for Resident 4, dated 2/12/2024, indicated appointment on 2/14/2024, at 8:40 a.m. in ORC 1. A review of Resident 4's nursing Progress Note, dated 2/15/2024 at 8:17 a.m., indicated Resident 4 was picked up at 6 a.m. 2/14/24 by Insurance Transportation 1 (IT 1) and was seen at his appointment. IT 1 arrived for pick up at 12:45 p.m. and waited 1.5 hours, Resident 4 was not able to be located. A review of Resident 4's nursing Progress Note, dated 2/15/2024 at 10:26 a.m., indicated doctor informed of Resident 4's discharge Against Medical Advice (AMA) who went out to his appointment yesterday, 2/14/24, and IT 1 was on time to pick Resident 4 at 12 p.m. and waited for 1 ½ hours but Resident 4 was nowhere to be found. ORC 1 confirmed that Resident 4 left after his appointment. A review of Resident 4's nursing Progress Note, dated 2/15/2024 at 12:01 p.m., indicated Sheriff Deputy came to the SNF 1 to obtain details related to Resident 4 who was reported because he never came back from an appointment. A review of Resident 4's nursing Progress Note, dated 2/15/2024 at 2:28 p.m. indicated OCR 1 was called and they verified they did see Resident 4 and he left the office after his visit. IT 1 also contacted and verified they did go back to pick resident up and they waited over an hour and Resident 4 was not there. A review of Resident 4's nursing Progress Note dated 2/15/2024 at 5:43 p.m. indicated Social Services Director (SSD) was made aware that Resident 4 did not come back from appointment yesterday. SSD had Transportation Coordinator (TC) call IT 1 to inquire about where Resident 4 was per TC 1 the resident told the driver to go back and pick up Resident 4 at 1 p.m. (pick up was scheduled for 12 p.m.) driver went back to pick up Resident 4 however Resident 4 was not there. The Assistant Director of Nursing (ADON) to call Sheriff, SSD filed Adult Protective Services (APS-agency to help elder adults [60 years and older] and dependent adults [18 to 59 who are disabled] when these adults are unable to meet their own needs, or are victims of abuse, neglect, or exploitation), and report also was faxed to the Ombudsman. A review of an email, dated 2/19/2024, from IT 1 indicated on the day of 2/14/2024 for Resident 4 they got there around 1:28 p.m. Once the driver got there, he went inside to look for Resident 4. Asked security and asked around for Resident 4 and once the driver could not locate Resident 4, he let us know what was going on so we contacted the car to let him know we could not locate Resident 4. During an interview on 2/22/2024 at 8 a.m. with Case Manager 1 (CM 1) for GACH 1, CM 1 stated Resident 4 was admitted to GACH 1 via ambulance. Resident 4 was found in a parking lot near ORC 1. CM 1 stated that Resident 4 said he was never picked up after his appointment at ORC 1 and waited in the parking lot of ORC 1. During an interview on 2/22/2024 at 1 p.m., Resident 4 stated he is currently at GACH 1. He had an appointment at ORC 1 on 2/14/2024 and was picked up from SNF 1 at 6 a.m. and arrived at ORC 1 at 9:05 a.m. Resident 4 stated his appointment was done a little past 12 p.m. and after his appointment he waited outside of ORC 1. Resident 4 stated his pickup was 12:30 p.m. but no one came so he called SNF 1 and no one answered. Resident 4 stated he spent all night there and the next day he was approached by someone who asked it he needed help. Resident 4 stated he was in a lot of pain by then and they called 911. During an interview on 2/22/2024 at 1:37 p.m., the SSD stated Resident 4 was picked up at 6 a.m. by IT 1 which was provided by Resident 4's insurance. The SSD stated Resident 4's pick up time was 12 p.m., the SSD stated she was made aware of Resident 4 not being found on 2/15/2024. The SSD stated nursing should be following up on resident when they go out to an appointment. The SSD stated was told by IT 1 that they arrived at 1 p.m. and went into ORC 1 to look for Resident 4 around 1:30 p.m. the SSD stated Resident 4 should have been picked up at the scheduled time of 12 p.m. The SSD stated it is a possibility that Resident 4 could have gotten hurt physically when Resident 4 was out of the facility. During an interview on 2/22/2024 at 2:10 p.m., Registered Nurse (RN 1) stated on 2/15/2024 during her shift 7a.m. to 3 p.m. there was a report that Resident 4 did not come back from his appointment on 2/14/2024. RN1 stated she asked Licensed Vocational Nurse 1 (LVN 1) to contact ORC 1 to ensure Resident 4 was seen and then contact the TC to see what happened. RN 1 stated she then reported to the ADON who would file a missing report and call the local Sheriffs department. RN 1 stated there is always a risk Resident 4 cannot walk; he is not independent and needs help and assistance. RN 1 stated for Resident 4 the weather is cold at night and morning there is a risk for him to get cold, hungry, and someone could have hurt Resident 4. RN1 stated the charge nurses are responsible of knowing where their residents are and should check if the resident is okay and if there is any issues it must be endorse to the next shift, or to the RN supervisor. During a concurrent interview and record review on 2/22/2024 at 2:30 p.m., TC stated she spoke to IT 1 who informed the TC that the driver arrived at ORC 1 at 12 p.m. after waiting a long-time driver spoke to security at ORC 1 who informed the driver that Resident 4 had already left. TC reviewed email sent by IT 1 TC stated it indicates in email that IT 1 arrived at 1:38 p.m. the IT 1 was late should have been there at 12 p.m. TC stated nursing is the one that ensure the resident go and return from their appointments. TC stated the latest time Resident 4 should have been back to the facility would have been at 4 p.m., staff should have ensured Resident 4 was back to the facility. During an interview on 2/22/2024 at 3:20 p.m., the Director of Nursing (DON) stated if a resident goes to an appointment and does not come back within a certain timeframe need to call the clinic. The DON stated it is the licensed nurses and the RN supervisors who should be following up on their residents. The DON stated give or take 2 hours with traffic staff should have been concerned around 3 or 4 p.m. why the resident is not back to the facility. The DON stated there is a risk for accidents with Resident 4 not return to the facility Resident 4 is wheelchair bound and has skin issues. The DON stated it is the facility's responsibility to ensure residents are safe. A review of the facility's current policy and procedure titled, Safety and Supervision of Residents, revised on 7/2017, indicated resident safety and supervision and assistance to prevent accidents are facility-wide priorities.

CONCERN (D) 📢 Someone Reported This

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

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 3), was provided necessary treatment and services to prevent formation of and promote healing of pressure sore by failing to implement the facility's policy on Braden Skin Risk Assessment Tool (a standardized, eveidence-based assessment tool commonly used in healthcare to assess and document a patient's risk for developing pressure injuries) for Prevention of Pressure Ulcers, by not having an appropriate assessment and that changes in condition are recognized, evaluated, addressed, when a new pressure ulcer developed within the facility. This deficient practice could potentially hinder the healing of Resident 3's pressure ulcers and cause infections. Findings: A review of Resident 3's admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses that included Parkinson's disease (is a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), major depressive disorder (is a mood disorder that causes a persistent feeling of sadness and loss of interest), and syncope (fainting or passing out) and collapse. A review of Resident 3's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 11/1/2023, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 3 required substantial/maximal assistance with shower/bathe self, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 3 required partial/moderate assistance with toileting and personal hygiene, and upper body dressing. The MDS further indicated that Resident 3 was at risk of developing pressure ulcers and resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. The MDS indicated skin and Ulcer/Injury treatments included turning/repositioning program. A review of Resident 3's MDS, dated [DATE], indicated the resident had severely impaired cognition. The MDS indicated Resident 3 required substantial/maximal assistance with toileting hygiene, lower body dressing, putting on/taking off footwear and dependent on staff for shower/bath self. The MDS further indicated that Resident 3 had one unstageable pressure ulcer with slough and/or eschar and one unstageable deep tissue injury. The MDS indicated that the determination of the Pressure ulcer/injury risk required the formal assessment instrument/tool (Braden Scale). The MDS indicated skin and Ulcer/Injury treatments included turning/repositioning program. A review of the Braden scale (used to predict pressure sore risk), dated 11/2/2023, it indicated that Resident 3 scored 17 (a score of 15-18 reflects mild risk for pressure ulcer). A review of the Braden scale, dated 2/27/2024, it indicated that Resident 3 scored 11 (a score of 10-12 reflects high risk for pressure ulcer). A review of Resident 3's Change in Condition Evaluation (COC), dated 2/01/2024, timed at 6:20 p.m., indicated Resident 3's initial redness on left hip that was previously noted was now terminal ulcer (is an unavoidable skin breakdown which occurs in some patients as part of the dying process). The site measurements indicated 2.7 centimeters (cm) length and 2.1 cm height and 0.4 cm depth, presenting 30 percentage (%) pink, 40 % yellow white, and 30% purple; with light serous drainage noted. The COC further indicated Resident 3's Coccyx (tail bone) was noted with terminal ulcer; wound measurements indicated 0.9 cm length and 0.4 cm height and noted deep red and purple. During a concurrent interview and record review on 2/29/2024, at 10:42 a.m., with Licensed Vocational Nurse 1 (LVN 1), Resident 3's medical record was reviewed. LVN 1 verified that Resident 3 did not have a Braden scale assessment completed after his significant change of condition for his pressure ulcer on 2/1/2024. She confirmed his last Braden Scale Assessment was completed on 11/23/2024 and anytime the resident has a COC it should have been done. LVN 1 stated that Braden scales are used to predict residents pressure ulcer risk. LVN 1 stated that it is important to continue to complete resident's Braden scale assessments when they have a change in skin assessment because this helps staff know what interventions to implement and continue certain treatments to prevent further skin breakdown of the resident. During a concurrent interview and record review on 2/29/2024, at 10:58 a.m., with Treatment Nurse Coordinator (TN Coordinator), Resident 3's medical record was reviewed. TN Coordinator stated that there was no Braden scale assessment done in between 11/23/2023 and 2/10/2024 for Resident 3 and there should have been one done on 2/1/2024 because Resident 3 had a significant change in condition on 2/1/2024. TN Coordinator stated that the Braden Scale gives the staff a scale to monitor and assess the residents' risk of obtaining further skin breakdown. In identifying the risk level, this will let the facility know what interventions to implement to prevent further skin breakdown for residents. On 12/29/2024, at 11:11 a.m., during an interview, the Director of Nursing (DON) stated that residents should have a new Braden Scale assessment anytime they have a significant change in condition. He stated that Resident 3 should have had a Braden Scale Assessment on 2/1/2024 when his pressure ulcer changed. The DON stated that Braden scale assessment are the best practice and help the facility staff establish parameters as to prevent the pressure injury from worsening and adjusting interventions. The scale helps to know if treatment is not effective. DON stated that pressure ulcer treatments include wound evaluation by the wound care doctor, change in medication treatments, and repositioning the resident. A review of the facility's policy and procedure (P&P) titled, Braden Scale Risk Assessment Tool, last reviewed on 12/28/2023, indicated, The Braden scale assessment should be completed following the schedule: Development of new pressure ulcer, Complete Braden Scale Risk Assessment weekly for 4 weeks or until wound/wounds are healed. The policy further indicated, Documentation addressing the rationale for discontinuation of the Braden Risk Assessment should be entered into the record and the Braden Risk Assessment should continue to be completed on a Quarterly basis or with Significant Change in condition.

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 F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Residents 3) received the necessary Restorative Nursing Program [RNP, nursing program that uses restorative nursing aides (RNA are health care professionals who are responsible for providing restorative and rehabilitation care for residents to maintain or regain physical, mental, and emotional well-being. Aides in this capacity are certified nurse assistants (CNAs), with specialized training in restorative care] to help residents improve or maintain one's functional ability and joint mobility by failing to provide RNP services consistently to Resident 3 from 1/2024 to 2/2024 as ordered by the physician and as recommended by the licensed therapist. This deficient practice had the potential to cause a further decline in ROM with worsening contractures (deformity and joint stiffness) to both upper and lower extremities and increased potential for skin injuries including pressure sores (injuries to the skin and underlying tissue caused by prolonged pressure on the skin), which could lead to moderate to severe pain. Findings: A review of Resident 3' s admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with multiple diagnoses that included Parkinson's disease (is a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), major depressive disorder (is a mood disorder that causes a persistent feeling of sadness and loss of interest), and syncope (fainting or passing out) and collapse. A review of Resident 3's Minimum Data Set (MDS, a standardized resident screening and care-planning tool), dated 11/1/2023, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 3 required substantial/maximal assistance with shower/bathe self, lower body dressing, and putting on/taking off footwear. The MDS indicated Resident 3 required partial/moderate assistance with toileting and personal hygiene, and upper body dressing. The MDS indicated skin and Ulcer/Injury treatments included turning/repositioning program. A review of Resident 3's MDS, dated [DATE], indicated the resident had severely impaired cognition. The MDS indicated Resident 3 required substantial/maximal assistance with toileting hygiene, lower body dressing, putting on/taking off footwear and dependent on staff for shower/bath self. The MDS further indicated that Resident 3 had one unstageable pressure ulcer with slough and/or eschar and one unstageable deep tissue injury. The MDS indicated that the determination of the Pressure ulcer/injury risk required the formal assessment instrument/tool (Braden Scale). The MDS indicated skin and Ulcer/Injury treatments included turning/repositioning program. A review of Resident 3's PT Discharge summary, dated [DATE], signed by PT 1 on 12/2/2024 at 8:49 p.m. indicated a RNP program was established for Resident 3 and training was provided to facilitate patient maintaining current level of performance and in order to prevent decline. A review of Resident 3's physician orders, dated 12/02/2023, indicated to provide the following Restorative Nursing Program: -Ambulation program every day five times per week (5x/week) using front wheel walker (FWW) and with two people assist for 50 feet or as tolerated. A review of Resident 3's physician orders, dated 1/09/2024, indicated to provide the following Restorative Nursing Program: -Active Assistance ROM (AAROM, movement of a joint through the range of motion with assistance from resident) to both arms and both legs, five times per week (5x/week) as tolerated A review of Resident 3's physician orders, dated 1/24/2024, indicated to provide the following Restorative Nursing Program: -AAROM, to both arms and both legs, followed by gentle passive stretching to bilateral hips and knees seven times per week (7x/week) as tolerated. During a concurrent interview and record review of Resident 3's RNA records (Restorative Administration Records and Documentation Survey Reports from 1/2024 to 2/2024) on 12/29/2024, at 12:57 p.m., the Director of Staff Development (DSD) stated there was no documented evidence the RNP services were provided to Resident 3 during the following dates: -January 2024 -1/1/2024, 1/2/2024, 1/3/2024, 1/4/2024, 1/5/2024, 1/6/2024, 1/7/2024, 1/8/2024, 1/11/2024, 1/13/2024, 1/14/2024, 1/15/2024, 1/20/2024, 1/21/2024, 1/22/2024, 1/272024, 1/28/2024, and 1/31/2024. -February 2024 -2/3/2024 and 2/4/2024. During an observation on 2/29/2024, at 12:13 p.m., Resident 3 was lying in bed, alert, nonverbal. Resident 3 had severe contractures to both legs. Resident 3 was observed with facial grimacing when Restorative Nursing Assistant 3 (RNA 3) slightly extended the left leg prior to an attempt to perform AAROM. RNA 3 stated Resident 3 did not receive RNA during most of January 2024 because the facility was short RNAs. RNA 3 asked permission to try Resident 3's right leg. He mouthed the word yes. RNA 3 was able to perform minimal extensions of Resident 3's right leg without resistance and then he expressed for her to stop. During an interview on 12/29/2024, at 1:38 p.m., the Assistant Administrator stated Resident 3 has an order for RNA, and he should have received his RNA as ordered. During an interview on 12/29/2024, at 3:20 p.m., the Director of Nursing (DON) stated if the RNA is not documented in Resident 3's chart for the dates RNA was blank for 1/2024 and 2/2024 then Resident 3 did not receive RNA. DON stated that whatever nursing intervention or program is ordered for a resident, it needs to be implemented by nursing staff. The DON stated that if the resident does not receive RNA services, he is at more risk for decline because of his disease process. DON stated that Resident 3 should have been getting RNA 7 days a week, to help with his restoration and extension of his legs and arms. DON stated that Resident 3 is contracted, and RNA could have helped prevent his contractures. A review of the facility's policy and procedure (P&P) titled, Restorative Nursing Program (RNP), last reviewed on 12/28/2023, indicated, The purpose of the RNP is to assist each resident in achieving the highest level of self-care possible. The concept of self-care is an integral part of daily nursing care and includes at least the following: Active range of motion exercises, Passive range of motion exercises. The policy further indicated, the RNA carries out the program according to the Physician order and documents on a daily/per care basis.

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 F0801 (Tag F0801)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure adequate oversight of the Food and Nutrition Services by qualified personnel when the Registered Dietitian did not conduct a comprehensive (complete) nutritional assessment (a detailed evaluation of the resident's nutritional health) by not talking to the resident or resident's family member and physically assessed a resident during the initial admission and quarterly assessment for one of one sampled resident (Resident 3) who had a weight loss. This failure had a potential to result in inaccurate nutrition assessment, ineffective nutrition intervention, and goals. Findings: A review of Resident 3's admission Record, indicated Resident 3 was initially admitted to the facility on [DATE] and then readmitted on [DATE] with diagnoses including Parkinson Disease (a progressive disorder that affects the nervous system and the parts of the body controlled by the nerves), unspecified dementia (loss of cognitive functioning, thinking, remembering and reasoning), and syncope (a temporary drop in blood flow to the brain from a sudden change in your blood pressure or heart rate). A review of Resident 3's Minimum Data Set (MDS - a standard assessment and care screening tool), dated 2/1/2024, indicated Resident 3's cognition was severely impaired (unable to understand and make decision) and able to eat with supervision or touching assistance (helper provides verbal cues and or touching/steadying and/or contact guard assistance as resident completes activity). During a concurrent interview with Licensed Vocational Nurse 1 (LVN 1 and weight coordinator) and record review of Resident 3's medical record on 2/29/2024 at 11:16 AM, LVN 1 stated Resident 3 was on soft mechanical chopped diet thin liquid and an oral supplement (high protein, high calorie drink) twice (2x) a day ordered by the physician on 11/2/2024. LVN 1 stated Resident 3 was initially admitted on [DATE] with an admission weight of 142 pounds (lbs, unit of measurement). LVN 1 stated Resident 3 had the following weight trends: 10/31/2023- 149 lbs. 11/7/2023- 145 lbs. 11/15/2023-145 lbs. 11/2/2023-141 lbs. 11/30/2023-140 lbs. 12/6/2023-138 lbs. 12/12/2023-134 lbs 12/19/2023-135 lbs 12/26/2023-137 lbs 1/1/2024-135 lbs 1/10/2024-135 lbs LVN 1 stated, Resident 3 triggered for monthly weight change of seven (7) lbs or 4.8% from 11/7/2023 to 12/6/2023. LVN 1 stated Resident 3's weight change was not significant however, they placed Resident 3 on weekly weights monitoring for extra precaution. LVN 1 stated they had an Interdisciplinary Team (IDT, composed of members from different disciplines working together) meeting with the physician, RD 1 and the Resident's wife. LVN 1 stated Resident 3's weight loss was attributed to varied food intake and the plan was to provide oral supplementation, appetite stimulant, encouragement during meals and feeding assistance. During a telephone interview with Registered Dietitian 1 (RD 1) on 2/29/2024 at 11:50 AM, RD 1 stated she was not sure if she talked to the resident on 12/6/2023 because it has been a long time and she could not go back to the medical records for more than 30 days. RD 1 stated she had her IDT notes dated 12/13/2023 and Resident 3 lost seven lbs. in one month attributed to varied PO intake. During a telephone interview with the Registered Dietitian 2 (RD 2) on 2/29/2024 at 12:44 PM, RD 2 stated she worked remotely and only visited the facility once in 6/2023. RD 2 stated she completed Resident 3's initial nutrition assessment on 11/1/2023 without talking to the resident and resident's family. RD 2 stated she also did not physically see the resident when she conducted the initial nutrition assessment. RD 2 stated she completed Resident 3's quarterly nutrition assessment on 2/7/2024 without seeing, talking to the resident and family. RD 2 stated she was not sure if not seeing and talking to the resident was a Registered Dietitian's standards of practice when conducting nutrition assessment for residents. RD 2 stated that the process for conducting nutrition assessment were as follows: · Obtained resident's information from the chart. · Talked to the certified nursing assistant, registered nurse. · Talked to the family if the resident was confused. · Estimated resident's needs. · Made recommendations based on the assessment. RD 2 stated she did not talk to Resident 3 because she did her assessment remotely and that Resident 3 was confused. RD 2 stated she did not complete a nutrition focused physical assessment because she worked remotely when she completed Resident 3's assessment. RD 2 stated Resident 3 was eating 26 to 74% and his food intake was not optimal. RD 2 stated she does not know why the resident was not eating and could not really pinpoint the reason of poor intake however poor food intake was possibly because of Resident 3's diagnosis. RD 2 stated it was important to talk and see the resident face to face when conducting nutrition assessments to determine why the resident not eating and to assess the resident's overall condition. During an interview with the Assistant Administrator (Assist-Adm) on 2/29/2024 at 4:22 PM, Assist-Adm stated he expected the Registered Dietitian to interview the family if the resident is not interviewable to ask resident's likes, dislikes, lifestyle, and other conditions when completing nutritional assessment. Assist-Admin stated Registered Dietitians were also expected to complete initial and quarterly assessment. Assist-Adm stated Registered Dietitian were expected to follow-up on the progress of the residents and assess if the nutrition intervention was working and needed to be modified. Assist-Adm stated not talking to the residents or family was not providing a comprehensive nutritional assessment and the nutrition intervention would not be customized to the resident's needs. A review of the facility's job description titled, Registered Dietitian Long-Term Care Description, not dated, indicated, Responsibilities and Duties (9) Applies the Nutrition Care Process (NCP) and workflow elements in providing person-centered nutrition care of individuals and evaluates the nutrition care workflow process for improving health outcomes. (c) Performs assessment via in person, or via electronical health record facility/practitioner assessment application system, or via other HIPPA compliant video conferencing. (f) Determines and documents client-centered outcomes of interventions reflecting input from all sources including other disciplinary team members, the client or responsible party. A review of the facility's dietitian job description titled, Job Description and Performance standards, not dated, indicated (2) Assess and document the nutritional needs of each resident in accordance with the resident comprehensive assessment and care plan. (7) Assess and document residents' food allergies and cultural backgrounds that may affect food consumption. (21) Consistently work collaboratively with residents, resident's representatives, facility staff, physicians, consultants and ancillary service providers. A review of the facility's competency titled, RD Annual Competency Assessment, signed by RD 1 and RD reviewer on 1/16/2023, indicated, RD 1 met the competency for Nutrition Assessment. A review of the facility's competency titled, RD Annual Competency Assessment, signed by RD 2 and RD reviewer on 1/16/2023, indicated RD 2 met the competency for Nutrition Assessment. A review of facility's Policies and Procedures (P&P) titled, The Nutritional Assessment Process, undated, indicated STANDARD. (3) Resident Care Plan is developed and modified as needed for any triggered areas on the MDS and/or nutritional concerns identified from reviewing the nutritional documentation and from any visual observation. A review of P&P titled, The Nutritional Management System, undated, indicated, Practice Guidelines. (1) An assessment of nutritional status is complete on each patient upon admission to this facility by completing the Nutritional History within 72 hours of admission and with the completion of any comprehensive MDS. A review of facility's P&P titled, Weight Loss Prevention and Management, dated 2/18 indicated (4) Those residents who are at risk for malnutrition are comprehensively assessed by the RD and IDT initially upon admission, quarterly and when there is significant change in resident's condition. A review of the facility contract with Registered Dietitians titled, Agreement to Provide Dietetic Consultation Services, dated 6/10/2019 indicated THE RESPONSIBILITY OF THE CONSULTANT DIETITIAN: The Consultant Dietitian shall give guidance and counsel to the Dietetic Service Department as follows: (4) Chart nutritional information in accordance with the policies of the facility and accepted standards of professional practice. A review of the Academy of Nutrition and Dietetics' Nutrition Care Process titled, NCP Step 1: Nutrition Assessment, indicated, Nutrition assessment is a systematic approach to collect, classify, and synthesize important and relevant data (indicator) needed to identify nutrition-related problem and their causes. This step also includes reassessment for comparing and re-evaluating data from previous interaction to the next and collection of new data that may lead to new revised nutrition diagnoses based on the client status or situation. Finding Nutrition Assessment Data: For individuals, data can come directly from the client through interview, observation and measurements, a health record, and the referring health care provider. A review of the Academy of Nutrition and Dietetics' Nutrition Care Process titled, NCP Step 3: Nutrition Intervention indicated, Nutrition intervention goals, ideally, developed collaboratively with the client, provide the basis for monitoring progress and measuring outcomes. Planning the nutrition intervention involves: Collaborating with the client to identify goals of the intervention for each diagnosis. Implementation is the action phase and involves: Collaborating with the client to carry out the plan of care. A review of the Academy of Nutrition and Dietetics' Nutrition Care Process titled, NCP Step 4: Nutrition Monitoring and Evaluation, undated, indicated, During the first interaction, appropriate outcomes/indicators are selected to be monitored and evaluated at the next interaction with the client. During subsequent interactions, these outcomes /indicators are used to demonstrate the amount of progress made and weather the goals or expected outcomes are being met.

CONCERN (D) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow infection control procedures for two of 18 sampled residents (Resident 13 and Resident 16) by failing to: a. Ensure Resident 16's water pitcher was not placed on an area used by other residents. b. Ensure Resident 13's wash basins were not placed on another resident's bathroom sink for hot water. These deficient practices placed Resident 13 and resident 16 at risk for exposure and contracting infections. Findings: a. A review of Resident 16's admission Record indicated the facility admitted the resident on 12/7/2021 with diagnoses including type 2 diabetes mellitus (occurs when the blood sugar is too high) with foot ulcer (wound), hemiplegia (paralysis that affects only one side of the body) and hemiparesis (one-sided muscle weakness) following cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting left non-dominant side, and pressure ulcer (damage to the skin and the underlying tissue caused by constant pressure or friction) of sacral region (portion of the spine between the lower back and tailbone). A review of Resident 16's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 2/11/2024, indicated the resident's cognition was moderately impaired. Resident 16 required maximal assistance on shower or bath, toileting, and personal hygiene. On 3/7/2024 at 9:16 a.m., during a concurrent observation and interview, observed Certified Nursing Assistant 10 (CNA 10) took a pitcher of water out of the microwave in nurse station 2 and brought it inside Resident 16's room. CNA 10 poured the water from the pitcher into Resident 16's basin of tap water and placed the pitcher in the resident's table. CNA 10 stated the water in the basin was not hot enough and she would heat more water at the station. CNA 10 wrapped the pitcher with plastic and went to nurse station 2. CNA 10 removed the pitcher from the plastic and placed it on top of the nurse station countertop. CNA 10 rinsed the pitcher with water and filled it with tap water from the faucet. CNA 10 heated the pitcher of water inside the microwave for three minutes and brought the pitcher with hot water in Resident 16's room. The countertop on nurse station 2 and the microwave where the used and unwashed pitcher was placed was not disinfected. On 3/7/2024 at 11:19 a.m., during a follow up interview, CNA 10 stated that she brought Resident 16's used water pitcher to the nurse station and the countertop and microwave were not disinfected before and after use. CNA 10 stated that she failed to follow infection control practices. CNA 10 stated that she should not take the used pitcher out of Resident 16's room and she should disinfect the table at the nurse station. CNA 10 stated that bringing the used pitcher to the nurse station and not disinfecting the countertop had the potential for cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or people to another). On 3/7/2024 at 2:14 p.m., during an interview, the Director of Nursing (DON) stated that used pitchers and basins should not be taken out from the residents' room or placed in the microwave. The DON stated that the microwave was used for heating the residents' food. The DON stated that these practices had the potential for cross contamination. A review of the facility's policy and procedure titled, Infection Control, dated 12/28/2023, indicated the facility's infection control policies and practices were intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. b. A review of Resident 13's admission Record indicated the facility admitted the resident on 1/22/2021 with diagnoses including type 2 diabetes mellitus, hemiplegia, and hemiparesis following cerebral infarction affecting left dominant side, and epilepsy (a condition that affects the brain and causes frequent seizures [sudden, uncontrolled body movements and changes in behavior that occurs because of abnormal electrical activity in the brain]). A review of Resident 13's MDS, dated [DATE], indicated the resident's cognition was severely impaired. Resident 13 was dependent on eating, oral hygiene, shower or bath, toileting, and personal hygiene. On 3/7/2024 at 9:38 a.m., during a concurrent observation and interview, observed Certified Nursing Assistant 8 (CNA 8) enter an occupied resident's room and went to the residents' bathroom. CNA 8 was not wearing gloves as she opened the restroom door and placed the basin on the bathroom sink to get hot water. CNA 10 brought the basin of hot water in Resident 13's room and placed it on the bedside table. CNA 8 stated that she would get more water using the same process. CNA 10 stated that the residents in the room where she got the water for Resident 13's bed bath used the bathroom for their activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive) such as toileting and brushing their teeth. CNA 10 stated that she failed to follow infection control procedures and had the potential to spread infection or bacteria to other residents. On 3/7/2024 at 2:14 p.m., during an interview, the Director of Nursing (DON) stated that used pitchers and basins should not be taken out from the residents' room or placed in the microwave. The DON stated that the microwave was used for heating the residents' food. The DON stated that these practices had the potential for cross contamination. A review of the facility's policy and procedure titled, Infection Control, dated 12/28/2023, indicated the facility's infection control policies and practices were intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0675 (Tag F0675)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure seven of 18 sampled residents (Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, and Resident 17) received the necessary care and preferred services, such as warm showers and bed bath, to attain and maintain the residents' highest practicable physical, mental, and psychosocial well-being. The facility failed to: a. Ensure continuous hot running water were available for Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, and Resident 17. b. Ensure that the water used for Resident 17 who had cognitive (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) impairment, was at comfortable temperature level. These deficient practices resulted in Resident 7, Resident 8, Resident 9, Resident 10, Resident 11, Resident 12, and Resident 17 not able to take a comfortable bed bath or shower. Findings: a. On 3/5/2024 at 8:12 a.m., during a concurrent observation and interview, water was ran in shower 1B in station 1 for 8 minutes. Maintenance Personnel (MP) took the water temperature and stated that the shower water temperature measured at 68.9 degrees Fahrenheit (°F - unit of measurement). On 3/5/2024 at 8:22 a.m., during a concurrent observation and interview, water was ran in shower 2A in station 2 for 2 minutes and 58 seconds. MP took the water temperature and stated that the shower water temperature measured at 70°F. MP stated that it takes two minutes for the water to reach the water temperature of 105°F. On 3/5/2024 at 8:27 a.m., during a concurrent observation and interview, water was ran in shower 4A in station 3 for 4 minutes and 43 seconds. MP took the water temperature and stated that the shower water temperature measured at 68.4°F. MP stated that the one of the water heaters that supplied station 1, station 2, and station 3 with hot water had been broken and the second water heater had been broken since last week. On 3/5/2024 at 8:34 a.m., during a concurrent observation and interview, water was ran in shower 4 whirlpool room in station 4 for 3 minutes and 20 seconds. MP took the water temperature and stated that the shower water temperature measured at 81.9°F. On 3/5/2024 at 8:39 a.m., during a concurrent observation and interview, water was ran in shower 5 in station 5 for 3 minutes and 50 seconds. MP took the water temperature and stated that the shower water temperature measured at 70.3°F. MP stated that none of the water temperatures in the observed shower rooms reached the required water temperature of 105 F. On 3/5/2024 at 8:46 a.m., during a concurrent observation and interview, observed water heater #2 room with two water heater machines and two hot water containers. The Maintenance Supervisor (MS) stated that the second water heater in the room was turned off because of the combustion smell and weas not safe to use. The MS turned on the water heater 2 and a smell of smoke came out of the water heater machine. The water heater 2 was observed with a black smoke stain on the top front side. The hot water container was observed with a black smoke stain on the left side adjacent to the water heater. The MS stated that water heater 1 had been broken for more than a year and station 1, station 2, and station 3 were only using water heater 2. The MS stated that station 1, station 2, and station 3 did not have hot water since 2/29/2024. The MS stated that there were residents complaining that the water was cold. The MS stated that the Administrator (ADM) and nursing staff were aware that water heater 1 and water heater 2 were broken. On 3/5/2024 at 9 a.m., during a concurrent observation and interview, the MS ran the water in nurse station 5 hand sink for 2 minutes and 58 seconds. The MS was observed measuring the water temperature and stated the water temperature was 101.9°F. On 3/5/2024 at 9:11 a.m., during a concurrent observation and interview, the MS ran the water in nurse station 4 hand sink for 2 minutes and 38 seconds. The MS was observed measuring the water temperature and stated the water temperature was 98.4°F. The MS stated that the water temperature did not reach the desired water temperature of 105°F to 120°F because a lot of residents had used the water in the station 4 and station 5. 3/5/2024 at 9:14 a.m., during a concurrent interview and record review, reviewed the facility's Hot Water Temperatures log, dated March 2024, indicated the water temperature should be between 105°F to 112°F. The log indicated that there were no water temperatures recorded for station 1, station 2, and station 3 from 3/1/2024 to 3/5/2024. MS stated that the water temperatures were not taken for station 1, station 2, and station 3 because the water heaters were turned off. On 3/5/2024 at 10:20 a.m., during a concurrent observation and interview, Certified Nursing Assistant 4 (CNA 4) stated that some residents in station 1 refused their showers and were provided bed baths instead because the water in the shower was cold. CNA 4 stated that the water for bed baths were a mixture of the cold tap water and hot water heated in the microwave. The microwave was observed inside station 1's utility room. CNA 4 stated that she did not use any device to measure the water temperature. CNA 4 stated that she used her hands to check for the water temperature or the resident was asked if the water temperature was to their liking. CNA 4 was unable to provide an answer when asked about the process on checking the water temperature for bed baths given to residents that were not cognitively (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) intact. On 3/5/2024 at 10:30 a.m., during an interview, CNA 5 stated that there were residents in station 1 that refused showers because the water in the shower was cold and did not want to go to another station to shower. CNA 5 stated that water used for bed baths were heated in the microwave and mixed with the water from the faucet. CNA 5 stated that he checked the water temperature with his hand. CNA 5 was unable to provide an answer when asked about the process on checking the water temperature for bed baths given to residents that were not cognitively intact. A review of Resident 7's admission Record indicated the facility admitted the resident on 6/23/2015 with diagnoses including multiple sclerosis (a disorder in which the body's immune system attacks the protective covering of the nerve cells in the brain, optic nerve, and spinal cord, called myelin sheath), type 2 diabetes mellitus (occurs when the blood sugar is too high), and essential hypertension (an abnormally high blood pressure that is not the result of a medical condition). A review of Resident 7's History and Physical, dated 10/21/2022, indicated that the resident had fluctuating capacity to understand and make decisions. A review of Resident 7's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 1/1/2024, indicated the resident's cognition was intact. Resident 7 required maximal assistance (helper lifts or holds the trunk or limbs and provides more than half the effort) on shower or bath and toileting hygiene. On 3/5/2024 at 10:35 a.m., during an interview. Resident 7 stated that it had been one week since the last shower was given and was only given bed baths after. Resident 7 stated the water in station 1 shower room was freezing cold. Resident 7 stated that the facility staff had to take the residents to station 4 for showers, passing other stations and resident rooms. Resident 7 stated that going to station 4 to shower was inconvenient. Resident 7 stated that not having hot water for showers made the resident angry, frustrated, and disgusted because the resident felt unclean. Resident 7 stated that the facility management lacked care for the residents in the facility. On 3/5/2024 at 11:28 a.m., during an interview, CNA 6 stated that some residents in station 2 complained that the water was cold. Stated that water for bed baths were heated in the microwave for 30 to 40 seconds and mixed with the cold tap water. CNA 6 stated that she checked the water temperature with her hand. CNA 6 was unable to provide an answer when asked about the process on checking the water temperature for bed baths given to residents that were not cognitively intact. On 3/5/2024 at 12:13 p.m., during an interview, CNA 7 stated that some residents were complaining that station 3 did not have hot water. CNA 7 stated that residents were brought to station 4 for showers. CNA 7 stated that water for bed baths were heated in the microwave and mixed with the water from the faucet. CNA 7 stated that she did not use a device to measure the water temperature. CNA 7 stated she used her hand to check the water temperature. A review of Resident 8's admission Record indicated the facility admitted the resident on 8/16/2021 with diagnoses including type 2 diabetes mellitus, chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems), and essential hypertension. A review of Resident 8's History and Physical, dated 11/12/2023, indicated that the resident had fluctuating capacity to understand and make decisions. A review of Resident 8's MDS, dated [DATE], indicated the resident's cognition was intact. Resident 8 required maximal assistance on shower or bath and toileting hygiene. A review of Resident 8's Bathing Task, dated 3/2024, indicated that the resident was dependent on facility staff to provide shower or bath. Resident 8 was not provided a shower from 3/1/2024 to 3/6/2024. On 3/5/2024 at 12:40 p.m., during an interview, Resident 8 stated that there was no hot water in the facility, and it had been one week since the last shower provided for the resident. Resident 8 stated that the facility staff provided bed baths, but the resident preferred to shower. Resident 8 stated that the CNAs microwave the water used for the resident's bed bath. Resident 8 stated that the facility staff placed wet washcloths inside a plastic bag and heats them in the microwave. Resident 8 stated that these wet washcloths were used when the resident's disposable briefs needed to be changed. A review of Resident 9's admission Record indicated the facility admitted the resident on 1/5/2024 with diagnoses including myocardial infarction (caused by decreased or complete cessation of blood flow to the portion of the heart), hemiplegia (paralysis that affects one side of the body) and hemiparesis (one-sided muscle weakness) following a cerebral infarction (result of disrupted blood flow to the brain because of problems with the blood vessels that supply it) affecting the left non-dominant side, and essential hypertension. A review of Resident 9's History and Physical, dated 1/5/2024, indicated that the resident had fluctuating capacity to understand and make decisions. A review of Resident 9's MDS, dated [DATE], indicated the resident's cognition was intact. Resident 9 required maximal assistance on shower or bath and toileting hygiene. A review of Resident 9's Bathing Task, dated 3/2024, indicated that the resident was dependent on facility staff to provide shower or bath. Resident 9 was not provided a shower from 3/1/2024 to 3/6/2024. On 3/5/2024 at 12:46 p.m., during an interview, Resident 9 stated that the bed bath provided to the resident was quick because the water used did not stay hot. Resident 9 stated that the facility staff informed the resident that they microwave the water used for bed baths. A review of Resident 10's admission Record indicated the facility admitted the resident on 1/23/2021 with diagnoses including age-related osteoporosis (occurs when bones naturally lose some of the density and the ability to regrow because of the person's age), anxiety disorder (excessive worry about everyday issues and situations), and essential hypertension. A review of Resident 10's History and Physical, dated 6/13/2023, indicated that the resident had fluctuating capacity to understand and make decisions. A review of Resident 10's MDS, dated [DATE], indicated the resident's cognition was intact. Resident 10 required moderate assistance (helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) on shower or bath. A review of Resident 10's Bathing Task, dated 3/2024, indicated that the resident required supervision on shower or bath. Resident 10 was not provided a shower from 3/1/2024 to 3/6/2024. On 3/5/2024 at 12:53 p.m., during an interview, Resident 10 stated that cold water was used to clean herself because the facility staff did not offer the resident to go to another station to shower. Resident 10 stated that the facility staff did not provide warm water to use. Resident 10 preferred warm water but stated that nothing could be done about it. A review of Resident 11's admission Record indicated the facility admitted the resident on 8/28/2023 with diagnoses including type 2 diabetes mellitus with foot ulcer (wound) and essential hypertension. A review of Resident 11's History and Physical, dated 8/28/2023, indicated that the resident had fluctuating capacity to understand and make decisions. A review of Resident 11's MDS, dated [DATE], indicated the resident's cognition was intact. Resident 11 required moderate assistance on shower or bath. On 3/5/2024 at 2:11 p.m., during an interview, Resident 11 stated that it took ten to 15 minutes before the water in the shower room becomes warm. Resident 11 stated that the warm water in the shower room did not last long especially in the morning. Resident 11 stated that showers were preferred in the morning. A review of Resident 12's admission Record indicated the facility admitted the resident on 10/20/2023 with diagnoses including COPD, diabetes mellitus, and cardiomegaly (enlarged heart). A review of Resident 12's History and Physical, dated 10/21/2023, indicated that the resident had fluctuating capacity to understand and make decisions. A review of Resident 12's MDS, dated [DATE], indicated the resident's cognition was intact. Resident 12 required maximal assistance on shower or bath and toileting hygiene. On 3/5/2024 at 2:19 p.m., during an interview, Resident 12 stated that the facility staff provide a bucket of water, but the water was not warm enough. On 3/5/2024 at 3:12 p.m., during an interview, the Director of Staff Development (DSD) stated that the residents' shower schedules were not changed since the hot water concern started on 2/29/2024. The DSD stated that residents in station 1, station 2, and station 3 were brought to station 4 and station 5 for showers. The DSD stated that the station 1, station 2, and station 3 residents take their showers in between the showers of the residents in station 4 and station 5. The DSD stated that residents complained that the water was cold but there were no complaints that residents were not provided with showers. The DSD stated that residents were not given a cold shower. On 3/5/2024, during a concurrent observation and interview, the MS stated the water temperature in station 4 and station 5 were hotter in the afternoon because less people were using it. The MS was observed checking the water temperature in the nurse station sinks using a probe thermometer and the following readings were observed: a. At 3:15 p.m., the water temperature at nurse station 1 hand sink was 75.1°F. b. At 3:17 p.m., the water temperature at nurse station 2 hand sink was 73.2°F. c. At 3:19 p.m., the water temperature at nurse station 3 hand sink was 75.1°F. d. At 3:22 p.m., the water temperature at nurse station 4 hand sink was 115.5°F. e. At 3:24 p.m., the water temperature at nurse station 5 hand sink was 112.9°F. A review of Resident 17's admission Record indicated the facility admitted the resident on 8/28/2019 with diagnoses including age-related osteoporosis, type 2 diabetes mellitus, and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 17's MDS, dated [DATE], indicated the resident's cognition was severely impaired. Resident 17 was dependent (the resident does none of the efforts to complete the activity) on facility staff on shower or bath and toileting hygiene. On 3/7/2024 at 9:01 a.m., during a concurrent observation and interview, observed Resident 17 on a shower chair inside shower room [ROOM NUMBER]. CNA 9 turned on the shower and pointed the water towards Resident 17's head and body. Resident 17 was observed agitated after CNA 9 placed the water on the resident. Surveyor checked the water temperature using the temperature probe and measured at 71.2°F. CNA 9 did not answer when asked if this is the water temperature used to shower residents. CNA 9 adjusted the water temperature and stated that she made sure the water was not too hot. Surveyor checked the water temperature using the temperature probe and measured 97.1°F. On 3/7/2024 at 9:16 a.m., during a concurrent observation and interview, CNA 10 was observed preparing a basin of water for a resident's bed bath. CNA 10 checked the water temperature using a gloved hand. CNA 10 stated that the water was not warm enough. CNA 10 heated a pitcher of water in the microwave and poured it in the basin with warm water. CNA 10 checked the water with a gloved hand and stated that the water was warm enough. The surveyor checked the water temperature using a temperature probe and measured 93.5°F. On 3/7/2024 at 11:19 a.m., during a follow up interview, CNA 10 stated that she checked the water temperature with a gloved hand. CNA 10 stated that checking the water temperature with a gloved hand meant net being able to feel the real water temperature CNA 10 stated that it had the potential for inaccurate water temperature. CNA 10 stated that it had the potential to burn residents' skin, or the water could be too cold and uncomfortable for the resident. On 3/7/2024 at 2:14 p.m., during an interview, the Director of Nursing (DON) stated that CNAs should get the water from station 4 or station 5 for the residents' bed bath. The DON stated that CNAs were instructed to take the residents to station 4 or station 5 for showers. A review of the facility's policy and procedure titled, Homelike Environment, dated 12/28/2023, indicated that residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. The policy indicated that staff provides person-centered care that emphasizes the residents' comfort, independence, and personal needs and preferences. The policy indicated that the facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting including . a. clean, sanitary, and orderly environment. A review of the facility's policy and procedures titled, Bath, Shower/Tub, dated 12/28/2023, indicated the purpose to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The policy and procedure indicated to fill the tub approximately one half full of warm water (105°F). test the water with the bath thermometer or the elbow. If using a shower, regulate the temperature and the flow of the water. A review of the facility's Maintenance and Plant Operations, dated 12/28/2023, indicated the purpose of maintenance of a safe and sanitary environment, ensures safety, affords protection, and enhances the well-being of the residents, public, and staff. The purpose indicated the maintenance activities included providing a functional, sanitary, and comfortable environment and ensuring that all equipment, buildings, spaces, and fixtures are kept in operable condition. The Water Supply, Plumbing, and Water Heating System section indicated the hot water temperature be maintained at not less than 105°F and not more than 120°F for all hot water used by residents.

CONCERN (E) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of 18 sampled residents (Resident 8, Resident 9, and Resident 16) were provided bed baths using a safe and comfortable water temperature. The facility staff used the microwave to heat the water for the resident's bed bath. This deficient practice placed the residents at risk for sustaining burns, scalding (injury from hot liquid or steam), and experiencing uncomfortable water temperatures. Cross reference to F675 and F908. Findings: On 3/5/2024 at 8:46 a.m., during a concurrent observation and interview, observed water heater #2 room with two water heater machines and two hot water containers. The Maintenance Supervisor (MS) stated that the second water heater in the room was turned off because it was not safe to use after a smell of combustion was observed. The MS turned on water heater 2 and smoke came out of the water heater machine. Water heater 2 was observed with a black smoke stain on the top front side. The hot water container was observed with a black smoke stain on the left side adjacent to the water heater. The MS stated that water heater 1 had been broken for more than a year and station 1, station 2, and station 3 were only using water heater 2. The MS stated that station 1, station 2, and station 3 did not have hot water since 2/29/2024. The MS stated that there were residents complaining that the water was cold. The MS stated that the Administrator (ADM) and nursing staff were aware that water heater 1 and water heater 2 were broken. On 3/5/2024 at 10:20 a.m., during a concurrent observation and interview, Certified Nursing Assistant 4 (CNA 4) stated she worked in station 1. CNA 4 stated the water used for bed baths wasa mixture of cold tap water and water heated in the microwave. The microwave was observed inside station 1's utility room. CNA 4 stated that she did not use any device to measure the water temperature. CNA 4 stated that she used her hands to check for the water temperature or the resident was asked if the water temperature was to their liking. CNA 4 was unable to provide an answer when asked about the process on checking the water temperature for bed baths given to residents that were not cognitively (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) intact. On 3/5/2024 at 10:30 a.m., during an interview, CNA 5 stated he worked in station 1. CNA 5 stated that water used for bed baths were heated in the microwave and mixed with the water from the faucet. CNA 5 stated that he checked the water temperature with his hand. CNA 5 was unable to provide an answer when asked about the process on checking the water temperature for bed baths given to residents that were not cognitively intact. On 3/5/2024 at 11:28 a.m., during an interview, CNA 6 stated she worked at station 2. CNA 6 stated the water used for bed baths was heated in the microwave for 30 to 40 seconds and mixed with the cold tap water. CNA 6 stated that she checked the water temperature with her hand. CNA 6 was unable to provide an answer when asked about the process on checking the water temperature for bed baths given to residents that were not cognitively intact. On 3/5/2024 at 12:13 p.m., during an interview, CNA 7 stated she worked in station 3. CNA 7 stated the water used for bed baths were heated in the microwave and mixed with the water from the faucet. CNA 7 stated that she did not use a device to measure the water temperature. CNA 7 stated she used her hand to check the water temperature. On 3/5/2024 at 12:35 p.m., during an interview, Licensed Vocational Nurse 4 (LVN 4) stated that facility staff heat up water in the microwave and mix it with the water from the faucet. LVN 4 stated that she was unsure about the process of getting hot water for the resident's bed baths. LVN 4 stated that she does not monitor the CNAs activities all day. A review of Resident 8's admission Record indicated the facility admitted the resident on 8/16/2021 with diagnoses including type 2 diabetes mellitus (occurs when the blood sugar is too high), chronic obstructive pulmonary disease (COPD - a group of diseases that cause airflow blockage and breathing-related problems), and essential hypertension (an abnormally high blood pressure that is not the result of a medical condition). A review of Resident 8's History and Physical, dated 11/12/2023, indicated that the resident had fluctuating capacity to understand and make decisions. A review of Resident 8's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 2/22/2024, indicated the resident's cognition was intact. Resident 8 required maximal assistance on shower or bath and toileting hygiene. A review of Resident 8's Bathing Task, dated 3/2024, indicated that the resident was dependent on facility staff to provide shower or bath. Resident 8 was not provided a shower from 3/1/2024 to 3/6/2024. On 3/5/2024 at 12:40 p.m., during an interview, Resident 8 stated that there was no hot water in the facility, and it had been one week since the last shower provided for the resident. Resident 8 stated that the facility staff provided bed baths, but the resident preferred to shower. Resident 8 stated that the CNAs microwave the water used for the resident's bed bath. Resident 8 stated that the facility staff placed wet washcloths inside a plastic bag and heats them in the microwave. Resident 8 stated that these wet washcloths were used when the resident's disposable briefs needed to be changed. A review of Resident 9's admission Record indicated the facility admitted the resident on 1/5/2024 with diagnoses including myocardial infarction (caused by decreased or complete cessation of blood flow to the portion of the heart), hemiplegia (paralysis that affects one side of the body) and hemiparesis (one-sided muscle weakness) following a cerebral infarction (result of disrupted blood flow to the brain because of problems with the blood vessels that supply it) affecting the left non-dominant side, and essential hypertension. A review of Resident 9's History and Physical, dated 1/5/2024, indicated that the resident had fluctuating capacity to understand and make decisions. A review of Resident 9's MDS, dated [DATE], indicated the resident's cognition was intact. Resident 9 required maximal assistance on shower or bath and toileting hygiene. A review of Resident 9's Bathing Task, dated 3/2024, indicated that the resident was dependent on facility staff to provide shower or bath. Resident 9 was not provided a shower from 3/1/2024 to 3/6/2024. On 3/5/2024 at 12:46 p.m., during an interview, Resident 9 stated that the bed bath provided to the resident was quick because the water used did not stay hot. Resident 9 stated that the facility staff informed the resident that they microwave the water used for bed baths. On 3/5/3024 at 3:12 p.m., during an interview, the Director of Staff Development (DSD) stated that water heated in the microwave had the potential to cause burns on residents. On 3/7/2024 at 9:16 a.m., during a concurrent observation and interview, observed CNA 10 took a pitcher of water out of the microwave in nurse station 2 and brought it inside Resident 16's room. CNA 10 stated that the water in the pitcher was hot. CNA 10 poured the water from the pitcher into the basin of tap water. CNA 10 used her gloved hand to check the water temperature in the bucket. CNA stated that it was not hot enough and needed to heat up more water. CNA 10 stated that the facility staff had been heating the water in the microwave since the hot water in the facility went out. CNA 10 stated that the DSD was aware that the facility staff use the microwave to heat up the water for bed baths. On 3/7/2024 at 10:29 a.m., during a concurrent observation and interview, CNA 9 demonstrated the process on how she gets hot water for the resident's bed bath. CNA 9 filled the basin with water from the faucet and placed the basin with water inside the microwave. The water in the basin was heated in the microwave four times for 30 seconds, once for 20 seconds and once for one minute with CNA 9 checking the water temperature with her hand in between the heating times. CNA 9 stated that the water temperature was the temperature she used for resident bed baths and the surveyor, using a probe thermometer, measured the water temperature at 101.2 degrees Fahrenheit (°F - unit of measurement). On 3/7/2024 at 10:50 a.m., during an interview, CNA 11 stated that she gets the hot water from the hot water dispenser used for facility staff coffee. CNA 11 stated that she mixed the hot water with the cold tap water to use for resident bed baths. CNA 11 stated the DSD informed the facility staff to make sure the water was warm but did not tell them where to get the hot water. On 3/7/2024 at 2:14 p.m., during an interview, the Director of Nursing (DON) stated that using the microwave to heat the water had the potential for residents to sustain burns. The DON stated that the water temperature heated in the microwave cannot be regulated and would be a hit and miss on the area of the water. A review of the facility's policy and procedure titled, Safety and Supervision of Residents, dated 12/28/2023, indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. A review of the facility's policy and procedure titled, Bath, Shower/Tub, dated 12/28/2023, indicated the purpose to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The policy and procedure indicated to fill the tub approximately one half full of warm water (105°F). test the water with the bath thermometer or the elbow. If using a shower, regulate the temperature and the flow of the water. A review of the facility's Maintenance and Plant Operations, dated 12/28/2023, indicated the purpose of maintenance of a safe and sanitary environment, ensures safety, affords protection, and enhances the well-being of the residents, public, and staff. The purpose indicated the maintenance activities included providing a functional, sanitary, and comfortable environment and ensuring that all equipment, buildings, spaces, and fixtures are kept in operable condition. The Water Supply, Plumbing, and Water Heating System section indicated the hot water temperature be maintained at not less than 105°F and not more than 120°F for all hot water used by residents.

CONCERN (E) 📢 Someone Reported This

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

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

Room Equipment (Tag F0908)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure boiler (a device providing hot water supply) room equipment were in good working condition and provided safe and comfortable environment for the residents, staff, and visitors, as indicated in the facility's policies and procedures. The facility failed to: 1. Maintain boilers in safe operating conditions in one of three boiler rooms. 2. Maintain required water temperature range of 105 degrees Fahrenheit (°F - unit of measurement) to 120°F in five of five resident shower rooms (station 1 shower 1B room, station 2 shower 2A room, station 3 shower 4A room, station 4 shower 4 whirlpool room, and station 5 shower 5 room) and five of five nurse station hand sinks (station 1, station 2, station 3, station 4, and station 5). These deficient practices resulted in residents not able to shower because of the uncomfortable and unsafe water temperatures. Findings: On 3/5/2024 at 8:12 a.m., during a concurrent observation and interview, water was ran in shower 1B in station 1 for 8 minutes. Maintenance Personnel (MP) took the water temperature and stated that the shower water temperature measured at 68.9°F. On 3/5/2024 at 8:22 a.m., during a concurrent observation and interview, water was ran in shower 2A in station 2 for 2 minutes and 58 seconds. MP took the water temperature and stated that the shower water temperature measured at 70°F. MP stated that it takes two minutes for the water to reach the water temperature of 105°F. On 3/5/2024 at 8:27 a.m., during a concurrent observation and interview, water was ran in shower 4A in station 3 for 4 minutes and 43 seconds. MP took the water temperature and stated that the shower water temperature measured at 68.4°F. MP stated that the one of the water heaters that supplied station 1, station 2, and station 3 with hot water had been broken and the second water heater had been broken since last week. On 3/5/2024 at 8:34 a.m., during a concurrent observation and interview, water was ran in shower 4 whirlpool room in station 4 for 3 minutes and 20 seconds. MP took the water temperature and stated that the shower water temperature measured at 81.9°F. On 3/5/2024 at 8:39 a.m., during a concurrent observation and interview, water was ran in shower 5 in station 5 for 3 minutes and 50 seconds. MP took the water temperature and stated that the shower water temperature measured at 70.3°F. MP stated that none of the water temperatures in the observed shower rooms reached the required water temperature of 105 F. On 3/5/2024 at 8:46 a.m., during a concurrent observation and interview, observed water heater #2 room with two water heater machines and two hot water containers. The Maintenance Supervisor (MS) stated that the two water heaters in the room were both turned off because of the combustion smell and they were not safe to use. The MS turned on the water heater 2 and a smell of smoke came out of the water heater machine. The water heater 2 was observed with a black smoke stain on the top front side. The hot water container was observed with a black smoke stain on the left side adjacent to the water heater. The MS stated that water heater 1 had been broken for more than a year and station 1, station 2, and station 3 were only using water heater 2. The MS stated that station 1, station 2, and station 3 did not have hot water since 2/29/2024. The MS stated that there were residents complaining that the water was cold. The MS stated that the Administrator (ADM) and nursing staff were aware that water heater 1 and water heater 2 were broken. On 3/5/2024 at 9 a.m., during a concurrent observation and interview, the MS ran the water in nurse station 5 hand sink for 2 minutes and 58 seconds. The MS was observed measuring the water temperature and stated the water temperature was 101.9°F. On 3/5/2024 at 9:11 a.m., during a concurrent observation and interview, the MS ran the water in nurse station 4 hand sink for 2 minutes and 38 seconds. The MS was observed measuring the water temperature and stated the water temperature was 98.4°F. The MS stated that the water temperature did not reach the desired water temperature of 105°F to 120°F because a lot of residents had used the water in the station 4 and station 5. 3/5/2024 at 9:14 a.m., during a concurrent interview and record review, reviewed the facility's Hot Water Temperatures log, dated March 2024, indicated the water temperature should be between 105°F 50 112°F. The log indicated that there were no water temperatures recorded for station 1, station 2, and station 3 from 3/1/2024 to 3/5/2024. MS stated that the water temperatures were not taken for station 1, station 2, and station 3 because the water heaters were turned off. On 3/5/2024 at 10:20 a.m., during a concurrent observation and interview, Certified Nursing Assistant 4 (CNA 4) stated that some residents in station 1 refused their showers and were provided bed baths instead because the water in the shower was cold. On 3/5/2024 at 10:30 a.m., during an interview, CNA 5 stated that there were residents in station 1 that refused showers because the water in the shower was cold and did not want to go to another station to shower. On 3/5/2024 at 10:35 a.m., during an interview. Resident 7 stated that it had been one week since the last shower was given and was only given bed baths after. Resident 7 stated the water in station 1 shower room was freezing cold. On 3/5/2024 at 11:28 a.m., during an interview, CNA 6 stated that some residents in station 2 complained that the water was cold. On 3/5/2024 at 12:13 p.m., during an interview, CNA 7 stated that some residents were complaining that station 3 did not have hot water. On 3/5/2024 at 12:40 p.m., during an interview, Resident 8 stated that there was no hot water in the facility, and it had been one week since the last shower provided for the resident. Resident 8 stated that the facility staff provided bed baths, but the resident preferred to shower. On 3/5/2024 at 12:46 p.m., during an interview, Resident 9 stated that the bed bath provided to the resident was quick because the water used did not stay hot. On 3/5/2024 at 12:53 p.m., during an interview, Resident 10 stated that cold water was used to clean herself because the facility staff did not offer the resident to go to another station to shower. Resident 10 stated that the facility staff did not provide warm water to use. Resident 10 preferred warm water but stated that nothing could be done about it. On 3/5/2024 at 2:11 p.m., during an interview, Resident 11 stated that it took ten to 15 minutes before the water in the shower room becomes warm. Resident 11 stated that the warm water in the shower room did not last long especially in the morning. Resident 11 stated that showers were preferred in the morning. On 3/5/2024, during a concurrent observation and interview, the MS stated the water temperature in station 4 and station 5 were hotter in the afternoon because less people were using it. The MS was observed checking the water temperature in the nurse station sinks using a probe thermometer and the following readings were observed: a. At 3:15 p.m., the water temperature at nurse station 1 hand sink was 75.1°F. b. At 3:17 p.m., the water temperature at nurse station 2 hand sink was 73.2°F. c. At 3:19 p.m., the water temperature at nurse station 3 hand sink was 75.1°F. d. At 3:22 p.m., the water temperature at nurse station 4 hand sink was 115.5°F. e. At 3:24 p.m., the water temperature at nurse station 5 hand sink was 112.9°F. On 3/7/2024 at 9:01 a.m., during a concurrent observation and interview, observed Resident 17 on a shower chair inside shower room [ROOM NUMBER]. CNA 9 turned on the shower and pointed the water towards Resident 17's head and body. Resident 17 was observed agitated after CNA 9 placed the water on the resident. Surveyor checked the water temperature using the temperature probe and measured at 71.2°F. CNA 9 did not answer when asked if this is the water temperature used to shower residents. CNA 9 adjusted the water temperature and stated that she made sure the water was not too hot. Surveyor checked the water temperature using the temperature probe and measured 97.1°F. On 3/7/2024 at 2:14 p.m., during an interview, the Director of Nursing (DON) stated that CNAs should get the water from station 4 or station 5 for the residents' bed bath. The DON stated that CNAs were instructed to take the residents to station 4 or station 5 for showers. A review of the facility's Maintenance and Plant Operations, dated 12/28/2023, indicated the purpose of maintenance of a safe and sanitary environment, ensures safety, affords protection, and enhances the well-being of the residents, public, and staff. The purpose indicated the maintenance activities included providing a functional, sanitary, and comfortable environment and ensuring that all equipment, buildings, spaces, and fixtures are kept in operable condition. The Water Supply, Plumbing, and Water Heating System section indicated the hot water temperature be maintained at not less than 105°F and not more than 120°F for all hot water used by residents.

Jan 2024 41 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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 200's admission Record (Face Sheet), dated 1/25/2024, indicated the facility admitted Resident 200 on 9/19/2023, with diagnoses including chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), diabetes mellitus (a common form of diabetes in which the body cannot properly store or use glucose [sugar], the main body's source of energy), and anemia (a condition in which the blood does not have enough red blood cells that carries oxygen from the lungs to other parts of the body). The Face Sheet indicated Resident 200 was self-responsible. A review of Resident 200's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/26/2023, indicated Resident 200 had the ability to make herself self-understood and understand others. The MDS indicated the resident required from partial/moderate assistance to substantial/maximal assistance in toileting hygiene, shower/bathe self, upper body dressing, lower body dressing and putting on/taking off foot footwear. During a concurrent interview and record review on 1/23/2024, at 1:00 p.m., with the Social Service Director (SSD), Resident 200's social services progress notes and care plan meeting / IDT notes were reviewed, the SSD stated there was no initial care plan meeting held for Resident 200 since she was admitted on [DATE]. The SSD stated the initial care plan meeting should have been done within 72 hours upon admission with the resident. The SSD stated failure to conduct initial care plan meeting with the resident could deprive her the right to participate in formulating her care plans for her own wellbeing. During an interview on 1/26/2024, at 9:40 a.m., with the Director of Staff Development (DSD), the DSD stated the social services should have scheduled the initial care plan meeting with Resident 200 so she could have been part of her plan of care. The DSD stated Resident 200 will be confused not knowing her treatment plan and discharge goals. During an interview on 1/26/2024, at 10:40 a.m., with the Director of Nursing (DON), the DON stated social services should have scheduled the initial care plan meeting with Resident 200 so she could have been part of her plan of care. The DON stated Resident 200's right to participate in planning her care was not honored which left her uninformed regarding her treatment and discharge plans. A review of care plan titled, Resident requires 24-hour care and will remain in facility long term under custodial care, initiated last 9/25/2023, indicated an intervention to encourage resident/responsible party to participate in plan of care. A review of the facility's recent policy and procedure titled, Interdisciplinary Team Meetings, last reviewed on 12/28/2023, indicated meeting will be held within the first 14 days of admit, quarterly and as needed. Social Services will notify the appropriate families and residents of the schedule for upcoming week. Based on interview and record review, the facility failed to ensure the initial care conference meeting was held with the resident or their representative for two of three sampled residents investigated during review of the residents' interdisciplinary team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the residents) care plan meeting (Resident 91 and Resident 200). This deficient practice had the potential to violate Resident 91 and Resident 200's right to be an active participants in their care and had the potential for delay in the provision of necessary care and services. Findings: 1. A review of Resident 91's admission Record indicated the facility admitted the resident on 11/8/2023 and readmitted the resident on 12/27/2023 with diagnoses including end stage renal disease (final stage of chronic kidney disease, where kidney function has declined to the point that the kidneys can no longer function on their own) epilepsy (a condition that happens as a result of abnormal electrical brain activity, also known as a seizure), and lumbar radiculopathy (also known as pinched nerve - a disorder that causes pain in the lower back and hip which radiates down the back of the thigh into the leg). A review of Resident 91's History and Physical (H&P) dated 11/9/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 91 's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 1/2/2024, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required substantial or maximal assistance with transfers; partial or moderate assistance with bathing, and upper and lower body dressing; and supervision with all other activities of daily living (ADLs, basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 91 was receiving hemodialysis. A review of Resident 91's electronic health record (EHR) did not indicate documented evidence an initial care plan meeting was held since admission. During a concurrent interview and record review on 1/25/2024 at 3:30 p.m., with the Assistant Director of Nursing (ADON), Resident 91's electronic health record was reviewed. The ADON verified there is no documented evidence that the initial care plan meeting was held with Resident 91 and/or his representative. During an interview on 1/25/2024 at 3:50 p.m., the Social Services Assistant (SSA) stated that during her review of Resident 91's electronic health record (EHR), there is no documented evidence the initial care plan meeting was held with Resident 91 and/or resident representative. The SSA stated the initial care plan meeting is held with the resident and or their representative within 72 hours of admission, quarterly and as needed. The SSA stated the MDS Coordinator provides the list of care plan meeting schedules to the social services department and the SSA or Social Service Director (SSD) notifies the resident and or resident representative. During an interview on 1/26/2024 at 1:15 p.m., with the Director of Nursing (DON), the DON stated it is facility's practice to hold the initial care plan meetings with the residents and or their representative within 72 hours of admission, quarterly, and as needed. The DON stated it is important to have an initial care plan meeting in order to address the resident's concerns and discuss their plan of care and discharge goals. The DON stated not having an initial care plan meeting can result in the delay of delivery of care and services. A review of the facility's policy and procedure titled, Interdisciplinary Team Meetings, last reviewed 12/28/2023, indicated the purpose of IDT meeting to review and or revise the plan of care, medications, and current physician orders to ensure the residents have all their medical and psychosocial needs met, and notify the residents and or their families of their total health status. The policy indicated the meeting will be held within the first 14 of admit, quarterly, and as needed. A review of the facility's policy and procedure titled, Interdisciplinary Team, last reviewed 12/28/2023, indicated every resident will have IDT collaboration based on the individually assessed need. The policy indicated IDT for residents is conducted through care conferences and documentation of recommendations will be established to address risk area and manage overall health condition of residents.

CONCERN (D)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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b. A review of Resident 233's admission Record indicated the facility admitted the resident on 1/4/2024 with diagnoses including cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting left non-dominant side and depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities). A review of Resident 233's Minimum Data Set (MOS, a standardized assessment and care screening tool), dated 1/10/2024, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated the resident required substantial to maximal assistance on upper body dressing, personal hygiene, showering/ bathing self, and toileting hygiene. A review of Resident 233's Fall Risk Assessment, dated 1/5/2024, indicated the resident was a high fall risk. A review of Resident 233's care plan, resident is at risk for falls with or without injury related to antihypertensive medication and unsteady gait, dated 1/5/2024, indicated an intervention to place call light within reach. A review of Resident 233's care plan, resident requires assistance related to cognitive impairment, dated 1/5/2024, indicated an intervention to encourage resident to use call light for assistance. During a concurrent observation and interview on 1/22/2024 at 10:02 a.m., with Certified Nursing Assistant 5 (CNA 5), observed Resident 233's call light hanging below the right side rail of the bed and Resident 233 was observed lying in bed and unable to reach his call light. CNA 5 stated Resident 233's call light is not within reach. CNA 5 stated he call light should be within the resident's reach. During an interview on 1/25/2024, at 10:31 a.m., Licensed Vocational Nurse 12 (LVN 12), LVN 12 stated the CNAs and the LVNs should make sure call lights should be within the residents' reach. LVN 12 stated that Resident 233's call light should be clipped to his gown and within reach because he has left sided weakness and he needs assistance when getting out of bed. During an interview on 1/25/2024, at 10:47 a.m., with the Director of Nursing, the (DON) stated Resident 233 should have his call light within reach so he can call for assistance and communicate his needs. A review of the facility's policy and procedure titled, Call Lights, last reviewed 12/28/2023, indicated, to meet the resident's requests and needs within an appropriate time period as well as those residents with special needs. The policy further indicated, assure the call light is within the resident's reach when in their room of on the toilet. Based on observation, interview, and record review the facility failed to keep the call light (an alerting device for nurses or other nursing personnel to assist a resident when in need) within reach of the resident for two out of five sampled residents (Resident 182 and Resident 233) investigated during review of environment facility task. These deficient practices had the potential to result in the resident not being able to call for facility staff assistance and delay in the provision of necessary care and services that can negatively affect the resident's comfort and well-being. Findings: a. A review of Resident 182's admission Record indicated the facility admitted the resident on 6/29/2023, with diagnoses including dysarthria (a motor speech disorder that makes it difficult to form and pronounce words), anarthria (a complete loss of speech), and subarachnoid hemorrhage (bleeding in the area between the brain and the thin tissues that cover the brain). A review of Resident 182's History and Physical (H&P), dated 6/30/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 182's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/5/2024, indicated the resident usually had the ability to make-self understood and understand others. The MDS indicated the resident was dependent on eating, the resident required substantial to maximal assistance on putting on and taking off footwear, lower body dressing, shower or bathe self, and toileting hygiene. A review of Resident 182's Care Plan titled, Activities of Daily Living (ADL) Self Performance requires: Legend ., initiated on 6/29/2023, indicated an intervention to place call light within reach and answer promptly. During a concurrent observation and interview on 1/22/2024, at 10:43 a.m., with Licensed Vocational Nurse 1 (LVN 1), observed Resident 182's call light hanging below the resident's left side rail. LVN 1 stated the call light should be within reach so the resident can call when he needs help. During an interview on 1/26/2024, at 9:16 a.m., with the Director of Staff Development (DSD), the DSD stated the staff should have uncoiled the call light from the side rails and placed them within reach of the resident so they will be able to call the staff for help when needed. The DSD stated the resident can fall when trying to reach for the call light. During an interview on 1/26/2024, at 10:48 a.m., with the Director of Nursing (DON), the DON stated the call light should be within the resident's reach for safety and to ensure their needs are met. A review of the facility's recent policy and procedure titled, Accommodation of Needs, last reviewed on 12/28/2023, indicated our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. Installing longer cords or providing remote controlled overhead or task lighting so they are easily accessible. A review of the facility's recent policy and procedure titled, Answering the Call Light, last reviewed on 12/28/2023, indicated the purpose of this procedure is to respond to the resident's requests and needs. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. A review of the facility's recent policy and procedure titled, Call Lights, last reviewed on 12/28/2023, indicated to assure that the call light is within the resident's reach when in their room or on the toilet.

CONCERN (D) 📢 Someone Reported This

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

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the residents' right to be free from physical abuse (deliberately aggressive or violent behavior with the intention to cause harm) for two of six sampled residents (Resident 23 and Resident 203). On 1/13/2024 at 11:30 a.m., in the hallway, Resident 203 threw a fruit cup and spat at Resident 23's face. Then, Resident 23 punched Resident 203 in the face followed by Resident 203 hitting Resident 23 back in the face. This deficient practice resulted in Resident 203 and Resident 23 subjected to physical abuse while under the care of the facility. This deficient practice also caused Resident 203 to report right eye pain and received pain medication. Findings: A review of Resident 203's admission Record indicated the facility admitted the resident on 12/28/2023 with diagnoses including dependence on supplemental oxygen, muscle weakness, and hypertension (high blood pressure). A review of Resident 203's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 1/3/2024, indicated the resident's cognitive skills (ability to understand and make decisions) were intact. The MDS indicated Resident 203 required supervision or touching assistance for toileting hygiene, showering/bathe self, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 203's Care Area assessment dated [DATE], triggered Care Areas and Care Planning Decision for mood State, behavior symptoms, and cognitive loss/dementia. A review of Resident 203's Change in Condition Evaluation (COC), dated 1/13/2024, timed at 11:30 a.m., indicated Resident 203 stated she was hit by another resident (Resident 23) while in the hallway near her room. Resident 203 stated when she did not move out of the hallway to allow another resident to pass, by the other resident (Resident 23) grazed (to touch lightly) her with an open hand over her left eyebrow. Resident 203 with no complaint of pain and with skin intact post (after) assessment. Both residents were separated by staff and monitored as needed. A review of Resident 203's Medication Administration Record (MAR - medications administered to the residents), indicated Hydrocodone (contains codeine)/Acetaminophen tablet (Norco) 10-325 milligram (mg- a unit of measure) give one (1) tablet by mouth every 4 hours as needed for moderate to severe pain, ordered on 12/28/2023. The MAR indicated Resident 203 received Norco on 1/13/2023 at 12:07 p.m. for pain level of 6 out of 10 (the numerical rating pain scale is a simple pain scale that grades pain levels from 0 [no pain] and 10 [worst pain possible] with 6 as moderate). A review of Resident 203's Interdisciplinary team (IDT-is a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological, and spiritual needs of the resident) investigation, dated 1/17/2024, indicated Resident 23 was provoked by Resident 203, who blocked her right of passage, resulting to Resident 203 throwing the fruit back and forth and Resident 23 got physical and struck Resident 203. A review of Resident 203's Social Services Notes, dated 1/13/2024 to 1/16/2024, indicated no one from Social Services came to monitor the resident's psychosocial wellbeing after the altercation. A review of Resident 203's care plan on possible resident to resident altercation with another resident on 1/13/2024. The care plan indicated Resident 203 stated she was hit in the face over the left eyebrow. A review of Resident 23 's admission Record indicated the facility admitted the resident on 9/16/2023, with a diagnosis of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a mental health diagnoses that lead to excessive nervousness, fear, apprehension, and worry), and psychosis (a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not). A review of Resident 23's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. The MDS indicated Resident 22 required partial/moderate assistance for toileting hygiene, showering/bathe self, upper and lower body dressing, and putting on/taking off footwear. A review of Resident 23's Change in Condition Evaluation, dated on 1/13/2024 at 2 p.m. indicated Resident 23 stated that while she was coming down the hallway, another resident refused to let her pass by. The COC indicated that Resident 23 stated the other resident tried to hit her by swinging her hand toward her and she tried to block the other resident and landed a hit to the other resident's (Resident 203) face. A review of Resident 23's Social Services Notes, dated 1/15/2024, indicated the other resident (Resident 203) threw a fruit cup, and Resident 23 then proceeded to hit the other resident in the face. On 1/22/2024 at 10:37 a.m. during an interview, Resident 203 stated that last week (1/13/2024) Resident 23 came up to her in the hallway and punched her in the face. Resident 203 stated that staff immediately separated them (Resident 203 and Resident 23), and she had some pain, and the nurse gave her pain medication. On 1/22/2024 at 10:37 a.m. during an interview, Resident 23 stated that last week (1/13/2024), she had an interaction with Resident 203 in front of the nurses' station and Resident 203 stopped in front of her and blocked her way and said, fat b----, I am not moving, and spat on her face and threw a fruit cup at her. Resident 23 stated that she punched Resident 203 in the face. Staff then separated her from Resident 203, and she has had no contact with the other resident since. On 1/22/2024 at 1:32 p.m. during an interview, Certified Nursing Assistant 8 (CNA 8) stated on 1/13/2024, around 11:30 a.m., she saw Resident 23 hit Resident 203. She had just come out of another resident's room, and she went and immediately separated the residents. On 1/24/2024 at 10:16 a.m. during an interview, Licensed Vocational Nurse 15 (LVN 15) stated on 1/13/2024 at around 11:30 a.m., she had been at the medication cart, and she did not directly see anything. The RN supervisor and the ADON told her what happened, and she went and did an assessment for Resident 203 and she complained of some pain to her head above her right eyebrow. LVN 15 stated that she gave her pain medication, Norco at around 12:00 p.m. On 1/24/2024 at 10:42 a.m., during an interview, Licensed Vocational Nurse 5 (LVN 5) stated on 1/13/2024 at around 11:30 a.m., she saw Resident 203 throw a fruit cup at Resident 23 and Resident 23 zoomed fast with her wheelchair over to Resident 203 and hit Resident 203 before staff could separate them. LVN 5 stated that she saw Resident 203 strike Resident 23 back in the head. LVN 5 stated that Resident 23 was placed on 1:1 supervision after the incident. On 1/24/2024 at 8:45 a.m., during an interview, the Director of Nursing (DON) stated that the abuse happened, Resident 23 hit Resident 203. A review of the facility's policy and procedure (P&P) titled, Abuse Prevention, last reviewed on 12/28/2023, indicated, Each resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family member(s) or legal guardian, friend(s), or other individuals. The facility's policy indicated, the purpose is to ensure the resident's rights are protected by providing a method for the prevention, reporting and investigation of any type of alleged resident abuse. The facility's policy indicated, If suspected perpetrator is another resident: Separate the residents so they do not interact with each other until circumstances of the reported incident can be determined.

CONCERN (D)

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a thorough investigation regarding allegations of abuse involving two of six residents (Residents 23 and Resident 203) investigated under the care area of abuse by failing to interview Licensed Vocational Nurse 5 (LVN 5) who witnessed the incident. This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from abuse. Findings: A review of Resident 203's admission Record indicated the facility admitted the resident on 12/28/2023 with diagnoses including dependence on supplemental oxygen, muscle weakness, and hypertension (high blood pressure). A review of Resident 203's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 1/3/2024, indicated the resident's cognitive skills (ability to understand and make decisions) were intact. The MDS indicated Resident 203 required supervision or touching assistance for toileting hygiene, showering/bathe self, lower body dressing, putting on/taking off footwear, and personal hygiene. A review of Resident 23 's admission Record indicated the facility admitted the resident on 9/16/2023, with a diagnosis of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a mental health diagnoses that lead to excessive nervousness, fear, apprehension, and worry), and psychosis (a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not). A review of Resident 23's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. The MDS indicated Resident 22 required partial/moderate assistance for toileting hygiene, showering/bathe self, upper and lower body dressing, and putting on/taking off footwear. On 1/22/2024 at 10:37 a.m., during an interview, Resident 203 stated last week (1/13/2024) Resident 23 came up to her in the hallway and punched her in the face. On 1/22/2024 at 10:37 a.m. during an interview, Resident 23 stated last week (1/13/2024), she had an interaction with Resident 203 in front of the nurses' station and Resident 203 stopped in front of her and blocked her way and said, fat b----, I am not moving, and spat at her face and threw a fruit cup at her. Resident 23 stated that she punched Resident 203 in the face. Staff then separated her from Resident 203, and she has had no contact with the resident since. On 1/24/2024 at 10:42 a.m., during an interview, LVN 5 stated on 1/13/2024 at around 11:30 a.m., she saw Resident 203 throw a fruit cup at Resident 23 and Resident 23 zoomed fast with her wheelchair over to Resident 203 and hit Resident 203 before staff could separate them. LVN 5 stated that she saw Resident 203 strike Resident 23 back in the head. LVN 5 stated this is the first time the residents have been physical with anyone at the facility that she is aware of. On 1/24/2024 at 12:45 p.m., during an interview, the Assistant Director of Nursing (ADON) stated that she did not interview LVN 5 and that she should have interviewed LVN 5. The ADON stated she did not know that LVN 5 saw the altercation between Resident 23 and Resident 203. The ADON stated that this would have changed how she investigated the incident. On 1/24/2024 at 12:48 p.m., during an interview, the Director of Nursing (DON) stated that the investigation between Resident 23 and Resident 203 should have been more thorough and the ADON should have interviewed LVN 5. A review of the facility's policy and procedure (P&P) titled, Abuse Prevention, last reviewed 12/28/2023, indicated, The facility shall make reasonable efforts to determine the cause of the alleged violation and take corrective action consistent with the investigation findings and to eliminate any ongoing dangers to the resident. The facility's policy further indicated, The Administrator or designee shall initiate an investigation immediately, which may include interviews of the involved resident(s), and other parties (employees, visitors, other residents, volunteers, family members, etc.) who have knowledge of the alleged incident. These statements should be in writing and signed by the person making the statement. A review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, exploitation and Misappropriation Prevention Program, last reviewed 12/28/2023, indicated, Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.

CONCERN (D)

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to send a copy of the notification of a resident's transfer/discharge to the office of the long-term care ombudsman (resident advocate) for one of three sampled residents investigated during review of closed records (Resident 240). The facility did not have documented evidence a copy of Resident 240's Notices of Transfer/Discharge, dated 12/4/2023 and 12/5/2023 was sent to the long-term care ombudsman office. This deficient practice had the potential for Resident 240 to have an unsafe discharge. Cross-reference to F-Tag F661, F625, and F641 Findings: A review of Resident 240's admission Record indicated the facility admitted Resident 240 on 10/7/2023 with diagnoses including, but not limited to, Wernicke's encephalopathy (a type of brain injury). A review of Resident 240's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/5/2023, indicated Resident 240 was discharged to a short-term general hospital on [DATE]. A review of Resident 240's History and Physical (H&P), dated 10/2/2023, indicated Resident 240 had fluctuating capacity to understand and make decisions. A review of Resident 240's Order Summary Report indicated: - An order placed on 12/4/2023, resident may discharge to a board and care (B&C - a residential care option catering to individuals requiring assistance with daily living activities). - An order placed on 12/4/2023, may send the resident to the general acute care hospital (GACH) due to chest pain for further evaluation and management. A review of Resident 240's Situation Background Assessment Recommendation Communication Form (SBAR - a structured communication framework that can help teams share information about the condition of a resident), dated 12/4/2023, indicated Resident 240 had complaints of chest pain and an order to transfer to the GACH was received. During an interview with Licensed Vocational Nurse (LVN) 2, on 1/24/2024, at 3:41 p.m., LVN 2 stated on 12/4/2023, Resident 240 was sent to the GACH for chest pain and further evaluation. LVN 2 stated on 12/5/2023, Resident 240 returned to the facility and was discharged to a B&C on the same day. During a concurrent interview and record review with the Assistant Director of Nursing (ADON), on 1/25/2024, at 1:03 p.m., Resident 240's Notice of Transfer/Discharge, dated 12/4/2023, was reviewed and indicated Resident 240 was transferred to the GACH due to welfare and the resident's needs could not be met at the facility. The notice of transfer/discharge did not indicate the date when the ombudsman's office was contacted. The ADON stated nursing or the social services department usually faxes the notification to the ombudsman and they attach the transmittal form. Resident 240's Notice of Transfer/Discharge, dated 12/5/2023, was reviewed and the ADON indicated Resident 240's discharge was appropriate because his health had improved sufficiently that the resident no longer required services provided by the facility. The ADON stated notices do not have an attached transmittal form or a date of when the notifications were sent to the ombudsman's office. The ADON stated it is important to send the notification to the ombudsman so that the ombudsman knows it is a safe discharge and that the facility is properly discharging the resident. During an interview with the Director of Nursing (DON), on 1/26/2024, at 1:30 p.m., the DON stated the ombudsman needs to be notified of all discharges by the social services department. The DON stated if there is no check mark on the section if the ombudsman was notified on the notification of transfer/discharge form, the facility would not know if the notification was sent or not. The DON further stated it is important to notify the ombudsman of a resident's transfer or discharge for the resident's safety and well-being. The DON stated the ombudsman is an advocate for the resident and the ombudsman would know where the resident was placed after discharge. A review of the facility's policy and procedure (P&P) titled, Transfer of Discharge Notice, last reviewed 12/28/2023, indicated a copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.

CONCERN (D)

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

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a bed-hold notice to a resident upon transfer to the general acute care hospital (GACH) for one of three sampled investigated during review of closed records (Resident 240). This deficient practice had the potential for Resident 240 to not know if they had a place to return to after hospitalization. Cross-reference F-Tag 661, F623, and F64. Findings: A review of Resident 240's admission Record indicated the facility admitted Resident 240 on 10/7/2023 with diagnoses including, but not limited to, Wernicke's encephalopathy (a type of brain injury). A review of Resident 240's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/5/2023, indicated Resident 240 was discharged to a short-term general hospital on [DATE], had severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect everyday life), and required setup or clean up assistance with eating, supervision or touching assistance with oral hygiene, and partial or moderate assistance with toileting hygiene, showering or bathing self, upper and lower body dressing, putting on or taking off footwear, and personal hygiene. A review of Resident 240's History and Physical (H&P), dated 10/2/2023, indicated Resident 240 had fluctuating capacity to understand and make decisions. A review of Resident 240's Order Summary Report indicated the following orders: - An order placed on 12/4/2023, may send the resident to the general acute care hospital (GACH) due to chest pain for further evaluation and management. - An order placed on 12/5/2023, a late entry for 12/4/2023 for bed hold for seven days. A review of Resident 240's Situation Background Assessment Recommendation Communication Form (SBAR - a structured communication framework that can help teams share information about the condition of a resident), dated 12/4/2023, indicated Resident 240 had complaints of chest pain and an order to transfer to the GACH was received. During an interview with Licensed Vocational Nurse (LVN) 2, on 1/24/2024, at 3:41 p.m., LVN 2 stated on 12/4/2023, Resident 240 was sent to the GACH for chest pain and further evaluation. During a concurrent interview and record review with the Assistant Director of Nursing (ADON), on 1/25/2024, at 1:03 p.m., Resident 240's Order Summary Report was reviewed and the ADON confirmed Resident 240 had an order placed on 12/5/2023 for a late entry for 12/4/2023, for bed hold for seven days. The ADON stated Resident 240 was transferred to the GACH on 12/4/2023. The ADON stated upon transfer, the resident and the responsible party are provided with the bed hold policy to inform the resident that the bed will be held for the resident for seven days. Further review of Resident 240's medical record indicated and was confirmed by the ADON there was no bed hold form present. The ADON further stated it is important to provide the resident and responsible party with the bed hold policy to alleviate the stress from the families and residents and assure the resident has a place to return to. During an interview with the Director of Nursing (DON), on 1/26/2024, at 1:30 p.m., the DON stated when a resident is transferred to the GACH, an order for bed hold is placed. The DON stated the bed hold policy is provided to the resident by the admissions department. The DON further stated it is important that the resident is provided with the bed hold policy so that the resident knows that the resident has a place to return to. A review of the facility's policy and procedure (P&P) titled, Bed-Holds and Returns, last reviewed 12/28/2023, indicated all residents or representatives are provided written information regarding the facility and state bed-hold polices, which address holding or reserving a resident's bed during periods of absence, such as hospitalization. The P&P indicated residents, regardless of payer source, are provided written notice about these policies at least twice, well in advance of any transfer and at the time of transfer.

CONCERN (D)

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

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to develop a baseline care plan (initial written guide that organizes information about the resident's care) within 48 hours of admission for one out of nine sampled residents (Resident 452) investigated under care planning care area. This deficient practice had the potential for Resident 452 not to receive the appropriate care and treatment specific to his needs. Findings: A review of Resident 452's admission Record indicated the facility admitted the resident on 1/19/2024 with diagnoses including sepsis (a condition that happens when an infection triggers a chain reaction throughout your body), epilepsy (a condition that happens as a result of abnormal electrical brain activity, also known as a seizure), and generalized muscle weakness. A review of Resident 452's History and Physical (H&P) dated 1/21/2024, indicated the resident had the capacity to understand and make decisions. A review of Resident 452 's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 1/25/2024, indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision with eating, sit to stand, and toilet transfers; substantial or maximal assistance with bathing, lower body dressing; and partial or moderate assistance with all other activities of daily living (ADLs, basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated the resident had pressure injury (PI - any injury to skin and underlying tissue resulting from prolonged pressure on the skin) upon admission. A review of Resident 452's physician's orders indicated the following: -Cleanse unstageable (a term for wounds that contain too much necrotic tissue [dead tissue due to little blood flow]) PI on sacrum (also known as tailbone, a large, triangular bone at the base of the spine) with normal saline (ns - a solution to clean wounds), pat dry, apply medihoney gel (a medical honey that enhances and accelerates wound healing) and cover with dry dressing every day or as needed. Re-evaluation weekly. Every day shift, with order date of 1/20/2024. -Cleanse deep tissue injury (DTI - defined as purple or maroon localized area of discolored intact skin or blood?filled blister due to damage of underlying soft tissue from pressure and/or shear) on right buttock with ns, pat dry, apply paint with betadine solution (a solution used to prevent and treat minor wounds and skin infections) and cover with dry dressing every day or as needed. Re-evaluation weekly. Every day shift, with order date of 1/26/2024. -Cleanse DTI on right heel with ns, pat dry, apply paint with betadine solution and cover with dry dressing every day or as needed. Re-evaluation weekly. Every day shift, with order date of 1/29/2024. During a concurrent interview and record review on 1/25/2024 at 1:45 p.m., Resident 452's electronic health record (EHR) was reviewed with Licensed Vocational Nurse 7 (LVN 7). LVN 7 verified there was no documented evidence that a baseline care plan for the pressure injuries were developed within 48 hours of admission. LVN 7 stated the care plan should have been developed upon admission to ensure that the appropriate goals and interventions for wound healing were being implemented, LVN 7 stated not having a baseline care plan had the potential for a delay in the delivery of necessary care Resident 452 needs. During an interview on 1/26/2024 at 1:00 p.m., the Director of Nursing (DON) stated baseline care plans are developed within 48 hours of admission by the admitting nurse so staff would be aware of the goals and interventions and prevent delay in the necessary care and services the resident needs. A review of the facility's policy and procedure titled, Care Planning/Interim, last reviewed 12/28/2023, indicated the following: -An interim care plan should be developed upon admission following completion of the admission nursing assessment ensuring care plan determinations are developed based on condition, complications and risk factors and the need for referrals to appropriate health professionals. -Upon admission a plan is initiated based on the assessment and indicated risk assessments. -All disciplines identify any immediate and appropriate problems, goals and approaches to accommodate special needs prior to completion of the comprehensive care plan.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to indicate and include the interdisciplinary team (IDT - professional disciplines that work together to provide the greatest benefit to the resident) members involved with a resident's plan of care for one of three sampled resident reviewed under care planning (Resident 6) when Resident 6's IDT notes, dated 3/2/2023, did not indicate whether the physician, registered nurse (RN), certified nursing assistant (CNA), and a member of the food and nutrition staff were present during Resident 6's care plan meeting and did not indicate who was present during the IDT meeting conducted on 9/12/2023. This deficient practice had the potential for the facility to be unaware of which disciplines were involved with the resident's plan of care and what their contributions were to the resident's plan of care. Findings: A review of Resident 6's admission Record indicated the facility admitted Resident 6 on 5/24/2021 with diagnoses including, but not limited to, chronic respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and type two diabetes mellitus (condition that affects the way the body processes blood sugar). A review of Resident 6's Minimum Data Set (MDS - a standardized assessment and care screening tool, dated 12/3/2023, indicated Resident 6 had moderate cognitive impairment (when a person has problems with their memory or thinking) and required setup or clean-up assistance with eating and oral hygiene, partial or moderate assistance with upper body dressing and personal hygiene, substantial or maximal assistance with toileting hygiene, showering/bathing self, lower body dressing, and was dependent with putting on/taking off footwear. A review of Resident 6's IDT Note, dated 3/2/2023, indicated the facility conducted a care plan meeting attended by the social services assistance, MDS nurse, and activities department. The IDT note did not indicate if Resident 6, Resident 6's physician, an RN with responsibility for the resident, a CNA with responsibility for the resident, and a member of the food and nutrition staff were present during the care plan meeting. Further review of Resident 6's IDT notes indicated the IDT note, dated 3/2/2023, was the most recent IDT note entry in the electronic medical record. During an interview with Resident 6, on 1/23/2024, at 11:35 a.m., Resident 6 stated she does not participate in making decisions regarding medicine, therapy, or treatments. During an interview with RN 1, on 1/24/2024, at 11:21 a.m., RN 1 stated Resident 6 is alert, oriented, and able to understand and make decisions. RN 1 stated the people involved during an IDT meeting include social services, the resident or family member, the charge nurse assigned to the resident, and the Director of Nursing (DON) or Assistant Director of Nursing (ADON). RN 1 further stated if a resident is able to understand and make decisions, they should be part of the IDT meeting. During an interview with Licensed Vocational Nurse (LVN) 8, on 1/24/2024, at 11:43 a.m., LVN 8 stated Resident 6 is alert, oriented, and able to understand and make decisions. LVN 8 stated if a resident is alert and oriented, the resident should be involved with their care planning. During an interview with the Social Services Director (SSD), on 1/24/2024, at 1:48 p.m., the SSD stated Resident 6 is alert, oriented, and can express what her needs are. The SSD stated people involved during an IDT meeting include social services, nursing, either the LVN or ADON, and possibly someone from the rehabilitation department, billing department, or activities department depending on the needs of the residents. The SSD stated the physicians are not involved in the IDT meetings and are invited to the IDT meetings if there is a concern that involves them. The SSD stated residents should be present at the IDT meetings, unless the resident refuses. During an interview with Resident 6, on 1/24/2024, at 2:26 p.m., Resident 6 stated she did not receive an invite for a care plan meeting back in September 2023. Resident 6 stated if she was invited to a care plan meeting, she would have liked to attend. During an interview with the DON, on 1/26/2024, at 1:30 p.m., the DON stated residents and their responsible parties should be invited to the quarterly care plan IDT meetings to have them involved and aware of their plan of care, medication regimen, and address issues relevant to the resident. The DON stated responsible parties should be involved with the care plan IDT meetings because they can share certain things that will facilitate provision of care for the resident. The DON stated staff involved in the IDT care plan meetings include a member from the nursing department, social services department, dietary department, activities department, and the rehabilitation department. The DON stated physicians are usually not involved in the care plan IDT meetings. The DON stated the IDT meeting notes should indicate who was present at the meeting. The DON further stated it is important to know who was involved in the meeting to know which disciplines were involved and what their contributions were and how a resident's issues were addressed and resolved. A review of the facility's policy and procedure (P&P) titled, Interdisciplinary Team, last reviewed 12/28/2023, indicated the IDT, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The P&P indicated the IDT includes: a. The Attending Physician; b. A registered nurse who has responsibility for the resident; c. A nurse aide who has responsibility for the resident; d. A member of the food and nutrition service staff; e. The resident and the resident's legal representative (to the extent practicable; and f. Other appropriate staff or professionals as determined by the resident's needs or as requested by the resident.

CONCERN (D)

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

Deficiency F0660 (Tag F0660)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to complete on a timely basis the resident's discharge plan by failing to follow-up the discharge planning process with the resident and the resident's representative for one of two sampled residents (Resident 107) investigated under the discharge care area. This deficient practice placed the resident at risk for not receiving the necessary care and services related to the resident's discharge goals and needs. Findings: A review of Resident 107's admission Record indicated the facility admitted the resident on 6/19/2023 with diagnoses including hemiplegia (paralysis that affects only one side of your body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following cerebral infarction (commonly known as stroke, caused by a blockage in a blood vessel in the brain, leading to brain damage) affecting left non-dominant side and encounter for attention to gastrostomy (a type of artificial opening to the stomach that requires special care). A review of Resident 107's History and Physical, dated 6/21/2023, indicated the resident has fluctuating capacity to understand and make decisions. A review of Resident 107's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/26/2023, indicated the resident usually made self-understood and usually understood others. During an interview on 1/22/2024 at 9:48 a.m., Resident 107 stated she has been having issues with her discharge planning. Resident 107 stated her representative is her power of attorney and they have requested last month, 12/2023, to be discharged home. Resident 107 stated her representative had been in contact with the social services staff but have not received an update. During an interview on 1/24/2024 at 10:38 a.m., with the Social Services Assistant (SSA), the SSA stated Resident 107 case manager handles the resident's discharge planning. The SSA stated she was not made aware of Resident 107's discharge plan. During a concurrent interview and record review on 1/25/2024 at 3:36 p.m., with Director of Admissions (DA), Resident 107's case management notes reviewed The case management notes, dated 12/27/2023 at 1:48 p.m., indicated the representative was advised the discharge plan takes two to three days and that Case Manager 1 (CM 1) will follow-up the week after. The DA stated there were no notes from CM 2 after 12/27/2023. During an interview on 1/25/2024 at 3:40 p.m., CM 1 stated she was not made aware of Resident 107's discharge plan and the need to follow-up on the discharge plan. CM 1 stated if CM 2 indicated the need to follow up the resident's discharge plan, then the resident and their representative should have been called/notified at the beginning of the month of January. CM 1 stated the purpose of completing the discharge follow-up with the family and insurance is to address the needs of the resident. During an interview on 1/26/2024 at 10:04 a.m., with the Director of Nursing (DON), the DON stated she was not aware the representative requested for Resident 107's discharge. The DON stated upon receiving insurance authorization, the case manager then proceeds with the resident's discharge plan through the social services department. The DON stated the case management team is responsible for coordinating the resident's durable medical equipment and all associated arrangements. The DON stated the delay in discharging the resident to her preferred setting, goes against the resident's rights and the responsible party's rights and may affect the resident's quality of life and care. The DON stated a follow-up should have been done by the social worker if the case manager was not there. A review of the facility's policy and procedure titled, Discharge Planning, reviewed and approved by the Patient Care and Quality Assurance Committee on 12/28/2023, indicated when a resident's discharge is anticipated, a post-discharge plan is developed to assist the resident with discharge. The procedure indicated the resident/representative is involved in the post-discharge planning process and informed of the final post-discharge plan.

CONCERN (D)

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

Deficiency F0678 (Tag F0678)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. During an interview on [DATE] at 10:22 a.m., the Director of Nursing (DON) stated the DSD and Assistant Director of Staff Development are responsible for ensuring employees maintain current CPR certification. The DON stated the CNAs are required to maintain their CPR certification every 2 years. During a concurrent interview and record review on [DATE] at 10:36 a.m., CNA 11's CPR certificate dated [DATE], was reviewed. The ADSD stated she spoke with CNA 11 on the phone and CNA 11 stated the CPR training was done on-line. The ADSD stated she does not know if CNA 11's CPR certification was certified by the American Red Cross or the American Heart Association. During an interview and concurrent review on [DATE] at 11:47 a.m., with the ADSD, the facility's P&P Emergency Procedure - Cardiopulmonary Resuscitation was reviewed. The ADSD stated non-licensed personnel includes CNAs. During a follow-up interview on [DATE] at 12:12 p.m., with the ADSD, the ADSD stated CNA 11 will be off the schedule until CNA 11 receives the AHA certified CPR training. During an interview on [DATE] at 1:11 p.m., with the DON, the DON stated if a CNA is not certified and a resident required resuscitation, there may be a delay in performing CPR which may lead to other complications such as death. A review of the facility's policy and procedure (P&P) titled, Emergency Procedure - Cardiopulmonary Resuscitation, reviewed and approved by the Patient Care and Quality Assurance Committee on [DATE], indicated key clinical staff members who will direct resuscitative efforts, including non-licensed personnel will obtain and/or maintain American Red Cross or American Heart Association certification in BLS or CPR. The P&P indicated the CPR team in this facility shall include at least one nurse, one licensed vocational nurse and two certified nursing assistants, all of whom have received training and certification in CPR/BLS. Based on interview and record review, the facility failed to implement their policy and procedure on cardiopulmonary resuscitation (CPR, an emergency procedure used to restart a person's heartbeat and breathing after one or both have stopped) by failing to ensure Certified Nursing Assistants maintain current CPR certification two of two Certified Nursing Assistants (CNA 4 and CNA 11) investigated during review of personnel files. These deficient practices had the potential of delayed provisions of emergency care for residents who wishes to have full treatment in a life-threatening situation. Findings: a. A review of Certified Nursing Assistant 4 (CNA 4) employee file on [DATE] at 3:30 p.m. indicated a CPR certificate dated [DATE] that is valid for two (2) years. During a concurrent interview and record review on [DATE] at 4:00 p.m., CNA 4's CPR card was reviewed with the Director of Staff Development (DSD). The DSD verified that the CPR card for CNA 4 was expired. The DSD stated the facility do not require the CNAs to be CPR certified. During an interview on [DATE] at 10:22 a.m., the Director of Nursing (DON) stated the DSD and Assistant Director of Staff Development are responsible for ensuring employees maintain current CPR certification. The DON stated the CNAs are required to maintain their CPR certification every two years. During a follow-up interview on [DATE] at 1:11 p.m., the DON stated CNA 4's CPR card should have been updated to be current per facility policy. The DON stated if a CNA is not certified and a resident required resuscitation (the act of bringing someone or something back to life), there may be a delay in performing CPR which may lead to other complications such as death. A review of the facility's policy and procedure titled, Emergency Procedure - Cardiopulmonary Resuscitation, last reviewed [DATE], indicated completed training on the initiation of CPR including defibrillation for victims of sudden cardiac arrest for personnel. The policy indicated the following: -Obtain and/or maintain American Red Cross (an organization led by volunteers that provide relief to victims of disasters and help people prevent, prepare for and respond to emergencies) or American Heart Association (a nonprofit organization in the United States that funds cardiovascular medical research, educates consumers on healthy living and fosters appropriate cardiac care in an effort to reduce disability and deaths caused by cardiovascular disease and stroke) certifications in CPR for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel. -The CPR team shall include at least 1 nurse, 1 Licensed Vocational Nurse (LVN), and 2 CNAs, all of whom have received training and certification in CPR. -Chances of surviving sudden cardiac arrest (sudden, unexpected loss of heart function, breathing, and consciousness) may be increased if CPR is initiated immediately upon collapse.

CONCERN (D)

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

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to ensure one of three sampled resident (Resident 200) has reading glasses as recommended by the optometrist (health care provider who specializes in eyecare) on 10/20/2023. This deficient practice resulted in Resident 200 not being able to read her books she enjoys. Findings: A review of Resident 200's admission Record (Face Sheet), dated 1/25/2024, indicated the facility admitted Resident 200 on 9/19/2023, with diagnoses including chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), diabetes mellitus (a common form of diabetes in which the body cannot properly store or use glucose [sugar], the main body's source of energy), and anemia (a condition in which the blood does not have enough red blood cells that carries oxygen from the lungs to other parts of the body). The Face Sheet indicated Resident 200 was self-responsible. A review of Resident 200's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/26/2023, indicated Resident 200 had the ability to make herself self-understood and understand others. The MDS indicated the resident required from partial/moderate assistance to substantial/maximal assistance in toileting hygiene, shower/bathe self, upper body dressing, lower body dressing and putting on/taking off foot footwear. A review of Resident 200's Eye Doctor Consultation Optometrist, dated 10/20/2023, indicated an initiation of diagnostic and treatment plan recommendation for new glasses. During a concurrent observation and interview on 1/22/2024, at 10:50 a.m., with Resident 200, observed Resident 200 lying in bed with head of bed elevated with no eyeglasses on. Resident 200 stated she had been at the facility for 15 weeks now and still have not gotten her reading glasses. Resident 200 stated there was not much to do in her room, she enjoyed reading books but cannot even do that because she does not have reading glasses. Resident 200 stated the social worker was aware she still has no reading glasses and still no news about having reading glasses. During a concurrent interview and record review on 1/23/2024, at 8:16 a.m., with Social Service assistant (SSA 1), of ancillary services log undated were reviewed, SSA 1 stated the facility have ancillary services log that showed Resident 200 was seen by the optometrist on 10/20/2023 with recommendation for eyeglasses. SSA 1 stated we do not have a process to follow up with the optometrist if they ordered the eyeglasses. SSA 1 stated we should have followed up within one to two weeks if the eyeglasses were ordered by the optometrist. SSA 1 stated Resident 200 had not been able to enjoy reading her books because she does not have her reading glasses. A record review of progress notes titled, Psychosocial Note, dated 1/23/2023, at 11:00 a.m., indicated, SSA 1 called optometry to get update on delivery of glasses and was informed the order for eyeglasses was put in January 2024 and could take five (5) weeks or less to received. During an interview on 1/26/2024, at 9:35 a.m., with the Director of Staff Development (DSD), the DSD stated the social services should have followed up with the optometrist regarding Resident 200 eyeglasses. The DSD stated Resident 200 was deprived of her rights to enjoy when she did not have eyeglasses to use to read books. During an interview on 1/26/2024, at 10:35 a.m., with the Director of Nursing (DON), the DON stated the social services should have followed up with the optometrist regarding Resident 200 eyeglasses as recommended. The DON stated not having eyeglasses had affected Resident 200's quality of life. A review of facility's recent policy and procedure titled, Availability of Services, Optometry, last reviewed on 12/28/2023, indicated all requests for routine and emergency eye services should be directed to Social Services/facility staff designee to assure that appointments can be made in a timely manner. Optometry services are available to all residents requiring routine and emergency optometry care. Residents with lost or damaged eyewear will be promptly referred to optometrist/ophthalmology.

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide care consistent with professional standards of practice to prevent pressure ulcer/injury (ulcers that happen on areas of the skin that are under pressure from lying in bed, sitting in a wheelchair, or wearing a cast for a long period) to two out of three sampled residents (Residents 73 and 194) being investigated under pressure ulcer care area, by failing to consistently perform weekly skin assessment to Residents 73 and 194 who had pressure ulcers at stage 4 (the sores extend below the subcutaneous fat into the deep tissues, including muscle, tendons, and ligaments) on the coccyx (the small bone at the end of the spine, also called tailbone). This deficient practice had the potential for development and worsening of pressure ulcers/injuries to the residents. Findings: 1. A review of Resident 73's admission Record indicated the facility admitted the resident on 8/3/2021 and readmitted the resident on 2/9/2022, with diagnoses including pressure ulcer of sacral region stage 4 and type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]) with other skin ulcer (open sores caused by poor blood circulation). A review of Resident 73's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/21/2023, indicated the resident had the ability to make self-understood and understood others. The MDS indicated the resident was totally dependent on chair/bed-to-chair transfer and on tub/shower transfer and required substantial/maximal assistance on lying to sitting on side of bed, sitting to lying, and rolling left and right on bed. The MDS indicated the resident was always incontinent of bowel (inability to control bowel movements, resulting in involuntary soiling). The MDS indicated the resident had an unhealed pressure ulcer/injury stage 4 and was at risk for developing pressure ulcer/injuries. A review of Resident 73's Order Summary Report, dated 11/2/2023, indicated a physician's order of Santyl external ointment 250 unit per gram (unit/gm, a unit of mass equal to one thousandth of a kilogram) (Collagenase). Apply to sacro coccyx (the small bone at the end of the spine) topically (used outside of the body) every day shift for unstageable (when stage is not clear) pressure injury (PI) presenting as a stage 4. Cleanse unstageable PI presenting as stage 4 on sacro coccyx with (w/) normal saline (ns, a mixture of sodium chloride [salt] and water), pat dry, apply Santyl external ointment, then Puracol Collagen reg and cover w/foam dressing. Every day (Q day) or as needed (PRN). A review of Resident 73's Braden Scale for Predicting Pressure Sore Risk, dated 8/4/2021, indicated the resident was at risk for development/worsening of pressure ulcer/injury. A review of Resident 73's Care Plan titled, Resident 73 has resolved pressure ulcer, diabetes mellitus (DM) ulcer, last revised on 5/10/2023, indicated an intervention of body assessment during weekly summary as needed. During a concurrent interview and record review on 1/25/2024, at 10:44 a.m., with Licensed Vocational Nurse 7 (LVN 7), reviewed the Weekly Skin & Wound Evaluation of Resident 73 with LVN 7. LVN 7 stated the resident had the pressure ulcer/injury on the sacrum, unstageable on admission of the resident to the facility on 8/3/2021. LVN 7 stated there were no weekly skin assessment and evaluation done on the weeks of 10/22/2023 to 10/28/2023, 12/31/2023 to 1/6/2024, and 1/7/2024 to 1/13/2024. LVN 7 added that on the week of 1/7/2024 to 1/13/2024, the resident was seen by LVN 7; however, she was not able to take pictures. LVN 7 stated she should have done the weekly wound evaluation consistently to ensure the wound was not getting worse or if the treatment needed to be changed or adjusted. 2. A review of Resident 194's admission Record indicated the facility admitted the resident on 8/18/2023 and readmitted the resident on 10/13/2023, with diagnoses including pressure ulcer of sacral region, stage 4, traumatic brain injury (a form of acquired brain injury caused by sudden trauma), and syncope (a loss of consciousness for a short period of time). A review of Resident 194's MDS, dated [DATE], indicated the resident usually had the ability to make self-understood and understand others. The MDS indicated the resident was dependent on chair/bed-to-chair transfer and required substantial/maximal assistance on lying to sitting on side of the bed, sitting to lying, and rolling left and right on bed. The MDS indicated the resident had an unhealed pressure ulcer/injury stage 4 and was at risk for developing pressure ulcer/injuries. The MDS indicated the resident was always incontinent of urine and stool. A review of Resident 194's Order Summary Report, indicated a physician's order for: - Cleanse significant scarring on sacro coccyx w/ n/s, pat dry, apply Dermaseptin (topical medication), leave open to air (LOA) every day (Q day) shift or PRN for prevention. Every day shift for prevention and as needed for lifting or soiled in 12/28/2023. - Wound Consultation w/ CMG 1 (wound care clinic) on 10/14/2023. A review of Resident 194's Braden Scale for Predicting Pressure Sore Risk, dated 8/18/2023, indicated the resident was at risk for development/worsening of pressure ulcer/injury. During a concurrent interview and record review on 1/25/2024, at 10:55 a.m., reviewed the Weekly Skin & Wound Evaluation of Resident 194 with LVN 7. LVN 7 stated on admission on [DATE] resident had a scar tissue on the coccyx. The resident was transferred to general acute care hospital (GACH) and came back on 9/26/2023 with scar tissue on the coccyx. The resident was again transferred to GACH and came back on 10/14/2023 with unstageable on the coccyx. LVN 7 stated there were missing skin evaluations on the following weeks: 10/22/2023 to 10/28/2023, 11/5/2023 to 11/11/2023, 11/26/2023 to 12/2/2023, 12/3/2023 to 12/9/2023, and on 12/28/2023 the wound was resolved. LVN 7 stated she should have done the weekly wound evaluation to ensure the wound was not getting worse or if the treatment needed to be changed or adjusted. During an interview on 1/26/2024, at 9:04 a.m., the Director of Staff Development (DSD) stated LVN 7 should have assessed the residents right away if there were missed days, should have documented if the wound got worse or better, and should have taken pictures of the wounds that day. The DSD stated the wounds can get worse if they (nurses) do not consistently assess. During an interview on 1/26/2024, at 10:36 a.m., the Director of Nursing (DON) stated residents' wounds should have been assessed weekly. The DON stated the wound should be assessed and documented per facility policy; the failure to assess the wound weekly could lead to worsening of the pressure ulcer/injury. A review of the facility's recent policy and procedure titled, Prevention/Management of Pressure Ulcers/Injuries, last reviewed on 12/28/2023, indicated the purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Assess the resident on admission (within eight hours) for existing pressure ulcer/injury risk factors. Repeat the assessment weekly in weekly summary and upon any applicable changes in condition.

CONCERN (D)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections (UTI, common infections that happen when bacteria, enter the urethra [duct that transmits urine from the bladder to the exterior of the body during urination], and infect the urinary tract) to one out of two sampled residents (Resident 73) being investigated under catheter care area, by failing to replace worn out Statlock (a device to secure the catheter to prevent tugging and pulling) in order to secure the urinary catheter (a procedure used to drain the bladder and collect urine, through a flexible tube called a catheter) of the resident. This deficient practice had the potential for the resident to develop catheter-associated urinary tract infection (CAUTI, an infection of the urinary tract caused by a tube [urinary catheter] that has been placed to drain urine from the bladder [an organ inside the body that stores urine until it is can be excreted]) due to tugging and pulling of the urinary catheter causing trauma to the urinary meatus (where urine leaves the body through a hole at the end of the urethra). Findings: A review of Resident 73's admission Record indicated the facility admitted the resident on 8/3/2021 and readmitted the resident on 2/9/2022, with diagnoses including benign prostatic hyperplasia (a benign [not cancer] condition in which an overgrowth of prostate tissue pushes against the urethra and the bladder, blocking the flow of urine) with lower urinary tract symptoms, obstructive and reflux uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow and can be either structural or functional), and pressure ulcer of sacral region, stage 4 (these sores extend below the subcutaneous fat into the deep tissues, including muscle, tendons, and ligaments). A review of Resident 73's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/21/2023, indicated the resident had the ability to make self-understood and understand others. A review of Resident 73's Order Summary Report, dated 10/27/2023, indicated a physician's order for indwelling Foley catheter (a thin, sterile tube inserted into the bladder to drain urine) 16 French (fr, the circumference of the urinary catheter in millimeters)/10 milliliters (ml, a unit of volume) diagnosis (DX): obstructive and reflux uropathy, unspecified. A review of Resident 73's Care Plan titled, Resident 73 needs indwelling catheter for DX: obstructive and reflux uropathy & benign prostatic hyperplasia with lower urinary tract symptoms, last revised on 5/9/2023, indicated an intervention of using a leg strap (a strap to securely anchor urinary catheters in place) to anchor incontinence catheter (I/C) tubing as tolerated. During a concurrent observation and interview on 1/22/2024, at 11:32 a.m., observed with Licensed Vocational Nurse 1 (LVN 1) the urinary catheter of Resident 73 was not anchored on the resident's thigh due to a worn out Statlock. LVN 1 stated he does not know when the Statlock was last replaced. LVN 1 stated the Statlock should be applied to prevent tugging and pulling of the tubing that could cause meatal trauma that could serve as a portal of entry for infection. During an interview on 1/26/2024, at 9:05 a.m., the Director of Staff Development (DSD) stated they should have changed the worn out Statlock of the urinary catheter. The DSD stated it could cause the Foley to pull and the resident to bleed and it could come out. The DSD stated it could cause discomfort because of the inflated balloon in the bladder moving around. The DSD stated the constant tugging and pulling could cause meatal tear that could be a portal of entry for infection. During an interview on 1/26/2024, at 10:37 a.m., the Director of Nursing (DON) stated they should have replaced the worn out Statlock or used a leg strap to anchor the tubing. The DON stated failure to anchor the urinary catheter could lead to dislodgment of the catheter and could cause pain. The DON stated the subsequent pulling of the tubing could cause the meatus to tear that could be an entry for infection. A review of the facility's recent policy and procedure titled, Indwelling (Foley) Catheter Insertion, Male Resident, last reviewed on 12/28/2023, indicated the purpose of this procedure is to provide guidelines for the aseptic insertion of an indwelling (Foley) urinary catheter in a male resident. Secure catheter tubing and/or bag to resident with approved catheter securement device. A review of the facility's recent policy and procedure titled, Urinary Tract Infections (Catheter-Associated), Guidelines for Preventing, last reviewed 12/28/2023, indicated the purpose of this procedure is to provide guidelines for the prevention of catheter-associated urinary tract infections (CAUTIs). Secure catheter after insertion to prevent movement.

CONCERN (D)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to discard a feeding formula bottle of Jevity (a calorically dense, fiber-fortified therapeutic nutrition that provides complete, balanced nutrition for long- or short-term tube feeding) 1.5 calories (a unit of energy), dated 1/16/2024 (observed on 1/22/2024), via gastrostomy tube (g-tube, a tube inserted through the belly that brings nutrition directly to the stomach) feeding and an undated irrigation syringe (used to administer medication and irrigate the feeding tube) to one out of one sampled resident (Resident 182) being investigated under tube feeding. The deficient practice had the potential for residents to experience gastrointestinal (GI) (relating to stomach and intestines) problems such as abdominal pain and diarrhea. Findings: A review of Resident 182's admission Record indicated the facility admitted the resident on 6/29/2023, with diagnoses including nontraumatic subarachnoid hemorrhage (a bleeding in the space that surrounds the brain), gastrostomy (a surgical opening into the stomach), and dysphagia (difficulty swallowing). A review of Resident 182's History and Physical (H&P), dated 6/30/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 182's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/5/2024, indicated the resident usually had the ability to make self-understood and understand others. The MDS indicated Resident 182 had a feeding tube. A review of Resident 182's Order Summary Report, dated 8/22/2023, indicated an order of enteral feed (a way of sending nutrition right to the stomach or small intestine). Every shift continuous g-tube feeding of Jevity 1.5 formula at 40 milliliters per hour (ml/hr, infusion rate) times (x) 10 hours to provide 400 milliliters (ml, a unit of volume)/600 kilocalories (kcal, one thousand calories). Pump to run from 8 p.m. to 6 a.m. or until dose limit met. During a concurrent observation and interview on 1/22/2024, observed with Licensed Vocational Nurse 1 (LVN 1), Resident 182's sterile formula bottle feeding of Jevity 1.5 calories with a hang date of 1/16/2024 on an intravenous pole (IV pole, a device that holds a bag(s) of intravenous fluids in place) attached to a pump with an undated irrigation syringe hanging on an IV pole. LVN 1 stated the formula was old and should be discarded. LVN also stated the old formula could cause GI issues. During an interview on 1/26/2024, at 8:51 a.m., with the Director of Staff Development (DSD), the DSD stated LVN 1 should have tossed the sterile formula bottle of Jevity 1.5 calories with a hang date of 1/16/2024 and the undated irrigation syringe. LVN 1 state the sterile formula bottle was only good for 48 hours once spiked and the irrigation syringe should have been dated to know when to change them again. LVN 1 stated bacteria could grow on the feeding formula because it was passed its approved hang time, the resident could get diarrhea and they could get sick. LVN 1 also stated the irrigation syringe could cause infection if not tossed out. During an interview on 1/26/2024, at 10:26 a.m., with the Director of Nursing (DON), the DON stated the sterile feeding bottle lasts for 48 hours, the formula was not good anymore after 48 hours. The DON stated they were following the guidelines of the maker of the formula. The DON stated the formula past its discard date could cause GI distress diarrhea, nausea, and abdominal distention to resident. The DON stated the irrigation syringe was good for 24 hours and it was supposed to be changed on the night shift. The DON stated they need to date the bag of the irrigation syringe of the date it was last changed. The DON stated they indicate on the sterile feeding formula the date and time it was hanged and the irrigation syringe for infection control, quality assurance, patient-centered care, and preventing complications to residents. A review of Care Plan titled, Resident observed with enteral feeding hanging at bedside with outdated label, initiated on 1/22/2024, indicated an intervention to ensure the appropriate enteral feeding is provided timely as ordered, monitor for any signs and symptoms (S/S) of G.I distress/ upset: change in bowel habit (loose stool, constipation or alternating symptoms), bloating, abdominal pain, bleeding per rectum (PR) or anemia. Follow up (F/U) with MD for concerns with the above and monitor resident for any concerns and f/u with MD as needed. A review of the facility's recent policy and procedure titled, Enteral Feedings- Safety Precautions, last reviewed on 12/28/2023, indicated to ensure the safe administration of enteral nutrition. Maintain strict adherence to storage conditions and timeframes: a. Refrigerate prepared or opened ready to feed formulas and discard within 24 hours. Maintain strict adherence to maximum hang times: c. Sterile formula in a closed system has a maximum hang time of 48 hours. A review of Complete Balanced Nutrition with Fiber, Jevity 1.5 CAL, [NAME] Nutrition [NAME] Laboratories Columbus, OH 43219, last updated 10/7/2023, provided by the facility, indicated on precautions, unless a shorter hang time is specified by the set manufacturer, hang product for up to 48 hours after initial connection when clean technique and only one new set are used. Otherwise hang for no more than 24 hours.

CONCERN (D)

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility licensed staff failed to ensure a resident who received dialysis (the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so) was assessed after dialysis treatment and failed to document the assessment in the Pre (before)- and Post (after)-Dialysis Communication Form for one of one sampled resident (Resident 63) investigated during review of dialysis care area. This deficient practice had the potential for unidentified complications such as swelling, pain, bleeding, and bruising and had the potential to result in lack of provision of necessary treatment and services after dialysis treatment. Findings: A review of Resident 63's admission Record indicated the facility admitted the resident on 11/22/2023 with diagnoses including dependence on renal dialysis and acute kidney failure (also known as acute kidney injury, condition in which the kidneys suddenly cannot filter waste from the blood). A review of Resident 63's History and Physical, dated 11/22/2023, indicated the resident has fluctuating capacity to understand and make decisions. A review of Resident 63's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/26/2023, indicated the resident made self-understood and understood others. The MDS indicated Resident 63 received dialysis on admission and while a resident. A review of Resident 63's Physician Order indicated the following orders: - Dialysis days have changed to twice a week, Tuesdays, and Thursdays, 12:45 sitting time, dated 12/19/2023. - Observed Central Venous Access Catheter (CVAC-a long, flexible, y-shaped tube that is inserted through one of the central veins to allow access to the bloodstream) for complications like bleeding at site, infection, redness, tenderness, swelling, drainage every shift, dated 11/25/2023. - Pre and Post Dialysis Assessment, dated 11/24/2023. A review of Resident 63's Care Plan, developed on 11/23/2023, indicated Resident 63 with permacath (a special tube placed in a big vein to make it easier to get to the blood for treatments like dialysis) on the right upper chest with interventions including pre and post dialysis assessment. During an interview on 1/26/2024 at 9:56 a.m., with the Director of Nursing (DON), the DON stated the pre dialysis assessment is started by the charge nurses in the facility and post-dialysis assessment is completed by the charge nurse receiving the resident back from the dialysis center. The DON stated the post-dialysis assessment is completed upon the resident's return form from dialysis. During a follow-up interview and concurrent review on 1/26/2024 at 9:59 a.m., with the DON, reviewed Resident 63's progress notes and Pre and Post-Dialysis Communication Forms. The DON stated the progress notes and the post-dialysis assessments were not completed for 12/30/2023, 1/6/2024, 1/9/2024, and 1/16/2024. The DON stated the charge nurses are supposed to be documenting the pre- and post- dialysis assessments. The DON stated if it was not completed it was not done. The DON stated post-dialysis assessments including monitoring the permacath site and the resident's vital signs should be done to ensure continuity of the resident's care. A review of the facility's policy and procedure titled, End-Stage Renal Disease, Care of a Resident with, reviewed and approved by the Patient Care and Quality Assurance Committee on 12/28/2023, indicated the resident's comprehensive care plan will reflect the resident's needs related to dialysis care. A review of the facility's policy and procedure titled, Dialysis, Coordination of Care and Assessment of Resident, reviewed and approved by the Patient Care and Quality Assurance Committee on 12/28/2023, indicated the facility has direct responsibility for the care of the resident, including the customary standard care provided assessment of the resident including monitoring of vital signs post dialysis or per physician order.

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

Dental Services (Tag F0791)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promptly provide dental services for two out of three sampled residents (Residents 97 and 39) reviewed under the dental investigative care area by failing to schedule an oral x-ray (use invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs on a film or digital media) per the dentist's treatment recommendation for Resident 97 and Resident 39. This deficient practice had the potential to result in discomfort and the inability to effectively chew foods, weight loss, lack of energy and loss of muscle mass of the residents. Findings: 1. A review of Resident 97's admission Record indicated the facility admitted the resident on 4/12/2023, with diagnoses including osteomyelitis (inflammation or swelling that occurs in the bone), type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar is too high), and moderate protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). A review of Resident 97's History and Physical (H&P), dated 4/15/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 97's Minimum Data Set (MDS, a standardized assessment and care screening tool), date 10/19/2023, indicated the resident had the ability to make self-understood and understand others. A review of Resident 97's Onsite Skilled Dental Care Notes, dated 8/17/2023, indicated the resident complained of a tooth pain. The dentist provided a treatment recommendation of evaluation with x-rays. During an interview and record review on 1/22/2024, at 2:30 p.m., Resident 97 stated he does not remember when he was last seen by a dentist and would like to see one. During an interview and record review on 1/24/2024, at 3:55 p.m., with Licensed Vocational Nurse 2 (LVN 2), reviewed Resident 97's Onsite Skilled Dental Care Notes, dated 8/17/2023. LVN 2 stated the resident was seen by the dentist and had ordered an x-ray of the oral cavity. LVN 2 stated she was unable to find documentation in the resident's medical record that indicated the x-ray was done. During a follow-up interview on 1/24/2024, at 4:22 p.m., with LVN 2, LVN 2 stated she dental office verified the x-ray was not done for the resident. LVN 2 stated it is important to make sure that the x-ray was done to prevent undue pain to the resident and development of dental carries (tooth decay or dental cavities). During an interview on 1/25/2024, at 10:25 a.m., with Social Services Assistant (SSA), the SSA stated they were not able to schedule the resident for an oral x-ray as prescribed by the dentist. The SSA stated it is important to make sure the residents get followed up for dental care for quality of care so they can eat and not lose weight. 2. A review of Resident 39's admission Record indicated the facility admitted the resident on 1/1/2021 and readmitted the resident on 1/5/2022, with diagnoses including hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a condition that develops when the heart does not pump enough blood for the body's needs), and vitamin D deficiency (can lead to a loss of bone density (hardness), which can contribute to fracture[broken bones]). A review of Resident 39's H&P, dated 1/19/2024, indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 39's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. A review of Resident 39's Onsite Skilled Dental Care Notes, dated 7/27/2023, indicated resident was seen by a dentist. The dental care notes indicated the resident had some missing teeth. The dentist recommended preventive treatment and evaluation with x-rays. During an interview on 1/23/2024, at 10:49 a.m., with Resident 39, Resident 39 stated her teeth fell off during the Coronavirus Disease 2019 (COVID-19 -a highly contagious disease spread from person to person through droplets released when an infected person coughs, sneezes, or talks) and was told by the dentist she will be provided with dentures. Resident 39 stated she has not seen the dentist for 4 months now. During a concurrent interview and record review on 1/24/2024, at 4:22 p.m., with LVN 2, reviewed Resident 39's Onsite Skilled Dental Cares Notes, dated 7/27/2023. LVN 2 stated the resident was seen by the dentist and recommended preventive treatment and evaluation with x-rays. LVN 2 stated the dental office verified the x-ray was not done for the resident. LVN 2 stated it is important to make sure that the x-ray was done to prevent undue pain to the resident and development of dental carries. During an interview on 1/25/2024, at 10:18 a.m., with the SSA, the SSA stated she is unable to find documentation that the resident had an oral x-ray as prescribed by the dentist. The SSA stated there were a lot of turnovers in their department which could have caused them to overlook the order. The SSA stated it is important for the resident to have the x-ray done to prevent undue pain and development of dental carries. During an in interview on 1/26/2024, at 8:55 a.m., with the Director of Staff Development (DSD), the DSD stated the staff should have called the medical director and called the dentist right away and scheduled the x-ray as soon as possible. The DSD stated the failure to provide the treatment prescribed by the dentist could cause the residents undue pain. During an interview on 1/26/204, at 10:30 a.m., with the Director of Nursing (DON), the DON stated the dentist, and the social services should have coordinated with each other. The DON stated the social services should have made a progress note and communicated the plan to nursing. The DON stated the failure to have the oral x-ray could delay resident care and could result in difficulty eating and weight loss. A review of the facility's recent policy and procedure titled, Referrals, Social Services, last reviewed on 12/28/2023, indicated Social Services personnel shall coordinate most resident referrals with outside agencies. Social Services will document the referral in the resident's medical record. Social Services will help arrange transportation to outside agencies, clinic appointments, etc. as appropriate. A review of the facility's recent policy and procedure titled, Dental Services, last reviewed on 12/28/2023, indicated it is the policy of this facility that residents receive routine and emergency dental services to meet their oral health needs as needed or upon request. The Social Services Department will be notified of a resident's need or request for dental services. Social Services personnel will assist the resident/family in making dental appointments and transportation arrangements as needed. A review of the facility's recent policy and procedure titled, Social Services, last reviewed on 12/28/2023, indicated the social worker/social services staff are responsible for: g. making referrals and obtaining needed services from outside entities.

CONCERN (D)

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

Deficiency F0809 (Tag F0809)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 70's admission Record indicated the facility admitted Resident 70 on 8/11/2023 with diagnoses including, but not limited to, hyperlipidemia (high cholesterol) and need for assistance with personal care. A review of Resident 70's H&P, dated 8/11/2023, indicated Resident 70 had fluctuating capacity to understand and make decisions. A review of Resident 70's MDS, dated [DATE], indicated Resident 70 had intact cognition and required setup or clean-up assistance with eating, supervision or touching assistance with oral hygiene, partial or moderate assistance with toileting hygiene, showering or bathing himself, upper and lower body dressing, and substantial or maximal assistance with putting on or taking off footwear and personal hygiene. A review of Resident 70's Order Summary Report, dated 9/20/2023, indicated Resident 70 was ordered a fortified no added salt diet with mechanical soft chopped meat texture and thin liquids consistency. During a concurrent observation and interview, on 1/22/2024, at 12:42 p.m., with Resident 70, inside Resident 70's room, no meal tray was observed on Resident 70's bedside table and Resident 70 stated he had not been served lunch yet. During a concurrent observation and interview, on 1/22/2024, at 1:22 p.m., with Resident 70, inside Resident 70's room, no meal tray was observed on Resident 70's bedside table. Resident 70 stated his unit usually gets served last and their trays are usually served around this time. Resident 70 further stated he is hungry, but he can wait. During an observation on 1/22/2024, at 2:05 p.m., inside Resident 70's room, a CNA was observed placing a meal tray on Resident 70's bedside table and setting up the tray for Resident 70. During a concurrent observation and interview, on 1/25/2024, at 4:14 p.m., with the Dietary Supervisor (DS), inside Dining Room One (1) & Two (2), the meal cart delivery times were posted on the bulletin board. The meal cart delivery times indicated an effective date of July 1, 2023, and lunch trays for Resident 70's station were scheduled for delivery to the station at 12:45 p.m. The DS stated meal trays on 1/22/2024 during lunch time were delivered late. The DS stated it is important for residents to receive their meals at their scheduled times because some residents receive medications that need to be taken with their meals, such as insulin (a hormone that regulates the amount of blood sugar in the body). During a concurrent observation and interview, on 1/25/2024, at 4:18 p.m., with the DS, inside Dining room [ROOM NUMBER], the bulletin board contained the menu, dated 1/22/2024 to 1/28/2024, a calendar for January 2024, and no posting for scheduled mealtimes. The DS confirmed the mealtimes were not posted on the bulletin board and stated it is important to post the mealtimes in the dining room so that the residents know what time their meals are being served. During an interview with the Director of Nursing (DON), on 1/26/2024, at 1:30 p.m., the DON stated it is important for residents to receive their meals according to schedule. The DON stated there should be proper intervals between meals so that food has enough time to be digested. The DON stated delays with meals can possibly cause issues with gastrointestinal motility (the way food moves from ingesting food through the mouth to outside of the body). The DON stated it might not feel homelike for the residents if their meals are not given at their scheduled times. The DON stated it is important to have mealtimes posted so that it is common knowledge for the residents to know when their mealtimes are and residents can anticipate their meals. The DON further indicated it is possible if the residents are not aware of when their meals are, they might miss their meals. During an interview with the Administrator, on1/26/2024, at 4:53 p.m., the Administrator stated the meal schedule should be followed as much as possible and ideally the facility would not want the meals to be served late. The Administrator further stated if residents are not served their meals according to schedule, the residents could potentially lose weight or become upset. A review of the facility's P&P titled, Dining/Meal Distribution, last reviewed 12/28/2023, indicated the facility will serve at least three meals or their equivalent daily at scheduled times. The P&P further indicated a schedule of mealtimes and snacks shall be posted in resident areas. Based on observation, interview, and record review, the facility failed to provide meals at regular times compared to normal mealtimes in the community for two of 17 sampled residents investigated during review of dining observation task (Resident 128 and 70) when the facility served Resident 128 and 70 their meal trays outside of the facility posted mealtime schedules and failed to post the meal serving times in Dining Room Three (3). These deficient practices had the potential to negatively affect the resident's nutritional and hydration status. Findings: 1. A review of Resident 128's admission Record indicated the facility originally admitted the resident on 8/3/2021 and readmitted the resident on 8/16/2023 with diagnoses including type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]) with diabetic neuropathy (a type of nerve damage that can occur by diabetes), and chronic peripheral venous insufficiency (failure of the veins to adequately circulate the blood). A review of Resident 128's History and Physical (H&P), dated 11/12/2023, indicated the resident has fluctuating capacity to understand and make decisions. A review of Resident 128's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/22/2023, indicated the resident has intact cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering). A review of Resident 128's Order Summary Report, dated 11/12/2023, indicated an order for consistent carbohydrate (a type of diet of eating the same amount of carbohydrates every day used to control diabetes), no added salt diet, regular texture, thin liquids consistency. A review of Resident 128's Care Plan, developed 8/1/2023, indicated the resident with diagnosis of protein calorie malnutrition as evidenced by diabetes with interventions including to provide diet as ordered. During an interview on 1/22/2024 at 9:11 a.m., Resident 128 stated he did not get his dinner meal tray at 8 p.m. last night. Resident 128 he was concerned because he is diabetic, and he takes insulin (a hormone that lowers the level of sugar in the blood). During an interview on 1/22/2024 at 1:20 p.m., with Certified Nursing Assistant 9 (CNA 9), CNA 9 stated Resident 128's lunch meal tray is on the last cart which would take another 30-40 minutes for the resident's meal to be delivered. During a concurrent observation and interview on 1/22/2024 at 2:13 p.m., at Resident 128's bedside, Resident 128 stated one of the CNAs delivered his meal tray just now. Resident 128 stated his meal trays are usually late, delivered after 1:30 p.m., Resident 128 stated delivery of dinner meal trays had been late too. During an interview on 1/22/2024 at 2:14 p.m., CNA 9 stated lunch meal trays have just been delivered to the residents in Resident 128's station. A review of the facility's policy and procedure (P&P) titled, Dining/ Meal Distribution, reviewed and approved by the Patient Care and Quality Assurance Committee on 12/28/2023, indicated each resident shall receive at least three (3) meals daily, at times comparable to typical mealtimes in the community, or in accordance with resident needs, preferences, requests, and the plan of care.

CONCERN (D)

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards by failing to: 1. Accurately document a pertinent individualized care plan for one out of six residents sampled being investigated under abuse (Resident 203) to indicate that abuse occurred between Resident 203 and Resident 23. This deficient practice resulted in Resident 203's medical records being inaccurate and had the potential to result in confusion regarding whether actual abuse took place between Resident 203 and Resident 23. 2. Document the name of the person who pronounced the resident expired (died) at the facility and by the physician failing to create a discharge summary indicating the resident's cause of death to one of three sampled residents (Resident 239) selected for closed record review. This deficient practice had the potential to result in inaccurate documentation in the medical record regarding Resident 239's death. Findings: 1. A review of Resident 203's admission Record indicated the facility admitted the resident on [DATE] with diagnoses including dependence on supplemental oxygen, muscle weakness, and hypertension (high blood pressure). A review of Resident 203's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated [DATE], indicated the resident's cognitive skills (ability to understand and make decisions) were intact (not affected). The MDS indicated Resident 203 required supervision or touching assistance for toileting hygiene, showering/bathe self, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 203's Care Area assessment dated [DATE], triggered Care Areas and Care Planning Decision for mood State, behavior symptoms, and cognitive loss/dementia. A review of Resident 203's care plan, initiated on [DATE], on possible resident to resident altercation with another resident on [DATE], indicated the resident stated she was hit in the face over the left eyebrow. A review of Resident 203's Interdisciplinary team (IDT-is a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological and spiritual needs of the resident) investigation, dated [DATE], indicated conclusion of the resident-to-resident altercation between Resident 203 and Resident 23 was Resident 23 was provoked by Resident 203, who blocked her right of passage, resulting with an impulsive reaction by Resident 203 throwing the fruit back and forth and Resident 23 got physical and struck Resident 203. On [DATE] at 10:37 a.m. during an interview, Resident 203 stated last week ([DATE]) Resident 23 came up to her in the hallway and punched her in the face. Resident 203 stated that Resident 23 will tell the surveyor that Resident 203 threw a fruit cup at and spit on her first. Resident 203 stated that she feels safe in the facility and can handle herself. Resident 203 stated that staff immediately separated the residents, and she had some pain, and the nurse gave her pain medication. Resident 203 stated that she felt fine after the incident and have no injuries. On [DATE] at 10:37 a.m. during an interview, Resident 23 stated last week ([DATE]), she had an interaction with Resident 203 in front of the nurses' station and Resident 203 stopped in front of her and blocked her way and said, fat b----, I am not moving, and spit in her face and threw a fruit cup at her. Resident 23 stated that she punched Resident 203 in the face. Staff then separated her from Resident 203, and she has had no contact with the resident since. Resident 23 stated that she was on her way to go see her friend to get her eyelashes done. Resident 23 stated that sometimes she sees Resident 203 on the smoking patio, but they are always supervised by staff, and she has had no contact with her. Resident 23 stated that she feels safe in the facility and had no pain or injuries after the incident. Resident 23 stated that staff came to check on her and they babysat her for 3days which made her feel a lot better. On [DATE] at 8:45 a.m., during a Director of Nursing (DON) stated that the abuse happened between Resident 23 hit Resident 203. The DON stated that she mentioned in her investigation report that the abuse happened. The DON stated that Resident 203's abuse care plan was not accurate and it should have been; the care plan should be individualized and should have indicated that abuse happened. A review of the facility's policy and procedure (P&P) titled, Abuse Prevention, last reviewed [DATE], indicated, The Director of Nursing Services or designee, shall initiate a care plan, where appropriate, to reflect the resident's condition and measure taken to prevent reoccurrence. 2. A review of Resident 239's admission Record indicated the facility admitted the resident on [DATE], with diagnoses including atrophy of kidney (terminal) (the kidney is smaller than normal), cutaneous abscess of abdominal wall (a pocket of pus located in the abdomen), and rectal abscess (an infected cavity filled with pus near the anus or rectum). A review of Resident 239's Order Summary Report indicated physician's orders for: -Full Code cardiopulmonary resuscitation (CPR, an emergency life-saving procedure that is done when someone's breathing, or heartbeat has stopped), date of order: [DATE]. - Release remains to Mortuary ([NAME]), Telephone Number (Tel), contact Mortician 1 (M1), date of order: [DATE]. A review of Resident 239's Progress Notes, dated [DATE], at 4:09 p.m., created by Registered Nurse 1 (RN 1), indicated the resident's sudden significant change of condition requiring the staff to call 911 immediately. The progress notes also indicated that cardiopulmonary resuscitation (CPR) was started immediately by the staff when the resident's vital signs (VS, measurements of the body's most basic functions) were unobtainable until the paramedics and Fire Dept. personnel arrived and took over resuscitation efforts. The resident's progress notes also indicated that Family Member 1 (FM 1) of Resident 239 was made aware that resident had a change of condition resulting in paramedics providing advanced cardiac life support (ACLS, refers to a set of clinical guidelines for urgent and emergent treatment of life-threatening cardiovascular conditions) and pronouncing resident's death at 2:22 p.m. During an interview and record review on [DATE], at 8:04 a.m., the Medical Records Director (MRD) stated she did not see the Discharge Summary on the Medical Records of Resident 239. The MRD stated the DON was following-up with the attending physician on the Discharge Summary of the resident at that time. During an interview and record review on [DATE], at 8:32 a.m., the DON stated they overlooked the Discharge Summary of Resident 239, and she was working on it at that moment. Reviewed the chart with DON and she stated she did not see the name of the person who pronounced the resident's death. The DON also stated that there was no emergency medical technician (EMT, a trained individual who responds to medical emergency calls) records in Resident 239's chart. During an interview on [DATE], at 9:07 a.m., the Director of Staff Development (DSD) stated the attending physician should have created a Discharge Summary per their facility policy and the staff should have documented the name of the person who pronounced the resident expired. The DSD stated documenting the specifics of the situation provides accurate description of the events and what lead to the situation could justify the interventions provided by the staff. During an interview on [DATE], at 10:39 a.m., the DON stated it was important to document accurately what transpired to know the cause of death and closure for the family. The DON stated it will be helpful to document the specific names of the staff involved and what was done during the event. A review of the facility's recent policy and procedure titled, Death of A Resident, Documenting, last reviewed on [DATE], indicated appropriate documentation shall be made in the clinical record concerning the death of a resident. All information pertaining to a resident's death (i.e., date, time of death, the name and title of the individual pronouncing the resident dead, etc.) must be recorded on the nurses' notes. The Attending Physician must record the cause of death in the progress notes and must complete and file a death certificate with the appropriate agency within twenty-four (24) hours of resident's death or as may be prescribed by state law. A review of the facility's recent policy and procedure titled, Charting and Documentation, last reviewed on [DATE], indicated the services provided to the resident progress toward the care plan goals. Any notable changes in the resident's medical, physical, functional, or psychosocial condition observed by staff, should be documented in the resident's medical record. The medical record is a format that facilitates communication between the interdisciplinary team. The following information are examples of documentation that may be included in the resident medical record: a. Objective observations; b. Medications administered; c. Treatments or services performed; d. Changes in the resident's condition, if indicated.

CONCERN (D)

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

Room Equipment (Tag F0908)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure a resident's low air loss mattress (LALM, designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was in good repair at all times for one of five sampled residents (Resident 128) investigated under the Environment facility task. This deficient practice had the potential to place the resident at risk for pressure ulcers (also called pressure injuries and decubitus ulcers - injuries to skin and underlying tissue resulting from prolonged pressure on the skin) due to inadequate pressure redistribution. Findings: A review of Resident 128's admission Record indicated the facility originally admitted the resident on 8/3/2021 and readmitted the resident on 8/16/2023 with diagnoses including morbid (severe) obesity (excessive fat accumulation that presents a risk to health) due to excess calories and chronic peripheral venous insufficiency (failure of the veins to adequately circulate the blood). A review of Resident 128's History and Physical, dated 11/12/2023, indicated the resident has fluctuating capacity to understand and make decisions. A review of Resident 128's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/22/2023, indicated the resident has intact cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) and requires substantial/maximal assistance with rolling from left and right, sitting to lying, and lying to sitting on the side of the bed. The MDS indicated the resident is at risk of developing pressure ulcers. A review of Resident 128's Order Summary Report, dated 11/13/2023, indicated a physician's order to monitor the LALM settings and functions every shift for prevention. A review of Resident 128's Care Plan, developed on 11/13/2023, addressing the resident's impaired skin integrity, significant scar tissue on the sacro (area at the base of the spine, near the hips) coccyx (tail bone), indicated interventions including monitoring of LALM settings and functions every shift for prevention. During a concurrent observation and interview on 1/22/2024 at 9:11 a.m., at Resident 128's bedside, Resident 128 stated the maintenance staff is aware that his bed was not working, but it has never been fixed. Resident 128 stated his bed mattress kept deflating and it was a little uncomfortable. During a concurrent observation and interview on 1/22/2024 at 9:17 a.m., at Resident 128's bedside, Certified Nursing Assistant 9 (CNA 9) stated Resident 128's bed deflating had always been an ongoing issue. CNA 9 stated the charge nurse or maintenance staff had to call the number written on the air mattress machine. CNA 9 stated the maintenance staff has been aware of this issue. During a concurrent observation and interview on 1/25/2024 at 8:59 a.m., at Resident 128's bedside, the Maintenance Supervisor (MS) stated the red light from the air mattress equipment was blinking and he would need to check it. Observed a blinking red light indicating power failure. The MS stated their process for LALM, since it was a rental, would be to report to the charge nurse assigned who will call the contracted company to check on the machine. During an interview on 1/25/2024 at 9:05 a.m., the MS stated he would only know of a mattress issue when the nurses provide him a work order slip. The MS stated he was not aware that Resident 128's LALM was not working. The MS stated he will find out from his other staff if the issue has been reported to them. During an interview on 1/25/2024 at 9:57 a.m., the MS stated he confirmed with his staff who reported that Resident 128's LALM power failure (blinking red light) has been an ongoing issue and they (maintenance staff) have been restarting it. The MS stated he does not keep a log of checking the LALM. The MS stated he wants to ensure that residents are safe and with working equipment. During an interview on 1/26/2024 at 10:15 a.m., the Director of Nursing (DON) stated they should have provided timely intervention like checking the connections. The DON stated nursing staff should have reported the issue to the maintenance department. The DON further stated the nursing staff then calls the bed company while the maintenance staff responds to the issue at hand with whatever they could do at that moment. During an interview on 1/26/2024 at 10:17 a.m., the DON stated Resident 128 uses the LALM for skin maintenance as the resident has sacral coccyx scarring and there is a potential for new onset or worsened pressure ulcers. A review of the undated User-Service Manual for LALM Manufacturer 1 indicated in case of an extended power failure, transfer the resident to a hospital mattress or other surface. The manual indicated troubleshooting when the therapy surface is not inflating include: - Ensure the hose connection from the therapy mattress system (mattress) to the control unit is securely connected. - Ensure that the control unit is plugged into an AC outlet. - Ensure that the power is not on Standby. - If on Standby, press the Power button. - Ensure that all air cells are connected to the internal mattress manifold. A review of the facility's policy and procedure (P&P) titled, Mattress/ Low Air Loss, reviewed and approved by the Patient Care and Quality Assurance Committee on 12/28/2023, indicated to monitor the mattress to assure that it is functioning properly. A review of the facility's policy and procedure titled, Maintenance related to maintenance and plant operations, reviewed and approved by the Patient Care and Quality Assurance Committee on 12/28/2023, indicated the center (facility) shall maintain a maintenance log of service visits, repairs, and inspections of the fixtures including equipment. The P&P indicated the facility shall maintain in good repair at all times all fixtures, equipment, and furnishings to provide a safe, clean, and comfortable environment for residents. The P&P indicated the facility shall contact service companies and obtain service when the facility's equipment is in need of repair or routine maintenance.

CONCERN (E) 📢 Someone Reported This

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

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

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. A review of Resident 99's admission Record indicated the facility admitted the resident on 12/22/2023 with diagnoses including lumbar spinal stenosis (a back condition affecting the legs due to narrowing of the spine that contains the nerves), abnormalities of gait and mobility, and lack of coordination. A review of Resident 99's History and Physical (H&P) dated 1/21/2024, indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 99 's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 12/22/2023, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required partial or moderate assistance with eating; unable to ambulate and sit to stand due to medical condition; substantial or maximal assistance with all other activities of daily living (ADLs, basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 99 was frequently incontinent of urine and always incontinent with bowel movements. During a concurrent observation and interview on 1/23/2024 at 10:15 a.m., Resident 99 was lying in bed, alert, and was answering to questions appropriately. Resident 99 stated CNA 4 did not ask permission prior to coming in the room with Certified Nursing Assistant 3 to assist in providing care for her. Resident 99 stated she is a private person and prefers not having another staff present, who is not familiar with her care routine. Resident 99 stated that CNA 4 should have asked permission from her prior to bringing CNA 2 in the room. During an interview on 1/23/2024 at 10:44 a.m., with CNA 4, CNA 4 stated she made a mistake and should have asked Resident 99's permission before having CNA 3 in the room. CNA 4 stated it is important to ask Resident 99's permission to preserve the resident's dignity and to make sure the resident does not feel embarrassed. During an interview on 1/26/2024 at 9:30 a.m., with the Director of Staff Development (DSD), the DSD stated all staff are supposed to knock and ask permission from residents regardless of the purpose of visit. The DSD stated CNA 4 should have asked Resident 99's permission prior to bringing in CNA 3 to assist her (CNA 4) in providing care to the resident. During an interview on 1/26/2024 at 12:59 p.m., with the Director of Nursing (DON), the DON stated CNA 4 should have introduced and asked Resident 99's permission first prior to bringing in CNA 3 to assist in providing care. The DON stated it was a dignity issue and invasion of their privacy. A review of the facility's policy and procedure titled, Dignity, last reviewed 12/28/2023, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The policy indicated the following: Residents are treated with dignity and respect at all times. The facility culture supports dignity and respect for residents by honoring residents' preferences. Staff are expected to knock and request permission before entering residents' rooms. Procedures are explained before they are performed. Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect in full recognition of their individuality for two of three sampled residents (Resident 143, 291, and 99) investigated under the dignity investigative care area by: 1. Failing to maintain Resident 143's privacy while addressing their behavior of removing clothes due to itchiness. 2. Failing to ensure Resident 291's shower preference was honored and respected. 3. Failing to ensure Certified Nursing Assistant 4 (CNA 4) asked Resident 99's permission prior to providing care. These deficient practices had the potential to affect the residents' self-worth and self-esteem. Findings: a. A review of Resident 143's admission Record indicated the facility originally admitted the resident on 2/5/2022 and readmitted on [DATE] with diagnoses including bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness). A review of Resident 143's Hospice Provider 2 (HP 2) physician visit note, dated 12/7/2023, indicated the resident with diagnoses including pruritis (rash). The visit note indicated the resident experiences significant itching, currently prescribed nystatin (treats and prevents infections caused by a fungus or yeast) topical (on the skin) ointment and methylprednisolone (drug used to reduce inflammation caused by many conditions) 4 milligrams (mg, a unit of measure) daily with instructions for skilled nurses to monitor and report any continuing symptoms. A review of Resident 143's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/23/2023, indicated the resident made self-understood and understood others. The MDS indicated the resident required substantial/maximal assistance with upper body dressing and personal hygiene and dependent with lower body dressing and putting on/taking off footwear. During a concurrent observation and interview on 1/24/2024 at 7:27 a.m., at Resident 143's bedside with MDS Coordinator 2 (MDSC 2), observed the privacy curtain not drawn and the resident lying in bed with no clothes on. MDSC 2 stated the resident should have been provided dignity by drawing the privacy curtain and assisting the resident put her clothes back on to promote the resident's dignity. During an interview on 1/24/2024 at 2:29 p.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated she is the assigned CNA to Resident 143. CNA 2 stated the resident has a known behavior of removing her clothes. During an interview on 1/26/2024 at 10:10 a.m., with the Director of Nursing (DON), the DON stated residents with behavior of removing clothes, the CNAs are expected to reinforce the resident's privacy, use privacy curtains, and find alternate ways of gowning the residents. The DON stated privacy should be provided to promote dignity and resident's rights. A review of the facility's policy and procedure titled, Dignity, reviewed and approved by the Patient Care and Quality Assurance Committee on 12/28/2023, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. b. A review of Resident 291's admission Record indicated the facility originally admitted the resident on 11/17/2023 and readmitted the resident on 1/17/2024, with diagnoses including sepsis (the body's extreme response to an infection) and spastic quadriplegic cerebral palsy (a permanent neuromuscular disorder causing limitation on all four limbs following a lesion on the developing brain). A review of Resident 291's History and Physical, dated 11/19/2024, indicated the resident has fluctuating capacity to understand and make decisions. A review of Resident 291's MDS, dated [DATE], indicated the resident has intact cognition and dependent with shower/bathing self and transferring in and out of the tub/shower. A review of Resident 291's Document Survey Report (document to record the resident's ADLs) for 1/2024, indicated on 1/18/2024, 1/21/2024, and 1/22/2024, Certified Nursing Assistants (CNA) provided bed bath to Resident 291, who required assistance with bathing. During an observation on 1/22/2024 10:49 a.m., observed posted outside of Resident 291's room a Contact Precautions (used to help prevent the spread of infectious agents that spread by direct or indirect contact with a resident or a resident's environment) signage indicating instructions to put on personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) and perform hand hygiene. During an interview on 1/22/2024 at 11:00 a.m., with Resident 291, the resident stated he wants to shower. During an observation on 1/22/2024 at 11:05 a.m., observed CNA 10 at Resident 291's bedside. CNA 10 stated he will provide bed bath to the resident because the resident is in an isolation room. During an interview on 1/24/2024 at 8:47 a.m., at Resident 291's bedside with Treatment Nurse 1 present, Resident 291 stated he has not had showers since he got readmitted to the facility. Resident 291 stated he had bed bath three times since he got back, but he wanted to have showers but was told because he is in isolation and could not be provided with a shower. Resident 291 stated his head itches and does not feel good. During an interview on 1/24/2024 at 12:43 p.m., with Registered Nurse 1 (RN 1), RN 1 stated residents who are in contact precautions isolation room are allowed to use the shower room. RN 1 stated staff are expected to disinfect the shower room and the equipment the resident used, such as shower bed or shower chair. RN 1 stated residents who are placed on contact precautions might feel embarrassed and isolated if they are not being provided with shower. A review of the facility's policy and procedure titled, Dignity, reviewed and approved by the Patient Care and Quality Assurance Committee on 12/28/2023, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P indicated the facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values, and beliefs.

CONCERN (E)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Obtain informed consent (a process during which residents or caregivers are educated regarding the potential risks and benefits of medication therapy) from the resident or their responsible party (a person delegated to make medical decisions for the resident in the event they are unable to do so) prior to treatment with injectable lorazepam (a medication used to treat mental illness) in one of six sampled residents investigated during review of unnecessary medications (Resident 14). 2. Obtain informed consent from the resident or their responsible party prior to treatment with Zyprexa (a medication used to treat mental illness) and Celexa (a medication used to treat mental illness) in one of six sampled residents investigated during review of unnecessary medications (Resident 232.) The deficient practice of failing to obtain informed consent prior to initiating treatment with psychotropic medications (medications that affect brain activities associated with mental processes and behavior) could have prevented Resident 14 and Resident 232 from exercising their right to decline to take psychotropic medications. This increased the risk that Resident 14 and Resident 232 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to psychotropic medications possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status. Findings: 1. A review of Resident 14's admission Record (a record containing diagnostic and demographic resident information), dated 1/24/24, indicated she was readmitted to the facility most recently on 8/18/23 with diagnoses including anxiety disorder (a mental condition characterized by intense, excessive, and persistent worry and fear about everyday situations), schizoaffective disorder (a mental condition characterized by visual or audible hallucinations, delusions, episodes and depressed mood, or manic periods of high energy), and psychosis (a mental condition characterized by a disconnection from reality.) A review of Resident 14's History and Physical (a comprehensive physician's note assessing a resident's current medical status), dated 8/31/23, indicated Resident 14 had the capacity to understand and make decisions. A review of Resident 14's Order Summary Report (a summary of all current physician orders), dated 12/22/23 indicated, on 12/17/23, Resident 14's attending physician prescribed lorazepam injectable solution 2 milligrams (mg - a unit of measure for mass) per milliliter (ml - a unit of measure for volume) to inject 0.5 ml intramuscularly (into the muscle) every 6 hours as needed for agitation manifested by constant yelling towards staff and peers . A review of Resident 14's clinical record indicated there was no documentation that Resident 14 or any responsible party received education regarding the risks and benefits of injectable lorazepam prior to its initiation on 12/17/23. During an interview with the Director of Nursing (DON) on 1/24/24 at 3:29 PM, the DON stated the facility failed to obtain informed consent from Resident 14 or a responsible party prior to prescribing lorazepam on 12/17/23. The DON stated it is a requirement to obtain informed consent from a resident or their representative prior to initiating any new psychotropic medication therapy. The DON stated the purpose of the informed consent is to allow the resident or their representative to be thoroughly educated regarding the risks and benefits of psychotropic medication allowing them to make an informed decision on whether they would like to proceed. The DON stated Resident 14 may be at risk of adverse effects of lorazepam due to the failure to obtain informed consent which could lead to a diminished quality of life. 2. A review of Resident 232's admission Record, dated 1/24/24, indicated she was admitted to the facility on [DATE] with diagnoses including depression (a mental condition characterized by depressed mood, loss of appetite, trouble sleeping, and lack of interest in usually enjoyable activities) and bipolar disorder (a mental condition characterized by rapid changes in mood from depressed lows to manic highs.) A review of Resident 232's History and Physical, dated 1/3/24, indicated she had fluctuating capacity to understand and make decisions. A review of Resident 232's Order Summary Report, dated 1/3/24, indicated, on 1/3/24, her attending physician prescribed the following psychotropic medications: 1. Celexa 10 mg by mouth one time a day for depression manifested by verbalization of sadness. 2. Zyprexa 2.5 mg by mouth two times a day for bipolar disorder manifested by lack of impulse control. A review of Resident 232's clinical record indicated there was no documentation that Resident 232 or any responsible party received education regarding the risks and benefits of Celexa or Zyprexa prior to their initiation on 1/3/24. During an interview on 1/24/24 at 4:11 PM The DON stated the facility failed to obtain informed consent from Resident 232 or her responsible party prior to prescribing Zyprexa or Celexa upon her admission to the facility. The DON stated Resident 232 may be at risk of experiencing increased adverse effects of Zyprexa or Celexa due to the failure to obtain informed consent which could lead to a diminished quality of life. A review of the facility's policy Psychotropic Medication Management, last revised 10/24/17, indicated Informed consent for the use of psychoactive medication must be contained in the clinical record. This can be located in the body of the order (following verbal verification from the physician), a statement from the physician documented in the progress notes or on the physician's orders, or a signed consent form from the resident, family, or legal representative.

CONCERN (E)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b. A review of Resident 194's admission Record indicated the facility admitted the resident on 8/18/2023 and readmitted the resident on 10/13/2023, with diagnoses of traumatic brain injury (a form of acquired brain injury caused by a sudden trauma), end stage renal disease (a medical condition in which the kidney cease functioning on a permanent basis leading to the need for a long term-dialysis or kidney transplant to maintain life), and metabolic encephalopathy (a group of conditions that cause brain dysfunction). A review of Resident 194's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/28/2023, indicated the resident usually had the ability to make self-understood and understand others. The MDS indicated the resident was an active participant in the assessment and goal setting process. A review of Resident 194's electronic medical record and physical chart indicated no documented evidence of an advance directive in place. During a concurrent interview and record review on 1/23/2024, at 10:19 a.m., with the Social Services Assistant (SSA), the SSA stated information on the option to formulate an advance directive should have been offered to the resident during the initial assessment. The SSA stated and it is important to provide the resident information regarding advance directive to ensure the resident's wishes regarding their care are followed. c. A review of Resident 222's admission Record indicated the facility admitted the resident on 12/1/2023, with diagnoses including essential hypertension (high blood pressure that is multifactorial and does not have one distinct cause), diabetes mellitus (a disorder in which the body does not produce enough or respond normally with insulin [a hormone that lowers the level of sugar in the blood]), and hypothyroidism (happens when the thyroid gland does not make enough thyroid hormone). A review of Resident 222's MDS, dated [DATE], indicated the resident usually had the ability to make self-understood and understand others. The MDS indicated the resident and the family member participated in the assessment and goal setting process. A review of Resident 222's electronic medical record and physical chart indicated no documented evidence of an advance directive in place. During a concurrent interview and record review on 1/23/2024, at 10:19 a.m., with the SSA, the SSA stated information on the option to formulate an advance directive should have been offered to the resident during the initial assessment. The SSA stated and it is important to provide the resident information regarding advance directive to ensure the resident's wishes regarding their care are followed. During an interview on 1/26/2024, at 9:09 a.m., with the Director of Staff Development (DSD), the DSD stated the SSA, or the licensed staff nurses should have offered the resident the option to formulate an advance directive on admission. The DSD stated the failure to offer the advance directive to the resident could result in providing care and treatment which may not align with the resident's wishes. During an interview on 1/26/2024, at 10:41 a.m., with the Director of Nursing (DON), the DON stated that it is important to offer information in formulating an advance directive on admission or as early as possible so they will know what Resident 222's wishes regarding his care. The DON stated the advance directive provides direction to the staff regarding life sustaining measures and choice of treatment the residents wishes when the resident gets incapacitated. A review of the facility's recent policy and procedure titled, Advance Directives, last reviewed on 12/28/2023, indicated the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her representative, about the existence of any written advance directives. The resident representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. Based on interview and record review, the facility failed to offer the resident or their resident representative assistance with formulating an Advance Directive (AD - a legal document telling the doctor one's wishes about their healthcare in the event they cannot make the decision for themselves) upon admission for three (Resident 4, 194, and 222) out of four sampled residents investigated during review of advance directive care area. This deficient practice violated the resident and/or their representative the right to be fully informed of the option to formulate an AD and had the potential to delay emergency treatment or the potential to force emergency, life-sustaining procedures against the resident's personal preferences. Findings: a. A review of Resident 4's admission Record indicated the facility admitted the resident on 10/21/2023 with diagnoses including fibromlyagia (a chronic [long-lasting] disorder that causes pain and tenderness throughout the body, as well as fatigue and trouble sleeping) and generalized muscle weakness. A review of Resident 4's History and Physical (H&P) dated 10/27/2023, indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 4 's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 10/27/2023, indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required partial or moderate assistance with eating, oral hygiene, and upper body dressing; and substantial or maximal assistance from staff with all other activities of daily living (ADLs, basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated AD was not discussed with the resident and was not completed. A review of Resident 4's Interdisciplinary Team (IDT - a group of health care professionals with various areas of expertise who work together toward the goals of the patients) Conference Notes dated 10/30/2023, did not indicate a discussion or review of resident's AD was done during the meeting. During a concurrent interview and record review on 1/24/2024 at 3:28 p.m., with the Social Services Assistant (SSA), Resident 4's IDT Conference Notes dated 10/30/2023 was reviewed. The SSA stated AD was not discussed or reviewed during the meeting. The SSA stated AD should have been offered and discussed during the initial assessment because it is important to offer assistance the resident and/or their representative formulate an AD to ensure the resident's wishes would be honored in case of an emergency. During an interview on 1/26/2024 at 1:13 p.m., with the Director of Nursing (DON), the DON stated, an AD is something that a resident formulates in advance when fully coherent. The DON stated the AD is a document that included the resident's wishes in case of an emergency. The DON stated without an AD, there is a potential Resident 4's wishes and choices related to their care will not be honored. A review of the facility's recent policy and procedure titled, Advance Directives, last reviewed on 12/28/2023, indicated the following: The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her representative, about the existence of any written advance directives. The resident representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.

CONCERN (E)

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

Deficiency F0604 (Tag F0604)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure a resident was free from physical restraint (refers to means of purposely limiting or obstructing the freedom of a person's bodily movement) for one of one sampled resident (Resident 222) investigated during review of physical restraints care area by failing to assess the need for a restraint and by failing to obtain an order from the physician when: 1. Resident 222's right side bed was pushed against the wall to prevent the resident from getting out of bed. 2. A booster pillow was placed on the left side of Resident 222's bed to prevent the resident from getting out of bed. 3. A tab alarm (features a pull-string that attaches magnetically to the alarm with garment clip to the resident) was applied to Resident 222 to notify staff the resident was getting out of bed. These deficient practices placed Residents 222 at risk for affecting their self-worth for being restricted with movement and had the potential to violate the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms. Findings: A review of Resident 222's admission Record indicated the facility admitted the resident on 12/1/2023, with diagnoses including repeated falls, lack of coordination, and depression (a constant feeling of sadness and loss of interest). A review of Resident 222's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/7/2023, indicated the resident usually had the ability to make self-understood and understand others. The MDS indicated the resident presents with fluctuation of behaviors such as inattention and altered level of consciousness. A review of Care Plans titled, Falls: Resident is at risk for falls with or without injury related to antihypertensive medication (medications that lower blood pressure) and history of falls, initiated on 12/3/2023 and Pain: At risk for pain or discomfort due to general body, initiated on 12/3/2023, indicated an intervention to maintain a calm and quiet environment and apply bed sensor alarm (devices that contain sensors that trigger an alarm or warning light when they detect a change in pressure) while in bed for fall management. During a concurrent observation, interview, and record review on 1/22/2024, at 10:34 a.m., with Licensed Vocational Nurse 1 (LVN 1), observed Resident 222's right side of the bed pushed against the wall, a booster pillow placed on the left side of the resident's bed, and a tab alarm applied to the resident's bed. LVN 1 stated the interventions in place are to prevent the resident from getting out of bed and sustaining a fall. LVN 1 stated there was no physician orders for placing the resident's bed against the wall, use of a booster pillow and tab alarm. During a concurrent interview and record review on 1/25/2024, at 9:53 a.m., with Licensed Vocational Nurse 2 (LVN 2), Resident 222's medical record was reviewed. LVN 2 stated a restraint assessment was not conducted because the resident was still able to move in bed. LVN 2 stated when the tab alarm sounds off it alerts the staff to check on the resident. LVN 2 stated they used the restraints to prevent falls. LVN 2 stated they should have asked the doctor for an order prior to applying the restraints. LVN 2 stated the interventions they provided resulted in denying the right of the resident to move around freely. During an interview on 1/26/2024, at 9:12 a.m., with the Director of Staff Development (DSD), the DSD stated the staff should have not applied any restraints Resident 222. The DSD stated they should have assessed the resident of the need for the physical restraints and obtain an order from the physician. The DSD stated the resident is at risk for feeling depressed due to restriction in movement and bed which may cause physical decline. The DSD stated restraints could potentially cause more injury because the resident may climb out of bed and fall. During an interview on 1/26/2024, at 10:44 a.m., with the Director of Nursing (DON), the DON stated staff should have not applied the booster pillow, tab alarm and placed Resident 222's bed against a wall without a doctor's order. The DON stated staff had applied restraints on the resident because it restricted the resident's movement and denied the resident of their right to move around. The DON stated that there were times that restraints can do more harm than good. The DON also stated the use of tab alarm conflicted with the intervention to a resident who needed to be provided with noise free, calm environment to promote comfort as indicated on the care plan. A review of the facility's recent policy and procedure titled, Alarms, use of Position Change Alarm, last reviewed on 12/28/2023, indicated it is the policy of this facility to use the least restrictive method of ensuring resident safety and to provide the highest degree of resident independence possible. Alarms should not be used for resident's whose care plan identified that their environment should not have loud noises. A physician order should include checking placement and functioning of the device. If any of these conditions apply, refer to the Physical Restraint Policy as the position change alarm now qualifies as a restraint. -Attempting to stand up. A review of the facility's recent policy and procedure titled, Use of Restraints, last reviewed on 12/28/2023, indicated restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted, including: d. placing a resident who uses a wheelchair so close to the wall that the wall prevents the resident from rising. Prior to placing a resident in restraints, there shall be a pre-restraining and review to determine the need for the residents. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms. Restraints shall only be used upon the written order of a physician and after obtaining consent form the resident and/or representative (sponsor). The order shall include the following: a. The specific reason for the restraint (as it relates to the resident's medical symptom); b. How the restraint will be used to benefit the resident's medical symptom; and c. The type of restraint, and period of time for the use of the restraint.

CONCERN (E)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 23 's admission Record indicated the facility admitted the resident on 9/16/2023, with a diagnosis of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a mental health diagnoses that lead to excessive nervousness, fear, apprehension, and worry), and psychosis (a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not). A review of Resident 23's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/23/2023, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was receiving high-risk drug classification of antianxiety medications. A review of Resident 23's Order Summary Report, dated 1/13/2024, indicated a physician's order for Seroquel oral tablet (Quetiapine Fumarate), give 100 milligrams (mg, a unit of weight) by mouth at bedtime for bipolar (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) manifested by angry outbursts as evidence by striking out at others. A review of Resident 23's Medication Administration Record (MAR) dated 1/13/2024-1/21/2024 indicated the resident received doses of Seroquel every night at bedtime from 1/13/2024-1/21/2024. A review of Resident 23's medical chart indicated the resident did not have a care plan for Seroquel. During a concurrent interview and record review on 1/25/2024, at 10:00 a.m., with Licensed Vocational Nurse 12 (LVN 12), Resident 23's medical record was reviewed. LVN 12 verified that Resident 23 did not have a care plan for Seroquel and stated that there should have been one in her medical record. LVN 12 stated that Resident 23 needs to be evaluated and monitored while taking Seroquel and other staff need to know the resident is taking Seroquel and to look out for potential side effects she might be experiencing. During an interview on 1/25/2024, at 11:06 a.m., with the Director of Nursing (DON), the DON stated that Resident 23 should have a care plan on Seroquel because it is a high-risk medication and staff needs to know what side effects to monitor. The DON stated that residents taking Seroquel are at greater risk for falling and need to be monitored more closely for falls. A review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive, last reviewed on 12/28/2023, indicated the policy of this facility to develop, in conjunction with the resident and/or representative, the Comprehensive Resident Care Plan. The Plan is directed toward achieving and maintaining optimal status or health, function, and quality of life. The interdisciplinary Team completes the Comprehensive Care plan no later than seven (7) days after the completion of the RAI (Resident Assessment Instrument) or by the day 21. It is reviewed and revised by the Interdisciplinary Team in quarterly conferences following completion of the MDS (Minimum Data Set) assessment and following assessment for significant changes. The process of care planning is one of looking at the resident as a whole. A review of the facility's P&P titled, Psychoactive Drug Monitoring, last reviewed on 12/28/2023, indicated, the Residents who receive antidepressant, hypnotic, anti-anxiety, or antipsychotic medications are monitored to evaluate the effectiveness of the medication. Residents receive a psychoactive medication only if designated medically necessary by the prescriber. The medical necessity is documented in the resident's medical record and in the care planning process. The continued need for the psychoactive medication is reassessed regularly by the prescriber and the care planning team. Based on interview and record review the facility: 1. Failed to develop a care plan on the use of anticoagulants (a blood thinner that treats and helps prevent blood clots) for two of four sampled residents (Resident 39 and Resident 194) investigated during review of anticoagulant care area by failing to develop a care plan for Resident 39's use of Eliquis (an anticoagulant medication) and by failing to develop a care plan for Resident 194's use of Xarelto (an anticoagulant medication). This deficient practice had the potential for failure to deliver necessary care and services and subjecting residents to adverse effects (a harmful or abnormal result) of significant medications. 2. Failed to develop a care plan on the use of antipsychotic (Seroquel, medication-used to treat disordered thinking associated with severe mental illness) for one out of six sampled residents (Resident 23) investigated during review of unnecessary medications. This deficient practice had the potential to result in inconsistent implementation of the care plan that may lead to a delay in or lack of delivery of care and services as well as subjecting residents to adverse effects (a harmful or abnormal result) of significant medications. 3. Failed to develop comprehensive care plans (a plan that outlines resident-specific interventions used to guide a resident's care for a given area of concern) identifying targeted interventions and specific goals of therapy regarding the use of Psychotropic medications (medications that affect brain activities associated with mental processes and behavior) to treat behavioral issues in four of five sampled residents (Residents 14, 128, 200, and 232) being investigated for unnecessary medications. The deficient practice of failing to create comprehensive, resident-specific care plans related to the use of psychotropic medications increased the risk that Residents 14, 128, 200, and 232's use of psychotropic medications would not be periodically reevaluated as intended. This increased the risk that Residents 14, 128, 200, and 232 may have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to psychotropic medications possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status. 4. Failed to develop a care plan with measurable objectives and interventions for one (Resident 91) out of one sampled resident reviewed with out on pass orders by failing to ensure Resident 91 had a care plan that addressed the non-compliance with physician's order for out on pass (OOP - a temporary permission of a patient to leave the facility in a specified time). This deficient practice placed Resident 91 at risk for accidents while out on pass. Findings: 1. a. A review of Resident 39's admission Record indicated the facility admitted the resident on 1/1/2021 and readmitted the resident on 1/5/2022, with diagnoses including hypertensive heart disease (refers to heart problems that occur because of high blood pressure that is present over a long time) with heart failure (a lifelong condition in which the heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen), atrial fibrillation (is a type of an abnormal heartbeat), and presence of artificial knee joint (a surgery to replace a knee joint with a man-made artificial joint). A review of Resident 39's History and Physical (H&P), dated 1/19/2024, indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 39's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/13/2024, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was dependent on tub or shower transfer and toilet transfer. The MDS also indicated the resident required substantial to maximal assistance on chair or bed-to chair transfer, sit to stand, lying to sitting on side of bed, and sit to lying. A review of Resident 39's Order Summary Report, dated 12/31/2023, indicated an order for: - Eliquis tablet 5 milligrams (mg, a unit of weight). Give 5 mg by mouth two times a day related to unspecified atrial fibrillation. Give with food. During a concurrent interview and record review on 1/24/2024, at 11:17 a.m., with Licensed Vocational Nurse 5 (LVN 5), reviewed Resident 39's care plans. LVN 5 stated she was not able to find the care plan for Eliquis. LVN 5 stated it is important to have a care plan for the use of Eliquis in order to implement interventions such as monitoring side effects of the medication. 1.b. A review of Resident 194's admission Record indicated the facility admitted the resident on 8/18/2023 and readmitted the resident on 10/13/2023, with diagnoses of traumatic brain injury (a form of acquired brain injury cause by sudden trauma) and syncope (a loss of consciousness for a short period of time). A review of Resident 194's MDS, dated [DATE], indicated the resident usually had the ability to make self-understood and understand others. The MDS indicated the resident was dependent on chair/bed-to-chair transfer and required substantial to maximal assistance on lying to sitting on side of bed, sit to lying, and roll left and right. A review of Resident 194's Order Summary Report, dated 12/14/2023, indicated an order for: -Xarelto oral tablet 10 mg. Give 1 tablet by mouth one time a day for deep vein thrombosis (DVT, a medical condition that occurs when a blood clot forms in a deep vein) prophylaxis (measures designed to preserve health and prevent the spread of disease). During a concurrent interview and record review on 1/24/2024, at 11:32 a.m., with LVN 5, Resident 194's care plans were reviewed. LVN 5 stated she was not able to find the care plan for Xarelto. LVN 5 stated it is important to have a care plan for the use of Xarelto in order to implement interventions such as monitoring side effects of the medication. During an interview on 1/26/2024, at 9 a.m., with the Director of Staff Development (DSD), the DSD stated the care plan directs staff on how to take care of the resident appropriately including monitoring for adverse reactions such as bleeding. During an interview on 1/26/2024, at 10:33 a.m., with the Director of Nursing (DON), the DON stated there should be a care plan in place to monitor for adverse effects of the anticoagulant because it could cause systemic bleeding that could be life threatening. A review of the facility's recent policy and procedure titled, Care Planning/Comprehensive, last reviewed on 12/28/2023, indicated it is the policy of this facility to develop, in conjunction with the resident and/or representative, the Comprehensive Resident Care Plan. The Plan is directed toward achieving and maintaining optimal status of health, function, and quality of life. The Interdisciplinary Team completes the Comprehensive Care plan no later than seven (7) days after the completion of the RAI (Resident Assessment Instrument) or by the day 21. A review of the facility's recent policy and procedure titled, Care Plans, last reviewed on 12/28/2023, indicated to assess resident upon admission and initiate a plan of care for the key problems or possible problems identified. The care plan will be completed within seven days. 4. A review of Resident 91's admission Record indicated the facility admitted the resident on 11/8/2023 and readmitted the resident on 12/27/2023 with diagnoses including end stage renal disease (a condition that occurs when the kidneys are no longer able to carry out their daily functions), epilepsy (a condition that happens as a result of abnormal electrical brain activity, also known as a seizure), and lumbar radiculopathy (also known as pinched nerve - a disorder that causes pain in the lower back and hip which radiates down the back of the thigh into the leg). A review of Resident 91's History and Physical (H&P) dated 11/9/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 91 's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 1/2/2024, indicated the resident had an intact cognition (mental action or process of acquiring knowledge and understanding) and required substantial or maximal assistance with transfers; partial or moderate assistance with bathing,, and upper and lower body dressing; and supervision with all other activities of daily living (ADLs, basic tasks that must be accomplished every day for an individual to thrive). A review of resident 91's physician's order indicated an order dated 1/18/2024 resident is allowed to go OOP with Family Member 2 (FM 2) from 1/19/2024 at 9 a.m. and to return 1/21/2024 at 8 p.m. The order indicated medication to be provided to family one time only until 1/21/2024 at 11:59 p.m. A review of the facility's Release of Responsibility for Leave of Absence Form indicated: 1. FM 2 signed out Resident 91 to go home on [DATE] at 12:53 p.m. Resident 91 returned to the facility on [DATE] at 8:46 a.m. 2. FM 2 signed out Resident 91 to go home on 1/19/2024 at 9:30 a.m. Resident 91 returned to the facility on 1/22/2024 at 2:50 p.m. During a review of Resident 91's care plan, there was no documented evidence of resident's non-compliance with OOP order. During a concurrent interview and record review on 1/22/2024 at 12:46 p.m., Resident 91's physician's order was reviewed with Licensed Vocational Nurse 6 (LVN 6). LVN 6 verified Resident 91 went OOP with FM 2 on 1/19/2024 and was to expected to return 1/21/2024 at 6 p.m. LVN 6 stated Resident 91 did not return yet. During an interview on 1/22/2024 at 12:50 p.m., Licensed Vocational Nurse 3 (LVN 3) stated she called Family Member 3 (FM 3) and stated Resident 91 will come back around 3 p.m. once the rain had calmed down. During a concurrent interview and record review on 1/25/2024 at 3:30 p.m., Resident 91's care plan was reviewed with the Assistant Director of Nursing (DON). The ADON verified there was no documented evidence of a care plan to address Resident 91's non-compliance with the OOP order. During an interview on 1/25/2024 at 4:58 p.m., the Director of Nursing (DON) verified there was no documented evidence a care plan was initiated to address Resident 91's non-compliance with the OOP orders. The DON stated any licensed nurse is responsible to initiate the care plan to address Resident 91's non-compliance. The DON stated the care plan should have been initiated so all staff would be aware of what is going on with the resident and continue to provide re-education regarding non-compliance with OOP order may result in loss of OOP order. The DON stated it had the potential to always affect resident's safety while out on pass. A review of the facility's policy and procedure titled, Resident Out on Pass, last reviewed 12/28/2023, indicated a policy statement that to maintain the safety and uninterrupted quality care for the residents at all times leaving the facility will have an out on pass order. The policy indicated non-compliance with the OOP procedure may result in loss of OOP order. A review of the facility's policy and procedure titled, Care Planning/Interim, last reviewed 12/28/2023, indicated an interim care plan is defined as a care plan developed on meeting resident immediate care needs. The policy indicated care plans are developed based on condition, complications, and risk factors and should include the presenting problems. A review of the facility's policy and procedure titled, Care Planning/Comprehensive, last reviewed 12/28/2023, indicated the care plan is directed toward achieving and maintaining optimal health status, function, and quality of life. The policy indicated changes in the care plan are made timely so the plan is always reflective of the care 3. a. A review of Resident 14's admission Record (a record containing diagnostic and demographic resident information), dated 1/24/24, indicated she was readmitted to the facility most recently on 8/18/23 with diagnoses including anxiety disorder (a mental condition characterized by intense, excessive, and persistent worry and fear about everyday situations), schizoaffective disorder (a mental condition characterized by visual or audible hallucinations, delusions, episodes and depressed mood, or manic periods of high energy), and psychosis (a mental condition characterized by a disconnection from reality.) A review of Resident 14's History and Physical (a comprehensive physician's note assessing a resident's current medical status), dated 8/31/23, indicated Resident 14 had the capacity to understand and make decisions. A review of Resident 14's Order Summary Report (a summary of all current physician orders), dated 12/22/23 indicated, Resident 14's attending physician prescribed the following psychotropic medications: 1. Order date 12/17/23 - Lorazepam (a medication used to treat mental illness) injectable solution 2 milligrams (mg - a unit of measure for mass) per milliliter (ml - a unit of measure for volume) to inject 0.5 ml intramuscularly (into the muscle) every 6 hours as needed for agitation manifested by constant yelling towards staff and peers . 2. Order date 8/18/23 - Rexulti (a medication used to treat mental illness) 1 mg by mouth one time a day for auditory hallucination manifested by hearing voices and talking to self related to unspecified psychosis . 3. Order date 8/18/23 - Seroquel (a medication used to treat mental illness) 50 mg by mouth two times a day for agitation leading to striking out related to schizoaffective disorder, bipolar type . 4. Order date 8/18/23 - Amitriptyline (a medication used to treat mental illness) 25 mg by mouth one time a day related to rheumatoid arthritis . A review of Resident 14's comprehensive care plans, last revised 1/23/24, indicated the following care plans were missing: 1. Antidepressant therapy care plan to monitor for side effects of amitriptyline between 8/18/23 and 1/24/24. 2. Antianxiety therapy care plan to monitor for side effects and effectiveness of lorazepam between 12/17/23 and 1/23/24. 3. Care plan for behaviors of striking out/hallucinations (Seroquel and Rexulti) between 8/18/23 to 1/23/24. 4. Care plan for behaviors of Angry outburst/yelling toward staff (lorazepam) from 12/17/23 to 1/23/24. During an interview with the Director of Nursing (DON) on 1/24/24 at 3:29 PM, the DON stated Resident 14's comprehensive care plans do not include any care plan related to the use of antidepressant medications between 8/18/23 and 1/23/23. The DON stated Resident 14's comprehensive care plans do not include any care plan related to the use of antianxiety medications between 12/17/23 and 1/23/23. The DON stated Resident 14's comprehensive care plans do not include any care plan related to the target behaviors of hearing voices and talking to herself and uncontrollable agitation leading to striking out identifying the use of Rexulti and Seroquel, respectively, as targeted interventions between 8/18/23 and 1/23/24. The DON stated Resident 14's comprehensive care plans do not include any care plan related to the target behaviors of agitation manifested by constant yelling toward staff and peers with angry outburst identifying lorazepam as a targeted intervention between 12/17/23 and 1/23/23. The DON stated it appears that the facility staff failed to create comprehensive care plans for these medications and behaviors when the medications were initially prescribed. The DON stated it is important that a care plan is created for all behaviors treated with psychotropic medications. The DON stated, because care plans are reviewed regularly, it gives the facility staff the ability to continue to reevaluate whether psychotropic medications used to treat behavioral issues continue to be safe and effective for the resident. The DON stated, because Resident 14 did not have a care plan for the use of psychotropic medications to treat problematic behaviors between 8/18/23 and 1/23/24, it is possible that Resident 14 may have received those medications for longer than necessary or at a higher dose than necessary which could lead to adverse side effects contributing to a decline in her quality of life. 3.b.A review of Resident 128's admission Record, dated 1/24/24, indicated he was readmitted to the facility most recently on 8/16/23 with diagnoses including anxiety disorder and depression (a mental condition characterized by depressed mood, loss of appetite, trouble sleeping, and lack of interest in usually enjoyable activities.) A review of Resident 128's History and Physical, dated 11/12/23, indicated he had fluctuating capacity to understand and make decisions. A review of Resident 128's Order Summary Report, dated 12/22/23 indicated, on 11/12/23, Resident 128's attending physician prescribed Lexapro (a medication used to treat depression) 10 mg by mouth one time a day for depression manifested by verbalization of sadness. A review of Resident 128's Comprehensive Care Plans, last reviewed 10/4/23, indicated there was no care plan addressing the use of Lexapro or the behavior of verbalization of sadness. During an interview with the DON on 1/24/24 at 3:59 PM, the DON stated Resident 128's comprehensive care plans do not include any care plan related to his used of Lexapro to treat behaviors of verbalization of sadness due to depression. The DON stated it appears that the facility staff failed to create a comprehensive care plan for these behaviors when the resident's Lexapro was initially prescribed. The DON stated, because Resident 128 does not have a care plan for the use of Lexapro to treat the behavior of verbalization of sadness, he may receive Lexapro for longer than necessary or at a higher dose than necessary which could lead to adverse side effects contributing to a decline in his quality of life. A review of Resident 200's admission Record, dated 1/24/24, indicated she was admitted to the facility on [DATE] with diagnoses including anxiety disorder and depression. A review of Resident 200's History and Physical, dated 9/19/23, indicated she had fluctuating capacity to understand and make decisions. A review of Resident 200's Order Summary Report, dated 12/22/23, indicated, on 9/19/23, her attending physician prescribed the following psychotropic medications: 1. Paxil 30 mg by mouth one time a day for depression manifested by verbalization of sadness. 2. Buspirone 5 mg by mouth at bedtime for anxiety manifested by overly concern about health. A review of Resident 200's Comprehensive Care Plans, last revised 12/29/23, indicated there were no care plans for anxiety disorder or behavior of overly concern about health and the existing care plans for antidepression medications and antianxiety medications did not list Resident 200's specific medications as targeted interventions, did not link behaviors of verbalization of sadness or overly concern about health to the use of her medications, or define any specific goals of therapy. During an interview with the DON on 1/24/24 at 3:59 PM, the DON stated Resident 200's comprehensive care plans do not include any care plan for her diagnosis of anxiety disorder or the target behavior of overly concern about health. The DON stated Resident 200's care plans regarding the use of antidepressant and anti-anxiety medication did not contain any targeted interventions specific to Resident 200 or her behaviors. The DON stated these care plans are pretty generic and not resident-focused. The DON stated it appears that the facility staff failed to create a comprehensive care plan for Resident 200's behavior of overly concern about health and even though care plans regarding the use of antidepressant and antianxiety medications were created, the facility failed to identify and include resident-specific interventions and goals of therapy. The DON stated it is important that a care plan is created and is resident-specific for all behaviors treated with psychotropic medications. The DON stated, because care plans are reviewed regularly, it gives the facility staff the ability to continue to reevaluate whether psychotropic medications used to treat behavioral issues continue to be safe and effective for the resident. The DON stated, because Resident 200's care plans were either not created or did not define resident-specific interventions and goals, it is possible that she may have received psychotropic medications for longer than necessary or at a higher dose than necessary which could lead to adverse side effects contributing to a decline in her quality of life. 3. c. A review of Resident 232's admission Record, dated 1/24/24, indicated she was admitted to the facility on [DATE] with diagnoses including depression and bipolar disorder (a mental condition characterized by rapid changes in mood from depressed lows to manic highs.) A review of Resident 232's History and Physical, dated 1/3/24, indicated she had fluctuating capacity to understand and make decisions. A review of Resident 232's Order Summary Report, dated 1/3/24, indicated, on 1/3/24, her attending physician prescribed the following psychotropic medications: 1. Celexa 10 mg by mouth one time a day for depression manifested by verbalization of sadness. 2. Zyprexa 2.5 mg by mouth two times a day for bipolar disorder manifested by lack of impulse control. A review of Resident 232's Comprehensive Care Plans, dated 1/3/24, indicated there were no care plans to address her diagnosis of depression or bipolar disorder and the existing care plans regarding her medications did not list them as a targeted interventions to treat the identified problem behaviors related to her diagnoses. During an interview with the DON on 1/24/24 at 4:11 PM, the DON stated the facility staff failed to create a comprehensive care plan for Resident 232's diagnoses of depression and bipolar disorder and the care plans regarding the use of Zyprexa and Celexa failed to identify target behaviors or include resident-specific goals of therapy. The DON stated it is important that a care plan is created and is resident-specific for all behaviors treated with psychotropic medications. The DON stated, because Resident 232's care plans were either not created or did not define resident-specific interventions and goals, it is possible that she may have received psychotropic medications for longer than necessary or at a higher dose than necessary which could lead to adverse side effects contributing to a decline in her quality of life. A review of the facility's undated policy Care Plans, Comprehensive Person-Centered indicated A comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs . A comprehensive, person-centered care plan should be developed by the interdisciplinary team (IDT), with input from the resident, and his/her family or legal representative . The Comprehensive person-centered care plan should be developed within the seven (7) days of the completion of the required MDS assessment (Admission, annual, or significant change in status), and should be completed within 21 days of admission . The comprehensive, person-centered care plan should: include measurable objectives and time frames .

CONCERN (E)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. c. and 2. A review of Resident 97's admission Record indicated the facility admitted the resident on 4/12/2023, with diagnoses including type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high), peripheral vascular disease (a systemic disorder that involves the narrowing of peripheral vessels [vessels situated away from the heart or the brain]), and bed confinement status. A review of Resident 97's History and Physical (H&P), dated 4/15/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 97's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/19/2023, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was receiving high-risk drug class medication anticoagulant (a substance that is used to prevent and treat blood clots in blood vessels and the heart) and hypoglycemic (medications that lower blood sugar level in the body). A review of Resident 97's Order Summary report indicated the following orders: -Heparin Sodium (Porcine) Injection Solution 5000 unit per milliliter (unit/ml, a milliliter is a unit of fluid volume equal to one-thousandth of a liter) (Heparin Sodium (Porcine)). Inject 1 milliliter (ml, a unit of volume) subcutaneously (beneath, or under, all the layers of the skin) every 12 hours for deep vein thrombosis (DVT, a medical condition that occurs when a blood clot forms in a deep vein) prophylaxis (measures designed to preserve health and prevent the spread of disease). Rotate injection sites. The order date was on 4/13/2023. -Anticoagulant medication side effects- Monitor for discolored urine, black tarry stools, sudden severe headache, nausea, and vomiting (N&V), diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs (v/s), shortness of breath (SOB), nose bleeds. Document: 'N' if no anticoagulant medication side effect(s) observed. Document Y for YES if any of anticoagulant medication side effect(s) was observed, notify MD. Select chart code 'Other/ See Nurses Notes' and progress note findings. The order date was on 4/12/2023. -Humulin R Injection Solution 100 unit/ml (Insulin Regular [Human]). Inject as per sliding scale (the increasing administration of the premeal insulin dose based on the blood sugar level before the meal): if 70 - 149 = 0 units Notify MD if blood sugar (BS) is less than (<) 70. Give orange juice (OJ) if responsive.; 150 - 199 = 2 units (a standardized way to quantify the effect of a medication); 200 - 249 = 4 units; 250 - 299 = 7 units; 300 - 349 = 10 units; 350+ = 12 units Give 12 units if BS is >350. Notify MD., subcutaneously three times a day for finger stick blood sugar (FSBS, a simple, common, safe blood test that can diagnose diabetes) before meal and at bedtime (AC/HS) related to type 2 diabetes mellitus with foot ulcer (an open sore or wound related to diabetes). Rotate injection sites. The order date was on 6/6/2023. A review of Resident 97's Location of Administration Report for Heparin and Insulin from 10/2023 to 1/2024 indicated the medication was administered on the following dates and times: -Heparin Sodium (Porcine) Injection Solution 5000 unit/ml 10/1/2023 at 10:04 a.m. on the Abdomen- Right Lower Quadrant (Abdomen-RLQ) 10/1/2023 at 9:09 a.m. on the Abdomen-RLQ 10/10/2023 at 8:05 p.m. on the Abdomen- Left Upper Quadrant (Abdomen-LUQ) 10/11/2023 at 9:18 p.m. on the Abdomen-LUQ 10/12/2023 at 8:35 a.m. on the Abdomen- Right Upper Quadrant (Abdomen-RUQ) 10/12/2023 at 8:35 p.m. on the Abdomen-RUQ 10/25/2023 at 9:39 p.m. on the Abdomen-RLQ 10/26/2023 at 8:42 a.m. on the Abdomen-RLQ 11/11/2023 at 9:02 a.m. on the Abdomen- Left Lower Quadrant (Abdomen-LLQ) 11/12/2023 at 9:24 a.m. on the Abdomen-LLQ 11/12/2023 at 8:49 p.m. on the Abdomen-LLQ 11/18/2023 at 11:19 a.m. on the Abdomen-RUQ 11/19/2023 at 8:09 a.m. on the Abdomen-RUQ 11/28/2023 at 8:32 a.m. on the Abdomen-RLQ 11/28/2023 at 8:02 a.m. on the Abdomen-RLQ 12/2/2023 at 11:53 a.m. on the Abdomen-LUQ 12/2/2023 at 9:08 p.m. on the Abdomen-LUQ 12/8/2023 at 11:49 a.m. on the Abdomen-RLQ 12/8/2023 at 9:52 p.m. on the Abdomen-RLQ 12/14/2023 at 10:29 a.m. on the Abdomen-LLQ 12/14/2023 at 8:50 p.m. on the Abdomen-LLQ 1/2/2024 at 8:35 a.m. on the Abdomen-LUQ 1/2/2024 at 8:51 p.m. on the Abdomen-LUQ 1/12/2024 at 9:39 p.m. on the Abdomen-RLQ 1/13/2024 at 10:17 a.m. on the Abdomen-RLQ 1/13/2024 at 9:24 p.m. on the Abdomen-RLQ -Humulin R Injection Solution 100 unit/ml 10/3/2023 at 11:05 a.m. on the Abdomen-RUQ 10/4/2023 at 11:05 a.m. on the Abdomen-RUQ 10/21/2023 at 6:38 p.m. on the Abdomen-LUQ 10/21/2023 at 9:15 p.m. on the Abdomen-LUQ 10/26/2023 at 8:25 p.m. on the Abdomen-LLQ 10/26/2023 at 8:32 p.m. on the Abdomen-LLQ 10/27/2023 at 12:18 p.m. on the Abdomen-RUQ 10/28/2023 at 5:11 p.m. on the Abdomen-RUQ 11/9/2023 at 10:34 p.m. on the Abdomen-LUQ 11/10/2023 at 6:56 p.m. on the Abdomen-LUQ 11/11/2023 at 8:57 p.m. on the Abdomen-LLQ 11/14/2023 at 6:57 p.m. on the Abdomen-LLQ 11/16/2023 at 10:09 p.m. on the Abdomen-RLQ 11/17/2023 at 4:31 p.m. on the Abdomen-RLQ 11/22/2023 at 9:38 p.m. on the Abdomen-LUQ 11/23/2023 at 8:49 p.m. on The Abdomen-LUQ 12/9/2023 at 6:30 p.m. on the Arm-right 12/10/2023 at 6:31 p.m. on the Arm-right 12/14/2023 at 1:37 p.m. on the Arm-right 12/28/2023 at 5:37 p.m. on the Abdomen-RLQ 12/28/2023 at 9:21 p.m. on the Abdomen-RLQ 1/5/2024 at 8:41 p.m. on the Abdomen-LLQ 1/8/2024 at 9:11 p.m. on the Abdomen-LLQ 1/10/2024 at 5:13 p.m. on the Abdomen-LLQ 1/10/2024 at 9:16 p.m. on the Abdomen-LLQ 1/16/024 at 12:47 p.m. on the Abdomen-LLQ 1/18/2024 at 11:10 a.m. on the Abdomen-LLQ 1/19/2024 at 4:59 p.m. on the Abdomen-LUQ 1/21/2024 at 6:09 p.m. on the Abdomen-LUQ 1/23/2024 at 9:28 p.m. on the Abdomen-LUQ 1/24/2024 at 8:57 p.m. on the Abdomen-LUQ A review of Resident 97's Care Plans titled, Resident has potential for hyper (high blood sugar)/hypoglycemic (low blood sugar) episode related to diagnosis of diabetes mellitus, last revised on 8/1/2023, and Resident has potential for bleeding or abnormal bruising /skin trauma secondary to heparin therapy, last revised on 1/20/2024, indicated interventions to follow medication as ordered and rotate injections sites. During a concurrent interview and record review on 1/24/2024, at 11 a.m., with Licensed Vocational Nurse 5 (LVN 5), reviewed Resident 97's location of administration sites of heparin and insulin. LVN 5 stated there were repeated administration of insulin and heparin to the same site documented on the resident's Location of Administration Record. LVN 6 stated insulin and heparin administration sites should be rotated to prevent bruising and lipodystrophy. 1.d. A review of Resident 73's admission Record indicated the facility admitted the resident on 8/3/2021 and readmitted the resident on 2/9/2022, with diagnoses including type 2 diabetes mellitus with other skin ulcer (open sores caused by poor blood circulation) and type 2 diabetes mellitus with diabetic retinopathy (a diabetes complication that affects eyes) without macular edema (swelling in part of the retina [the light-sensitive layer of the tissue of the back of the eye). A review of Resident 73's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was receiving high-risk drug class hypoglycemic medication. A review of Resident 73's Order Summary Report, dated 10/2/2023, indicated the following order: - Humulin R Injection Solution 100 unit/ml (Insulin Regular (Human)). Inject as per sliding scale: if 70 - 149 = 0 units Notify MD if BS is <70. Give OJ if responsive.; 150 - 199 = 1 unit; 200 - 249 = 3 units; 250 - 299 = 5 units; 300 - 349 = 7 units; 350+ = 8 units Give 8 units if BS is >350. Notify MD., subcutaneously before meals and at bedtime for diabetes. Rotate injection sites. A review of Resident 73's Location of Administration Report for insulin from 10/2023 to 1/2024 indicated the medication was administered on the following dates and sites. -Humulin R Injection Solution 100 unit/ml 10/8/2023 at 11:32 a.m. on the Abdomen-RUQ 10/9/2023 at 12:10 p.m. on the Abdomen-RUQ 10/21/2023 at 11:02 a.m. on the Arm-left 10/21/2023 at 5:04 p.m. on the Arm-left 10/28/2023 at 9:19 p.m. on the Abdomen-LLQ 10/30/2023 at 5:36 a.m. on the Abdomen-LLQ 12/4/2023 at 4:47 p.m. on the Abdomen-RLQ 12/4/2023 at 9:28 p.m. on the Abdomen-RLQ 12/9/2023 at 1:06 p.m. on the Abdomen-LLQ 12/10/2023 at 12:50 p.m. on the Abdomen-LLQ 12/11/2023 at 4:38 p.m. on the Abdomen-LLQ 12/12/2023 at 7:17 a.m. on the Abdomen-LLQ 12/24/2023 at 2:24 p.m. on the Arm-left 12/25/3023 at 12:38 p.m. on the Arm-left 12/27/2023 at 5:36 p.m. on the Abdomen-LLQ 12/27/2023 at 11:54 p.m. on the Abdomen-LLQ 12/28/2023 at 10:12 p.m. on the Abdomen-LLQ 12/29/2023 at 7:03 a.m. on the Abdomen-LLQ 12/30/2023 at 3;12 p.m. on the Abdomen-LLQ 1/1/2024 at 5:47 a.m. on the Abdomen-RLQ 1/1/2024 at 2:03 p.m. on the Abdomen-RLQ 1/2/2024 at 4:30 p.m. on the Abdomen-LUQ 1/3/2024 at 9:04 p.m. on the Abdomen-LUQ 1/4/2024 at 6:07 a.m. on the Abdomen-RLQ 1/4/2024 at 9:52 p.m. on the Abdomen-RLQ 1/11/2024 at 11:16 a.m. on the Abdomen-LLQ 1/11/2024 at 5:26 p.m. on the Abdomen-LLQ 1/11/2024 at 9:25 p.m. on the Abdomen-LLQ 1/14/2024 at 3:16 p.m. on the Abdomen-LLQ 1/15/2024 at 6:16 a.m. on the Abdomen-LLQ A review of Resident 97's Care Plan titled, Resident has type 2 diabetes mellitus, last reviewed on 1/12/2024, indicated an intervention to follow medication order. During an interview and record review on 1/24/2024, at 3:47 p.m., with Licensed Vocational Nurse 2 (LVN 2), reviewed Resident 97's location of administration of insulin from 10/2023 to 1/2024. LVN 2 stated there were repeated administration of insulin to the same site documented on the resident's Location of Administration Record from 10/2023 to 1/2024. LVN 2 stated insulin administration sites should be rotated to prevent bruising and lipodystrophy. During an interview on 1/26/2024, at 8:57 a.m., with the Director of Staff Development (DSD), the DSD stated the sites of administration for heparin and insulin should be rotated to prevent malabsorption (prevents the body from effectively absorbing) of medication. During an interview on 1/26/2024, at 10:32 a.m., with the Director of Nursing (DON), the DON stated the sites of administration for heparin and insulin should be rotated to prevent massive discoloration, hardening of the tissue, pain, and inflammation of the site frequently administered with the medication. A review of the facility's recent policy and procedure titled, Subcutaneous Injections (Heparin, etc.), last reviewed on 12/28/2023, indicated the purpose of this procedure is to provide guidelines for the administration of medications by subcutaneous injection. Select appropriate injection site. Rotate site per manufacturer's guidelines. A review of the Highlights of Prescribing Information on the use of Humulin R (insulin human) injection, for subcutaneous or intravenous use, with initial U.S. Approval in 1982, indicated to rotate injection sites within the same region from one injection to the next to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. Do not inject into areas of lipodystrophy or localized cutaneous amyloidosis [see Warnings and Precautions (5.2) and Adverse Reactions (6)]. Based on interview and record review, the facility's licensed nursing staff failed to provide care in accordance with professional standards by: 1. Failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of insulin (a hormone that lowers the level of sugar in the blood) to four out of four sampled residents (Residents 73, 97, 1, and 6) investigated for insulin use. 2. Failing to rotate subcutaneous administration sites of heparin (is used to prevent formation of blood clots in the vessels) to one out of four sampled residents (Resident 97) investigated for anticoagulant use. The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin and heparin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs). Findings: 1. a. A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 1/24/2021 with diagnoses including, but not limited to, type two diabetes mellitus. A review of Resident 1's MDS, dated [DATE], indicated Resident 1 was able to understand and make decisions, required setup or clean-up assistance with eating and oral hygiene, and required substantial or maximal assistance with toileting hygiene, showering/bathing herself, upper and lower body dressing, putting on or taking off footwear, and personal hygiene. A review of Resident 1's Order Summary Report indicated the following orders: - On 11/3/2023, Humulin R Injection Solution 100 unit/ml Inject five units subcutaneously with meals for diabetes mellitus rotate injection site. - Insulin Aspart Injection Solution (a rapid acting hormone used to lower the levels of sugar in the blood) 100 unit/ml Injection as per sliding scale: if 71 to 200 = 0 units; 201 to 250 = one unit; 251 to 300 = two units; 301 to 350 = three units; 351 to 400 = four units Notify MD if more than 400, subcutaneously before meals and at bedtime for diabetes mellitus. - On 11/3/2023, Insulin glargine (a type of hormone used to lower the levels of sugar in the blood) solution 100 unit/ml injection 25 units subcutaneously at bedtime for diabetes mellitus rotate injection site. A review of the Resident 1's Location of Administration Report, dated 1/1/2024 to 1/31/2024, indicated Resident 1 was administered Humulin R Injection Solution 100 unit/ml on the following dates, times, and locations: - 1/1/2024 7:30 a.m., subcutaneously Abdomen - RLQ - 1/01/2024 11:30 a.m., subcutaneously Abdomen - RLQ - 1/03/2024 11:30 a.m., subcutaneously Abdomen - RLQ - 1/03/2024 5:30 p.m., subcutaneously Abdomen - RLQ - 1/05/2024 7:30 a.m., subcutaneously Abdomen - LLQ - 1/05/2024 11:30 a.m., subcutaneously Abdomen - LLQ - 1/06/2024 5:30 p.m., subcutaneously Abdomen - LLQ - 1/07/2024 7:30 a.m., subcutaneously Abdomen - LLQ - 1/07/2024 11:30 a.m., subcutaneously Abdomen - LLQ - 1/07/2024 5:30 p.m., subcutaneously Abdomen - LLQ - 1/18/2024 4:30 p.m., subcutaneously Abdomen - LLQ - 1/19/2024 6:30 a.m., subcutaneously Abdomen - LLQ - 1/20/2024 6:30 a.m., subcutaneously Abdomen - LUQ - 1/20/2024 11:30 a.m., subcutaneously Abdomen - LUQ - 1/21/2024 4:30 p.m., subcutaneously Abdomen - RLQ - 1/22/2024 11:30 a.m., subcutaneously Abdomen - RLQ A review of Resident 1's Care Plan, last revised 11/4/2023, indicated Resident 1 has potential for skin discoloration related to insulin injections with interventions or tasks to rotate injection sites regularly. During an interview with the DON, on 1/26/2024, at 1:30 p.m., the DON stated it is important to rotate injection sites to prevent skin integrity complications, including inflammation, redness, pain, thickening, discoloration, and bruising. A review of the facility's recent policy and procedure titled, Subcutaneous Injections (Heparin, etc.), last reviewed on 12/28/2023, indicated the purpose of this procedure is to provide guidelines for the administration of medications by subcutaneous injection. Select appropriate injection site. Rotate site per manufacturer's guidelines. A review of the Highlights of Prescribing Information on the use of Humulin R (insulin human) injection, for subcutaneous or intravenous use, with initial U.S. Approval in 1982, indicated to rotate injection sites within the same region from one injection to the next to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. Do not inject into areas of lipodystrophy or localized cutaneous amyloidosis [see Warnings and Precautions (5.2) and Adverse Reactions (6)]. 1. b. A review of Resident 6's admission Record indicated the facility admitted Resident 6 on 5/24/2021 with diagnoses including, but not limited to, chronic respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and type two diabetes mellitus. A review of Resident 6's MDS, dated [DATE], indicated Resident 6 had moderate cognitive impairment (when a person has problems with their memory or thinking) and required setup or clean-up assistance with eating and oral hygiene, partial or moderate assistance with upper body dressing and personal hygiene, substantial or maximal assistance with toileting hygiene, showering/bathing self, lower body dressing, and was dependent with putting on/taking off footwear. A review of Resident 6's Order Summary Report indicated Resident 6 as ordered the following: - On 7/15/2021, Admelog Solution (Insulin lispro - a rapid acting hormone used to lower the levels of sugar in the blood) 100 unit/ml inject eight units subcutaneously three times a day for fingerstick blood sugar related to type two diabetes mellitus without complications give before meals, rotate injection sites, hold if blood sugar is less than 100. - On 7/15/2021, Admelog Solution 100 unit/ml inject as per sliding scale: if 70 to 149 = 0 units notify physician if blood sugar is less than 70 give orange juice if responsive; 150 to 199 = one unit; 200 to 249 = three units; 250 to 299 = five units; 300 to 349 = seven units; 350+ = eight units; if greater than 350 give eight units and notify physician for further instruction, subcutaneously before meals and at bedtime for fingerstick blood sugar before meals and at bedtime related to type two diabetes mellitus without complications and rotate injection sites. A review of Resident 6's Location of Administration Report, dated 1/1/2024 to 1/31/2024, indicated Resident 1 was administered Admelog Solution 100 unit/ml on the following dates, times, and locations: - 1/01/2024 4:30 p.m., subcutaneously Abdomen - LLQ - 1/02/2024 6:30 a.m., subcutaneously Abdomen - LLQ - 1/02/2024 11:30 a.m., subcutaneously Abdomen - LLQ - 1/02/2024 4:30 p.m., subcutaneously Abdomen - LLQ - 1/03/2024 6:30 a.m., subcutaneously Abdomen - LLQ - 1/07/2024 11:30 a.m., subcutaneously Abdomen - LLQ - 1/07/2024 4:30 p.m., subcutaneously Abdomen - LLQ - 1/08/2024 6:30 a.m., subcutaneously Abdomen - RLQ - 1/08/2024 11:30 a.m., subcutaneously Abdomen - RLQ - 1/08/2024 4:30 p.m., subcutaneously Abdomen - LLQ - 1/09/2024 6:30 a.m., subcutaneously Abdomen - LLQ - 1/09/2024 4:30 p.m., subcutaneously Abdomen - LLQ - 1/10/2024 6:30 a.m., subcutaneously Abdomen - LLQ - 1/10/2024 11:30 a.m., subcutaneously Abdomen - LLQ - 1/14/2024 4:30 p.m., subcutaneously Abdomen - LLQ - 1/15/2024 6:30 a.m., subcutaneously Abdomen - LLQ - 1/16/2024 6:30 a.m., subcutaneously Abdomen - RUQ - 1/16/2024 11:30 a.m., subcutaneously Abdomen - RUQ - 1/19/2024 6:30 a.m., subcutaneously Abdomen - RUQ - 1/19/2024 11:30 a.m., subcutaneously Abdomen - RUQ - 1/22/2024 4:30 p.m., subcutaneously Abdomen - LLQ - 1/23/2024 6:30 a.m., subcutaneously Abdomen - LLQ - 1/23/2024 4:30 p.m., subcutaneously Abdomen - LLQ - 1/24/2024 6:30 a.m., subcutaneously Abdomen - LLQ - 1/04/2024 6:30 a.m., subcutaneously Abdomen - LLQ - 1/04/2024 4:30 p.m., subcutaneously Abdomen - LLQ - 1/07/2024 4:30 p.m., subcutaneously Abdomen - LLQ - 1/07/2024 9:00 p.m., subcutaneously Abdomen - LLQ - 1/08/2024 6:30 a.m., subcutaneously Abdomen - RUQ - 1/08/2024 11:30 a.m., subcutaneously Abdomen - RUQ A review of Resident 6's Care Plans, last revised 6/2/2023, indicated Resident 6 was at risk for skin discoloration related to insulin injections and interventions and tasks included rotating injection sites regularly. During an interview with Registered Nurse (RN) 1, on 1/24/2024, at 11:32 a.m., RN 1 stated Resident 6 receives insulin. RN 1 stated insulin is usually injected into the stomach or arms and the injections sites should be rotated. RN 1 stated it would not be appropriate for residents to receive injections in the same site consecutively. RN 1 further stated injections sites should be rotated to prevent bruising and if sites are not rotated, there is a possibility that medications might not be as effective. During an interview with Licensed Vocational Nurse (LVN) 8, on 1/24/2024, at 11:43 a.m., LVN 8 stated she is assigned to Resident 6 and that Resident 6 receives insulin four times a day on a sliding scale. LVN 8 further stated injection sites should be rotated to prevent injections, lumps, bruising, and lipodystrophy. During an interview with the DON, on 1/26/2024, at 1:30 p.m., the DON stated it is important to rotate injection sites to prevent skin integrity complications, including inflammation, redness, pain, thickening, discoloration, and bruising. A review of the facility's recent policy and procedure titled, Subcutaneous Injections (Heparin, etc.), last reviewed on 12/28/2023, indicated the purpose of this procedure is to provide guidelines for the administration of medications by subcutaneous injection. Select appropriate injection site. Rotate site per manufacturer's guidelines. A review of the Highlights of Prescribing Information on the use of Admelog (insulin lispro injection), for subcutaneous or intravenous use, with initial U.S. Approval in 1996, indicated to rotate injection sites to reduce the risk of lipodystrophy and localized cutaneous amyloidosis.

CONCERN (E)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide needed care and services that are resident centered for two of two sampled residents reviewed under non-pressure skin conditions (Resident 105 and 134) and (Resident 196 Care Area/Universe) when: 1. The facility failed to follow up with Resident 105 regarding the effectiveness of his rash treatments. 2. The facility failed to provide treatment for Resident 134's surgical wound as ordered by the physician. These deficient practices had the potential for Resident 105 and 134's skin conditions to worsen or delay healing. Cross-reference F745 Findings: 1. A review of Resident 105's admission Record indicated the facility originally admitted Resident 105 on 8/4/2020 and readmitted the resident on 5/16/2022 with diagnoses including polyneuropathy (when multiple nerves become damaged) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). A review of Resident 105's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/23/2023, indicated Resident 105 was able to understand and make decisions, required setup or clean-up assistance with eating and oral hygiene, required supervision or touching assistance with toileting hygiene, required partial or moderate assistance with showering or bathing themselves, upper body dressing, and personal hygiene, and required substantial or maximal assistance with lower body dressing and putting on or taking off footwear. A review of Resident 105's Skin & Wound Evaluation, dated 6/14/2023, indicated Resident 105 had dermatitis (condition of the skin in which it becomes red, swollen, and sore) on both legs. A review of Resident 105's Skin & Wound Evaluation, dated 6/28/2023, indicated Resident 105 presented condition has resolved and an order to apply A+D ointment (ointment used to help soothe and protect skin from irritation and inflammation) with drops of tea tree oil (essential oil used topically as an antibacterial, antifungal, and anti-oxidant [substance that prevents or delays cell damage] to help reduce inflammation and enhance healing) were ordered. A review of Resident 105's Care Plans, last revised 11/24/2023, indicated a focus on Resident 105's skin rash of unknown etiology (cause) on both sides of the buttocks, both lower extremities (legs and feet), and upper back extending to the lower back side. The care plans interventions and tasks include administering treatment as ordered, applying tea tree oil mixed with A+D ointment to rash two times a day for fourteen days, and encourage avoiding scratching. A review of Resident 105's Order Summary Report indicated Resident 105 was ordered: - On 10/17/2023, apply triamcinolone acetonide external cream 0.1% (medication used to treat a variety of skin conditions, including dermatitis and rash) apply to throughout body everyday shift. - On 11/2/2023, apply tea tree oil mixed with A+D ointment to upper back extending to lower twice a day for 14 days, until 11/16/2023. - On 11/2/2023, apply tea tree oil mixed with A+D ointment to rash on left lower extremity (leg leg) twice a day for 14 days, until 11/16/2023. - On 11/2/2023, apply tea tree oil mixed with A+D ointment to rash on right lower extremity (right leg) twice a day for 14 days, until 11/16/2023. - On 11/2/2023, apply tea tree oil mixed with A+D ointment to rash on both side of the buttock twice a day for 14 days, until 11/16/2023. During a concurrent observation and interview with Resident 105, on 1/23/2024, at 8:14 a.m., inside Resident 105's room, Resident 105 was in bed and observed with circular redness on the right shin, redness on both upper legs, redness on the mid to lower back, and redness on the upper and lower part of the abdomen. Resident 105 was observed scratching himself on the locations of the skin with redness. Resident 105 stated the redness feels like he had been bitten by an ant or bee. Resident 105 stated Treatment Nurse (TN) 2 made a mixture of creams that helped with his itching and since TN 2 resigned from the facility, his treatments have not been working as well. During a concurrent interview and record review with TN 1, on 1/25/2024, at 9:50 a.m., Resident 105's treatment administration record (TAR) was reviewed and indicated Resident 105 received triamcinolone cream all over his body. TN 1 stated she provides Resident 105 with the cream in a medication cup and Resident 105 will apply it to his body. TN 1 stated she does not mix anything else with the cream. TN 1 stated Resident 105 does not receive A+D ointment. Resident 105's Care Plan, last revised 11/24/2023, with a focus on Resident 105's rash was reviewed, and TN 1 stated Resident 105 does not have an order on the TAR for tea tree oil and A+D ointment administration. TN 1 stated she follows the orders on the TAR and if the order is not indicated on the TAR she would not know to follow through with the order. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 7, on 1/25/2024, at 10:11 a.m., Resident 105's medical record was reviewed and indicated Resident 105's order for tea tree oil and A+D ointment mixture was ended on 11/16/2023. LVN 7 stated there are no progress note to indicate why the order was discontinued or if the order should be continued. Resident 105's care plan for rash, last revised 11/24/2023, was reviewed and LVN 7 confirmed the intervention to apply tea tree oil and A+D ointment were still present on the care plan. During a concurrent interview and record review with TN 2, on 1/25/2024, at 10:48 a.m., Resident 105's TAR, dated 11/2023, was reviewed and indicated TN 2 administered the tea tree oil and A+D ointment mixture to Resident 105. TN 2 further stated he administered treatments as ordered. During an interview with Resident 105, on 1/25/2024, at 11:20 a.m., Resident 105 stated he may have received tea tree oil mixed with A+D ointment before and it was effective. Resident 105 further stated his rashes make him itch and it makes it difficult for him to fall asleep and stay asleep. During an interview with the Director of Nursing (DON), on 1/26/2024, at 1:30 p.m., the DON stated it is important to follow-up with a resident's skin care to see if the skin condition is responding to treatment and whether the skin condition is resolving, remaining stable, or worsening. The DON stated if a treatment is effective for a resident, an order should be obtained, and the treatment should be monitored to assess for effectiveness. The DON further stated if there is no follow up or reorder, the resident's skin condition could worsen. A review of the facility's policy and procedure (P&P) titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, last reviewed 12/28/2023, indicated current approaches should be reviewed for whether they remain pertinent to the resident's medical condition, are affected by factors influencing wound development or healing, and the impact of specific treatment choices made by the resident or a substitute decision-maker. 2. A review of Resident 134's admission Record indicated the facility admitted Resident 134 on 9/27/2021 with diagnoses including, but not limited to, anxiety disorder and history of malignant neoplasm of the skin (abnormal growth of skin cells that invade other tissues and spread). A review of Resident 134's MDS, dated [DATE], indicated Resident 134 was able to understand and make decisions, required supervision or touching assistance with eating and oral hygiene, and required substantial or maximal assistance with toileting hygiene, showering/bathing self, upper body and lower body dressing, putting on or taking off footwear, and personal hygiene. A review of Resident 134's Order Summary Report, dated 12/5/2023, indicated Resident 134 was ordered Mupirocin External Ointment 2% (medication used to prevent bacteria growth and kill bacteria on the skin) apply to affected areas topically three times a day for surgical wound. A review of Resident 134's Care Plans, last revised 5/26/2023, indicated a focus on Resident 134 presenting with impaired skin integrity related to open wound secondary to squamous carcinoma (a type of skin cancer characterized by abnormal, accelerated growth on the cells of the skin) on the scalp. Resident 134's care plan indicated interventions including administering treatment as ordered by cleansing the open wound on the scalp with normal saline (a mixture of sodium chloride and water), pat dry, apply collagen powder (medication used to assist with wound healing), then Mupirocin External Ointment 2%, and cover with dry dressing every day and as needed for dislodgement. During an interview with Resident 134, on 1/22/2024, at 10:50 a.m., Resident 134 stated she had concerns that her dressing on her head is not changed every day. During an interview with Resident 134, on 1/23/2024, at 9:13 a.m., Resident 134 stated she has a history of squamous cell carcinoma removal on the top of her head and she has an order for the dressing to changed daily. During a concurrent interview and record review with TN 3, on 1/26/2024, at 10:22 a.m., Resident 134's TAR, dated 1/2024, was reviewed and indicated Mupirocin External Ointment 2% apply to affected areas topically three times a day for surgical wound was not documented as administered on the following dates and times: - 1/3/2024 at 9:00 p.m. - 1/5/2024 at 9:00 p.m. - 1/6/2024 at 9:00 a.m. - 1/6/2024 at 2:00 p.m. - 1/12/2024 at 2:00 p.m. - 1/14/2024 at 9:00 a.m. - 1/14/2024 at 2:00 p.m. - 1/14/2024 at 9:00 p.m. TN 3 confirmed there was no documentation of treatment administration on reviewed dates and times and stated if the administration was not documented, the facility would not know if the administration was performed or not. TN 3 stated it is important to document administration to show that the interventions were performed. TN 3 stated if treatment is not administered, the site could get dirty and possibly infected. During an interview with the DON, on 1/26/2024, at 1:30 p.m., the DON stated it is important for orders to be carried out to continue healing. The DON stated it is important to document treatment administrations to see if the order was carried out, the wound healing is progressing, worsening, or if the treatment needs to be changed. The DON stated if the treatment administration is documented, the treatment was not done. The DON further stated if the treatment was not done, the wound can worsen, will not heal, and can cause infection. A review of the facility's P&P titled, Charting and Documentation, last reviewed 12/28/2023, indicated documentation of procedures and treatments should include care-specific details, including items such as: a. The date and time the procedure /treatment was provided; b. The name and title of the individual(s) who provided the care; c. The assessment data and/or any unusual findings obtained during the procedure/treatment, if applicable; d. Whether the resident refused the procedure/treatment; e. Notification of family, physician or other staff, if indicated; and f. The signature and title of the individual documenting.

CONCERN (E)

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

Deficiency F0694 (Tag F0694)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to administer parenteral fluids (the intravenous administration of medication) consistent with professional standards of practice by failing to: 1. Flush the peripherally inserted central catheter (PICC, a long, thin tube that is inserted through a vein in the arm and passed through the larger veins in the heart) line/central line (a tube that doctors placed in a large vein in the neck, chest, groin, or arm to give fluids, blood, or medications or do medical tests quickly) with 10 milliliters (ml, a unit of volume) of normal saline (NS, a mixture of sodium chloride [salt] and water) prior to administration of intravenous (IV, within a vein) antibiotics to one of one sampled residents (Resident 446) investigated under infection control task. This deficient practice had the potential to impair the patency of the PICC/Central line causing occlusion (blockage). 2. Indicate the date when the IV tubing was last changed for one of one resident (Resident 452) with intravenous (IV) catheter (a thin plastic tube inserted into a vein using a needle) and indicate the date, time, and initials on the IV antibiotic (a medication used to treat infections) bag when it was last administered for Resident 452. These deficient practices had the potential to place Resident 452 at risk for developing complications such as inflammation of the vein and infection. Findings: 1. A review of Resident 446's admission Record indicated the facility admitted the resident on 1/8/2024, with methicillin resistant staphylococcus aureus (MRSA) infection (infection caused by a type of staph bacteria that has become resistant to many of the antibiotics), bacteremia (viable bacteria in the blood), and urinary tract infection (common infections that happen when bacteria, often from the skin or rectum, enter the urethra, and infect the urinary tract). A review of Resident 446's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/14/2024, indicated the resident had the ability to make self-understood and understand others. The MDS indicated Resident 446 was taking a high-risk drug class IV antibiotic medication. The MDS also indicated Resident 446 had an IV access. A review of Resident 446's Order Summary Report, dated 1/8/2024, indicated an order of Ceftaroline Fosamil Intravenous Solution Reconstituted 600 milligrams (mg, a unit of weight) (Ceftaroline Fosamil) and to use 600 mg intravenously every 12 hours for MRSA bacteremia for 5 weeks. A review of Resident 446's Care Plan on having a central line to be maintained: right upper extremity (RUE) double lumen (two separate ports of access) PICC for antibiotic therapy administration, initiated on 1/17/2024, indicated an intervention to check catheter for leaking, clogging, cracks, migration, where applicable. During an observation and interview on 1/24/2024, at 8:13 a.m., with Registered Nurse 1 (RN 1), observed RN 1 went inside Resident 446's room with personal protective equipment (PPEs, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) on. Observed RN 1 approached Resident 446 and introduced herself. Observed RN 1 placed the IV antibiotic medication on the IV pole, attached them in the machine pump, scrubbed the hub of one port of the PICC line on the right upper arm, and flushed the PICC with 3 ml of normal saline. Then RN 1 attached the IV tubing on the flushed port and ran the machine. RN 1 removed the gloves and then the gown. RN 1 used the alcohol-based hand rub (ABHR) to cleanse the hands. RN 1 stated that she flushed one port with 3 ml of normal saline. During an interview on 1/25/2024, at 10:05 a.m., with Registered Nurse 2 (RN 2), RN 2 stated they use 10 ml of normal saline to flush the central line or PICC line before and after administering IV medications to maintain patency of the line and to prevent them from clogging. During an interview on 1/26/2024, at 10:46 a.m., with the Director of Nursing (DON), the DON stated they flush the PICC line with 5 ml before and after administration of IV medications to keep the patency of the PICC line and the central line intact. A review of the facility's recent policy and procedure titled, Central Venous Catheter Flushing and Locking, last reviewed on 12/28/2023, indicated the purpose of this procedure are to maintain patency of central venous catheters (CVADS); to prevent mixing of incompatible medications and solutions; and to ensure entire dose of solution or medication is administered into the venous system. Use a syringe barrel size of 10 ml or greater when flushing to avoid excessive pressure inside the catheter, prevent potential rupture of the catheter, and prevent dislodgement of clots. Flush with preservative-free 0.9% sodium chloride using the push-pause technique. Leave 0.5 to 1.0 ml of flush in syringe to avoid pushing air into catheter. 2. A review of Resident 452's admission Record indicated the facility admitted the resident on 1/19/2024 with diagnoses including sepsis (a condition that happens when an infection triggers a chain reaction throughout your body), epilepsy (a condition that happens as a result of abnormal electrical brain activity, also known as a seizure), and generalized muscle weakness. A review of Resident 452's History and Physical (H&P), dated 1/21/2024, indicated the resident had the capacity to understand and make decisions. A review of Resident 452 's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 1/25/2024, indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision with eating, sit to stand, and toilet transfers; substantial or maximal assistance with bathing, lower body dressing; and partial or moderate assistance with all other activities of daily living (ADLs, basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 452 received IV antibiotic. A review of Resident 452's physician's order indicated an order, dated 1/20/2024, for levofloxacin (an antibiotic used to treat several different infections) IV solution use 500 milligrams (mg - a unit of measurement) intravenously in the evening for sepsis for seven days with start date of 1/20/2024 5 p.m. During an observation on 1/22/2024 at 2:38 p.m., observed an IV pole at Resident 452's right side of the bed with an empty IV antibiotic bag hanging labeled levofloxacin 500 mg. The IV bag did not indicate the date and time it was last administered and the initials of the nurse who administered the antibiotic and the tubing did not indicate the last date and time it was changed. During a concurrent observation and interview on 1/22/2024 at 2:45 p.m., Registered Nurse 1 verified the IV tubing and IV bag for levofloxacin did not indicate the date and time it was started and the initials of the nurse who administered the medication. RN 1 stated IV tubing for intermittent infusions are to be changed every 24 hours per policy. RN 1 stated the IV tubing and the IV levofloxacin bag should have indicated the date, time, and initials of the nurse who last administered the medication. During a concurrent observation and interview on 1/22/2024 at 2:48 p.m., the Assistant Director of Nursing (ADON) verified that the IV tubing and IV levofloxacin bag did not indicate the date, time, and initials when they were last changed. The ADON stated the IV tubing, and IV levofloxacin bag should have been labeled with the date, time, and initials of the nurse who administered the medication. A review of the facility's policy and procedure titled, Administration Set/Tubing Changes, last reviewed 12/28/2023, indicated a purpose to provide guidelines for aseptic (free from contamination) administration set changes in order to prevent infections associated with contaminated IV therapy equipment. The policy indicated label tubing with date, time, and initials it was initiated and when tubing should be discontinued or changed.

CONCERN (E)

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

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to ensure effective pain management by failing to identify the resident's pain level after administration of pain medication for one of one sampled resident (Resident 203), who was investigated under the care area of pain management. Resident 203 had no pain level assessments after pain medications were given on: 1/1/2024 at 9:45 a.m.; 1/1/2024 at 2 p.m.; 1/1/2024 at 6 p.m.; 1/3/2024 at 9 a.m.; 1/3/2024 at 5:36 p.m.; 1/4/2024 at 2 p.m.; 1/5/2024 at 2 p.m.; 1/8/2024 at 8:45 a.m.; 1/9/2024 at 3:15 p.m.; 1/10/2024 at 11:30 a.m.; 1/10/2024 at 8:47 p.m.; 1/11/2024 at 9:30 a.m.; 1/11/2024 at 8:10 p.m.; 1/12/2024 at 1 a.m.; 1/14/2024 at 12:15 p.m.; 1/15/2024 at 11 a.m.; 1/16/2024 at 1:20 a.m.; 1/19/2024 at 5:30 a.m.; 1/19/2024 at 11 a.m.; 1/21/2024 at 1 p.m.; and 1/22/2024 at 12:11 p.m. This deficient practice had the potential to result in lack of detection of unrelieved pain, placing Resident 203 to unnecessarily suffer with pain. Findings: A review of Resident 203's admission Record indicated the facility admitted the resident on 12/28/2023 with diagnoses including generalized edema, dependence on supplemental oxygen, muscle weakness, and hypertension (high blood pressure). A review of Resident 203's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 1/3/2024, indicated the resident's cognitive skills (ability to understand and make decisions) were intact. The MDS indicated Resident 203 required supervision or touching assistance for toileting hygiene, showering/bathe self, lower body dressing, putting on/taking off footwear, and personal hygiene. A review of Resident 203's Order Summary Report, dated 12/28/2023, indicated a physician's order for Hydrocodone (contains codeine)/Acetaminophen tablet (Norco) 10-325 milligram (mg- a unit of measure) give one (1) tablet by mouth every 4 hours as needed for moderate to severe pain, ordered 12/28/2023. A review of Resident 203's Medication Administration Record (MAR - medications administered to the residents), indicated Hydrocodone (contains codeine)/Acetaminophen tablet (Norco) 10-325 milligram (mg- a unit of measure) give one tablet by mouth every 4 hours as needed for moderate to severe pain, ordered 12/28/2023. During a concurrent interview and record review on 1/24/2024 at 2:10 p.m., with Licensed Vocational Nurse (LVN) 12, reviewed Resident 203's Controlled Drug Record form (CDR/Narcotic run sheet- accountability record of medications that are considered to have a strong potential for abuse) and MAR. LVN 12 verified the following: - One dose of Norco 10-325 mg documented on the CDR form for 1/1/2024 at 9:45 a.m. was not documented on the MAR. There was no pain level assessment documented after medication administration. - One dose of Norco 10-325 mg documented on the CDR form for 1/1/2024 at 2 p.m. was not documented on the MAR. There was no pain level assessment documented after medication administration. - One dose of Norco 10-325 mg documented on the CDR form for 1/1/2024 at 6 p.m. was not documented on the MAR. There was no pain level assessment documented after medication administration. - One dose of Norco 10-325 mg documented on the CDR form for 1/3/2024 at 9 a.m. was not documented on the MAR. There was no pain level assessment documented after medication administration. - One dose of Norco 10-325 mg documented on the CDR form for 1/3/2024 at 5:36 p.m. was not documented on the MAR. There was no pain level assessment documented after medication administration. - One dose of Norco 10-325 mg documented on the CDR form for 1/4/2024 at 2 p.m. was not documented on the MAR. There was no pain level assessment documented after medication administration. - One dose of Norco 10-325 mg documented on the CDR form for 1/5/2024 at 2 p.m. was not documented on the MAR. There was no pain level assessment documented after medication administration. - One dose of Norco 10-325 mg documented on the CDR form for 1/8/2024 at 8:45 a.m. was not documented on the MAR. There was no pain level assessment documented after medication administration. - One dose of Norco 10-325 mg documented on the CDR form for 1/9/2024 at 3:15 p.m. was not documented on the MAR. There was no pain level assessment documented after medication administration. - One dose of Norco 10-325 mg documented on the CDR form for 1/10/2024 at 11:30 a.m. was not documented on the MAR. There was no pain level assessment documented after medication administration. - One dose of Norco 10-325 mg documented on the CDR form for 1/10/2024 at 8:47 p.m. was not documented on the MAR. There was no pain level assessment documented after medication administration. - One dose of Norco 10-325 mg documented on the CDR form for 1/11/2024 at 9:30 a.m. was not documented on the MAR. There was no pain level assessment documented after medication administration. - One dose of Norco 10-325 mg documented on the CDR form for 1/11/2024 at 8:10 p.m. was not documented on the MAR. There was no pain level assessment documented after medication administration. - One dose of Norco 10-325 mg documented on the CDR form for 1/12/2024 at 1 a.m. was not documented on the MAR. There was no pain level assessment documented after medication administration. - One dose of Norco 10-325 mg documented on the CDR form for 1/14/2024 at 12:15 p.m. was not documented on the MAR. There was no pain level assessment documented after medication administration. - One dose of Norco 10-325 mg documented on the CDR form for 1/15/2024 at 11 a.m. was not documented on the MAR. There was no pain level assessment documented after medication administration. - One dose of Norco 10-325 mg documented on the CDR form for 1/16/2024 at 1:20 a.m. was not documented on the MAR. There was no pain level assessment documented after medication administration. - One dose of Norco 10-325 mg documented on the CDR form for 1/19/2024 at 5:30 a.m. was not documented on the MAR. There was no pain level assessment documented after medication administration. - One dose of Norco 10-325 mg documented on the CDR form for 1/19/2024 at 11 a.m. was not documented on the MAR. There was no pain level assessment documented after medication administration. - One dose of Norco 10-325 mg documented on the CDR form for 1/21/2024 at 1 p.m. was not documented on the MAR. There was no pain level assessment documented after medication administration. - One dose of Norco 10-325 mg documented on the CDR form for 1/22/2024 at 12:11 p.m. was not documented on the MAR. There was no pain level assessment documented after medication administration. On 1/26/2024, at 12:17 p.m., during an interview, the Director of Nursing (DON) stated residents' pain assessments should be documented before and after resident's receive pain medication. DON stated Resident 203 should have had her pain assessments completed after she received pain medication. A review of the facility's policy and procedure (P&P) titled, Pain Assessment and Management, last reviewed 12/28/2023, indicated, Document the resident's reported level of pain with adequate detail (i.e., enough information to gauge the status of pain the and the effectiveness of interventions for pain) as necessary and in accordance with the pain management program. Upon completion of the pain assessment, the person conducting the pain assessment shall record the information obtained from the assessment in the resident's medical record.

CONCERN (E)

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

Deficiency F0745 (Tag F0745)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 203's admission Record indicated the facility admitted the resident on 12/28/2023 with diagnoses including dependence on supplemental oxygen, muscle weakness, and hypertension (high blood pressure). A review of Resident 203's MDS, dated [DATE], indicated the resident's cognitive skills (ability to understand and make decisions) were intact (not affected). The MDS indicated Resident 203 required supervision or touching assistance for toileting hygiene, showering/bathe self, lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 203's Care Area assessment dated [DATE], triggered Care Areas and Care Planning Decision for mood State, behavior symptoms, and cognitive loss/dementia. A review of Resident 23 's admission Record indicated the facility admitted the resident on 9/16/2023, with a diagnosis of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a mental health diagnoses that lead to excessive nervousness, fear, apprehension, and worry), and psychosis (a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not). A review of Resident 23's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. The MDS indicated Resident 22 required partial/moderate assistance for toileting hygiene, showering/bathe self, upper and lower body dressing, and putting on/taking off footwear. On 1/22/2024 at 10:37 a.m. during an interview, Resident 203 stated last week (1/13/2024) Resident 23 came up to her in the hallway and punched her in the face. Resident 203 stated that Resident 23 will tell the surveyor that Resident 203 threw a fruit cup at and spit on her first. Resident 203 stated that staff immediately separated the residents, and she had some pain, and the nurse gave her pain medication. Resident 203 stated that she felt fine after the incident and have no injuries. On 1/22/2024 at 10:37 a.m. during an interview, Resident 23 stated Resident 203 spit in her face and threw a fruit cup at her. Resident 23 stated that she punched Resident 203 in the face. Staff then separated her from Resident 203, and she has had no contact with the resident since. During a concurrent interview and record review on 1/24/2024, at 10:22 a.m., with Licensed Vocational Nurse 12 (LVN 15), Resident 203's medical record was reviewed. LVN 15 verified social services never came and saw the resident and did not provide the 72-hour monitoring after the altercation. LVN 15 stated social services handle situations like argument, disagreements, resident to resident altercations, room change, and they see how to make the situation better. LVN 15 stated it would be more beneficial to have either Resident 23 or Resident 203 transfer to a room farther away from each other so the residents would not have to see each other as often and to prevent any further altercations. On 1/24/2024 at 11:03 a.m., during an interview Social Services Director (SSD) stated that she does not think that Resident 203 received 72 hour psychosocial monitoring after the altercation with Resident 23. The SSD stated that both residents should be separated farther from each other. The SSD stated that it could have been better for both residents' safety if one of the residents had been moved. On 1/24/2024 at 1:26 p.m., during an interview with the DON, the DON stated nursing is responsible for the physical assessment and social services is responsible for the mental assessment of the residents after the incident. The DON stated that the facility was unable to find documentation of social services monitoring Resident 203. A review of the facility's policy and procedure (P&P) titled, Abuse Prevention, last reviewed 12/28/2023, indicated, Where the circumstances of the alleged violation warrants, the Director of Nursing of Services or designee shall initiate a physical and mental assessment of the resident and document the findings. Factual information only shall be documented, not assumptions. The Director of Nursing Services or designee shall notify the attending physician regarding the alleged violation, assessment findings and document in the medical record. A review of the facility's P&P titled, Social Services, last reviewed 12/28/2023, indicated, Our facility provides medically related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being. The social worker/social services staff are responsible for: identifying and seeking ways to support resident needs through the assessment and care planning process (i.e., making supportive visits as deemed necessary for potential negative effects during complaints/grievances/allegations of abuse). Based on observation, interview, and record review, the facility failed to provide necessary medically related social services to maintain the highest practicable physical, mental, and psychosocial well-being for one of two sampled residents investigated during review of non-pressure skin conditions care area (Resident 105) and one of six sampled residents reviewed under the abuse investigative care area (Resident 203) when: 1. The facility failed to follow up with Resident 105's dermatology (branch of medicine dealing with the skin) consult for itching. 2. The facility failed to identify and assess Resident 203's need for mental and emotional support after a resident-to-resident altercation between Resident 203 and Resident 23 on 1/13/2024. These deficient practices resulted in a delay in provision of care for Resident 105 and had the potential to result in distress and frustration and for not meeting the needs of Resident 203. Cross-reference F600, F610, and F684. Findings: 1. A review of Resident 105's admission Record indicated the facility originally admitted Resident 105 on 8/4/2020 and readmitted the resident on 5/16/2022 with diagnoses including, but not limited to, polyneuropathy (when multiple nerves become damaged) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). A review of Resident 105's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/23/2023, indicated Resident 105 was able to understand and make decisions, required setup or clean-up assistance with eating and oral hygiene, required supervision or touching assistance with toileting hygiene, required partial or moderate assistance with showering or bathing themselves, upper body dressing, and personal hygiene, and required substantial or maximal assistance with lower body dressing and putting on or taking off footwear. A review of Resident 105's History and Physical (H&P), dated 7/25/2023, indicated Resident 105 had the capacity to understand and make decisions. A review of Resident 105's Order Summary Report, dated 10/9/2023, indicated Resident 105 was ordered a dermatology consult for itchiness. During a concurrent observation and interview with Resident 105, on 1/23/2024, at 8:14 a.m., inside Resident 105's room, Resident 105 was in bed and observed with circular redness on the right shin, redness on both upper legs, redness on the mid to lower back, and redness on the upper and lower part of the abdomen. Resident 105 was observed scratching himself on the locations of the skin with redness. Resident 105 stated the redness feels like he had been bitten by an ant or bee. Resident 105 further stated he was waiting for an appointment to see what is going on with his skin. During a concurrent interview and record review with Treatment Nurse (TN) 1, on 1/25/2024, at 9:50 a.m., Resident 105's Order Summary Report, dated 10/9/2023, was reviewed and confirmed Resident 105 had a dermatology consult ordered. TN 1 stated she was not sure if the consult was followed up. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 7, on 1/25/2024, at 10:11 a.m., Resident 105's Order Summary Report, dated 10/9/2023, was reviewed and confirmed Resident 105 had a dermatology consult ordered. LVN 7 stated the facility did not follow up on Resident 105's dermatology order. LVN 7 stated the order is usually sent to the case manager to process and schedule the resident's appointment. Resident 105's order summary report was reviewed and LVN 7 confirmed there were no appointments scheduled for Resident 105 to see a dermatologist (physician that specializes in skin conditions). LVN 7 stated it is important for Resident 105 to be seen by a dermatologist and receive care to help improve Resident 105's skin condition. LVN 7 further stated if the facility does not follow up with Resident 105's appointments, his skin condition can get worse, or the resident can get an infection. During a concurrent interview and record review with the Case Manager (CM), on 1/25/2024, at 3:38 p.m., Resident 105's Order Summary Report, dated 10/9/2023, was reviewed and confirmed Resident 105 had a dermatology consult ordered. Further record review of Resident 105's medical record indicated the resident did not have a referral to dermatology. The CM stated both social services and case management can place the follow up referral for ancillary services, including dermatology. The CM stated referrals should be processed within a day of receiving the order. The CM stated if referrals are not followed through, there could be a delay in care. During an interview with the Director of Nursing (DON), on 1/26/2024, at 1:30 p.m., the DON stated nursing and social services are responsible for following up with consultations. The DON stated the CM needs to get authorization from the resident's insurance provider. The DON stated once the CM obtains authorization, nursing will follow up with scheduling an appointment with the consultation. The DON stated social services will then setup transportation. The DON stated consultations should be referred to case management immediately. The DON further stated if a resident does not get seen by their consultation there would be a delay or absence of care. A review of the facility's policy and procedure (P&P) titled, Social Services, last reviewed 12/28/2023, indicated the social worker or social services staff are responsible for making referrals and obtaining needed services from outside entities.

CONCERN (E)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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2. A review of Resident 203's admission Record indicated the facility admitted the resident on 12/28/2023 with diagnoses including generalized edema, dependence on supplemental oxygen, muscle weakness, and hypertension (high blood pressure). A review of Resident 203's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 1/3/2024, indicated the resident's cognitive skills (ability to understand and make decisions) were intact (not affected). The MDS indicated Resident 203 required supervision or touching assistance for toileting hygiene, showering/bathe self, lower body dressing, putting on/taking off footwear, and personal hygiene. A review of Resident 203's Order Summary Report, dated 12/28/2023, indicated a physician's order for Hydrocodone (contains codeine)/Acetaminophen tablet (Norco) 10-325 milligram (mg- a unit of measure) give one (1) tablet by mouth every 4 hours as needed for moderate to severe pain, ordered 12/28/2023. A review of Resident 203's Medication Administration Record (MAR - medications administered to the residents), indicated an order Hydrocodone (contains codeine)/Acetaminophen tablet (Norco) 10-325 milligram (mg- a unit of measure) give one (1) tablet by mouth every 4 hours as needed for moderate to severe pain, ordered 12/28/2023. During a concurrent interview and record review on 1/24/2024 at 2:10 p.m., with Licensed Vocational Nurse (LVN) 12, reviewed Resident 203's Controlled Drug Record form (CDR/Narcotic run sheet- accountability record of medications that are considered to have a strong potential for abuse) and MAR. LVN 12 verified the following: - One dose of Norco 10-325 mg documented on the CDR form for 1/1/2024 at 9:45 a.m. was not documented on the MAR. - One dose of Norco 10-325 mg documented on the CDR form for 1/1/2024 at 2:00 p.m. was not documented on the MAR. - One dose of Norco 10-325 mg documented on the CDR form for 1/1/2024 at 6:00 p.m. was not documented on the MAR. - One dose of Norco 10-325 mg documented on the CDR form for 1/3/2024 at 9:00 a.m. was not documented on the MAR. There was no pain level assessment was documented after medication administration. - One dose of Norco 10-325 mg documented on the CDR form for 1/3/2024 at 5:36 p.m. was not documented on the MAR. - One dose of Norco 10-325 mg documented on the CDR form for 1/4/2024 at 2:00 p.m. was not documented on the MAR. - One dose of Norco 10-325 mg documented on the CDR form for 1/5/2024 at 2:00 p.m. was not documented on the MAR. - One dose of Norco 10-325 mg documented on the CDR form for 1/8/2024 at 8:45 a.m. was not documented on the MAR. - One dose of Norco 10-325 mg documented on the CDR form for 1/9/2024 at 3:15 p.m. was not documented on the MAR. - One dose of Norco 10-325 mg documented on the CDR form for 1/10/2024 at 11:30 a.m. was not documented on the MAR. - One dose of Norco 10-325 mg documented on the CDR form for 1/10/2024 at 8:47 p.m. was not documented on the MAR. - One dose of Norco 10-325 mg documented on the CDR form for 1/11/2024 at 9:30 a.m. was not documented on the MAR. - One dose of Norco 10-325 mg documented on the CDR form for 1/11/2024 at 8:10 p.m. was not documented on the MAR. - One dose of Norco 10-325 mg documented on the CDR form for 1/12/2024 at 1:00 a.m. was not documented on the MAR. - One dose of Norco 10-325 mg documented on the CDR form for 1/14/2024 at 12:15 p.m. was not documented on the MAR. - One dose of Norco 10-325 mg documented on the CDR form for 1/15/2024 at 11:00 a.m. was not documented on the MAR. During a concurrent interview and record review on 1/24/2024 at 2:32 p.m., with LVN 12, reviewed Resident 203's CDR form and MAR. LVN 12 verified the following: - One dose of Norco 10-325 mg documented on the CDR form for 1/4/2024 at 2:00 p.m. was not documented on the MAR. - One dose of Norco 10-325 mg documented on the CDR form for 1/4/2024 at 4:00 p.m. and documented on the MAR at 4:41 p.m. LVN 12 stated nurses need to document the medication they give to the residents on both the MAR and the CDR form because there might be a confusion when the resident last received the medication, and the medication could be given too closely together. LVN 12 confirmed that Resident 203 received Norco on 1/4/2024 at both 2:00 p.m. and 4:41 p.m. and the order was to receive the Norco every 4 hours as needed. On 1/25/2024 at 10:43 a.m., during an interview with the Director of Nursing (DON), the DON stated that there is a possibility Resident 203 did not receive the Norco if it was only documented on the CDR sheet and not the MAR. The DON stated that if the medication is not documented on both the MAR and the CDR form, Resident 203 could receive more of the narcotic and become over sedated, or the medication could be diverted, and she might not have received it at all. The DON stated that all nurses are trained to document medications on both the MAR and the CDR form. A review of the facility's policy and procedure (P&P) titled, Controlled Medications, last reviewed, 12/28/2023, indicated, When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record: Date and time of administration, Amount administered, Signature of the nurse administering the dose, completed after the medication is actually administered. Based on observation, interview, and record review: 1. The facility failed to accurately account for one dose of a controlled medication (medications with a high potential for abuse) affecting Resident 205 in one of five inspected medication carts (Station 3 Cart A.) This deficient practice increased the risk that Resident 205 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization. 2. The facility failed to ensure the Controlled Drug Record form (CDR/Narcotic run sheet- accountability record of medications that are considered to have a strong potential for abuse) coincided with the Medication Administration Record (MAR) for one of two sampled residents (Resident 203). This deficient practice resulted in inaccurate reconciliation of the controlled medication and placed the facility at potential for inability to readily identify loss and drug diversion (illegal distribution of abuse of prescription drugs or their use for unintended purposes) of controlled medications. Findings: 1. During an observation and concurrent interview of Station 3 Cart A, on 1/23/24 at 2:11 PM, with the Licensed Vocational Nurse (LVN 8), the following discrepancies were found between the Narcotic and Hypnotic Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication): Resident 205's Narcotic and Hypnotic Record for hydrocodone/apap (a medication used to treat pain) 5/325 milligrams (mg - a unit of measure for mass) indicated there were 27 doses left, however, the medication card contained 26 doses. During a concurrent interview, LVN 8 stated she administered Resident 205's missing dose of hydrocodone/apap 5/325 this morning around 9:08 AM but failed to sign the Narcotic and Hypnotic Record immediately after the administration. LVN 8 stated she understands the policy is to sign the accountability record immediately after administering the medication to the resident in order to maintain accountability of the controlled medications. LVN 8 stated failing to sign this log immediately increases the risk that Resident 205 may have received the medication more often than prescribed or that his medication could have been misappropriated which could lead to medical complications. Review of the facility's policy Controlled Substances, dated revised November 2022, indicated .an individual resident controlled substance record is made for each resident who will be receiving a controlled substance . this record contains . signature of nurse administering medications . Review of the facility's policy Policies and Procedures for Med Pass, last reviewed 12/28/23, indicated When a controlled medication is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record: Date and time of administration . Signature of the nurse administering the dose, completed after the medication is actually administered .

CONCERN (E)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure the consultant pharmacist identified and reported the medication irregularities of failing to monitor for adverse effects and target behaviors related to psychotropic (medications that affect brain activities associated with mental processes and behavior) medication therapy in one of five sampled residents (Resident 14). 2. Facility failed to ensure a Medication Regimen Review (MRR - a monthly report from the consultant pharmacist identifying any medication irregularities in a resident's current medication regimen) request was completed upon admission for one of five sampled residents (Resident 232.) The deficient practices of failing to ensure the consultant pharmacist identifies medication irregularities related to the failure to monitor psychotropic medications for adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) and efficacy and failing to conduct a MRR upon admission increased the risk that Residents 14 and 232 could have experienced adverse effects related to their medication therapy possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status. Findings: A review of Resident 14's admission Record (a record containing diagnostic and demographic resident information), dated 1/24/24, indicated she was readmitted to the facility most recently on 8/18/23 with diagnoses including anxiety disorder (a mental condition characterized by intense, excessive, and persistent worry and fear about everyday situations), schizoaffective disorder (a mental condition characterized by visual or audible hallucinations, delusions, episodes and depressed mood, or manic periods of high energy), and psychosis (a mental condition characterized by a disconnection from reality.) A review of Resident 14's History and Physical (a comprehensive physician's note assessing a resident's current medical status), dated 8/31/23, indicated Resident 14 had the capacity to understand and make decisions. A review of Resident 14's Order Summary Report (a summary of all current physician orders), dated 12/22/23 indicated Resident 14's attending physician prescribed the following psychotropic medictions: 1. Order date 12/17/23 - Lorazepam (a medication used to treat mental illness) injectable solution 2 milligrams (mg - a unit of measure for mass) per milliliter (ml - a unit of measure for volume) to inject 0.5 ml intramuscularly (into the muscle) every 6 hours as needed for agitation manifested by constant yelling towards staff and peers . 2. Order date 8/18/23 - Rexulti (a medication used to treat mental illness) 1 mg by mouth one time a day for auditory hallucination manifested by hearing voices and talking to self related to unspecified psychosis . 3. Order date 8/18/23 - Seroquel (a medication used to treat mental illness) 50 mg by mouth two times a day for agitation leading to striking out related to schizoaffective disorder, bipolar type . 4. Order date 8/18/23 - Amitriptyline (a medication used to treat mental illness) 25 mg by mouth one time a day related to rheumatoid arthritis . A review of Resident 14's Medication Administration Record (MAR - a record of all medications administered, and all regular monitoring done for a resident) between 8/18/23 and 1/23/24 indicated the following: 1. There was no monitoring of adverse effects related to antidepressant medication therapy between 8/18/23 and 1/23/24. 2. There was no monitoring of adverse effects related to antipsychotic medication therapy between 8/18/23 and 12/23/23. 3. There was no monitoring of adverse effects related to antianxiety medication therapy between 12/17/23 to 12/23/23. 4. There was no monitoring of Resident 14's behaviors of hearing voices and talking to herself between 8/18/23 and 1/23/24. 5. There was no monitoring of Resident 14's behaviors of uncontrollable agitation leading to striking out between 8/18/23 and 12/23/23. 6. There was no monitoring of Resident 14's behaviors of agitation manifested by constant yelling towards staff & peers w/ angry outburst between 12/17/23 and 12/23/23. A review of the Consultant Pharmacist's (CP) MRR reports between 10/1/23 and 12/26/23 indicated CP made no recommendations to facility staff concerning the facility's failure to monitor any of the adverse effects or target behaviors related to Resident 14's psychotropic medications listed above. During a telephone interview with CP on 1/24/24 at 3:08 PM, CP stated she is this facility's consultant pharmacist and performs the monthly medication regimen reviews for the facility's residents. CP stated reviewing the MAR thoroughly is part of performing her monthly medication review. CP stated she failed to identify the irregularities or make any reports or notifications regarding Resident 14's lack of monitoring for target behaviors or adverse effects related to the use of Seroquel, Rexulti, amitriptyline, or lorazepam between 8/18/23 and 1/23/24. CP stated sometimes she makes recommendations verbally to facility staff when onsite but cannot be sure if she made any recommendations concerning the irregularities above. CP stated it is better to make the recommendations to the facility in writing to ensure follow-through and accountability. A review of Resident 232's admission Record, dated 1/24/24, indicated she was admitted to the facility on [DATE] with diagnoses including depression (a mental condition characterized by depressed mood, loss of appetite, trouble sleeping, and lack of interest in usually enjoyable activities) and bipolar disorder (a mental condition characterized by rapid changes in mood from depressed lows to manic highs.) A review of Resident 232's History and Physical, dated 1/3/24, indicated she had fluctuating capacity to understand and make decisions. A review of Resident 232's Order Summary Report, dated 1/3/24, indicated, on 1/3/24, her attending physician prescribed the following psychotropic medications: 1. Celexa 10 mg by mouth one time a day for depression manifested by verbalization of sadness. 2. Zyprexa 2.5 mg by mouth two times a day for bipolar disorder manifested by lack of impulse control. A review of Resident 232's New admission Medication Reconciliation, dated 1/3/24, indicated the section to be completed by the pharmacy (indicating whether the resident's medication regimen contained any irregularities) was blank and had not been completed by the consultant pharmacist. During an interview with the Director of Nursing (DON) on 1/24/24 at 3:29 PM, the DON stated the facility did not receive any recommendations from CP between 8/18/23 and 1/23/24 regarding the facility's failure to monitor adverse effects and target behaviors related to Resident 14's psychotropic medications. The DON stated it is important for the pharmacist to identify medication irregularities, including a failure to monitor psychotropic therapy properly, to ensure the best outcome for the resident. The DON stated because the pharmacist failed to identify the facility's failure to monitor Resident 14's psychotropic medications, Resident 14 may have received those medications for longer than necessary or at a higher dose than necessary which could lead to adverse side effects contributing to a decline in her quality of life. During an interview with the DON on 1/24/24 at 4:11 PM, the DON stated when residents are newly admitted to the facility, the facility faxes a request to perform a medication regimen review (MRR) to the pharmacy to check for any medication irregularities such as therapeutic duplications, medication interactions, etc . The DON stated the facility created a MRR form for Resident 232 upon her admission, but failed to fax it to the pharmacy and so the initial medication evaluation was never performed. The DON stated this increased the risk that Resident 232 could have experienced medical complications due to medication-related issues possibly resulting in hospitalization. A review of the facility's policy Medication Regimen Reviews, revised May 2019, indicated The Consultant Pharmacist reviews the medication regimen of each resident at least monthly . Medication regimen reviews are done upon admission (or as close to admission as possible) and at least monthly thereafter, or more frequently if indicated . The MRR involves a thorough review of the resident's medical record to prevent, identify, report, and resolve medication related problems, medication errors and other irregularities, for example . inadequate monitoring for adverse consequences . other medication errors, including those related to documentation .

CONCERN (E)

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 194's admission Record indicated the facility admitted the resident on 8/18/2023, and readmitted the resident on 10/13/2023, with diagnoses including traumatic brain injury (a form of acquired brain injury caused by sudden trauma), syncope (a loss of consciousness for a short period of time), and history of falling. A review of Resident 194's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/28/2023, indicated the resident usually had the ability to make self-understood and understand others. The MDS indicated the resident was receiving high-risk drug class anticoagulant medication (a substance that is used to prevent and treat blood clots in the blood vessels and the heart). A review of Resident 194's Order Summary Report indicated the following orders: - Anticoagulant Medication- Monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting (N&V), diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs (v/s), shortness of breath (SOB), nose bleeds. (Y)= noted and see progress note (N)= none noted. Every shift on 11/8/2023. - Xarelto Oral Tablet 10 mg (Rivaroxaban). Give 1 tablet by mouth one time a day for deep vein thrombosis (DVT, a medical condition that occurs when a blood clot forms in a deep vein) prophylaxis (measures designed to preserve health and prevent the spread of disease) on 12/14/2023. A review of Resident 194's Medication Administration Record (MAR) for 12/2023 to 1/2024 indicated missing monitoring on the use of anticoagulant (Xarelto) on the following dates and shifts: 10/1/2023, night shift 10/2/2023, night shift 10/20/2023, night shift 10/22/2023, night shift 10/23/2023, evening shift 11/8/2023, day shift 11/23/2023, evening shift 12/24/2023, day shift 12/27/2023, night shift 12/29/2023, evening shift During a concurrent interview and record review on 1/24/2024, at 11:27 a.m., with Licensed Vocational Nurse 5 (LVN 5), reviewed Resident 194's Medication Administration Record from 10/2023 to 1/2024. LVN 5 stated there were missing documentation of monitoring for side effects for anticoagulant (Xarelto) use from 10/2023 to 1/2024. LVN 5 stated it is important to consistently monitor for side effects of anticoagulant use to make sure the resident was not experiencing the adverse effects of the medication such as bleeding. LVN 5 stated if it was not documented in the MAR, it was not done. During an interview on 1/26/2024, at 9:11 a.m., with the Director of Staff development (DSD), the DSD stated it is important for licensed nurses to consistently monitor the side effects on residents who use anticoagulants because they could potentially experience bleeding. During an interview on 1/26/2024, at 10:42 a.m., with the Director of Nursing (DON), the DON stated the staff should have monitored daily the side effects on residents who use an anticoagulant (Xarelto) to detect adverse effects of the medication and mitigate them. A review of the facility's recent policy and procedure titled, Anticoagulation- Clinical Protocol, last reviewed on 12/28/2023, indicated as part of the initial assessment, the physician and staff will identify individuals who are currently anticoagulated; for example, those with a recent history of deep vein thrombosis (DVT), or heart valve replacement, atrial fibrillation or those who have had recent joint replacement surgery. The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. a. If an individual on anticoagulation therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next scheduled dose of anticoagulant. b. The physician will order measures to address any complications, including holding or discontinuing the anticoagulant as indicated. c. In individuals receiving anticoagulation who are bleeding or who have a markedly elevated PT/INR, it may suffice to stop the anticoagulant and recheck the PT/INR if the individual is stable, there is no more than minor bleeding, and the INR is not more than 9. Once Vitamin K is given to try to reverse the effects of warfarin, it can hamper subsequent resumption of anticoagulation for a week or more. Based on interview and record review, the facility failed to ensure residents who receive Xarelto (Rivaroxaban, a blood thinner that treats and helps prevent blood clots that are related to certain conditions involving the heart and blood vessels) were monitored for side effects (an often harmful and unwanted effect) as indicated in the care plan for two of four sampled residents (Resident 194 and Resident 1) investigated during review of anticoagulant use. This deficient practice placed the residents at risk for unnecessary medication and undetected side effects. Findings: 1. A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 1/24/2021 with diagnoses including, but not limited to, hypotension (low blood pressure). A review of Resident 1's MDS, dated [DATE], indicated Resident 1 was able to understand and make decisions, required setup or clean-up assistance with eating and oral hygiene, and required substantial or maximal assistance with toileting hygiene, showering/bathing herself, upper and lower body dressing, putting on or taking off footwear, and personal hygiene. A review of Resident 1's Order Summary Report indicated Resident 1 has the following orders: - On 11/3/2023, rivaroxaban (Xarelto) 10 mg give 10 mg by mouth one time a day for venous thromboembolism (VTE - when blood clots form in the vein)/DVT prophylaxis. - On 11/3/2023, Anticoagulant Medication- Monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting (N&V), diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs (v/s), shortness of breath (SOB), nose bleeds. (Y)= noted and see progress note (N)= none noted. Every shift. A review of Resident 1's Care Plan, revised 11/4/2023, indicated Resident 1 was on anticoagulant therapy, Xarelto related to DVT prophylaxis and impaired mobility. The care plan further indicated interventions and tasks including monitoring side effects and effectiveness every shift. A review of Resident 1's Medication Administration Record, dated 12/2023, indicated Resident 1 had an order for Anticoagulant Medication- Monitor for discolored urine, black tarry stools, sudden severe headache, nausea and vomiting (N&V), diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs (v/s), shortness of breath (SOB), nose bleeds. (Y)= noted and see progress note (N)= none noted. Every shift. Resident 1's MAR further indicated no documentation of monitoring on the following days and shifts: - 12/11/2023 Day Shift - 12/15/2023 Night Shift During an interview with the DON, on 1/26/2024, at 1:30 p.m., the DON stated it is important to monitor adverse effects from anticoagulant use because anticoagulants can cause bleeding, low hemoglobin (s protein that carries oxygen from the lungs to the tissues and organs in the body) and hematocrit (the ratio of the volume of red blood cells to the total volume of blood) levels, and possible bleeding to death. A review of the facility's policy and procedure (P&P) titled, Adverse Consequences and Medication Errors, last reviewed 12/28/2023, indicated the staff and practitioner strive to minimize adverse consequences by following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration and monitoring of the medication. The P&P further indicated residents receiving medication are monitored for adverse consequences.

CONCERN (E)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. A review of Resident 23 's admission Record indicated the facility admitted the resident on 9/16/2023, with a diagnosis of major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a mental health diagnoses that lead to excessive nervousness, fear, apprehension, and worry), and psychosis (a collection of symptoms that happen when a person has trouble telling the difference between what's real and what's not). A review of Resident 23's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/23/2023, indicated the resident had the ability to make self-understood and understand others. A review of Resident 23's Order Summary Report, dated 1/13/2024, indicated a physician's order for Seroquel oral tablet (Quetiapine Fumarate), give 100 milligrams (mg, a unit of weight) by mouth at bedtime for Bipolar (a mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) manifested by angry outbursts as evidence by striking out at others. A review of Resident 23's Order Summary Report, dated 1/20/2024, indicated an order for orthostatic blood pressure directions for orthostatic blood pressure: -monitor orthostatic hypotension blood pressure while lying and sitting every 7:00 a.m.-3:00 p.m. shift every week on Saturday day shift. A review of Resident 23's Medication Administration Record (MAR) dated 1/13/2024-1/21/2024 indicated the resident received doses of Seroquel every night at bedtime from 1/13/2024-1/21/2024. A review of Resident 23's Medication Administration Record (MAR) dated 1/1/2024-1/31/2024, indicated orthostatic blood pressure was documented that it was completed on 1/20/2024. A review of Resident 23's vital signs dated 1/20/2024, did not indicate that blood pressure was taken while lying, and then while sitting within five minutes of each other and the results were not recorded. During a concurrent interview and record review on 1/25/2024 at 9:45 a.m., with Licensed Vocational Nurse 12 (LVN 12), Resident 23's medical record was reviewed. LVN 12 verified that on 1/20/2024, the orthostatic blood pressure was not taken for Resident 23. LVN 12 stated that there was no orthostatic blood pressure taken. LVN 2 stated the BP should be taken five minutes apart between sitting and lying down and if there is a difference of 20 millimeters of mercury (mmHg- a measurement of pressure) in between the blood pressure when sitting and lying down, the doctor should be notified, and the resident should be monitored. LVN 12 stated the side effects of Seroquel included orthostatic hypotension and risk for falling. During an interview on 1/25/2024, at 11:00 a.m., Director of Nursing (DON) stated that Resident 23 should have had her orthostatic blood pressure checked while taking Seroquel because she is high risk for falls and developing orthostatic blood pressure. The DON stated residents taking Seroquel are at greater risk for falling and need to be monitoring more closely for falls. A review of the facility's policy and procedure (P&P) titled, Antipsychotic Medication Use, last reviewed on 12/28/2023, indicated, Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician: Cardiovascular: orthostatic hypotension, arrhythmias. A review of the facility's P&P titled, Psychoactive Drug Monitoring, last reviewed on 12/28/2023, indicated, the Residents who receive antidepressant, hypnotic, anti-anxiety, or antipsychotic medications are monitored to evaluate the effectiveness of the medication. Residents who are receiving antipsychotic drug therapy are adequately monitored for significant side effects of such therapy. Based on interview and record review, the facility failed to: 1. Ensure a new order for PRN (as needed) injectable lorazepam (a medication used to treat mental illness) was limited to a 14-day duration in one of six sampled residents investigated during review of unnecessary medications (Resident 14.) 2. Identify and define specific, measurable target behaviors related to the use of Zyprexa (a medication used to treat mental illness) in one of six sampled residents investigated during review of unnecessary medications (Resident 232.) The deficient practice of failing to limit PRN orders for lorazepam to a 14-day duration or identify specific, measurable target behaviors related to the use of Zyprexa increased the risk that Residents 14 and 232 could have experienced adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) related to their medication therapy possibly leading to impairment or decline in their mental or physical condition or functional or psychosocial status. 3. Monitor adverse effects (unwanted, uncomfortable, or dangerous effects that a drug may have) and target behaviors (behaviors related to a diagnoses of mental illness) related to psychotropic medication (medications that affect brain activities associated with mental processes and behavior) therapy between 8/18/23 and 1/23/24 in one of six sampled residents investigated during review of unnecessary medications (Resident 14.) The deficient practice of failing to monitor for adverse effects and target behaviors increased the risk Resident 14 could have experienced adverse effects related to her psychotropic medication therapy possibly leading to impairment or decline in her mental or physical condition or functional or psychosocial status. 4. Monitor and document the resident's postural/orthostatic hypotension- (a drop in blood pressure [hypotension] due to a change in body position when a person moves to a more vertical position: from sitting to standing or from lying down to sitting or standing postural/orthostatic hypotension and can lead to falls and injuries of the residents) readings while taking Seroquel (an antipsychotic medication-used to treat disordered thinking associated with severe mental illness) per physician's order for one of six sampled residents investigated during review of unnecessary medications (Resident 23). This deficient practice had the potential to result in overuse of an antipsychotic medication and antidepressant medication, without monitoring for the effectiveness and/or ineffectiveness of the medication and can lead to adverse drug reactions. Cross reference to F756 Findings: 1. A review of Resident 14's admission Record (a record containing diagnostic and demographic resident information), dated 1/24/24, indicated she was readmitted to the facility most recently on 8/18/23 with diagnoses including anxiety disorder (a mental condition characterized by intense, excessive, and persistent worry and fear about everyday situations), schizoaffective disorder (a mental condition characterized by visual or audible hallucinations, delusions, episodes and depressed mood, or manic periods of high energy), and psychosis (a mental condition characterized by a disconnection from reality.) A review of Resident 14's History and Physical (a comprehensive physician's note assessing a resident's current medical status), dated 8/31/23, indicated Resident 14 had the capacity to understand and make decisions. A review of Resident 14's Physician's Order, dated 12/17/23 indicate the attending physician prescribed lorazepam injectable solution 2 milligrams (mg - a unit of measure for mass) per milliliter (ml - a unit of measure for volume) to inject 0.5 ml intramuscularly (into the muscle) every 6 hours as needed for agitation manifested by constant yelling towards staff and peers . Further review of this PRN medication order revealed there was no stop-date indicated or duration specified. During an interview with the Director of Nursing on 1/24/24 3:29 PM, the DON stated PRN psychotropics are limited to 14 days the first time they are prescribed and then must be reevaluated before they can be prescribed for longer. The DON stated the facility failed to limit Resident 14's order for injectable lorazepam 2 mg/ml to 14 days on 12/17/23 as there is no stop date and the order is currently still active. The DON stated it is important to limit the duration of PRN psychotropic medications to ensure they are continually reevaluated to ensure their conditions for use still exist. The DON stated because Resident 14's PRN order for lorazepam was not limited to 14 days, it is possible that she could have received it unnecessarily, possibly leading to adverse effects and a diminished quality of life. 2. A review of Resident 232's admission Record, dated 1/24/24, indicated she was admitted to the facility on [DATE] with diagnoses including depression (a mental condition characterized by depressed mood, loss of appetite, trouble sleeping, and lack of interest in usually enjoyable activities) and bipolar disorder (a mental condition characterized by rapid changes in mood from depressed lows to manic highs.) A review of Resident 232's History and Physical, dated 1/3/24, indicated she had fluctuating capacity to understand and make decisions. A review of Resident 232's Order Summary Report, dated 1/3/24, indicated, on 1/3/24, her attending physician prescribed Zyprexa 2.5 mg by mouth two times a day for bipolar disorder manifested by lack of impulse control. Further review of the Order Summary Report and the rest of Resident 232's clinical record indicated there were no specific, measurable target behaviors identified to define lack of impulse control. During an interview with the DON on 1/24/24 at 4:11 PM, the DON stated the facility failed to identify and define specific target behaviors for Resident 232's use of Zyprexa. The DON stated poor impulse control is not a specific behavior and cannot be monitored objectively as which behaviors constitute poor impulse control are not further defined. The DON stated the failure to define specific target behaviors prior to the use of antipsychotic medication makes it difficult to periodically assess whether the benefits of the continued use of the medication outweigh the risks. The DON stated if the use of Zyprexa cannot be periodically reevaluated fairly, it may cause Resident 232 to receive it for longer than necessary or at higher doses than necessary leading to a diminished quality of life due the adverse effects related to its use. A review of the facility's policy Psychotropic Medication Management, revised 10/24/17 indicated When psychoactive medications are prescribed for a specific condition or targeted behavior, the clinical record will be reflective of the diagnoses, reasons for use (functional impairment), and have a care plan in place with the medication use and non-drug interventions that had been attempted to alleviate the condition. The effectiveness of these medications and non-drug approaches should be regularly documented in the nurses' notes . PRN orders for psychotropic drugs are limited to 14 days. Except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN orders to be extended beyond 14 days, he/she should document his/her rationale in the resident's medical record and indicate the duration of the PRN order . 3. A review of Resident 14's admission Record (a record containing diagnostic and demographic resident information), dated 1/24/24, indicated she was readmitted to the facility most recently on 8/18/23 with diagnoses including anxiety disorder (a mental condition characterized by intense, excessive, and persistent worry and fear about everyday situations), schizoaffective disorder (a mental condition characterized by visual or audible hallucinations, delusions, episodes and depressed mood, or manic periods of high energy), and psychosis (a mental condition characterized by a disconnection from reality.) A review of Resident 14's History and Physical (a comprehensive physician's note assessing a resident's current medical status), dated 8/31/23, indicated Resident 14 had the capacity to understand and make decisions. A review of Resident 14's Order Summary Report (a summary of all current physician orders), dated 12/22/23 indicated, Resident 14's attending physician prescribed the following psychotropic medications: 1. Order date 12/17/23 - Lorazepam (a medication used to treat mental illness) injectable solution 2 milligrams (mg - a unit of measure for mass) per milliliter (ml - a unit of measure for volume) to inject 0.5 ml intramuscularly (into the muscle) every 6 hours as needed for agitation manifested by constant yelling towards staff and peers . 2. Order date 8/18/23 - Rexulti (a medication used to treat mental illness) 1 mg by mouth one time a day for auditory hallucination manifested by hearing voices and talking to self-related to unspecified psychosis . 3. Order date 8/18/23 - Seroquel (a medication used to treat mental illness) 50 mg by mouth two times a day for agitation leading to striking out related to schizoaffective disorder, bipolar type . 4.Order date 8/18/23 - Amitriptyline (a medication used to treat mental illness) 25 mg by mouth one time a day related to rheumatoid arthritis . A review of Resident 14's Medication Administration Record (MAR - a record of all medications administered, and all regular monitoring done for a resident) between 8/18/23 and 1/23/24 indicated the following: 1. There was no monitoring of adverse effects related to antidepressant medication therapy between 8/18/23 and 1/23/24. 2. There was no monitoring of adverse effects related to antipsychotic medication therapy between 8/18/23 and 12/23/23. 3. There was no monitoring of adverse effects related to antianxiety medication therapy between 12/17/23 to 12/23/23. 4. There was no monitoring of Resident 14's behaviors of hearing voices and talking to herself between 8/18/23 and 1/23/24. 5. There was no monitoring of Resident 14's behaviors of uncontrollable agitation leading to striking out between 8/18/23 and 12/23/23. 6. There was no monitoring of Resident 14's behaviors of agitation manifested by constant yelling towards staff & peers w/ angry outburst between 12/17/23 and 12/23/23. During an interview with the Director of Nursing on 1/24/24 at 3:29 PM, the DON stated the facility failed to monitor adverse effects of Resident 14's amitriptyline between 8/18/23 and 1/23/24. The DON stated the facility failed to monitor for adverse effects of Resident 14's Seroquel and Rexulti between 8/18/23 and 12/23/24. The DON stated the facility failed to monitor for adverse effects of Resident 14's lorazepam between 12/17/23 and 12/23/23. The DON stated the facility failed to monitor Resident 14's target behaviors of hearing voices and talking to herself related to her use of Rexulti between 8/18/23 and 1/23/24. The DON stated the facility failed to monitor Resident 14's target behaviors of uncontrollable agitation leading to striking out related to her use of Seroquel between 8/18/23 and 12/23/23. The DON stated the facility failed to monitor Resident 14's target behaviors of agitation manifested by constant yelling towards staff and peers with angry outburst between 12/17/23 and 12/23/23. The DON stated it is imperative to monitor for adverse effects and incidents of the target behaviors to ensure that the physician and IDT team can periodically determine whether a medication's benefits continue to outweigh the risks at the current dose. The DON stated it appears that the facility staff failed to enter the proper orders for monitoring when this patient was readmitted on [DATE]. The DON stated that day or the week was a Friday, and typically Fridays are busy for admission due to local hospitals discharging several patients. The DON stated the facility did five or six new admissions on that day and it is likely that the orders for monitoring Resident 14's psychotropic medications were accidentally omitted. The DON stated that because Resident 14's psychotropic therapy was not monitored properly, she could have experienced adverse effects from taking the medications longer than necessary or at higher doses than necessary which could have led to medical complications or a diminished quality of life. A review of the facility's policy Psychotropic Medication Management, revised 10/24/17, indicated Medication effects will be monitored and documented on the medication administration record, to include targeted behavior monitoring, and monitoring for adverse effects when the medications are used.

CONCERN (E)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. c. and 2. A review of Resident 97's admission Record indicated the facility admitted the resident on 4/12/2023, with diagnoses including type 2 diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, is too high), peripheral vascular disease (a systemic disorder that involves the narrowing of peripheral vessels [vessels situated away from the heart or the brain]), and bed confinement status. A review of Resident 97's History and Physical (H&P), dated 4/15/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 97's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/19/2023, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was receiving high-risk drug class medication anticoagulant (a substance that is used to prevent and treat blood clots in blood vessels and the heart) and hypoglycemic (medications that lower blood sugar level in the body). A review of Resident 97's Order Summary report indicated the following orders: -Heparin Sodium (Porcine) Injection Solution 5000 unit per milliliter (unit/ml, a milliliter is a unit of fluid volume equal to one-thousandth of a liter) (Heparin Sodium (Porcine)). Inject 1 milliliter (ml, a unit of volume) subcutaneously (beneath, or under, all the layers of the skin) every 12 hours for deep vein thrombosis (DVT, a medical condition that occurs when a blood clot forms in a deep vein) prophylaxis (measures designed to preserve health and prevent the spread of disease). Rotate injection sites. The order date was on 4/13/2023. -Anticoagulant medication side effects- Monitor for discolored urine, black tarry stools, sudden severe headache, nausea, and vomiting (N&V), diarrhea, muscle joint pain, lethargy, bruising, sudden changes in mental status and/or vital signs (v/s), shortness of breath (SOB), nose bleeds. Document: 'N' if no anticoagulant medication side effect(s) observed. Document Y for YES if any of anticoagulant medication side effect(s) was observed, notify MD. Select chart code 'Other/ See Nurses Notes' and progress note findings. The order date was on 4/12/2023. -Humulin R Injection Solution 100 unit/ml (Insulin Regular [Human]). Inject as per sliding scale (the increasing administration of the premeal insulin dose based on the blood sugar level before the meal): if 70 - 149 = 0 units Notify MD if blood sugar (BS) is less than (<) 70. Give orange juice (OJ) if responsive.; 150 - 199 = 2 units (a standardized way to quantify the effect of a medication); 200 - 249 = 4 units; 250 - 299 = 7 units; 300 - 349 = 10 units; 350+ = 12 units Give 12 units if BS is >350. Notify MD., subcutaneously three times a day for finger stick blood sugar (FSBS, a simple, common, safe blood test that can diagnose diabetes) before meal and at bedtime (AC/HS) related to type 2 diabetes mellitus with foot ulcer (an open sore or wound related to diabetes). Rotate injection sites. The order date was on 6/6/2023. A review of Resident 97's Location of Administration Report for Heparin and Insulin from 10/2023 to 1/2024 indicated the medication was administered on the following dates and times: -Heparin Sodium (Porcine) Injection Solution 5000 unit/ml 10/1/2023 at 10:04 a.m. on the Abdomen- Right Lower Quadrant (Abdomen-RLQ) 10/1/2023 at 9:09 a.m. on the Abdomen-RLQ 10/10/2023 at 8:05 p.m. on the Abdomen- Left Upper Quadrant (Abdomen-LUQ) 10/11/2023 at 9:18 p.m. on the Abdomen-LUQ 10/12/2023 at 8:35 a.m. on the Abdomen- Right Upper Quadrant (Abdomen-RUQ) 10/12/2023 at 8:35 p.m. on the Abdomen-RUQ 10/25/2023 at 9:39 p.m. on the Abdomen-RLQ 10/26/2023 at 8:42 a.m. on the Abdomen-RLQ 11/11/2023 at 9:02 a.m. on the Abdomen- Left Lower Quadrant (Abdomen-LLQ) 11/12/2023 at 9:24 a.m. on the Abdomen-LLQ 11/12/2023 at 8:49 p.m. on the Abdomen-LLQ 11/18/2023 at 11:19 a.m. on the Abdomen-RUQ 11/19/2023 at 8:09 a.m. on the Abdomen-RUQ 11/28/2023 at 8:32 a.m. on the Abdomen-RLQ 11/28/2023 at 8:02 a.m. on the Abdomen-RLQ 12/2/2023 at 11:53 a.m. on the Abdomen-LUQ 12/2/2023 at 9:08 p.m. on the Abdomen-LUQ 12/8/2023 at 11:49 a.m. on the Abdomen-RLQ 12/8/2023 at 9:52 p.m. on the Abdomen-RLQ 12/14/2023 at 10:29 a.m. on the Abdomen-LLQ 12/14/2023 at 8:50 p.m. on the Abdomen-LLQ 1/2/2024 at 8:35 a.m. on the Abdomen-LUQ 1/2/2024 at 8:51 p.m. on the Abdomen-LUQ 1/12/2024 at 9:39 p.m. on the Abdomen-RLQ 1/13/2024 at 10:17 a.m. on the Abdomen-RLQ 1/13/2024 at 9:24 p.m. on the Abdomen-RLQ -Humulin R Injection Solution 100 unit/ml 10/3/2023 at 11:05 a.m. on the Abdomen-RUQ 10/4/2023 at 11:05 a.m. on the Abdomen-RUQ 10/21/2023 at 6:38 p.m. on the Abdomen-LUQ 10/21/2023 at 9:15 p.m. on the Abdomen-LUQ 10/26/2023 at 8:25 p.m. on the Abdomen-LLQ 10/26/2023 at 8:32 p.m. on the Abdomen-LLQ 10/27/2023 at 12:18 p.m. on the Abdomen-RUQ 10/28/2023 at 5:11 p.m. on the Abdomen-RUQ 11/9/2023 at 10:34 p.m. on the Abdomen-LUQ 11/10/2023 at 6:56 p.m. on the Abdomen-LUQ 11/11/2023 at 8:57 p.m. on the Abdomen-LLQ 11/14/2023 at 6:57 p.m. on the Abdomen-LLQ 11/16/2023 at 10:09 p.m. on the Abdomen-RLQ 11/17/2023 at 4:31 p.m. on the Abdomen-RLQ 11/22/2023 at 9:38 p.m. on the Abdomen-LUQ 11/23/2023 at 8:49 p.m. on The Abdomen-LUQ 12/9/2023 at 6:30 p.m. on the Arm-right 12/10/2023 at 6:31 p.m. on the Arm-right 12/14/2023 at 1:37 p.m. on the Arm-right 12/28/2023 at 5:37 p.m. on the Abdomen-RLQ 12/28/2023 at 9:21 p.m. on the Abdomen-RLQ 1/5/2024 at 8:41 p.m. on the Abdomen-LLQ 1/8/2024 at 9:11 p.m. on the Abdomen-LLQ 1/10/2024 at 5:13 p.m. on the Abdomen-LLQ 1/10/2024 at 9:16 p.m. on the Abdomen-LLQ 1/16/024 at 12:47 p.m. on the Abdomen-LLQ 1/18/2024 at 11:10 a.m. on the Abdomen-LLQ 1/19/2024 at 4:59 p.m. on the Abdomen-LUQ 1/21/2024 at 6:09 p.m. on the Abdomen-LUQ 1/23/2024 at 9:28 p.m. on the Abdomen-LUQ 1/24/2024 at 8:57 p.m. on the Abdomen-LUQ A review of Resident 97's Care Plans titled, Resident has potential for hyper (high blood sugar)/hypoglycemic (low blood sugar) episode related to diagnosis of diabetes mellitus, last revised on 8/1/2023, and Resident has potential for bleeding or abnormal bruising /skin trauma secondary to heparin therapy, last revised on 1/20/2024, indicated interventions to follow medication as ordered and rotate injections sites. During a concurrent interview and record review on 1/24/2024, at 11 a.m., with Licensed Vocational Nurse 5 (LVN 5), reviewed Resident 97's location of administration sites of heparin and insulin. LVN 5 stated there were repeated administration of insulin and heparin to the same site documented on the resident's Location of Administration Record. LVN 6 stated insulin and heparin administration sites should be rotated to prevent bruising and lipodystrophy. 1. d. A review of Resident 73's admission Record indicated the facility admitted the resident on 8/3/2021 and readmitted the resident on 2/9/2022, with diagnoses including type 2 diabetes mellitus with other skin ulcer (open sores caused by poor blood circulation) and type 2 diabetes mellitus with diabetic retinopathy (a diabetes complication that affects eyes) without macular edema (swelling in part of the retina [the light-sensitive layer of the tissue of the back of the eye). A review of Resident 73's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident was receiving high-risk drug class hypoglycemic medication. A review of Resident 73's Order Summary Report, dated 10/2/2023, indicated the following order: - Humulin R Injection Solution 100 unit/ml (Insulin Regular (Human)). Inject as per sliding scale: if 70 - 149 = 0 units Notify MD if BS is <70. Give OJ if responsive.; 150 - 199 = 1 unit; 200 - 249 = 3 units; 250 - 299 = 5 units; 300 - 349 = 7 units; 350+ = 8 units Give 8 units if BS is >350. Notify MD., subcutaneously before meals and at bedtime for diabetes. Rotate injection sites. A review of Resident 73's Location of Administration Report for insulin from 10/2023 to 1/2024 indicated the medication was administered on the following dates and sites. -Humulin R Injection Solution 100 unit/ml 10/8/2023 at 11:32 a.m. on the Abdomen-RUQ 10/9/2023 at 12:10 p.m. on the Abdomen-RUQ 10/21/2023 at 11:02 a.m. on the Arm-left 10/21/2023 at 5:04 p.m. on the Arm-left 10/28/2023 at 9:19 p.m. on the Abdomen-LLQ 10/30/2023 at 5:36 a.m. on the Abdomen-LLQ 12/4/2023 at 4:47 p.m. on the Abdomen-RLQ 12/4/2023 at 9:28 p.m. on the Abdomen-RLQ 12/9/2023 at 1:06 p.m. on the Abdomen-LLQ 12/10/2023 at 12:50 p.m. on the Abdomen-LLQ 12/11/2023 at 4:38 p.m. on the Abdomen-LLQ 12/12/2023 at 7:17 a.m. on the Abdomen-LLQ 12/24/2023 at 2:24 p.m. on the Arm-left 12/25/3023 at 12:38 p.m. on the Arm-left 12/27/2023 at 5:36 p.m. on the Abdomen-LLQ 12/27/2023 at 11:54 p.m. on the Abdomen-LLQ 12/28/2023 at 10:12 p.m. on the Abdomen-LLQ 12/29/2023 at 7:03 a.m. on the Abdomen-LLQ 12/30/2023 at 3;12 p.m. on the Abdomen-LLQ 1/1/2024 at 5:47 a.m. on the Abdomen-RLQ 1/1/2024 at 2:03 p.m. on the Abdomen-RLQ 1/2/2024 at 4:30 p.m. on the Abdomen-LUQ 1/3/2024 at 9:04 p.m. on the Abdomen-LUQ 1/4/2024 at 6:07 a.m. on the Abdomen-RLQ 1/4/2024 at 9:52 p.m. on the Abdomen-RLQ 1/11/2024 at 11:16 a.m. on the Abdomen-LLQ 1/11/2024 at 5:26 p.m. on the Abdomen-LLQ 1/11/2024 at 9:25 p.m. on the Abdomen-LLQ 1/14/2024 at 3:16 p.m. on the Abdomen-LLQ 1/15/2024 at 6:16 a.m. on the Abdomen-LLQ A review of Resident 97's Care Plan titled, Resident has type 2 diabetes mellitus, last reviewed on 1/12/2024, indicated an intervention to follow medication order. During an interview and record review on 1/24/2024, at 3:47 p.m., with Licensed Vocational Nurse 2 (LVN 2), reviewed Resident 97's location of administration of insulin from 10/2023 to 1/2024. LVN 2 stated there were repeated administration of insulin to the same site documented on the resident's Location of Administration Record from 10/2023 to 1/2024. LVN 2 stated insulin administration sites should be rotated to prevent bruising and lipodystrophy. During an interview on 1/26/2024, at 8:57 a.m., with the Director of Staff Development (DSD), the DSD stated the sites of administration for heparin and insulin should be rotated to prevent malabsorption (prevents the body from effectively absorbing) of medication. During an interview on 1/26/2024, at 10:32 a.m., with the Director of Nursing (DON), the DON stated the sites of administration for heparin and insulin should be rotated to prevent massive discoloration, hardening of the tissue, pain, and inflammation of the site frequently administered with the medication. A review of the facility's recent policy and procedure titled, Subcutaneous Injections (Heparin, etc.), last reviewed on 12/28/2023, indicated the purpose of this procedure is to provide guidelines for the administration of medications by subcutaneous injection. Select appropriate injection site. Rotate site per manufacturer's guidelines. A review of the Highlights of Prescribing Information on the use of Humulin R (insulin human) injection, for subcutaneous or intravenous use, with initial U.S. Approval in 1982, indicated to rotate injection sites within the same region from one injection to the next to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. Do not inject into areas of lipodystrophy or localized cutaneous amyloidosis [see Warnings and Precautions (5.2) and Adverse Reactions (6)]. Based on interview and record review the facility failed to ensure residents were free of any significant medication errors by: 1. Failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) administration sites of insulin (a hormone that lowers the level of sugar in the blood) to four out of four sampled residents (Residents 73, 97, 1, and 6) investigated for insulin use. 2. Failing to rotate subcutaneous administration sites of heparin (is used to prevent formation of blood clots in the vessels) to one out of four sampled residents (Resident 97) investigated for anticoagulant use. The deficient practices had the potential for adverse effect (unwanted, unintended result) of same site subcutaneous administration of insulin and heparin such as lipodystrophy (abnormal distribution of fat) and cutaneous amyloidosis (a rare disease that occurs when a protein called amyloid builds up in organs). Cross reference to F658. Findings: 1. a. A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 1/24/2021 with diagnoses including, but not limited to, type two diabetes mellitus. A review of Resident 1's MDS, dated [DATE], indicated Resident 1 was able to understand and make decisions, required setup or clean-up assistance with eating and oral hygiene, and required substantial or maximal assistance with toileting hygiene, showering/bathing herself, upper and lower body dressing, putting on or taking off footwear, and personal hygiene. A review of Resident 1's Order Summary Report indicated the following orders: - On 11/3/2023, Humulin R Injection Solution 100 unit/ml Inject five units subcutaneously with meals for diabetes mellitus rotate injection site. - Insulin Aspart Injection Solution (a rapid acting hormone used to lower the levels of sugar in the blood) 100 unit/ml Injection as per sliding scale: if 71 to 200 = 0 units; 201 to 250 = one unit; 251 to 300 = two units; 301 to 350 = three units; 351 to 400 = four units Notify MD if more than 400, subcutaneously before meals and at bedtime for diabetes mellitus. - On 11/3/2023, Insulin glargine (a type of hormone used to lower the levels of sugar in the blood) solution 100 unit/ml injection 25 units subcutaneously at bedtime for diabetes mellitus rotate injection site. A review of the Resident 1's Location of Administration Report, dated 1/1/2024 to 1/31/2024, indicated Resident 1 was administered Humulin R Injection Solution 100 unit/ml on the following dates, times, and locations: - 1/1/2024 7:30 a.m., subcutaneously Abdomen - RLQ - 1/01/2024 11:30 a.m., subcutaneously Abdomen - RLQ - 1/03/2024 11:30 a.m., subcutaneously Abdomen - RLQ - 1/03/2024 5:30 p.m., subcutaneously Abdomen - RLQ - 1/05/2024 7:30 a.m., subcutaneously Abdomen - LLQ - 1/05/2024 11:30 a.m., subcutaneously Abdomen - LLQ - 1/06/2024 5:30 p.m., subcutaneously Abdomen - LLQ - 1/07/2024 7:30 a.m., subcutaneously Abdomen - LLQ - 1/07/2024 11:30 a.m., subcutaneously Abdomen - LLQ - 1/07/2024 5:30 p.m., subcutaneously Abdomen - LLQ - 1/18/2024 4:30 p.m., subcutaneously Abdomen - LLQ - 1/19/2024 6:30 a.m., subcutaneously Abdomen - LLQ - 1/20/2024 6:30 a.m., subcutaneously Abdomen - LUQ - 1/20/2024 11:30 a.m., subcutaneously Abdomen - LUQ - 1/21/2024 4:30 p.m., subcutaneously Abdomen - RLQ - 1/22/2024 11:30 a.m., subcutaneously Abdomen - RLQ A review of Resident 1's Care Plan, last revised 11/4/2023, indicated Resident 1 has potential for skin discoloration related to insulin injections with interventions or tasks to rotate injection sites regularly. During an interview with the DON, on 1/26/2024, at 1:30 p.m., the DON stated it is important to rotate injection sites to prevent skin integrity complications, including inflammation, redness, pain, thickening, discoloration, and bruising. A review of the facility's recent policy and procedure titled, Subcutaneous Injections (Heparin, etc.), last reviewed on 12/28/2023, indicated the purpose of this procedure is to provide guidelines for the administration of medications by subcutaneous injection. Select appropriate injection site. Rotate site per manufacturer's guidelines. A review of the Highlights of Prescribing Information on the use of Humulin R (insulin human) injection, for subcutaneous or intravenous use, with initial U.S. Approval in 1982, indicated to rotate injection sites within the same region from one injection to the next to reduce the risk of lipodystrophy and localized cutaneous amyloidosis. Do not inject into areas of lipodystrophy or localized cutaneous amyloidosis [see Warnings and Precautions (5.2) and Adverse Reactions (6)]. 1. b.A review of Resident 6's admission Record indicated the facility admitted Resident 6 on 5/24/2021 with diagnoses including, but not limited to, chronic respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and type two diabetes mellitus. A review of Resident 6's MDS, dated [DATE], indicated Resident 6 had moderate cognitive impairment (when a person has problems with their memory or thinking) and required setup or clean-up assistance with eating and oral hygiene, partial or moderate assistance with upper body dressing and personal hygiene, substantial or maximal assistance with toileting hygiene, showering/bathing self, lower body dressing, and was dependent with putting on/taking off footwear. A review of Resident 6's Order Summary Report indicated Resident 6 as ordered the following: - On 7/15/2021, Admelog Solution (Insulin lispro - a rapid acting hormone used to lower the levels of sugar in the blood) 100 unit/ml inject eight units subcutaneously three times a day for fingerstick blood sugar related to type two diabetes mellitus without complications give before meals, rotate injection sites, hold if blood sugar is less than 100. - On 7/15/2021, Admelog Solution 100 unit/ml inject as per sliding scale: if 70 to 149 = 0 units notify physician if blood sugar is less than 70 give orange juice if responsive; 150 to 199 = one unit; 200 to 249 = three units; 250 to 299 = five units; 300 to 349 = seven units; 350+ = eight units; if greater than 350 give eight units and notify physician for further instruction, subcutaneously before meals and at bedtime for fingerstick blood sugar before meals and at bedtime related to type two diabetes mellitus without complications and rotate injection sites. A review of Resident 6's Location of Administration Report, dated 1/1/2024 to 1/31/2024, indicated Resident 1 was administered Admelog Solution 100 unit/ml on the following dates, times, and locations: - 1/01/2024 4:30 p.m., subcutaneously Abdomen - LLQ - 1/02/2024 6:30 a.m., subcutaneously Abdomen - LLQ - 1/02/2024 11:30 a.m., subcutaneously Abdomen - LLQ - 1/02/2024 4:30 p.m., subcutaneously Abdomen - LLQ - 1/03/2024 6:30 a.m., subcutaneously Abdomen - LLQ - 1/07/2024 11:30 a.m., subcutaneously Abdomen - LLQ - 1/07/2024 4:30 p.m., subcutaneously Abdomen - LLQ - 1/08/2024 6:30 a.m., subcutaneously Abdomen - RLQ - 1/08/2024 11:30 a.m., subcutaneously Abdomen - RLQ - 1/08/2024 4:30 p.m., subcutaneously Abdomen - LLQ - 1/09/2024 6:30 a.m., subcutaneously Abdomen - LLQ - 1/09/2024 4:30 p.m., subcutaneously Abdomen - LLQ - 1/10/2024 6:30 a.m., subcutaneously Abdomen - LLQ - 1/10/2024 11:30 a.m., subcutaneously Abdomen - LLQ - 1/14/2024 4:30 p.m., subcutaneously Abdomen - LLQ - 1/15/2024 6:30 a.m., subcutaneously Abdomen - LLQ - 1/16/2024 6:30 a.m., subcutaneously Abdomen - RUQ - 1/16/2024 11:30 a.m., subcutaneously Abdomen - RUQ - 1/19/2024 6:30 a.m., subcutaneously Abdomen - RUQ - 1/19/2024 11:30 a.m., subcutaneously Abdomen - RUQ - 1/22/2024 4:30 p.m., subcutaneously Abdomen - LLQ - 1/23/2024 6:30 a.m., subcutaneously Abdomen - LLQ - 1/23/2024 4:30 p.m., subcutaneously Abdomen - LLQ - 1/24/2024 6:30 a.m., subcutaneously Abdomen - LLQ - 1/04/2024 6:30 a.m., subcutaneously Abdomen - LLQ - 1/04/2024 4:30 p.m., subcutaneously Abdomen - LLQ - 1/07/2024 4:30 p.m., subcutaneously Abdomen - LLQ - 1/07/2024 9:00 p.m., subcutaneously Abdomen - LLQ - 1/08/2024 6:30 a.m., subcutaneously Abdomen - RUQ - 1/08/2024 11:30 a.m., subcutaneously Abdomen - RUQ A review of Resident 6's Care Plans, last revised 6/2/2023, indicated Resident 6 was at risk for skin discoloration related to insulin injections and interventions and tasks included rotating injection sites regularly. During an interview with Registered Nurse (RN) 1, on 1/24/2024, at 11:32 a.m., RN 1 stated Resident 6 receives insulin. RN 1 stated insulin is usually injected into the stomach or arms and the injections sites should be rotated. RN 1 stated it would not be appropriate for residents to receive injections in the same site consecutively. RN 1 further stated injections sites should be rotated to prevent bruising and if sites are not rotated, there is a possibility that medications might not be as effective. During an interview with Licensed Vocational Nurse (LVN) 8, on 1/24/2024, at 11:43 a.m., LVN 8 stated she is assigned to Resident 6 and that Resident 6 receives insulin four times a day on a sliding scale. LVN 8 further stated injection sites should be rotated to prevent injections, lumps, bruising, and lipodystrophy. During an interview with the DON, on 1/26/2024, at 1:30 p.m., the DON stated it is important to rotate injection sites to prevent skin integrity complications, including inflammation, redness, pain, thickening, discoloration, and bruising. A review of the facility's recent policy and procedure titled, Subcutaneous Injections (Heparin, etc.), last reviewed on 12/28/2023, indicated the purpose of this procedure is to provide guidelines for the administration of medications by subcutaneous injection. Select appropriate injection site. Rotate site per manufacturer's guidelines. A review of the Highlights of Prescribing Information on the use of Admelog (insulin lispro injection), for subcutaneous or intravenous use, with initial U.S. Approval in 1996, indicated to rotate injection sites to reduce the risk of lipodystrophy and localized cutaneous amyloidosis.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to: 1. Ensure two unopened vials of latanoprost (a medication used to treat eye conditions) eye drops were stored in the refrigerator according to the manufacturer's requirements affecting Residents 165 and 341 in two of five inspected medication carts (Station 2 Cart B and Station 5 Medication Cart.) 2. Ensure lorazepam oral solution (a medication used to treat mental illness) and injectable lorazepam solution (a medication used to treat mental illness) were stored in the refrigerator per the manufacturer's requirements affecting residents 143 and 211 in one of five inspected medication carts (Station 3 Cart A.) 3. Ensure six unopened vials of insulin (a medication used to treat high blood sugar) were stored in the refrigerator per the manufacturer's requirements affecting residents 71, 169, 176, 197, and 207 in one of five inspected medication carts (Station 5 Medication Cart.) The deficient practices of failing to store or label medications per the manufacturers' requirements increased the risk that Residents 71, 143, 165, 169, 176, 197, 207, 211, and 341 could have received medication that had become ineffective or toxic due to improper storage possibly leading to health complications resulting in hospitalization or death. Findings: During a concurrent observation and interview on [DATE] at 1:47 PM of Station 2 Cart B with the Licensed Vocational Nurse (LVN 13), the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications: 1.One unopened bottle of latanoprost for Resident 165 was found stored in the cart at room temperature. According to the product labeling, unopened bottles of latanoprost eye drops should be stored in the refrigerator. LVN 13 stated Resident 165's latanoprost is unopened but stored at room temperature without a date. LVN 13 stated when latanoprost is unopened, it must remain in the refrigerator. LVN 13 stated if latanoprost is stored improperly, including at the wrong temperature, it could be less effective or toxic when administered to a resident. LVN 13 stated, because Resident 165's latanoprost was stored improperly, it could have caused medical complications possibly leading to hospitalization. During a concurrent observation and interview on [DATE] at 2:11 PM of Station 3 Cart A with LVN 8, the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications: 1. One bottle of lorazepam 2 milligrams (mg - a unit of measure for mass) per milliliter (ml - a unit of volume) oral solution for Resident 143 was found stored in the medication cart at room temperature. According to the manufacturer's product labeling, lorazepam 2 mg/ml oral solution should be stored in the refrigerator. 2.Several vials of injectable lorazepam 2 mg/ml solution for Resident 211 were found stored in the mediation cart at room temperature. According to the manufacturer's product labeling, injectable lorazepam 2 mg/ml solution should be stored in the refrigerator. LVN 8 stated Resident 143's lorazepam oral solution is stored improperly as it requires refrigeration. LVN 8 stated this medication should never be in the medication cart. LVN 8 stated Resident 211's injectable lorazepam solution is stored improperly as it requires refrigeration. LVN 8 stated failing to store these medications according to the manufacturer's specifications could cause them to be ineffective when administered which may cause Residents 205 and 211 medical complications. During a concurrent observation and interview on [DATE] at 2:48 PM of Station 5 Medication Cart with LVN 14, the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications: 1. One unopened vial of Humulin R (a type of insulin used to control high blood sugar) for Resident 207 was found stored in the cart at room temperature. According to the manufacturer's product labeling, unopened vials of Humulin R should be stored in the refrigerator. 2. One unopened vial of Humalog (a type of insulin used to control high blood sugar) for Resident 197 was found stored in the cart at room temperature. According to the manufacturer's product labeling, unopened vials of Humalog should be stored in the refrigerator. 3. One unopened vial of Humalog for Resident 169 was stored in the cart at room temperature. According to the manufacturer's product labeling, unopened vials of Humalog should be stored in the refrigerator. 4. One unopened vial of Lantus for Resident 71 (a type of insulin used to control high blood sugar) was found stored in the cart at room temperature. According to the manufacturer's product labeling, unopened vials of Lantus should be stored in the refrigerator. 5. One unopened vial of Humalog for Resident 71 was found stored in the cart at room temperature. According to the manufacturer's product labeling, unopened vials of Humalog should be stored in the refrigerator. 6. One unopened vial of Humalog for Resident 176 was found stored in the cart at room temperature. According to the manufacturer's product labeling, unopened vials of Humalog should be stored in the refrigerator. 7. One unopened vial of latanoprost for Resident 341 was found stored in the cart at room temperature. According to the manufacturer's product labeling, unopened vials of latanoprost should be stored in the refrigerator. LVN 14 stated the insulin vials for Residents 71, 169, 176, 197, and 207 are unopened and should be stored in the refrigerator. LVN 14 stated the latanoprost for Resident 341 is unopened and should be stored in the refrigerator. LVN 14 stated it is likely that whoever is receiving the medication from the pharmacy on this unit does not know that certain unopened medications should be stored in the refrigerator rather than the cart. LVN 14 stated if insulin or latanoprost are not stored properly it could cause them to be ineffective or toxic if administered and could cause residents 71, 169, 176, 197, 207, and 341 to experience medication complications possibly leading to hospitalization. A review of the facility's policy Storage of Medications, revised [DATE], indicated Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls . Medication requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location .

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. There was no air gap (the unobstructed vertical space designed to prevent any backflow of contaminated water into the [NAME] supply) between the ice machine drainage pipe and the floor drain. 2. There was no thermometer kept inside the walk-in freezer. 3. The paper towel dispenser next to the hand washing station was empty and not replaced immediately after the previous roll was emptied. These deficient practices had the potential to result in harmful bacterial growth and foodborne illnesses (any illness of a toxic or infectious nature contracted through consumption of contaminated water or food). Findings: 1. During a concurrent observation and interview with the Dietary Supervisor (DS), on 1/22/2024, at 8:03 a.m., inside the kitchen next to the ice machine, the drainpipe leading outside the ice machine was situated going through an open grate on the floor to the floor drain. The DS stated there should be a gap of at least four inches between the floor drain and the ice machine drainage pipe. The DS stated an air gap between the floor drain and the ice machine drainage pipe prevents backflow and cross-contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another). During an interview with the Maintenance Supervisor (MS), on 1/26/2024, at 10:56 a.m., the MS stated there should be a gap between the ice machine drainage pipe and the floor drain. The MS stated in the event of flooding, the water could backflow into the ice machine drainage pipe and cause contamination in the ice machine. During an interview with the Director of Nursing (DON), on 1/26/2024, at 1:30 p.m., the DON stated there should be an air gap between the ice machine drainage pipe and the floor drain to prevent cross-contamination. The DON stated if there is cross-contamination, it can cause ill effects to the residents and staff that use the ice. A review of the facility's policy and procedure (P&P) titled, Ice Machines and Ice Storage Chests, last reviewed 12/28/2023, indicated ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice. A review of the United States Food and Drug Administration Food Code 2022, dated 1/18/2023, indicated under 5-202.14 Backflow Prevention, Air Gap, An air gap between the water supply inlet and the 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 [millimeters] ([one] inch). 2. During a concurrent observation and interview with the DS, on 1/22/2024, at 8:39 a.m., inside the kitchen walk-in freezer, no visible thermometers were observed. The DS confirmed there were no thermometers inside the walk-in freezer and stated there needs to be a thermometer inside the freezer so that the staff knows that the food is being stored in the right temperature. The DS further stated, if the food is not stored in the correct temperature, the food inside might spoil. During an interview with the MS, on 1/26/2024, at 10:56 a.m., the MS stated thermometers should be kept inside the walk-in freezer to get an accurate reading of the temperature in the walk-in freezer. The MS further stated it is important to have an accurate reading of the temperature to prevent food stored in the freezer from spoiling. During an interview with the DON, on 1/26/2024, at 1:30 p.m., the DON stated it is important to keep the thermometer in the freezer to make sure the food is stored in the correct temperature. The DON further stated if food is not kept in the correct temperature, the food might spoil and cause foodborne illnesses. A review of the facility's P&P titled, Food Receiving, Labeling and Storage, last reviewed 12/28/2023, indicated food shall be received and stored in a manner that complies with safe food handling practices and functioning of the refrigeration and food temperatures are monitored daily and at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state-specific requirements. 3. During a concurrent observation and interview with the DS, on 1/23/2024, at 9:59 a.m., inside the kitchen at the handwashing station, the paper towel dispenser was not dispensing paper towels and contained an empty paper towel roll. The DS confirmed the paper towel dispenser was empty and requested Dietary Aide (DA) 1 to replace the paper towel dispenser. During an interview with the MS, on 1/26/2024, at 10:56 a.m., the MS stated paper towels should be readily available at the hand washing station and if it becomes empty it should be replaced. The MS stated anyone working in the kitchen can replace the paper towel roll and that the kitchen has their own supplies. The MS stated if there were no paper towels available, the staff would not be able to dry their hands after washing their hands. The MS stated if staff are not able to perform hand hygiene properly in the kitchen, there would be cross-contamination with the food. During an interview with the DON, on 1/26/2024, at 1:30 p.m., the DON stated paper towels in the paper towel dispenser should be replaced every shift and as needed. The DON stated it is important to have paper towels available during hand washing to wipe off excess residue from hands. The DON further stated hand hygiene prevents cross contamination when handling food. A review of the facility's P&P titled, Food Receiving, Labeling and Storage, last reviewed 12/28/2023, indicated food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness.

CONCERN (E)

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

Deficiency F0849 (Tag F0849)

Could have caused harm · This affected multiple residents

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b. A review of Resident 129's admission Record indicated the facility admitted the resident on 12/7/2021 and readmitted the resident on 11/4/2022 with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (also known as stroke - refers to damage to tissues in the brain due to a loss of oxygen to the area) affecting left dominant side, dysphagia (difficulty swallowing), and encounter for palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness). A review of Resident 129's History and Physical (H&P) dated 11/8/2023, indicated that the resident had the capacity to understand and make decisions. A review of Resident 129 's Minimum Data Set (MDS, a standardized assessment and screening tool) dated 11/11/2023, indicated the resident had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and required supervision with eating and oral hygiene; and maximal to total assistance from staff with all other activities of daily living (ADLs, basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated hospice care was performed while the resident was a resident of the facility. A review of Resident 129's facility care plan on hospice care, initiated on 11/7/2022, last reviewed 1/22/2024, indicated the resident will be kept comfortable, will receive dignified terminal care, and will be assisted in identifying and utilizing coping mechanisms. The care plan indicated the following interventions: Hospice will coordinate with facility social services department and nursing for family or resident's spiritual, emotional, and mental support. Collaborate with hospice as much as needed in order to provide a cohesive and continuous program of care. A review of Resident 129's Order Summary Report, indicated a physician's order dated 8/12/2022 to admit resident to Hospice Provider 1 (HP 1). A review of Resident 129's Physician Certification for Hospice Benefit, effective date 11/4/2022 to 2/27/2024, indicated the resident was re-certified for hospice benefit and the resident is terminally ill and needed to continue provision of hospice service under routine level of care. A review of Resident 129's HP 1 hospice calendar indicated the following scheduled Registered Nurse (RN) visits: RN visit on 10/4/2023, 10/11/2023, 10/18/2023, and 10/25/2023. RN visit on 11/1/2023, 11/8/2023, 11/15/2023, 11/22/2023, and 11/29/2023. RN visit on 12/7/2023, 12/14/2024, 12/21/2023, and 12/28/2023. RN visit on 1/4/2024, 1/11/2024, 1/18/2024, and 1/25/2024. A review of Resident 129's electronic health record (EHR) indicated 3/20/2023 as the last documented IDT meeting with Hospice Provider 1 (HP 1) representative. During a concurrent interview and record review on 1/25/2024 at 10:13 a.m., HP 1's binder and Resident 129's EHR were reviewed with Licensed Vocational Nurse 2 (LVN 2). LVN 2 stated the IDT meetings with HP1 were supposed to be held quarterly. LVN 2 verified that the last documented IDT meeting in the EHR with HP 1 was 3/20/2023. LVN 2 verified there was no documented evidence of HP 1's plan of care in the hospice binder. LVN 2 verified the hospice Registered Nurse's (RN) notes provided by HP 1 were 8/2/2023, 9/13/2023, 10/4/2023, 11/22/2023, and 12/12/2023. LVN 2 verified hospice RN had seen Resident 129 every week. LVN 2 stated the RN writes her notes once a month, but visits were every week. LVN 2 stated the IDT meetings should have been held with HP 1 quarterly per policy to discuss or collaborate Resident 129's plan of care and address any issues or concerns, HP 1 RN should have provided weekly notes so facility staff would be aware of Resident 129's progress or needs, and HP 1 should have developed their own plan of care, LVN 2 stated these placed Resident 129 at risk for a delay in the delivery of necessary care and services the resident need. During an interview on 1/26/2024 at 10:14 a.m., the Director of Nursing (DON) stated the HP 1 RN should have provided their weekly notes according to their visit schedule, HP 1 should have developed their own plan of care, and the IDT meetings should have been held quarterly to discuss the integration of care plan with HP 1 and to collaborate the care provided to Resident 129. The DON stated it had the potential for a delay in the necessary care and services Resident 129 needs. A review of the facility's policy and procedure titled, Interdisciplinary Team Meetings, last reviewed 12/28/2023, indicated IDT meetings will be held within the first 14 days of admission, quarterly, and as needed to ensure that the residents have all their medical and psychosocial needs met. A review of the facility's policy and procedure titled, Hospice Program, last reviewed 12/28/2023, indicated the following: -It is the responsibility of the hospice provider to manage the resident's care as it relates to the terminal illness and related conditions including determining the appropriate hospice plan of care. -The facility has designated the DON to coordinate care provided to the resident by: -Collaborating with hospice representative and coordinating facility staff participation in the hospice care planning process for residents receiving these services. -Obtaining the most recent hospice plan of care specific to each resident. -Coordinated care plans for residents receiving hospice services will include the most recent hospice plan of care as well as the care and services provided by the facility in order to maintain the resident's highest practicable physical, mental, and psychosocial well-being. -The coordinated care plan will reflect the resident's goals and wishes and shall be revised and updated as necessary to reflect the resident's current status. Based on interview and record review, the facility failed to ensure necessary care was provided consistently for two of two sampled residents (Resident 129 and 143) investigated addressing hospice services (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill) by failing to: 1. Ensure there was documented evidence that interdisciplinary team (IDT, a team of healthcare professionals from different professional disciplines who work together to manage the physical, psychological, and spiritual needs of the patient) meetings were held to collaborate with hospice representatives on the hospice plans of care for Residents 129 and 143. 2. Ensure there was documented evidence that the hospice aide visited the resident according to the hospice calendar provided to the facility for Resident 143. 3. Ensure the hospice staff provided the licensed nurse visitation notes to the facility during their weekly visits for Resident 129. 4. Ensure the hospice provider developed the hospice plan of care per facility policy for Resident 129. These deficient practices had the potential to negatively affect the residents' physical comfort and psychosocial well-being and had the potential to result in the delay or lack of necessary hospice care and services. Findings: a. A review of Resident 143's admission Record indicated the facility originally admitted the resident on 2/5/2022 and readmitted the resident on 11/28/2023 with diagnoses including bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels, and concentration) and palliative care (specialized medical care that focuses on providing relief from pain and other symptoms of a serious illness). A review of Resident 143's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/23/2023, indicated the resident was able to make self-understood and understood others. The MDS indicated the resident required substantial/maximal assistance with upper body dressing and personal hygiene, and was dependent with lower body dressing and putting on/taking off footwear. A review of Resident 143's Physician Certification for Hospice Benefit, indicated the effective date of certification from 12/6/2023 to 3/4/2024 with hospice diagnosis of senile degeneration of the brain. A review of Resident 143's Plan of Care, dated 12/11/2023, indicated the frequency of visit for hospice aide was three times a week. A review of Resident 143's Order Summary Report, dated 12/11/2023, indicated a physician's order to admit resident to Hospice Provider 2 (HP 2). During a concurrent interview and record review on 1/24/2024 at 10:10 a.m., reviewed Resident 143's HP 2 binder with MDS Coordinator 2 (MDSC 2). MDSC 2 stated there were no visit notes on 1/19/2024. MDSC 2 stated the hospice calendar for 1/2024 indicated that the hospice aid was scheduled to visit last 1/19/2024. During a concurrent interview and record review on 1/26/2024 at 9:40 a.m., reviewed Resident 143's IDT notes addressing hospice care with the Director of Nursing (DON). The DON stated she is the hospice coordinator. The DON stated the resident had a significant change in condition and so there should have been an IDT meeting done. The DON stated there was no documentation that the IDT meeting was done to address the resident's hospice care. The DON stated the IDT meeting was meant to go over the revision of Resident 143's plan of care and expectations because the resident has terminal end stage diagnosis. During an interview on 1/26/2024 at 9:52 a.m., the DON stated the medical record staff audits the calendar for the attendance for hospice visits, certification, and sign in sheet. The DON stated the charge nurses in charge of the station and hospice registered nurse or licensed vocational nurse should have been coming on the assigned visit dates and should have verified that the hospice staff visits took place. The DON stated hospice aides provide assistance with activities of daily living including showers and feeding, and the care may not be delivered for the resident and would fall back to the facility because both the hospice and the facility provide the combined care. The DON stated the IDT meeting includes comprehensive care planning regarding the resident's comfort, medications, and nutritional status to project a new plan of care; if the IDT meeting was not done, then they would not know what the goals are for the resident. A review of the facility's policy and procedure (P&P) titled, Hospice, reviewed and approved by the Patient Care and Quality Assurance Committee on 12/28/2023, indicated hospice services are available to residents at the end of life. The P&P indicated it is the responsibility of the facility to meet 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 including communicating the hospice provider (and documenting such communication) to ensure that the needs of the resident are addressed and met 24 hours per day. The P&P indicated the hospice coordinator is responsible for coordinating with hospice representatives and coordinating facility staff participation in the hospice care planning process for residents receiving these services.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. A review of Resident 203's admission Record indicated the facility admitted the resident on 12/28/2023 with diagnoses including pleural effusion (buildup of fluid between the layers of tissue that line the lungs and chest cavity), dependence on supplemental oxygen, muscle weakness, and hypertension (high blood pressure). A review of Resident 203's MDS, dated [DATE], indicated the resident's cognitive skills (ability to understand and make decisions) were intact. The MDS indicated Resident 203 required supervision or touching assistance for toileting hygiene, showering/bathe self, lower body dressing, putting on/taking off footwear, and personal hygiene. A review of Resident 203's Order Summary Report, dated 12/28/2023, indicated the resident had a physician's order for oxygen at two liters per minute via nasal cannula continuously every shift for shortness of breath (SOB). A review of Resident 203's care plan, titled Oxygen: resident requires the use of oxygen, dated 12/28/2023, indicated an intervention to change the oxygen tubing as indicated. During a concurrent observation and interview on 1/22/2024 at 10:53 a.m., inside Resident 203's room, Resident 203's nasal cannula prongs were observed coiled on the ground next to the resident's bed and connected to an oxygen concentrator (medical device that provides supplemental oxygen). Resident 203's oxygen tubing had no label with a date. Resident 203 stated that the facility has never changed her nasal cannula and she has been wearing the same nasal cannula since admission. She stated that she just puts the nasal cannula tubing back in her nose after it goes on the floor. During a concurrent observation and interview on 1/22/2024 at 10:59 a.m., with Treatment Nurse/Licensed Vocational Nurse (TN) 1, inside Resident 203's room, TN 1 confirmed Resident 203's nasal cannula was touching the floor and had no date. TN 1 stated that Resident 203's nasal cannula should not be touching the floor because she is at greater risk for infection. TN 1 stated Resident 203's nasal cannula should be changed every seven days and there should be a date on it so that staff knows when the last time the tubing was changed. TN 1 stated that if there is no date on the tubing, they can assume that tubing was not changed. On 1/24/2024 at 2:55 p.m., during an interview, the Infection Preventionist (IP) stated that residents should not have their oxygen tubing on the floor to prevent infection. On 1/25/2024 at 10:09 a.m., during an interview, LVN 12 stated resident's oxygen tubing should be changed weekly or as needed and should always have a date so that staff knows when the tubing was last changed. LVN 12 stated that if the nasal cannula tubing is on the floor, staff needs to make sure they change the tubing right away because this leaves the resident at greater risk for infection. On 1/25/2024, during an interview, at 10:47 a.m., the DON stated that Resident 203's nasal cannula should not be on the ground and should always be dated so that staff knows when the tubing was last changed. The DON stated that if the resident is placing the tubing back in her nose after it was on the ground, she is at greater risk to develop an infection. A review of the facility's recent policy and procedure (P&P) titled, Policy for the use of Disposable Oxygen Humidifiers, Oxygen Tubing, Oxygen Masks, and Cannulas for Residents receiving Oxygen Therapy, last reviewed on 12/28/2023, indicated the pre-filled oxygen humidifiers, tubing masks, and cannulas will be changed every ten days or when fluid reaches the replace level. Each oxygen humidifier, tubing, mask, and cannula will be labeled with the date replaced. Based on observation, interview, and record review the facility failed to implement and maintain an infection control program by failing to: 1. Label the humidifier bottle (medical device that increase the humidity while using supplemental oxygen) with the date it was last changed for one out of four residents (Resident 39) identified during screening and was investigated under infection control. 2. Label the nasal cannula (NC, a medical device to provide supplemental oxygen therapy to people who have lower oxygen levels) with the date it was last changed for two of four residents (Residents 39 and 64) identified during screening and was investigated under infection control. 3. Label the urinal bottle (a container used to collect urine and is made for either male or female anatomy) with the name and room number of the resident to prevent cross contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) for one of one sampled resident (Resident 142) identified during screening and was investigated under infection control. 4. Develop and implement policy and procedures for water management (programs that identify hazardous conditions and takes steps to minimize the growth and transmission of Legionella [a severe form of pneumonia, lung inflammation caused by infection] and other waterborne pathogens [organism that causes disease] in building water systems) for 12 out of 12 months (1/20/2023 to 1/22/2024) investigated under infection control facility task. 5. Label and date the oxygen tubing and keep the oxygen tubing off the floor for one of two sampled residents (Resident 203) reviewed under respiratory care area. 6. Remove personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) before Certified Nursing Assistant 1 (CNA 1) exited a contact precaution (used to help prevent the spread of infectious agents that spread by direct or indirect contact with a resident or a resident's environment) isolation room for one of five sampled residents (Resident 236) investigated under infection control facility task. These deficient practices had the potential to spread infection among residents and staff. Findings: 1. A review of Resident 39's admission Record indicated the facility admitted the resident on 1/1/2021 and readmitted the resident on 1/5/2022, with diagnoses including chronic respiratory failure (a condition in which not enough oxygen passes from the lungs into the blood) with hypoxia (low levels of oxygen in the body tissues) and chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems). A review of Resident 39's History and Physical (H&P), dated 1/19/2024, indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 39's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 1/13/2024, indicated the resident had the ability to make self-understood and understand others. During an observation and interview on 1/22/2024, at 9:36 a.m., with Certified Nursing Assistant 6 (CNA 6), observed with CNA 6 Resident 39's nasal cannula and humidifier bottle not dated when it was last changed. CNA 6 stated the nasal cannula and the humidifier bottle should have been dated for infection control and to know when to change them again. During an interview on 1/26/2024, at 9:02 a.m., with the Director of Staff Development (DSD), the DSD stated humidifier bottles and nasal cannula tubings are changed every seven days and should be dated when they were last changed so they know when to change them again. The DSD stated the failure to label the nasal cannula tubings and humidifier bottles with the date they were last changed could cause spread of infection. During an interview on 1/26/2024, at 10:34 a.m., with the Director of Nursing (DON), the DON stated the nasal cannula oxygen tubing and the humidifier bottle are changed on a weekly basis; all those contraptions should be dated with the date they were last changed to know when to replace them and to prevent infection. A review of the facility's recent policy and procedure (P&P) titled, Policy for the use of Disposable Oxygen Humidifiers, Oxygen Tubing, Oxygen Masks, and Cannulas for Residents receiving Oxygen Therapy, last reviewed on 12/28/2023, indicated the pre-filled oxygen humidifiers, tubing masks, and cannulas will be changed every ten days or when fluid reaches the replace level. Each oxygen humidifier, tubing, mask, and cannula will be labeled with the date replaced. The humidifiers will be checked each shift by the nurse in-charge for appropriate fluid levels and that the oxygen tubing, masks, and cannulas are properly labeled and stored when not in use (emphasis on infection control). 2. A review of Resident 64's admission Record indicated the facility admitted the resident on 6/23/2023, with diagnoses including cerebral ischemia (acute brain injury that results from impaired blood flow to the brain), hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), and sleep apnea (a disorder that causes a person to stop breathing while asleep). A review of Resident 64's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. A review of Resident 64's Order Summary Report, dated 6/25/2023, indicated a physician's order to provide oxygen via NC at 2 liters per minute (LPM) if needed (PRN). May titrate (adjust the oxygen level to achieve the desired effect) to 4 LPM to maintain oxygen saturation (measurement of the amount of oxygen in the bloodstream) above 90% as needed. During a concurrent observation and interview on 1/22/2024, at 1:51 p.m., with Licensed Vocational Nurse 1 (LVN 1), observed with LVN 1 Resident 64's oxygen tubing via nasal cannula not labeled with the date it was last changed. LVN 1 stated the nasal cannula tubing should be dated with the date it was last changed. LVN 1 stated not dating the tubing could potentially cause infection. During an interview on 1/26/2024, at 9:02 a.m., the DSD nasal cannula tubings are changed every seven days and should be dated when they were last changed so they know when to change them again. The DSD stated the failure to label the nasal cannula tubings with the date they were last changed could cause spread of infection. During an interview on 1/26/2024, at 10:34 a.m., with the Director of Nursing (DON), the DON stated nasal cannula oxygen tubings are changed on a weekly basis; all those contraptions should be dated with the date they were last changed to know when to replace them and to prevent infection. 3. A review of Resident 142's admission Record indicated the facility admitted the resident on 2/4/2022 with diagnoses including hemiplegia (paralysis that affects only one side of the body) and hemiparesis (weakness or the inability to move on one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) and abnormalities of gait (a manner of walking or moving on foot) and mobility. A review of Resident 142's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. During a concurrent observation and interview on 1/22/2024, at 1:51 p.m., with LVN 1, observed with CNA 7 Resident 142's two urinal bottles hanging at the right upper side rails not labeled with the name and room number of the resident. CNA 7 stated the urinals should have been labeled with the name and room number of the resident to prevent switching of urinals that could cause infection. During an interview on 1/24/2024, at 3:05 p.m., with the Infection Preventionist (IP), the IP stated the staff should label the urinal with the date and room number of the resident to prevent switching of urinals and to prevent cross contamination among residents. 4. During an interview and record review on 1/24/2024, at 9:38 a.m., with the Maintenance Supervisor (MS), the MS stated they do not have a policy for water management system. The MS stated they just contacted a company to consult regarding their water system. The MS stated the Administrator (ADM) was aware that they do not have water management system in place. The MS stated they do not have a diagram of their water system. The MS stated they were keeping the temperature of the water in the facility between 105-112 degrees Fahrenheit (a temperature scale) for residents' comfort. Reviewed with the MS the Water Temperature Log between 10/2023 to 1/2024 and found missing temperatures on the monitoring log. The MS stated it was important to have a water management program to ensure the water was safe for residents in the facility. During an interview on 1/24/2024, at 10:55 a.m., the ADM stated he was just made aware few weeks ago about the facility needing to have a water management system program. The ADM stated they have not drafted a policy for water management yet. The ADM stated the consulting company will come the following week to start the process. The ADM and the MS stated they do not have any case of Legionella in the facility. A review of the facility's recent policy and procedure titles, Infection Prevention and Control Program, last reviewed on 12/28/2023, indicated an infection control prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. A review of the facility's recent policy and procedure titled, Administrative Management (Governing Board), last reviewed on 12/28/2023, indicated the governing board shall be responsible for the management and operation of the facility. Establishment and annual review of policies and procedures governing facility operations and provision of a safe physical environment equipped and staffed to maintain the facility and services. 6. A review of Resident 236's admission Record the facility admitted the resident on 1/5/2024 with diagnoses including influenza (a communicable viral disease that affects the upper and lower respiratory tract) due to identified novel influenza A virus (an influenza A virus with a subtype that is different from the flu viruses that usually spread in people) with other respiratory manifestations and methicillin-resistant staphylococcus aureus infection (MRSA infection, an infection that is difficult to treat because of resistance to some antibiotics). A review of Resident 236's Admission/readmission Evaluation/Assessment, dated 1/6/2024, indicated the resident has intact cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering), who required assistance with transfers, bathing, dressing, grooming/hygiene, toileting, and bed mobility. A review of Resident 236's physician order, dated 1/23/2024, indicated transmission-based precaution (safety steps taken to stop the spread of germs that can be spread through the air, through droplets, or by touching contaminated surfaces) - contact precautions, MRSA of right chest surgical site drain (a thin, flexible rubber tube used to remove excess fluid or blood). A review of Resident 236's Care Plan, developed on 1/7/2024 and revised on 1/26/2024, indicated Resident 236 requires contact isolation precautions due to MRSA of right chest surgical site with drain. The interventions included performing hand washing after completing care and leaving the room and use of PPE as recommended for type of infection. During an observation and interview on 1/24/2024 at 8:57 a.m., in Station D, observed outside of Resident 236's room a contact precaution isolation sign posted. Observed CNA 1 exiting Resident 236's room wearing disposable gown and gloves while carrying a meal tray and observed CNA 1 place the tray on the meal cart. Observed CNA 1 close Resident 236's door. Observed CNA 1 remove the isolation gown and gloves out in Station D. CNA 1 stated the disposal bin is usually outside the room and she did not know why it was not here. CNA 1 stated she did not know where to dispose her gown and gloves. During an observation on 1/24/2024 at 8:59 a.m., observed LVN 17 spoke to CNA 1 in Station D and reminded CNA 1 that before exiting an isolation room, gown and gloves should be removed inside the room and they should perform hand washing inside the isolation room. Observed CNA 1 opened Resident 236's door, entered the room, and removed her gown and gloves. During an interview on 1/24/2024 at 2:55 p.m., the IP stated all staff are expected to remove their gown and gloves before exiting a transmission-based precaution room including contact precautions room. The IP stated they are to do so to prevent the cross-contamination of germs to other residents and staff. A review of the facility's policy and procedure (P&P) titled, Isolation - Categories of Transmission- Based Precautions, reviewed and approved by the Patient Care and Quality Assurance Committee on 12/28/2023, indicated staff and visitors wear gloves (clean, non-sterile) when entering the room and gloves are removed and hand hygiene performed before leaving the room. The P&P indicated staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0637 (Tag F0637)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to follow the facility's policy and procedure titled Resident Assessment to create a Minimum Data Set (MDS, a standardized assessment and care screening tool) significant change in status assessment when there was a decline in residents' activity of daily living (ADL) and skin condition, for one of the three sampled residents (Resident 20). This failure placed Resident 20 at risk for not receiving the necessary care and services related to health care needs. Findings: A review of Resident 20's admission Record (Face Sheet), dated 3/8/2011, indicated Resident 20 was admitted to the facility on [DATE], and was readmitted on [DATE], with diagnoses including chronic anemia (a condition in which the blood does not have enough red blood cells that carries oxygen from the lungs to other parts of the body), chronic kidney disease (progressive loss of kidney function), and paraplegia (complete or partial loss of sensation and movement of the legs). A review of Resident 20's MDS, dated [DATE], indicated Resident 20 had the ability to make herself self-understood and understand others. The MDS indicated Resident 20 required from substantial/maximal assistance to dependent in toileting hygiene, shower/bathe self, upper body dressing, lower body dressing and putting on/taking off foot footwear. The MDS indicated Resident 20's skin conditions had Stage 4 pressure ulcer (open wound with exposed bone, tendon, muscle, and dead tissue on some part of the wound bed, a type of bed sore that occurs due to prolonged pressure on a specific area of the skin.) A review of Resident 20's MDS 5-day Medicare with Assessment Reference Date ([ARD]- the specific end point for the look back period in the MDS assessment/observation process) 6/24/2023 was reviewed, Resident 20's bed mobility was coded with two (2) persons physical assist for support, locomotion on unit requiring extensive assistance for self-performance and an unstageable pressure ulcer (wound bed was covered by dead tissue, occurs due to prolonged pressure on a specific area of the skin), under skin condition. A review of Resident 20's Quarterly MDS, ARD 3/22/2023, indicated Resident 20's bed mobility was coded with one (1) person assist for support, locomotion on unit requiring limited assistance for self-performance and no skin breakdown under skin condition. During a concurrent interview and record review on 1/25/2023, at 9:20 a.m., with MDS Coordinator (MDSC) 1. Resident 20's MDS 5-day Medicare with ARD of 6/24/2023 was reviewed and compared with Resident 20's Quarterly MDS with ARD of 3/22/2023, MDSC 1 stated Resident 20 had more than one area of health status that were affected or had changes, a decline in her ADL and skin condition. The MDSC 1 stated a significant change in status should have been done and failing to complete one has a potential to affect residents plan of care and could delay of necessary interventions. During an interview on 1/26/2024, at 10:25 a.m., with the Director of Nursing (DON), the DON stated an MDS significant change in status should have been done for Resident 20 since there were two health areas that were affected (ADL's and skin condition) which could delay the necessary care for the resident. A review of the facility's policy and procedure titled, Resident Assessment, last reviewed on 12/28/2023, indicated OBRA (Omnibus Budget Reconciliation Act of 1987, regulations require nursing homes that are Medicare certified and Medicaid certified or both, to conduct initial and periodic assessments for all their residents) Required Assessments are federally mandated, and therefore must be performed for all residents of Medicare and/or Medicaid certified nursing homes include Significant Change in Status Assessment (SCSA). A review of Centers for Medicare and Medicaid Services (CMS) specified RAI ([Resident Assessment Instrument] process, helps nursing home staff look at residents as individuals for whom quality of life and quality of care are mutually significant and necessary) Version 3.0 Manual titled, CH2: Assessments for the RAI Significant Change In Status Assessment (SCSA), last reviewed on 12/28/2023, indicated SCSA is a comprehensive assessment for a resident that meets the significant change guidelines. The Interdisciplinary Team ([IDT] a group of health care professional with various areas of expertise who work together toward the goals of their residents) determines if the resident had a significant change. A significant change is a decline or improvement in a resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions, is not self-limiting (for declines only); Impacts more than one area of the resident's health status; and requires interdisciplinary review and/or revision of the care plan.

MINOR (B)

Minor Issue - procedural, no safety impact

MDS Data Transmission (Tag F0640)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to transmit the Minimum Data Set (MDS, a standardized assessment and care screening tool) timely for one of three sampled residents (Resident 101) investigated under the Resident Assessment facility task. These deficient practices had the potential to result in care that does not address the resident's specific care needs. Findings: A review of Resident 101's admission Record indicated the facility admitted the resident on 9/5/2023 with diagnoses including sepsis (the body's extreme response to an infection), unspecified organism and syncope (fainting, temporary loss of consciousness) and collapse. A review of Resident 101's Psychosocial Note, dated 9/25/2023, indicated the resident did not return to the facility since 9/23/2023. A review of Resident 101's Discharge summary, dated [DATE], indicated the resident was discharged against medical advice with discharge date of 9/25/2023. During a concurrent interview and record review on 1/24/2024 at 10:09 a.m., reviewed Resident 101's Final Validation Report (facility's documentation of successful MDS file submission) with MDS Coordinator 1 (MDSC 1). MDSC 1 stated Resident 101's MDS Discharge Assessment, dated 9/22/2023 was transmitted to Centers for Medicare & Medicaid Services (CMS, a federal agency that administers major healthcare programs) yesterday, 1/23/2024. MDSC 1 stated the assessment was completed but he did not know why the MDS was not transmitted timely. MDSC 1 stated after the Validation Reports (facility's documentation of successful MDS file submission) were requested, they proceeded to transmit the MDS. MDSC 1 stated Resident 101's Validation Report indicated a submission date and time of 1/23/2024 at 8:04 p.m. During an interview on 1/26/2024 at 8:27 a.m., MDSC 1 stated Resident 101's Discharge Assessment should have been completed 10 days from the Assessment Reference Date (ARD - observation end date) of 9/22/2023. MDSC 1 stated the MDS should have been completed on 10/5/2023 and transmitted within 14 days from the completion date. MDSC 1 stated the Validation Reports would indicate that the records submitted were processed. MDSC 1 stated the importance of transmitting the MDS assessments timely is to comply with the regulations. MDSC 1 stated he is responsible for maintaining the validation reports and he missed this one. A review of the Centers for Medicare & Medicaid Services (CMS, a federal agency that administers major healthcare programs) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2023, indicated providers must transmit all sections of the MDS 3.0 required for their State-specific instrument and all tracking or correction information. The MDS must be transmitted electronically no later than 14 calendar days after the MDS completion date. A review of the facility's policy and procedure titled, Electronic Transmission of the MDS, reviewed and approved by the Patient Care and Quality Assurance Committee on 12/28/2023, indicated the MDS Coordinator is responsible in maintaining the MDS feedback and validation reports for historical purposes and for tracking.

MINOR (B)

Minor Issue - procedural, no safety impact

Assessment Accuracy (Tag F0641)

Minor procedural issue · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct accurate assessments for one of three sampled residents investigated during review of closed records (Resident 240) by failing to accurately code in the Minimum Data Set (MDS, - a standardized assessment and care screening tool) the resident's discharge status. The MDS dated [DATE], indicated Resident 240 was discharged to the general acute care hospital (GACH) when Resident 240 was discharged to a board and care (B&C - a residential care option catering to individuals requiring assistance with daily living activities). This deficient practice had the potential for facility staff to be unable to track where the resident was discharged and ensure the resident was discharged to an appropriate setting. Cross-reference F-Tag F661, F623, and F625 Findings: A review of Resident 240's admission Record indicated the facility admitted Resident 240 on 10/7/2023 with diagnoses including, but not limited to, Wernicke's encephalopathy (a type of brain injury). A review of Resident 240's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/5/2023, indicated Resident 240 was discharged to a short-term general hospital on [DATE], had severe cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect everyday life), and required setup or clean up assistance with eating, supervision or touching assistance with oral hygiene, and partial or moderate assistance with toileting hygiene, showering or bathing self, upper and lower body dressing, putting on or taking off footwear, and personal hygiene. A review of Resident 240's History and Physical (H&P), dated 10/2/2023, indicated Resident 240 had fluctuating capacity to understand and make decisions. A review of Resident 240's Order Summary Report indicated: - An order placed on 12/4/2023, resident may discharge to a board and care (B&C - a residential care option catering to individuals requiring assistance with daily living activities). - An order placed on 12/4/2023, may send the resident to the general acute care hospital (GACH) due to chest pain for further evaluation and management. A review of Resident 240's Situation Background Assessment Recommendation Communication Form (SBAR - a structured communication framework that can help teams share information about the condition of a resident), dated 12/4/2023, indicated Resident 240 had complaints of chest pain and an order to transfer to the GACH was received. During an interview with Licensed Vocational Nurse (LVN) 2, on 1/24/2024, at 3:41 p.m., LVN 2 stated on 12/4/2023, Resident 240 was sent to the GACH for chest pain and further evaluation. LVN 2 stated on 12/5/2023, Resident 240 returned to the facility and was discharged to a B&C on the same day. During a concurrent interview and record review with the Assistant Director of Nursing (ADON), on 1/25/2024, at 1:03 p.m., Resident 240's MDS, dated [DATE], was reviewed. The ADON confirmed the MDS indicated Resident 240 was discharged to the GACH on 12/5/2023 and was not expected to return. The ADON stated Resident 240 was discharged to a B&C and the MDS was not accurate. The ADON stated the MDS should be accurate to trace where a resident was discharged and to ensure the discharge was appropriate. During an interview with the Director of Nursing (DON), on 1/26/2024, the DON stated Resident 240 was discharged to a B&C and not the GACH. The DON further stated it is important to have an accurate MDS assessment for discharge so that post discharge care can be monitored. A review of the facility's policy and procedure (P&P) titled, Resident Assessments, last reviewed 12/28/2023, indicated information in the MDS assessments will consistently reflect information in the progress notes, plans of care and resident observations/interviews.

Jan 2024 6 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 7) receive treatment and care in accordance with professional standards of practice by failing to check for Resident 7's identification and physician's order prior to transporting Resident 7 to a medical appointment intended for Resident 11 on 12/20/2023. Resident 11 was discharged to General Acute Care Hospital 1 (GACH) on 12/15/2023. As a result Resident 7 was brought by a transportation service arranged by the facility to a medical appointment intended for Resident 11. This deficient practice had the potential to create confusion in the delivery of care and services to Resident 7. Findings: A review of Resident 11 ' s admission Record indicated the facility admitted the resident on 9/21/2023 with diagnoses that included unspecified (unconfirmed) hydronephrosis (is a condition that occurs when a kidney swells and can't get rid of urine [pee] like it should), calculus of kidney (kidney stones-are hard deposits made of minerals and salts that form inside your kidney) and Alzheimer ' s (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks). A review of Resident 11 ' s History and Physical dated 11/20/2023 indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 11 ' s MDS dated [DATE], indicated Resident 11 had intact cognition. A review of Resident 11 ' s Physician Order dated 12/14/2023, indicated an order for an appointment with Medical Doctor 1 (MD 1) on 12/20/2023 at 9:30 a.m. A review of Resident 11 ' s Situation Background Assessment Recommendation (SBAR, a technique that provides a framework for communication between members of the health care team about a resident ' s condition) Communication Form dated 12/15/2023 indicated Resident 11 was transferred to GACH 1 emergency room due to abnormal laboratory results. A review of Resident 7 ' s admission Record (Face Sheet) indicated the facility admitted the resident on 12/18/2023 with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic inflammatory lung disease that causes obstructed airflow from the lungs), chronic respiratory failure with hypoxia (condition in which not enough oxygen passes the lungs into your blood) and spinal stenosis (the spaces in the spine narrow and create pressure on the spinal cord and nerve roots). A review of Resident 7 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 12/20/2023, indicated Resident 7 ' s had intact cognition (mental action or process of acquiring knowledge and understanding). During an interview on 1/3/2024 at 10 a.m., with Family Member 1 (FM 1), FM 1 stated she was notified by the facility that they made a mistake of sending Resident 7 to a medical appointment on 12/20/2023, without a physician's orders. FM 1 stated facility admitted making a mistake of sending Resident 7 without any doctor ' s order. During an interview on 1/5/2024 at 10:42 a.m., with the Assistant Director of Nursing (ADON), the ADON stated Resident 7 and Resident 11 had the same first name. The ADON stated that on 12/20/2023 Resident 11 had a medical appointment but when transportation staff (TS) came, they picked up Resident 7 instead of Resident 11. The ADON stated LVN 5 should have verified the name of Resident 7 with TS inside the resident's room prior to allowing them (TS) to bring Resident 7 to the medical appointment. The ADON stated the medical clinic called the facility and notified them of the mistake. The ADON stated the medical appointment was for Resident 11, who was transferred to the hospital on [DATE]. During an interview on 1/3/2024 at 1:19 p.m., with the Director of Nursing, the DON stated Resident 11 had a medical appointment on 12/20/23 but she was transferred to the hospital on [DATE] and did not come back to the facility. The DON stated Social Services Director 1 (SSD 1) was not aware that Resident 11 was no longer in the facility when SSD 1 arranged the transportation on the morning of 12/20/2023. The DON stated when TS came and called Resident 11 ' s first name, Resident 7 answered and was brought to the medical appointment intended for Resident 11. The DON stated LVN 5 and TS failed to check Resident 7's identification bracelet to identify the resident. The DON stated a name alert should have been observed and LVN 5 should have printed the resident's face sheet and physician order, then escort TS inside the resident ' s room and endorse the paperwork after checking the residents arm band. The DON stated the SSD did not check if Resident 11 was still in the facility before arranging the transportation on 12/20/2023. A review of facility ' s policy and procedure titled, Resident Identification dated 2/2004 and reviewed on 12/28/2022 indicated, Upon admission, all residents will have a hospital identification bracelet made and applied to their wrist and the name of the resident on the door. A review of facility ' s Job Description: for Social Services Director dated 3/2023 indicated, Assists in making outpatient appointments as ordered and schedule on-site ancillary patient services to include optometry (specialized health care profession that involves examining the eyes), podiatry (treatment of the feet) , dentistry (the treatment of diseases and other conditions that affect the teeth and gums) and psychiatric services (the management, evaluation, diagnosis, treatment and prevention of mental illness).

CONCERN (D) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the failed to maintain accurate and complete medical record for one of five sampled residents (Resident 7) by failing to ensure the facility documented information of Resident 7's transport to a medical appointment intended for Resident 11. This deficient practice had the potential to cause confusion in care and the medical records containing inaccurate documentation and can result in the delay of delivery of care. Findings: A review of Resident 7 ' s admission Record (Face Sheet) indicated the facility admitted the resident on 12/18/2023 with diagnoses that included chronic obstructive pulmonary disease (COPD-a chronic inflammatory lung disease that causes obstructed airflow from the lungs), chronic respiratory failure with hypoxia (condition in which not enough oxygen passes the lungs into your blood) and spinal stenosis (the spaces in the spine narrow and create pressure on the spinal cord and nerve roots). A review of Resident 7 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 12/20/2023, indicated Resident 7 ' s had intact cognition (mental action or process of acquiring knowledge and understanding). A review of Resident 11 ' s admission Record indicated the facility admitted the resident on 9/21/2023 with diagnoses that included unspecified (unconfirmed) hydronephrosis (is a condition that occurs when a kidney swells and can't get rid of urine [pee] like it should), calculus of kidney (kidney stones-are hard deposits made of minerals and salts that form inside your kidney) and Alzheimer ' s (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks). A review of Resident 11 ' s History and Physical dated 11/20/2023 indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 11 ' s MDS dated [DATE], indicated Resident 11 had intact cognition. A review of Resident 11 ' s Physician Order dated 12/14/2023, indicated an order for an appointment with Medical Doctor 1 (MD 1) on 12/20/2023 at 9:30 a.m. A review of Resident 11 ' s Situation Background Assessment Recommendation (SBAR, a technique that provides a framework for communication between members of the health care team about a resident ' s condition) Communication Form dated 12/15/2023 indicated Resident 11 was transferred to GACH 1 emergency room due to abnormal laboratory results. During an interview on 1/3/2024 at 10 a.m., with Family Member 1 (FM 1), FM 1 stated she was notified by the facility that they made a mistake of sending Resident 7 to a medical appointment on 12/20/2023, without a physician's orders. FM 1 stated facility admitted making a mistake of sending Resident 7 without any doctor ' s order. During an interview on 1/3/2024 at 1:19 p.m., with the Director of Nursing, the DON stated Resident 11 had a medical appointment on 12/20/23 but she was transferred to the hospital on [DATE] and did not come back to the facility. The DON stated the Social Services Director (SSD) was not aware that Resident 11 was no longer in the facility when the SSD arranged the transportation on the morning of 12/20/2023. The DON stated when TS came and called Resident 11 ' s first name, Resident 7 answered and was brought to the medical appointment intended for Resident 11. The DON stated LVN 5 and TS failed to check Resident 7's identification bracelet to identify the resident. The DON stated a name alert should have been observed and LVN 5 should have printed the Resident 11 ' s face sheet and physician order, and escort TS inside the resident ' s room and endorse the paperwork after checking the resident ' s arm band. The DON stated the SSD did not check if Resident 11 was still in the facility before arranging the transportation on 12/20/2023. The DON stated the incident should have been documented in Resident 7's medical record. The DON stated the mistake could have resulted in the resident receiving an invasive treatment and create confusion in the delivery of care. A review of facility ' s policy and procedure titled, Charting and Documentation dated 12/2022 indicated The medical record is a format that facilitates communication between the interdisciplinary team, (IDT- professionals from various disciplines who work in collaboration to address a patient with multiple physical and psychological needs). Documentation in the medical record should be objective.

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

Social Worker (Tag F0850)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to employ a qualified social service on a full-time basis that met the qualifications as indicated in the facility ' s job description for Social Service Director (SSD). This deficient practice had a potential for the residents residing in the facility not being assisted with obtaining medically related necessary care to attain their highest practicable well-being. Findings: During an interview on 1/5/2024 at 2:05 p.m., with the Administrator (ADM), the ADM stated the facility hired Social Service Director 1 (SSD 1) three months ago. The ADM stated they checked SSD 1 ' s records and was deemed qualified for the position. The ADM stated SSD 1 had worked in multiple skilled nursing facilities as Social Services Director. A review of SSD 1 ' s Employee Maintenance File dated 8/31/2023 indicated SSD 1 was hired full time for the position of Co- Director of Social Services. A review of SSD 1 ' s Job Description and Performance Standards undated indicated SSD 1 signed for the title Social Service Director (Designee-a person who has been officially chosen to do or be something). During an interview on 1/8/2024 at 3:20 p.m., with SSD 1, SSD 1 stated she was hired on 8/31/2023 as a Social Service Co-Director to SSD 2. SSD 1 stated SSD 2 resigned on 10/13/2023. SSD 1 stated she does not have a bachelor's degree (a degree that is given to a student by a college or university usually after four years of study).and is aware a bachelor ' s degree is a requirement to be qualified to work as an SSD. SSD 1 stated she works with Social Service staff 1 (SSS 1). During an interview on 1/8/2024 at 3:14 p.m., with Social Service Staff 1 (SSS 1), SS1 stated she had worked in the facility for 22 years and do not have a bachelor ' s degree. During an interview on 1/11/2024 at 3:06 p.m., with the ADM, the ADM stated the SSD should have a bachelor ' s degree to be qualified to work in Social Service. The ADM stated they have two staff working in social service department and both SSD 1 and SSS 1 do not have a bachelor ' s degree. A review of facility ' s job Description for Social Service Director dated 3/2023 indicated Qualification- bachelor ' s degree in social work or in Human Services and two years of supervised social work experience in health care setting working directly with individuals.

CONCERN (D) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to ensure two of five sampled staff (admission Assistant 1 [AA 1] and Payroll Staff [PS 1]) wore surgical mask (a respiratory protective device that provides barrier protection against large particles droplets) during an outbreak (a sudden increase in occurrences of a disease when cases are in excess of normal expectancy) of Coronavirus Disease 2019 (COVID-19- highly contagious respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks) in the facility. This deficient practice has the potential to result in the spread of COVID-19 to all staff and residents. Findings: During an observation on 1/3/2024 at 9:10 a.m., observed Activity Assistant 1 (AA 1) sitting in the front office and observed Payroll Staff 1 (PS 1) standing by the copier machine inside the same office without a surgical mask. During a concurrent observation and interview on 1/3/2024 at 9:11 a.m., with the Director of Nursing (DON) in the lobby, observed AA 1 and PS 1 without a surgical mask. The DON stated all staff should be wearing N95 mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles)inside the facility because of the COVID-19 outbreak. During an interview on 1/3/2024 at 9:18 a.m., with PS 1, PS 1 stated she was aware of the COVID-19 outbreak and she should have been wearing N95 mask while inside the facility. PS 1 stated she forgot to put her N95 mask on. PS 1 stated the N95 mask helps prevent the spread of COVID-19 infection. During an interview on 1/3/2024 at 9:20 a.m., with AA 1, AA 1 stated he was informed of the COVID 19 positive cases in the facility yesterday (1/2/2024) and is aware that it is mandatory (required) to wear N95 inside the facility, but he forgot to do so. AA 1 stated N95 mask helps to contain the infection and prevent the spread of COVID-19 to other staff and residents. During an interview on 1/3/2024 at 11:04 a.m., with the Infection Preventionist (IP), the IP stated the COVID-19 outbreak in the facility started on 12/29/2023. The IP stated AA 1 and PS 1 should at least wear surgical mask to prevent exposure from COVID-19 since they do not work in residents care areas. A review of facility ' s COVID-19 Outbreak Notification dated 12/29/2023 indicated In other areas of the facility, staff are required to wear surgical/procedure mask as per Los Angeles County Department of Public Health ' s (LAC-DPH ' s) Masking in Healthcare and Direct Care Settings Health Officer order. A review of facility ' s policy and procedure titled, Coronavirus Disease (COVID-19)- Visitors and Communal Activities dated 3/2023 indicated, Core principle of COVID-19 prevention and best practices to reduce COVID-19 transmission are adhered at all times, including, c. face covering or mask (covering mouth and nose) in accordance with current Centers for Disease Control and Prevention (CDC) guidance, state and local health departments and individual facility circumstances.

CONCERN (E) 📢 Someone Reported This

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

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents received care consistent with professional standards of practice to prevent pressure ulcers (PU, a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear) for two of six residents (Resident 1 and Resident 4) by failing to: 1. Ensure the air pressure redistribution mattress (APM - a mattress composed of inflatable air cushions that is used to relieve pressure on body parts) for Resident 1 was turned on and functioning. 2. Ensure there were appropriate number of linens between Resident 1 and the mattress per manufacturer ' s recommendation. 3. Ensure there was a physician order for the APM setting for Resident 1 and Resident 4. 4. Ensure the indwelling catheter (a tube that was inserted into the bladder, allowing urine to drain freely) ports were not pressed on Resident 1 ' s skin. 5. Ensure Resident 1 was turned and repositioned every two hours. These deficient practices had placed Resident 1 and Resident 4 at risk for the development and worsening of pressure ulcers. Findings: a. A review of Resident 1 ' s admission Record indicate the facility admitted the resident on 3/14/2012 with diagnoses including type two diabetes mellitus (a disease that occurs when the blood glucose, also called blood sugar, was too high), chronic obstructive pulmonary disease (COPD – a group of diseases that causes airflow blockage and breathing-related problems), and Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out the simplest task). A review of Resident 1 ' s Care Plan on skin impairment, revised on 3/14/2023, indicated the resident had the potential for skin breakdown or PU because of decreased total dependence with bed mobility, incontinence of bowel and scar tissue to coccyx (tailbone) and bilateral (both sides) of the buttocks. The interventions included were observe skin for presence of redness and signs and symptoms of skin breakdown, impairment, or trauma, pressure reducing devices in bed, and turn and reposition every two hours and as needed. A review of Resident 1 ' s Care Plan on skin, revised on 9/15/2023, indicated the resident had scar tissue on the right and left gluteal (buttocks) fold and scar tissue on the sacrum (a triangular bone at the base of the spine) extending to the coccyx. The care plan indicated Resident 1 ' s risk factor as incontinence, resident ' s total dependence with bed mobility and transfer. The care plan intervention included turning and repositioning Resident 1at least every two hours and incontinent care every two hours. A review of Resident 1 ' s Care Plan on activities of daily living, revised on 9/15/2023, indicated the resident was dependent on facility staff on bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and bathing. The care plan intervention included to meet Resident 1 ' s needs promptly and with care. The intervention indicated that Resident 1 to be turned and repositioned every two hours. A review of Resident 1 ' s Physician Order, dated 10/13/2023, indicated an order for pressure reducing mattress every shift. There was no order for the pressure reducing mattress setting. A review of Resident 1 ' s History and Physical, dated 10/19/2023, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Date Set (MDS – a standardized assessment and care screening tool), dated 12/12/2023, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding). The functional limitations in range of motion section indicated that Resident 1 had impairment on both sides of the upper extremities (shoulder, elbow, write, and hand) and the lower extremities (hip, knee, ankle, and foot). The MDS indicated that Resident 1 was fully dependent (full staff performance) on facility staff on eating, oral (mouth) hygiene, toilet hygiene, shower or bath, upper and lower body dressing, personal hygiene, rolling left and right, sit to lying, lying to sitting, and transfers. The bladder (a hollow organ that stores urine) and bowel (part of the digestive system) section of the MDS indicated that Resident 1 had an indwelling catheter and was incontinent (loss of control) on bowel. The MDS indicated that Resident 1 was at risk for developing PU. The treatments included pressure reducing device for bed and turning and repositioning program. A review of Resident 1 ' s Weight and Vitals Summary, dated 12/12/2023, indicated the resident ' s weight was 143 pounds (lbs. – unit of weight measurement). A review of Resident 1 ' s Care Plan on skin impairment, dated 12/29/2023, indicated that the resident was at risk for delayed healing and infection related to the fluid filled blister on the right groin (the fold on either side of the body where the thigh joins the abdomen) and severe scar tissue on the sacrococcyx (a triangular bone located at the base of the spine extending to the tailbone). The care plan interventions included to check Resident 1 ' s skin during daily care provisions, encourage and assist the resident in repositioning. A review of Resident 1 ' s documented turning and repositioning intervention and task, dated 12/2023, indicated that the resident was turned and repositioned once every day on the 7 a.m. to 3 p.m. shift. The report indicated that on the following dates, 12/1 to 2/2023, 12/8/2023, 12/11 to 13/2023, 12/19 to 20/2023, and 12/25 to 26/ 2023, the resident was turned and repositioned once on the 3 p.m. to 11 p.m. shift. The report indicated that on 12/23/2023, Resident 1 was turned and repositioned twice on the 3 p.m. to 11 p.m. shift. The report indicated that on the following dates, 12/1 to 12/11/2023 and 12/13 to 29/2023, Resident 1 was turned and repositioned once on the 11 p.m. to 7 a.m. shift. On 12/12/2023 at 11 p.m. to 7 a.m., there were no documentation that the resident was turned and repositioned. On 12/28/2023 at 2:46 p.m., during an observation, Resident 1 ' s pressure reducing mattress machine ' s power was off. Observed Resident 1 lying on the middle of the bed on a sunken mattress. On 12/28/2023 at 3:33 p.m. during a concurrent observation and interview, Licensed Vocational Nurse 1 (LVN 1) stated that Resident 1 ' s APM was off, and the resident ' s mattress was deflated. Observed LVN 1 turn on Resident 1 ' s APM machine and the machine comfort level setting indicated level 1. LVN 1 stated that the setting on Resident 1 ' s APM machine was the setting when it was turned off. LVN 1 Stated that the APM machine setting was based on Resident 1 ' s body mass index (BMI – a measure that uses a person ' s height and weight to identify if the person ' s weight was healthy) which was 23.8 BMI. LVN 1 stated that there was no physician order for Resident 1 ' s APM setting. Observed multiple layers of linens between Resident 1 and the APM. LVN 1 stated that Resident 1 ' s mattress had a fitted sheet, cloth chux (a disposable or washable under pads), folded draw sheet creating 4 layers, a disposable chux and a disposable brief. LVN 1 stated that there were eight layers of linen between Resident 1 and the APM. LVN 1 stated that there should only be two layers between Resident 1 and the APM to allow air flow. Observed Resident 1 ' s indwelling catheter port was pressed on the resident ' s right thigh and created a red mark with the shape of the indwelling catheter port. LVN 1 stated that Resident 1 ' s tubing should not press on the resident ' s skin. LVN 1 stated that Resident 1 had the potential to develop PU. On 12/29/2023 at 2:34 p.m., during a concurrent observation and record review, observed an APM guide attached to an APM machine. A review of the manufacturer ' s guidelines indicated the following BMI setting suggestions: comfort level 1 setting for BMI 12-20, comfort level 2 setting for BMI 21-35, comfort level 3 setting for BMI 36-50, comfort level 4 setting for BMI 50 – 70, and comfort level 5 setting for BMI 71 – 100. On 12/29/2023 at 4:51 p.m. during an interview, the Assistant Director of Nursing (ADON) stated residents that were high risk for developing or worsening of PU should be turned every two hours and documented in the resident ' s medical records. The ADON stated that the APM should be on the correct setting with physician orders based on the resident ' s BMI. The ADON stated that LVN 1 had the copy of the APM machine setting guide and the facility staff call LVN 1 at any time if there were any questions or concerns on the APM setting. The ADON stated that Resident 1 had the potential for an increased risk of developing PU. A review of the facility ' s policy and procedure titled, Prevention of Pressure Injuries, dated 12/28/2022, indicated the purpose to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. The mobility and repositioning section indicated to reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team. The device-related pressure injuries section indicated to monitor regularly for comfort and signs of pressure-related injury. A review of the facility ' s policy and procedure titled, Mattress / Low Air Loss, dated 12/28/2022, indicated the purpose to decrease pressure from the resident ' s weight while lying in bed and to promote healing or prevention of pressure ulcers. The policy indicated to place the mattress on the bed and follow the manufacturer ' s directions for appropriate setting. The policy indicated to avoid multiple layers of linens under the resident and a single cotton draw sheet may be used for turning and to absorb incontinence. The policy indicated that specialized incontinence pads may also be used as long as they did not contain plastic. The policy indicated to monitor the mattress to assure that it was functioning properly. A review of the manufacturer ' s recommendations on the use of Pressure Guard Custom Care Convertible, manufacturer of the APM machine, general directions on bed linens section indicated that multiple layering of linens or under pads beneath the patient should be avoided for the prevention and treatment of pressure ulcers. b. A review of Resident 4 ' s admission Record indicate the facility admitted the resident on 9/22/2023 with diagnoses including pneumonia (an infection of one or both of the lungs caused by bacteria, viruses, or fungi), [NAME] ' s encephalopathy (a brain disorder related to vitamin B1 [thiamine] deficiency), and hypotension (low blood pressure). A review of Resident 4 ' s Minimum Date Set (MDS – a standardized assessment and care screening tool), dated 9/28/2023, indicated the resident ' s cognition (mental action or process of acquiring knowledge and understanding) was intact. The MDS indicated that Resident 4 required limited assistance (facility staff provide guided maneuvering of limbs or other non-weight bearing assistance) on bed mobility and transfers. A review of Resident 4 ' s History and Physical, dated 9/28/2023, indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 4 ' s Physician Order, dated 9/22/2023, indicated an order for pressure reducing mattress every shift. There was no order for the pressure reducing mattress setting. A review of Resident 4 ' s Care Plan on skin, initiated on 9/24/2023, indicated the resident was at risk for skin breakdown The care plan intervention included to provide Resident 4 with air mattress as ordered. On 12/29/2023 at 2:34 p.m., during a concurrent interview and record review, Licensed Vocational Nurse 1 (LVN 1) stated that Resident 4 had history of PU and currently healed. LVN 1 stated that the APM was ordered for Resident 4 to prevent the development of pressure ulcers. LVN 1 stated that there was no physician order for Resident 4 ' s APM setting. LVN 1 stated physician orders on APM setting was needed to identify the comfort level setting for Resident 4. LVN 1 stated that Resident 4 had the potential to develop a PU again because of incorrect setting. On 12/29/2023 at 4:51 p.m. during an interview, the Assistant Director of Nursing (ADON) stated that the APM should be on the correct setting with physician orders based on the resident ' s BMI. The ADON stated that LVN 1 had the copy of the APM machine setting guide and the facility staff call LVN 1 at any time if there were any questions or concerns on the APM setting. The ADON stated that Resident 1 had the potential for an increased risk of developing PU. A review of the facility ' s policy and procedure titled, Prevention of Pressure Injuries, dated 12/28/2022, indicated the purpose to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. A review of the facility ' s policy and procedure titled, Mattress / Low Air Loss, dated 12/28/2022, indicated the purpose to decrease pressure from the resident ' s weight while lying in bed and to promote healing or prevention of pressure ulcers. The policy indicated to place the mattress on the bed and follow the manufacturer ' s directions for appropriate setting.

CONCERN (E) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biological) for three of five sampled residents (Resident 8, 9, 1and 1) by: 1. Failing to ensure Resident 8 was not administered neutral protamine [NAME] (NPH- intermediate acting [works throughout the day and night to provide you with low levels of insulin all the time]) with regular (short acting-starts to work quickly) when the resident ' s blood sugar was below 150 milligrams per deciliter (area of measurement) as ordered by the physician. 2. Failing to ensure Resident 9 was not administered amlodipine (medication used to treat high blood pressure) and hydrochlorothiazide (also known as water pill, medication used to reduce the amount of water in the body by increasing the flow of urine) when the resident ' s systolic blood pressure (sbp- pressure in the arteries when the heart beats) was less than 110 as ordered by the physician. 3. Failing to ensure Resident 1 was not administered hydralazine (medication used to treat high blood pressure) and Cardizem (medication used to treat high blood pressure) when the resident ' s sbp was less than 110 as ordered by the physician. These deficient practices placed the residents at risk for adverse reactions (any unexpected or dangerous reaction to a drug) including bradycardia (slow heart rate), hypotension (low blood pressure) and hypoglycemia (low blood sugar). Findings: a. A review of Resident 8 ' s admission Record (Face Sheet) indicated the facility admitted the resident on 9/16/2023 with diagnoses that included hemiplegia (severe or complete loss of strength) and hemiparesis (one-sided muscle weakness) following other nontraumatic (not caused by trauma) intracranial hemorrhage (bleeding inside the head), apraxia (a disorder of the brain and nervous system in which a person is unable to perform tasks or movements when asked), type 2 diabetes mellitus (a long-term medical condition in which your body doesn't use insulin properly, resulting in unusual blood sugar levels) and hypertensive heart disease (a long-term condition that develops over many years in people who have high blood pressure) with heart failure. A review of Resident 8 ' s History and Physical dated 9/28/2023 indicated the resident had capacity to understand and make decisions. A review of Resident 8 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 12/23/2023, indicated Resident 8 had intact cognition (mental action or process of acquiring knowledge and understanding). A review of Resident 8 ' s Physicians Order dated 10/12/2023 indicated the following order: - neutral protamine [NAME] (NPH intermediate acting [works throughout the day and night to provide you with low levels of insulin all the time]) and Regular (short acting-starts to work quickly) insulin (medication used to lower blood sugar) 70/30(70 NPH and 30 Regular), 100 units per milliliter (ml-unit of measurement), inject (to use a needle and syringe [ small tube] to put a liquid such as a medication into a person's body) 10 units subcutaneously (under all the layers of skin) two times a day for type 2 diabetes, hold for blood sugar less than 150. A review of Resident 8 ' s Medication Administration Record (MAR- record of medication received by the resident) dated 12/2023 indicated NPH with Regular insulin was given to resident on the following dates and times: 1. 12/5/2023 at 9 a.m.- blood sugar 128 2. 12/6/2023 at 5 p.m.- blood sugar 147 3. 12/10/2023 at 5 p.m.- blood sugar 114 4. 12/11/2023 at 5 p.m.- blood sugar 132 5. 12/13/2023 at 5 p.m.- blood sugar 135 6. 12/14/2023 at 5 p.m.- blood sugar 135 7. 12/15/2023 at 9 a.m.- blood sugar 132 8. 12/15/2023 at 5 p.m.- blood sugar 148 9. 12/19/2023 at 5 p.m.- blood sugar 125 10. 12/20/2023 at 5 p.m.- blood sugar 139 11. 12/21/2023 at 5 p.m.- blood sugar 120 12. 12/23/2023 at 5 p.m.- blood sugar 102 13. 12/25/2023 at 5 p.m.- blood sugar 142 14. 12/26/2023 at 5 p.m.- blood sugar 140 15. 12/29/2023 at 9 a.m.- blood sugar 138 16. 12/29/2023 at 5 p.m.- blood sugar 125 17. 12/30/2023 at 5 p.m.- blood sugar 148 A review of Resident 8 ' s Care Plan on diabetes dated 9/18/2023 indicated an intervention to administer medication as ordered. During a concurrent interview and record review on 1/5/2024 at 10:42 with the Assistant Director of Nursing (ADON), Resident 8 ' s Physicians Order dated 10/12/2023 and MAR dated 12/2023 werereviewed. The ADON stated check marks in the MAR indicate the medication was given to the resident. The ADON stated NPH with regular insulin should have not been given to the resident when the resident ' s blood sugar was less than 150. The ADON stated the nurses should have followed the physician ' s order to prevent the resident from experiencing hypoglycemia. During an interview on 1/5/2024 at 1:19 p.m., the Director of Nursing (DON) stated insulin is a medication that can cause hypoglycemia. b. A review of Resident 9 ' s admission Record indicated the facility admitted the resident on 10/30/2023 with diagnoses that included unspecified (unconfirmed) fracture (broken bone) of the right wrist and hand, unspecified asthma (a chronic lung disorder that causes airways [the tubes that carry air into and out of the lungs] to become inflamed, which means that they swell and produce lots of thick mucus) and essential hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition). A review of Resident 9 ' s History and Physical dated 10/31/2023 indicated the resident had capacity to understand and make decisions. A review of Resident 9 ' s MDS dated [DATE], indicated Resident 9 had intact cognition. A review of Resident 9 ' s Physician Order dated 10/30/2023 indicated the following orders: 1. amlodipine besylate (medication used to treat elevated blood pressure) oral tablet five milligram (mg-unit of measurement) by mouth one time a day for hypertension (uncontrolled elevated blood pressure), hold for systolic blood pressure (sbp-pressure in the arteries when the heart beats) less than 110 or pulse rate of less than 60. 2 hydrochlorothiazide (medication used to reduce the amount of water in the body by increasing the flow of urine) oral tablet 25 mg by mouth one time a day for hypertension, hold for sbp less than 110 or pulse rate of less than 60. A review of Resident 9 ' s Care Plan on use of diuretic (also known as water pills, are a common treatment for high blood pressure that helps reduce fluid buildup in the body) medication related to hypertension dated 10/30/2023 indicated an intervention to administer medication as ordered. A review of Resident 9 ' s MAR dated 12/2023 indicated on 12/16/2023 at 9 a.m., the resident received amlodipine and hydrochlorothiazide for a blood pressure of 108/66. During a concurrent interview and record review on 1/5/2024 at 10:42 a.m., with ADON, Resident 9 ' s Physician Order dated 10/30/2023 and MAR dated 12/2023 were reviewed. The ADON stated nurses should follow the physician order to hold the medication when the resident ' s sbp was less than 110 to prevent hypotension (low blood pressure). During an interview on 1/5/2023 at 1:19 p.m., with the DON, the DON stated nurses should check the order first before giving any medication to residents to prevent medication error that can result in hypotension. c. A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 3/14/2012 with diagnoses that included encounter for attention to gastrostomy (opening into the stomach from the abdominal wall, made surgically for the introduction of food), type 2 diabetes mellitus and hypertensive heart disease with heart failure. A review of Resident 1 ' s History and Physical dated 10/19/2023 indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1 ' s MDS dated [DATE], indicated resident ' s cognitive skills for daily decisions were severely impaired. A review of Review of Resident 1 ' s Physician Order dated 7/29/2020 indicated the following orders: 1. Cardizem (medication used to treat elevated blood pressure) tablet 60 mg via gastrostomy tube (g-tube, a flexible tube surgically inserted through abdomen into the stomach for feeding, fluid and medication administration), three times a day for essential hypertension, hold for sbp less than 110 or pulse rate less than 60. 2. hydralazine hydrochloride (medication used to treat elevated blood pressure) tablet 50 mg via g tube two times a day for essential hypertension, hold for sbp less than 110 or pulse rate less than 60. A review of Resident 1 ' s Care Plan on at risk for respiratory / cardiac complications dated 12/14/2020 indicated an intervention to administer medications / treatments as ordered. A review of Resident 1 ' s MAR dated 10/2023 indicated the resident received Cardizem and hydralazine on the following dates and times: 1. 10/1/2023 at 5 p.m.- blood pressure (bp) 98/67 2. 10/3/2023 at 5 p.m.- bp 108/64 3. 10/5/2023 at 5 p.m.- bp 91/63 4. 10/29/2023 at 9 a.m.- bp 109/61 5. 10/31/2023 at 5 p.m.- bp 108/62 During a concurrent interview and record review on 1/5/2024 at 10:42 a.m., with the ADON, Resident 1 ' s Physician Order dated 7/29/2020 and MAR dated 10/2023 were reviewed. The ADON stated the nurses administered both Cardizem and hydralazine five times on 10/2023 despite physician ' s order to hold the medication. The ADON stated the resident ' s blood pressure may further drop after receiving a blood pressure medication. During an interview on 1/5/2024 at 1:19 p.m., with the DON, the DON stated nurses should read the physician order and follow it. The DON stated giving blood pressure to a resident with low blood pressure can further cause hypotension. A review of facility ' s policy and procedure titled, Administering Medications dated 12/2012 and reviewed on 12/28/2022, indicated Medications must be administered in accordance with the orders, including any required time frame.

Nov 2023 4 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report the allegation of resident-to-resident abuse to the State Survey Agency (SSA) for two of seven sampled residents (Resident 1 and Resident 2). On 11/16/2023 at 9:30 a.m., Resident 2 reported an allegation of abuse by Resident 1 to Charge Nurse 1 (CN 1). On 11/16/2023 at 6:10 p.m., the Abuse Coordinator reported the allegation to the SSA, 8 hours and 40 minutes after the allegation of abuse was made. This deficient practice had the potential to result in unidentified abuse and failure to protect other residents from abuse. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 10/18/2023 with diagnoses including traumatic brain injury (an injury that affects how the brain works), traumatic subdural hemorrhage (a condition where blood collects between the skull and the surface of the brain), and osteoarthritis (a degenerative joint disease in which the tissues of the joint breaks down over time) of the left knee. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 10/24/2023, indicated the resident ' s cognitive (involving conscious intellectual activity such as thinking, reasoning, or remembering) skills was moderately impaired. The behavior section indicated Resident 1 had verbal behavior symptoms directed toward others such as threatening other, screaming at others, and cursing at others. The MDS indicated that Resident 1 ' s behaviors placed others at significant risk for physical injury, significantly intrude on the privacy or activity of others, and significantly disrupt care or living environment. A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 10/1/2023 with diagnoses including hemiplegia (one-sided muscle paralysis or weakness) and hemiparesis (weakness or inability to move on one side of the body) of the right dominant side, chronic obstructive pulmonary disease (COPD - refers to a group of diseases that cause airflow blockage and breathing-related problems), and essential hypertension (abnormal blood pressure that was not the result of a medical condition). A review of Resident 2 ' s MDS, dated [DATE], indicated the resident ' s cognitive skills was intact. The MDS indicated that Resident 2 required supervision or touching assistance on sit to stand and on walking 10 feet. A review of the facility ' s Interdisciplinary Team (IDT) investigation report included CN 1 ' s undated written statement indicated that on 11/16/2023 at 9:30 a.m., Resident 2 reported an alleged verbal aggression of Resident 1 towards Resident 2. The report also indicated that Resident 1 bumped into Resident 2 as the resident was coming in from the smoking patio. The report indicated that Resident 2 felt unsafe. On 11/29/2023 at 4:01 p.m., attempted to contact CN 1 but she did not answer and did not return the call. On 11/29/2023 at 4:59 p.m., during a concurrent interview and record review, reviewed the IDT investigation report with the Assistant Director of Nursing (ADON). The ADON stated that CN 1 knew on 11/16/2023 at 9:30 a.m., the allegation of verbal and physical abuse of Resident 1 to Resident 2 but did not report the allegation of abuse to the Administrator (ADM). The ADON stated that the ADM was the facility ' s abuse coordinator. The ADON stated that allegations of abuse should be reported within two hours to prevent potential harm to the residents. On 11/29/2023 at 5:50 p.m., during an interview, The ADM stated that he was the facility ' s abuse coordinator. The ADM stated that allegations of abuse should be reported to him within 2 hours. A review of the facility ' s policy and procedure titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated 12/28/2022, indicated that if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the Administrator and the other officials according to the state law. The policy also indicated that immediately was defined as within two hours of an allegation involving abuse ult in serious bodily injury.

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to develop a comprehensive, person-centered care plan with measurable objectives and interventions for one of seven sampled residents (Resident 1). The facility failed to develop and implement individualized care plans and interventions addressing Resident 1 ' s aggressive behavior. This deficient practice had placed Resident 1 for not receiving the necessary services and assistance that can result in injury to other residents, visitors, and facility staff. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 10/18/2023 with diagnoses including traumatic brain injury (an injury that affects how the brain works), traumatic subdural hemorrhage (a condition where blood collects between the skull and the surface of the brain), and osteoarthritis (a degenerative joint disease in which the tissues of the joint breaks down over time) of the left knee. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 10/24/2023, indicated the resident ' s cognitive (involving conscious intellectual activity such as thinking, reasoning, or remembering) skills was moderately impaired. The MDS indicated Resident 1 had verbal behavior symptoms directed toward others such as threatening other, screaming at others, and cursing at others. The MDS indicated that Resident 1 ' s behaviors placed others at significant risk for physical injury, significantly intrude on the privacy or activity of others, and significantly disrupt care or living environment. A review of Resident 1 ' s Progress Notes, dated 10/27/2023, indicated the resident ' s responsible party was informed about the resident ' s aggressive behavior exhibited on 10/27/2023. A review of Resident 1 ' s Situation, Background, Appearance, and Review (SBAR) Communication Form, dated 10/27/2023, indicated the resident was argumentative with verbal aggression towards nursing staff and peers, screaming, racial slurs, and shaking with outburst that led to attempt physical aggression. The communication form indicated Resident 1 ' s aggressive behavior had happened before. A review of Resident 1 ' s SBAR, dated 11/16/2023, indicated the resident had a verbal and physical aggression towards another resident. The communication form indicated that Resident 1 ' s behavioral symptoms got worse. Resident 1 ' s primary physician was notified and had ordered for the resident to have a sitter (a person that provides support and direction to patients while in a healthcare facility). On 11/29/2023 at 3:19 p.m., during a telephone interview, CNA 1 stated that Resident 1 started yelling rude comments and racial slurs towards her and another resident. CNA 1 stated that Resident 1 rushed towards her and tried to grab her arm. CNA 1 further stated that Resident 1 attempted to throw the ice chest to her and other facility staff. On 11/29/2023 at 4:59 p.m., during a concurrent interview and record review, Resident 1 ' s care plans were reviewed with the Assistant Director of Nursing (ADON). The ADON stated that there were no care plans addressing Resident 1 ' s aggressive behaviors since admission. The ADON stated that care plans should have been created based on Resident 1 ' s behavior assessment to prevent and control the resident ' s aggression. The ADON stated that care plans should be individualized, and resident centered. A review of the facility ' s policy and procedure titled, Care Plans, Comprehensive Person-Centered, dated 12/28/2022, indicated a comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident ' s physical, psychosocial, and functional needs. The policy indicated that a car plan should be developed by the interdisciplinary team (IDT), with the input from the resident and family or legal representative.

CONCERN (D) 📢 Someone Reported This

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

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

Staffing Information (Tag F0732)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to follow their policy and procedure on meeting the staff posting requirements. The facility also failed to provide the Direct Care Service Hours Per Patient Day (DHPPD refers to the actual hours of work performed per patient day by a direct caregiver) for one of seven sampled residents (Resident 3) after the resident ' s verbal request. This deficient practice had the potential to keep residents and visitors unaware of the total number of staff and the actual hours worked by staff in the facility. Findings: On 11/28/2023 at 9:08 a.m., during an observation, the DHPPD dated 8/26/2023 was posted at the facility lobby. On 11/28/2023 at 9:11 a.m., during a concurrent observation and interview, observed that there was no DHPPD posted at nurse station 1. Observed the DHPPD dated 8/26/2023 was posted at the nurse station 2, 3, 4, and 5. The Assistant Director of Nursing (ADON) stated that an updated DHPPD should be posted in the facility lobby and at the nurse stations 1, 2, 3, 4, and 5. The ADON stated the Director of Staff Development (DSD) prints the DHPPD and the Registered Nurse (RN) supervisor should post the DHPPD during the 11 p.m. to 7 a.m. shift. The ADON stated that the DHPPD were posted to inform the residents, visitors, and staff that the facility was adequately staffed to provide services. A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 12/27/2022 with diagnoses including chronic obstructive pulmonary disease (COPD - refers to a group of diseases that cause airflow blockage and breathing-related problems), malignant neoplasm (cancerous and abnormal cell growth) of the lungs, and essential hypertension (abnormal blood pressure that was not the result of a medical condition). On 11/28/2023 at 10:10 a.m., during an interview, Resident 3 stated that the request for facility staffing was not provided after the resident ' s verbal request was made. On 11/28/2023 at 3:46 p.m. during an interview, the DSD stated that her responsibility was to make sure the facility met the adequate staffing as indicated in the DHPPD. The DSD stated that the DHPPD should be made available for residents, visitors, and staff. A review of the facility ' s policy and procedure titled Posting Direct Care Daily Staffing Numbers, dated 12/28/2022, indicated the facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. The policy indicated that within two hours of the beginning of each shift, the charge nurse or designee computes the number of direct care staff and completes the nurse staffing information form. The charge nurse completes the form and posts the staffing information in the location designated by the administrator. The policy indicated that staffing information during the recorded time period was made available to residents, family members, and the public within 24 hours of a written or verbal request.

CONCERN (E) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow infection control procedures for two of seven sampled residents (Resident 6 and Resident 7) by failing to ensure Licensed Vocational Nurse 2 (LVN 2): 1. Performed hand hygiene (hand washing with soap and water and use of alcohol-based hand sanitizer) before and after gloves use while administering medications to Resident 7. 2. Performed hand hygiene before and after touching Resident 6 and Resident 7 and the resident ' s surroundings without wearing gloves. 3. Disinfected the glucometer (a medical device for determining the approximate concentration of blood sugar) before it was returned in the medication cart drawer. These deficient practices placed Resident 6 and Resident 7 at risk for exposure and contracting infections. Findings: A review of Resident 6 ' s admission Record indicated the facility admitted the resident on 9/19/2023 with diagnoses including type two diabetes mellitus (a disease that occurs when the blood sugar is too high), chronic obstructive pulmonary disease (COPD - refers to a group of diseases that cause airflow blockage and breathing-related problems), and respiratory failure (a serious condition that made it difficult to breath) with hypoxia (low level of oxygen in the body). A review of Resident 6 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/25/2023, indicated the resident ' s cognition (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was intact. Resident 6 required extensive assistance (resident involved in activity and staff provided guided maneuvering) on bed mobility, transfer, dressing, toilet use, and personal hygiene. A review of Resident 7 ' s admission Record indicated the facility admitted the resident on 6/16/2023 with diagnoses including type two diabetes mellitus (a disease that occurs when the blood sugar is too high), dysphagia (difficulty swallowing, and essential hypertension (abnormal blood pressure that was not the result of a medical condition). A review of Resident 7 ' s MDS, dated [DATE], indicated the resident ' s cognition was moderately impaired. Resident 7 required extensive assistance on bed mobility, transfer, dressing, toilet use, and personal hygiene. On 11/28/2023 at 9:32 a.m., during a concurrent observation and interview, LVN 2 was observed preparing Resident 7 ' s medications. LVN 2 wore gloves, went inside Resident 7 ' s room, touched the bedside table, and placed the medication cup on top of the resident ' s table. LVN 2 removed her gloves, opened the medication cart to cut Resident 7 ' s medication pill, and then handed the medication cup to Resident 7. LVN 2 did not perform hand hygiene during the medication administration process. LVN 2 placed the glucometer on top of Resident 7 ' s table but the resident refused the blood sugar check. LVN 2 opened the medication cart and placed the glucometer inside the medication cart drawer. LVN 2 did not disinfect the glucometer before returning it inside the medication cart. Observed LVN 2 went back inside the residents ' room and touched Resident 6 ' s bedside rails. LVN 2 opened the medication cart and touched the computer without performing hand hygiene. LVN 2 stated that she should wash her hands or use the hand sanitizer before and after providing care to a resident. LVN 2 stated that the glucometer should have been disinfected before it was returned inside the medication cart. LVN 2 further stated that she had the potential to spread germs, bacteria, and infections to other residents and staff. On 11/29/2023 at 5:25 p.m., during a telephone interview, the Infection Preventionist Nurse (IPN) stated that hand hygiene should be done before and after resident contact and before and after glove use. The IPN stated that equipment used for resident care should be disinfected after use. The IPN stated that infection control procedures that were not followed had the potential to spread germs and cause cross contamination to residents and staff. A review of the facility ' s policy and procedure titled, Infection Control, dated 12/28/2022, indicated the facility ' s infection control policies and practices were intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. A review of the facility ' s policy and procedure titled, Handwashing / Hand Hygiene, ' dated 12/28/2022, indicated the facility considered hand hygiene the primary means to prevent the spread of infections. The policy indicated all personnel shall follow the handwashing / hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The policy indicated that alcohol-based hand rub should be used before and after direct contact with residents, after removing gloves, before preparing or handling medications, and after contact with objects such as medical equipment in the immediate vicinity of the resident. A review of the facility ' s policy and procedure titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated 12/28/2022, indicated that reusable items were cleaned and disinfected between residents.

Nov 2023 5 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to provide the necessary services for one of 15 sampled residents (Resident 15) who was unable to carry out activities of daily living received the necessary services to maintain good grooming when Resident 15 was observed with long curled nails. This deficient practice had the potential for Resident 15 to have discomfort. Findings: A review of Resident 15 ' s admission Record indicated the facility admitted the resident on 9/18/2023 with diagnoses that included anoxic brain damage (caused by a complete lack of oxygen to the brain, which results in the death of brain cells after approximately four minutes of oxygen deprivation), legal blindness, and functional quadriplegia (complete immobility due to frailty or severe physical disability). A review of Resident 15 ' s Minimum Data Set (MDS – a standardized assessment and care screening tool), dated 9/24/2023 indicated Resident 15 had the ability to understand and be understood. The MDS indicated Resident 15 was totally dependent on staff for bed mobility, transfer, location on and off the unit, dressing, eating, toilet use and personal hygiene. A review of Resident 15 ' s care plan initiated on 9/19/2023, indicated resident has actual risk for Activity of Daily Living (ADL) mobility decline and requires assistance. The interventions included hygiene assistance of nails: diabetic, nurse to trim nails, nails: trim nails with bathing schedule and am and pm care assistance. During an interview on 11/7/2023 at 10:55 a.m., Resident 15 stated her nails were long and they even curl up, she would like her nails to be cut. Resident 15 stated no one from the facility has offered to cut her nails. Resident 15 stated the nails do not hurt or dig into her hands. During a concurrent observation and interview on 11/7/2023 at 11:15 a.m. with Certified Nursing Assistant 3 (CNA 3) at Resident 15's bedside, CNA 3 stated Resident 15 nails are long and they curl up at the ends, but Resident 15 refuses to get her nails cut. CNA 3 stated she has offered Resident 15 multiple times to cut her nails, CNA 3 stated if resident is refusing should be documented and informed to the charge nurse, CNA 3 stated not sure if its documented. During an interview on 11/7/2023 at 1:29 p.m. , Treatment Nurse 1 (TN 1) stated or Resident 15 the treatment nurse can trim her nails but not sure if they have offered to trim Resident 15 ' s nails. TN 1 stated not offering Resident 15 to trim her nails is a right and she should be offered it. TN 1 stated not trimming Resident 15 nails can be a risk for Resident 15 to have pain if nails are long, they can dig into her hand, she is contracted. TN 1 stated nails are daily care but for toenails since she is diabetic needs to be done by podiatrist, is being seen today by podiatrist for toenails. During an interview on 11/7/2023 at 1:44 p.m., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) stated that Resident 15 ' s nails are long and curly. The ADON stated there is a care plan for ADL but nothing regarding Resident 15 refusing to have her nails cut. The ADON stated there is no progress note of Resident 15 refusing nail care. The ADON stated nails should have been cut and trimmed and if she refused should have communicated and documented it. The DON stated not providing Resident 15 with trimming of nails is a risk for continuity of care and a risk for discomfort to resident. During an interview on 11/7/2023 at 2:28 p.m. with the Administrator (Adm) stated Resident 15 ' s nails appear long. The Adm stated he felt like Resident 15 is refusing the care and his staff did not document it appropriately. The Adm stated if Resident 15 is wanting her nails to be cut the facility should be providing it. The Adm stated not providing nail trimming is an issue should be respecting the resident right to dignity. A review of the facility ' s policies and procedures titled, Fingernails/Toenails, Care of, last revised on 2/2018 indicated nail care includes daily cleaning and regular trimming, trimmed and smooth nails prevent the residents from accidentally scratching and injuring his or her skin. Reporting indicated notify the supervisor if the resident refuses the care, report other information in accordance with facility policy and professional standard of practice. A review of the facility ' s policies and procedures titled, Activities of Daily Living (ADLs), Supporting, last revised on 3/2018 indicated resident will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. A review of the facility ' s policies and procedures, titled Resident Rights, last revised on 12/2016 indicated employees shall treat all resident with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all resident of this facility. These rights include the resident ' s right to: a. A dignified existence. b. Be treated with respect, kindness, and dignity.

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide adequate nutritional and hydration care and services to residents when: 1. The facility failed to provide physician ordered high calorie (Kcal, a unit of energy used to express the nutritional value of foods), high protein (a type of nutrient a person needed for growth and development of muscles) nutritional supplement (product used to add kcal and protein in the diet) of preference. 2. The facility failed to prepare foods by methods that conserved flavor and appearance for Resident 1 causing varied oral intake (PO intake). These deficient practiced caused 14.4% severe unplanned weight loss in six (6) months of one (1) of three (3) sampled residents (Resident 1). Findings: A review of Resident 1 ' s admission Record, dated 10/31/2023, indicated Resident 1 was initially admitted to the facility on [DATE] and then readmitted on [DATE] with diagnoses including malignant neoplasm of upper lobe, right bronchus or lung (a type of lung cancer that begins in the upper part of the right lung), chronic obstructive pulmonary disease (COPD, a lung disease characterized by persistent cough and progressive breathing) and unspecified protein-calorie malnutrition (a condition of insufficient food intake resulting to weight loss, muscle loss and impaired growth and development). A review of Resident 1 ' s Minimum Data Set (MDS – a standardized assessment and care screening tool), dated 8/8/2023, indicated Resident 1 was cognitively intact (able to understand and make decisions), able to eat with limited assistance, and needed one-person physical assist when eating. A review of Resident 1 ' s diet type report order by physician, dated 7/18/2023, indicated fortified regular (adding high kcal, high protein food items to the tray such as butter, milk, and margarine), soft mechanical chopped meat (a diet including foods that are chopped to help residents having chewing issues), regular thin liquid consistency. A review of Resident ' s 1 supplement order by physician, dated 9/27/2023 at 11:19 PM, indicated, Ensure Supplement two times (BID) a day for supplement chocolate Ensure Plus. A review of Resident ' s 1 care plan, revised 7/10/2023, indicated, Potential weight loss interventions included Ensure three times a day (TID). During an interview with Resident 1 on 10/31/2023 at 10:38 AM, Resident 1 stated the menu served was not followed regularly, large amount of starch such as rice and pasta were served, and vegetables like green beans were not seasoned. Resident 1 stated that the tuna sandwich tasted like cardboard, powdered eggs were used instead of real eggs, zesty spinach were not zesty, breaded fish fillet had so much breading than fish and the menu sounds delicious, but the food served was not edible. Resident 1 stated, the sandwiches sold in the gasoline station was a better tasting than the food served in the facility. Resident 1 stated that she sometimes would request soup and was given vegetable soup diluted with water that has no nutrients. Resident 1 stated she had a physician ' s order of Ensure (a brand of nutritional shake and drink) high kcal, high protein drink but was substituted with a different brand, Resource 2.0 (a brand of oral supplement that is high protein, high kcal). Resident stated she has informed the Dietary Supervisor (DS), Certified Nursing Assistants (CNA), and other Licensed Vocational Nurses (LVN) of the food concerns and that she prefers drinking Ensure chocolate but was told that the facility could not provide the Ensure as it ' s not part of their formulary. Resident 1 stated, Resource 2.0 and Boost (a brand of nutritional drink, high in kcal, and protein) supplement made her sick as it contained more sugar. Resident 1 stated she has lost ten (10) pounds (lbs, a unit of measurement) but not sure for how long. During a record review facility document titled, Weights and Vitals Summary, dated 10/31/2023, indicated, resident ' s weight was eighty-eight (88) lbs on 4/11/2023, eighty-five (85) lbs on 5/9/2023, eighty-four (84) lbs on 6/14/2023, eighty-three (83) lbs on 8/8/20234, and seventy-five (75) lbs on 10/11/2023. Resident had 9.63% weight loss in two (2) months and 14.77% in 6 months indicative of severe weight loss. During a concurrent interview with LVN 1 and record review of Resident 1 ' s PO intake on 10/31/2023 at 3:30 PM, LVN 1 stated she did not physically take care of Resident 1 but monitored Resident 1 ' s weight and PO intake. LVN 1 stated she weighed Resident 1 on 10/11/2023 with a weight of 75 lbs., however, Resident 1 refused to be weighed in 9/2023. LVN 1 stated there was an eight (8) lbs weight loss from 83 lbs. in 8/8/2023 to 75 lbs. in 10/11/2023. LVN 1 stated Resident 1 disliked Resource 2.0, Glucerna, health shakes, and milk but interested in having her food preferences catered by the kitchen. LVN 1 stated Resident 1 ' s PO intake records varied but were mostly ranging from 50-100% and on 10/30/2023 Resident 1 ate 50-75% for breakfast, 50-75% for lunch and refused her dinner meal. LVN 1 stated that further PO intake records indicated were as follows: 10/29/2023 76-100% for breakfast, refused her meal for lunch, 50-75% for dinner. LVN 1 stated Resident 1 ' s PO intake varied from 50-100%, 3 episodes of meal refusals and oral supplement refusals on 10/16/2023. During an interview with CNA 1 on 10/31/2023 at 4:07 PM, CNA 1 stated she took good care of Resident 1 and Resident 1 was very particular with her food and eat some of her food but would not finish what was served to her because she does not like the quality of the food. During an interview with LVN 2 on 10/31/2023 at 4:23 PM, LVN 2 stated Resident 1 loss weight and there were changes in appetite due to pain. LVN 2 stated Resident 1 was on pain medications such as Norco, ibuprofen, morphine, Robaxin and oxycodone (medications for pain). During a concurrent interview with the DS and record review of Resident 1 ' s medical records on 11/1/2023 at 10:50 AM, DS stated on 10/12/2023 at 4:26 PM, she visited Resident 1 for food preferences and Resident 1 added a lot of seasoning on the side in her trays and does not like a lot of pork but requested small portions of pork to taste. DS stated Resident 1 liked small portions of food. DS stated she revisited Resident 1 on 10/16/2023 at 10:55 AM to talk about food preferences and that Resident 1 requested for chocolate pudding, peanut butter, and black pepper for breakfast. DS stated Resource 2.0 was ordered by the physician on 1/25/2023 and with a discontinue date of 8/28/2023. DS stated she heard from LVN1, Resident 1 liked Ensure and was ordered by the physician on 9/28/2023 at 9:00 AM with indefinite ending date. DS stated she saw that there was an order of Ensure on 10/16/2023 but nurses always gave Resource as a substitute. DS stated, we can always ask our supplier to get Ensure, it ' s not a problem. A review of Resident ' s 1 progress notes written by DS on 9/21/2023 at 12:50 PM, indicated, Resident 1 ' s food preferences in the morning were hard-boiled eggs, small amount of tuna, cottage cheese mixed with tomatoes and seasonings of her choice. Resident 1 liked fruits such as melon, grapes or sliced oranges, and disliked salt as a condiment but preferred black pepper instead. Resident 1 stated she does not like liquid eggs and juice in a box. Resident 1 concerned was to get certain items quickly in the morning. During an interview with LVN 1 on 11/1/2023 at 11:10 AM, LVN 1 stated the physician ordered Ensure on 9/28/2023 with an indefinite ending date for Resident 1 and Resource 2.0 was also a standing order since 1/25/2023. LVN 1 stated, LVN 4 who worked from 3 p.m. to 11 p.m. was the one who put the order in the medical records. During an interview with CNA 2 on 11/1/2023 at 11:33 PM, CNA 2 stated Resident 1 ' s appetite was getting less for the past two weeks because she had a lot of pain in her tooth. CNA 2 stated she usually eat tomatoes in the morning and sometimes does not like the food for lunch as it does not taste good. CNA 2 stated, Resident 1 did not drink Resource 2.0 today, but she drank some of it the other days. CNA 2 stated, Resident 1 liked chocolate flavor of Ensure a week ago or so. CNA 2 stated she told the charge nurse and was told Ensure was not available and the facility only had Boost (brand of high kcal, high protein supplement) and Resource 2.0. CNA 2 stated Resident 1 did not get the Ensure supplement. CNA 2 stated high kcal, high protein shakes were given to residents with weight loss as it contained vitamins (are nutrient needed for growth and development), high protein, and high kcal. CNA 2 stated, Resident 1 was not eating enough nutrients and was not getting the supplement she preferred resulting to more weight loss. During a concurrent interview with LVN 3 and record review of Resident 1 ' s weight records on 11/1/2023 at 11:53 AM, weight records for Resident 1, indicated 75 lbs on 10/11/2023 and 83 lbs on 8/8/2023. LVN 3 stated Resident 1 liked small portions of food and eat approximately half of the meals. LVN 3 stated, Resident 1 eat some food for lunch and set aside some food for snacks however, Resident 1 did not have a snack order in place. LVN 3 stated Resident 1 refused Resource 2.0 oral supplements a lot of times and that Resident 1 did not want to drink it. LVN 3 stated oral supplements like Resource 2.0 and Ensure provided high kcal, high protein and nutrients for residents who were not eating their meals and were losing weight. LVN 3 stated the possible outcome for resident who were not eating were weight loss and skin injury. LVN 3 stated she was aware of Ensure and Resource 2.0 as two active orders of oral supplement for Resident 1. LVN 3 stated resident 1 got Ensure once in October as she liked it better than Resource 2.0 but cannot recall the exact the date. LVN 3 stated Ensure could have helped Resident 1 prevent weight loss as she will drink it more because it was her preference. During a phone interview with the Registered Dietitian (RD) on 11/1/2023 at 1:00 PM, RD stated she is familiar with Resident 1 ' s weight loss concerns but did not recall going at bedside. RD stated Resident 1 ' s weight loss was discussed in the interdisciplinary meeting on 10/25/2023 and that Resident 1 has low Body Mass Index (BMI, weight to height ratio calculating the degree of obesity and underweight), undergoing treatment for cancer, low PO intake however Resident 1 was on an oral supplementation but she does not exactly recall which type of supplement. RD stated that she was not aware of two oral supplements were ordered by a physician for Resident 1 and didn ' t know that Resident 1 had preference of Ensure to drink. RD stated Ensure would have helped Resident 1 with weight loss. A review of Resident 1 ' s Progress notes written by RD on 10/25/2023 at 11:01 PM, indicated, Resident 1 assessed on monthly weight variance by Interdisciplinary Team (IDT) for significant weight loss of thirteen (13) lbs in 6 months (14.8%). The weight of Resident 1 at the time of review was 75lbs which was below Resident 1 ' susual body weight (UBW, normal or healthy weight) of 90-95lbs. Resident 1 ' s BMI=13.7 severely underweight status There were multiple interventions in place to prevent weight loss and per Interdisciplinary team (IDT, team consist of different health professionals) to continue monthly weights. During an interview with Resident 1 on 11/1/2023 at 2:03 PM, Resident 1 stated that facility never got her Ensure but her oncologist gave her 5-6 cans of Ensure last 10/2023 during her oncology visit. Resident 1 stated when she told the facility that she preferred Ensure, she was told that it was not in facility formulary (a set of formula, supplements a facility have on hand), and it was not possible to get. Resident 1 stated, she loved the taste of the creamy Ensure dark chocolate but it was unfortunate that facility could not get it. Resident 1 stated, she wanted to get her weight back to 85 lbs and wanted to gain muscles and not just fat. During an interview with LVN 4 on 11/1/2023 at 3:30 PM, LVN 4 stated he placed the order for Ensure on 9/27/2023 and that this order was carried out from Resident 1 ' s oncologist appointment. LVN 4 stated he substituted Ensure with Resource 2.0 as he assumed that the facility did not have Ensure. LVN 4 stated he should have asked the facility if Ensure was available. LVN 4 stated Resident 1 ' s PO intake varied from 70-75% that was why it was important for Resident 1 to drink the supplements. LVN 4 stated Resident 1 ' s weight was low, Resident 1 was on the thin side and oral supplements were necessary to complete the rest of the nutrients Resident 1 was not getting from the rest of the food. LVN 4 stated the possible outcome for Resident 1 not getting all the nutrients needed for the day was weight loss, muscle breakdown, weakness of the bones, loss of important nutrients such as calcium (a nutrient needed for maintenance of bones and teeth), phosphorus (important mineral needed to maintain normal function of the body) and other essential vitamins. LVN 4 stated if Ensure was the Resident ' s preference for oral supplement, it would have helped her prevent further weight loss if she drank it. LVN 4 stated he endorsed the Ensure orders to the upcoming shifts but not sure how it got missed. During an interview with LVN 5 on 11/1/2023 at 3:51 PM, LVN 5 stated Resident 1 PO intake was minimal because she did not tolerate food much due to pain and lung cancer, it was difficult for Resident 1 to consume food. LVN 5 stated Resident 1 liked and drank liquids as she tolerated it better than solid foods. LVN 5 stated she gave Resident 1 broth and Resource 2.0 in the morning however, Resident 1 only drank half of the Resource 2.0. LVN 5 stated she was not aware Resident 1 prefers to have Ensure than Resource 2.0 as Ensure would have helped Resident 1 lose more weight. LVN 5 stated Resident 1 was given oral supplement and made sure she had all the nutrient she needed and to keep weight stable. LVN 5 stated, The supplement order fell off through the cracks and I don ' t know why I missed it. LVN 5 stated, Resident 1 might have consumed Ensure with better tolerance if that was her preference. During an interview with Director of Nursing (DON) on 11/1/2023 at 4:09 PM, DON stated she was not aware of Resident 1 ' s weight loss and the two oral supplement order for Resident 1. DON stated we do not have Ensure here at the facility, so we provided alternative. We usually honor resident ' s preferences of what they need. It was a miscommunication because the LVN monitoring the weights was not aware of the Ensure order. DON stated supplements were given to residents to prevent further weight loss and Ensure will probably help Resident 1 as she would have drank it more than what was given to her. DON stated, she could have discussed resident ' s request with the Administrator, however it was not done because she wasn ' t aware of supplement preference. During an interview with LVN 1 on 11/1/2023, LVN 1 stated the last laboratory orders for Resident 1 was on 9/29/2023 for complete blood count (CBC, blood test to look at overall health and find a wide range of conditions) with comprehensive metabolic panel (CMP, test that measures 14 different substance in the blood) and LDH (Lactate Dehydrogenase, a type of blood test) and had the following results: Albumin 3.3, Protein 5.9, Hemoglobin 9.5, Hematocrit 28.9. LVN 1 stated there were no recent laboratory weights ordered for Resident 1 ' s weight loss. A review of facility ' s policy and procedure (P&P) titled Food Preferences dated 2018, indicated POLICY: Resident ' s food preferences will be adhered to within reasons. Substitutes for all foods disliked will be given for appropriate food group. PROCEDURE: Food preferences will be obtained as soon as possible through the initial resident screen. Assessment must be completed within 7 days of admission by the FNS Director. Food preferences will be done as residents ' needs change and/or during the quarterly review. A review of facility ' s P&P titled Nutritional Screening/Assessment/Resident Care Planning dated 2020, indicated POLICY: The resident ' s nutritional status and his nutritional needs will be assessed. A nutritional program specific to his needs will be planned and implemented, and then reassessed periodically for progress. Change in eating habits, difference is eating pattern, eating problems, weight and other problems will be recorded in the dietary progress notes and resident care plan. A review of facility ' s P&P titled Nutrition (Impaired)/Unplanned Weight Loss-Clinical Protocol revised 9/2017 indicated Treatment/Management (1) the staff and physician will identify pertinent interventions based on identified causes and overall resident condition, prognosis, and wishes. Monitoring: (1) The physician and staff will monitor nutritional status, an individual ' s response to interventions, and possible complications of such interventions (for example, additional weight gain or loss, nausea, or vomiting).

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure one of 15 sampled residents (Resident 1) was free from significant medication error by failing to ensured licensed staff did not administer oxycodone (a pain-relief medicine used to treat severe pain) with Gabapentin (medication used to treat epilepsy [a disorder of the brain characterized by repeated seizures] also taken for nerve pain) to Resident 15. This deficient practice placed Resident 15 at risk for respiratory depression, coma, and death. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 4/28/2021 and readmitted the resident on 12/27/2022 with diagnoses that included chronic obstructive pulmonary disease (COPD- is a common lung disease causing restricted airflow and breathing problems), emphysema (a chronic obstructive pulmonary disease that causes coughing and breathing difficulties), and chronic pain syndrome (CPS- when people have symptoms beyond pain alone, like depression and anxiety, which interfere with their daily lives). A review of Resident 1 ' s Minimum Data Set (MDS – a standardized assessment and care screening tool), dated 8/8/2023, indicated Resident 1 had the ability to understand and be understood. The MDS indicated Resident 1 required extensive assistance with bed mobility, dressing, toilet use and personal hygiene. A review of the Physician ' s Order for Resident 1, dated 9/14/2023, indicated Gabapentin Oral Capsule 400 milligrams (mg - a unit of measurement) by mouth three times a day for CPS resident prefers this time 4 a.m., 12 p.m., and 8 p.m. A review of the Physician ' s Order for Resident 1, dated 8/4/2023, indicated Oxycodone 15 mg by mouth every 4 hours as needed for moderate pain (4 to 6 in the pain scale, with 10 as the highest) and severe pain (7 to 10 in the pain scale). A review of Resident 1 ' s Medication Administration Record (MAR- a report detailing the drugs administered to a patient by a healthcare professional at a treatment facility) for 11/5/2023 at 11p.m. indicated Resident 1 ' s blood pressure was 118/68 (Normal blood pressure for most adults is defined as a systolic pressure of less than 120 and a diastolic pressure of less than 80), pulse rate of 60 (normal range from 60 to 100 beats per minute), respiration rate of 17 (normal respiration rates for an adult person at rest range from 12 to 16 breaths per minute), and oxygen saturation of 97 (normal is between 95% and 100%.). A review of Resident 1 ' s MAR on 11/5/2023 indicated Gabapentin 400 mg was given at 4 a.m. and Oxycodone 15 mg was given at 4:11 a.m. A review of the facilities Black Box Warning (is the strictest and most serious type of warning that the FDA gives a medication. A black box warning is meant to draw attention to a medication's serious or life-threatening side effects or risks) indicated concomitant use of opioids with other CNS depressants, may result in profound sedation, respiratory depression, comma, and death. During an interview on 11/7/2023 at 12p.m., Resident 1 stated on 11/5/2023 around 4 a.m. Licensed Vocational Nurse 6 (LVN 6) refused to give her gabapentin and oxycodone. Resident 1 stated LVN 6 informed her that she could not give those two medications together due to it would cause an interaction. Resident 1 stated LVN 6 came in around 4 and gave her the gabapentin then around 4:15 gave her the oxycodone. During an interview on 11/9/2023 at 4:15 p.m. with LVN 6 stated she worked with Resident 1 on 11/5/2023 from 11 p.m. to 7 a.m. shift. LVN 6 stated she did initially refuse to give Resident 1 the gabapentin and oxycodone. LVN 6 stated she educated Resident 1 she could not give the medication because it would suppress her respiration. LVN 6 stated Resident 1 was heavily sedated she had to shake Resident 1 to wake her up, initially thought Resident 1 had passed away. LVN 6 stated she did give the oxycodone within 30 minutes after she gave the gabapentin. LVN 6 stated facility is giving into Resident 1 and are going to end up killing her. During a concurrent record review and interview on 11/7/2023, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) stated oxycodone has a black box warning indicating a black box warning with drugs that may cause CNS depression and gabapentin could be one. The ADON stated that the gabapentin was given at 4 a.m. and oxycodone was given at 4:11 a.m. The DON stated that was 11 minutes in between each medication it was given too close in between. The DON stated in this case possibility of CNS depressant, could have risked decrease of respiration, level of consciousness, and sedation. During an interview on 11/15/2023 at 2:36 p.m., the facility's Pharmacist Consultant (PC) stated only complaint for giving oxycodone with gabapentin is if the resident is dizzy, drowsy and or is having difficulty breathing. The PC stated if the resident is having these complaints can be a risk for further respiratory depression and sedation. A review of the facility ' s policies and procedures titled, Medication Administration, indicated medications are administered in accordance with the written orders of the attending physician.

CONCERN (E) 📢 Someone Reported This

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

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow menu for residents when: - Ninety (90) out of two hundred forty-seven (247) residents on soft mechanical chopped meats diet got of big pieces of chicken that measured one and a half inches (1 ½) to two (2) inches in size. - Ten (10) out of 247 residents on regular diet got 2 oz of chicken with rosemary sauce instead of 3 oz and 1 oz of boiled potatoes instead of 4 oz. These deficient practices had the potential to decreased nutritional value for carbohydrate, and protein content not consistent to the physician ' s diet order. Furthermore, soft mechanical chopped diet receiving 1 ½ to 2 of meat may result to difficulty eating, swallowing, and choking (blocked airway causing difficulty in breathing) which decreased food intake resulting to weight loss. Findings: During an interview with Resident 3 on 10/31/2023 at 10:23 AM, Resident 1 stated the menu was not accurate with what was written and what was served for type of food and portions. Resident 1 stated she received some type of macaroni and tomato sauce, a big red-hot dog, a little relish and mustard yesterday but did not know what it was exactly. Resident 3 stated, I didn ' t like the food. A review of Resident 3 ' s admission Record, dated 10/31/2023, indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of colon (cancer of the large intestines), diabetes mellitus (DM type 2, increase blood sugar) and essential hypertension (HTN, high blood pressure). A review of Resident 3 ' s Minimum Data Set (MDS – a standard assessment and care screening tool), dated 10/25/2023, indicated Resident 3 had moderately impaired cognition (ability to understand and make decisions), and able to eat with supervision. A review of Resident 3 ' s diet type report order by Physician, dated 8/8/2023 indicated Fortified (adding high kcal, high protein food items to the tray such as butter, milk, margarine, etc.) consistent carbohydrate (CCHO, diet that contain consistent carbohydrate amounts in each meal), regular texture with thin liquid consistency. During an interview with Resident 1 on 10/31/2023 at 10:38 AM, Resident 1 stated the menu was not followed regularly, portion sizes were usually not followed when trays were served. A review of Resident 1 ' s admission Record, dated 10/31/2023, indicated Resident 1 was initially admitted to the facility on [DATE] and then readmitted on [DATE] with diagnoses including malignant neoplasm of upper lobe, right bronchus or lung (a type of lung cancer that begins in the upper part of the right lung), chronic obstructive pulmonary disease (COPD, a lung disease characterized by persistent cough and progressive breathing) and unspecified protein-calorie malnutrition (a condition of insufficient intake of protein and calories resulting to weight loss, muscle loss and impaired growth and development). A review of Resident 1 ' s MDS, dated [DATE], indicated Resident 1 was cognitively intact (able to understand and make decisions), able to eat with limited assistance, and needed one-person physical assist when eating. A review of Resident 1 ' s diet type report order by Physician, dated 7/18/2023, indicated Fortified soft mechanical chopped meat (a diet including foods that are chopped to help residents having chewing and swallowing issues), regular thin liquid consistency. A review of facility ' s lunch menu (a list of available foods served for each resident), on 10/31/23, the following items will be served on regular diet: - Baked chicken 3 ounces (oz, a unit of measurement) - [NAME] Sauce 1-2 oz - Boiled red potatoes ½ cup (c) - Seasoned peas ½ c - Parsley garnish - Plain bread 1 piece (pc) - Margarine 1 teaspoon (1 tsp) - Ice Cream #12 scoops (3 oz) - Milk 4 oz A review of facility ' s lunch on 10/31/23, the following items will be served on soft mechanical chopped meats diet: - Chopped baked chicken 3 oz - [NAME] sauce 1-2 oz - Soft Boiled red potatoes 4 oz - Seasoned peas ½ c - Plain ice cream 3 oz During trayline (area used to plate food of the residents) observation, on 10/31/2023 at 12:18 AM, 10 trays received four (4) small pieces of boiled red potatoes, and one (1) small piece of chicken on regular diet trays. During a concurrent observation of the weight of the chicken and potatoes using a weighing scale and interview with the Dietary Supervisor (DS) on 10/31/2023 at 12:30 PM, chicken with rosemary sauce weighed 2 oz and potatoes weighed 1 oz. DS stated the chicken should be weighing 3 oz, rosemary sauce 1-2 oz and potatoes 4 oz which was not the correct portion for the residents. During a concurrent observation of the soft mechanical chopped trays and concurrent interview with the DS, on 10/31/2023 at 12:50 PM, [NAME] 1 chopped the chicken and used the tong to portion it. Chopped chicken measured 1 ½ to 2 in size. DS stated the portion size for soft mechanical chopped chicken was 3 oz and that [NAME] 1 estimated what was served to the resident ' s tray was not accurate. DS stated resident won ' t be meeting the nutrients they needed and will result to weight loss due to lesser calorie and protein served. DS stated [NAME] 1 should be using a scoop for accuracy instead of tong. During an observation of the resident ' s tray with soft mechanical chopped diet for Resident 4 on 10/31/2023 at 1:19 AM, Resident 4 tray was served 1.5 by 1.5 (1.5 x 1.5) cube chicken pieces. During an observation of the resident ' s tray with soft mechanical chopped diet for Resident 5 on 10/31/2023 at 1:20 AM, Resident 5 tray was served 2 x 2 cube chicken pieces. During the same observation of the resident ' s tray with soft mechanical chopped diet for Resident 6, Resident 6 tray was served 1.5 x 2 of long strips sliced chicken. During an observation of the resident ' s tray with soft mechanical chopped diet for Resident 7 on 10/31/2023 at 1:25 AM, Resident 7 tray was served 1.5 x 1.5 pieces of chicken. During an observation of the resident ' s tray with soft mechanical chopped diet for Resident 8 on 10/31/2023 at 1:30 AM, Resident 8 tray was served 1.5 x 1.5 cube chicken pieces and 2x2 long strips of sliced chicken. During the same observation of the resident ' s tray with soft mechanical chopped diet for Resident 9, Resident 9 was served 1.5x 1.5 of chicken pieces. During an interview with [NAME] 1 on 10/31/2023 at 2:05 PM, [NAME] 1 stated regular diet received 3 oz of baked chicken but does not know the portion size for soft mechanical diet. [NAME] 1 stated mechanical soft diet was chopped and that it should be cut to a bite sized but doesn ' t follow a measurement. [NAME] 1 stated that it is important to chop the meat because residents on soft mechanical chopped meat were at risk of chocking. During a test tray observation for soft mechanical diet conducted with the DS on 10/31/2023 at 2:05 PM, soft mechanical tray contained 1.5 x 1.5 and 2 x 2 of chicken portions. DS stated soft mechanical diet are for resident with having difficulty using their hands when they have arthritis, hand fracture and dentition problems (difficulty chewing). DS stated the guidance of meat sizes for soft mechanical diet is 1 or less as it becomes a safety issue if it was served bigger. DS stated possible outcome was the risk of residents [NAME] and won ' t be able to eat the food if portions are bigger than 1. During an interview with the DS on 11/1/2023 at 10:04 AM, DS stated soft mechanical diet was not properly chopped and portioned by [NAME] 1 yesterday. During an interview with [NAME] 1 on 11/1/2023 at 2:53 PM, [NAME] 1 stated the portion size for soft mechanical chopped chicken for yesterday ' s lunch was 3 oz. [NAME] 1 stated the DS told her about the portion sizes as well as the size of the meat should be 1 inch or less for soft mechanical chopped diet. [NAME] 1 stated resident were at risk for chocking if they were given bigger sizes of chicken. A review of facilities ' document titled, Addition to the Spreadsheet Regarding the Diet Order Chopped Meat, not dated and signed by the facility Registered Dietitian on 4/14/2020, indicated, Description: A diet may read regular with chopped meat or mechanical soft with chopped meat. In place of any whole meats the cook will chop the meat 1 inch or less in size unless otherwise specified for either diet. A review of facility ' s document titled, Regular Mechanical Soft Diet, dated 2020, indicated, DESCRIPTION: The Mechanical Soft diet is designed for residents who experienced chewing or swallowing limitations. The regular diet is modified in texture to a soft, chopped or ground consistency as per foods below. Foods Avoided for Meats, Poultry and Fish: Whole or chopped meat. Dry meat (chopped meat only allowed when ordered by Speech therapist). A review of the facilities ' document titled Recipe: Chicken with [NAME] Sauce not dated, indicated, Special Diets: Mechanical Soft Grind Chicken #10 scoop, serve with sauce. A review of the facilities ' Policies and Procedures (P&) titled Menu Planning dated 2020, indicated, (4) The menus are planned to meet nutritional needs of the residents in accordance with established nutritional guidelines, physician ' s orders and, to the extent medically possible.

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0804 (Tag F0804)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prepare food by methods that conserved flavor and appearance. In addition, food portions were not correct. This deficient practice placed two hundred one (201) of two hundred forty-seven (247) facility residents at risk of unplanned weight loss, a consequence of poor food intake. Findings: During an interview with Resident 1 on 10/31/2023 at 10:38 AM, Resident 1 stated the menu was not followed regularly, portion sizes were usually not followed when trays were served, and food lacked taste and seasoning. Resident 1 stated the menu sounds delicious in paper but it is not edible. Resident 1 stated, the kitchen served huge servings of starch like rice and pasta and fish was covered with large portions of breading. Vegetables such as green beans do not have any seasonings, zesty spinach was not zesty, and the tuna tasted like cardboard. Deli meats that they used in sandwiches were thin slices of meat and even the gasoline station sandwiches were better compared to what the kitchen served. Resident stated, What I eat is important and I am losing weight in the last month. A review of Resident 1 ' s admission Record, dated 10/31/2023, indicated Resident 1 was initially admitted to the facility on [DATE] and then readmitted on [DATE] with diagnoses including malignant neoplasm of upper lobe, right bronchus or lung (a type of lung cancer that begins in the upper part of the right lung), chronic obstructive pulmonary disease (COPD, a lung disease characterized by persistent cough and progressive breathing) and unspecified protein-calorie malnutrition (a condition of insufficient intake of protein and calories resulting to weight loss, muscle loss and impaired growth and development). A review of Resident 1 ' s Minimum Data Set (MDS – a standard assessment and care screening tool), dated 8/8/2023, indicated Resident 1 was cognitively intact (able to understand and make decisions), able to eat with limited assistance, and needed one-person physical assist when eating. A review of Resident 1 ' s diet type report order by Physician, dated 7/18/23, indicated Fortified Regular (adding high kcal, high protein food items to the tray such as butter, milk, margarine, etc), soft mechanical chopped meat (a diet including foods that are chopped to help residents having chewing issues), regular thin liquid consistency. A review of the facility ' s fall menu spreadsheets dated 10/31/2023, indicated regular diet included the following food items on the tray: Baked chicken 3 ounces (oz, unit of measurement) Rosemary Sauce 1-2 oz Boiled Red Potatoes ½ cup (c) Seasoned Peas ½ c Parsley garnish Plain Bread 1 pc Margarine 1 teaspoon (tsp) Ice cream 3 oz Milk 4 oz During trayline (an area for food assembly) service in the kitchen observation on 10/31/2023 at 12:18 PM, kitchen staff started dishing resident food from the steam table (a kitchen equipment used to keep food hot at the proper temperature) to the resident plates. Boiled red potatoes looked mushy and portion sizes were 3 to 4 pcs small pieces of potatoes. Chicken portion size is 1 pc small chicken. Kitchen staff were using the following in portioning food items: - Tong (an instrument with two movable arms that are joined together at one end, used to picking p and holding food) to portion chicken. - 2 oz ladle to portion rosemary sauce, - 4 oz perforated spoodle (a serving spoon to aid with draining excess liquid from food) to portion boiled red potatoes. During a concurrent observation of weighting of the food on the tray and interview with the Dietary Supervisor (DS) on 10/31/2023 at 12: 30 PM, chicken with rosemary sauce weighed a total of 2 oz, boiled potatoes weighed 1 oz. DS sated the chicken was lacking 1 oz in portion or more and potatoes were missing 3 oz more. During an interview with the DS on 10/31/2023 at 12:50 PM, DS stated that the cool was not using a scoop to portion the chicken and was estimating the amount to put on the tray. DSS stated some trays received small portions of chicken than 3oz which means residents got less protein on their tray. DS stated the resident would not be meeting the nutrients they needed and may cause weight loss. During a test tray conducted with on 10/31/2023 at 2:05 PM for regular diet, DS stated that the presentation of the food does not look appetizing because the sliced bread was on top of the food touching all the main food such as chicken, rosemary sauce, potatoes, and seasoned peas. DS stated the chicken breast was tough, dry and boiled potatoes were bland and needed a little bit seasoning. DS stated bread should be individually packed and served on the side and food should be garnished. DS stated when chicken was dry and tough, it will be hard to chew causing resident not to eat the food causing unintentional weight loss. During an interview with [NAME] 1 on 11/1/2023 at 2:53 PM, [NAME] 1 stated that she got training about scoops sizes, portions, diets and always following standardized recipes. [NAME] 1 stated she followed the recipe for boiled potatoes and seasoned it however she did not season it with parsley and used a little bit of margarine instead. [NAME] 1 stated not following the recipes will result in a different taste and resident wont like it as it wont taste the same and wont be tasty. [NAME] 1 stated, residents might lose weight if they don ' t like the food. [NAME] 1 also stated that using a tong is not appropriate in measuring the chicken and it was hard to gauge if residents were getting what they are supposed to be getting. [NAME] 1 stated if residents received more chicken, it could cause unplanned weight gain and if residents received less chicken, it could cause unplanned weight loss. [NAME] 1 stated, she needed to use the right scoop sizes in trayline. A record review of the facility ' s recipe titled, Recipe: Boiled or Steamed Potatoes not dated, indicated Portion size: ½ cup ingredients: red or white potatoes, boiling water, margarine, parsley, minced. A record review of the facility ' s policies and procedures (P&P) titled, Food Preparation, dated 2018, indicated, Policy: Food shall be prepared by methods that conserve nutritive value, flavor and appearance. Procedure: (1) The facility will use approved recipes, standardized to meet the resident census. This count is to be kept current so that an accurate amount of food is prepared. (2) Recipes are specific to portion yield, method of preparation, amounts of ingredients, and time and temperature guide. (4) Poorly prepared food will not be served. Such food is to either be improved, prepared again, or replaced with an appropriate substitution. May add increased amounts of herbs and spices (not salt) since potency of products may vary. A record review of the facility ' s policies and procedures titled, Recipe: Menu Planning, dated 2018, indicated, To meet recommended daily dietary allowances. Protein Group: serve two or more servings everyday to equal at least 6 oz of cooked meat or the equivalent. One serving is three (3) ounces of cooked meat, fish, or poultry without bone or fat. All kinds of meat, fish, and poultry, eggs, dried beans or peas, lentils, and peanut butter are included in this group.

Nov 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) was free from physical abuse inflicted by Resident 3. On 10/25/2023 at 3:05 p.m., Resident 3 grabbed the back collar of Resident 2 ' s shirt and pushed her away from Resident 3 ' s door. This deficient practice resulted to Resident 2 being subjected to physical abuse while under the care of the facility. Findings: 1. A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 6/27/2023 with diagnoses that included complete atrioventricular block (an abnormal heart rhythm that happens when the electrical impulses that control your heartbeat are delayed or blocked), encephalopathy (damage or disease that affects the brain leaving you confused and not acting like you usually do) and altered mental status (an abnormal state of alertness or awareness). A review of Resident 2 ' s History and Physical (H&P), dated 6/30/2023, indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/3/2023, indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 2 required maximum assistance from staff for activities of daily living (ADL-personal hygiene and bed mobility). Resident 2 was able to wheel herself using a manual wheelchair for mobility. A review of Resident 2 ' s Situation Background Assessment and Recommendation Communication Form (SBAR-form that provides communication between members of the health care team), dated 10/25/2023, indicated Resident 2 was blocking Resident 3 ' s doorway and Resident 3 asked Resident 2 to move but she did not move away from the door. The SBAR indicated Resident 3 grabbed Resident 2 ' s sweater and pushed Resident 2 away. A review of Resident 2 ' s Progress Note, dated 10/25/2023 at 3:36 p.m., documented by the Social Service Director (SSD) indicated a resident-to-resident altercation. The Progress Note indicated Resident 3 shook and hit Resident 2 in the right arm. A review of Resident 2 ' s written interview conducted by the Social Service Assistant (SSA), dated 10/25/2023 at 3:15 p.m., indicated Resident 2 reported that Resident 3 attacked her and that she did not feel safe next to Resident 3. A review of Resident 2 ' s Interdisciplinary Team (IDT - a health care team that works together to ensure that residents' healthcare needs are addressed and met in a time-efficient manner) Investigation Summary, dated 10/27/2023, indicated on 10/25/2023 at 2:10 p.m., Resident 3 grabbed Resident 2 ' s shirt and with another hand pushed her away as witnessed by Certified Nursing Assistant 1 (CNA 1) and CNA 2. 2. A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 8/31/2023 with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), cerebrovascular disease (also referred to stroke or a brain attack, is an interruption in the flow of blood to cells in the brain) and schizophrenia (a serious brain disorder that causes people to interpret reality abnormally). A review of Resident 3 ' s H&P, dated 8/31/2023, indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 3 ' s MDS, dated [DATE], indicated resident ' s cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 3 required supervision from staff for activities of daily living (ADL- bed mobility, walking and eating). During an interview on 11/1/2023 at 8:54 a.m., CNA 1 stated on 10/25/2023 before 3 p.m., she was in Nurses Station 3 when she saw Resident 3 standing in front of her room facing the hallway and Resident 2 seated on the wheelchair with her back turned away and blocking Resident 3 ' s room. CNA 1 stated she witnessed the two residents talking until Resident 3 leaned forward and grabbed the back collar of Resident 2 ' s shirt and pushed Resident 2 away. CNA 1 stated not respecting personal space and grabbing someone ' s collar without their permission would be an abuse. During an interview on 11/1/2023 at 9:29 a.m., Registered Nurse 1 (RN 1) stated LVN 1 reported that Resident 3 wanted to go out of her room but Resident 2 was seated in front of her door. RN 1 stated Resident 3 tried to tell Resident 2 to move but she did not, causing her to get mad and pulled the collar of Resident 2 ' s shirt. RN 1 stated it is not ok when someone grabs a collar without permission as it is abuse. RN 1 stated she assessed both residents for injury but did not document her assessment in their medical records. During an interview on 11/1/2023 at 9:52 a.m. the SSD stated on 10/25/2023 at 3:05 p.m., CNA 2 reported to her that Resident 2 and Resident 3 had exchange of words and Resident 3 shook Resident 2 ' s shirt and punched her in the arm. SSD stated residents have the right to be free from abuse. SSD stated they were not able to protect Resident 2 from abuse inflicted by Resident 3 when she punched her in the arm and shook her. During an interview on 11/1/2023 at 10:19 a.m., the Assistant Director of Nursing (ADON) stated residents have the right to be free from abuse. A review of facility ' s policy and procedure titled, Abuse and Neglect-Clinical Protocol, dated 3/2018 and reviewed on 12/28/2022 indicated, Abuse is defined at S483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful as defined at S483.5 and as used in the definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure that licensed nurses followed the physician's order for one of three sampled residents (Resident 1) by: 1. Failing to ensure resident was given propranolol (medication used to treat high blood pressure) despite physician ' s order to hold medication if systolic blood pressure (sbp- pressure in the arteries when the heart beats) was below 110 millimeters of mercury (mmHg- unit of measurement) as indicated in residents 10/2023 Medication Administration Record (MAR- record of medications received by the resident). 2. Failing to ensure resident was given amlodipine (medication used to treat high blood pressure) despite physician ' s order to hold medication if sbp was below 110 as indicated in residents 10/2023 MAR. These deficient practices can potentially lower Resident 1's blood pressure. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 3/10/2018 with diagnoses that included cerebral infarction (when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen), Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), dementia (the loss of cognitive functioning [thinking, remembering, and reasoning] that interferes with a person's daily life and activities), and hypertension (uncontrolled elevated blood pressure). A review of Resident 1 ' s History and Physical, dated 3/30/2022, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 9/20/2023, indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 1 required extensive assistance from staff for all activities of daily living (ADL-personal hygiene, bed mobility, dressing, and transfers). A review of Resident 1 ' s Physician Order, dated 3/10/2018, indicated an order for propranolol (medication used to treat high blood pressure) 20 milligrams (mg-unit of measurement), one tablet by mouth two times a day for hypertension and hold (do not give) if systolic blood pressure (sbp-measures the pressure in your arteries when your heart beats) is less than 110 or heart rate less than 60. A review of Resident 1 ' s Care Plan on compromised cardiac function (heart condition that affects the heart's ability to pump a sufficient amount of blood to the rest of the body) related to hypertension, dated 5/7/2021 and revised on 12/27/2022, indicated an intervention to medicate as ordered. During a concurrent interview and record review on 11/1/2023 at 10:19 a.m., with the Assistant Director of Nursing (ADON), Resident 1 ' s Medication Administration Record (MAR- record of medications received by the resident) dated 10/15/2023 was reviewed. The MAR indicated on 10/15/2023 at 5 p.m., Licensed Vocational Nurse 4 (LVN 4) gave propranolol to Resident 1 with a blood pressure of 93/55. The ADON stated LVN 4 should held the medication following the physician order. The ADON stated Resident 1's blood pressure can further drop as a result. b. A review of Resident 1 ' s Physicians Order, dated 9/17/2021, indicated an order for amlodipine besylate five mg tablet by mouth at bedtime for hypertension and hold if sbp is less than 110 or heart rate less than 60. During a concurrent interview and record review on 11/1/2023 at 10:19 a.m., with the ADON, Resident 1 ' s MAR dated 10/15/2023 was reviewed. The MAR indicated on 10/15/2023 at 9 p.m., resident received amlodipine with a blood pressure of 103/65. The ADON stated LVN 4 should held the medication following the physician order. The ADON stated residents blood pressure can cause hypotension (low blood pressure). A review of facility ' s policy and procedure titled, Administering Oral Medications, dated 10/2010 and reviewed on 12/28/2022, indicated, Verify that there is a physicians medication order for this procedure.

CONCERN (E) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for three of three sampled residents (Resident 1, Resident 2, and Resident 3) by: 1. Facility failed to ensure Registered Nurse 1 (RN 1) documented head to toe body assessment after Resident 3 grabbed the back collar and pushed Resident 2 while seated on a wheelchair away from Resident 3 ' s door on 10/25/2023. 2. Facility failed to ensure RN 1 documented administration of amlodipine (medication used to treat high blood pressure) accurately and per physician ' s order for Resident 1 on 10/2023 Medication Administration Record (MAR-record of medications received by the resident). 3. Facility failed to ensure RN 1 documented administration of Lipitor (medication used to lower cholesterol and triglyceride [fat] levels in the blood) on Resident 3 ' s 10/2023 MAR. These deficient practices resulted to inaccurate information entered into residents ' medical records and may potentially cause medication error. Findings: a. A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 6/27/2023 with diagnoses that included complete atrioventricular block (an abnormal heart rhythm that happens when the electrical impulses that control your heartbeat are delayed or blocked), encephalopathy (damage or disease that affects the brain leaving you confused and not acting like you usually do) and altered mental status (an abnormal state of alertness or awareness). A review of Resident 2 ' s History and Physical (H&P) dated 6/30/2023 indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 2 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 10/3/2023, indicated resident ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were severely impaired. The MDS indicated Resident 2 required maximum assistance from staff for activities of daily living (ADL-personal hygiene and bed mobility). Resident 2 was able to wheel herself using a manual wheelchair for mobility. A review of Resident 2 ' s Situation Background Assessment and Recommendation Communication Form (SBAR-form that provides communication between members of the health care team), dated 10/25/2023, indicated Resident 2 was blocking Resident 3 ' s doorway and Resident 3 asked Resident 2 to move but did not move away from the door. The SBAR indicated Resident 3 grabbed Resident 2 ' s sweater and pushed Resident 2 away. A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 8/31/2023 with diagnoses that included dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), cerebrovascular disease (also referred to stroke or a brain attack, is an interruption in the flow of blood to cells in the brain) and schizophrenia (a serious brain disorder that causes people to interpret reality abnormally). A review of Resident 3 ' s H&P, dated 8/31/2023, indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 3 ' s MDS, dated [DATE], indicated resident ' s cognitive skills for daily decisions were moderately impaired. The MDS indicated Resident 3 required supervision from staff for ADL (bed mobility, walking and eating). During an interview on 11/1/2023 at 9:29 a.m., Registered Nurse 1 (RN 1) stated LVN 1 reported that Resident 3 wanted to go out of her room but Resident 2 was seated in front of her door. RN 1 stated Resident 3 tried to tell Resident 2 to move but she did not cause her to get mad and pulled the collar of Resident 2 ' s shirt. RN 1 stated she assessed Resident 2 for injury but did not document her head-to-toe assessment in her medical records. RN 1 stated if it was not documented, it was not done. During an interview on 11/1/2023 at 9:41 a.m., the Assistant Director of Nursing (ADON) stated RN 1 should have documented her head to toe assessment in Resident 2 ' s medical record. ADON stated assessment can only be done by RN. A review of facility ' s policy and procedure titled, Abuse and Neglect-Clinical Protocol, dated 3/2018 and reviewed on 12/28/2022, indicated, The nurse will assess the individual and document related findings. b. A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 3/10/2018 with diagnoses that included cerebral infarction (when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen), Alzheimer ' s disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks) and hypertension (uncontrolled elevated blood pressure). A review of Resident 1 ' s H&P, dated 3/30/2022, indicated the resident did not have the capacity to understand and make decisions. A review of Resident 1 ' s MDS, dated [DATE], indicated resident ' s cognitive skills for daily decisions were severely impaired. The MDS indicated Resident 1 required extensive assistance from staff for ADL (personal hygiene, bed mobility, dressing, and transfers). A review of Resident 1 ' s Physicians Order, dated 9/17/2021, indicated an order for amlodipine besylate five milligram (mg-unit of measurement) tablet by mouth at bedtime for hypertension and hold (do not give) if systolic blood pressure (sbp-measures the pressure in your arteries when your heart beats) is less than 110 or heart rate less than 60. A concurrent interview and record review on 11/1/2023 at 10:19 a.m., with the ADON, Resident 1 ' s Medication Administration Record (MAR- record of medications received by the resident) dated 10/2023 was reviewed. The MAR indicated amlodipine was given at 9 p.m. on the following dates: 10/3/2023 with blood pressure (bp)- 102/60 millimeters of mercury (mmHg - unit of measurement for blood pressure) 10/4/2023 with bp- 100/60 mmHg 10/5/2023 with bp- 107/66 mmHg The ADON stated LVN 2 should held the medication as per physician ' s order to prevent hypotension (low bp) and document the reason why it was not given in resident progress note. During an interview on 11/1/2023 at 3:17 p.m., LVN 2 stated she did not give amlodipine to Resident 1 on 10/3/2023, 10/4/2023 and 10/5/2023 at 9 p.m., because residents blood pressure was low. LVN 2 stated she should have documented in the resident ' s Progress notes that she held the medications. c. A review of Resident 3 ' s Order Summary Report, dated 8/31/2023, indicated an order for Lipitor (medication used to lower cholesterol and triglyceride [fats] levels in the blood) 40 mg by mouth at bedtime for cholesterol (a type of fat found in your blood). During a concurrent interview and record review on 11/1/2023 at 10:19 with the ADON, Resident 3 ' s MAR dated 10/2023 was reviewed. The MAR indicated Lipitor was blank on 10/15/2023 and 10/22/2023 at 9 p.m. The ADON stated LVN 3 should document if medication were given for resident ' s accurate medical record. During an interview on 11/1/2023 at 4:11 p.m., LVN 3 stated she gave the medication but forgot to document. LVN 3 stated she should document administration of medication to prevent medication error. A review of facility ' s policy and procedure titled, Documentation of Medication Administration, dated 11/2022, indicated A nurse or certified medication aide (where applicable) documents all medications administered to each residents on the resident medication administration record (MAR). Administration of medication is documented immediately after it is given.

Oct 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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Based on interview and record review the facility failed to inform the resident ' s responsible party when the resident had laboratory results with out of range values for one of six sampled residents (Resident 1). This deficient practice violated the resident ' s rights and/or the representative ' s right to be fully informed of Resident 1 ' s change of condition. Findings A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 3/14/2012 ,with diagnoses including encounter for attention to gastrostomy (a feeding tube surgically inserted on the abdomen directly to stomach to provide nutritional needs), type ll diabetes mellitus (characterized by having high amounts of sugar in the blood), and Alzheimer ' s disease (brain disorder that worsens over time causing memory loss and mental decline). A review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and screening tool), dated 9/12/2023, indicated Resident 1 was severely impaired with thought process and decision-making tasks. The MDS indicated Resident 1 required total dependence from staff for transfers (moving from bed to chair), dressing, eating, toilet use (how resident uses toilet room, cleansing after elimination), and personal hygiene. On 10/19/2023 at 11:25 a.m., during a concurrent interview and record review with Registered Nurse 1 (RN 1), Resident 1' medical records including laboratory results were reviewed. RN 1 stated Resident 1 ' s blood samples were collected by the laboratory on 10/7/2023 at 7:01 a.m. and the facility received the blood results on the same day (10/7/2023) at 12:28 p.m. The laboratory results indicated: -White blood count ([WBC-reference range of 4.0 – 10.5 thous/mc] blood sample used in monitoring for possible infection) was 14.9 thousand/microliter ([thous/mcl] unit of measure). -Blood Urea Nitrogen ([BUN- reference range of 7 -25 mg/dl] laboratory result to indicate how effective body organs are removing waste and extra water from the body) was 154 milligrams/deciliter ([mg/dl] unit of measure). RN 1 stated on 10/17/2023 at 7 p.m., Resident 1 had a change in condition (COC) and the physician was notified of the COC and the resident's laboratory test results. RN 1 further stated the physician ordered Resident 1 to be transferred to the nearest General Acute Care Hospital (GACH) via 911 emergency response for further evaluation of Altered level of consciousness (change in condition from baseline). On 10/19/2023 at 12:50 p.m., during an interview with Registered Nurse 2 (RN 2), RN 2 stated laboratory results that were out of range should have been reported to Resident 1's responsible party (RP) so the RP can make informed decisions regarding treatment. RN 2 stated there was no documented evidence that Resident 1's responsible party was notified of the laboratory results received on 10/7/2023 at 12:28 p.m. A review of the facility policy titled, Change in Resident ' s Condition or Status, with last revised date of 2/2021, indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident ' s medical/mental condition and/or status. The policy also stated that a Significant change of condition is a major decline or improvement in the resident ' s status that: will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions.

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 F0773 (Tag F0773)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to promptly notify the resident's physician of laboratory results that fall outside of clincal reference ranges for one of six sampled residents (Resident 1). This deficient practice had the potential for a delay in treatment and delivery of care and services for Resident 1. Findings: A review of Resident 1 ' s admission Record indicated the facility admited the resident on 3/14/2012 with diagnoses including encounter for attention to gastrostomy (a feeding tube surgically inserted on the abdomen directly to stomach to provide nutritional needs), type ll diabetes mellitus (characterized by having high amounts of sugar in the blood), and Alzheimer ' s disease (brain disorder that worsens over time causing memory loss and mental decline). A review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and screening tool), dated 9/12/2023, indicated Resident 1 was severely impaired with thought process and decision-making tasks. The MDS indicated Resident 1 required total dependence from staff for transfers (moving from bed to chair), dressing, eating, toilet use (how resident uses toilet room, cleansing after elimination), and personal hygiene. On 10/19/2023 at 11:25 a.m., during a concurrent interview and record review with Registered Nurse 1 (RN 1), Resident 1' medical records including laboratory results were reviewed. RN 1 stated Resident 1 ' s blood samples were collected by the laboratory on 10/7/2023 at 7:01 a.m. and the facility received the blood results on the same day (10/7/2023) at 12:28 p.m. The laboratory results indicated: -White blood count ([WBC-reference range of 4.0 - 10.5 thous/mc] blood sample used in monitoring for possible infection) was 14.9 thousand/microliter ([thous/mcl] unit of measure). -Blood Urea Nitrogen ([BUN- reference range of 7 -25 mg/dl] laboratory result to indicate how effective body organs are removing waste and extra water from the body) was 154 milligrams/deciliter ([mg/dl] unit of measure). RN 1 stated on 10/17/2023 at 7 p.m., Resident 1 had a change in condition (COC) and the physician was notified of the COC and the resident's laboratory test results. RN 1 further stated the physician ordered Resident 1 to be transferred to the nearest General Acute Care Hospital (GACH) via 911 emergency response for further evaluation of Altered level of consciousness (change in condition from baseline). On 10/19/2023 at 12:43 p.m., during an interview, Licensed Vocational Nurse (LVN 1) stated that notifying the physician of residents' laboratory results is the responsibility of all licensed lnurses. LVN 1 stated it is important to report residents' laboratory results to the physician so that the physician is aware of any abnormal laboratory results and to discuss any symptoms (physical signs or features that indicate condition or disease) that the resident may be having related to change in condition. On 10/19/2023 at 12:50 p.m., during an interview, Registered Nurse 2 (RN 2) stated laboratory results that are out of range should be reported to the physician. RN 2 stated there was no documented evidence that Resident 1's physician was notified of the laboratory results received on 10/7/2023 at 12:28 p.m. A review of the facility policy and procedure titled, Lab and Diagnostic Test Results - Clinical Protocol, with last revision date 9/2012 stated, The person who is to communicate results to a physician will review and be prepared to discuss the following (to the extent that such information is available): a. The individual ' s current condition and any recent changes in status, including vital signs and mental status. d. How test results might relate to the individual ' s current status, treatments, or medications; and e. Any concerns or issues the physician will be expected to address upon receiving the results. A review of the facility policy titled, Change in Resident ' s Condition or Status, with last revised date of 2/2021, indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident ' s medical/mental condition and/or status. The policy also stated that a Significant change of condition is a major decline or improvement in the resident ' s status that: will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. Based on interview and record review, the facility failed to promptly notify the resident's physician of laboratory results that fall outside of clincal reference ranges for one of six sampled residents (Resident 1). This deficient practice had the potential for a delay in treatment and delivery of care and services for Resident 1. Findings: A review of Resident 1's admission Record indicated the facility admited the resident on 3/14/2012 with diagnoses including encounter for attention to gastrostomy (a feeding tube surgically inserted on the abdomen directly to stomach to provide nutritional needs), type ll diabetes mellitus (characterized by having high amounts of sugar in the blood), and Alzheimer's disease (brain disorder that worsens over time causing memory loss and mental decline). A review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and screening tool), dated 9/12/2023, indicated Resident 1 was severely impaired with thought process and decision-making tasks. The MDS indicated Resident 1 required total dependence from staff for transfers (moving from bed to chair), dressing, eating, toilet use (how resident uses toilet room, cleansing after elimination), and personal hygiene. On 10/19/2023 at 11:25 a.m., during a concurrent interview and record review with Registered Nurse 1 (RN 1), Resident 1' medical records including laboratory results were reviewed. RN 1 stated Resident 1's blood samples were collected by the laboratory on 10/7/2023 at 7:01 a.m. and the facility received the blood results on the same day (10/7/2023) at 12:28 p.m. The laboratory results indicated: -White blood count ([WBC-reference range of 4.0 – 10.5 thous/mc] blood sample used in monitoring for possible infection) was 14.9 thousand/microliter ([thous/mcl] unit of measure). -Blood Urea Nitrogen ([BUN- reference range of 7 -25 mg/dl] laboratory result to indicate how effective body organs are removing waste and extra water from the body) was 154 milligrams/deciliter ([mg/dl] unit of measure). RN 1 stated on 10/17/2023 at 7 p.m., Resident 1 had a change in condition (COC) and the physician was notified of the COC and the resident's laboratory test results. RN 1 further stated the physician ordered Resident 1 to be transferred to the nearest General Acute Care Hospital (GACH) via 911 emergency response for further evaluation of Altered level of consciousness (change in condition from baseline). On 10/19/2023 at 12:43 p.m., during an interview, Licensed Vocational Nurse (LVN 1) stated that notifying the physician of residents' laboratory results is the responsibility of all licensed lnurses. LVN 1 stated it is important to report residents' laboratory results to the physician so that the physician is aware of any abnormal laboratory results and to discuss any symptoms (physical signs or features that indicate condition or disease) that the resident may be having related to change in condition. On 10/19/2023 at 12:50 p.m., during an interview, Registered Nurse 2 (RN 2) stated laboratory results that are out of range should be reported to the physician. RN 2 stated there was no documented evidence that Resident 1's physician was notified of the laboratory results received on 10/7/2023 at 12:28 p.m. A review of the facility policy and procedure titled, Lab and Diagnostic Test Results – Clinical Protocol, with last revision date 9/2012 stated, The person who is to communicate results to a physician will review and be prepared to discuss the following (to the extent that such information is available): a. The individual's current condition and any recent changes in status, including vital signs and mental status. d. How test results might relate to the individual's current status, treatments, or medications; and e. Any concerns or issues the physician will be expected to address upon receiving the results. A review of the facility policy titled, Change in Resident's Condition or Status, with last revised date of 2/2021, indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The policy also stated that a Significant change of condition is a major decline or improvement in the resident's status that: will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions.

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 F0885 (Tag F0885)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to notify residents, resident ' s representatives, and families of suspected or confirmed COVID-19 (a viral infection, highly contagious, that easily transmits from person to person, causing respiratory problems and may cause death) cases in the facility along with mitigating actions in a timely manner. This deficient practice resulted in residents, their representatives, and their families not receiving notifications regarding the status and impact of COVID-19 in the facility. Findings: During an interview on 10/30/2023 at 4:15 p.m., with the Infection Preventionist Nurse (IPN), the IPN stated that on 10/15/2023, Registered Nurse 3 (RN 3) tested positive for COVID-19. The IPN stated that it is the Social Services staff responsibility to notify residents and resident representatives (RP) via telephone or email regarding COVID-19 cases in the facility. During an interview on 10/30/2023 at 4:21 p.m., with the Social Services (SS) staff, the SS staff stated that she is unable to provide documentation of the notification to all residents, residents representatives (RP) and family members (FM) regarding COVID-19 cases in the facility on 10/15/2023 through 10/30/2023. The SS staff stated that residents and RP should be notified of COVID -19 cases in the facility as soon as possible via telephone or email. A review of facility ' s undated policy and procedure titled COVID-19 Mitigation plan indicated that the facility will report any positive tests in accordance with current Local Health Departments (LHD) and California Department of Public Health (CDPH) guidance.

Oct 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to provide an odor free and sanitary environment for one of three sampled residents (Resident 1). This deficient practice placed Resident 1 at risk for increased level of discomfort and had the potential to negatively impact the resident's quality of life. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 12/31/2022 with diagnoses that included diabetes mellitus (uncontrolled elevated blood sugar), encephalopathy (any disturbance of the brain's functioning that leads to problems like confusion and memory loss), methicillin resistant staphylococcus aureus (MRSA- a type of bacteria that is resistant to several antibiotics [medication used to treat infection]), and respiratory failure (condition in which not enough oxygen passes the lungs into the blood). A review of Resident 1's History and Physical, dated 5/18/23, indicated the resident had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 10/3/2023, indicated resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 1 required maximum assistance from staff for toileting and personal hygiene. During an observation on 10/17/2023 at 8 a.m., Resident 1's door was closed with enhanced precaution (an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO-a germ that is resistant to many antibiotics] in nursing homes) signage posted by the door. Resident 1's window was closed with construction ongoing outside in the patio. Resident 1's bathroom when opened, had a strong musty smell. Observed an opened dry wall with visible stained pipes behind the toilet. During an interview on 10/17/2023 at 8:03 a.m., Resident 1 stated he cannot stand the smell when he opens the bathroom, Resident 1 stated the bathroom smelled like molds and he cannot open his window for the smell to come out because of the dust outside from the construction. Resident 1 stated he told Licensed Vocational Nurse 1 (LVN 1) on 10/10/2023 to move him out of the room, but nothing happened. Resident 1 stated he felt ignored and nobody had checked on him. During an interview on 10/17/2023 at 10:25 a.m., LVN 1 stated Resident 1's room smelled terrible like its wet and rotten. LVN 1 stated Resident 1 reported to her on 10/12/2023 and she had notified the Social Service Director (SSD) and Registered Nurse 1 (RN 1) of his request to move out of the room due to the smell. LVN 1 stated she wore a mask and yet she can still smell the bad odor. LVN 1 stated the smell can affect the residents breathing and he cannot open the window for ventilation (movement of air into, out of, or within a room) because of the dust from the construction outside. During an interview on 10/17/2023 at 10:44 a.m., the Assistant Administrator (AADM) stated on 10/11/2023 he was informed during a stand-up meeting (were regularly held gatherings which team members share status reports on their work) about Resident 1's room to check for molds and wet spot on the dry wall. The AADM stated he forgot to follow up. The AADM stated Resident 1 had been in that room since 10/10/2023. During an interview on 10/17/2023 at 10:56 a.m., the Assistant Director of Nursing (ADON) stated she was not aware of Resident 1's concern. The AADON stated if she had been informed, she could have made arrangement for room change. The AADON stated mold like smell can cause respiratory issues. A review of facility provided policy and procedure titled, Maintenance and Plant Operations, dated 10/31/1991 and reviewed on 7/28/2022 indicated, This facility shall properly maintain and service the heating, cooling and ventilation systems so as to ensure a comfortable environment for residents as free as possible of air pollutants and odors. This facility shall maintain in good repair at all times all interior surfaces, fixtures, emergency and fire systems, equipment's, appliances and furnishing to provide a safe, clean, and comfortable environment for residents. Be familiar with the needs and special problems of residents in a long-term care 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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure prompt attempts were made to resolve the grievance (an official statement of a complaint over something believed to be wrong or unfair) for one of three sampled residents (Resident 1). This deficient practice violated Resident 1's right to have his grievance addressed. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 12/31/2022 with diagnoses that included diabetes mellitus (uncontrolled elevated blood sugar), encephalopathy (any disturbance of the brain's functioning that leads to problems like confusion and memory loss), methicillin resistant staphylococcus aureus (MRSA- a type of bacteria that is resistant to several antibiotics [medication used to treat infection]), and respiratory failure (condition in which not enough oxygen passes the lungs into the blood). A review of Resident 1's History and Physical, dated 5/18/23, indicated the resident had capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 10/3/2023, indicated resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 1 required maximum assistance from staff for toileting and personal hygiene. During an observation on 10/17/2023 at 8 a.m., Resident 1's door was closed with enhanced precaution (an infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDRO-a germ that is resistant to many antibiotics] in nursing homes) signage posted by the door. Resident 1's window was closed with construction ongoing outside in the patio. Resident 1's bathroom when opened, had a strong musty smell. Observed an opened dry wall with visible stained pipes behind the toilet. During an interview on 10/17/2023 at 8:03 a.m., Resident 1 stated he cannot stand the smell when he opens the bathroom. Resident 1 stated the bathroom smelled like molds and he cannot open his window for the smell to come out because of the dust outside from the construction. Resident 1 stated he told Licensed Vocational Nurse 1 (LVN 1) on 10/10/2023 to move him out of the room, but nothing happened. Resident 1 stated he felt ignored and nobody had checked on him. Resident 1 stated he does not know what grievance (an official statement of a complaint over something believed to be wrong or unfair) is for. During an interview on 10/17/2023 at 10:25 a.m., LVN 1 stated Resident 1's room smelled terrible like its wet and rotten. LVN 1 stated resident reported to her on 10/12/2023 and she had notified the Social Service Director (SSD) and Registered Nurse 1 (RN 1) of his request to move out of the room due to the bad smell. LVN 1 stated she wore a mask and yet she can still smell the bad odor. LVN 1 stated the smell can affect the residents breathing and he cannot open the window for ventilation (movement of air into, out of, or within a room) because of the dust from the construction outside. During an interview on 10/17/2023 at 10:39 a.m., Social Service Assistant (SSA) stated she was not informed of Resident 1's room issues. SSA stated she was not sure if any grievance was filed about the resident's concern. SSA stated Social Service Director (SSD) no longer works at the facility since 10/13/2023. SSA stated SSD should have filed a grievance so residents concerns can be resolve or at least made an attempt for room change. During an interview on 10/17/2023 at 10:44 a.m., the Assistant Administrator (AADM) stated on 10/11/2023 he was informed during a stand-up meeting (are regularly held gatherings which team members share status reports on their work) about Resident 1's room to check for molds and wet spot on the dry wall. The AADM stated he forgot to follow up. The AADM stated the resident had been in that room since 10/10/2023. During an interview on 10/17/2023 at 10:56 a.m., the Assistant Director of Nursing (ADON) stated she was not aware of Resident 1's concern. The AADON stated if she had been informed, she could have made arrangement for room change. The AADON stated mold like smell can cause respiratory issues. A review of facility's Grievance Log dated 10/2023 indicated no entry of Resident 1's concern from 10/10/2023 to 10/12/2023. A review of facility provided policy and procedure titled, Social Service Policy and Procedure-Grievances, reviewed on 7/28/2022, indicated A grievance may be filed orally or in writing; a grievance can be filed without the form, as well as anonymously, but staff will document for the purposes of Continuous Quality Improvement (CQI) reporting. Residents who need assistance to complete the form will be assisted without influence or bias. The facility will make prompt effort to resolve grievance and keep a log of those resolutions. The facility will actively seek a resolution and keep the resident appropriately apprised of its progress toward a resolution. Corrective action will be taken promptly after filing the report.

Oct 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on interview and record review the facility failed to ensure the resident 's safety for one out of three sampled residents (Resident 1) by failing to provide transportation to a medical appointment. The facility staff transported Resident 1 via wheel chair to the local General Acute Care Hospital (GACH 1). This deficient practice placed the resident at risk for injuries resulting from an accident. A review of Resident 1 ' s admission Records indicated the facility admitted the resident on 9/1/2023 with diagnosis that included sepsis (the body's extreme response to an infection) unspecified organism, type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high) with other diabetic kidney complications, and acquired absence of left leg below knee. A review of Resident 1 ' s Minimum Data Set (MDS – a standardized assessment and care screening tool), dated 9/7/2023 had the ability to understand and be understood. The MDS indicated Resident 1 required extensive assistance with bed mobility, toilet use and personal hygiene and was totally dependent on transfer, and locomotion on and off the unit. A review of Resident 1 ' s physician orders dated 9/12/2023 indicated the following orders: -Ceftriaxone 1 gm intravenous one time a day for osteomyelitis (an infection in a bone) for 4 weeks. -Daptomycin 700 milligrams (mg-a unit of measurement) intravenous one time a day for osteomyelitis for 4 weeks. A review of Resident 1 ' s physician orders dated 9/14/2023 indicated an order for PICC line insertion scheduled for 9/18/2023 at 8 a.m. at GACH 1. A review of Resident 1 ' s Situational, Background, Assessment, Recommendation (SBAR) dated 9/18/2023 indicated PICC line insertion at GACH 1. During an interview on 10/5/2023 at 10:09 a.m., Resident 1 stated she had to go to GACH 1 to get her PICC line replaced. Resident 1 stated she was transported to GACH 1 via wheelchair assisted by two staff using the sidewalk not through a van or special transportation vehicle. During an interview on 10/5/2023 at 11:09 a.m., the Transportation Coordinator (TC 1) stated the facility van was not working and Resident 1 had an appointment at GACH 1 at 8 a.m. TC 1 stated she informed the Social Services Director (SSD) and the SSD instructed them to transport Resident 1 via wheelchair to GACH 1 using the sidewalk. TC 1 stated that a CNA went with her, but it placed the resident at risk for an accident if the resident had a fall or had medical emergency on the way to GACH 1. During an interview on 10/5/2023 at 11:25 a.m., the SSD stated she was aware Resident 1 had a scheduled appointment at GACH 1 but on the day of the appointment the van was not working. The SSD stated that in order for the resident not to miss the appointment, Resident 1 was transported to GACH 1 via wheelchair. The SSD stated Resident 1 ' s appointment should have been rescheduled because transporting the resident to GACH 1 via wheelchair placed the resident at risk for accidents. During an interview on 10/5/2023 at 12:39 p.m., Registered Nurse 1 (RN 1) stated transporting Resident 1 via wheelchair using the sidewalk is a safety concern because of the busy street to GACH 1. RN 1 stated that if the resident had a medical emergency, the staff that accompanied Resident 1 may have not been able to provide the needed care to the resident. During an interview on 10/5/2023 at 12:49 p.m., the Assistant Director of Nursing (ADON), stated she was only made aware of Resident 1 being transferred via wheelchair using the sidewalks when Resident 1 told her after it had happened. The ADON stated it was not appropriate because it was not safe for the resident. The ADON stated Resident 1 could have fallen and could have been tired because it was a long walk. During an interview on 10/5/2023 at 1:06 p.m., the Assistant Administrator (AAdm), stated Resident 1 being transferred via wheelchair using sidewalk was an injury hazard because the motorists can lose control and an accident can occur. The AAdm stated this also placed the resident at risk for accidents since the resident could have fallen and gotten hurt. The AAdm stated staff should have informed him so he could have requested for an emergency transportation. A review of the facility ' s policies and procedures, titled, Transportation, last revised on 6/2019 indicated the policy of this facility to assist residents in accessing transportation according to their needs. The policy further indicated the facility is expected to help residents evaluate options and access public or private transportation according to their means and abilities to travel safely in the community. A review of the facility ' s policies and procedures, titled, Safety and Supervision of Residents, last revised on 7/2017 indicated facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.

Sept 2023 2 deficiencies

CONCERN (E) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to implement its infection prevention and control program by: 1. Failing to ensure a resident's oxygen tubing (used for oxygen delivery) was not touching the floor for one of eight (Resident 5) sampled residents. 2. Failing to ensure the Screener (SC) screened visitors for signs and symptoms of Coronavirus Disease 2019 (COVID-19, a highly contagious disease spread from person to person through droplets released when an infected person coughs, sneezes, or talks) prior to entering the facility. 3. Failing to ensure ice scoopers in Station 3 and Station 4 were kept in a closed container. These deficient practices had the potential for cross contamination (unintentional transfer of bacteria/germs or other contaminants from one surface to another) of infection among residents and increase the risk of spreading COVID-19 to residents and staff. Findings: 1. A review of Resident 5 ' s admission Record indicated the facility admitted Resident 5 on 7/19/2023, with diagnoses including sepsis (a body ' s extreme reaction to an infection), respiratory failure (a serious condition that makes it difficult to breathe), and bacteremia (the presence of bacteria in the bloodstream). A review of Resident 5 ' s History and Physical (H&P), dated 7/20/2023, indicated Resident 5 had the capacity to understand and make decisions. A review of Resident 5 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 7/25/2023, indicated Resident 5 had the ability to make self-understood and understand others. A review of Resident 5 ' s Order Summary Report, dated 7/19/2023, indicated the following orders: -Oxygen at 2 liters per minute (LPM, a measurement of the velocity at which air flows into the sample probe) via nasal cannula (a medical device to provide supplemental oxygen to people who have lower oxygen levels) inhalation if needed (PRN) for shortness of breath (SOB); may titrate (to ascertain the quantity) up to 4 LPM to maintain oxygen saturation (a measure of how much hemoglobin [iron-containing protein in the blood] is currently bound to oxygen) above 90 percent (%, out of each hundred or per one hundred) as needed. -Monitor oxygen (O2) saturation every (q) shift. During a concurrent observation and interview on 9/13/2023, at 12:48 p.m., with Certified Nursing Assistant 2 (CNA 2), observed the oxygen tubing of Resident 5 touching the floor. The oxygen tubing was dated 9/8/2023. CNA 2 stated the tubing should not be touching the floor due to infection control issues. During an interview on 9/13/2023, at 2:22 p.m., the Director of Staff Development (DSD) stated if the oxygen tubing touches the floor, it is considered contaminated and needed to be changed for infection control. During an interview on 9/13/2023, at 2:38 p.m., the Infection Preventionist (IP) stated if the tubing touched the floor, it should be changed to prevent cross contamination. During an interview on 9/13/2023, at 3:04 p.m., the Assistant Director of Nursing (ADON) stated the tubing should touch the floor because it is an infection control issue. The ADON added the floor is not sanitary and the staff should be mindful. A review of the facility ' s recent in-service titled O2 Tubing Not Dragging/Touching the Floor, dated 9/13/2023, indicated oxygen tubing should not be touching or dragging on the floor to prevent infection. 2. During an observation and interview on 9/13/2023, at 12 p.m., observed a signage on the reception area of the facility that indicated COVID-19 symptoms needed to be reported before entering the facility. The SC did not screen the surveyor for signs and symptoms of COVID-19 (a highly contagious disease spread from person to person through droplets released when an infected person coughs, sneezes, or talks).The Screener (SC) stated when visitors come in, she tells them to sign in and she takes their temperature, provides them a face mask, and gives the room number and instructions on how to get there. The SC stated no one has instructed her to screen visitors for signs and symptoms of COVID-19. During an interview on 9/13/2023, at 2:22 p.m., the Director of Staff Development (DSD) stated the SC should have the screening questionnaire form filled out by the visitors and asked for signs and symptoms of COVID-19 before allowing visitors and vendors to get inside the facility. The DSD added this is a part of infection control during an outbreak (a sudden rise in the number of cases of a disease). During an interview on 9/13/2023, at 2:38 p.m., the Infection Preventionist (IP) stated the SC should ask for signs and symptoms of COVID-19 before letting the visitors in. The IP added if the visitors are not feeling well, they should reschedule their visits. A review of the facility ' s COVID-19 Outbreak Notification, last revised on 6/28/2023, indicated restrict entry to any visitor if they have any of the following: 1) recent positive viral test for SRS-CoV (the causal agent of COVID-19); 2) COVID symptoms, and or close contact less than or equal to (<) 14 days. A review of the facility ' s recent policy and procedure titled Visitation, last reviewed on 12/28/2022, indicated in general, visitors with signs and symptoms of a transmissible infection (e.g., a visitor is febrile and exhibiting signs and symptoms of an influenza-like illness) are asked to defer visitation until no longer potentially infectious (e.g., 24 hours after resolution of fever without antipyretic medication), or according to Centers for Disease Control and Prevention (CDC, is a federal agency that conducts and supports health promotion, prevention and preparedness activities in the United States, with the goal of improving overall public health) guidelines, and/or local health department recommendations. A review of the facility ' s recent policy and procedure titled Visitation, Infection Control During, last reviewed on 12/28/2022, indicated visitors who are symptomatic of communicable diseases may be denied visitation at the discretion of the charge nurse until appropriate evaluation and treatment of the visitor has been established. 3. During a concurrent observation and interview on 9/13/2023, at 12:28 p.m., at Station 4, observed with Licensed Vocational Nurse 3 (LVN 3) the scooper inside the ice scooper container was partially closed. LVN 3 stated the lid of the scooper was not shut properly, particles could come in and cause infection. During a concurrent observation and interview on 9/13/2023, at 1:11 p.m., at Station 3, observed with the IP the ice scooper was placed inside the ice scooper container without the lid on. The IP stated the ice scooper should have been placed inside the container with the lid shut to prevent cross contamination. During an interview on 9/13/2023, at 2:22 p.m., the DSD stated the staff should have replaced the lid of the ice scooper container to prevent contamination. During an interview on 9/13/2023, at 3:04 p.m., the ADON stated the ice scooper should be returned inside the container and the lid closed to prevent infection because if it was open the airborne pathogens (bacteria or viruses that are most commonly transmitted through small respiratory droplets) could come in. A review of the facility ' s recent policy and procedure titled Ice Procedures, last reviewed on 12/28/2022, indicated a covered plastic or stainless-steel container will be used to hold the scoop. Put the scooper back to the plastic or stainless-steel container after use.

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

Staffing Information (Tag F0732)

Minor procedural issue · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure an updated staffing information was posted daily. As a result, the total number of staff and the actual hours worked by the staff was not readily accessible to residents and visitors. Findings: During a concurrent observation and interview on 9/13/2023, at 1:01 p.m., with Licensed Vocational Nurse 3 (LVN 3), observed with LVN 3 the hours per patient day (HPPD, the number of productive hours worked by Registered Nurses [RNs] with direct patient care responsibilities per patient day for each in-patient unit in a calendar month) Staff Posting at Station 5 was outdated. The date that was indicated on the posting was 9/11/2023. LVN 3 stated that it was important to post the updated staffing for the family to know that they have enough staff to care for their residents. During an interview on 9/13/2023, at 2:22 p.m., the Director of Staff Development (DSD) stated the nursing supervisor of 11 p.m. to 7 a.m. should have posted the updated HPPD Staffing so that the staff and visitors are aware that the facility has enough staff to provide care to their residents. During an interview on 9/13/2023, at 3:04 p.m., the Assistant Director of Nursing (ADON) stated the Nurse Supervisor at night should have changed the HPPD Staffing Sheet early in the morning to show that they have enough staff to care for the residents. A review of the facility ' s recent policy and procedure titled Administrative Manual, last reviewed on 12/28/2022, indicated staffing based on resident census, the number of nursing staff on duty for each shift (staff to resident ratio), including registered nurses, licensed vocational nurses, certified nurse aides, any staff who provide direct care to residents or who supervise those giving direct care. At the beginning of each shift post: i. Facility Name; ii. Current date; iii. Resident Census at the start of the shift (Registered Nurse, Licensed Vocational Nurse, Licensed Practical Nurse, Certified Nursing Assistants); iv. Facility-specific shits for the 24-hour period (for example, 7 a.m. through 3 p.m., 3 p.m. through 11 p.m., and 11 p.m. through 7 a.m.); v. Categories of nursing staff employed or contracted by the facility per shift; vi. Actual time worked for the specified categories of nursing staff, including split shifts; vii. Number of nursing staff working per shift; and account for actual hours.

Jul 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program by failing to: 1. Ensure that the isolation cart and appropriate isolation precaution sign was placed outside Resident 1 ' s room. 2. Ensure that a physician ' s order on the type of isolation for Resident 1 was entered in the electronic health record (EHR). These deficient practices had the potential to transmit infection to other residents and staff. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 6/21/2007 and readmitted on [DATE] with diagnoses including gastrostomy, altered mental status, hydronephrosis, multiple sclerosis, and diabetes mellitus type 2. A review of Resident 1 ' s History and Physical indicated the resident was awake, alert, and answers only to yes or no. A review of Resident 1 ' s Minimum Data Set (MDS- a standardized assessment and screening tool), dated 4/20/2023, indicated the resident had severely impaired cognition (mental action or process of acquiring knowledge and understanding) and required extensive assistance from staff with bed mobility, dressing, and eating, and totally dependent with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). During an observation on 7/25/2023 at 10:25 a.m. observed Resident 1 ' s room without isolation cart and the type of isolation precaution sign posted by the door. During a concurrent observation and interview on 7/25/2023 at 10:26 a.m., Certified Nursing Assistant 1 (CNA 1) stated she was not aware of any isolation precaution for Resident 1. CNA 1 stated it was not mentioned during the morning hand off report that the resident is not on any isolation. During an interview on 7/25/2023 at 10:35 a.m., Licensed Vocational Nurse 1 (LVN 1) stated that Resident was not on any isolation precautions. LVN 1 stated if a resident was on isolation, an isolation cart and isolation precaution sign should be outside the door to prevent spread of infection in the facility. During a concurrent observation and interview on 7/25/2023 at 12:38 p.m., the Infection Preventionist stated she was aware that Resident 1 was readmitted from the hospital with methicillin resistant staphylococcus (MRSA – a group of bacteria that is resistant to many antibiotics) of the nares (also known as nostrils) and extended spectrum beta-lactamase (ESBL – enzymes [proteins that act as biological catalysts by accelerating chemical reactions]produced by certain bacteria which makes infections harder to treat with antibiotics). The IP stated there was no isolation cart and contact isolation precaution sign posted outside Resident 1 ' s door. The IP stated and validated that there was no physician ' s order for the type of Resident 1 ' s isolation precaution in the HER. The IP stated there should have been an isolation cart and contact isolation precaution sign outside the door and there should have been a physician ' s order in the EHR to make all the staff aware and prevent spread of infection to staff and other residents. During an interview and record review on 7/25/2023 1:15 p.m., the Assistant Director of Nursing (ADON) stated there was no physician ' s order for Resident 1 ' s contact isolation precaution in the EHR and it should have been entered upon admission per facility policy. The ADON stated there should have been an isolation cart and contact isolation precaution sign posted outside Resident 1 ' s door to make all the staff aware and prevent the spread of infection to staff and other residents. A review of the facility ' s policy and procedure titled, Isolation – Categories of Transmission-Based Precautions, last reviewed 12/22/2022 indicated the following: 1. Transmission-Based Precautions shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others to prevent or control the spread of infection. 2. Contact Precautions should be implemented for residents known or suspected to be infected with organisms that can be transmitted by direct contact with the resident or indirect contact with surfaces or resident-care items such as MRSA. 3. The facility will implement as system to alert staff to the type of precaution resident requires with contact precaution signs. A review of the facility ' s policy and procedure titled, Physician Orders/Verbal, last reviewed 12/22/2022, indicated all orders must be written on the physician ' s order.

Jul 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to develop an individualized plan of care addressing the resident ' s behavior of refusing podiatry care for one out of four sampled residents (Resident 3). This deficient practice had the potential to negatively affect the delivery of care and services and had the potential to result in complications such as fungal infection to Resident 3. Findings: A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 12/12/2018 with diagnoses that included type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high) with diabetic neuropathy (a type of nerve damage that can occur if you have diabetes), age-related nuclear cataract (an opacity or clouding that develops in the lens nucleus), bilateral (two-sided) and absolute glaucoma (loss of vision on both eyes due to uncontrolled raised ocular [connected to the eyes] pressure). A review of Resident 3 ' s Minimum Data Set (MDS – a standardized assessment and care screening tool), dated 6/23/2023 indicated Resident 3 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS also indicated the resident can usually make self-understand and can usually be understood by others. The MDS indicated Resident 3 required limited assistance with bed mobility, transfer, toilet use and personal hygiene. A review of Resident 3 ' s orders, dated 12/12/2018, indicated podiatry consultation as needed. A review of Resident 3's Subject Objective Assessment Procedure Note (SOAP) note, dated 4/8/2022, indicated Resident 3 was seen by the podiatrist. The note indicated painful elongated thickened toenails. A review of Resident 3's Progress Note, dated 6/8/2022, indicated Resident 3 was scheduled to be seen by podiatry but refused services at that time. During a concurrent observation and interview on 7/13/2023 at 10:32 a.m., Resident 3 stated he has not had his toenails cut. Resident 3 stated the last time he had his toenails cut may have been 9 months ago. Resident 3 stated his toenails are painful, will get caught on the sheets and pull. Resident 3 removed his shoe and observed yellow, thick, and long toenails which were curving inwards. During a concurrent observation and interview on 7/13/2023 at 1 p.m., Certified Nursing Assistant 2 (CNA 2) stated Resident 3's foot was dry. CNA 2 also stated the resident's toenails were long and yellow with a black spot. CNA 2 stated for any changes of condition, they need to report to their charge nurse; CNA 2 stated she did not report the resident's condition. CNA 2 stated if Resident 3's condition is not reported, the resident is diabetic and he can have pain and ingrown toenails, the resident can lose his toes, and the resident can scratch his legs with his toenails. During a concurrent observation and interview on 7/13/2023 at 1:33 p.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 3 appeared to have some sort of fungal infection on the toenails and the toenails need to be trimmed. LVN 1 stated not getting the resident's toenails cut can be a risk for infection because the toenails are long can get caught on something; the toes can be painful as he will be wearing shoes. LVN 1 stated if Resident 3 is refusing care, they need to have a care plan to address refusal and to implement interventions. During a concurrent observation and interview on 7/13/2023 at 2 p.m., Social Services Director (SSD) stated Resident 3's nails were white and long and looked like they needed to be cut; the resident needed to be seen by the podiatrist because Resident 3 is diabetic. The SSD stated the last note for Resident 3 being seen by podiatry was on 4/8/2022. The SSD stated for refusal on 6/8/2022, there was no care plan done about the refusal. During an interview on 7/13/2023 at 3 p.m., the Assistant Administrator (AAdm) stated there was no care plan or follow up on refusal of care for Resident 3. The AAdm stated not creating a care plan for refusal of care has the potential to further deterioration of condition. A review of the facility ' s policies and procedures titled, Care Plans-Comprehensive, last revised on 12/2009, indicated assessment of residents are ongoing and care plans are revised as information about the resident and the resident ' s condition change.

CONCERN (D) 📢 Someone Reported This

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

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure that one of four sampled residents (Resident 3) who had bilateral absolute glaucoma (loss of vision on both eyes due to uncontrolled raised ocular [connected to the eyes] pressure) received supervision with eating and assistance with meal set-up. This deficient practice had the potential for Resident 3 to not eat when the food is cold and may lead to weight loss, dehydration, or nutritional problems. Findings: A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 12/12/2018 with diagnoses that included type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high) with diabetic neuropathy (a type of nerve damage that can occur if you have diabetes), age-related nuclear cataract (an opacity or clouding that develops in the lens nucleus), and bilateral absolute glaucoma. A review of Resident 3 ' s Minimum Data Set (MDS – a standardized assessment and care screening tool), dated 6/23/2023 indicated Resident 3 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS also indicated the resident can usually make self-understand and can usually be understood by others. The MDS indicated Resident 3 required limited assistance with bed mobility, transfer, toilet use and personal hygiene; and required supervision with eating and assistance with meal set-up. A review of Resident 3 ' s physician ' s orders dated 12/5/2019 indicated controlled carbohydrate (CCHO), no added salt (NAS) diet, mechanical soft with chopped meat and veggies, texture thin/regular liquid consistency. A review of Resident 3 ' s care plan initiated on 12/13/2018, indicated nutritional problem and potential nutritional problem related to therapeutic diet, blurred vision. The interventions included diet as ordered and explain and encourage the resident to adhere with CCHO diet. During an interview on 7/13/2023 at 10:32 a.m., Resident 3 stated he cannot see, and he requires a lot of assistance with setting up his tray. Resident 3 stated since he is blind, he cannot see his meal tray and staff will just leave the tray without telling him. Resident 3 stated by the time he is aware of his meal tray, his food is already cold. Resident 3 stated Certified Nursing Assistant 2 (CNA 2) delivered his tray that morning to him without telling him. Resident 3 stated that Housekeeper (HK) came in later and asked him if he was going to eat. Since the food was cold, HK warmed his breakfast up. During an interview on 7/13/2023 at 11:01 a.m., HK stated Resident 3 complained that staff placed his meal tray in his room without telling him. HK stated that around 7 a.m. that day, HK saw Resident 3 ' s meal tray on the bedside table and saw the resident in bed. HK stated then asked Resident 3, who was upset, if he was going to eat. HK stated she warmed up Resident 3 ' s food as requested because the food was cold. HK stated she is aware of Resident 3 not being told when his tray is at bedside because it was not the first time; she has had to tell him his tray was at bedside. HK stated she sometimes visits Resident 3 and she tries to help by setting up his meal tray. HK tells Resident 3 that his tray was there and she helps warm up the resident's food if needed. During an interview on 7/13/2023 at 1 p.m., CNA 2 stated Resident 3 requires assistance with bed being made, showering, and setting up his meal tray. CNA 2 stated she was the one that gave Resident 3 his meal tray that morning. CNA 2 stated Resident 3 was in bed asleep at that time and so she placed his tray on bedside and left the room to get sugar. CNA 2 stated she left for about six minutes, and when she came back, she saw HK setting up Resident 3 ' s meal tray. CNA 2 stated since Resident 3 is blind and so she must tell him when his tray is there, what foods are on his tray, and if he needs assistance setting up his tray. CNA 2 stated if Resident 3 is not being told about the tray, the food may get cold; Resident 3 has told CNA 2 that he will not eat if his food was cold. During an interview on 7/13/2023 at 3 p.m., the Director of Staff Development (DSD) stated staff are aware that Resident 3 is blind, and that staff should be informing the resident about his tray. The DSD stated Resident 3 will decline to eat and was at risk for not eating if his food was cold. During an interview on 7/13/2023 at 2:45 p.m., the Assistant Administrator (AAdm) stated Resident 3 ' s not being informed about his meal tray being delivered is a risk for the resident for weight loss. The AAdm also stated that when it is time to collect the meal trays, CNAs will think the resident ate and take the tray away without the resident eating. A review of the facility ' s policies and procedures, titled, Assisting the Resident with In -Room Meals, last revised in 12/2013 indicated the facility is to provide appropriate assistance for residents who choose to receive meals in their rooms.

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 F0687 (Tag F0687)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure one out of four sampled residents (Resident 3) received podiatry care (medical care and treatment of the human foot) as ordered. This deficient practice placed Resident 3 at risk for increased pain and foot infection. Findings: A review of Resident 3 ' s admission Record indicated the facility admitted the resident on 12/12/2018 with diagnoses that included type 2 diabetes mellitus (a disease that occurs when your blood glucose, also called blood sugar, is too high) with diabetic neuropathy (a type of nerve damage that can occur if you have diabetes), age-related nuclear cataract (an opacity or clouding that develops in the lens nucleus), bilateral absolute glaucoma (loss of vision on both eyes due to uncontrolled raised ocular [connected to the eyes] pressure). A review of Resident 3 ' s Minimum Data Set (MDS – a standardized assessment and care screening tool), dated 6/23/2023 indicated Resident 3 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding). The MDS also indicated the resident can usually make self-understand and can usually be understood by others. The MDS indicated Resident 3 required limited assistance with bed mobility, transfer, toilet use and personal hygiene. A review of Resident 3 ' s physician orders, dated 12/12/2018, indicated podiatry consultation as needed. During a concurrent observation and interview on 7/13/2023 at 10:32 a.m., Resident 3 stated he has not had his toenails cut. Resident 3 stated the last time he had his toenails cut may have been 9 months ago. Resident 3 stated his toenails are painful, will get caught on the sheets and pull. Resident 3 removed his shoe and observed yellow, thick, and long toenails which were curving inwards. During a concurrent observation and interview on 7/13/2023 at 1 p.m., Certified Nursing Assistant 2 (CNA 2) stated Resident 3's foot was dry. CNA 2 also stated the resident's toenails were long and yellow with a black spot. CNA 2 stated for any changes of condition, they need to report to their charge nurse; CNA 2 stated she did not report the resident's condition. CNA 2 stated the resident is diabetic and he can have pain and ingrown toenails, the resident can lose his toes, and the resident can scratch his legs with his toenails. During a concurrent observation and interview on 7/13/2023, Licensed Vocational Nurse 1 (LVN 1) stated Resident 3 appeared to have some sort of fungal infection on the toenails and the toenails need to be trimmed. LVN 1 stated not getting the resident's toenails cut can be a risk for infection because the toenails are long can get caught on something; the toes can be painful as he will be wearing shoes. LVN 1 stated if Resident 3 is refusing care, they need to have a care plan to address refusal and to implement interventions. During a concurrent interview and observation on 7/13/2023 at 1:33 p.m., Licensed Vocational Nurse 1 (LVN 1) stated Resident 3 appears to have some sort of fungal infection on toenails and need to be trimmed. LVN 1 stated not getting toenail cut can be a risk for infection because nails are long can get caught on something can also be painful because he will be wearing shoes. During a concurrent observation and interview on 7/13/2023 at 2 p.m., Social Services Director (SSD) stated Resident 3's nails were white and long and looked like they needed to be cut; the resident needed to be seen by the podiatrist because Resident 3 is diabetic. The SSD stated the last note for Resident 3 being seen by podiatry was on 4/8/2022. The SSD stated it is a concern, it is unhealthy, and must be uncomfortable for the resident. During an interview on 7/13/2023 at 3 p.m., the Director of Staff Development (DSD) stated Resident 3 not being seen by podiatry is a risk because the resident is diabetic. The DSD stated Resident 3 must be seen by podiatry because the resident's feet can get sores causing pain and discomfort. During a concurrent observation and interview on 7/13/2023 at 2:45 p.m., the Assistant Administrator (AAdm) stated Resident 3 ' s toenails looked discolored, the toenails were sharp and can create an open skin break; the resident may have fungus because of the discoloration at the tip of the toenail. The AAdm stated the issue should have been addressed upon daily showers. The AAdm stated when CNAs see resident during showers and if there are any changes or usual skin issues, they need to report to charge nurse and then the charge nurse needs to assess and report to doctor as well as develop a care plan. The AAdm stated the issue of the resident was overlooked; for a diagnosis of fungal inefction, the resident needs to be assessed by doctor and given orders; there was a risk for delay of care for hygiene; diabetic residents can only be touched (cared for) by podiatry. A review of the facility ' s policies and procedures, titled, Nursing Care of the Older Adult with Diabetes Mellitus, last revised on 11/2020 indicated toenails should be trimmed by personnel qualitied to do so.

Jul 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report an allegation of resident-to-resident abuse within two hours to the State Survey Agency (SSA), Long-Term Care Ombudsman (representatives that assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal concerns), and law enforcement agency for two of five sampled residents (Resident 1 and Resident 2). This deficient practice had the potential to delay the investigation and place the residents at risk for abuse. Findings: a. A review of Resident 1's admission Record indicated the facility admitted the resident on 1/1/2021 with a diagnoses that included displacement (change in position) of nephrostomy catheter (a small flexible, rubber tube that is placed through your skin into the kidney to drain the urine), hydronephrosis (a condition where one or both kidneys become stretched and swollen as the result of a build-up of urine inside them) with renal and ureteral calculous obstruction (stone blocking the kidney) and chronic obstructive pulmonary disease (COPD- a group of diseases that cause airflow blockage and breathing-related problems). A review of Resident 1's History and Physical Examination, dated 12/31/2022, indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 4/14/2023, indicated resident's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 1 required extensive assistance from staff for bed mobility, dressing, toilet use, and personal hygiene. A review of Resident 1's Situation Background Assessment Recommendation (SBAR- technique that provides a framework for communication between members of the health care team about a resident's condition) Communication Form dated 7/4/2023 indicated Resident 1 was verbally threatened by Resident 2. A review of Resident 1's Interdisciplinary Team (IDT-a coordinated group of experts from several different fields who work together) Investigation Summary dated 7/6/2023, indicated on 7/4/2023 at around 8:57 a.m., Resident 1 reported to charge nurse that Resident 2 made threatening comments on her. b. A review of Resident 2's admission Record indicated the facility admitted the resident on 6/16/2023 with a diagnoses that included diabetes mellitus (uncontrolled elevated blood sugar) with hyperglycemia (high blood sugar), hypertension (HTN-uncontrolled elevated blood pressure) and schizoaffective disorder (mental illness that can affect thoughts, mood, and behavior). A review of Resident 2's History and Physical Examination, dated 6/18/2023, indicated the resident had capacity to understand and make decisions. A review of Resident 2's MDS, dated [DATE], indicated resident had intact cognition. The MDS indicated Resident 2 required extensive assistance from staff for bed mobility, transfer, dressing, toilet use, and personal hygiene. A review of Resident 2's SBAR Communication Form, dated 7/4/2023, indicated Resident 2 made verbal threat to Resident 1. c. A review of Resident 6's admission Record indicated the facility admitted the resident on 1/26/2018 with a diagnoses that included pneumonia (lung infection), COPD and hypertension. A review of Resident 6's History and Physical, dated 1/25/2023, indicated the resident had capacity to understand and make decisions. A review of Resident 6's MDS, dated [DATE], indicated resident had intact cognition. During an interview on 7/14/2023 at 10:23 a.m., Social Service 1 (SS 1) stated on 7/4/2023 at around 9 a.m., Licensed Vocational Nurse 1 (LVN 1) informed her that Resident 1 was verbally threatened by Resident 2. SS 1 stated she faxed the report to State Survey Agency (SSA) and Ombudsman (representatives that assist residents in long-term care facilities with issues related to day-to-day care, health, safety, and personal concerns) at 4:24 p.m., more than two hours from the time the incident happened. SS 1 stated she was dealing with other things that day but should report within two hours because residents can be exposed to possible abuse. During an interview on 7/14/2023 at 10:37 a.m., LVN 1 stated LVN 2 informed her about Resident 1 and Resident 2 between 8 a.m., to 10 a.m. on 7/4/2023. LVN 1 stated she notified Registered Nurse 1 (RN 1) and SS 1. During an interview on 7/14/2023 at 11 a.m., Certified Nursing Assistant 1 (CNA 1) stated on 7/4/2023 at 7:30 a.m., Resident 6 reported that the night of 7/2/2023, Resident 1 told Resident 2 not to smoke inside their room because she uses an oxygen and Resident 2 responded with a verbal threat. CNA 1 stated she reported to LVN 2 right away. During an interview on 7/14/2023 at 11:07 a.m. LVN 2 stated on 7/4/2023 between 8 a.m., to 8:30 a.m., CNA 1 informed her of the incident between Resident 1 and Resident 2. LVN 2 stated she reported to LVN 1 and SS 1. During an interview on 7/14/2023 at 11:20 a.m., RN 1 stated LVN 1 notified her of the incident on 7/4/2023 between 9 a.m., to 10 a.m. RN 1 stated report of allegation of abuse was not sent to SSA, Ombudsman and call was not placed to law enforcement until 3 p.m. RN 1 stated residents can be exposed to further abuse because report was not done timely. During an interview on 7/14/2023 at 12:36 p.m., the Director of Nursing (DON) stated allegation of abuse should be reported within two hours. A review of facility's policy and procedure titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating , dated 9/2022 indicated, If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports his to her suspicion to the following persons or agencies: A. The state licensing/certification agency responsible for surveying/licensing the facility. B. The local/state ombudsman E. Law enforcement officials. Immediately is defined as a. within two hours of an allegation involving abuse or result in serious bodily injury.

Jul 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the licensed nursing staff failed to provide professional standards of care to one out of four sampled residents (Resident 1) by failing to rotate (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin (a hormone that lowers the level of sugar in the blood) administration sites. The deficient practice had the potential to unnecessary tissue trauma and hardening of the area where frequent subcutaneous administration occurred that impairs absorption (a condition in which the body takes in another substance) of insulin. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 3/26/2023, with diagnoses including diabetes type 2 (a disease that occurs when blood glucose, also called blood sugar, is too high), mild protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), and malignant neoplasm of brain (a fast-growing cancer that spreads to other areas of the brain and spine). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/2/2023, indicated the resident had the ability to make self-understood and understand others. The MDS indicated that the resident was on insulin injections. A review of Resident 1's Order Summary Report, indicated an order on: -6/19/2023, Humalog Injection Solution 100 units per milliliter (unit/ml, the concentration of insulin in one milliliter) (Insulin Lispro, a fast-acting insulins used to control high blood sugar in adults and children with diabetes) Inject as per sliding scale (the does is based on blood sugar level): If 70 – 149= 0 units Notify MD if blood sugar (BS) is less than (<)70 150 - 199= 2 units 200 – 249= 4 units 250 – 299= 7 units 300 – 349= 10 units 350 + = 12 units Give 12 units if BS greater than (>) 350. Notify MD. Subcutaneously three times a day for Fasting Finger Stick Blood Sugar (FSBS, drawing a drop of blood from the fingertip with a single-use, auto-disabling finger stick device for testing in a clinical care setting) take before meal (AC)/ take at bedtime (HS) related to type 2 diabetes mellitus without complications. Rotate injection sites. -6/122/2023, Lantus Subcutaneous Solution 100 unit/ml (Insulin Glargine, a long-acting modified form of medical insulin). Inject 30 unit subcutaneously in the morning. Written related to type 2 diabetes mellitus without complications. Rotate injection sites. A review of Resident 1's Medication Administration Record (MAR) from April 2023 through July 5, 2023, indicated: -Lantus Subcutaneous Solution 100 unit/ml 4/6/2023 at 9 p.m. given at the Abdomen- Right Lower Quadrant (RLQ) 4/7/2023 at 8:25 p.m. given at the Abdomen- RLQ 5/11/2023 at 8:21 p.m. given at the Abdomen- Right Upper Quadrant (RUQ) 5/12/2023 at 8:37 p.m. given at the Abdomen- RUQ -Humalog Injection Solution 100 unit/ml 4/6/2023 at 6:47 a.m. given at the Abdomen- RUQ 4/6/2023 at 9 p.m. given at the Abdomen- RUQ 4/7/2023 at 4:08 p.m. given at the Abdomen- RLQ 4/8/2023 at 11:30 a.m. given at the Abdomen- RLQ 4/8/2023 at 3:55 p.m. given at the Abdomen- RLQ 4/16/2023 at 11:35 a.m. given at the Abdomen- Left Lower Quadrant (LLQ) 4/16/2023 at 11:39 a.m. given at the Abdomen- LLQ 4/21/2023 at 6:30 a.m. given at the Abdomen- LLQ 4/21/2023 at 11:30 a.m. given at the Abdomen- LLQ 5/8/2023 at 11:04 a.m. given at the Abdomen- LLQ 5/8/2023 at 4:21 p.m. given at the Abdomen- LLQ 5/9/2023 at 12:232 p.m. given at the Abdomen- LLQ 5/25/2023 at 4:17 p.m. given at the Abdomen- RUQ 5/26/2023 at 4:12 p.m. given at the Abdomen- RUQ 5/28/2023 at 4:27 p.m. given at the Abdomen-RUQ 5/29/2023 at 4:24 p.m. given at the Abdomen- RUQ 6/18/2023 at 5:16 p.m. given at the Abdomen- LLQ 6/19/2023 at 12:10 p.m. given at the Abdomen- LLQ During a concurrent interview and record review on 7/5/2023, at 12:31 p.m., with Licensed Vocational Nurse 5 (LVN 5), observed repeated insulin administration sites documented on the MAR of Resident 1 for the months of April through July 5, 2023. LVN 5 stated the insulin injection sites should be rotated to prevent infection, pain, and hardening of the skin where the insulin was administered repeatedly. During an interview on 7/5/2023, at 2:30 p.m., with the Director of Nursing (DON), the DON stated the insulin injection sites should be rotated to prevent skin complications. A review of the facility's recent policy and procedure titled, Administration of Subcutaneous Medications, undated, indicated a safe and effective method will be used consistently to provide for the administration of subcutaneous medications, such as insulin or heparin. When administering heparin or insulin, a diagram of common injection sites should be used to establish a precise record of sites used and sites remaining. Injection sites must be rotated to avoid unnecessary trauma to tissue and to aid in medication absorption. A review of the Manufacturer's Guidelines on the use of Humalog (insulin lispro injection, unique value proposition ([USP, the essence of what makes your product or service better than competitors] [rDNA origin, molecules of DNA from two different species that are inserted into a host organism to produce new genetic combinations]) for injection with initial United States (U.S.) approval in 1996 indicated Humalog administered by subcutaneous injection should be given in the abdominal wall, thigh, upper arm, or buttocks. Injection sites should be rotated within the same region (abdomen, thigh, upper arm, or buttocks) from one injection to the next to reduce the risk of lipodystrophy (abnormal distribution of fat). A review of the Manufacturer's Guidelines on the use of Lantus (insulin glargine injection) for subcutaneous injection with initial U.S. approval in 2000 indicated rotate injection sites to reduce the risk of lipodystrophy.

CONCERN (E) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents safety to four out of four sampled residents (Resident 1,2,3 and 4) by failing to: 1. Provide a fire-retardant smoking apron (designed as a drape-style cover to protect the user against light ash and other cigarette debris). 2. Provide a safe environment for Resident 1 who uses a wheelchair to smoke. 3. Provide smoking supervision to Resident 3 while smoking in the patio. 4. Ensure that Resident 3 did not keep extra cigarettes to smoke. These deficient practices had the potential to cause injuries such as cigarette burns and falls to residents. Findings: 1. A review of Resident 1's admission Record indicated the facility admitted the resident on 3/26/2023, with diagnoses including malignant neoplasm of the brain (a fast-growing cancer that spreads to other areas of the brain and spine), seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain), and history of falling. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/2/2023, indicated the resident had the ability to make self-understood and understand others. The MDS indicated the resident uses a walker and a wheelchair to ambulate. A review of Resident 1's Care Plan, initiated on 3/27/2023, indicated a care plan for high risk for further fall. The care plan indicated an intervention to provide a safe environment free of clutter, clear floors, and adequate lighting. A review of Resident 1's Smoking Safety Evaluation, dated 3/28/2023, indicated for safety, the resident needed a smoking apron, supervision, one-to-one assistance, and facility to store smoking materials. A review of Resident 1's Care Plan, initiated on 3/30/2023, indicated a care plan for resident being a smoker. The care plan indicated an intervention to observe for any signs of injury due to smoking/signs of unsafe smoking abilities (i.e. burns on clothes, skin, etc.) A review of Resident 1's Fall Risk Evaluation, dated 7/2/2023, indicated the resident was high risk for fall. During an interview on 7/5/2023, at 9:11 a.m., with Resident 1, in the Designated Smoking Area, Resident 1 stated that the facility allowed him and his wife to use another patio where the Coronavirus Disease 2019 (COVID-19 -a highly contagious disease spread from person to person through droplets released when an infected person coughs, sneezes, or talks) residents were housed before in the facility. Resident 1 stated that the pavement in that patio was uneven and could cause an accident to residents that uses walking equipment. During an interview on 7/5/2023, at 10:24 a.m., with the Social Services Director (SSD), the SSD stated she was approached by the Ombudsman regarding a complaint of a family member that she was approached by 2 residents for cigarettes. SSD offered the patio near the designated COVID-19 unit for the family to use for smoking to avoid being asked by other residents for cigarettes. During an interview on 7/5/2023, at 2:30 p.m., with the Administrator (ADM), the ADM stated the patio should be repaved to prevent injury to residents on assistive devices. A Review of the facility's recent policy and procedure titled, Exterior General Maintenance, undated, indicated to inspect exterior of the building. Check weather stripping and insulation. A review of Resident 2's admission Record indicated the facility admitted the resident on 6/19/2023, with diagnoses including pressure ulcer of left heel (localized injury to the heel because of pressure sometimes in association with other factors), type 2 diabetes mellitus (a disease that occurs when blood glucose, also called blood sugar, is too high), and allergic rhinitis (inflammation of the inside of the nose caused by an allergen, such as pollen, dust, mold, or flakes of skin). A review of Resident 2's H&P, dated 6/21/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 2's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. A review of Resident 2's Smoking Safety Evaluation, dated 6/19/2023, indicated for safety, the resident needed a smoking apron, cigarette holder, supervision, one to one assistance, and the facility to store smoking materials. A review of Resident 4's admission Record indicated the facility admitted the resident on 6/19/2023, with diagnoses including fracture of left acetabulum (a break in the socket portion of the hip joint), hyperlipidemia (high cholesterol), and psychosis (a severe mental disorder in which a person loses the ability to recognize reality or relate to others). A review of Resident 4's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. A review of Resident 4's Smoking Safety Evaluation, dated 6/19/2023, indicated for safety, the resident needed a smoking apron, cigarette holder, supervision, one-to-one assistance, and facility to store smoking materials. During a concurrent observation and interview on 7/5/2023, at 9:46 a.m., with Activity Assistant 1 (AA 1), observed Residents 1, 2, and 4 wearing a thin black permeable cloth apron while smoking in the designated smoking area. AA 1 stated that they have been using the cloth apron for a long time. AA 1 stated that the cloth apron will not be able to protect the resident from burns because it was thin and can easily burn. During an interview on 7/5/2023, at 2:30 p.m., with the Director of Nursing (DON) and the Administrator (ADM), the DON stated they were using the same apron for smoking for a long time. The DON stated that the apron was thin, it was made of cloth. The DON stated it could burn easily. The ADM stated that they will purchase a wipeable/fire-retardant (having the ability or tendency to slow up or halt the spread of fire) smoking apron to effectively prevent residents from cigarette burns. 2. A review of Resident 3's admission Record indicated the facility admitted the resident on 6/8/2023, with diagnoses including muscle weakness, frostbite (an injury caused by freezing of the skin and underlying tissues) of left foot, and fracture of neck of left femur (a particular type of hip fracture that occurs at the femur [leg bone] ). A review of Resident 3's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. The MDS also indicated the resident had impaired vision. The MDS indicated the resident required extensive assistance on bed mobility, dressing, toilet use, and personal hygiene and required extensive assistance on transfer, locomotion on and off unit. A Review of Resident 3' Smoking Safety Evaluation, dated 6/8/2023, indicated for safety, the resident needed supervision and the facility to store smoking materials. A review of Resident 3's Care plan, initiated on 6/23/2023, indicated a care plan for resident being a smoker. The care plan indicated that the resident needed assistance going to designated areas (functionality) and assistance lighting cigarettes (dexterity, skill in performing tasks, especially with the hands). The care plan also indicated an intervention to observe for any signs of injury due to smoking/signs of unsafe smoking abilities (i.e. burns on clothes, skin etc.) During an interview on 7/5/2023, at 11:04 a.m., with Licensed Vocational Nurse 2 (LVN 2), in the Designated Smoking Area, Resident 3 was not following the designated smoking time, and was smoking without smoking apron and staff supervision. LVN 2 stated that the resident should have a smoking apron on and should be supervised by a staff to prevent accidents such as fire and burns on resident. Resident 2 stated that she saved her cigarette from yesterday to smoke today. A review of the facilities recent policy and procedure titled, Smoking Policy and Procedures- Residents, last reviewed on 7/5/2023, indicated that it is the policy of the facility to provide reasonable accommodation for a resident's smoking preference and to provide reasonable supervision during smoking. - Smoking is permitted during designated times in specially designated areas only. - Designated Smoking area is outside, behind Station 4 in the South Parking lot - Designated Smoking schedule as follows: 9:30 a.m. to 9:45 a.m. 1:30 p.m. to 1:45 p.m. 4:00 p.m. to 4:15 p.m. This schedule is subject to change · Residents will be allowed to smoke with staff supervision only unless otherwise directed by the Administrator. · Residents will not be allowed to keep cigarettes, lighters, or any smoking paraphernalia in their possession. · Cigarettes, lighters, and smoking paraphernalia including those from visitors should be approved and held by the Activity department for safekeeping. · Residents will be provided with fire retardant smoking aprons and will be sanitized after each use by the smoking monitor attendant. · Residents will not ask or receive cigarettes and smoking paraphernalia from other residents or any staff other than activities.

CONCERN (E) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to observe infection control measures for three of three sampled residents (Residents 1, 2, and 4) by failing to provide a smoking apron that can be sanitized in between resident use. The deficient practice had the potential to spread infection among residents in the facility. Findings: A review of Resident 1's admission Record indicated the facility admitted the resident on 3/26/2023, with diagnoses including essential hypertension (persistent raised blood pressure with no secondary cause identified), type 2 diabetes mellitus (a disease that occurs when blood glucose, also called blood sugar, is too high), and mild protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). A review of Resident 1's History and Physical (H&P), dated 3/30/2023, indicated the resident was on hospice (focuses on the care, comfort, and quality of life of a person with a serious illness approaching the end of life) for brain tumor (an abnormal mass of tissue in which cells grow and multiply uncontrollably). The resident had undergone craniotomy (an operation in which a small hole is made in the skull or a piece of bone from the skull is removed to show a part of the brain), radiation (a cancer treatment that uses high dose of radiation to kill cancer cells and shrink tumors), and chemotherapy (treatment that uses drugs to stop the growth of cancer cells). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 7/2/2023, indicated the resident had the ability to make self-understood and understand others. A review of Resident 1's Smoking Safety Evaluation, dated 3/28/2023, indicated for safety, the resident needed a smoking apron (prevents users be burned by a lit cigar, cigarette, or match). A review of Resident 2's admission Record indicated the facility admitted the resident on 6/19/2023, with diagnoses including pressure ulcer of left heel (localized injury to the heel because of pressure sometimes in association with other factors), type 2 diabetes mellitus, and allergic rhinitis (inflammation of the inside of the nose caused by an allergen, such as pollen, dust, mold, or flakes of skin). A review of Resident 2's H&P, dated 6/21/2023, indicated the resident had the capacity to understand and make decisions. A review of Resident 2's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. A review of Resident 2's Smoking Safety Evaluation, dated 6/19/2023, indicated for safety, the resident needed a smoking apron. A review of Resident 4's admission Record indicated the facility admitted the resident on 6/19/2023, with diagnoses including fracture of left acetabulum (a break in the socket portion of the hip joint), hyperlipidemia (high cholesterol), and psychosis (a severe mental disorder in which a person loses the ability to recognize reality or relate to others). A review of Resident 4's MDS, dated [DATE], indicated the resident had the ability to make self-understood and understand others. A review of Resident 4's Smoking Safety Evaluation, dated 6/19/2023, indicated for safety, the resident needed a smoking apron. During a concurrent observation and interview on 7/5/2023, at 9:46 a.m., with Activity Assistant 1 (AA 1), observed Residents 1, 2, and 4 wearing a thin black permeable cloth apron that was not wipeable with an antiseptic wipe. Observed the residents returned the apron to AA 1. AA 1 did not wipe the used smoking apron with an antiseptic wipe. AA 1 stated that they wash the vest once a week. During an interview on 7/5/2023, at 2:30 p.m., with the Director of Nursing (DON), the DON stated they were using the same apron for smoking for a long time. The DON stated that the apron was not wipeable and has a potential to spread infection among residents. A review of the facility's recent policy and procedure titled, Smoking Policy and Procedures- Residents, last reviewed on 7/5/2023, indicated that it is the policy of the facility to provide reasonable accommodation for a resident's smoking preference and to provide reasonable supervision during smoking. This also addresses exposure to secondhand smoke. Residents will be provided with fire retardant smoking aprons and will be sanitized after each use by the smoking monitor attendant.

Jun 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise the care plan for one of three sampled residents (Resident 1) when Resident 1's care plans for pain medications and antianxiety medications were not revised to include Resident 1's current medications. This deficient practice had the potential to negatively affect the provision of care for Resident 1. Findings: A review of Resident 1's admission Record, dated 6/15/2023, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of brain (a fast-growing cancer that spreads to other areas of the brain), anxiety disorder, history of falling, and generalized muscle weakness. A review of Resident 1's Minimum Data Set (MDS - an assessment and care planning tool), dated 4/1/2023, indicated Resident 1 was cognitively intact (able to understand and make decisions), required supervision to one-person limited assistance with activities of daily living (ADL - tasks of everyday life, such as surface to surface transfers, dressing, eating, and personal hygiene), and has fallen in the facility two or more times since admission. A review of Resident 1's History and Physical (H&P), dated 3/30/2023, indicated Resident 1 was ordered morphine concentrate (a type of pain medication) 100 milligrams (mg) per five milliliters (ml) oral solution, lorazepam (also known as Ativan, medication used to treat anxiety) one mg oral tablet, and alprazolam (also known as Xanax, a medication used to treat anxiety) 0.25 mg oral tablet. A review of Resident 1's Order Summary Report, dated 6/1/2023, indicated Resident 1 was ordered Tramadol (a type of pain medication) 50 mg by mouth every eight hours as needed for moderate pain, if not relieved by Tylenol (a type of pain medication). A review of Resident 1's Order Summary Report, dated 6/7/2023, indicated Resident 1's order for morphine sulfate concentration was discontinued. A review of Resident 1's Care Plan, dated 3/27/2023, indicated Resident 1 had the potential for alteration in comfort related to pain secondary to muscle pain and cancer. The care plan indicated interventions included to administer Tylenol for mild pain and morphine sulfate oral solution for moderate to severe pain. The care plan did not indicate to administer tramadol for moderate pain. The care plan further indicated there were no revisions made to the care plan. A review of Resident 1's Order Summary Report, dated 3/31/2023, indicated Resident 1's Xanax oral tablet 0.25 mg order was completed and discontinued. A review of Resident 1's Order Summary Report, dated 6/7/2023, indicated Resident 1 was ordered Ativan one mg by mouth at bedtime for irritability related to anxiety disorder. A review of Resident 1's Care Plan, dated 3/27/2023, indicated Resident 1 uses anti-anxiety medications (Xanax) related to anxiety disorder. The care plan did not indicate to administer Ativan for anxiety. The care plan further indicated there were no revisions made to the care plan. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1, on 6/15/2023, at 2:54 PM, Resident 1's medication orders and care plans were reviewed. Resident 1's medication orders indicated Resident 1 was taking Tylenol and tramadol for pain and Ativan for anxiety. Resident 1's care plans indicated Resident 1 had care plans for the use of Tylenol, morphine, and Xanax, but no care plans for tramadol and Ativan. LVN 1 stated Resident 1's care plans did not indicate revisions to remove the discontinued medications and include tramadol and Ativan. LVN 1 further stated Resident 1's care plan should be revised when medication was changed, and an error may affect Resident 1's plan of care. During a concurrent interview and record review with the MDS Coordinator, on 6/15/2023, at 3:23 PM, Resident 1's medication orders and care plans were reviewed. Resident 1's medication orders indicated Resident 1 was taking Tylenol and tramadol for pain and Ativan for anxiety. Resident 1's care plans indicated Resident 1 had care plans for the use of Tylenol, morphine, and Xanax, but no care plans for tramadol and Ativan. MDS Coordinator stated Resident 1's care plans did not indicate revisions to remove the discontinued medications and include tramadol and Ativan. The MDS Coordinator stated whoever received the orders should be able to change the care plan or inform the MDS Coordinator. The MDS Coordinator further stated if they are not informed, they will not be able to update the care plan. During a concurrent interview and record review with the Director of Nursing (DON), on 6/16/2023, at 2:40 PM, Resident 1's medication orders and care plans were reviewed. Resident 1's medication orders indicated tramadol, morphine, and Ativan were ordered and morphine and Xanax were discontinued. A review of Resident 1's care plan indicated the MDS Coordinator revised the care plan to include tramadol and Ativan and remove morphine and Xanax on 6/15/2023. The DON stated the nurse who took in the order should have revised the care plan when the order was placed. A review of the facility's policy and procedure, revised 2/2004 and reviewed 7/28/2022, indicated any changes in the resident's status will be put on the care plan as they occur.

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 F0659 (Tag F0659)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a qualified person in accordance with the written plan of care for one of three sampled residents (Resident 1) when the following occurred: A. Security Guard (SG) 1 was assigned to Resident 1 as a one-to-one sitter (staff member that is responsible for closely watching over and assisting residents as needed). B. Certified Nursing Assistant (CNA) 2, who was pending official certification at the time of assignment, was assigned to Resident 1 as a one-to-one sitter. This deficient practice had the potential for Resident 1's care to be negatively affected and delayed. Findings: A review of Resident 1's admission Record, dated 6/15/2023, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of brain (a fast-growing cancer that spreads to other areas of the brain), anxiety disorder, history of falling, and generalized muscle weakness. A review of Resident 1's Minimum Data Set (MDS - an assessment and care planning tool), dated 4/1/2023, indicated Resident 1 was cognitively intact (able to understand and make decisions), required supervision to one-person limited assistance with activities of daily living (ADL - tasks of everyday life, such as surface to surface transfers, dressing, eating, and personal hygiene), and has fallen in the facility two or more times since admission. A review of Resident 1's Care Plan, revised 4/17/2023, indicated Resident 1 is a high risk for further falls due to unsteady gait (manner of walking), unsteady balance, noncompliance with safety device, behavioral problems, medication side effects, weakness, and recent fall on 4/17/2023. The care plan indicated fall management interventions include one-to-one sitter. The care plan indicated other interventions include CNAs, Licensed Vocational Nurses (LVN), Registered Nurses (RN), Physical Therapists (PT), and Physical Therapy Assistants (PTA) observe for unsteady gait and or balance and assist as necessary. The care plan indicated CNAs, LVNs, and RNs provide safe environment, free of clutter, clear floors, and adequate lighting. The care plan did not indicate that a security guard can carry out the interventions. A. A review of SG 1's Employment Application, dated 10/18/2022, indicated SG 1 applied for any work and the dietary department. A review of the facility's Staff Assignment, dated 5/5/2023, indicated SG 1 was assigned to Resident 1 as a one-to-one sitter from 11:00 PM to 7:00 AM. During an interview with Responsible Person (RP) 1, on 6/14/2023, at 3:00 PM, RP 1 stated Resident 1 had a SG as his one-to-one sitter. During an interview with the Assistant to the Administrator (AA), on 6/16/2023 at 11:16 AM, the AA stated SG 1 no longer works in the kitchen and usually works security at night. During an interview with the Housekeeping Supervisor (HS), on 6/16/2023, at 11:23 AM, the HS stated SG 1 works security and part-time in the laundry department. HS further stated SG 1 worked with the dietary department a couple months ago. During an interview with SG 1, on 6/16/2023, at 11:28 AM, SG 1 stated he has been working in the facility since 1/2023 and started as a dietary aide. SG 1 stated he currently works part time as security. SG 1 stated he was assigned as a one-to-one sitter to Resident 1 for two shifts. SG 1 stated he is not a CNA or a licensed staff member, such as a RN or LVN. SG 1 stated he was limited to what he can do for Resident 1. SG 1 stated if Resident 1 needed to be cleaned or changed, SG 1 would need to call on CNAs to assist Resident 1. SG 1 further stated when someone who is not certified is sitting for a resident, there is a possibility for a delay in care because the uncertified staff member would have to call for assistance for the resident, which could take between 10 to 15 minutes to have the resident's needs addressed. During an interview with the Director of Staff Development (DSD), on 6/16/2023, at 2:11 PM, the DSD stated he was told that anyone can be used as a one-to-one sitter. The DSD further stated that SG 1 is not part of the nursing staff. During an interview with the Director of Nursing (DON), on 6/16/2023, at 2:40 PM, the DON stated she was not aware the SG 1 was assigned as a one-to-one sitter for Resident 1. The DON further stated based on the policy, SG 1 should not have been assigned as a one-to-one sitter. B. A review of CNA 2's Employment Application, dated 5/22/2023, indicated CNA 2 applied for a CNA position in the facility. A review of CNA's 2's Licensing & Certification Detail Page, dated 6/13/2023, indicated CNA 2's title is CNA and is effective as of 6/8/2023 and the status is active and employable. During an interview with CNA 2, on 6/16/2023, at 10:45 AM, CNA 2 stated she started working in the facility on 5/30/2023. CNA 2 stated on 6/4/2023 and 6/5/2023, she was assigned to Resident 1 as a one-to-one sitter. CNA 2 stated she was limited at what she can do for Resident 1 as a one-to-one sitter because she was waiting for her certification number. CNA 2 stated when Resident 1 needed help to go to the restroom or use the bathroom, she had to call other CNAs to help Resident 1. During an interview with the DON, on 6/16/2023, at 2:40 PM, the DON stated, CNAs waiting for certification can be sitters, they are just waiting to be certified. A review of the facility's Policy & Procedures (P&P), dated 8/2006 and reviewed 7/28/2022, indicated the facility's nursing staff may serve as a private duty sitter when approved by the Director of Nursing Services.

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 F0947 (Tag F0947)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide in-services or training for two of two sampled staff members (Certified Nursing Assistant [CNA] 2 and Security Guard [SG 1]) when CNA 2 and SG 1 were not provided training regarding one-to-one sitter (staff member that is responsible for closely watching over and assisting residents as needed) prior to taking care of one of three sampled residents (Resident 1) with a one-to-one sitter. This deficient practice had the potential for CNA 2 and SG 1 to not provide adequate care to Resident 1. Findings: A review of Resident 1's admission Record, dated 6/15/2023, indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of brain (a fast-growing cancer that spreads to other areas of the brain), anxiety disorder, history of falling, and generalized muscle weakness. A review of Resident 1's Minimum Data Set (MDS - an assessment and care planning tool), dated 4/1/2023, indicated Resident 1 was cognitively intact (able to understand and make decisions), required supervision to one-person limited assistance with activities of daily living (ADL - tasks of everyday life, such as surface to surface transfers, dressing, eating, and personal hygiene), and has fallen in the facility two or more times since admission. A review of Resident 1's Care Plan, revised 4/17/2023, indicated Resident 1 is a high risk for further falls due to unsteady gait (manner of walking), unsteady balance, noncompliance with safety device, behavioral problems, medication side effects, weakness, and recent fall on 4/17/2023. The care plan indicated fall management interventions include one-to-one sitter. During an interview with CNA 2, on 6/16/2023, at 10:45 AM, CNA 2 stated she was assigned to Resident 1 as a one-to-one sitter on 6/4/2023 and 6/5/2023. CNA 2 stated prior to working as a sitter, she did not receive in-service or training to be a sitter. CNA 2 stated she was told to just watch the resident and make sure he does not fall. CNA 2 further stated if she had more training as a sitter, she would feel more comfortable taking care of the residents. During an interview with SG 1, on 6/16/2023, at 11:28 AM, SG 1 stated he was assigned to Resident 1 as a one-to-one sitter for two shifts. SG 1 stated he did not receive training prior to being assigned to Resident 1 as a one-to-one sitter. During an interview with the Director of Staff Development (DSD), on 6/16/2023, at 2:11 PM, the DSD stated CNA 2 and SG 1 did not receive training or in-service regarding one-to-one sitter. The DSD further stated CNA 2 and SG 1 were verbally told what to do. The DSD stated there is no paperwork to indicate CNA 2 and SG 1 were given verbal instructions for one-to-one sitter. During an interview with the Director of Nursing (DON), on 6/16/2023, at 2:40 PM, the DON stated CNAs do not require training or in-services because they already have training to take care of residents. The DON further stated non-nursing staff sitters should have been given training for one-to-one sitting. A review of the facility's policy and procedure (P&P) titled, In-Service Training Program, Nurse Aide, revised 9/2011 and reviewed 7/28/2022, indicated all training classes attended by the employee shall be entered on the respective employee's Employee Training Attendance Record by the department supervisor or other person(s) as designated by the supervisor. The P&P further indicated records shall be filed in the employee's personnel file or shall be maintained by the department supervisor.

Jun 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to report the allegation of staff to resident abuse to the State Survey Agency (SSA) for one of nine sampled residents (Resident 2). This deficient practice had the potential to result in unidentified abuse and failure to protect other residents from abuse. Findings: A review of Resident 2 ' s admission Record indicated the facility admitted the resident on 5/15/2023 with diagnoses including peritoneal adhesions (an irritation of a membrane that lines the inside of the abdomen and pelvis by infection or surgical trauma), type two diabetes mellitus (a disease that occurs when the blood sugar levels were too high), and anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread , and uneasiness). A review of Resident 2 ' s Minimum Data Set (MDS – a standardized assessment and care-screening tool), dated 5/21/2023, indicated the resident was cognitively (conscious mental activities including thinking, reasoning, understanding, learning, and remembering) intact. The MDS indicated Resident 2 did not have behavior symptoms. Resident 2 required extensive assistance (resident involved in activity and staff provide weight bearing support) on bed mobility. A review of Resident 2 ' s Situation, Background, Assessment, and Recommendation (SBAR) Communication Form and Progress Note, dated 6/7/2023, indicated that CNA 2 allegedly pushed the resident on the wall. Resident 2 ' s family was notified on 6/7/2023 at 9:52 a.m. and the primary care clinician was notified on 6/7/2023 at 10 a.m. On 6/14/2023 at 6:15 a.m. and 7:55 a.m., attempted to contact CNA 2 but she did not answer and did not return the call. On 6/14/2023 at 6:48 a.m., during an interview, LVN 4 stated that on 6/7/2023 at 3:30 a.m., the family member called the facility and stated he received a text message from the resident indicating CNA 2 hit the resident. LVN 4 went to check on Resident 2 while the family member was on the phone and found the resident sitting in bed and holding the cellphone. LVN 4 stated that CNA 2 was sitting on a chair, close to bed B ' s foot part of the bed, facing Resident 2 with a safety mattress in between the resident and the CNA. LVN 4 stated she reported the incident to RN 4. On 6/14/2023 at 12:24 p.m., during an interview, the Administrator (ADM) stated he is the facility ' s abuse coordinator. The ADM stated that the allegation of abuse happened on 6/7/2023 at 3:30 a.m. and he was informed immediately, and an investigation was initiated. The ADM stated that he did not report the incident to SSA because Resident 2 ' s statements were constantly changing and later retracted the allegation. The ADM stated he was aware allegations of abuse must be reported within two hours to the SSA, Ombudsman, and to the law enforcement. A review of the facility ' s policy and procedure titled, Elder Justice Act, revised on 7/28/2023, indicated the ADM, Director of Nursing (DON), or any other designated individual will report within the required time frames, any reasonable suspicion of a crime against a resident to the SSA and local law enforcement agency. The policy also indicated the timing of reporting if the event involves abuse or results in serious bodily injury, the suspicion will be reported immediately but no later than 2 hours after forming the suspicion.

Apr 2023 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure four of five sampled residents (Resident 5, Resident 7, Resident 8, and Resident 9) were free of any significant medication errors (administration of medications which was not in accordance with accepted professional standards and principles). This deficient practice had the potential to result in the residents' blood pressure, heart rate, and blood sugar to increase and place the residents' health and safety at risk. Findings: A. A review of Resident 5 ' s admission Record indicated the facility admitted the resident on 8/16/21 with diagnoses including intellectual development disorder (a type of disorder when individual have trouble with learning, communicating, thinking rationally, making judgments, and planning), tachycardia (rapid beating of the heart), ileostomy and colostomy (openings in the belly to create an opening from an area inside the body to outside). A review of Resident 5 ' s History and Physical (H&P), dated 12/28/2022, indicated that the resident lacked the capacity to make decisions. A review of Resident 5 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 2/23/2023, indicated the resident had severe impaired cognition (when person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS further indicated the resident required supervision with eating, two-person assistance with mobility and transferring, one person assistance with dressing and toileting and personal hygiene and bathing. A review of Resident 5 ' s Order Summary, dated 12/7/2022, indicated to give Metoprolol Tartare Tablet 25 milligrams (mg/a unit of measurement) by mouth in the morning for high HR (heart rate), hold medication for HR below 60 or SBP (Systolic Blood Pressure) less than 110 and administer with meal. On 4/3/2023 at 12:27 p.m., during a concurrent medication administration observation and interview, Licensed Vocational Nurse (LVN )1 took Resident 5 ' s BP (blood pressure) with measurement of 112/72 and a pulse 93. LVN 1 administered Metoprolol 25 mg by mouth to Resident 5. LVN 1 stated she was administering the medication scheduled for 9 a.m. late because the facility was short of staff today. LVN 1verified she came in late to help administer medication. LVN 1further stated she regularly works as MDS nurse. B. A review of Resident 7 ' s admission Record indicated the facility admitted the resident on 2/7/2023 with diagnoses of essential hypertension( a condition in which the blood vessels have persistently raised pressure), congestive heart failure( a condition that develops when your heart does not pump enough blood for your body ' s needs), and seizures (a condition a burst of uncontrolled electrical activity between brain cells that caused temporary abnormalities in muscle tone or movements, behaviors, sensations or states of awareness). A review of Resident 7 ' s H & P, dated 1/11/2023, indicated Resident 7 had the capacity to understand and make decisions. A review of Resident 7 ' s MDS, dated [DATE], indicated Resident 7 required supervision with eating, required two-person extensive assistance with bed mobility, walking and transferring, required one-person assistance with dressing, toileting, personal hygiene, and bathing. A review of Resident 7 ' s Order summary, dated 1/10/2023, indicated Amlodipine Besylate Oral Tablet 10 mg by mouth one time a day related to essential hypertension. The order further indicated to hold for SBP less than 110 or pulse less than 60. A review of Resident 7 ' s medication administration record (MAR), dated 3/28/2023, indicated that Amlodipine Besylate scheduled at 9 a.m. was administered to resident at 11:30 a.m. A review of Resident 7 ' s MAR, dated 4/3/2023, indicated Amlodipine Besylate scheduled at 9 a.m. and administered to resident at 11:51 a.m. C. A review of Resident 8's admission Record indicated the facility admitted the resident on 1/26/2023 with diagnoses including cerebral infarction (a type of stroke that occurs when the supply of blood to the brain is reduced or blocked completely), essential hypertension, type 2 diabetes mellitus. A review of Resident 8's H & P, dated 1/26/2023, indicated Resident 8 had fluctuating capacity to understand and make decisions. A review of Resident 8's MDS, dated [DATE] indicated the Resident 8 was unable to walk, required supervision for eating, and two-person extensive assistance with bed mobility and, transfer. A review of Resident 8's order summary, dated 1/26/2023, indicted to give Lisinopril Oral Tablet 20 mg by mouth one time a day related to essential hypertension. Hold for SBP less than 110 or pulse less than 60. A review of Resident 8's MAR, dated 4/1/2023, indicated Lisinopril 20 mg was scheduled for administration at 9 a.m. and was administered at 11:41a.m. A review of Resident 8's MAR, dated 4/03/2023, indicated Lisinopril 20 mg was scheduled for administration at 9 a.m. and was administered at 2:11 p.m. D. A review of Resident 9 ' s admission Record, indicated the facility admitted the resident on 5/17/2021 with diagnosis including type 2 diabetes mellitus, atrial fibrillation (an irregular heartbeat that occurs when the electric signals in the atria (the two upper chamber of the heart) fire rapidly at the same time), and muscle weakness (a lack of strength in the muscles). A review of H&P, dated 1/17/2023, indicated Resident 9 had fluctuating capacity to understand and make decisions. A review of Resident 9 ' s MDS, dated [DATE], indicated Resident 9 was unable to walk, required supervision with eating, and extensive 2-person assistance with transferring. A review of Resident 9 ' s Order Summary from 1/9/2023, indicated order for Amiodarone HCL give 100 mg by mouth one time a day related to atrial fibrillation, hold for pulse less than 60. A review of Resident 9 ' s MAR, dated 3/28/2023, indicated Amiodarone HCL was scheduled at 9 a.m. and administered to Resident 9 at 10:19 p.m. A review of Resident 9 ' s MAR, dated 3/31/2023, indicated Amiodarone HCL was scheduled at 9 a.m. and administered to Resident 9 at 10:32 p.m. A review of Resident 9 ' s MAR. dated 3/31/2023, indicated Amiodarone HCL was scheduled at 9 a.am. and administered to Resident 9 at 12:05 p.m. A review of Resident 9 ' s Order Summary on 3/7/2023, indicated to inject Humulin 70/30 10 units subcutaneously two times a day related to type 2 diabetes mellitus, to give with meal, and rotate sites. A review of Resident 9 ' s MAR, dated 3/28/2023, indicated 10 units of Humulin70/30 scheduled at 9 a.m. and 5 p.m. administered at 10:24 a.m. and 6:42 p.m. The MAR further indicated a blood sugar reading of 457 at 10:24 a.m. and 352 at 6:42 p.m. A review of Resident 9 ' s MAR, dated 4/03/2023, indicated 10 units of Humulin 70/30 scheduled at 9 a.m. and 5 p.m. and was administered at 12:05 p.m. and 8:55 p.m. On 4/4/2023 at 11:19 a.m., during an interview, LVN 2 stated that according to Policy and Procedure the medication should be administered within one hour of scheduled time. LVN 2 stated Nurse should prioritize administration of medication for residents in pain, antibiotics, and high blood pressure medication. LVN 2 stated late administration of medications can potentially affect residents' outcome and compromise residents' health. On 4/4/2023 at 11:49 a.m., during an interview, Licensed Vocational Nurse (LVN )3 stated scheduled medications can be administered 30 minutes before or after scheduled time. LVN stated, it was not acceptable to administer blood pressure medications late because of risk of stroke to the resident. On 4/4/2023 at 2:47 p.m., during an interview and concurrent record review, the Director of Nursing (DON) stated medications can be administered within one hour of schedule, nurses should prioritize administration of insulins, blood pressure medications, antibiotics, and pain medications. DON stated late administration of medications has a potential for interactions with next scheduled medications and may lead to change in residents' condition. A review of the facility ' s policy and procedure titled, Medication administration, reviewed on 7/28/2022, indicated, Medications are to be administered within one (1) hour before or one (1) after the prescribed time.

Apr 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure blood pressure medications were not administered as per physician's order for one of four sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to develop adverse effects such as low blood pressure, low pulse rate, dizziness, and shortness of breath. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 2/20/2023 with diagnoses including end stage renal disease (ESRD - a condition in which the kidneys cease functioning on a permanent basis leading to the need for dialysis (the process of removing excess water, and toxins from the blood in people whose kidneys can no longer perform these functions naturally) to maintain life, atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and congestive heart failure (a condition in which the heart doesn't pump blood as well as it should). A review of Resident 1 ' s Minimum Data Set (MDS – an assessment and care screening tool), dated 2/26/2023, indicated resident had an intact cognition (mental action or process of acquiring knowledge and understanding). The MDS indicated Resident 1 required supervision with eating, required total assistance from staff with transfers and dressing, and extensive assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). A review of Resident 1 ' s physician ' s order indicated the following orders: 1. Metoprolol succinate ER [extended release - slowly released into the body over a period of time, usually 12 or 24 hours] (medication used to treat high blood pressure) oral tablet 50 milligrams (mg – unit of measure) give 50 mg by mouth every 12 hours. Hold if systolic blood pressure (SBP - the top number, measures the force your heart exerts on the walls of your arteries each time it beats) is less than 110 or pulse less than 60 and to give with food. 2. Valsartan oral tablet 40 mg by mouth one time a day. Hold for SBP less than 110 or pulse less than 60. During a concurrent interview and record review, on 3/17/2023 at 12:53 p.m., the Medication Administration Record (MAR) and physician ' s order were reviewed with the Assistant Director of Nursing. The ADON stated Resident 1 ' s physician ' s order was to hold metoprolol succinate ER and valsartan if SBP is less than 110 or pulse is less than 60. The ADON stated that the metoprolol succinate ER 50 mg and valsartan 40 mg were administered on the following days and time: 1. On 2/21/2023 9 a.m., metoprolol succinate ER 50 mg was given even if Resident 1's SBP was 90 millimeters of mercury (mmHg – a unit of measurement). 2. On 2/21/2023 9 a.m., valsartan 40 mg was given even if Resident 1's SBP was 90 mmHg. 3. On 2/21/2023 9 p.m., metoprolol succinate ER 50 mg was given even if Resident 1's SBP was 94 mmHg. The ADON stated the licensed nurses check the vital signs including blood pressure and heart rate before giving a blood pressure medication and document in the resident ' s medical records. The ADON stated that licensed nurse should not have administered the medications as indicated in the physician ' s order since Resident 1 ' s SBP was below 110 and ADON further stated the ordered parameters were not followed. The ADON stated administering blood pressure medications below the ordered parameters have the potential to further drop the resident ' s blood pressure. A review of the facility ' s policy and procedure titled, Administering Medications, last revised on 4/2019, indicated medications are administered in accordance with the prescriber orders, including any required time frame.

Apr 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0624 (Tag F0624)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to safely discharge on e of four sampled residents (Resident 1). On 12/2/2022, the facility discharged Resident 1 to an unlicensed independent living with no wheelchair access This deficient practice resulted in Resident 1 not being happy in the facility and moving to another location. Findings: A review of Resident 1 ' s admission Record (Face Sheet) indicate the facility admitted the resident on 9/9/2022 with diagnoses including non-ST elevation myocardial infarction (NSTEMI - a less severe form of heart attack because it inflicts less damage to the heart), right elbow effusion (abnormal collection of fluid in hollow spaces or between tissues of the body), muscle weakness, and hypertension (uncontrolled elevated blood pressure). A review of Resident 1 ' s History and Physical exam dated 9/21/2022 indicated the resident had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 9/15/2022, indicated the resident was able to understand, communicate needs and able to make decisions. Resident 1 needed extensive assistance from staff for most activities of daily living (ADLs - bed mobility, transfers, dressing, toilet use and personal hygiene). Resident 1 uses an electric chair as mobility device. A review of Resident 1 ' s Progress Notes, dated 11/11/2022, indicated a discharge care planning was held with Social Service Director (SSD), Fall Coordinator (FC), Charge Nurse (CN 1), Resident 1, and Referral Services Representative 1 (RSR 1). The RSR 1 indicated Resident 1 was accepted at Homeowner 1 ' s (HO 1). A review of the Physician ' s Order for Resident 1, dated 12/1/2022, indicated to discharge the resident to an assisted living private residence on 12/2/2022. A review of Resident 1 ' s Post Discharge Plan of Care dated 12/2/2022 indicated, resident had electric wheelchair. A review of Resident 1 ' s Progress Notes dated 12/5/2022 timed at 14:59 indicated the Social Service Assistant (SSA) made a discharge follow up call to Resident 1 and the resident indicated he was doing fine but was not happy with the place. During an interview on 4/7/2023 at 12:30 p.m., Licensed Vocational Nurse 1 (LVN 1) stated she discharged the resident on 12/2/2022 to a private residence. LVN 1 stated Resident 1 informed her the residence had a wheelchair access. LVN 1 stated if she had known that the residence did not have a wheelchair access, she would not discharge him for his safety. During an interview on 4/7/2023 at 12:48 p.m., the SSD stated she did not check if the home had a wheelchair access. The SSD stated s HO 1 informed her that the residence had a wheelchair access, and HO 1 came to visit the resident at the facility, but she did not document it in the Resident 1 ' s medical record. During an interview on 4/7/2023 at 2:08 p.m., the Assistant Director of Nursing (ADON) stated the facility ' s policy did not indicate a need to discharge residents to a licensed facility. During an interview on 4/7/2023 at 2:32 p.m., the SSA stated she made the follow up call on 12/5/2022 after Resident 1 was discharged on 12/2/2022. The SSA stated Resident 1 informed her he was not happy in HO 1 ' s residence. SSA stated she did not recall asking Resident 1 way was him the reason why he was not happy in his new residence. The SSA stated she reported it to the SSD. During an interview on 4/7/2023 at 2:56 p.m., DON stated she was not informed of the follow up call after Resident 1 ' s was discharged . During an interview on 4/7/2023 at 3:41 p.m., ADM stated the discharge of Resident 1 should be according to resident ' s needs. During an interview on 4/11/2023 at 4:52 p.m., RSR 2 stated she had received complaints about HO 1 ' s residence. RSR 2 stated they were informed Resident 1 had a problem getting in and out the home and had a hard time turning around in the bathroom. RSR 2 stated Resident 1 left HO 1 ' s residence. RSR 2 stated HO 1 had a licensed residence somewhere else but not the residence where Resident 1 was discharged . A review of facility ' s policy and procedure titled, Transfer or Discharge Documentation, dated 12/2016 and reviewed on 7/28/2022, indicated, Should a resident be transferred or discharged for any reason, the following information will be communicated to the receiving facility or provider, g. All other necessary information, including a copy of the resident ' s discharge summary, and any other documentation, as applicable, to ensure a safe and effective transition of care.

Feb 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided a safe environment. On 1/23/2023 at 8:01 p.m., three visitors forcibly took Resident 1 out of bed onto a wheelchair, out of the facility and into a van, driving off to an unknown location. The door (located at Nursing Station 5) used by the three abductors to gain access to Resident 1 should have been locked at 6 p.m. As a result, Resident 1 did not receive the necessary nutrition and oxygen supply on 1/23/2023 from 8:00 p.m. to 11:25 p.m., when the police located Resident 1 and paramedics (emergency medical services [EMS]) transferred him to General Acute Care Hospital 1 (GACH 1) because of shortness of breath. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 12/15/2022 with diagnoses including COVID-19 (Coronavirus Disease 2019, a highly contagious respiratory disease that spread from person to person), dysphagia (difficulty swallowing) with gastrostomy tube (GT, a soft tubing inserted surgically [means of a medical operation] into the stomach through the abdominal wall for the purpose of administering food and medication), hypertension (uncontrolled elevated blood pressure), and urinary tract infection (UTI). A review of Resident 1 ' s Power of Attorney (POA - legal document that allows someone else to act on his behalf), dated 12/3/2022 (prior to the resident ' s admission to the facility), indicated Resident 1 appointed Family Member 1 (FM 1) to make all medical decisions on his behalf. The POA was signed and dated by Resident 1, FM 1, first witness, and second witness on 12/3/2022. A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 12/21/2022, indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision-making were moderately impaired. Resident 1 required extensive assistance with bed mobility, transferring from and to bed, toilet use and personal hygiene. A review of Resident 1 ' s nursing Progress Notes, dated 1/3/2023, indicated FM 1 told staff not to allow Female Visitor 1 (FV 1) to visit Resident 1. Social Service Director (SSD) and Wound Coordinator (WC) explained to FV 1 the wishes of FM 1. A review of the Physician ' s Orders for Resident 1, dated 1/17/2023, indicated: - Jevity® 1.5 feeding formula at 70 cubic centimeters per hour (cc/hr), pump (feeding delivery machine) to run for 20 hours from 1 p.m. to 9 a.m. or until dose limit met. - Oxygen at 2 liters per minute (L/min) via nasal cannula (soft tubing device designed to administer oxygen, one end splits into two prongs which are placed in the nostrils [the two openings in the nose] and from which a mixture of air and oxygen flows into the nose) as needed for shortness of breath and may titrate (increase) up to 4 L/min to maintain oxygen saturation (blood oxygen level) above 90%). A review of Resident 1 ' s History and Physical exam dated 1/18/2023, the attending physician indicated the resident was hospitalized from [DATE] to 1/17/2023, due to altered level of consciousness (ALOC, a state of reduced alertness or inability to arouse due to low awareness of the environment). Resident 1 was found to have bacteremia (blood infection) and tested positive for COVID-19. Resident 1 was ordered two antibiotics (to treat infections) through the GT for 14 days (ending on 1/27/2023). A review of Resident 1 ' s nursing Progress Notes, dated 1/20/2023, indicated the resident had a male visitor (MV 1) who was unable to provide the password, set by FM 1 as a security measure, before anybody could visit Resident 1. Registered Nurse 1 (RN 1) asked MV 1 to leave and MV 1 got mad and used foul language. A review of Resident 1 ' s Situation Background Assessment Recommendation (SBAR, technique that provides a framework for communication between members of the health care team about a resident ' s condition) Communication Form, dated 1/23/2023, indicated at 8 p.m., Resident 1 was forcibly taken out of the facility by FV 1, MV 1, and MV 2. The SBAR indicated the nurses called 911 (emergency telephone number to request police assistance). Police officers arrived after Resident 1 was already taken away in a van by the three visitors (FV 1, MV 1, and MV 2). On 1/24/2023 at 12:18 p.m. during an interview, Licensed Vocational Nurse 2 (LVN 2) stated that at the time of the abduction (on 1/23/2023 at 8:01 p.m.) Resident 1 was receiving continuous GT feeding (GT was connected to the feeding formula; when GT is not connected it needs to be closed to prevent the gastric content to get out) and was receiving oxygen at 2 L/min via nasal cannula. LVN 2 stated the abduction placed Resident 1 at risk for complications because the GT feeding and the resident needed the ordered oxygen rate to assist him with breathing. On 1/24/2023 at 1 p.m., a review of the facility ' s surveillance video from Camera # 6 (located in the lobby) and Camera # 21 (located outside the facility) for the abduction of Resident 1 on 1/23/2023 was conducted with the Assistant Administrator (AADM) and the Administrator (ADM). Camera #6: 7:59:25 p.m. - FV 1 walking out in the lobby wearing a white mask carrying a blue bag going to the main door. 7:59:34 p.m. - Resident 1 seated in the wheelchair. Wheelchair is pushed by MV 2 towards the direction of the main door. LVN 1 walking with them towards the door. 7:59:39 p.m. - LVN 4 following LVN 1. 7:59:42 p.m. - LVN 1 attempting to hold Resident 1 ' s wheelchair. FV 1 came closer to LVN 1 and lifted Resident 1 ' s wheels in front. 7:59:52 p.m. - FV 1 and MV 2 took Resident 1 out of the main door. 7:59:54 p.m. - LVN 1 and LVN 4 walk back inside the facility. 8:00:46 p.m. - MV 1 appear on the camera wearing a blue jacket and carrying a black cloth. 8:01:10 p.m. - Registered Nurse 1 (RN 1) with LVN 1 and two other staff walking towards the door and went out of the facility. Camera #21: 7:59:56 p.m. - FV 1 and MV 2 left with Resident 1. On 1/24/2023 at 1:14 p.m. during an interview, LVN 1 stated on 1/23/2023 before 8 p.m. she went to Nursing Station 5 to pick up a medicine and saw FV 1 with MV 1 and MV 2 walking in the hallway. LVN 1 stated she recognized FV 1 who was not supposed to visit Resident 1. LVN 1 stated she walked back to Nursing Station 1 to Resident 1 ' s room and saw the resident in bed and the three visitors standing beside Resident 1. LVN 1 stated she informed FV 1 that she was not allowed to visit Resident 1, but FV 1 got confrontational and claimed she had the POA. LVN 1 stated she went out of Resident 1's room and paged (using a loudspeaker system) RN 1 and called LVN 4 for assistance. LVN 1 stated she and LVN 4 went back to Resident 1's room and saw the three visitors wheeling the resident out in the hallway and they followed them until they reached the main entrance. LVN 1 stated the forgot to page Dr. Strong (the code to announce when there is combative or aggressive resident). LVN 1 stated if she had announced the code, staff could have helped and maybe prevent the three visitors from taking Resident 1 out of the facility. On 1/24/2023 at 1:31 p.m., during an interview, the AADM stated LVN 1 should have paged the code if she wanted to stop somebody from coming in or from coming out of the facility. The AADM stated RN 1 hesitated calling the code because she thought she could stop the visitors from taking the resident out. On 1/24/2023 at 1:48 p.m. during an interview, RN 1 stated she heard the overhead page to go to Station 1 on 1/23/2023 around 8 p.m. and she went right away. LVN 1 informed her of what had happened, she ran outside, and saw the three people transferring Resident 1 from the wheelchair to a white van parked in the street. RN 1 stated Resident 1 was moaning and appeared to be in pain but when she touched the wheelchair, FV 1 told RN 1 not to touch Resident 1. RN 1 stated MV 2 was holding on the oxygen tank. RN 1 stated LVN 1 should have called the code first rather than just calling RN 1 and could have prevented the three visitors from taking Resident 1 away. On 1/27/2023 at 11:31 a.m., a review of the facility ' s surveillance video from Camera # 11 (located in the parking lot) and Camera # 9 (located in Nursing Station 5) for the abduction of Resident 1 on 1/23/2023 was conducted with the AADM and the ADM. Camera # 11: 19:41:58 p.m. - FV 1 walking in the parking lot followed by MV 2 and MV 1 was pushing a wheelchair. 19:42: 07 p.m. - FV 1 opened Station 5 door 19:42:19 p.m. - The three visitors were all inside the facility with wheelchair. Camera # 9: 7:42:17 pm - The three visitors opened the door and walked inside towards Nursing Station 5. 7:47:03 pm - The three visitors turned to the right towards Nursing Station 3. During an interview on 1/27/2023 at 12:13 p.m., LVN 1 stated she called 911 using her cellphone on 1/23/2023 at 8 p.m. while they were already outside trying to stop the visitors from transferring Resident 1 from wheelchair to the van. LVN 1 stated she did not know who disconnected Resident 1's GT. On 1/27/2023 at 4:13 p.m., during an interview, the ADM stated the door to the outside at Nursing Station 5 should be locked at 6 p.m. The ADM was not able to provide any other policies and procedures on resident safety, code to call, and doors being locked from the outside that is related to this situation. A review of Resident 1 ' s (GACH 1) emergency room (ER) documentation dated 1/23/2023 timed at 11:37 p.m., indicated Emergency Medical Service (EMS) brought Resident 1 from a residence with fever, congestion (excessive mucus in the air passages), and 87% oxygen saturation (normal above 95%). A review of Resident 1 ' s readmission to the facility indicated, the resident returned to the facility on 1/23/2023.

CONCERN (D) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility staff failed to maintain complete and accurate medical records in accordance with accepted professional standards for one of three sampled residents (Resident 1) who was forcibly taken out of the facility on 1/23/2023. This deficient practice had the potential to result in confusion in the care and services rendered to Resident 1 and resulted in inaccurate information entered into Resident 1's clinical record. Findings: A review of Resident 1 ' s admission Record indicated the facility admitted the resident on 12/15/2022 with diagnoses including Coronavirus Disease 2019 (COVID-19- highly contagious respiratory disease is thought to spread from person to person through droplets released when an infected person coughs, sneezes or talks. It may also be spread by touching a surface with the virus on it and then touching one ' s mouth, nose, or eyes), sepsis (body ' s overwhelming and life-threatening response to infection), dysphagia (difficulty in swallowing), and hypertension (uncontrolled elevated blood pressure). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care-screening tool), dated 12/21/2022, indicated Resident 1 ' s cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions were moderately impaired. The MDS indicated Resident 1 requires extensive assistance for moving in bed, transferring to bed to chair, toilet use and personal hygiene. The MDS indicated Resident 1 had an abdominal tube (feeding tube - a flexible tube surgically inserted through abdomen into the stomach for feeding, fluid, and medication administration). A review of Resident 1 ' s Situation Background Assessment and Recommendation (SBAR) Communication form, dated 1/23/2023, indicated at 8 p.m., Resident 1 was forcefully taken out of the facility by one female visitor (FV 1) and two male visitors (MV1 and MV 2). A review of Resident 1 ' s Progress Note, dated 1/23/2023, indicated Family Member 1 (FM 1) was informed that at 8:15 p.m., FV 1 entered the facility with MV 1 and MV 2 and forcibly removed Resident 1 out of the facility and placed him in a white vehicle. During an interview on 1/24/2022 at 1:14 p.m., Licensed Vocational Nurse 1 (LVN 1) stated on 1/23/2023 before 8 p.m., she went to Station 5 to pick up a medicine and saw FV 1, MV 1, and MV 2 walking in the hallway. LVN 1 stated she recognized FV 1 and there was a request from FM 1 to not allow FV 1 to see Resident 1 in the facility. LVN 1 stated she immediately went to the front lobby and asked Screener 1 if there were any visitors for Resident 1. LVN 1 stated the screener informed her that no one came through the front entrance for Resident 1. LVN1 stated she immediately went to Resident 1 ' s room and saw the three visitors standing beside Resident 1 ' s bed. LVN 1 stated she informed FV 1 that she was not allowed to visit the resident. LVN 1 stated FV 1 became confrontational, so LVN 1 stepped out of Resident 1's room and overhead paged Registered Nurse 1 (RN 1) and called LVN 4's assistance. LVN 1 stated while they waited for RN 1, she and LVN 4 went back to Resident 1's room and saw resident already seated in a wheelchair being wheeled out of the room in the hallway by MV 2. LVN 1 stated she and LVN 4 tried to stop them until they reach the lobby, but FV 1 and MV 2 were able to take Resident 1 out of the building. LVN 1 stated she and LVN 4 went back inside to call for more assistance. LVN 1 stated RN 1 came with three other staff, but Resident 1 was already out in the street. LVN 1 stated she called 911 at 8:02 p.m. when Resident 1 was already being transferred to the van from the wheelchair by the three visitors. During an interview on 1/26/2023 at 7:32 p.m., and concurrent record review of Resident 1 ' s Progress Notes, dated 1/23/2023, RN1 stated the Progress Notes indicated LVN 1 documented Resident 1 was forcefully taken out of the facility by FV 1. The RN 1 stated LVN 1 should document accurately all the interventions provided before the resident was taken out of the facility by the three visitors because if it was not documented it was not done. During an interview on 1/27/2023 at 10:49 a.m., the Director of Staff Development (DSD) stated nurses should document all the things they did to stop the three visitors from taking Resident 1 out of the facility for legal purposes. During an interview on 2/6/2023 at 11 a.m., the Director of Nursing (DON) stated LVN 1 did not document interventions done before Resident 1 was taken out of the facility. DON stated LVN 1 should document all interventions to show what actions were done in these situations and for resident safety. A review of facility ' s policy and procedure titled, Charting and Documentation, dated 7/2017, indicated, All services provided to the resident, progress toward the care plan goals, or any changes in the residents medical, physical, functional, or psychosocial condition, shall be documented in the residents ' medical records. The medical record should facilitate communication between the interdisciplinary team regarding the resident ' s condition and response to care. Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate.

Feb 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure that one of four licensed vocational nurses (LVN 1) had the required license necessary to provide care and treatment to all residents in the facility. LVN 1 was hired on 10/6/2022 and the license issue date was 12/20/2022. This deficient practice had the potential to risk the residents' care and safety. Findings: During an interview on 12/29/2022 at 1:30 p.m., and concurrent record review of LVN 1's employee file, the Director of Staff Development (DSD) stated LVN 1 ' s employee file indicated the hire date and the license issue date. The DSD stated LVN 1 was hired on 10/6/2022 and worked with residents but LVN 1's license issue date was 12/20/2022. The DSD stated he was not sure what happened. During an interview on 12/29/2022 at 1:45 p.m., LVN 1 stated she was hired on 10/6/2022, and her license was issued on 12/20/2022. LVN 1 stated she passed her National Council Licensure Examination (NCLEX) on 9/17/2022 and had a congratulation letter. LVN 1 stated she thought her license was already issued at that time. LVN 1 stated that during the hiring process she told the facility she passed the exam and they told her they will check it online. LVN 1 stated her school forgot to pay the required fees to get the license issued. LVN 1 stated she was working the 3 p.m. to 11:30 p.m. shift after she was hired. During a phone interview on 1/4/2023 at 2:54 p.m., the Director of Nursing (DON) stated LVN 1 was hired on 10/6/2022. The DON stated licensed nurses are not supposed to do patient care as a licensed vocational nurse when they do not have a license. During a phone interview on 1/4/2023 at 3:16 p.m., the DSD stated that he does not remember anything and he is not sure if he checked LVN 1 ' s license on 10/6/2022. The DSD stated LVN 1 started working as LVN before her license issue date. The DSD stated that the policy indicated that LVNs should not be hired without a license and they are not supposed to give treatment to resdients for the safety of the residents. A review of the facility ' s policy titled, Credentialing of Nursing Services Personnel, revised on 8/2006, indicated, Nursing personnel who require a license or certification to perform resident care or treatment without direction or supervision must present verification of such license/certification to the Director of nursing Services prior to or upon employment.

Jan 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to provide an environment free from accidents and hazards by failing to ensure the hi/low bed (usually less than a foot [12 inches] from the floor) was not left in the high position increasing the risk for falls with injury for two of two sampled residents (Resident 1 and Resident 2). This deficient practice had a potential for Resident 1 and Resident 2 for falls and sustain a fracture (a partial or complete break in the bone). Findings: 1. A review of Resident 1 ' s admission Record indicated that the facility admitted the resident on 12/15/2022, with diagnoses including signs and symptoms involving the musculoskeletal system (includes bones, muscles, tendons, ligaments, and soft tissues), abnormalities of gait (a manner of walking or moving on foot) and mobility, and sepsis (is the body ' s overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death). A review of Resident 1 ' s History and Physical (H&P), dated 12/3/022, indicated that the resident was awake, alert, oriented, no focal deficits (problems with nerve, spinal cord, or brain function). The H&P indicated Resident 1 was cooperative and with appropriate mood and affect (emotion that changes thoughts or actions). A review of Resident 1 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/21/2022, indicated that the resident had the ability to make self-understood and ability to understand others. The MDS indicated Resident 1 required extensive assistance on bed mobility, transfer, dressing, toilet use, and personal hygiene. The MDS indicated Resident 1 was totally dependent on locomotion on the unit with one to two-persons physical assist. The MDS further indicated Resident 1 was not steady only to stabilize with staff assistance when moving from seated to standing position, walking, turning around, moving on and off the toilet, and surface to surface transfer, such as transfer between bed and chair or wheelchair. A review of Resident 1 ' s Order Summary Report, indicated an order for: -Hi-Lo Bed for safety- bed in low position as much as possible while in bed. Monitor bed position every shift with order date of 12/15/2022. A review of Resident 1 ' s Situation, Background, Assessment, and Recommendation (SBAR, a verbal or written communication tool that helps provide essential, concise information, usually during crucial situations) Communication Form, dated 12/25/2022, indicated that the resident was found sitting on the floor by his bed, no changes in level of consciousness, range of motion (ROM, the extent or limit to which part of the body can be moved around a joint or a fixed point) at baseline. A review of Resident 1 ' s Fall Risk Evaluation, dated 12/25/2022, indicated that the resident was high risk for fall. The Fall Risk Evaluation indicated a plan of hi-low bed, encouraged to keep bed at lowest position, educated on safety and fall risk, preference to perform task independently, encouraged to use call light (a bedside button tethered to the wall in a resident ' s room, which directs signals the nursing station) for help. A review of Resident 1 ' s Care Plan, dated 12/15/2022, indicated that the resident was at risk for further fall(s) related to unsteady gait/balance. The Care Plan indicated hi-lo bed for safety- bed in low position as much as possible while in bed, monitor bed position every shift. During an observation on 1/9/2023, at 10:36 a.m., Resident 1 ' s low bed was on a high position. The bed height indicated 37 inches (in., a unit of length) off the floor using a tape measure. During a concurrent interview, LVN 2 stated that the bed was too high, Resident 1 can fall and sustain a fracture. During a concurrent interview and record review of Resident 1's care plan, LVN 2 stated Resident 1 was at risk for further fall. 2. A review of Resident 2 ' s admission Record indicated that the facility admitted the resident on 1/6/2023, with diagnoses including hemiplegia (a symptom that involves one-sided paralysis) and hemiparesis (a muscular weakness or paralysis restricted to one side of the body) following cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting right dominant side. A review of Resident 2 ' s H&P, dated 12/21/2022, indicated that the resident was awake but does not interact. The H&P also indicated Resident 2 had weakness to the right side of extremities. A review of Resident 2 ' s Order Summary Report, indicated an order for: - Hi-Lo bed for safety- bed in low position as much as possible while in bed. Monitor bed position every shift with order date of 1/6/2023. A review of Resident 2 ' s Care Plan, dated 1/7/2023, indicated that the resident was at risk for fall. During an observation on 1/9/2023, at 1:22 p.m., Resident 2 ' s bed was on a high position with fall mats (are made from high-impact foam and are designed to help prevent injury from potential falls) on both sides of the bed. During a concurrent interview, Nursing Supervisor (Nsg Sup) stated that the bed was placed on a high position because he was going to administer an intravenous (IV, into or within a vein) medication to the resident. During an observation on 1/9/2023, at 1:53 p.m., Resident 2 ' s bed was still in the high position. During an observation on 1/9/2023, at 2:02 p.m., Resident 2 ' s bed was still in the high position. The bed height was measured using a measuring tape indicating 27 in. from the floor to the mattress surface. During an observation on 1/9/2023, at 2:05 p.m., observed RN Sup changed the oxygen tubing (a medical devise to provide supplemental oxygen therapy to residents who have lower oxygen levels) of Resident 2 and placed a date on it. The bed was still not placed on the lowest position. During an observation on 1/9/2023, at 2:14 p.m., observed the height of Resident 2 ' s bed still in the high position. During a concurrent interview of the Nsg Sup and record review of Resident 2's care plan, Nsg Sup stated that Resident 2 was at risk for fall. Nsg Sup stated that he forgot to lower the bed down. Nsg Sup stated that Resident 2 ' s bed should be at the lowest position to prevent falls with injury. During an interview on 1/9/2023, at 11:45 a.m., the Infection Preventionist (IP) stated that the bed of fall risk residents should be placed on the lowest position, with the height of 37 in., it could cause injury such as fracture (a break, usually in a bone). During an interview on 1/9/2023, at 2:40 p.m., the Director of Nursing (DON) stated that the bed should be placed on the lowest position (less than a foot [12 inches] from the floor) for residents who are high risk for fall to prevent injuries such as fractures. A review of the facility ' s current policy and procedure titled, Falls and Fall Risk Managing, dated 6/2018, indicated that based on previous evaluations and current data, the staff will identify interventions related to the resident ' s specific risks and causes to try to prevent the resident from falling and to try to minimize the complications from falling. If falling recurs despite initial interventions, staff will implement additional or different interventions. One or more of the following interventions may be used: - Personal alarm on the bed and/or wheelchair - High/low bed - Sitter select for bed and/or wheelchair - Safety mats - Mattress on the floor - Posey soft rails - Bean bag chair - Increase attendance in Activity Programs - Increased visual monitoring

CONCERN (E) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain its Coronavirus Disease 2019 (COVID-19, a highly contagious disease spread from person to person through droplets released when an infected person coughs, sneezes, or talks) infection prevention and control program by failing the following: 1. Ensure the transport staff transported Resident 3 with a mask covering the resident ' s nose and mouth from a clinic appointment to the resident ' s room. 2. Ensure Certified Nursing Assistant 1 (CNA 1) transported Resident 4 with a mask on to the shower room. 3. Ensure CNA 2 transported Resident 5 with a mask on from the shower room to the resident ' s room. 4. a. Ensure CNA 3 transported Resident 6 with a mask on to the shower room. b. Ensure CNA 3 kept the oxygen tubing (a medical devise to provide supplemental oxygen therapy to people who have lower oxygen levels) off the floor while transporting Resident 6 to the resident ' s room. c. Ensure Staff dated the oxygen tubing of Resident 6 that they use for transport. 5. Ensure CNA 4 transported Resident 7 with a mask on from the shower room to the resident ' s room. 6. Ensure Staff dated the oxygen tubing at the bed side of Resident 2. 7. Ensure Licensed Vocational Nurse 5 (LVN 5) and Dietary Staff (DS) perform hand hygiene (a way of cleaning one's hands that substantially reduces germs on the hands) after COVID-19 testing. 8. Ensure Screener (SC) taught Family Member 1 (FM) how and when to use personal protective equipment (PPE [equipment worn to minimize exposure to hazards that cause serious injuries and illnesses]) while in the facility. These deficient practices had the potential to transmit infectious microorganisms (minute organisms such as bacteria, viruses) to residents and staff in the facility. Findings: 1. A review of Resident 3 ' s admission Record indicated that the facility admitted the resident on 2/7/2020 and readmitted on [DATE] with diagnoses including hypertensive heart disease (heart problems that occur because of high blood pressure that is present over a long time), diabetes mellitus type II (an impairment in the way the body regulates and uses sugar [glucose] as fuel), and heart failure (a condition that develops when your heart does not pump enough blood to the body ' s needs). A review of Resident 3 ' s Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/17/2022, indicated that the resident usually had the capacity to make self-understood and understand others. A review of Resident 3 ' s Care Plan, dated 8/22/2022, indicated that the resident was at risk for COVID-19. During an observation on 1/9/2023, at 9:07 a.m., Resident 3, with the mask on the chin, was being wheeled inside by the ambulance transport (used to get a resident to and from the hospital quickly) staff. Resident 3 was checked in at the nurse ' s station, but nobody asked the transport staff to place the mask correctly to cover the nose and the mouth. During an interview on 1/9/2023, at 9:10 a.m., at Resident 3 ' s Room, CNA 1 stated that the mask was on the chin of the resident and it should cover the nose and mouth of Resident 3 to prevent viruses. During an interview on 1/9/2023, at 9:13 a.m., the Ambulance Transport 1 (AT 1) stated that Resident 3 should wear the mask properly, covering the nose and the mouth when being transported to prevent COVID-19. 2. A review of Resident 4 ' s admission Record indicated that the facility admitted the resident on 8/28/2019 and readmitted on [DATE] with diagnoses including diabetes type II, chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), and asthma (a condition in which the airways narrow and swell and may produce extra mucus [a thick liquid produced in the body such as the nose and throat]). A review of Resident 4 ' s MDS, dated [DATE], indicated that the resident usually had the ability to make self-understood and understand others. A review of Resident 4 ' s Care Plan, dated 8/22/2022, indicated that the resident was at risk for reinfection of COVID-19. The Care plan indicated an intervention to encourage and assist resident to practice infection control i.e., handwashing, social distancing, wear face covering when out of the room. During a concurrent observation and interview on 1/9/2023, at 9:18 a.m., CNA 1 transported Resident 4 to the shower room without a mask on. CNA 1 stated that she forgot to place the mask on Resident 4. CNA 1 stated that she should have placed the mask on to prevent infection to Resident 4. 3. A review of Resident 5 ' s admission Record indicated that the facility admitted the resident on 6/25/2022 and readmitted on [DATE], with diagnoses including enterocolitis (an inflammation of the small intestine and the colon [large intestine]) due to clostridium difficile (is a bacterium that causes an infection of the large intestine), diabetes type II, and chronic obstructive pulmonary disease (a type of lung disease marked by permanent damage to tissues in the lungs, making it hard to breathe). A review of Resident 5 ' s History and Physical (H&P), dated 12/26/2022, indicated that the resident did not have the capacity to understand and make decisions. A review of Resident 5 ' s MDS, dated [DATE], indicated that the resident had usually the ability to make self-understood and understand others. A review of Resident 5 ' s Care Plan, dated 1/9/2023, indicated that the resident had exposure to COVID-19 positive individual. During a concurrent observation and interview on 1/9/2023, at 10:06 a.m., CNA 2 transported Resident 5 from the shower to the resident ' s room without a mask on. CNA 2 stated that she left the mask in the shower room. CNA 2 stated that it was important to have Resident 5 wore a mask on to prevent infection. 4. A review of Resident 6 ' s admission Record indicated that the facility admitted the resident on 11/23/2015 and readmitted on [DATE] with diagnoses including respiratory failure (when the lungs cannot get enough oxygen into the blood), pneumonia (a severe inflammation of the lungs in which the alveoli [tiny air sacs] are filled with fluid), and chronic obstructive pulmonary disease. A review of Resident 6 ' s MDS, dated [DATE], indicated that the resident had the ability to make self-understood and understand others. A review of Resident 6 ' s Care Plan, dated, 1/9/2023, indicated that the resident had exposure to COVID-19 positive individual. a. During a concurrent observation and interview on 1/9/2023, at 10:13 a.m., CNA 3 transported Resident 6 outside of her room to the shower room without a mask on. CNA 3 stated that Resident 6 should be transported with a mask on to prevent infection. b. During a concurrent observation and interview on 1/9/2023, at 10:27 a.m., Resident 6 was being transported via wheelchair with oxygen tubing touching the floor. CNA 3 stated that the oxygen tubing should not be touching the floor when transporting residents to prevent infection. c. During an observation and interview on 1/9/2023, at 10:30 a.m., Resident 6 ' s oxygen tubing that was used to transport the resident was not dated. CNA 3 stated that the oxygen tubing should be dated to know when to discard them and replaced with a new one to prevent infection. During an interview on 1/9/2023, at 10:47 a.m., Licensed Vocational Nurse 3 (LVN 3) stated that the oxygen tubing should be changed every 7 days. If it touched the floor, it should be changed because it was contaminated already. 5. A review of Resident 7 ' s admission Record indicated that the facility admitted the resident on 11/7/2017 and readmitted on [DATE] with diagnoses including diabetes mellitus type II, chronic kidney disease, and chronic obstructive pulmonary disease. A review of Resident 7 ' s MDS, dated [DATE], indicated that the resident had the ability to make self-understood and understand others. During a concurrent observation and interview on 1/9/2023, at 10:39 a.m., CNA 4 transported Resident 7 from the shower room to the resident ' s room without a mask on. CNA 4 stated that she forgot to put a mask on because of another resident screaming at the hallway. CNA 4 stated that she should put a mask on Resident 7 for infection purposes. 6. A review of Resident 2 ' s admission Record indicated that the facility admitted the resident on 1/6/2023 with a diagnosis of pneumonia. A review of Resident 2 ' s Order Summary Report indicated an order: - COVID-19 person under investigation (PUI, someone who has symptoms, however, has not yet tested positive for COVID-19) vital signs (the pulse rate, body temperature, number of breaths taken per minute, and blood pressure of the resident) and monitoring every four hours till discontinue from isolation (separates sick residents with contagious disease from residents who are not sick). COVID-19 PUI for 14 days, with order date of 1/6/2023. - Transmission Based Precautions- droplet (TBP, used for disease or germs that are spread in tiny droplets caused by coughing and sneezing) due to exposure to individual positive for COVID-19, with order date of 1/6/2023. During a concurrent observation and interview on 1/9/2023, at 1:50 p.m., Resident 2 ' s oxygen tubing was not dated. Nursing Supervisor (Nsg Sup) stated that the oxygen tubing was good for 3 days. Nsg Sup stated that the tubing should be dated for infection purposes. During an interview on 1/9/2023, at 11:21 a.m., the Infection Preventionist (IP), stated that the residents in the green zone (area for residents who were not exposed and tested negative for COVID-19) should wear mask to prevent infection. The IP stated that the oxygen tubing should be changed every 7 days. The IP stated that the tubing that was dated 1/2/2023 should have been changed yesterday and the tubing should be always off the floor due to potential for infection. During an interview on 1/9/2023, at 2:40 p.m., the Director of Nursing (DON) stated that the staff should place a mask on the residents when transporting to the bathroom or going outside of the rooms to prevent the spread of infection. The DON also stated that oxygen tubing should be changed every 7 days and should be dated to determine if it was time to change the oxygen tubing. Failure to date the oxygen tubing had a potential of keeping the oxygen tubing longer on the rooms developing harmful bacteria and viruses which could cause infection. A review of the facility ' s recent policy and procedure titled Oxygen Administration, revised on 1/15, indicated that oxygen administration will be ordered by the physician (unless used in an emergency) and administered to the resident by a licensed nurse. The oxygen humidifiers (a medical device that provides moisture for patient comfort during oxygen therapy) and tubings will be changed at least every 10 days. A review of the facility ' s COVID-19 Mitigation Plan, last reviewed on 12/19/2022, indicated all residents must be provided a clean mask daily. Medical-grade surgical/procedure masks are required for any resident that is COVID-19- positive or assumed to be COVID-19-positive. All residents, if tolerated, should wear a mask when outside their room including those who regularly leave the facility for care (e.g., dialysis [a treatment for residents whose kidneys are failing]), unless they are not able to wear a mask or if they are participating in an activity where masking is not required. Facility must ensure residents are wearing a facemask (as they are able to tolerate) whenever they leave their room or are around others, including whenever they leave the skilled nursing facility (SNF, an in-patient rehabilitation and medical treatment center staffed with trained medical professionals) for essential medical appointments. A review of the facility ' s in-service (ongoing education at work) titled, COVID-19 Donning (to put on) and Doffing (to take off) personal protective equipment (PPE, equipment worn to minimize exposure to hazards that cause serious injuries and illness), dated 12/23/2022, indicated that all staff were educated on the importance of how to properly don and doff personal protective equipment including washing hands, putting on the gowns, masks, face shields or goggles, and gloves. A review of the facility ' s in- service titled COVID-19 What You Need to Know, dated 12/12/2022, indicated that staff were educated on the importance of keeping the facility and equipment clean and disinfected. The in-service also educated staff on modes of infection transmission. A review of the facility ' s recent policy and procedure titled Infection Prevention and Control Manual Resident Care Equipment, dated 5/2019, indicated that the facility must protect indirect transmission through decontamination (i.e., cleaning, sanitizing, or disinfecting) of an object to render it safe for handling. 7. On 1/9/2023, at 9:57 a.m., during an observation, LVN 5 was self-testing for COVID-19 in the facility ' s designated testing room monitored by Restorative Nurse Assistant 1 (RNA 1). LVN 5, with gloved hands, retrieved a test kit (an easy-to-use tests that provide quick results of COVID-19 on from the table, pulled down her N95 mask, swabbed both nostrils, replaced her N95 mask over her nose and mouth, and applied her nasal sample to the sample tray while waiting for the results with RNA 1. After verifying her test was negative, RNA 1 retrieve the test tray to dispose of it into a designated trash bin, while LVN 5 removed and disposed her gloves and left the testing site without performing hand hygiene. On 1/9/2023, at 10:25 a.m., during an observation, DS was self-testing for COVID-19 in the facility designated testing room monitored by RNA1. DS, with gloved hands, retrieved a test kit from the table, pulled down her cloth mask, swabbed both nostrils, replaced her cloth mask over her nose and mouth, and applied her nasal sample to the sample tray while waiting for the results with the RNA1. After verifying her test was negative, RNA 1 retrieved the test tray to dispose of it in a designated trash bin, while DS removed and disposed her gloves and left the testing site without performing hand hygiene. A review of facility Lesson Plan for the in-service topic Hand washing / Hygiene, dated 1/6/2023, indicated, all participants will know the importance of hand washing, how to protect yourself and your family, and difference of hand sanitizing and handwashing. An attendance sign-in sheet indicated LVN 5, RNA 1, and DS took the course. A review of the facility's policy titled, Infection Prevention & Control, revised 12/19/2022, indicated, Encourage all resident, staff, and visitors to perform HH (hand hygiene) after contact with respiratory secretions or contact with contaminated materials (e.g. tissues). 8. On 1/9/2023, at 1:19 p.m., during an observation, FM 1was in the resident room in the Red Quarantine Area (Formerly Yellow Zone). The FM 1 was wearing the N95 mask (simple filtering respirator worn over the nose and mouth) upside down with her face shield on top of her head. FM 1 was not wearing a gown or gloves. Outside the resident ' s door was an isolation cart with gloves, gown, and sanitizing gel, along with instructions to how put on PPE. FM 1 stated she signed-in at the front of the facility, was provided with a mask and face shield, but no facility staff taught her how to use the mask, or the requirement to wear PPE when visiting facility residents. 1/9/2023, at 1:45 p.m., SC was observed screening residents at facility entrance. A family member was screened and signed in, and SC directed the visitor to the direction where to find their resident. No education provided to family member regarding how to wear PPE was observed. During an interview on 1/9/2023, at 1:50 p.m., SC stated she provides education and demonstration how to wear an N95 mask to visitors. She stated she asks screening questions and provides rapid tests for visitors and provide face shield after confirmation of a negative test. SC stated after visitors are cleared, they can go directly into the resident rooms, and if visitors get lost, SC instructs them to ask someone at the nursing station. SC did not state education and teaching for resident visitors how and when to wear PPE or the importance of transmission prevention. On 1/9/2023, at 3:23 p.m., during an interview, the Infection Preventionist (IP) stated facility visitors need to be provided teaching and education to teach the mode of transmission and to prevent infection. A policy and procedure related to how the facility visitors are provided education and teaching about infection prevention was requested from Infection Preventionist (IP). No Policy and Procedure was provided regarding how the facility visitors are provided education and teaching about infection prevention.

Jan 2023 23 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

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Based on interview and record review, the facility failed to ensure that the resident was asked during the initial assessment on admission if he/she wants to self-administer medications for one of one sampled resident (Resident 154) investigated for right to self-administer medications. This deficient practice violated the resident`s right to be fully informed of the option to self-administer medications. Findings: A review of Resident 154's Face Sheet indicated that the facility admitted the resident on 12/30/2022 with diagnoses including including gastroesophageal reflux disease (occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach) and osteoporosis (a condition in which bones become weak and brittle). A review of Resident 154's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 01/05/2022, indicated that Resident 154's cognitive skills (relating to thinking, reasoning, understanding, learning, and remembering) for daily decision-making was intact. The MDS indicated Resident 154 required one-person extensive assistance with transfer, toilet use, personal hygiene, and bathing. On 01/17/23 at 03:49 p.m., during an interview in Resident 154`s room, Resident 154 stated that he had been using Ammonium Lactate Cream 12% (used to treat dry, scaly skin conditions and can also help relieve itching) for his skin dryness for more than thirty-two years. According to Resident 154, the staff does not give him enough of the cream and they will just give him a small amount in a 30 milliliter (ml) medicine cup. According to the resident, the amount of medication he gets was barely enough for his legs and wants to keep it at his bedside so he can apply the Ammonium Lactate Cream appropriately to the part of his body where it itches and there is skin dryness. A review of Resident 154`s physician's order, dated 12/30/2022, indicated an order for Ammonium Lactate Cream 12%to apply to left leg topically (on the surface of the body) in the morning for dry skin. On 01/19/23 at 11:12 a.m., during a concurrent interview and record review, during Resident 154`s medical record was reviewed with the Assistant Director of Nursing (ADON). The ADON stated that there was no documented evidence that the resident has been asked as to whether he wants to self-administer medications. The ADON stated that on admission the facility staff will discuss with the resident his rights including the right to self-administer medication. The ADON further stated that if the resident was assessed to have the cognitive and functional capability to self-administer medications, the facility staff will then obtain an order from the physician. The ADON also stated resident rights, including the right to medication self-administration should be always upheld because in not doing so is a violation of his rights. A review of the facility`s policy and procedure, titled Pharmaceutical Services, last reviewed on 7/28/2022, indicated that during the initial assessment interviews, the resident is asked as to whether he/she wants to self-administer medications. To aid residents in making an informed decision, the process, responsibilities, limitations and potential problems are explained. A review of the facility`s policy and procedure, titled Resident Rights, last reviewed on 7/28/2022, indicated that Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident`s right to self-administer medication, if the interdisciplinary care planning team determines it is safe .

CONCERN (D)

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

Deficiency F0557 (Tag F0557)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure an inventory of personal belongings was completed upon readmission to the facility for one of three sampled residents (Resident 113). This deficient practice had the potential for personal belongings to get lost and negatively affect the resident's psychosocial well-being. Findings: A review of Resident 113's admission Record indicated the facility admitted the resident on 4/28/2021, and most recently readmitted the resident on 12/27/2022, with diagnoses including malignant neoplasm (cancerous tumor) of right upper lobe bronchus (main passageways into the lungs), bacteriuria (presence of bacteria in the urine), and anxiety disorder (intense, excessive and persistent worry and fear about everyday situations). A review of Resident 113's MDS, a standardized assessment and care screening tool), dated 11/5/2022, indicated the resident had the ability to make self sometimes understood and had the ability to sometimes understand others. The MDS further indicated Resident 113 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene and was totally dependent on staff with transfers. During a concurrent interview and record review, on 1/19/2023 at 8:11 a.m., reviewed Resident 113's medical record with the Social Services Assistant 1 (SSA 1). The SSA confirmed the inventory of personal belongings for the resident was blank and was not completed when the resident was readmitted from the general acute care hospital (GACH) on 12/27/2022. SSA 1 stated the social services staff is responsible for reviewing the inventory with the resident and documenting the description and quantity of each item on the inventory list if the resident is admitted during the day and on weekends from 8 a.m. to 4 p.m. when a social services staff is available. SSA 1 also stated the certified nursing assistants (CNAs) are responsible for going over the resident's belongings and completing the inventory list if the facility admits a resident after 4 p.m., when social services staff is not available. SSA 1 stated the assigned CNA should have completed the inventory list for Resident 113 upon readmission since the resident returned to the facility after 4 p.m. SSA 1 stated the importance of completing an inventory list to keep track of the resident's belongings since items can get lost. During an interview, on 1/20/2023 at 8:14 a.m., the Director of Nursing (DON) stated an inventory list needs to be completed with each readmission from the hospital. The DON stated an inventory list should have been completed by the CNA if Resident 113 returned to the facility after 4 p.m. and should have been followed up by social services staff to ensure it was completed. The DON stated inventory list should be completed and updated as needed to ensure residents rights to personal property are preserved as personal belongings can have sentimental value for the residents. The DON further stated it is important to keep track of all resident's belongings to ensure it does not get lost and if the inventory was not done, the facility will be responsible for reimbursing lost items. A review of the facility's policy and procedure titled, Policy and Procedure for Personal Property, last reviewed on 7/28/2022, indicated the facility will ensure that the resident's right to personal property be preserved. The policy and procedure further indicated after recording all clothing and items on the inventory list, ask the resident or responsible party to sign the list and give them a copy.

CONCERN (D)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure that a call light (a device used by a patient to signal his or her need for assistance from a professional staff) was within reach for two of six sampled residents (Residents 523 and 106). This deficient practice had placed Residents 523 and 106 at risk for injury for not having a way to reach staff when help is needed. Findings: a. A review of Resident 523's admission Record indicated the facility originally admitted the resident on 4/20/2015 and readmitted the resident on 1/14/2023, with diagnoses including cerebral infarction (brain cell death due to prolonged ischemia [a condition in which blood flow is restricted or reduced]). A review of Resident 523's Admit/Re-Admit Nursing Evaluation, dated 1/14/2023, indicated the resident was alert and oriented to person, place, and time. A review of Resident 523's Activities of Daily Living (ADL) Care Plan, dated 1/16/2023, indicated the resident needed assistance with ADL related to cerebral infarction. The ADL Care Plan indicated the resident required extensive assistance with bed mobility, transfer, ambulation (walking), wheelchair propulsion (the action of driving or pushing forward), dressing, toilet use, personal hygiene, and bathing; required limited assistance or supervision with eating. The ADL Care Plan indicated keep call light within reach and answer promptly. During a concurrent observation and interview on 1/18/2023 at 8:24 a.m., in Resident 523's room, observed with Assistant Director of Nursing (ADON) the resident's call light was not within the resident's reach. The ADON stated the resident's call light was not within the resident's reach but should have been. The ADON stated the call light was stuck in the railing of the bed. The ADON stated the resident was placed at risk for falls because the resident could attempt to help himself. During a second observation and concurrent interview on 1/19/2023 at 8:30 a.m., in Resident 523's room, observed with Certified Nursing Assistant 2 (CNA 2) the resident's call light was dangling off the resident's right side of the bed and not within the resident's reach. CNA stated the resident's call light was almost on the floor and not within the resident's reach but should have been within the resident's reach. CNA 2 stated she did not pay attention to the resident's right side of the bed when she first saw the resident at the beginning of her shift at around 7:05 a.m. CNA 2 stated it was important to keep the call light within the resident's reach so that the resident have a way to call staff for help. CNA 2 stated when the call light was not placed within Resident 523's reach, it placed the resident at risk for potentially getting out of bed on his own. During an interview on 1/19/2023 at 9:11 a.m., Licensed Vocational Nurse 2 (LVN 2) stated a call light should be within the residents' reach so that they could call for assistance when needed. LVN 2 stated if Resident 523 could not get the help when he needed it, the resident could possibly get up unassisted and potentially injure himself. A review of the facility's policy and procedure (P&P), titled, Call Lights, reviewed on 7/28/2022, indicated, To meet the resident's requests and needs within an appropriate time period as well as those residents with special needs . Assure that the call light is within the resident's reach when in their room or on the toilet . b. A review of Resident 106's admission Record indicated the facility originally admitted the resident on 1/13/2020 and readmitted the resident on 10/28/2021, with diagnoses including asthma (a chronic [long-term] disease that causes the airways of the lungs to swell and narrow) and generalized muscle weakness. A review of Resident 106's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/4/2022, indicated the resident had a severe cognitive (relating to thinking, reasoning, or remembering) impairment (loss or damage). The MDS indicated Resident 106 required one-person extensive assistance with bed mobility, dressing, toilet use, personal hygiene, and bathing; required two-person extensive assistance with transfer; and required setup and supervision with eating. A review of Resident 106's ADL Care Plan, dated 10/2/2021, indicated the resident needed assistance with ADLs related to dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and weakness. The ADL Care Plan indicated keep call light within reach and answer promptly. A review of Resident 106's Injury/Fall Care Plan, dated 10/28/2021, indicated the resident had a fall risk score of 15 indicating high fall risk. During a concurrent observation and interview on 1/17/2023 at 12:49 p.m., in Resident 106's room, observed with LVN 3 the resident's call light was on the floor. LVN 3 stated the resident's call light was on the floor with the cord wrapped around the bottom of the rail of the bed. LVN 3 stated this was not a proper way as the call light should have been within the resident's reach. LVN 3 stated the call light not within the resident's reach placed the resident at risk for not being able to call for help. During an interview on 1/19/2023 at 8:14 a.m., CNA 3 stated a call light should be within a resident's reach. CNA 3 stated when a call light was not within a resident's reach, it could cause problems such as distress, fall by getting out of bed unassisted, becoming upset, and feeling of being neglected. A review of the facility's P&P, titled, Call Lights, reviewed on 7/28/2022, indicated, To meet the resident's requests and needs within an appropriate time period as well as those residents with special needs . Assure that the call light is within the resident's reach when in their room or on the toilet .

CONCERN (D)

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

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to provide privacy for 16 of 16 residents when the electronic health records, with residents' names exposed, were left opened and unattended by staff. This deficient practice violated the residents' right to privacy and confidentiality of their medical records. Findings: During an observation on 1/18/2023 at 2:50 p.m., observed Medication Cart Station 2 A with the computer screen open with 16 residents' names on the screen. Did not observe licensed nursing staff at the computer and did not observe licensed nursing staff walking away from the computer. After a minute, Registered Nurse 1 (RN 1) came to the computer and closed the screen. RN 1 stated he should have closed it when he stepped away from the medication cart. RN 1 stated it could expose residents' name to those who should not see them. During an interview with LVN 4 on 1/19/2023 at 9:26 a.m., she stated RN 1 should have locked the computer when stepping away from the medication cart. LVN 4 stated that is the practice for all licensed nurses to follow. During an interview with the Director of Nurses (DON) on 1/19/2023 at 9:35 a.m., she stated RN 1 should have locked the medication cart when stepping away. The DON stated it is important to maintain residents' privacy. The DON stated leaving a computer open could expose their names to someone who should not see them. A review of the facility's policy and procedure titled Electronic Health Records, reviewed 7/28/2022, indicated the electronic medical records system has safeguards to prevent unauthorized access. The policy and procedure indicated the electronic medical records are permitted by authorized persons who has an individual password and a user ID code.

CONCERN (D) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain hot water temperature between 105 degrees to 120 degrees Fahrenheit (F, a unit of measure for temperature) as indicated in the facility policy for one of two sampled shower rooms (Shower room [ROOM NUMBER]). This deficient practice had the potential to negatively impact the resident's comfort and quality of life. Findings: A review of Resident 113's admission Record indicated the facility admitted the resident on 4/28/2021, and most recently readmitted the resident on 12/27/2022, with diagnoses including malignant neoplasm (cancerous tumor) of right upper lobe bronchus (main passageways into the lungs), bacteriuria (presence of bacteria in the urine), and anxiety disorder (intense, excessive and persistent worry and fear about everyday situations). A review of Resident 113's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/5/2022, indicated the resident had the ability to make self sometimes understood and had the ability to sometimes understand others. The MDS further indicated Resident 113 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene and was totally dependent on staff with transfers. During an interview, on 1/18/2023 at 2:45 p.m., Resident 113 stated the certified nursing assistant (CNA) took her to the shower room the previous day to provide her with a shower. However, Resident 113 stated she refused and did not end up getting a shower, because there was no hot water coming out of the shower. During a concurrent observation and interview, observed Maintenance Supervisor (MS) checking the water temperature of hot running water in Shower room [ROOM NUMBER] after allowing it to run for ten minutes with a thermometer. The MS stated the temperature reading was 89 degrees F. The MS felt the running hot water from the shower stall using his hands and verified the water was cool and lukewarm. The MS stated the hot water temperature should be between 105 to 120 degrees F per facility policy. The MS stated that maintenance staff checks the water temperature in resident bathrooms and shower rooms daily and maintains a water temperature log. The MS stated staff should be reporting to him if they are aware of any maintenance issues. The MS stated he was not informed by any staff or residents regarding water temperature issues in the shower room. The MS stated the importance of maintaining water temperature between 105 to120 degrees F to ensure residents are able to bathe or shower comfortably. The MS also stated maintaining hot water temperature is important for safety reasons since the temperature should be no higher than 120 degrees to prevent burns and scalding of residents. A review of the facility's policy and procedure titled, Water Supply, Plumbing, and Water Heating System,' last reviewed on 7/28/2022, indicated to check and record water temperature daily in resident bathrooms, showers, and other rooms used by residents. The policy and procedure further indicated hot water temperature should be maintained at not less than 105 degrees F and not more than 120 degrees F for all hot water used by residents per regulations and to set thermostats on all boilers or hot water heaters to obtain required temperature.

CONCERN (D) 📢 Someone Reported This

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

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

Grievances (Tag F0585)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to address Resident 30's grievance of staff not providing appropriate care while the resident resided in station five for one (Resident 30) of eight residents investigated for residents' rights. This deficient practice had the potential for Resident 30's grievance to go unnoticed causing anger and distress to the resident; and had the potential to result in a delay of care and services. Findings: A review of Resident 30's Face Sheet (admission record) indicated the facility originally admitted the resident on 2/21/2006 and readmitted the resident on 7/01/2015 with diagnoses including attention to colostomy (a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall to bypass a damaged part of the colon), intestinal ulcer (a sore that develops on part of the intestine [the tract that food passes from the stomach to the anus]), and gastrointestinal hemorrhage (bleeding that is in the digestive tract). A review of Resident 30's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/31/2022, indicated Resident 30 was cognitively intact (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 30 required one-person extensive assistance (resident involved in activity, staff provide weight-bearing support) with toilet use and one-person limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs) with personal hygiene. A review of Resident 30's Complaint/Grievance Form (provided by the Social Services Director), dated 1/05/2023, authored by Ombudsman 1 (OMB 1, an individual appointed to investigate resident complaints and if unable to find a resolution, will then report to Department of Health), indicated Resident 30 stated she was bleeding from her colostomy bag and none of the certified nursing assistants or charge nurses would help her except for Licensed Vocational Nurse 5 (LVN 5) who called 911. The form indicated administration was informed and endorsed to nursing staff to check on Resident 30 often. During an observation and interview with Resident 30 on 1/17/2023 at 12 p.m., observed resident in bed. The resident stated when she returned from the general acute care hospital (GACH, or simply hospital) in late October 2022, she was placed in station five. Resident 30 stated staff in station five ignored her call light and was slow to help her if she needed help with her colostomy bag (bag that is attached to the opening in which feces [waste product] is collected). Resident 30 stated Licensed Vocational Nurse 6 (LVN 6) provided care to her during her first night back in the facility but did not assist her changing her leaking colostomy bag until the end of the shift. Resident 30 stated LVN 6 would not let Certified Nursing Assistant 8 (CNA 8) change her clothes until he had called the doctor. Resident 30 stated she told many people when she returned to her room in station three from station five, but no one listened to her. During an interview with CNA 8 on 1/17/2023 at 3:59 p.m., CNA 8 stated when Resident 30 was admitted from the hospital LVN 6 changed Resident 30's colostomy bag near the end of his shift, approximately 11 p.m. During an interview with LVN 6 on 1/18/2023 at 1:13 p.m., he stated he provided care for Resident 30 in station five. LVN 6 stated station five is the yellow zone (a section of the facility used for residents who have been exposed to the Covid-19 virus [a life-threatening virus in which one has lung damage, resulting in one not being able to breath and possibly death] or have been out of the facility for more than 24 hours). LVN 6 stated he worked the night of her readmission from the hospital and that Resident 30 asked him to help change her colostomy bag many times. LVN 6 stated the licensed nurses can change a colostomy bag. LVN 6 stated there was no unit manager (a licensed nurse who helps with daily activities to lessen the licensed charge nurse's work) on duty and he was busy and could not change Resident 30's colostomy bag until the end of the shift, at approximately 11 p.m. During an interview with LVN 7 on 1/18/2023 at 4:56 p.m., she stated, when a resident has a grievance, she calls Social Services Director (SSD)to address the issue. LVN 7 stated if a social services staff member is not on duty at that time, the manager of the day (MOD, a department head in other disciplines such as dietary, physical therapy, etc. who can address issues brought up by residents) will listen to the issue and notify social services when they come back to work. During an interview with the Social Services Director (SSD) on 1/18/2023 at 5:58 p.m., she stated she is the grievance officer who addresses and investigates any grievance a resident may have. The SSD stated Resident 30 was readmitted from the GACH on 10/23/2022 and was in station five until 11/04/2022. The SSD stated Resident 30 never complained about staff not helping her while she was residing in station five. During an interview with Resident 30 in the presence of the Director of Nurses (DON) and LVN 4 on 1/18/2023 at 6:50 p.m., Resident 30 stated she would not go back to station five if she returns from the hospital again. Resident 30 stated she had bleeding episodes from her colostomy but refused to go to the hospital because she did not want to return to quarantine on station five. Resident 30 stated the reason was because when she asked LVN 6 to help change the colostomy bag, LVN 6 would not change it until the end of the shift even though her colostomy bag was leaking. Resident 30 stated it was six hours before LVN 6 returned to help her change the colostomy bag. Resident 30 stated staff on station five ignore her requests for help. A review of Resident 129's Face Sheet indicated the facility admitted the resident on 9/27/2021, with diagnoses that included hypertension (high blood pressure). A review of Resident 129's Minimum Data Set, dated [DATE], indicated Resident 129 was cognitively intact with skills required for daily decision making. The MDS indicated Resident 129 required one-person extensive assistance with bed mobility and personal hygiene. During an interview with Resident 129, who is Resident 30's roommate, on 1/18/2023 at 6:50 p.m., she stated she heard Resident 30 tell staff from station three at least 15 times that staff was not helping Resident 30 when she was residing in station five, and that LVN 6 would not change the colostomy bag for many hours when she was first readmitted from the GACH. Resident 129 stated she heard Resident 30 tell LVN 5 that staff was not helping Resident 30 while she stayed in station 5. During an interview with LVN 5 on 1/18/2023 at 7:35 p.m., she stated Resident 30 had told her staff did not help her when she called them with her call light when she was in station 5. LVN 5 stated she thought Resident 30 had told many staff and the SSD. LVN 5 stated she did not notify the SSD of the grievance because she thought Resident 30 had already told her. LVN 5 stated she should have told the SSD the grievance to make sure she knew of the issue. During an interview with the DON on 1/19/2023 at 9:35 a.m., she stated addressing grievances is important. The DON stated Resident 30's grievance regarding staff not providing appropriate care in station five should have been addressed. The DON stated not addressing a grievance could result in a delay in care which could potentially be life threatening such as bleeding from a stoma sight that Resident 30 had had in the past. A review of the facility's policy and procedure titled, Grievances, reviewed 7/28/2022, indicated a grievance may be filed orally or in writing; staff will document for the continuous quality improvement reporting. The policy and procedure indicated when a grievance form is received by a staff member, they will notify their supervisor, and the grievance form will be forwarded to the grievance official. The policy and procedure indicated the grievance will be initiated as soon as practicably possible, and there will be timely follow-up by the department manager, grievance official and administrator.

CONCERN (D)

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

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to provide a written notice of the bed-hold policy to the resident or responsible party following transfer to the general acute care hospital (GACH) for one of three sampled residents (Resident 113). This deficient practice had the potential for the resident or responsible party to not be aware of the resident's rights to a bed hold which can result in the resident not being able to return to the facility. Findings: A review of Resident 113's admission Record indicated the facility admitted the resident on 4/28/2021, and most recently readmitted the resident on 12/27/2022, with diagnoses including malignant neoplasm (cancerous tumor) of right upper lobe bronchus (main passageways into the lungs), bacteriuria (presence of bacteria in the urine), and anxiety disorder (intense, excessive and persistent worry and fear about everyday situations). A review of Resident 113's MDS, a standardized assessment and care screening tool), dated 11/5/2022, indicated the resident had the ability to make self sometimes understood and had the ability to sometimes understand others. The MDS further indicated Resident 113 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene and was totally dependent on staff with transfers. A review of Resident 113's progress note dated 12/18/2022 at 9:03 a.m. indicated emergency medical services (911) arrived and resident left the facility. A review of Resident 113's progress note dated 12/27/2022 at 11:24 p.m. indicated the resident returned from GACH and readmitted to the facility. During a concurrent interview and record review, on 1/19/2023 at 12:02 p.m., Resident 113's medical record was reviewed with the Admissions Coordinator (AC). The AC stated she reviews the admission packet which includes the bed hold notification form with newly admitted residents upon admission. The AC, however, stated the facility does not give a bed hold notice to resident or family member upon transfer to a hospital. The AC reviewed the facility's policy and procedure for bed hold and confirmed that the admissions staff should be mailing either the resident or the responsible party a written notification for bed hold the next day following transfer for hospitalization as indicated in the policy. The AC verified the bed hold notification form was not completed and provided to the resident upon transfer to GACH on 12/18/2022. The AC stated the bed hold notification form for Resident 113 should have been provided upon transfer to GACH per facility policy to ensure that residents are made aware that the facility will hold the resident's bed for seven days and that they might not be able to return to their previous room if hospitalized beyond the seven days. The AC further stated the importance of providing a written bed hold notification to ensure residents are aware of their rights and they are provided with an option to pay privately if they wish for the facility to hold the room for the resident. During an interview, on 1/20/2023 at 7:54 a.m., the Director of Nursing (DON) reviewed the facility's policy for bed hold and confirmed that a written bed hold notice should be provided to residents upon admission and transfer to a hospital. The DON stated the admissions department should have provided a written notice to Resident 113 for bed hold the next day following transfer to the hospital per facility policy. The DON stated bed hold notices should be provided to ensure residents understand that the facility will hold the bed for them for up to seven days, and to promote continuity of care and a homelike environment. A review of the facility's policy and procedure titled, Policy and Procedure for Bed-hold, last reviewed on 7/28/2022, indicated admissions will mail to the resident or the responsible party/legal representative the written notification for bed-hold the next day following the transfer for hospitalization of therapeutic leave unless there is a standing agreement for bed-hold in place.

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to implement the Comprehensive Care Plan (reflect shared decisions made with patients, caregivers and families about the tests, interventions, treatments and other activities needed to achieve the goals of care) interventions for two of three sampled residents (Resident 14 and 74) by failing to: a. Ensure Resident 14's Insulin Injection administration sites for were rotated and documented. This deficient practice had the potential to result in bruising, swelling, pain around the insulin injection sites. b. Ensure Resident 74, who was on anticoagulant therapy, was monitored for signs and symptoms of bleeding. This deficient practice had the potential to result in unrecognized signs and symptoms of bleeding such as excessive bruising, hematuria (blood in the urine) and hemoptysis (coughing up of blood) for resident`s receiving anticoagulant therapy which could lead to serious complications such as death. Findings: a. A review of Resident 14's Face Sheet (a document that gives a patient's information at a quick glance) indicated the facility admitted the resident on 09/06/2022 with diagnoses including type 2 diabetes mellitus (DM - an impairment in the way the body regulates and uses sugar as a fuel) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). A review of Resident 14's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/13/2022, indicated the resident had intact cognition (thought processes) and required limited assistance from staff for bed mobility, transfers, and extensive assistance for dressing, toilet use, and personal hygiene. A review of Resident 14`s Physician`s Orders dated 09/06/2022, indicated the following orders: -Lantus (controls high blood sugar in people with diabetes) Insulin 100 Unit/Milliliter (ml), to inject 30 units subcutaneously (under the skin) every 12 hours related to Type 2 DM, rotate injection sites. -Novolog (controls blood sugar around mealtimes) Solution 100 Unit/ml, to inject per sliding scale (varies the dose of insulin based on blood sugar level), rotate injection sites. A review of Resident 14`s Comprehensive Care Plan related to diabetes mellitus, created on 01/09/2023, indicated an intervention to rotate injection sites regularly. On 01/20/23 at 11:00 a.m., during a concurrent interview and record review, Resident 14's Medication Administration Record (MAR-where medications given to a client are documented) for the month of December 2022 was reviewed with the ADON. The ADON confirmed that there was no documented evidence in the resident's MAR that indicated the insulin injection sites were rotated and documented. The ADON stated insulin injection sites should be rotated because insulin is viscous (having a thick, sticky consistency) and the injection can be painful if injected on the same site. Per ADON, its important to rotate and document the injection site so that the next nurse will know which injection site was last used. A review of the facility`s policy and procedure, titled Insulin Administration, last reviewed on 7/28/2022, indicated that injection sites should be rotated, preferably within the same general area. A review of the facility`s policy and procedure, titled Care Plans- Comprehensive, last reviewed on 7/28/2022, indicated that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed and implemented for each resident. b. A review of Resident 74's Face Sheet (a document that gives a patient's information at a quick glance) indicated the facility admitted the resident on 06/17/2022 with diagnoses including type 2 diabetes mellitus (DM - an impairment in the way the body regulates and uses sugar as a fuel) and end stage renal disease (a medical condition in which a person's kidneys cease functioning on a permanent basis). A review of Resident 74's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 11/24/2022, indicated the resident had intact cognition (thought processes) and required limited assistance from staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of Resident 74`s Physician`s Orders dated 06/17/2022, indicated an order for Eliquis (used to treat and prevent blood clots) Tablet 5 milligram (mg), one tablet by mouth two times a day to unspecified atrial fibrillation (an irregular and often very rapid heart rhythm). On 01/19/23 at 09:33 a.m., during a concurrent interview and record review, reviewed Resident 74's MAR for the month December 2022 with the Assistant Director of Nursing (ADON). The ADON stated that residents on anticoagulant therapy are at higher risk for bleeding. According to the ADON, the resident's care plan indicated interventions to monitor for bleeding and to monitor for signs and symptoms of bleeding. The ADON stated it is important to monitor the resident for signs and symptoms of internal bleeding because the resident could hemorrhage and die from blood loss if not attended to promptly. The ADON stated the monitoring should be documented so that the nurses will be able to intervene timely when there is a resident change of condition. A review of Resident 74`s Care Plan (contains relevant information about a patient's diagnosis, the goals of treatment, the specific nursing orders, and an evaluation plan) for Potential for bleeding secondary to Eliquis Therapy, with next target date of 02/22/2023, indicated an intervention to Monitor for bruise or bleeding episodes and report promptly. A review of the facility`s policy and procedure, titled Anticoagulation-Clinical Protocol, last reviewed on 7/28/2022, indicated that the staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems. If an individual on anticoagulant therapy shows signs of excessive bruising, hematuria, hemoptysis, or other evidence of bleeding, the nurse will discuss the situation with the physician before giving the next schedule dose of anticoagulant. A review of the facility`s policy and procedure, titled Care Plans- Comprehensive, last reviewed on 7/28/2022, indicated that an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed and implemented for each resident.

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure that Licensed Vocational Nurse 1 (LVN 1) did not leave medications unattended and out of eyesight at a resident's bedside for one (Resident 122) out of eight sampled residents observed during medication administration. This deficient practice had the potential to increase the risk of other residents having access to the medications. Findings: A review of Resident 122's admission Record indicated the facility admitted the resident on 7/21/2021 with diagnoses including encounter for attention to gastrostomy (a surgical procedure used to insert a tube into the stomach). A review of Resident 122's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/28/2022, indicated the resident had intact cognition (thought processes) and required extensive assistance from staff for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. On 1/17/2023 at 4:04 p.m., during a medication administration observation, observed LVN 1 leave the following medications and supplement unattended at Resident 122's bedside: 1. Cranberry (used to prevent urinary tract infection [UTI - an infection in any part of the urinary system]) 425 milligrams (mg - unit of measurement) 2. Metoclopramide (used to prevent nausea and vomiting) 10 mg 3. Pro-Stat liquid (indicated for increased protein needs) 10 mg Observed LVN 1 leave the medications and supplement at the resident's bedside while she went into the bathroom to wash her hands. Resident 122 was in bed A, closest to the hallway, while the bathroom was at the opposite end of the room, closest to bed C. The privacy curtain was pulled all the way between bed A and B. The medications and supplement were on the resident's bedside table behind the privacy curtain. On 1/17/2023 at 4:29 p.m., during an interview, LVN 1 confirmed she had left the medications and supplement unattended and out of eyesight at the resident's bedside while she washed her hands in the bathroom. On 1/20/2023 at 8:58 a.m., during a concurrent interview and record review, Minimum Data Set Nurse 1 (MDS Nurse 1) stated he could not find an assessment for self-administration of medications (evaluates if a resident is able to safely self-administer medications) in Resident 122's medical record. On 1/20/2023 at 10:20 a.m., during an interview, the Director of Nursing stated it was not okay to leave medications unattended at a resident's bedside because you would not want anything to happen while the nurse's back is turned. The DON stated a confused resident could also have access to the medications. A review of the facility's policy and procedure titled, Medication Administration, last reviewed on 7/28/2022, indicated that prepared drugs are not left with the resident (unless the resident has asked for and has had the approved right to self-administration).

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide quality care in accordance with professional standards of practice to meet the resident's physical, mental, and psychosocial needs by failing to follow up and ensure residents received their authorized durable medical equipment timely for one of three sampled residents (Resident 113). This deficient practice had the potential to negatively affect Resident 113's physical and psychosocial well-being from the delay in receiving her specialized wheelchair. Findings: A review of Resident 113's admission Record indicated the facility admitted the resident on 4/28/2021, and most recently readmitted the resident on 12/27/2022, with diagnoses of malignant neoplasm (cancerous tumor) of right upper lobe bronchus (main passageways into the lungs), spinal stenosis (narrowing of the spaces inside the spine) of cervical (relating to the neck) region, and muscle spasm. A review of Resident 113's MDS, a standardized assessment and care screening tool), dated 11/5/2022, indicated the resident had the ability to make self sometimes understood and had the ability to sometimes understand others. The MDS indicated Resident 113 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene and was totally dependent on staff with transfers. The MDS further indicated the resident had impairment on both sides of lower extremities. A review of Resident 113's Authorization Request Form indicated a specialty wheelchair and fitting were requested on 7/22/2022. During a concurrent interview and record review, on 1/19/2023 at 10:50 a.m., Case Manager 1 (CM 1) stated a customized wheelchair was requested from physical therapy for Resident 113 since the resident needed special positioning to prevent her from constantly sliding out of her wheelchair. CM 1 reviewed Resident 113's chart and stated the authorization request form for the customized wheelchair was sent to the insurance company on 7/22/2022. CM 1 stated he spoke with a representative from the DME supplier who stated the wheelchair was authorized on 10/25/2022 and that they came to the facility prior to Resident 113's hospitalization on 12/18/2022 to measure the resident for the customized wheelchair but the resident was uncooperative and refused to be measured at the time. However, CM 1 verified that he did not follow up with the DME supplier to check on the status of Resident 113's authorized specialty wheelchair once the resident returned from the hospital on [DATE]. CM 1 reviewed Resident 113's progress notes and confirmed there was no documented evidence of attempts to call the DME supplier and follow up on the status of the wheelchair. CM 1 also verified there was no documented evidence in Resident 113's progress notes that the DME supplier came to the facility to fit the resident for the wheelchair and that the resident had refused to be measured. CM 1 stated that he called DME supplier today and was told that wheelchair is ready and that they can deliver it today. During an interview, on 1/20/2023 at 1:47 p.m., the Director of Nursing (DON) stated physical therapy first evaluates the resident and will make a referral if it is determined that a resident needs a certain equipment. The DON explained the case manager will then send the referral for authorization to the insurance company and are responsible for following up to ensure the ordered equipment is delivered to the resident upon authorization. The DON confirmed there was a delay in Resident 113 receiving her specialty wheelchair and stated CM 1 should have followed up with the DME supplier since the resident still had not received her equipment that was authorized on 7/22/2022. The DON stated the importance of following up on referrals and ensuring residents receive their ordered DME to allow them to be more active and get out of bed, pursue activities, and maintain their functional status. The DON further stated Resident 113 should have received her specialty wheelchair timely to prevent any potential decline in mobility and functional status. A review of the facility's policy and procedure titled, Rental Equipment Protocol, last reviewed on 7/28/2022, indicated all rental durable medical equipment must be fully accounted for from the time it was ordered, delivered to facility until the resident is discharged .

CONCERN (D)

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

Deficiency F0691 (Tag F0691)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the licensed nurses failed to monitor daily for Resident 30's bleeding at the colostomy stoma (colostomy is an operation to divert an end of the colon [part of the bowel] through an opening in the stomach. The opening is called a stoma.) site after the resident had bleeding episodes and failed to obtain a colonoscopy report from the resident in a timely manner for 1 (Resident 30) of 2 residents investigated for colostomy care. This had the potential for Resident 30 to lose volume of blood circulating in the body which could result in decrease in blood pressure, the body not receiving enough oxygen, hospitalization, and death. Findings: A review of Resident 30's Face sheet (admission record) indicated the facility originally admitted the resident on 2/21/2006 and readmitted on [DATE] with diagnoses including attention to colostomy, intestinal ulcer (a sore that develops on part of the intestine [the tract that food passes from the stomach to the anus]), and gastrointestinal hemorrhage (bleeding that is in the digestive tract). A review of Resident 30's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/31/2022, indicated Resident 30 was cognitively intact (the process of acquiring knowledge and understanding through thought, experience, and the senses) with skills required for daily decision making. The MDS indicated Resident 30 required one-person extensive assistance (resident involved in activity, staff provide weight-bearing support) with toilet use and one-person limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs) with personal hygiene. A review of Resident 30's Care Plan for Colostomy, initiated 1/03/2019, indicated a goal that Resident 30 will have regular bowel elimination. One of the interventions indicated was to monitor for any bleeding or inflammation every shift and notify the doctor if noted. The care plan indicated Resident 30 had bleeding on 10/21/2022 and went to the GACH and had a colonoscopy done. The care plan indicated on 11/05/2022, Resident 30 had bleeding from the ostomy site (an artificial opening performed during surgery in an organ in the body, i.e. colostomy) and colostomy bag. The care plan indicated Resident 30 refused to go to the hospital and for licensed nurses to monitor and apply pressure on the ostomy site. A review of Resident 30's SBAR, dated 10/21/2022, indicated Resident 30 was observed with bright red blood coming out of the stoma and stoma bleeding. The SBAR indicated licensed staff obtained an order to send Resident 30 to the hospital. A review of Resident 30's GACH Notes, indicated Resident 30 was admitted to GACH on 10/21/2022 with bleeding from the colostomy. The notes indicated Resident 30 had a colonoscopy (a procedure in which a tube is inserted through the anus to observe the gastrointestinal tract) and a hemoclip (a small metal clip placed in the intestine to prevent bleeding) was placed at the base of an ulcer. A review of Resident 30's SBAR, dated 11/05/2022, indicated Resident 30 bled from the colostomy site. The SBAR indicated Resident 30's physician was notified, Resident 30 did not want to go back to the hospital, and an order to monitor presently and put pressure on the site to stop bleeding. A review of Resident 30's Physician's Orders, dated 11/07/2022, indicated an order to monitor the ostomy site for bleeding if observed bleeding and notify the physician every shift for one month. A review of Resident 30's SBAR, dated 12/17/2022, indicated Resident 30 had an episode of bleeding from the colostomy site, the physician was notified, Resident 30 refused to go to the hospital, and the physician ordered blood labs to be drawn immediately. During an interview with Resident 30 on 1/17/2023 at 12 p.m., she stated back in October and early November 2022, the licensed nurses were not monitoring the bleeding from her colostomy site when she was residing in station five. Resident 30 stated she can empty the colostomy bag contents herself but needs assistance from the licensed nurses in changing the colostomy bag. During an interview with Licensed Vocational Nurse 4 (LVN 4) and the Director of Nurses (DON) on 1/18/2023 at 6:36 p.m., LVN 4 stated she was one of the facility's treatment nurses. LVN 4 stated the licensed nurses help Resident 30 with colostomy bag changes. LVN 4, stated, since Resident 30 empties the colostomy bag herself in her restroom, licensed staff do not always see the stoma or the contents of the colostomy. LVN 4 stated, on 1/6/2023, the licensed nurses started observing for bleeding from Resident 30's colostomy site every shift. LVN 4 stated, before 1/06/2023, the licensed nurses were checking the colostomy site everyday but sometimes would just question the resident but not observing the stoma site themselves. The DON stated, just two weeks ago, the facility obtained the 10/21/2022 colonoscopy results from Resident 30 which she had on her person. The DON stated she should have followed up right after the colonoscopy that was on 10/23/2022 because that is part of Resident 30's assessment. During an interview with LVN 4 and concurrent record review on 1/19/2023 at 9:26 a.m., reviewed Resident 30's Treatment Administration Record (TAR) for the month of December 2022. When asked about the undocumented spaces on the December 2022 TAR for providing colostomy care, instead of a check indicating the task was completed for the dates: 12/02/2022 evening, 12/07/2022 night, 12/12/2022 evening, 12/20/2022 evening, and 12/21/2022 evening, LVN 4 stated if they were not documented they not were done. LVN 4 stated it was important to monitor for bleeding because bleeding from a colostomy site is abnormal and could be life threatening if not treated. During a concurrent interview and record review with the DON on 1/19/2023 at 9:35 a.m., reviewed the facility's policy and procedure titled, Acute Condition Changes - Clinical Protocol, reviewed 7/28/2022. The DON stated the policy and procedure does not indicate that a resident must be monitored every day for a problem such as bleeding. The DON stated the policy indicated the staff will monitor and document the resident's progress and responses to treatment. The DON stated the licensed nurses should have been monitoring each shift and not just after 01/06/2023. The DON stated it is important to monitor for bleeding because the resident could have symptoms such as, fainting, dizziness, drop in blood counts which affects blood's ability to care oxygen. The policy also indicated the physician and nursing staff will identify any complications and/or problems that occurred during a recent hospital stay which refers to obtaining Resident 30's colonoscopy results after return from the hospital and not obtaining them two months later.

CONCERN (D)

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 521) investigated under hydration had water at bedside. This deficient practice placed Resident 521 at risk for health complications such as dehydration (the absence of a sufficient amount of water in your body) and constipation (a condition in which stool becomes hard, dry, and difficult to pass). Findings: A review of Resident 521's admission Record indicated the facility admitted the resident on 1/15/2023 with diagnoses including left femur fracture (femur fracture - break in the thighbone) and type 2 diabetes mellitus (a condition that affects the way the body regulates and uses blood sugar). A review of Resident 521's History and Physical (H&P), dated 1/16/2023, indicated the resident was alert and oriented to person, place, and time. A review of Resident 521's Activities of Daily Living (ADL) Care Plan, dated 1/16/2023, indicated the resident required extensive assistance with bed mobility, transfers, ambulation (walking), wheelchair propulsion (the action of driving or pushing forward), dressing, eating, toilet use, personal hygiene, and bathing. A review of Resident 521's Alteration in Bowel Elimination Care Plan, dated 1/16/2023, indicated the resident was at risk for constipation; the Care Plan indicated to encourage the resident to drink fluids. During a concurrent observation and interview on 1/17/2023 at 3:44 p.m., in Resident 521's room, observed Resident 521 licking his lips as he tried to talk. Resident 521 stated his mouth felt dry and he could not remember when he last had a drink of water. Observed no water pitcher at the resident's bedside. During a concurrent observation and interview on 1/17/2023 at 4 p.m., in Resident 521's room, observed with Licensed Vocational Nurse 2 (LVN 2) the resident did not have a water pitcher at the bedside. LVN 2 stated the resident was not on fluid restriction and should have had water readily available for the resident to drink at the bedside. LVN 2 stated the resident was placed at risk for dehydration when the resident was left with no water at the bedside. LVN 2 stated some of the signs of dehydration could be dry mouth and feelings of thirst. During an interview on 1/20/2023 at 8:50 a.m., the Assistant Director of Nursing (ADON) stated water pitchers were to be kept at the bedside to ensure residents were well hydrated. The ADON stated Certified Nursing Assistants (CNAs) were to ensure that a water pitcher was always available at the bedside. The ADON stated Resident 521 was placed at risk for dehydration when water pitcher was not provided for him at the bedside. The ADON stated a dry mouth could be a sign of dehydration. The ADON stated dehydration could cause abnormalities in the blood chemistry (blood chemistry - are substances such as sodium [a mineral needed by the body to keep body fluids in balance], potassium [a mineral that helps muscles to contract and helps your heartbeat stay regular], chloride [a chemical compound that keep the proper balance of body fluids], fat, and sugar) that could affect the resident's entire body system. The ADON further stated the Resident was placed at risk for elevated blood sugar if the resident were to suffer from dehydration. A review of the facility's policy and procedure (P&P), titled, Hydration, reviewed on 7/28/2022, indicated, Hydration is a concern that can be particularly challenging with the elderly population, and which requires many different approaches . Fresh water (with or without ice per resident preference) will be passed out on all shift and kept within reach of residents, as diet allows. Those residents unable to assist themselves will be assisted and encouraged to drink water frequently throughout the day by licensed nurses and CNAs .

CONCERN (D)

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

Deficiency F0694 (Tag F0694)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to monitor the Intake and Output (I&O- amount of fluid a resident takes in and comparing this to the amount of fluids a resident puts out) for one of two sampled resident (Resident 24) receiving Intravenous (IV) Fluid therapy (IV fluids are specially formulated liquids that are injected into a vein to prevent or treat dehydration). This deficient practice placed Resident 24 at risk for potential complications of fluid overload which could lead to collections of fluid in the lungs and around the heart. Findings: A review of Resident 24's Face Sheet (admission Record) indicated the facility admitted the resident on 12/26/2022 with diagnoses that included sepsis (a potentially life-threatening condition that occurs when the body's response to an infection damages its own tissues) and type 2 diabetes mellitus (DM - an impairment in the way the body regulates and uses sugar as a fuel). A review of Resident 24's Minimum Data Set (MDS - an assessment and care screening tool), dated 1/1/2022, indicated the resident had the ability to make self-understood and had the ability to understand others. The MDS further indicated Resident 24 required extensive assistance from staff with bed mobility, toilet use, personal hygiene, and bathing. A review of Resident 24`s Situation, Background, Assessment and Recommendation (SBAR- a tool to aid in facilitating and strengthening communication between nurses), dated 1/13/2022, indicated the resident complained of weakness and was noted with poor oral intake and consumed 10% to 30% of diet order. A review of Resident 24's physician order, dated 1/13/2022, indicated an order for Dextrose Intravenous Solution 5% (Dextrose 5% in water is used to treat low blood sugar and dehydration (fluid loss), use 75/milliliter (ml - unit of measurement) per hour intravenously (through or within a vein) every shift for poor oral intake supplement for three days, start at 10:30 p.m. on 1/13/2023. A review of Resident 24`s SBAR, dated 1/15/2022, indicated an abnormal urinalysis (often done to check for a urinary tract infection, kidney problem, or diabetes) result with presence of Klebsiella Pneumoniae (a common gut bacteria, causes problems when it moves outside the gut and causes infection) in urine. Physician and Nurse Practitioner was notified with new order received. A review of Resident 24's physician order, dated 1/15/2022, indicated an order for Ceftriaxone Sodium (used to treat bacterial infections in many different parts of the body) IV Solution Reconstituted, use 1 gram (gm - unit of measurement) intravenously one time a day for Klebsiella Pneumonias for three days. A review of Resident 24`s Comprehensive Care Plan (documentation of the patient's needs and wants, as well as the nursing interventions), with a focus on Resident 24`s requiring IV therapy of Ceftriaxone Sodium, with a target date of 1/20/223, included an intervention to monitor I&O for the length of the therapy. On 1/19/23 at 3:14 p.m., during a concurrent record review and interview, the Assistant Director of Nursing (ADON) stated Resident 24 was on antibiotic therapy and IV fluid therapy for dehydration due to poor oral intake and had to have their fluid intake and output monitored. The ADON stated there was no documented evidence of I&O monitoring for Resident 24, for the antibiotic therapy and IV fluid hydration therapy. According to the ADON, without the I&O monitoring, they cannot determine if the resident is having fluid loss or retaining fluids which could result to complications such as UTI or pneumonia. A review of the facility's policy and procedure titled, Intake and Output Monitoring, last reviewed on 7/28/2022, indicated that the purpose of monitoring intake and output (I&O) is to assure adequate hydration. The residents having the following therapies and/or treatments have I&O monitoring until therapy or treatment is discontinued: a. Fluid Restrictions b. IV administration of fluids

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to provide oxygen (a colorless, odorless, and tasteless gas) therapy according to physician's orders for one of eight sampled residents (Resident 517) investigated under respiratory care. This deficient practice had the potential to place Resident 517 at risk for receiving unnecessary oxygen therapy not indicated for the resident's current medical condition. Findings: A review of Resident 517's admission Record indicated the facility admitted the resident on 1/15/2023 with diagnoses including atrial fibrillation (a. fib. A-fib - is an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), second-degree heart block (when the electrical signal that controls your heartbeat is partially or completely blocked), and heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs). A review of Resident 517's Admit/Re-admit Nursing Evaluation, dated 1/15/2023, indicated the resident was alert and oriented to person, place, time, and situation. A review of Resident 517's Order Summary Report, dated 1/15/2023, indicated the following: 1. Admit under hospice care (care designed to give supportive care in the final phase of a terminal illness and focus on comfort and quality of life). 2. Oxygen at two liters per minute (LPM - a measurement of the flow rate at which air flows into the nostrils [openings to your nose] over a period of one minute) via nasal cannula (a medical device used to provide supplemental oxygen) as needed for shortness of breath (SOB). May titrate (adjust) up to four LPM to maintain blood oxygen level above 90 (percent) %. A review of Resident 517's Care Plan indicated the resident had end stage heart failure and receiving hospice care. The Care Plan indicated the facility to work together with hospice to provide a cohesive and continuous program of care. During an observation on 1/18/2023 at 9:20 a.m., in Resident 517's room, observed the resident on a non-rebreather (NRB - a special medical device that helps provide a resident with high concentrations of oxygen in emergencies) mask and a nasal cannula at the same time. During a concurrent observation and interview on 1/18/2023 at 9:35 a.m., in Resident 517's room, observed with the Assistant Director of Nursing (ADON) the resident on a NRB mask and on a nasal cannula at the same time. The ADON stated the resident was on a nasal cannula at four LPM via an oxygen concentrator (a type of medical device used for delivering oxygen to individuals) and on an NRB mask via a portable oxygen tank at six LPM. Resident 517's Family Member 1 (FM 1) who was at the bedside stated she stayed overnight (night of 1/17/2023); FM 1 stated around 1 a.m. to 2 a.m., a nurse placed a NRB mask on the resident. The ADON stated placing a resident on a nasal cannula and NRB mask at the same time was not a professional standard of practice. The ADON stated an NRB mask should only be used when indicated. During a concurrent interview and record review on 1/20/2023 at 9:14 a.m., the ADON stated the resident was admitted to hospice care on 1/15/2023. The ADON stated hospice care meant no acute (health care where a patient receives active but short-term treatment for a severe injury or illness) interventions to manage the resident's medical condition but rather to provide comfort to prevent suffering. The ADON stated placing the resident on a NRB mask was not part of the resident's plan of care and physician's orders at the time of observation on 1/18/2023 at 9:20 a.m. The ADON stated she interviewed Licensed Vocational Nurse 12 (LVN 12), the nurse who took care of the resident during the night shift (11 p.m. to 7 a.m.) of 1/17/2023; the ADON stated LVN 12 admitted to placing the resident on an NRB mask after the resident's family stated a mask gave the resident comfort. The ADON stated there was no record to indicate that the resident had an oxygen level below 90% or had a change of condition that would warrant the use of a NRB mask. The ADON stated the resident's recorded oxygen level on the night shift of 1/17/2023 was 92%. The ADON stated there was no record to indicate that hospice was notified of any changes in the resident's condition on the night shift of 1/17/2023. The ADON stated LVN 12 could have educated the family that a NRB mask was not ordered and not necessary at the time. The ADON stated LVN 12 could have used a simple mask (usually used to deliver a low to moderate amount of oxygen) instead of a NRB mask. The ADON stated an NRB mask is used in an emergency. The ADON stated the resident had lorazepam (is a drug commonly prescribed to alleviate symptoms of anxiety) 0.5 milligrams (mg-unit of measure) every six hours around the clock should the resident suffer from hyperventilation (rapid breathing). The ADON stated the resident was provided with intervention (a treatment, procedure, or other action taken to prevent or treat disease, or improve health in other ways) that was not in line with Resident 517's plan of care. The ADON further stated that it was not beneficial for the resident when an intervention provided was not in line with the plan of care. During an interview on 1/20/2023 at 2:50 p.m., Hospice Nurse (HN) stated she was not aware of any changes in Resident 517's condition that would require the use of NRB mask. HN stated an NRB mask was not part of the resident's plan of care and not in the physician's orders. HN stated an NRB mask is not a typical intervention for a resident in hospice care or comfort measures. HN stated if Resident 517 was having SOB, the approach would be to start the resident on a nasal cannula and manage the SOB with lorazepam. HN stated the resident was on scheduled lorazepam to manage SOB. A review of the facility's policy and procedure (P&P), titled, Oxygen Administration, reviewed on 7/28/2022, indicated, Oxygen administration will be ordered by the physician (unless used in an emergency) and administered to the resident by a licensed nurse . A review of the facility's P&P, titled, Hospice Program, reviewed on 7/28/2022, indicated, When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other uncomfortable symptoms .

CONCERN (D)

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure one of six sampled resident's (Resident 18) drug regimen was free of unnecessary medications by failing to indicate a specific diagnosis for Levaquin (antibiotic used to variety of bacterial infections) in the physician's order. This deficient practice had the potential to result in Resident 18 receiving unnecessary medication and placed the resident at risk for adverse consequences (unwanted, uncomfortable, or dangerous effects that a drug may have) from prolonged use of antibiotics including antibiotic resistance. Findings: A review of Resident 18's admission Record indicated the facility admitted the resident on 4/8/2010 with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting right nondominant side and diabetes mellitus type two (chronic health condition characterized by inappropriately elevated blood sugar levels). A review of Resident 18's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/24/2022, indicated the resident had the ability to make self sometimes understood and had the ability to sometimes understand others. The MDS further indicated Resident 18 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene, and was totally dependent on staff with transfers. A review of Resident 18's physician's order indicated an order for Levaquin oral tablet 500 milligrams (mg - unit of measure), give 500 mg by mouth one time a day for possible infection noted by fever for six days, ordered on 1/12/2023. During a concurrent interview and record review, on 1/20/2023 at 10:02 a.m., the Infection Preventionist (IP) reviewed Resident 18's physician's order and confirmed the order for Levaquin did not have a specific diagnosis or infection. The IP explained an order for antibiotics should include the dose, duration or length of treatment including stop date, frequency, route, and the specific diagnosis or type of infection. The IP verified possible infection is not an adequate indication for antibiotic use and stated the antibiotic order should have included a specific diagnosis or infection for staff to know why the resident is on antibiotics and what is actually being treated. The IP further stated there is potential outcome for antibiotic resistance (when bacteria/germs change in some way that reduces or eliminates the effectiveness of drugs designed to cure or prevent infections) if antibiotics do not have a specific indication and are used inappropriately. A review of the facility's policy and procedure titled, Infection Prevention and Control Manual - Antibiotic Stewardship and Multidrug-Resistant Organism (MDROs), last reviewed on 7/28/2022, indicated if antibiotic therapy is ordered, documentation will include diagnosis, medication, dose, route, and duration.

CONCERN (D)

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

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure licensed nurses accurately monitored a resident's targeted behaviors when administering lorazepam (used to treat anxiety) as needed (PRN) by failing to ensure that the number of documented behaviors reflected the number of times the medication was given for one (Resident 130) out of five sampled residents investigated for unnecessary medications. This deficient practice placed the resident at increased risk of experiencing adverse side effects (any unexpected or dangerous reaction to a drug) from the medication. Findings: A review of Resident 130's admission Record indicated the facility originally admitted the resident on 6/9/2022 and readmitted the resident on 7/6/2022 with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe on your own) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). A review of Resident 130's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 1/12/2023, indicated the resident had intact cognition (thought processes) and required limited assistance from staff for transfers, walking in the room and in the corridor, dressing, toilet use, and personal hygiene. On 1/19/2023 at 10:23 a.m., during a concurrent interview and record review, Minimum Data Set Nurse 1 (MDS Nurse 1) stated Resident 130 was currently taking lorazepam 2 milligrams (mg - unit of measurement) by mouth (PO) every 6 hours (q6h) as needed (PRN) for verbalization of anxiety leading to hyperventilation (rapid or deep breathing usually caused by anxiety or panic) related to anxiety disorder. A review of Resident 130's Medication Administration Record (MAR - documents medications given to the resident) for 1/2023 indicated the following: 1. On 1/2/2023 at 8:45 a.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 2. On 1/2/2023 at 10:42 p.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 3. On 1/3/2023 at 7:21 a.m. and 2:37 p.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 4. On 1/3/2023 at 10:04 p.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 5. On 1/4/2023 at 7:57 a.m. and 2:33 p.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 6. On 1/4/2023 at 9:01 p.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 7. On 1/5/2023 at 3:20 a.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 8. On 1/5/2023 at 3:56 p.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 9. On 1/6/2023 at 5:26 a.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 10. On 1/6/2023 at 8:46 p.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 11. On 1/7/2023 at 7 a.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 12. On 1/8/2023 at 8:25 a.m. and 2:30 p.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 13. On 1/8/2023 at 8:30 p.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 14. On 1/9/2023 at 8:21 a.m. and 3 p.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 15. On 1/9/2023 at 9:16 p.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 16. On 1/10/2023 at 6:15 a.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 17. On 1/10/2023 at 2:27 p.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 18. On 1/10/2023 at 8:52 p.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 19. On 1/11/2023 at 4:53 a.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 20. On 1/11/2023 at 12:37 p.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 21. On 1/11/2023 at 9:09 p.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 22. On 1/12/2023 at 7:24 a.m. and 2:45 p.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 23. On 1/12/2023 at 10:51 p.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 24. On 1/13/2023 at 7:55 a.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 25. On 1/13/2023 at 3:53 p.m. and 10:45 p.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 26. On 1/14/2023 at 7:56 a.m. and 2:02 p.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 27. On 1/14/2023 at 8:33 p.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 28. On 1/15/2023 at 3:51 a.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 29. On 1/15/2023 at 12:46 p.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 30. On 1/15/2023 at 9:08 p.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 31. On 1/16/2023 at 7:42 a.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 32. On 1/16/2023 at 5:20 p.m. the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 33. On 1/17/2023 at 1:50 a.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. 34. On 1/17/2023 at 7:50 a.m. and 2:54 p.m., the nurse documented that lorazepam 2 mg was administered. The number of documented behaviors of hyperventilation during that shift was 0. On 1/19/2023 at 10:23 a.m., during a concurrent interview and record review, MDS Nurse 1 verified that Resident 130 was receiving lorazepam 2 mg daily but that the number of behaviors exhibited did not reflect the number of times the medication was being administered. MDS Nurse 1 stated the numbers should indicate the number of behaviors the resident exhibited during the entire shift. MDS Nurse 1 stated that nurses should be documenting that number at the end of their shift. On 1/19/2023 at 11:57 a.m., during an interview, Licensed Vocational Nurse 6 (LVN 6) stated that Resident 130 received lorazepam as needed. LVN 6 stated he gave the resident lorazepam when the resident would ask for one. LVN 6 stated the behavior being monitored was hyperventilation. On 1/20/2023 at 10:01 a.m., during an interview, the Director of Nursing (DON) stated that the behavioral monitoring should reflect the administration of the medication. The DON stated it was important to ensure that the number of behavioral episodes were being accurately tallied to see if the medication was still necessary or to determine if it needed to be decreased. A review of the policy and procedure titled, PRN Psychotropic Medications (any drug that affects behavior, mood, thoughts, or perception), last reviewed on 7/28/2022, indicated to identify the behavior ., document the behavior ., and document the psychotropic medication given and the effectiveness of the medication.

CONCERN (D)

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

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to implement its antibiotic stewardship (set of commitments and actions designed to optimize treatment of infections while reducing the adverse events associated with antibiotic [medication used to treat bacterial infection] use) policy by failing to notify the physician and recommend discontinuation of antibiotics when they were no longer needed for one of two sampled residents (Resident 18) investigated under care area of antibiotic use. This deficient practice had the potential for Resident 18 to develop antibiotic resistance (when bacteria/germs change in some way that reduces or eliminates the effectiveness of drugs designed to cure or prevent infections) from unnecessary or inappropriate antibiotic use. Findings: A review of Resident 18's admission Record indicated the facility admitted the resident on 4/8/2010 with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area) affecting right nondominant side and diabetes mellitus type two (chronic health condition characterized by inappropriately elevated blood sugar levels). A review of Resident 18's A review of Resident 18's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 10/24/2022, indicated the resident had the ability to make self sometimes understood and had the ability to sometimes understand others. The MDS further indicated Resident 18 required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene, and was totally dependent on staff with transfers. A review of Resident 18's physician's order indicated an order for Levaquin oral tablet 500 milligrams (mg - unit of measure), give 500 mg by mouth one time a day for possible infection noted by fever for six days, ordered on 1/12/2023. A review of Resident 18's Medication Administration Record (MAR) for January 2023 indicated Levaquin was administered daily as ordered from 1/13/2023 to 1/18/2023 for a total of six days. A review of Resident 18's Mcgeer's Criteria (standard used for defining infections for surveillance purposes) for Infection Control Surveillance Form, dated 1/13/2023, indicated Resident 18 was observed with no respiratory signs and symptoms and therefore met only two of three necessary criteria for lower respiratory tract infection. However, the form indicated documentation from the Infection Preventionist (IP) that the resident meets Mcgeer's criteria for antibiotic usage. During a concurrent interview and record review, on 1/20/2023 at 10:02 a.m., the Infection Preventionist (IP) stated the facility uses the Mcgeer's criteria to define infections for infection surveillance purposes. The IP reviewed Resident 18's Mcgeer's Criteria for Infection Control Surveillance Form and stated the resident had fever, chills, and leukocytosis (elevated white blood cell count) but did not have any respiratory signs and symptoms. The IP confirmed the resident did not meet the Mcgeer's criteria for lower respiratory tract infection and verified at least two of the following respiratory subcriteria should have been present for diagnosis of lower respiratory tract infection: new or increased cough, new or increased sputum production, oxygen saturation (amount of oxygen you have circulating in the blood) less than 94 percent on room air or reduction in oxygen saturation of greater than three percent from baseline, new or changed lung examination abnormalities, pleuritic (two large, thin layers of tissue that separate the lungs from chest wall) chest pain, and respiratory rate of greater than or equal to 25 breaths per minute. The IP explained that she contacts the physician to ask if it is possible to discontinue the ordered antibiotic therapy if the resident does not meet the Mcgeer's criteria for a suspected infection. The IP confirmed there was no documented evidence upon reviewing Resident 18's progress notes from 1/12/2023 to 1/18/2023 that the physician was notified and made aware that the resident did not meet the Mcgeer's criteria for lower respiratory tract infection. The IP stated the importance of notifying the physician when residents do not meet the criteria for a suspected infection to discontinue the antibiotic therapy if possible and ensure antibiotics are used appropriately. The IP further stated inappropriate antibiotic use can lead to antibiotic resistance and higher susceptibility for multidrug-resistant organisms (MDROs) which can be more difficult to treat. A review of the facility's policy and procedure titled, Infection Prevention and Control Manual - Antibiotic Stewardship and MDROs, last reviewed on 7/28/2022, indicated it is the policy of this facility to provide systematic efforts to optimize the use of antibiotics in order to maximize their benefits to resident while minimizing both the rise of antibiotic resistance as well as adverse effects to patients from unnecessary antibiotic therapy. The policy and procedure further indicated antibiotic stewardship will include an assessment process, use of evidence-based criteria, efforts to identity the microbe responsible for disease, selecting the appropriate antibiotic along with documentation indicating the rationale for use, appropriate dosing, route, and duration of antibiotic therapy, and to ensure discontinuation of antibiotics when they are no longer needed.

CONCERN (E)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

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b. A review of Resident 80's admission Record indicated the facility admitted the resident on 9/14/2022, with diagnoses including unspecified sequelae of unspecified cerebrovascular disease (a stroke), dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), and muscle weakness. A review of Resident 80's Minimum Data Set (MDS - an assessment and screening too) dated 12/21/2022, indicated the resident had the ability to be understood by others and had the ability to make self-understood. The MDS indicated the resident required extensive assistance with bed mobility, dressing, eating, toilet use and personal hygiene. A review of Resident 80's Care Plan titled, Potential for weight loss, initiated 9/16/2022, indicated a goal that the resident would not have significant weight loss. A review of Resident 80's Care Plan titled, Requires assistance with activities of daily living, initiated 9/14/2022, indicated the resident required one person assistance with eating. During an observation on 1/17/2023 at 12:20 p.m., observed Resident 80 sitting at bedside in a wheelchair with the lunch tray on the table in front of the resident. Observed RNA 1 standing next to Resident 80 and used a spoon to place food in Resident 80's mouth. During an interview on 1/17/2023 at 12:30 p.m., RNA 1 stated Resident 80 needed assistance with eating because she could not feed herself. RNA 1 stated she did not sit while feeding Resident 80 because she did not take the time to get a chair. RNA 1 stated she should always sit face to face with residents while feeding them to provide care in an environment that encourages eating. During an interview on 1/19/2023 at 11:45 a.m., the Director of Nursing (DON) stated the RNA dining program was to assist and encourage residents to eat. The DON stated the program benefited residents who had difficulty or lost interest in eating or had weight loss. The DON stated Resident 80 had a history of stroke and needed assistance with feeding. The DON stated the RNA encourages intake (of food) by providing interaction to make sure the resident's feeding is not hurried. The DON stated the RNA should have sat at eye level with the resident while feeding to provide the resident care with dignity. A review of the facility policy and procedure titled, Quality of Life - Dignity, last reviewed 10/28/2022, indicated each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall be treated with respect and dignity at all times. Treated with Dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. A review of the facility policy and procedure titled, Dining Program, last reviewed 10/28/2022, indicated the facility shall have a process in place to provide an enjoyable and safe dining experience while meeting Federal/State/Facility's standards in regard to dining. The dining component of the Nutritional Management System will ensure necessary services to maintain and /or improve each patient's dining skills and enhance quality of life by providing enjoyable food in a supportive setting. Restorative dining includes patients with mild to minimal self-feeding/swallowing difficulties, which require a directed Care Plan with specific goals but not skilled therapy. Patients are monitored and staff trained under the supervision of a licensed nurse. Staff sit while assisting residents. c. A review of the admission Record indicated the facility admitted Resident 158 on 12/15/2022, with diagnoses including spinal stenosis ([or narrowing] is a common condition that occurs when the small spinal canal, which contains the nerve roots and spinal cord, becomes compressed), urinary tract infection([UTI] is an infection in any part of the urinary system), and obstructive and reflux uropathy (a condition in which the kidneys are damaged by the backward flow of urine into the kidney). A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 2/21/2022, indicated Resident 158 had the ability to make self-understood and understand others. The MDS indicated Resident 158 required extensive assistance with bed mobility, transfer, dressing, and toilet use. The MDS also indicated the resident had an indwelling urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) During a concurrent observation and interview on 1/18/2023 at 3:30p.m., observed Resident 158 sitting up in bed with catheter bag hanging on side of bed with no dignity bag. Licensed Vocational Nurse 10 (LVN 10) at bedside confirmed that Resident 158 did not have a dignity bag. LVN 10 stated that if residents do not have a dignity bag for the catheter it can affect the resident's self-worth. During an interview on 1/19/2023 at 2:56 p.m., with the Director of Nursing (DON), the DON stated Resident 158 not having a dignity bag for the urinary catheter is a dignity concern because his urine bag was exposed. A review of facility's policy and procedures titled Quality of Life-Dignity, last revised on 7/28/2022 indicated demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: helping the resident to keep urinary catheter bags covered. Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for three (Resident 122, Resident 80, and Resident 158) of four sampled residents investigated for dignity by failing to: 1. Ensure that Licensed Vocational Nurse 1 (LVN 1) provided privacy to Resident 122 during a gastrostomy tube (g-tube - a tube inserted through the belly that brings nutrition directly to the stomach) medication administration by failing to close the privacy curtain (curtain that helps to maintain the dignity and privacy of residents) all the way around the resident's bed. 2. Ensure Restorative Nursing Assistant 1 (RNA 1) was sitting at eye level with Resident 80 while feeding the resident on the Restorative Nursing Assistant (RNA, a certified nursing assistant with additional training to assist residents attain or maintain their highest possible physical, mental, and emotional well-being) dining program. 3. Ensure Resident 158's urinary catheter bag (urine drainage bags used to collect urine. Your bag will attach to a catheter [tube] that is inside your bladder) was covered. These deficient practices had the potential to affect the residents' sense of self-worth and self-esteem. Findings: a. A review of Resident 122's admission Record indicated the facility admitted the resident on 7/21/2021, with diagnoses including encounter for attention to gastrostomy (a surgical procedure used to insert a tube into the stomach). A review of Resident 122's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 10/28/2022, indicated the resident had intact cognition (thought processes) and required extensive assistance from staff for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. On 1/17/2023 at 4:04 p.m., during a medication administration observation, observed LVN 1 giving medication to Resident 122 through his g-tube. The resident's abdomen (stomach) was exposed. The privacy curtain was open at the foot of the resident's bed. The resident's roommate had a visitor at the bedside. On 1/17/2023 at 4:29 p.m., during an interview, LVN 1 stated she had forgotten to close the resident's privacy curtain all the way around the resident's bed. On 1/20/2023 at 10:20 a.m., during an interview, the Director of Nursing (DON) stated one of the things that nurses can do to maintain the resident's dignity during medication administration is to provide the resident with privacy. The DON stated she would not want the resident to be exposed to others, and she would not want anyone to know what procedure is being done for the resident. A review of the facility's policy and procedure titled, Quality of Life - Dignity, last reviewed on 07/28/2022, indicated that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth. Staff shall promote, maintain, and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures.

CONCERN (E)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to provide a resident environment that remained free of accident hazards and adequate supervision to prevent accidents by failing to: 1. Ensure a resident with a potential for falls was not left unattended by staff with the bed in the high position for one of five sampled residents (Resident 72) investigated under the Accidents care area. This deficient practice had the potential to result in Resident 72 sustaining an injury from a fall. 2. Ensure the side rails were padded per physician's order for one of one sampled resident (Resident 37) with a history of seizures (sudden, uncontrolled electrical activity in the brain). This deficient practice had the potential for Resident 37 to suffer an injury during a seizure episode. Findings: a. A review of Resident 72's admission Record indicated the facility admitted the resident on 10/25/2022 and readmitted the resident on 12/6/2022 with diagnoses that included gastrointestinal hemorrhage (bleeding in the stomach or intestines), atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), and other disorders of bone density (amount of minerals in the bones that determines their strength). A review of Resident 72's Minimum Data Set (MDS - an assessment and screening too) dated 10/31/2022, indicated the resident usually had the ability to be understood by others and usually had the ability to make self-understood. The MDS indicated the resident required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene. A review of Resident 72's Care Plan (CP) titled, Potential for falls related to period of confusion, unsteady gait/balance, poor safety awareness, and weakness, initiated 10/25/2022 indicated a goal that the resident would have reduced risk for falls and injury associated with falls. The CP interventions indicated to provide a safe environment and to keep the bed at the lowest position. The CP further indicated fall risk (was) discussed, falls can lead to injury, fracture (broken bone), and even death. A review of Resident 72's Physician Orders indicated an order for a Hi-Lo bed (an adjustable bed with enhanced head, foot, and height adjustability), bed in low position as much as possible while in bed, dated 12/6/2022. During an observation on 1/17/2023 at 12:50 p.m., Resident 72 lay in bed with the bed elevated to the high position. Observed Resident 72 move his left leg toward the edge of the bed. During an observation and interview on 1/17/2023 at 1 p.m., Certified Nursing Assistant 4 (CNA 4) exited a resident's room located down the hall from Resident 72's room. CNA 4 stated she was caring for Resident 72 and sometimes the resident was confused. CNA 4 assessed Resident 72 and stated the bed was in the high position. CNA 4 asked Resident 72 if he wanted the bed lowered and Resident 72 stated yes. Observed CNA 4 lower Resident 72's bed to the low position. CNA 4 stated she left Resident 72's bed in the high position because she was going to assist Resident 72 with lunch, but the tray did not arrive, and she left the room to assist another resident. CNA 4 stated she should not have left the bed in the high position because the resident could fall. During an interview on 1/19/2023 at 9:30 a.m., Licensed Vocational Nurse 5 (LVN 5) stated Resident 72 had periods of confusion and was weak. LVN 5 stated Resident 72 was a fall risk. LVN 5 stated Resident 72 received physical therapy and stated he wanted to move around and get out of bed. LVN 5 stated if the bed was left in the high position the resident could have fallen and hurt himself by hitting his head, bleeding from lacerations, breaking bones, or something worse. During an interview on 1/19/2023 at 11:45 a.m., the Director of Nursing (DON) stated Resident 72 was a risk for falls and had a fall risk intervention to keep the bed in the low position. The DON stated the CNA that left the bed in the high position caused concern because there was a potential for the resident to fall. The DON stated if the resident fell from the bed in the high position, there was a potential for injury, like a fracture. The DON reviewed the facility policy and procedure and stated it did not specifically state to keep the bed in the low position, but the bed has to be kept in the low position if the resident is unattended by staff. A review of the facility policy and procedure titled, Falls and Fall Risk Management, last reviewed 10/28/2022, indicated based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. The staff will identify and implement relevant interventions to try to minimize serious consequences of falling. b. A review of Resident 37's admission Record indicated the facility admitted the resident on 3/11/2016, and most recently readmitted the resident on 4/1/2022, with diagnoses that included seizures, atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), and sleep apnea (sleep disorder in which breathing repeatedly stops and restarts). A review of Resident 37's Minimum Data Set (MDS - an assessment and care screening tool), dated 1/8/2023, indicated the resident had the ability to make self understood and had the ability to understand others. The MDS further indicated Resident 37 required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. A review of Resident 37's physician's orders indicated the following: 1. Phenytoin Sodium (medication used to control seizures) Extended Capsule 300 milligrams (mg - unit of measure). Give one capsule by mouth one time a day related to seizures, ordered on 4/1/2022. 2. Padded side rails times two, ordered on 4/3/2022. 3. Monitor for seizures every shift. Notify medical doctor (MD) of any seizure activity, ordered on 4/3/2022. A review of Resident 37's care plan indicated potential for high risk for trauma and injuries related to seizure disorder and included an intervention for padded side rails, created on 5/23/2022. During an observation, on 1/18/2023 at 12;50 p.m., observed Resident 37 laying in bed with bilateral side rails up without padding. During a concurrent observation, interview, and record review, Licensed Vocational Nurse 11 (LVN 11) observed and verified both side rails on Resident 37's bed were not padded. LVN 11 reviewed Resident 37's physician's orders and confirmed orders for seizure precautions and padded side rails times two. LVN 11 stated Resident 37 has a diagnosis of seizures and explained seizure precautions are being implemented for the resident's safety that include low bed position, padded side rails, and monitoring for seizure episodes. LVN 11 confirmed both side rails should have been padded following the physician's order since there is potential outcome for injury due to uncontrollable movements if the resident starts to have a seizure activity. During a concurrent interview and record review, on 1/20/2023 at 8:06 a.m., the Director of Nursing (DON) confirmed seizure precautions are implemented for all residents with diagnosis of seizures, including padding bilateral side rails. The DON verified an order for padded side rails upon reviewing Resident 37's physician's orders and stated both side rails should have been padded to prevent injuries that can potentially occur from the resident accidentally hitting the side rails during a seizure episode. A review of the facility's policy and procedure titled, Seizure Precautions, last reviewed on 7/28/2022, indicated to prevent injury to the resident during a seizure and assess for the need for padded bed rails.

CONCERN (E)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.b. A review of the admission Record indicated Resident 110 was admitted on [DATE], with diagnoses including chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should), anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), and hyperlipidemia (high cholesterol, means you have too many lipids (fats) in your blood). A review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 12/8/2022, indicated Resident 110 had the ability to make self understood and understand others. A review of Resident 110 orders, dated 11/23/2022, indicated an order for Norco tablet 5-325 mg (hydrocodone-acetaminophen) 1 tablet by mouth one time a day for pain management. On 1/19/2023 at 2:13 p.m., during an inspection of the medication cart B in station 3 with Licensed Vocational Nurse (LVN13), performed the narcotic count. A review of Resident 110's Norco tablet 5-325 mg indicated the narcotic count was 24, actual on hand was 23. LNV13 stated should have documented medication once she gave medication on the narcotic book, if not documented somebody can think it was not given and the count would be off. A review of Resident 110's MAR dated 1/19/2023 indicated Norco 5-325 was given by LVN13. During an interview on 1/19/2023 at 2:23 p.m., the Director of Nursing (DON) stated that when medication is not documented after administration can be an issue with drug accuracy and an issue with reconcile medication. The DON stated the license staff should be documenting in MAR and the narcotic book once the medication is given. A review of facility's policy and procedures titled, Preparation for Medication Administration, last revised on 7/28/2022 indicated the individual who administers the medication dose records the administration on the resident MAR directly after the medication is given. At the end of each medication pass, the person administering the medication reviews the MAR to ensure necessary doses were administered and documented. 3.c. A review of the admission Record indicated Resident 95 was admitted on [DATE] and readmitted on [DATE], with diagnoses including anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness), Alzheimer's disease (a brain disorder that usually starts in late middle age or old age and gets worse over time. Symptoms include loss of memory, confusion, difficulty thinking, and changes in language, behavior, and personality), and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). A review of Resident 95's MDS, dated [DATE], indicated Resident sometimes can make self understood and sometimes understand others. A review of Resident 95's orders, dated 7/10/2021, indicated Xanax tablet 0.25 mg (alprazolam) give 0.25 mg by mouth three times a day for mood behavior increased restlessness related to anxiety disorder. On 1/18/2023 at 2:12 p.m., during an inspection of medication cart A in station 2 with Registered Nurse (RN1), performed the narcotic count. A review of Resident 95's alprazolam 0.25mg indicated the narcotic count was 6, actual on hand was 5. RN1 stated he did not document the medication in the narcotic book and he should have documented it as soon as he gave the medication. RN1 stated not documenting medications as soon as they are given can cause the count to be off. A review of Resident 95's MAR, dated 1/18/2023, indicated alprazolam was given by RN1. During an interview on 1/19/2023 at 2:23 p.m., the Director of Nursing (DON) stated that when medication is not documented after administration can be an issue with drug accuracy and an issue with reconcile medication. The DON stated the license staff should be documenting in MAR and the narcotic book once the medication is given. A review of facility's policy and procedures titled, Preparation for Medication Administration, last revised on 7/28/2022, indicated the individual who administers the medication dose records the administration on the resident MAR directly after the medication is given. At the end of each medication pass, the person administering the medication reviews the MAR to ensure necessary doses were administered and documented. Based on observation, interview, and record review, the facility failed to: 1. Ensure licensed nurses did not administer a resident's blood pressure (BP - the pressure of circulating blood against the walls of blood vessels) medication outside of the physician's prescribed parameters (indicates when a medication should or should not be administered) for one of two sampled residents (Resident 156). This deficient practice placed Resident at increased risk of experiencing adverse side effects due to the blood pressure medication. 2. Ensure that Licensed Vocational Nurse 1 (LVN 1) flushed the gastrostomy tube (g-tube - a tube inserted through the belly that brings nutrition directly to the stomach) with water between each medication administered for one of eight sampled residents (Resident 122). This deficient practice placed Resident 122 at increased risk of medication interactions (occurs when two or more medications interact with each other, which can change the drug's effect on the body). 3. Ensure the narcotic count record reconciled with the corresponding medication administration record (MAR) for three out of twelve residents (Resident 95, Resident 110, and Resident 126). This deficient practice had a potential for the facility staff to not secure and safeguard controlled medications and not be able to account for the medications that were administered to the residents safely and accurately. Findings: 1. A review of Resident 156's admission Record indicated the facility admitted the resident on 12/7/2022 with diagnoses including hypotension (low blood pressure) and hypertension (high blood pressure). A review of Resident 156's Minimum Data Set (MDS - a standardized assessment and care screening tool), dated 12/13/2022, indicated the resident had intact cognition (thought processes) and required extensive assistance from staff for bed mobility, transfers, walking in the room and in the corridor, locomotion on and off the unit, dressing, toilet use, and personal hygiene. A review of Resident 156's Order Summary Report (a summary of the resident's physician's orders) indicated an order for Midodrine hydrochloride (HCl) (medication used to treat low blood pressure) 10 milligrams (mg - unit of measurement) by mouth (PO) three times a day (TID) for low blood pressure. The order indicated to hold (not administer the medication) for systolic blood pressure (SBP - indicates how much pressure blood is exerting against the artery walls when the heart beats) greater than 100 millimeters of mercury (mmHg - unit of measurement for blood pressure). A review of Resident 156's 12/2022 Medication Administration Record (MAR - documents medications given to the resident) indicated the following: 1. On 12/15/2022 at 9 a.m., the resident's BP was 101/68 mmHg. The nurse documented that midodrine was administered. 2. On 12/15/2022 at 1 p.m., the resident's BP was 101/68 mmHg. The nurse documented that midodrine was administered. 3. On 12/16/2022 at 9 a.m., the resident's BP was 108/68 mmHg. The nurse documented that midodrine was administered. 4. On 12/16/2022 at 1 p.m., the resident's BP was 120/60 mmHg. The nurse documented that midodrine was administered. 5. On 12/17/2022 at 9 a.m., the resident's BP was 106/66 mmHg. The nurse documented that midodrine was administered. 6. On 12/17/2022 at 1 p.m., the resident's BP was 108/68 mmHg. The nurse documented that midodrine was administered. 7. On 12/18/2022 at 9 a.m., the resident's BP was 109/73 mmHg. The nurse documented that midodrine was administered. 8. On 12/22/2022 at 9 a.m., the resident's BP was 110/65 mmHg. The nurse documented that midodrine was administered. 9. On 12/22/2022 at 1 p.m., the resident's BP was 110/65 mmHg. The nurse documented that midodrine was administered. 10. On 12/26/2022 at 9 a.m., the resident's BP was 117/76 mmHg. The nurse documented that midodrine was administered. 11. On 12/27/2022 at 1 p.m., the resident's BP was 113/67 mmHg. The nurse documented that midodrine was administered. 12. On 12/30/2022 at 1 p.m., the resident's BP was 110/56 mmHg. The nurse documented that midodrine was administered. A review of Resident 156's 1/2023 MAR indicated the following: 1. On 1/9/2023 at 5 p.m., the resident's BP was 112/60 mmHg. The nurse documented that midodrine was administered. 2. On 1/14/2023 at 5 p.m., the resident's BP was 106/69 mmHg. The nurse documented that midodrine was administered. 3. On 1/16/2023 at 1 p.m., the resident's BP was 114/66 mmHg. The nurse documented that midodrine was administered. 4. On 1/18/2023 at 9 a.m., the resident's BP was 108/73 mmHg. The nurse documented that midodrine was administered. On 1/19/2023 at 8:37 a.m., during a concurrent interview and record review, Minimum Data Set Nurse 1 (MDS Nurse 1) stated that midodrine should not have been given to Resident 156 on the dates indicated above since the resident's systolic blood pressure was greater than 100 mmHg. On 1/19/2023 at 1:53 p.m., during an interview, Licensed Vocational Nurse 8 (LVN 8) stated he had been assigned to the resident twice. LVN 8 stated that if there was a check mark next to his name on the MAR, then that meant the medication was given to the resident. On 1/20/2023 at 10:16 a.m., during a concurrent interview and record review, the Director of Nursing (DON) stated that midodrine should have been held on the dates indicated above. The DON stated that midodrine further increases the resident's blood pressure, and if the physician's prescribed parameters are not followed, then there can be an unwanted increase in the resident's blood pressure. A review of the facility's policy and procedure titled, Medication Administration, last reviewed on 7/28/2022, indicated that medications are administered in accordance with the written orders of the attending physician. 2. A review of Resident 122's admission Record indicated the facility admitted the resident on 7/21/2021 with diagnoses that included encounter for attention to gastrostomy (a surgical procedure used to insert a tube into the stomach). A review of Resident 122's MDS, dated [DATE], indicated the resident had intact cognition and required extensive assistance from staff for bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. A review of Resident 122's Order Summary Report indicated a physician's order, dated 7/21/2021, to flush tube with 30 milliliters (ml - unit of measurement) of water before and after administration of medication. On 1/17/2023 at 4:04 p.m., during a medication administration observation, LVN 1 administered the following medications to Resident 122 via gastrostomy tube (g-tube) without flushing the g-tube with water between each medication administration: 1. Cranberry (used to prevent urinary tract infection [UTI - an infection in any part of the urinary system]) 425 milligrams (mg - unit of measurement) 2. Metoclopramide (used to prevent nausea and vomiting) 10 mg 3. Pro-Stat liquid (indicated for increased protein needs) 10 mg On 1/17/2023 at 4:29 p.m., during an interview, LVN 1 stated she should have flushed the g-tube with 30 ml of water after administering each medication. On 1/20/2023 at 10:20 a.m., during an interview, the DON stated it was important to flush the g-tube with water after administering each medication to ensure that the medication infuses through the tube for proper effectiveness and efficacy. A review of the facility's policy and procedure titled, Medication Administration, last reviewed on 7/28/2022, indicated that medications are administered in accordance with the written orders of the attending physician.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored appropriately by failing to: 1. Ensure the removal of expired medication in one of four (Station 4 medication cart B) medication carts. This deficient practice had the potential to result in the use of ineffective medications for the residents. 2. Ensure personal items were stored separately from the medications in two of three (Station 1 and Station 2) medication storage rooms reviewed. This deficient practice had the potential for cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) of personal items with the medications and the potential for the residents to receive contaminated medications. Findings: a. On 1/18/2023 at 3:23 p.m., during an inspection of medication cart B in station 4 with Licensed Vocational Nurse (LVN14), observed glucose gel (over the counter medication that treats low blood sugar levels) with expiration date of 6/22. LVN14 stated the glucose gel was expired and should have been removed from the cart. LVN14 stated there is a risk of giving the medication that may no longer be effective to a resident because the medication had expired. During an interview on 1/19/2023 at 2:51 p.m. with the Director of Nursing (DON), the DON stated expired medications should not be in the medication cart. The DON stated the efficacy may not be there. The DON stated non-controlled (not regulated by law about possession and use), expired medication should be taken out of the cart, logged, and placed into the hazard container; expired controlled (drug or other substance that is tightly controlled by the government because it may be abused or cause addiction) medications are surrendered to the DON for disposition. A review of facility's policy and procedures titled Drug Disposition, last revised on 7/28/2022 indicated drugs discontinued by a physician order and outdated drugs that cannot be returned to the pharmacy for credit, can be returned for pharmacy proper disposal, are to be properly marked and disposed of in accordance with California's Medical Waste Management Act. Documentation of disposal is to be maintained. b. During a concurrent observation and interview on 1/18/2023 at 1:33 p.m., of the station 1 medication room with Licensed Vocational Nurse (LVN15), observed the following items: a. Wound vac b. Speaker c. Sugar packets d. Birthday candles e. Resident hearing aids f. Pacemaker g. Phone charger h. Knitting kit i. Staff coat LVN15 stated the coat belongs to her; hearing aids are from previous residents that are no longer in facility. LVN15 stated items found should not be in medication room because the medications may become contaminated. During a concurrent observation and interview on 1/18/2023 at 2:27 p.m., of the station 2 medication room with Licensed Vocational Nurse (LVN6), observed: 1. Resident hearing aids 2. Wound vac LVN 6 stated hearing aids are sent with residents when they get discharged and the Social Service staff should have informed the resident's family to collect the items left by resident in the facility. LVN 6 stated the wound vac should have not been stored in the medication room for infection control purposes. During an interview on 1/19/2023 at 2:50 p.m. with the Director of Nursing (DON), the DON stated personnel items should not be in the medication room. The DON stated the medication room is meant for medications only, personnel items in medication room can be a risk for infection control. A review of facility policies and procedures titled Medication Storage in the facility, last revised on 7/28/2022 indicated medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to follow safe food handling practices by failing to: 1. Ensure 15 of 15 observed breads (five English muffins and ten hotdog buns) had best buy dates (indicates when a product will be of best flavor or quality). 2. Ensure one of one observed hamburger bun was not past the best buy date. 3. Label 43 of 43 observed individual food containers (40 cream cheese and three shredded cheese) with transfer date (date a food item was transferred from its original box to a container) and best buy date. 4. Label tuna salad mix according to the facility's policy and procedure (P&P). These deficient practices had placed the residents at risk for consumption of substandard quality food and placed the residents at risk for foodborne illnesses (food poisoning - caused by eating contaminated food, beverages, or water). Findings: a. During a concurrent observation and interview on 1/17/2023 at 8:34 a.m., observed with [NAME] 1 a bag of English muffin and a bag of hotdog bun with no expiration or best buy date. [NAME] 1 stated there should have been an expiration date on the bags; [NAME] 1 stated the bags did not have the clips that would have had the expiration date written on them. During a concurrent observation and interview on 1/17/2023 at 8:47 a.m., observed with the Dietary Supervisor (DS) a bag of English muffins with five English muffins inside and a bag hotdog bun with ten hotdog buns inside with no best buy date. The DS stated the facility follow the products' best buy dates. During an interview on 1/19/2023 at 2:06 p.m., the DS stated the facility's policy was to label food items with delivery date to be able to track the age of the product and to ensure the freshness of the food. The DS stated it was the facility's policy that bread was not labeled with open date but instead use the delivery date which can be found on a small white sticker label and follow the best buy date. The DS stated the freshness of the breads were not guaranteed when the breads had no best buy date label. The DS stated bread could become moldy and if served to residents could cause sickness. The DS stated if the bread was stale or if the bread served was beyond the best buy date, the residents would be unhappy, unsatisfied, and might not eat at all. b. During a concurrent observation and interview on 1/17/2022 at 8:47 a.m., observed with the DS one hamburger bun with best buy date 1/12/2023. The DS stated the facility follows the products' best buy dates. During an interview on 1/19/2023 at 2:27 p.m., the DS stated it was not appropriate to keep the hamburger bun because it had already past its best buy date. The DS stated the hamburger bun should have been discarded. The DS stated serving hamburger bun beyond used by date was not acceptable because the hamburger bun may have turned stale, or no longer fresh that could affect the presentation, palatability (being satisfactory to taste), and quality. c. During a concurrent observation and interview on 1/17/2023 at 9:20 a.m., observed with the DS 40 individual cream cheese and three individual containers of shredded cheese with no transfer date and best buy date. The DS stated the correct process was when the 40 individual cream cheese and three individual shredded cheese were transferred to the container, they should have been labeled with the date of transfer and best buy date located in the products' original box. During an interview on 1/19/2023 at 2:35 p.m., the DS stated it was not an appropriate practice to store 40 individual cream cheese in the refrigerator without labeling with transfer date and best buy date. The DS stated if the kitchen staff did not know the best buy date and if the cream cheese were served to the residents, the residents could become sick with loose stools and stomach pain. The DS stated the facility did not follow the facility's policy and procedure for safe food handling and storage when 40 individual cream cheese and three individual shredded cheese were stored in the refrigerator ready to be served without best buy dates. d. During an observation on 1/17/2023 at 9:23 a.m., observed with the DS a container of tuna salad mix labeled with preparation date 1/16/2023 and use by date 1/20/2023. During an interview on 1/19/2023 at 3 p.m., the DS stated tuna salad mix was good for three days from preparation date. The DS stated the tuna salad mix was labeled incorrectly; the DS stated the tuna salad mix was prepared on 1/16/2023 and should have had a use by date of 1/18/2023. The DS stated when the tuna salad mix was labeled with preparation date of 1/16/2023 and use by date of 1/20/2023, it was labeled good for five days and did not follow safe food handling and labeling. The DS stated if the tuna salad mix was served past 1/18/2023, it could be spoiled and could make the residents sick. The DS stated it was important to follow proper labeling and storing of food to prevent foodborne illnesses. A review of the facility's current policy and procedure (P&P), titled, Labeling and Dating of Foods, reviewed on 7/28/2022, indicated, All food items in the storeroom, refrigerator, and freezer need to be labeled and dated . All prepared foods need to be covered, labeled, and dated. Items can be dated individually or in bulk stored on a tray with masking tape if going to be used for meal service (i.e. salads, drinks, and other miscellaneous items for tray line) . Refrigerated Storage Guide . tuna salad 3 days maximum refrigeration .

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. a. A review of Resident 21's admission Record indicated the facility admitted the resident on 6/24/2011 and readmitted the resident on 9/6/2022 with diagnoses that included multiple sclerosis (a chronic disease affecting the central nervous system) and obstructive and reflux uropathy (a condition in which the flow of urine is blocked) and chronic obstructive pulmonary disease (COPD, a chronic lung disease that causes difficulty breathing). A review of Resident 21's MDS, dated [DATE], indicated the resident sometimes had the ability to be understood by others and sometimes had the ability to make self understood. The MDS indicated Resident 21 required extensive assistance with bed mobility, dressing, eating, toilet use, and personal hygiene. A review of Resident 21's Physician Orders indicated an order for oxygen at 2 liters per minute (LPM, a unit of measurement) via nasal cannula continuous inhalation for COPD and may use humidifier for concentrator (a device that separates oxygen from the air and delivers it to a patient) use. During an observation on 1/17/2023 at 11:25 a.m., Resident 21 was lying in bed with the NC applied, humidification bottle attached to the concentrator, and the concentrator set to 2 LPM. Observed no labeled date on the NC or humidification bottle. During an observation and interview on 1/17/2023 at 11:35 a.m., Certified Nursing Assistant 5 (CNA 5) stated the licensed vocational nurses change the oxygen tubing, but she would change the tubing if it became yellowish. CNA 5 stated the tubing and humidification bottle should be labeled with the date last changed to know when to change them next. CNA 5 assessed Resident 21 and stated the NC tubing and humidification bottle were not labeled. During an observation and interview on 1/17/2023 at 11:40 a.m., Registered Nurse 1 (RN 1) stated the oxygen tubing was changed every Saturday by the restorative nursing assistants. RN 1 stated the NC tubing and humidification bottle should be labeled with the date the tubing was last changed. RN 1 assessed Resident 21 and stated the NC tubing and humidification bottle were not labeled but should have been labeled. RN 1 stated the importance of labeling the tubing and bottle with the date last changed was to make sure they were replaced each week for infection control purposes. RN 1 stated regularly changing the tubing decreased the likelihood of (respiratory) infection. During an interview on 1/19/2023 at 11:45 a.m., the Director of Nursing (DON) stated Resident 21 had a history of COPD and needed oxygen. The DON stated the humidification was to prevent dryness of the passageways. The DON stated the facility policy and procedure indicated to change the NC and humidification bottle at least every ten days, but it was the facility practice to change every seven days. The DON stated the importance of labeling the NC and bottle with the date they were last changed was the only way to know the tubing and bottle were changed per policy. The DON stated the importance of changing the tubing was for infection control. A review of the facility policy and procedure titled, Oxygen, last reviewed 7/28/2022, indicated oxygen administration will be ordered by the physician and administered to the resident by a licensed nurse. The oxygen humidifiers and tubing will be changed at least every ten days. 3.b. A review of Resident 21's Physician Orders indicated an order for indwelling catheter French 16 (catheter size) for diagnosis of obstructive and reflux uropathy. A review of Resident 21's Care Plan (CP) titled, needs indwelling catheter, initiated 7/30/2021 indicated a CP goal that the resident would remain free from symptoms of urinary tract infection. The CP interventions indicated to (provide) FC care per protocol with soap and water, pat dry with clean towel every shift. During a FC/perineal care (cleaning of the FC tubing, genital, and rectal area) observation on 1/19/2023 at 1:30 p.m., CNA 5 used soap, water, and washcloths to clean Resident 21's FC tubing and perineal area. Observed four times: CNA 5 removed soiled gloves, donned (put on) clean gloves without performing hand hygiene, and then proceeded with FC care. During an interview on 1/19/2023 at 2:15 p.m., CNA 5 stated she did not always wash her hands or use hand sanitizer between changing gloves while providing care to Resident 21. CNA 5 stated she knew she should have, but she did not, and she was sorry. CNA 5 stated the importance of hand hygiene during FC care was to prevent (urinary tract) infection. During an interview on 1/19/2023 at 2:20 p.m., RN 1 stated hand hygiene should always be done before putting on clean gloves and after taking dirty gloves off, and again prior to putting clean gloves on. RN 1 stated the importance of performing hand hygiene was to prevent bacteria from the dirty surface transferring to the clean gloves then touching the FC tubing which could cause a urinary tract infection. During an interview on 1/19/2023 at 2:30 p.m., the DON stated hand hygiene should be performed between changing from dirty to clean gloves. The DON stated the importance was for infection control and to minimize the transmission of invasive infections by the (FC) tubing. A review of the facility policy and procedure titled, Infection Control Guidelines for All Nursing Procedures, last reviewed 7/28/2022, indicated the purpose of the policy and procedure was to provide guidelines for general infection control while caring for residents. Standard precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard precautions apply to blood, body fluids, secretions, and excretions regardless of whether they contain visible blood, non-intact skin, and/or mucous membranes. Employees must wash their hands for ten to fifteen seconds using antimicrobial soap and water under the following conditions: before and after direct contact with residents; after contact with body fluids, secretions, mucous membranes; after removing gloves; after handling items potentially contaminated with body fluids or secretions. In most situations, the preferred method of hand hygiene is with an alcohol-based hand rub. If hands are not visibly soiled, use alcohol-based hand rub containing 60-95% ethanol or isopropanol for all the following situations: before and after direct contact with a resident; before moving from a contaminated body site to a clean body site during resident care; after removing gloves. A review of the facility policy and procedure titled, Handwashing, last reviewed 7/28/2022, indicated all staff thoroughly cleanse the hands before and after resident care and after handling contaminated articles. The Purpose of the policy and procedure is to reduce transmission of organisms from resident to resident, nursing staff to resident, and resident to nursing staff. 6. During a concurrent observation and interview on 1/18/2023 at 1:33 p.m., of Station 1's medication room with Licensed Vocational Nurse (LVN15), observed: a. Wound vac (a treatment used for surgical wounds consisting of a pump that applies negative pressure to a wound space via tubing inserted into the wound) b. Speaker c. Sugar packets d. Birthday candles e. Resident hearing aids f. Pacemaker (a small device that is placed under the skin in your chest to help control the heartbeat) g. Phone charger h. Knitting kit i. Staff coat LVN 15 stated the coat was hers, hearing aids are from previous residents that are no longer in facility. LVN 15 stated items found should not be in medication room it is a concern for medications being contaminated, only medications should be stored in medication room. During a concurrent observation and interview on 1/18/2023 at 2:27 p.m., of the station 2 medication room with LVN 6, observed: 1. Resident hearing aids 2. Wound vac LVN 6 stated hearing aids go home with residents, if resident is discharged social service should call family to pick up hearing aids, wound vac should not be in medication room, would be a concern for infection control. During an interview on 1/19/2023 at 2:50 p.m., the DON stated personnel items should not be in the medication room. The DON stated the medication room is meant for medications only, personnel items in medication room can be a risk for infection control. A review of facility policies and procedures titled, Medication Storage in the facility, last revised on 7/28/2022, indicated medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures. Based on observation, interview, and record review, the facility failed to implement its infection control policy and procedure for eight of eight sampled residents (Residents 37, 3, 21, 15, 17, 130, 42, 58), by failing to: 1. Ensure the nasal cannula (thin, flexible tube containing two open prongs used to deliver oxygen) was changed and labeled with the date of change for Resident 37. 2. Ensure the tubing for enteral nutrition (tube feeding - delivery of nutrients through the gastrointestinal tract) feeding was changed and labeled with the date and time for Resident 3. 3. For Resident 21: a. Ensure the nasal cannula was changed and labeled with the date of change. b. Ensure Certified Nursing Assistant 6 (CNA 6) performed hand hygiene (washing or sanitizing hands) between glove changes during indwelling catheter (foley catheter [FC], a flexible tube placed in the bladder to drain urine) care. 4. Ensure there were no unlabeled urinals (bottle for urination) and wash basin inside two residents' rooms sharing one bathroom for five of five sampled residents (Residents 15, 17, 130, 42, and 58) investigated for infection control. 5. Ensure the nasal cannula was changed for Resident 130. 6. Keep two of three medication storage rooms (Station 1 and Station 2) free of personnel items. These deficient practices had the potential to transmit infectious microorganisms and placed the residents and staff at risk for infection. Findings: 1. A review of Resident 37's admission Record indicated the facility admitted the resident on 3/11/2016, and most recently readmitted the resident on 4/1/2022, with diagnoses that included heart failure (a condition that occurs when the heart cannot pump enough blood and oxygen to support other organs in the body), atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), and sleep apnea (sleep disorder in which breathing repeatedly stops and restarts). A review of Resident 37's Minimum Data Set (MDS - an assessment and care screening tool), dated 1/8/2023, indicated the resident had the ability to make self understood and had the ability to understand others. The MDS further indicated Resident 37 required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. During an observation, on 1/17/2023 at 12:47 p.m., Resident 37 in bed on three liters of oxygen via nasal cannula. Observed tubing for nasal cannula unlabeled with no date. During a concurrent observation and interview, on 1/17/2023 at 12:50 p.m., Licensed Vocational Nurse 11 (LVN 11) observed and verified that the nasal cannula was not labeled. LVN 11 stated the nasal cannula is changed once a week and as needed if contaminated from dropping on the floor by the licensed nurses. LVN 11 stated the nasal cannula is labeled every time it is changed with the date for staff to know when the tubing was last changed. LVN 11 stated the importance of changing the nasal cannula weekly is for infection control. During an interview, on 1/20/2023 at 7:47 a.m., the Director of Nursing (DON) stated per facility policy, the nasal cannula tubing should be changed at least every ten days. However, the DON stated the license nurses working the dayshift have been changing the nasal cannula tubing weekly on Saturdays. The DON stated Resident 37's nasal cannula tubing should have been labeled with the date, time, and initials for staff to know that it was changed and when it needs to be changed again for infection control purposes. A review of the facility's policy and procedure titled, Oxygen Administration, last reviewed on 7/28/2022, indicated oxygen humidifiers and tubing will be changed at least every 10 days. 2. A review of Resident 3's admission Record indicated the facility admitted the resident on 7/11/2022, and most recently readmitted the resident on 1/26/2012, with diagnoses that included dysphagia (difficulty swallowing) and encounter for attention to gastrostomy (surgical opening through the skin of the abdomen to the stomach). A review of Resident 3's MDS, dated [DATE], indicated the resident's cognitive skills for daily decision making was moderately impaired. The MDS further indicated Resident 3 required extensive assistance with bed mobility, dressing, and personal hygiene and was totally dependent on staff for transfers and toilet use. During an observation, on 1/17/2023 at 11:38 a.m., Resident 3's tubing connected to the enteral nutrition formula bottle was with no date and time on the label. During a concurrent observation and interview, on 1/17/2023 at 12:31 p.m., Licensed Vocational Nurse 11 (LVN 11) stated the enteral nutritional formula bottle along with the tubing is changed every 24 hours or when the dose limit is met by the licensed nurse and explained both the bottle and tubing should be labeled with date, time, and staff initials. LVN 11 observed and verified the tubing connected to the enteral nutrition formula bottle was not labeled with the date, time, and staff initials. LVN 11 stated the tubing should have been changed with the enteral nutritional formula bottle and labeled for staff to know when it was last changed and when it should be changed again for infection control. During an interview, on 1/20/2023 at 7:31 a.m., the Director of Nursing (DON) stated Resident 3's tubing for the enteral nutrition should have been labeled with the date and time it was changed along with staff initials. The DON stated the enteral nutritional formula is good for 48 hours but the tubing still needs to be changed every 24 hours by the night shift nurse. The DON stated the importance of changing and labeling the tubing to ensure staff know when it was last changed and when it needs to be changed again for infection control. The DON further stated there is potential for the feeding to clog the tubing if the tubing is not changed regularly. During an interview, on 1/20/2023 at 7:40 a.m., the DON stated the facility does not have a specific policy that addresses changing and labeling the tubing for enteral nutrition. However, the DON stated the facility practice is to change the tubing every 24 hours and label with the date, time, and staff initials. 4. A review of Resident 15's admission Record indicated the facility originally admitted the resident on 8/3/2015 and readmitted the resident on 9/27/2022 with diagnoses including end stage renal disease (when your kidneys can no longer support your body's needs). A review of Resident 15's MDS, dated [DATE], indicated the resident had intact cognition (thought processes) and required extensive assistance from staff for bed mobility, dressing, toilet use, and personal hygiene. A review of Resident 17's admission Record indicated the facility admitted the resident on 4/7/2017 with diagnoses including paraplegia (paralysis that mainly affects the legs). A review of Resident 17's MDS, dated [DATE], indicated the resident had moderately impaired cognition and was totally dependent on staff for transfers and toilet use. A review of Resident 130's admission Record indicated the facility originally admitted the resident on 6/9/2022 and readmitted the resident on 7/6/2022 with diagnoses including respiratory failure (a serious condition that makes it difficult to breathe on your own) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). A review of Resident 130's MDS, dated [DATE], indicated the resident had intact cognition and required limited assistance from staff for transfers, walking in the room and in the corridor, dressing, toilet use, and personal hygiene. A review of Resident 42's admission Record indicated the facility admitted the resident on 7/13/2017 with diagnoses including type 2 diabetes mellitus (an impairment in the way the body regulates and uses sugar [glucose] as fuel). A review of Resident 42's MDS, dated [DATE], indicated the resident was moderately impaired in cognition and required extensive assistance from staff for bed mobility, transfers, walking in the room and in the corridor, locomotion on and off the unit, dressing, toilet use, and personal hygiene. A review of Resident 58's admission Record indicated the facility admitted the resident on 2/20/2022 with diagnoses including cirrhosis of the liver (a late-stage disease in which healthy liver tissue is replaced with scar tissue and the liver is permanently damaged). A review of Resident 58's MDS, dated [DATE], indicated the resident had severely impaired cognition and required extensive assistance with transfers, dressing, toilet use, and personal hygiene. On 1/17/2023 at 10 a.m., during a concurrent observation and interview, observed two unlabeled urinals and one unlabeled wash basin inside the five residents' (Residents 15, 17, 130, 42, and 58) shared bathroom (for two rooms). Certified Nursing Assistant 9 (CNA 9) stated that none of them were labeled and stated they should have been labeled with resident identifiers to know to whom they belonged to. On 1/19/2023 at 11:57 a.m., during an interview, Licensed Vocational Nurse 6 (LVN 6) stated it was the responsibility of nurses and certified nursing assistants (CNAs) to ensure that urinals and wash basins were labeled with resident identifiers. LVN 6 stated it was important to label them for sanitary purposes and for infection control. LVN 6 stated they should be labeled with the resident's room and bed number. On 1/20/2023 at 10:09 a.m., during an interview, the Director of Nursing (DON) stated it was the CNA's responsibility to ensure that urinals and wash basins were labeled. The DON stated it was important to label them for infection control, so you know to whom they belonged to. On 1/20/2023 at 11:42 a.m., during an interview, the Infection Preventionist (IP) stated that all staff are responsible for labeling residents' urinals and wash basins. The IP stated they should be labeled with the resident's bed number and the date it was last changed. The IP stated it was important to label them to ensure there is no cross-contamination (the physical movement or transfer of harmful bacteria from one person, object, or place to another) among residents. A review of the facility's policy and procedure titled, Urinal/Assisting With, last reviewed on 7/28/2022, indicated that urinals should be labeled with the resident's room and bed number. [NAME] A. 5. A review of Resident 130's admission Record indicated the facility originally admitted the resident on 6/9/2022 and readmitted the resident on 7/6/2022 with diagnoses including respiratory failure and anxiety disorder. A review of Resident 130's MDS, dated [DATE], indicated the resident had intact cognition and required limited assistance from staff for transfers, walking in the room and in the corridor, dressing, toilet use, and personal hygiene. On 1/17/2023 at 9:54 a.m., during a concurrent observation and interview, observed Resident 130 asleep in bed. The resident was receiving oxygen therapy via nasal cannula (a medical device used to provide supplemental oxygen therapy). When asked if the oxygen tubing had a date on it of when it was last changed, CNA 9 stated it was dated 12/24/2022. On 1/19/2023 at 11:57 a.m., during an interview, LVN 6 stated that among some of the nurse's responsibilities when a resident was on oxygen therapy was to make sure to label the tubing with the date of when it was last changed. LVN 6 stated the tubing was usually changed every Sunday or as needed. LVN 6 stated it was important to change the oxygen tubing weekly to ensure that the resident always had a clean one because bacteria can build up in the tubing. LVN 6 stated it was done for sanitary reasons. On 1/20/2023 at 10:09 a.m., during an interview, the DON stated that residents' oxygen tubing was changed every 7 days to ensure infection control. The DON stated that was the purpose of labeling the tubing with the date. The DON stated they also wanted to make sure that the tubing remains patent and viable. On 1/20/2023 at 11:42 a.m., during an interview, the IP stated that residents' oxygen tubing was changed every Saturday or as needed. The IP stated that was the reason why it labeled with a date. The IP stated they want to change the tubing weekly for infection control purposes. A review of the facility's policy and procedure titled, Oxygen Administration, last reviewed on 7/28/2022, indicated that oxygen humidifiers (device used to humidify supplemental oxygen) and tubing will be changed at least every 10 days.

Nov 2022 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0885 (Tag F0885)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to notify residents, residents' representatives, and families of suspected or confirmed COVID-19 (a viral infection, highly contagious, that easily transmits from person to person, causing respiratory problems and may cause death) cases in the facility along with mitigating actions in a timely manner. This deficient practice resulted in a delay of notification of residents, residents' representatives and families regarding COVID-19 status of the facility. Findings: A review of Resident 1's admission Record indicated the facility admitted Resident 1 on 2/25/2022 with diagnoses including chronic kidney disease (occurs when a disease or condition impairs kidney function, causing kidney damage to worsen over several months or years), anemia (condition in which the blood doesn ' t have enough health red blood cells), and osteoporosis (weak bones). A review of Resident 1 ' s progress note, dated 10/28/2022, indicated resident had cough and congestion on 10/27/2022 and Resident 1 tested positive with rapid antigen COVID-19 test on 10/27/2022. During an interview on 11/11/2022 at 12:50 p.m., and concurrent record review of Resident 1 ' s COVID 19, the Infection Preventionist (IP) stated she was aware of the positive COVID-19 result of Resident 1 on 10/27/2022. IP stated the facility needs to notify all residents, residents' representatives and family members on the day or day after regarding the facility ' s COVID-19 status of any staff or resident who tested positive. During an interview on 11/14/2022 at 1:25 p.m., Social Services (SS) stated was unable to provide documentation of the notification of all residents, residents' representatives and family members on 10/27/2022 and or 10/28/2022. SS stated that the facility sent an email notification on 11/2/2022. A review of facility ' s undated policy and procedure titled, COVID-19 Mitigation plan, with revised date of 1/3/2022, indicated that the facility shall have a communication plan with staff, residents and their families regarding the status and impact of COVID-19 in the facility, including the prevalence of confirmed cases of COVID-19 in staff and residents.

Nov 2022 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the nursing staff failed to ensure call lights were within reach for one of four sampled residents (Resident 3). This deficient practice had the potential to result in the residents not being able to summon staff for assistance for care and services as needed, which could lead to accidents such as falls with injuries. Findings: A review of Resident 3 ' s admission Record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses of hip fracture, diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]) Parkinson ' s disease, generalized muscle weakness, chronic pain and osteoarthritis on both knees. A review of Resident 3's Minimum Data Set (MDS-a standardized assessment and care screening tool), dated August 12, 2022, indicated the resident was moderate cognitive (relating to the mental processes of perception, memory, judgment, and reasoning) impairment and required extensive assistance on staff for activities of daily living (ADLs- transfers, locomotion on and off the unit, dressing and toilet use). A review of the care plan dated August 4, 2021, indicated Resident 3 was at risk for falls and skin breakdown related to resident ' s progressive neurological disease. The goal indicated the resident was to be free from injury, encourage independence, and encourage participation and self-independence with ADL ' s. During an observation and interview on November 21, 2022, at 9:57 am, Resident 3 was heard calling nurse multiple times in gerichair (a specialized padded recliner that is designed to help residents with limited mobility) position to left side. At 10:02 am, Assistant Director of Nursing (ADON) went into the room and stated Resident 3 needed repositioning. The ADON verified the call light was not within reach because the call light was stuck in the bed. ADON stated the call light needs to be within reach to meet resident needs. A review of the facility ' s Policy and Procedure for Call Lights, indicated assure that the call light is within the resident ' s reach when in their room or on the toilet.

CONCERN (F) 📢 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 F0838 (Tag F0838)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility failed to revise and provide a current staffing plan in the Facility's Assessment to meet resident's needs. This deficient practice placed the residents at risk for lack or delay of care and treatment services. Findings: A review of the Facility ' s Assessment on November 21, 2022 at 10:40 a.m., indicated the Facility Assessment was last revised for the period of May 11, 2020 to May 11, 2021. No updated Facility Assessment was provided. The assessment provided was for a census of 146 residents with no staffing plan indicated. Under the section for Staffing Plan, the columns to indicate the desired number of full-time employees (FTE) for employed Registered Nurse (RN), Licensed Vocational Nurse (LVN) and Certified Nursing Assistant (CNA) was left blank. A review of the facility census for November 21, 2022, indicated 163 residents. A review of the facility assignment sheet for November 21, 2022, for the 7:00 am to 3:00 pm shift indicated the following: Station 1 RN=1, LVN=4, CNA=6, for a census of 54 residents Station 2 RN=1, LVN=4, CNA=7, for a census of 57 residents Station 3 RN=1, LVN=5, CNA=7, for a census of 33 residents Station 4 RN=1, LVN=0, CNA=1, for a census of 9 residents Station 5 RN=1, LVN=0, CNA=2, for a census of 10 residents During an interview on November 21, 2022, at 10:14 am, when asked about workload for the day, Certified Nursing Assistant 1 (CNA 1) stated the facility was short staff and as a result she had to care for 10 residents. CNA 1 further stated it was difficult to provide care to all the residents because of their request. During an interview on November 21, 2022, at 1:10 pm, with the Facility Scheduler (FS), the FS stated he creates the staff schedule based on residents and tries to staff each station well. The FS further stated he does not use the facility assessment from the facility and was not aware of the purpose of a facility assessment. When asked about the facility ' s process for call offs, the FS stated he calls staff who are off or are part-time. The FS further explained when he has no luck (meaning cannot find a replacement staff) the service to meet resident needs goes down. During an interview on November 21, 2022, at 1:35 pm, the Administrator verified he had not updated the Facility Assessment since May 11, 2021 and had not completed a detailed staffing plan to meet the residents ' need. According to Centers for Medicare and Medicaid Services (CMS) the intent of the facility assessment was for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents require. Specifically, under Acuity Section 1.5. the facility was to describe the residents' acuity levels to help them understand the potential implications regarding the intensity of care and services needed. The intent of this was to give an overall picture of acuity data obtain from data sources such as RUGs (Resource Utilization Groups are significant because they are the core of the nursing home payment system), MDS data, and resident/patient acuity tools to plan for staffing across the different shifts in the facility. https://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Provider-Calls-and-Events-Items/2017-09-07-Dementia-Care-in-Nursing-Homes-Call.html

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"What safeguards are in place to prevent abuse and neglect?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• Licensed and certified facility. Meets minimum state requirements.

Concerns

• Multiple safety concerns identified: Federal abuse finding, 3 life-threatening violation(s), Special Focus Facility, 1 harm violation(s), $134,479 in fines. Review inspection reports carefully.
• 247 deficiencies on record, including 3 critical (life-threatening) violations. These warrant careful review before choosing this facility.
• $134,479 in fines. Extremely high, among the most fined facilities in California. Major compliance failures.
• Grade F (0/100). Below average facility with significant concerns.

Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.

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About This Facility

What is Mirage Post Acute's CMS Rating?

CMS assigns MIRAGE POST ACUTE an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within California, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Mirage Post Acute Staffed?

CMS rates MIRAGE POST ACUTE's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 45%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Mirage Post Acute?

State health inspectors documented 247 deficiencies at MIRAGE POST ACUTE during 2022 to 2025. These included: 3 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, 238 with potential for harm, and 5 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Mirage Post Acute?

MIRAGE POST ACUTE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by PACS GROUP, a chain that manages multiple nursing homes. With 299 certified beds and approximately 236 residents (about 79% occupancy), it is a large facility located in LANCASTER, California.

How Does Mirage Post Acute Compare to Other California Nursing Homes?

Compared to the 100 nursing homes in California, MIRAGE POST ACUTE's overall rating (1 stars) is below the state average of 3.1, staff turnover (45%) is near the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Mirage Post Acute?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the substantiated abuse finding on record.

Is Mirage Post Acute Safe?

Based on CMS inspection data, MIRAGE POST ACUTE has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 3 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility is currently on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes nationwide). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in California. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Mirage Post Acute Stick Around?

MIRAGE POST ACUTE has a staff turnover rate of 45%, 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 Mirage Post Acute Ever Fined?

MIRAGE POST ACUTE has been fined $134,479 across 4 penalty actions. This is 3.9x the California average of $34,424. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.

Is Mirage Post Acute on Any Federal Watch List?

MIRAGE POST ACUTE is currently an SFF Candidate, meaning CMS has identified it as potentially qualifying for the Special Focus Facility watch list. SFF Candidates have a history of serious deficiencies but haven't yet reached the threshold for full SFF designation. The facility is being monitored more closely — if problems continue, it may be added to the official watch list. Families should ask what the facility is doing to address the issues that led to this status.

Facility Details

Beds: 299
Avg. Residents: 236
Occupancy: 79.0%
Ownership: For profit - Partnership
Chain: PACS GROUP
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
3 Immediate Jeopardy citations: -36
1 Actual Harm citation: -5
247 Deficiencies: -10
Fines ($134,479): -15
Abuse Finding: -15
Special Focus Facility: -20
Final Score: 0/100

Nearby Alternatives

MOUNT SAN ANTONIO GARDENS 5-star MONTECITO HEIGHTS HEALTHCARE &... 5-star MARYCREST MANOR 5-star

View all in LANCASTER →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 056039