What is LAWNDALE HEALTHCARE & WELLNESS CENTRE LLC's CMS rating?

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

Does LAWNDALE HEALTHCARE & WELLNESS CENTRE LLC have any serious inspection findings?

Yes, LAWNDALE HEALTHCARE & WELLNESS CENTRE LLC has 2 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 67 total deficiencies from recent inspections.

What are the staffing levels at LAWNDALE HEALTHCARE & WELLNESS CENTRE LLC?

LAWNDALE HEALTHCARE & WELLNESS CENTRE LLC has a four-star staffing rating from CMS with 1.19 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 LAWNDALE HEALTHCARE & WELLNESS CENTRE LLC located?

LAWNDALE HEALTHCARE & WELLNESS CENTRE LLC is located in LAWNDALE, CA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does LAWNDALE HEALTHCARE & WELLNESS CENTRE LLC have?

LAWNDALE HEALTHCARE & WELLNESS CENTRE LLC has 59 certified beds.

Who owns LAWNDALE HEALTHCARE & WELLNESS CENTRE LLC?

LAWNDALE HEALTHCARE & WELLNESS CENTRE LLC is a for profit - limited liability company facility and operates independently (not part of a chain).

Is LAWNDALE HEALTHCARE & WELLNESS CENTRE LLC safe?

LAWNDALE HEALTHCARE & WELLNESS CENTRE LLC has documented safety concerns including a substantiated abuse finding on record, 2 immediate jeopardy citations. Families should ask about corrective actions taken.

Do nurses at LAWNDALE HEALTHCARE & WELLNESS CENTRE LLC stick around?

LAWNDALE HEALTHCARE & WELLNESS CENTRE LLC has average staff turnover at 34%, which is typical for the nursing home industry.

Was LAWNDALE HEALTHCARE & WELLNESS CENTRE LLC ever fined?

Yes, LAWNDALE HEALTHCARE & WELLNESS CENTRE LLC has been fined $62,004 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is LAWNDALE HEALTHCARE & WELLNESS CENTRE LLC on any federal watch list?

No, LAWNDALE HEALTHCARE & WELLNESS CENTRE LLC is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at LAWNDALE HEALTHCARE & WELLNESS CENTRE LLC?

Medicare inspectors have found 67 deficiencies at LAWNDALE HEALTHCARE & WELLNESS CENTRE LLC: 2 critical, 2 serious, 63 moderate. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting LAWNDALE HEALTHCARE & WELLNESS CENTRE LLC?

Families visiting LAWNDALE HEALTHCARE & WELLNESS CENTRE LLC 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 LAWNDALE HEALTHCARE & WELLNESS CENTRE LLC compare to other nursing homes?

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

LAWNDALE HEALTHCARE & WELLNESS CENTRE LLC | 0/100 (Grade F)

Sept 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 F0559 (Tag F0559)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1.Ensure a written room change with a reason was prov...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1.Ensure a written room change with a reason was provided for one of 4 sampled residents (Resident 1). This deficient practice resulted in Resident 1 losing his bed while in the hospital.Findings:During a review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included metabolic encephalopathy (a condition where the brain's metabolism is disrupted, leading to altered brain function), pneumonia (an infection/inflammation in the lungs), type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 1's history and physical (H&P), dated 8/28/2025, the H&P indicated Resident 1 did not have the capacity to make decisions and was unable to make his needs known. During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 9/2/2025, the MDS indicated Resident 1 was cognitive (thinking) skills were severely impaired. The MDS also indicated Resident 1 was dependent on staff members with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's Change of Condition (COC) form, dated 9/2/2025, the COC indicated Resident 1 was transferred to the general acute care hospital (GACH) due to persistent cough, increased secretions despite receiving intravenous (IV) antibiotic treatment for pneumonia. During a review of the facility's census, dated 9/3/2025, the census showed Resident 1's bed was occupied by another resident. During a concurrent interview and record review, on 9/10/2025 at 10:23 a.m., with the Director of Nursing (DON), the DON reviewed the census for 9/2/2025 and 9/3/2025. The DON stated Resident 1 was transferred to the hospital on 9/2/2025 and on 9/3/2025, Resident 1's bed was occupied by another resident due to a room change. The DON stated she did not know why a room change occurred. The DON stated, This should not have happened. The DON stated the risk of conducting a room change when a resident is transferred to the hospital could result in a resident losing their bed. During a review of the facility's policy and procedures (P&P), titled Room or Roommate Change, revised 3/2019, the P&P indicated, Prior to changing a room or roommate assignment, the resident, the resident's representative (if available), and the resident's new roommate will be provided timely advance notice of such a change. and The notice of a change in room or roommate assignment must be in writing and will be given the reason(s) for such change.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0627 (Tag F0627)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon interview and record review, the facility failed to: 1.Ensure one of 4 sample residents (Resident 1) was readmitted t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon interview and record review, the facility failed to: 1.Ensure one of 4 sample residents (Resident 1) was readmitted to the facility after being admitted to the General Acute Care Hospital. This deficient practice resulted in Resident 1 not being re-admitted to the facility and prolonging his GACH stay (four days).Findings:During a review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included metabolic encephalopathy (a condition where the brain's metabolism is disrupted, leading to altered brain function), pneumonia (an infection/inflammation in the lungs), type 2 diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing) and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 1's history and physical (H&P), dated 8/28/2025, the H&P indicated Resident 1 did not have the capacity to make decisions and was unable to make his needs known. During a review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 9/2/2025, the MDS indicated Resident 1 was cognitive (thinking) skills were severely impaired. The MDS also indicated Resident 1 was dependent on staff members with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1's Change of Condition (COC) form, dated 9/2/2025, the COC indicated Resident 1 was transferred to the general acute care hospital (GACH) due to persistent cough, increased secretions despite receiving intravenous (IV) antibiotic treatment for pneumonia. During a review of the facility's September 2025 census, there was no open male beds from 9/6/2025 to 9/10/2025. During a review of the facility's census on 9/10/2025, Resident 1 remained out of the facility. During a telephone interview, on 9/10/2025 at 8:15 a.m., with the GACH Social Worker (GACHSW), the GACHSW stated the facility's Regional Marketer (RM) informed her that Resident 1 was not coming back to the facility. The GACHSW stated the RM also stated the facility will not honor Resident 1's bed hold. GACH SW stated Resident 1 had discharge orders for 9/6/2025 and the facility stopped answering the phone. The GACHSW stated, If we can get him back to the facility, then that will be fine. During an interview, on 9/10/2025, at 9:03 a.m., with the admission Coordinator (AC), the AC stated he was responsible for facilitating residents' return to the facility after hospitalization. The AC stated all residents who were transferred to a hospital were required to have a 7-day bed hold. The AC stated Resident 1 was transferred to the GACH on 9/2/2025. The AC stated he was informed by the facility's RM stating she spoke with Resident 1's Public Guardian (PG) who stated she did not want Resident 1 to return to the facility. The AC stated the risk of not being readmitted to a resident could result in a resident not being able to return to their home. During an interview, on 9/10/2025 at 9:46 a.m., with the Regional Marketer (RM), the RM stated she was responsible for being the liaison between the hospitals and the facility. The RM stated all residents required a bed hold for up to 7 days. The RM stated a case manager from the GACH called and informed her that Resident 1 would not be returning to the facility per Resident 1's PG request due to being unhappy with the care at the facility. The RM stated she called Resident 1's PG and Resident 1's PG stated she did not speak to anyone at the hospital. The RM stated the GACH's discharge planner called on the facility on 9/8/2025 stating Resident 1 was able to return to the facility. The RM stated she informed the GACH's discharge planner that she spoke with the GACH's case manager who stated Resident 1 was not returning to the facility. The RM stated the GACH's case manager stated she did not tell the facility that Resident 1 would not be returning. The RM stated the risk f not readmitting a resident could result in, I don't know, I just know it's not something I've done before so I wouldn't know what the risk are. During a concurrent interview and record review, on 9/10/2025 at 10:23 a.m., with the Director of Nursing (DON), the DON stated the protocol for readmitting a resident required her (the DON) to be notified if a resident was to be readmitted to the facility by the AC and RM. The DON stated she was not aware of Resident 1 being denied readmission to the facility. The DON reviewed the census for 9/2/2025-9/3/2025 and stated Resident 1 was transferred to the hospital on 9/2/2025. The DON stated on 9/3/2025, Resident 1's bed was occupied by another resident. The DON stated Resident 1's bed hold was not honored. The DON stated the risk of not readmitting a resident could result in a resident's rights issue. The DON stated, It is a resident's right to want to come back to their home. During an interview, on 9/10/2025 at 11:00 a.m., with the Administrator (Admin), the admin stated he was informed by the facility's RM and Resident 1's doctor that Resident 1 would not be returning to the facility per Resident 1's PG. The admin stated bed holds are honored for 7 days. The admin stated the risk of not readmitting a resident could result in a lack of patient care causing a resident to be stranded in a hospital. During an interview, on 9/10/2025 at 11:33 a.m., with Resident 1's PG, Resident 1's PG stated she was informed by the GACH SW that Resident 1 could not return to the facility due to her stating she did not want Resident 1 to return. Resident 1's PG stated she never said that. Resident 1's PG stated the facility had given Resident 1's bed away. Resident 1's PG stated she called the RM and told her she never said Resident 1 could not return to the facility. Resident 1's PG stated Resident 1 should have been able to return to the facility. Resident 1's PG stated the facility did not honor Resident 1's bed hold. During a review of the facility's policy and procedures (P&P), titled Readmission, revised 10/2013, the P&P indicated The Facility will allow residents who were previously residents of the Facility to be readmitted to the Facility.

May 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0627 (Tag F0627)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon interview and record review, the facility failed to: 1. Ensure one out of 4 sampled residents was readmitted to the f...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon interview and record review, the facility failed to: 1. Ensure one out of 4 sampled residents was readmitted to the facility after being hospitalized (Resident 1). This deficient practice resulted in Resident 1 staying in the hospital for 30 days. Findings: During a review of Resident 1 ' s face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included metabolic encephalopathy (a brain dysfunction resulting from problems with the body's metabolism or chemical imbalances), spinal stenosis (a condition where the spinal canal narrows, potentially compressing the spinal cord and nerves), type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing) 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 federally mandated resident assessment tool), dated 4/8/2025, the MDS indicated Resident 1 was cognitive (thinking) skills were cognitively intact. The MDS also indicated Resident 1 required substantial assistance with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). During a review of Resident 1 ' s progress note, dated 4/8/2025, the progress note indicated Resident 1 was transferred to the general acute care hospital (GACH) due to increased confusion and per family ' s request. During a review of the facility ' s April census, one female bed was available from 4/8/2025 to 4/20/2025. During a review of the facility ' s May census, there was one available female bed on 5/2/2025 and 5/28/2025. During a review of the facility ' s census on 5/29/2025, Resident 1 remained out of the facility. During an interview, on 5/29/2025, at 9:15 a.m., with the admission Coordinator (AC), the AC stated he was responsible for facilitating a residents return to the facility after a hospitalization. The AC stated Resident 1 was transferred to the GACH on 4/8/2025. The AC stated he could not recall if he spoke to a case manager at the GACH where Resident 1 was located. The AC stated Resident 1 was denied readmission to the facility by their regional marketer due to a change in Resident 1 ' s insurance. The AC stated the risk of denying readmission to a resident could result in a resident ' s rights violation and being reported by the hospital. During an interview, on 5/29/2025, at 10:10 a.m., with the Director of Nursing (DON), the DON stated the protocol for readmitting a resident required her (the DON) to be informed if a resident was to be readmitted to the facility by the admission Coordinator. The DON stated she was not aware of Resident 1 being denied of readmission to the facility. The DON stated the facility ' s regional marketer did not have the authority to deny a resident ' s return to the facility. The DON stated the risk of not denying a resident ' s return to the facility could result in a placement issue as the resident wouldn ' t be able to return to their home which is the facility, a placement issue. The DON stated, I did not know the hospital called to return the resident to the facility. During a review of the facility ' s policy and procedures (P&P), titled Readmission, revised 10/2013, the P&P indicated The Facility will allow residents who were previously residents of the Facility to be readmitted to the Facility.

Apr 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

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Grievances and Complaints which indicated the facility would promptly review, investigate and resolve grievances and complaints for one out of three sampled residents (Resident 1). This failure had the potential for unaddressed and unresolved grievances for Resident 1 and had the potential to negatively affect the resident's quality of life and safety. Findings: During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including lack of coordination and hypertensive heart disease (a condition where the heart is damaged or malfunctions due to persistently high blood pressure [hypertension]). A review of Resident 1's History and Physical (H&P) dated 12/24/2024, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 2/24/2025, indicated Resident 1 had no cognitive (the ability to think and reason) impairment. The MDS indicated Resident 1 required substantial/maximum assistance (helper does more than half the effort) to perform Activities of Daily Living (ADLs) such as toileting hygiene and to perform changes in position such as sitting to standing. During a review of the facility's Grievance Log dated 03/2025-04/2025, the Log did not indicate there was any grievance or concern from Resident 1. During an interview on 4/8/2025 at 10:50 a.m. with Resident 1, Resident 1 stated her roommate kept touching the (privacy) curtain and it bothered her. Resident 1 stated she reported the issue to a staff member (unknown) the previous day and nothing was done about it. During an interview on 4/8/2025 at 1:02 p.m. with the Social Services Director (SSD), the SSD stated, Resident 1 notified her that she (Resident 1) was having an issue with her roommate closing the privacy curtain. SSD stated she offered Resident 1 a room change, and the resident declined. SSD stated, any grievances and potential issue of roommate incompatibility, should have been documented on the grievance log and followed up on. SSD stated there was no supporting documentation to indicate a room change was offered or any follow-up was completed to resolve the grievance by Resident 1. During an interview on 4/9/2025 at 1:51 p.m. with the Director of Nursing (DON), the DON stated, if a resident has a grievance related to their room or roommate, the grievance should be written down to be discussed along with solutions that were offered. The DON stated that if it was not documented on the grievance log, the problem was not acknowledged. The DON stated a room change should have been offered to prevent any altercation between Resident 1 and her roommate. During a review of the facility's P&P titled, Grievances and Complaints dated 12/2017, the P&P indicated, The disposition of all written grievances and/or complaints is recorded on the Resident Grievance/Complaint Log (i.e. resolved, dispute, etc.) The P&P indicated, upon receiving a grievance/complaint report, the Grievance Official or designee provides a copy of the report to the appropriate department manager to begin the investigation, and subsequent resolution. The P&P indicated, if follow-up is required, the Grievance Official is responsible for ensuring that the follow-up action is taken in a timely manner.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure pain management was effective for one of three sampled resid...

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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 pain management was effective for one of three sampled residents (Resident 1) by failing to: 1.Thoroughly assess and reassess Resident 1 when the resident complained of 4 out of 10 pain (pain rating reference: 1-4=mild pain, 5-7=moderate pain, 8-9= severe pain, 10=excruciating pain) 2.Administer pain medication and/or provide non-nonpharmacological interventions (techniques other than medications to alleviate pain) as ordered by the physician. This failure had the potential to leave Resident 1 with unresolved pain and had the potential to negatively affect Resident 1's physical, mental, and psychosocial wellbeing. Findings: During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including lack of coordination and hypertensive heart disease (a condition where the heart is damaged or malfunctions due to persistently high blood pressure [hypertension]). During a review of Resident 1's History and Physical (H&P) dated 12/24/2024, indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool) dated 2/24/2025, indicated Resident 1 had no cognitive (the ability to think and reason) impairment. The MDS indicated Resident 1 required substantial/maximum assistance (helper does more than half the effort) to perform Activities of Daily Living (ADLs) such as toileting hygiene and to perform changes in position such as sitting to standing. During a review of Resident 1's Physician Order Summary report dated 4/01/2025, the Order Summary indicated the following: -On 3/9/2025, the physician ordered to administer acetaminophen oral tablet 500 milligrams ([mg] a unit of measurement) tablet, two tablets by mouth every six hours as needed for mild pain. The order indicated non-pharmacological interventions including heat, repositioning, relaxation breathing, food/fluids, massage, exercise and immobilization. -On 1/4/2025, the physician ordered to assess for pain every shift and chart intensity of pain using 1-10 numeric pain scale. During a review of Resident 1's Medication Administration Record (MAR) dated 3/2025, the MAR indicated Resident 1 reported 4 out of 10 pain on 3/29/2025 and 3/30/2025. The MAR did not indicate acetaminophen and/or non-pharmacological interventions were provided to Resident 1 as ordered by the physician. During a review of Resident 1's Medication Administration Notes dated 3/2025, the Notes did not indicate Resident 1's was thoroughly assessed nor any interventions provided 3/29/2025 and 3/30/2025 after the resident reported 4 out of 10 pain. During a concurrent record review and interviews on 4/8/2025 at 2:28 p.m. and 2:56 p.m. with the Director of Nursing (DON), the DON stated residents should be assessed for pain including location of the pain, the pain rating and whether any interventions were provided. The DON stated, there should also be a pain reassessment 30 minutes to one hour after to ensure the medication/interventions provided were effective in relieving the resident's pain. The DON stated, Resident 1 had 4 out 10 pain on 3/29/2025 and 3/30/2025 and there was no supporting documentation to indicate Resident 1 was thoroughly assessed and reassessed, nor given any interventions for pain. During a record review of facility's policy and procedure (P&P) titled, Pain Management dated 5/25/2023, the P&P indicated, a pain assessment will be completed when there is a new onset of pain. P&P indicated, the Licensed Nurse will administer pain medication as ordered and document medication administered on the MAR. The P&P indicated, after medications/interventions are implemented, the licensed nurse will re-evaluate the resident's level of pain within one hour and the Licensed Nurse will assess the resident for pain and document results on the MAR each shift.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a functional call device (a device used by res...

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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 functional call device (a device used by residents to communicate their needs to staff) for two out of three sampled residents (Residents 1 and 2). This failure had the potential to result in a delay in care for Resident 1 and Resident 2 and the resident ' s needs not being met. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with diagnoses including lack of coordination and hypertensive heart disease (a condition where the heart is damaged or malfunctions due to persistently high blood pressure [hypertension]). A review of Resident 1 ' s History and Physical (H&P) dated 12/24/2024, indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set ([MDS] a resident assessment tool) dated 2/24/2025, indicated Resident 1 had no cognitive (the ability to think and reason) impairment. The MDS indicated Resident 1 required substantial/maximum assistance (helper does more than half the effort) to perform Activities of Daily Living (ADLs) such as toileting hygiene and to perform changes in position such as sitting to standing. During a concurrent observation and interview on 4/8/2025 at 9:03 a.m. with Resident 1 in Resident 1 ' s room, Resident 1 ' s call light did not turn on when the resident pressed it. There was no call bell or other means to call staff observed at the resident ' s bedside. During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 2 ' s diagnosis included polyneuropathy (a condition where many nerves throughout the body are damaged or malfunctioning, affecting sensation and movement). A review of Resident 2 ' s H&P dated 3/25/2025, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2 ' s MDS dated [DATE], indicated Resident 2 had no cognitive impairment. The MDS indicated Resident 2 required substantial/maximal assistance to perform ADLs such as lower body dressing, transfers and walking 10 feet. During a concurrent observation and interview on 4/8/2025 at 8:56 a.m. with Resident 2 in Resident 2 ' s room, Resident 2 ' s call light did not turn on when the resident pressed it. There was no call bell or other means to call staff observed at the resident ' s bedside. Resident 2 stated she has not been able to use her call light to call the nurses. Resident 2 stated her call light had not been working for two weeks and had to go to the nurse ' s station whenever she needed medication. During a concurrent observation, record review and interview on 4/8/2025 at 9:23 a.m. with Restorative Nursing Assistant (RNA) 1, the facility ' s Maintenance Request Log dated 4/6/2025 was reviewed. RNA 1 stated the call lights for Resident 1 and Resident 2 ' s room did not work when pressing the call light button. RNA 1 stated this issue started on 4/6/2025. RNA 1 stated, Resident 1 and Resident 2 ' s call light had an issue with not turning off and there was no documentation to support that the call light issue was resolved on 4/6/2025. RNA 1 stated, this is not acceptable for residents not to have a functional call light because Resident 1 and Resident 2 could not be attended to right away. During an interview on 4/8/2025 at 2:28 p.m. with the Director of Nursing (DON), the DON stated residents whose call lights did not work and could not be repaired right away, should have call bells to alert the staff of their needs. The DON stated residents should not be left without a call light because it placed the resident at risk for fall or accidents. During a review of facility ' s policy and procedure (P&P) titled, Communication – Call System, dated 2022, the P&P indicated, the call alert device will be placed within the resident ' s reach and If the call alert system cannot be repaired immediately, an alternative call alert process will be put in place (i.e. tap bells, auxiliary aids, etc.). Enter comment here

Mar 2025 11 deficiencies

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to perform an accurate fall assessment for one of 17 residents (Reside...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to perform an accurate fall assessment for one of 17 residents (Resident 49) after a fall. This deficient practice had the potential to result in Resident 49 to have recurrent falls and could have lead to improper care planning. Findings: During a review of Resident 49's admission Record, the admission Record indicated Resident 49 was admitted to the facility on [DATE], with diagnosis of lack of coordination and muscle weakness. During a review of Resident 49's History and Physical (H&P), dated 12/24/2024, H&P indicated Resident 49 had the capacity to understand and make decisions. During a review of Resident 49's Care Plan titled Resident is high fall risk and risk for injury dated 12/31/2024, the care plan interventions indicated to follow facility fall protocol. During a review of Resident 49's Minimum Data Set ([MDS] a resident assessment tool), dated 2/25/2025, the MDS indicated Resident 49 was able to understand and be understood by others. The MDS indicated Resident 49 required set up for eating and moderate assistance with oral hygiene. The MDS indicated Resident 49 required maximal assistance with toileting hygiene, showering/bathing, dressing, putting on and taking off footwear, and personal hygiene. During a review of Resident 49's Fall Risk Evaluation dated 3/21/2025 at 10:55 p.m., the Evaluation did not indicate Resident 49's fall on 3/21/2025. The Evaluation did not include Resident 49's level of consciousness, gait (manner of walking) and/or balance, and medications. The evaluation did not indicate a fall risk score. During a concurrent interview and record review on 3/23/2025 at 10:43 a.m. with the Director of Nursing (DON), the DON stated the Fall Risk Evaluation was not done properly and did not indicate Resident 49's fall on 3/21/2025, level of consciousness, gait and/or balance, and medications. The DON stated that not having a complete and correct assessment could lead to improper care planning and interventions for Resident 49. The DON stated it could also lead to a recurrent fall and the nurse should have completed the assessment completely to have a correct fall score and to determine the resident's risk of falling. During a review of the facility's Policy and Procedures (P&P) titled Fall Management Program dated March 13, 2021, the P&P indicated a licensed nurse will conduct a new fall risk evaluation quarterly, annually, upon identification of a significant change of condition, post fall and as needed.

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a care plan for three of four sampled residen...

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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 care plan for three of four sampled residents (Resident 43 and Resident 44 and Resident 12) by failing to: 1. Develop a care plan for Resident 43's Restorative Nursing Assistance (RNA) services. 2. Develop a care plan for the use Resident 44's antipsychotic (class of medications used to treat mental illness) medication Risperdal (type of antipsychotic medication that treats mental health conditions such as schizophrenia [a mental illness that is characterized by disturbances in thought] and bipolar disorder [sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs]). 3. Implement a care plan addressing Resident 12's fingernails. These deficient practices had a potential to result in inconsistent implementation of the care plan that may place Resident 43, Resident 44, and Resident 12 at risk of inadequate health care. Findings: a. During a review of Resident 43's admission Record, the admission Record indicated Resident 43 was admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses including cerebral infarction (blood flow to the brain is interrupted, leading to damage or death of brain tissue), hemiplegia and hemiparesis (hemiplegia refers to complete paralysis on one side of the body, while hemiparesis describes a more mild weakness or partial paralysis on one side), and quadriplegia unspecified (partial or complete loss of motor function in all four limbs). During a review of Resident 43's History and Physical (H&P) dated 10/1/2024, the H&P indicated Resident 43 does not have the mental capacity to understand and make medical decisions. During a review of residents 43's Minimum Data Set (MDS - a mandated resident assessment tool), dated 12/17/2024, the MDS indicated Resident 43 had cognitive impairment (ability to think and reason). The MDS indicated Resident 43 was dependent with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), transfer (moving between surfaces to and from bed, chair, and wheelchair), and bed mobility (how resident moves from lying to turning side to side). During a review of Resident 43's physicians orders dated 9/30/2024, the physicians orders indicated an order for Restorative Nurse Assistance (RNA) program for passive range of motion (PROM, the movement of a joint by an external force, such as a therapist or a machine, without the patient's active muscle contraction) to the bilateral (pertaining to both sides) lower extremities (BLE) and bilateral upper extremities (BUE) daily, 5 times a week, as tolerated. During an interview on 3/23/2025 at 3:00 p.m. with Registered Nurses (RN) 1, RN 1 stated the care plan was the care nurses must provide to residents. RN 1 stated the care plan was personalized and based on the residents condition. RN 1 stated residents in the RNA program would need to have an RNA care plan. RN 1 stated the care plan would include a goal and interventions for Resident 43. RN 1 stated the treatment would be evaluated if it is working or needed to be changed. RN 1 stated the care plan for Resident 43 was created 3/23/2025. RN 1 stated there was not a care plan for Resident 43 prior to 3/23/2025. b. During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses including muscle wasting and atrophy (loss of muscle mass and strength), degenerative disease of the nervous system (disorder that affect the nervous system, causing progressive deterioration and loss of function), and quadriplegia unspecified (partial or complete loss of motor function in all four limbs). During a review of Resident 44's H&P dated 9/17/2024, the H&P indicated Resident 44 does not have the mental capacity to understand and make medical decisions. During a review of residents 44's MDS, dated [DATE], the MDS indicated Resident 44 had cognitive impairments. The MDS indicated Resident 44 required dependent assistance with ADLs. During a review of Resident 44's physicians orders dated 12/23/2024, the physicians orders indicated Resident 44 had an order for Risperdal oral tablet 0.5 milligrams (mg, unit of measurement) give 1 tablet by mouth two times a day for schizophrenia (chronic mental health condition characterized by a combination of symptoms that significantly impair a person's thinking, perception, emotions, and behavior). During a review of Resident 44's medical record on 3/23/2025 at 2:00 p.m., there was not a care plan on file for the use of Risperdal or any antipsychotic medications. During a concurrent interview and record reviewed on 3/23/2025 at 2:04 p.m. with RN 2, RN 2 reviewed Resident 44 's care plans and was not able to find a care plan for Risperdal. RN 2 stated care plan is developed for any resident receiving antipsychotic medication. RN 2 stated the care plan addresses the problem, goals, and interventions needed for Resident 44 while taking this medication. RN 2 stated if nurses failed to develop a care plan, staff would be unaware of the medications efficiency. RN 2 stated nurses need to make sure that a care plan was developed and Resident 44 was receiving accurate care. During an interview on 3/23/2025 at 3:18 p.m. with the Director of Nursing (DON), the DON stated the care plans are individualized based on resident's needs. The DON stated on any occasion residents are receiving care with medications or exercises must have a care plan that reflects the residents' needs. The DON stated if nurses failed to develop a care plan Resident 43 and Resident 44 are at risk of neglect because they are not receiving the care they need. The DON stated Resident 43 and Resident 44 were at risk of health status decline which could lead to serious health complications. c. During a review of Resident 12's admission Record, dated 3/23/2025, the admission Record indicated Resident 12 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (a change in how the brain works due to a chemical imbalance in the blood), spinal stenosis (a condition when the space inside the backbone is too small), and type 2 diabetes mellitus (a chronic condition when the body cannot use insulin correctly and sugar builds up in the blood). During a review of Resident 12's H&P, dated 2/21/2025, the H&P indicated Resident 12 had fluctuating capacity to understand and make decisions. During a review of Resident 12's MDS, dated [DATE], the MDS indicated Resident 12 was able to understand and be understood by others. The MDS indicated Resident 12 was moderately cognitively impaired. The MDS indicated Resident 12 was dependent on staff for ADLs. The MDS indicated Resident 12 required substantial assistance from staff for ADLS such as upper body dressing, partial assistance from staff for oral hygiene and supervision for eating. The MDS indicated Resident 12 was dependent on staff for sitting to standing and chair to bed transfer and required substantial assistance from staff for rolling left to right, sitting to lying, and lying to sitting on the edge of bed. During a review of Resident 12's care plan titled, At risk for infection related to long nails, potential trauma/injury (scratches, abrasion), and inability to properly clean nails ., dated 3/21/2025 and revised on 3/23/2025, the care plan interventions indicated, if necessary, assist the patient in trimming nails or refer to a podiatrist or nail care specialist for proper trimming. During a concurrent observation and interview on 3/22/2025 at 9:55 a.m. with Resident 12, in Resident 12's room, Resident 12 was observed with long fingernails. Resident 12 stated her fingernails were long and no one had offered to trim her nails. Resident 12 stated she wanted her fingernails trimmed. During an interview on 3/23/2025 at 3:57 p.m. with the Infection Preventionist Nurse (IPN), the IPN stated she looked at all the residents' nails on 3/21/2025 and Resident 12 requested to have a professional do her nails. The IPN stated she initiated the care plan on 3/21/2025 but did not finish the care plan until 3/23/2025. During a concurrent interview and record review on 3/23/2025 at 4:49 p.m. with the DON, Resident 12's care plan and care plan history was reviewed. The DON stated according to the care plan history, the care plan was created on 3/23/2025. The DON stated the care plan was not created on 3/21/2025 and it was supposed to be created at the time the problem was identified, which was 3/21/2025. The DON stated if the care plan was not created, the problem was not addressed and nothing was being done. During a review of the facility's policy and procedures (P&P) titled Restorative Nursing Program Guidelines dated 9/19/2019, the P&P indicated measurable objectives and interventions are documented in the Care plan and in the medical record. The P&P indicated if a Restorative Nursing Program is in place when a Care Plan is being revised, it is appropriate to reassess progress, goals, and duration/ frequency as part of the care planning process. During a review of the facility's P&P titled Comprehensive Person-Centered Care Planning dated 8/24/2023, the P&P indicated the facility will provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral and environmental needs of residents to obtain or maintain the highest physical, mental and psychosocial well- being. The P&P indicated the purpose of the policy was to ensure t0hat a comprehensive person-centered care plan was developed for each resident and additional changes or updates to the resident's comprehensive care plan would be made based on the assessed needs 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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to create a care plan timely for the use of side rails for one of 30 s...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to create a care plan timely for the use of side rails for one of 30 sampled residents (Resident 7). This deficient practice had the potential to cause Resident 7 to not have the appropriate interventions in place. Findings During a review of Resident 7's admission Record, dated 3/23/2025, the admission Record indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including muscle weakness (decreased strength in the muscles), glaucoma (an eye disease that gradually damages the optic nerve and can lead to blindness), and legal blindness (a significant level of vision loss). During a review of Resident 7's History and Physical (H&P), dated 3/6/2025, the H&P indicated Resident 7 did not have the capacity to understand and make decisions. During a review of Resident 7's Minimum Data Set (MDS, a mandated resident assessment tool), the MDS indicated Resident 7 sometimes understand and was sometimes understood by others. The MDS indicated Resident 7 was severely cognitively impaired (ability to think and reason). The MDS indicated Resident 7 had impairments on both lower extremities (legs). The MDS indicated Resident 7 was dependent on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and required substantial assistance from staff for eating and oral hygiene. The MDS indicated Resident 7 was dependent on staff for sitting to standing and for chair to bed transfer. The MDS indicated Resident 7 required substantial assistance from staff for rolling left and right, sitting to lying, and lying to sitting on the side of the bed. During a review of Resident 7's order summary report, dated 2/26/2025, the report indicated bedside railings (1/2) applied on bed due to poor bed mobility and poor trunk control. During a review of Resident 7's bed rail assessment, dated 3/4/2025, the assessment indicated bilateral (pertaining to both sides) side rails were recommended, and side rails were indicated. The assessment indicated the side rails served as an enabler to promote independence. During a review of Resident 7's care plan titled, The resident has high risk for falls, dated 3/4/2025, the care plan interventions indicated the resident needed a safe environment. During a review of Resident 7's Situation, Background, Assessment, Recommendation (SBAR) communication form, dated 3/15/2025, the SBAR communication form indicated on 3/15/2025, Resident 7 fell and was observed sitting on the floor. The SBAR communication form indicated there was a small red lump on Resident 7's forehead but no bleeding noted and Resident 7 stated she did not have pain. During a review of Resident 7's bed rail assessment, dated 3/15/2025, the assessment indicated bilateral side rails were recommended, and side rails were indicated and served as an enabler to promote independence. During a review of Resident 7's care plan titled, Resident uses bilateral full side rails for bed mobility and repositioning, dated 3/18/2025, the care plan interventions included monitoring the resident for any signs of discomfort, entrapment, or injury and to regularly check bed rails during ADL care. During a concurrent interview and record review on 3/22/2025 at 1:44 p.m. with RN 1, Resident 7's bed rail assessment, dated 3/4/2025 was reviewed. RN 1 stated the side rail recommendation was for bilateral side rails and side rails were indicated and served as an enabler to promote independence. RN 1 stated side rails were recommended since 3/4/2025 and there was supposed to be side rails at the time of Resident 7's fall on 3/15/2025. During a concurrent interview and record review on 3/23/2025 at 2:04 p.m. with the Director of Nursing (DON), Resident 7's care plan dated 3/4/2025 and 3/18/2025 was reviewed. The DON stated Resident 7's family requested to have side rails for fall precautions and as an enabler because Resident 7 was legally blind and the side rails were for the resident to hold on to when staff provided care. The DON stated there should have been side rails since 3/4/2025 because the bed rail assessment indicated Resident 7 needed side rails. The DON stated Resident 7 did not have side rails at the time of her fall on 3/15/2025. The DON stated the bed rail assessment was created on 3/4/2025 but the bed rail care plan was created on 3/18/2025. The DON stated the care plan should have been done at the time of the assessment and the bed rail care plan was late and so the problem was not addressed and the interventions were not in place. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 8/24/2023, the P&P indicated additional changes or updates to the resident's comprehensive care plan would be made based on the assessed needs of the resident. During a review of the facility's P&P titled, Bed Rails, dated 5/30/2024, the P&P indicated a care plan would be developed regarding the use of bed rails.

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 30 sampled residents (Resident 12) was ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 30 sampled residents (Resident 12) was provided care and services to maintain good grooming and personal hygiene. This deficient practice resulted in Resident 12 not receiving nail care and had the potential to cause an infection or injury from the long fingernails. Findings During a review of Resident 12's admission Record, dated 3/23/2025, the admission Record indicated Resident 12 was admitted to the facility on [DATE] with diagnoses of metabolic encephalopathy (a change in how the brain works due to a chemical imbalance in the blood), spinal stenosis (a condition when the space inside the backbone is too small), and type 2 diabetes mellitus (a chronic condition when the body cannot use insulin correctly and sugar builds up in the blood). During a review of Resident 12's History and Physical (H&P), dated 2/21/2025, the H&P indicated Resident 12 had fluctuating capacity to understand and make decisions. During a review of Resident 12's Minimum Data Set (MDS, a mandated resident assessment tool), dated 3/6/2025, the MDS indicated Resident 12 was able to understand and be understood by others. The MDS indicated Resident 12 was moderately cognitively impaired (ability to think and reason). The MDS indicated Resident 12 was dependent on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves). The MDS indicated Resident 12 required substantial assistance from staff for ADLS such as upper body dressing, partial assistance from staff for oral hygiene and supervision for eating. The MDS indicated Resident 12 was dependent on staff for sitting to standing and chair to bed transfer and required substantial assistance from staff for rolling left to right, sitting to lying, and lying to sitting on the edge of the bed. During a concurrent observation and interview on 3/22/2025 at 9:55 a.m. with Resident 12, in Resident 12's room, Resident 12 was observed with long fingernails. Resident 12 stated her fingernails were long and no one had offered to trim her nails. Resident 12 stated she wanted her fingernails trimmed. During a concurrent observation and interview on 3/23/2025 at 1:23 p.m. with Certified Nursing Assistant (CNA 5), Resident 12's fingernails were observed. CNA 5 stated Resident 12's nails could be shorter for safety. During an interview on 3/23/2025 at 1:27 p.m. with Licensed Vocational Nurse (LVN 1), LVN 1 stated Resident 12's fingernails were long, and dirt and germs could get underneath them. LVN 1 stated Resident 12 could scratch herself which could lead to an infection. LVN 1 stated Resident 12's fingernails could use a trim. During a concurrent observation and interview on 3/23/2025 at 1:52 p.m. with the Director of Nursing (DON), Resident 12's fingernails were observed. The DON stated Resident 12's fingernails were really long. The DON stated if the fingernails were long, dirt and bacteria could catch underneath the fingernails and the resident could get an infection from scratching herself or from eating. The DON stated Resident 12 could injure herself or other people if her nails break. The DON stated the CNAs should have noticed Resident 12's nails were long during daily bedside care and if the charge nurse missed the long fingernails, the CNA could report it to the charge nurse and both the CNA and licensed nurse could have spoken to the resident about trimming the nails. The DON stated no one brought up Resident 12's fingernails to her. During a review of the facility's policy and procedure (P&P) titled, Grooming Care of the Fingernails and Toenails, dated 10/21/2021, the P&P indicated fingernails are trimmed by CNAs, except for residents with diabetes or circulatory impairments. The P&P indicated a Licensed Nurse would trim those residents' nails.

CONCERN (D)

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of seven residents (Resident 43 and Reside...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of seven residents (Resident 43 and Resident 44), with limited range of motion (ROM, the extent of movement of a joint), received restorative nursing program (designed to improve or maintain the functional ability of residents) care five times a week daily as indicated in the physician order. This deficient practice had the potential to place Residents 43 and 44 at increased risk for ROM decline. Findings: a. During a review of Resident 43's admission Record, the admission Record indicated Resident 43 was admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses including cerebral infarction (blood flow to the brain is interrupted, leading to damage or death of brain tissue), hemiplegia and hemiparesis (hemiplegia refers to complete paralysis on one side of the body, while hemiparesis describes a more mild weakness or partial paralysis on one side), and quadriplegia unspecified (partial or complete loss of motor function in all four limbs). During a review of Resident 43's History and Physical (H&P) dated 10/1/2024, the H&P indicated Resident 43 does not have the mental capacity to understand and make medical decisions. During a review of residents 43's Minimum Data Set (MDS - a mandated resident assessment tool), dated 12/17/2024, the MDS indicated Resident 43 had cognitive impairments (ability to think and reason). The MDS indicated Resident 43 was dependent with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), transfer (moving between surfaces to and from bed, chair, and wheelchair), and bed mobility (how resident moves from lying to turning side to side). During a review of Resident 43's physicians orders dated 9/30/2024, the physicians orders indicated for Restorative Nurses Assistance (RNA) program for passive range of motion (PROM, the movement of a joint by an external force, such as a therapist or a machine, without the patient's active muscle) to the bilateral (pertaining to both sides) lower extremities (BLE) and bilateral upper extremities (BUE) daily 5 times a week as tolerated. During a review of Resident 43's Nursing Rehab/Restorative report dated 2/2025, the report indicated Resident 43 did not receive RNA services on 2/3/2025, 2/4/2025, 2/12/2025, 2/14/2025, 2/17/2025, 2/21/2025, 2/25/2025, 2/26/2025, 2/27/2025, and 2/28/2025 During a review of Resident 43's Nursing Rehab/Restorative report dated 3/2025, the report indicated Resident 43 did not receive RNA services on 3/3/2025, 3/6/2025, and 3/11/2025, During a review of Resident 43's Weekly Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal of a resident) progress notes - Restorative Nursing, the progress notes indicated there was no weekly progress notes for the weeks ending 3/7/2025, 3/14/2025 and 3/21/2025. During an interview on 3/23/2025 at 9:56 a.m. with RNA 1, RNA 1 stated Resident 43 received RNA services 5 times a week. RNA 1 stated the services for the upper and lower extremities usually took about 15 minutes. RNA 1 stated the RNAs have a weekly meeting with the Director of Staff Development (DSD) and Director of Nursing (DON) to see if the residents are improving or not and if the residents needed to be referred to the physical therapist (PT). RNA 1 stated the DSD and DON documented the weekly progress notes. b. During an observation on 3/22/2025 at 9:56 a.m. in Resident 44's room, Resident 44 was observed lying in bed. Resident 44's bilateral hands and fingers were contracted (a stiffening/shortening at any joint, that reduces the joint's range of motion). During a review of Resident 44's admission Record, the admission Record indicated Resident 44 was admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses including muscle wasting and atrophy (loss of muscle mass and strength), degenerative disease of nervous system (disorders that affect the nervous system, causing progressive deterioration and loss of function), and quadriplegia unspecified (partial or complete loss of motor function in all four limbs). During a review of Resident 44's H&P dated 9/17/2024, the H&P indicated Resident 44 does not have the mental capacity to understand and make medical decisions. During a review of residents 44's MDS, dated [DATE], the MDS indicated Resident 44 had cognitive impairments. The MDS indicated Resident 44 was dependent with ADLs and transfer. During a review of Resident 44's physicians orders dated 12/23/2024, the physicians orders indicated RNA program for PROM to the BLE and BUE daily 5 times a week as tolerated. During a review of Resident 44's Nursing Rehab/Restorative report dated 2/2025, indicated Resident 44 did not receive RNA services on 2/3/2025, 2/4/2025, 2/13/2025, 2/17/2025, 2/21/2025, 2/25/2025, 2/26/2025, 2/27/2025, and 2/28/2025. During a review of Resident 44's Nursing Rehab/Restorative dated 3/2025, indicated Resident 44 did not receive RNA services on 3/3/2025, 3/6/2025, and 3/11/2025. During a review of Resident 44's Weekly IDT progress notes - Restorative Nursing, the progress notes indicated there were no weekly progress notes for the weeks ending 3/14/2025 and 3/21/2025. During an interview on 3/23/2025 at 8:00 a.m. with RNA 1, RNA 1 stated Resident 44 received RNA therapy 5 days a week and tolerated all the exercises. RNA 1 stated Resident 44 used a hand roll daily for his hand contractures. RNA 1 stated she had not documented the therapy Resident 44 received. RNA 1 stated the missing days were 3/14/2025 and 3/21/2025 because the DSD was not at the facility. RNA 1 stated, I understand it is not a good reason, but we had not had the weekly meetings. During a concurrent interview and record review on 3/23/2025 at 10:47 a.m. with RNA 1, Resident 44's Nursing Rehab/Restorative dated 2/2025 was reviewed. RNA 1 stated every time treatment was done it needed to be documented. RNA 1 stated the orders for RNA services needed to be follow. RNA 1 stated if the order was for 5 days a week, it needed to reflect 5 days of documentation. RNA 1 stated sometimes I forgot to document. RNA 1 stated I know that if I do not document it means that the therapy was not done. RNA 1 stated, I understand the documentation needs to be consistent. During an interview on 3/23/2025 at 10:20 a.m. with the DON, the DON stated it was important to document a weekly progress and therapy provided daily. The DON stated the documented information would indicate how Resident 43 and Resident 44 were doing with the RNA therapy. The DON stated based on the information, the facility can see if the residents needed any recommendations from PT or any changes of condition that needed to be reported. The DON stated the facility needed to prevent Resident 43 and Resident 44 from experiencing a decrease in their mobility. During a review of the facility's policy and procedures (P&P) titled Restorative Aid- Job Description undated, the P&P indicated to document on the RNA sheet daily what was done and how the resident responded. The P&P indicated to summarize this in a weekly progress note and follow the physicians orders as written. During a review of the facility P&P titled Documentation dated 1/1/2012, the P&P indicated Daily RNA charting and weekly documentation will be done on the RNA flow sheet. During a review of the facility's P&P titled Restorative Nursing Program Guidelines dated 9/19/2019, the P&P indicated measurable objectives and interventions are documented in the Care plan and in the medical record. The P&P indicated good clinical practice would indicate that the results of the reassessment should be documented in the residents' 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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide side rails as ordered for one of 30 sampled residents (Resi...

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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 side rails as ordered for one of 30 sampled residents (Resident 7). This deficient practice caused Resident 7 to fall and had the potential to cause Resident 7 to have injuries from the fall. Findings During a review of Resident 7's admission Record, dated 3/23/2025, the admission Record indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including muscle weakness (decreased strength in the muscles), glaucoma (an eye disease that gradually damages the optic nerve and can lead to blindness), and legal blindness (a significant level of vision loss). During a review of Resident 7's History and Physical (H&P), dated 3/6/2025, the H&P indicated Resident 7 did not have the capacity to understand and make decisions. During a review of Resident 7's Minimum Data Set (MDS, a mandated resident assessment tool), the MDS indicated Resident 7 sometimes understand and was sometimes understood by others. The MDS indicated Resident 7 was severely cognitively impaired (ability to think and reason). The MDS indicated Resident 7 had impairments on both lower extremities (legs). The MDS indicated Resident 7 was dependent on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and required substantial assistance from staff for eating and oral hygiene. The MDS indicated Resident 7 was dependent on staff for sitting to standing and for chair to bed transfer. The MDS indicated Resident 7 required substantial assistance from staff for rolling left and right, sitting to lying, and lying to sitting on the side of the bed. During a review of Resident 7's order summary report, dated 2/26/2025, the report indicated bedside railings (1/2) applied to the bed due to poor bed mobility and poor trunk control. During a review of Resident 7's bed rail assessment, dated 3/4/2025, the assessment indicated bilateral side rails were recommended. The assessment indicated the side rails were indicated and served as an enabler to promote independence. During a review of Resident 7's care plan titled, The resident has high risk for falls, dated 3/4/2025, the care plan interventions indicated the resident needed a safe environment. During a review of Resident 7's Situation, Background, Assessment, Recommendation (SBAR) communication form, dated 3/15/2025, the SBAR communication form indicated on 3/15/2025, Resident 7 fell and was observed sitting on the floor. The SBAR communication form indicated there was a small red lump on Resident 7's forehead but no bleeding noted and Resident 7 stated she did not have pain. During a review of Resident 7's bed rail assessment, dated 3/15/2025, the assessment indicated bilateral side rails were recommended, and side rails were indicated and served as an enabler to promote independence. During an interview on 3/22/2025 at 1:27 p.m. with Registered Nurse (RN 1), RN 1 stated on 3/15/2025, RN 1 saw Resident 7 sitting on the floor. RN 1 stated Resident 7 was sitting on the floor and she did not have side rails in place. RN 1 stated Resident 7 did not have side rails until 3/17/2025. During a concurrent interview and record review on 3/22/2025 at 1:44 p.m. with RN 1, Resident 7's bed rail assessment, dated 3/4/2025 was reviewed. RN 1 stated the side rail recommendation was for bilateral side rails to serve as an enabler to promote independence. RN 1 stated side rails were recommended since 3/4/2025 and there was supposed to be side rails at the time of Resident 7's fall on 3/15/2025. During an interview on 3/23/2025 at 2:04 p.m. with the Director of Nursing (DON), the DON stated Resident 7's family requested Resident 7 to have side rails for fall precautions and as an enabler because Resident 7 was legally blind. The DON stated the side rails were for Resident 7 to hold on to when staff provided care. The DON stated there should have been side rails since 3/4/2025 since the bed rail assessment indicated Resident 7 needed side rails but Resident 7 did not have side rails at the time of her fall on 3/15/2025. The DON stated she was not sure how long Resident 7 did not have side rails. The DON stated not having the side rails in place did not honor the family's preference and the side rails could have prevented the fall from occurring. During a review of the facility's policy and procedure (P&P) titled, Fall Management Program, dated 3/13/2021, the P&P indicated the purpose is to provide residents a safe environment that minimizes complications associated with falls. During a review of the facility's P&P titled Bed Rails, dated 5/30/2024, the P&P indicated the licensed nurse would complete the bed rail evaluation prior to the use and or installation of any bed rail and notify the maintenance department to install the bed rails, inspect fixed bed rail, or remove them as appropriate.

CONCERN (D)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to follow the pureed diet (diet that involves consuming foods that are blended, mashed, or strained to a smooth, pudding-like co...

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Based on observation, interview, and record review, the facility failed to follow the pureed diet (diet that involves consuming foods that are blended, mashed, or strained to a smooth, pudding-like consistency, making them easier to swallow for individuals with chewing or swallowing difficulties) recipe during breakfast by serving liquid consistency French toast. This deficient practice had the potential to result in inadequate nutrition status and placed the residents at a high risk of choking (person can not breath due to blocked airway). Findings: During a concurrent observation and interview on 3/22/2025 at 7:32 a.m. with [NAME] 1, [NAME] 1 was observed plating a pureed diet, which consisted of pureed French toast and pureed eggs. The French toast plated in a cup was liquidly. [NAME] 1 stated the plate was a pureed diet and the bread should have more consistency and not be as watery. [NAME] 1 stated he would add more bread and blend it to make it the French toast pureed. [NAME] 1 was observed blending more French toast with milk to get more a pureed consistency. [NAME] 1 did not follow or review the pureed recipe. [NAME] 1 stated it was important to do it right for the residents safety and to avoid any problems with choking. During an interview on 3/23/2025 at 1:34 p.m. with the Kitchen Supervisor (KS), the KS stated the recipes were to be followed by the cook. The KS stated when preparing pureed diets, the preparation needed to be done as described in the recipe. The KS stated it was important to follow the recipe to maximize the residents nutrition. The KS stated the puree consistency must be like pudding and a smooth consistency. The KS stated if the food was not pureed it would be difficult for residents with a stroke (a medical emergency that occurs when blood flow to the brain is interrupted) to swallow. The KS stated not preparing the food correctly could cause a loss of nutrients and it would not be appealing look for residents. During an interview on 3/23/2025 at 3:25 p.m. with the Director of Nursing (DON), the DON stated a pureed diet was mashed, ground, grinded, or blended and did not have a watery or liquid consistency. The DON stated residents could choke with a liquid pureed diet. The DON stated resident were at risk of aspiration (the accidental inhalation of foreign substances, such as food, liquid, or saliva, into the lungs). The DON stated the cook must follow the recipe for a pureed diet to prevent any accidents. During a review of the facility's policy and procedures (P&P) titled Recipe: Pureed Level 4 Breads, dated 2024, the P&P indicated 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.

CONCERN (D)

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

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the call light was within reach and accessible for one out of one sampled resident (Resident 8) who needed assistance. This deficient practice resulted in Resident 8 feeling unheard and forgotten while screaming for assistance. Findings: During a review of Residents 8's admission Record, the admission Record, indicated Resident 8 was originally admitted to the facility on [DATE], with diagnoses including a history of muscle weakness and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 8's History and Physical (H/P), dated 3/12/2025, the H/P indicated Resident 8 could make needs known but could not make medical decisions. During a review of Resident 8's Care plan titled High Risk for Falls dated 3/12/2025, the care plan's interventions included to place the resident's call light within reach and encourage the use of the call light. During a review of Resident 8's Minimum Data Set ([MDS] a resident assessment tool), dated 2/27/2025, the MDS indicated Resident 8 usually had the ability to understand and be understood by others. The MDS indicated Resident 8 required substantial assistance for eating and oral hygiene and was dependent for bed mobility, toileting hygiene, showering/bathing, dressing, putting on/taking off footwear, and personal hygiene. During a concurrent observation and interview on 3/22/2025 at 7:57 a.m., with Resident 8, observed Resident 8 screaming for help. Resident 8 stated he did not know where the call light was. Resident 8's roommate pressed his own call light to get assistance for Resident 8. During a concurrent observation and interview on 3/22/2025 at 8:12 a.m., with Certified Nurse Assistant (CNA 2), observed CNA 2 looking for Resident 8's call light. CNA 2 found the call light on the floor in which the clip on the call light was broke. CNA 2 stated that was the reason the call light had fallen on the floor. CNA 2 stated not having a call light within reach could lead to accidents such as Resident 8 falling from the bed or leave the resident feeling neglected. During an interview on 3/22/2025 at 8:15 a.m. with Resident 8, Resident 8 stated the clip on the call light had been broken for three days. Resident 8 stated he had to scream for help every day and that made him feel angry and forgotten. During a concurrent observation and interview on 3/23/2025 at 7:52 a.m., with Resident 8 and CNA 3, observed Resident 8 was screaming for help. Resident 8 stated he could not find his call light. Resident 8's roommate was observed using his call light to call the staff on Resident 8's behalf. CNA 3 entered the room and stated she was not assigned to Resident 8, but she noticed the call light and entered to assist the resident. CNA 3 stated the call light was supposed to be on the bed, but it kept falling. CNA 3 stated the call light did not have a clip which was why the call light kept falling. CNA 3 stated she did not know long the clip had been broken. CNA 3 stated not having the call light within reach could lead to an accident. During an interview on 3/23/2025 at 9:15 a.m. with the Maintenance Director, the Maintenance Director stated he had plenty of clips for the call lights and he was just told that morning (3/23/2025) about Resident 8's call light. During a review of the facility's policy and procedures (P/P) titled Communication - Call System, revised 8/24/2024, the P/P indicated the call alert device would be placed within the resident's reach. The P/P indicated if the call alert system was defective, it would be reported to maintenance for immediate repair. The P&P indicated if the call system could not be repaired immediately, an alternative call alert process would be put in place (i.e. tap bells, auxiliary aids, etc.).

CONCERN (E)

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide sufficient staff for resident care and safety for one of 30...

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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 sufficient staff for resident care and safety for one of 30 sampled residents (Resident 7). This deficient practice caused a delayed response to care for Resident 7 after Resident 7's fall and the potential to affect the entire facility. Findings During a review of Resident 7's admission Record, dated 3/23/2025, the admission Record indicated Resident 7 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis including muscle weakness (decreased strength in the muscles), glaucoma (an eye disease that gradually damages the optic nerve and can lead to blindness), and legal blindness (a significant level of vision loss). During a review of Resident 7's History and Physical (H&P), dated 3/6/2025, the H&P indicated Resident 7 did not have the capacity to understand and make decisions. During a review of Resident 7's Minimum Data Set (MDS, a mandated resident assessment tool), the MDS indicated Resident 7 sometimes understand and was sometimes understood by others. The MDS indicated Resident 7 was severely cognitively impaired (ability to think and reason). The MDS indicated Resident 7 had impairments on both lower extremities (legs). The MDS indicated Resident 7 was dependent on staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and required substantial assistance from staff for eating and oral hygiene. The MDS indicated Resident 7 was dependent on staff for sitting to standing and for chair to bed transfer. The MDS indicated Resident 7 required substantial assistance from staff for rolling left and right, sitting to lying, and lying to sitting on the side of the bed. During a review of Resident 7's Situation, Background, Assessment, Recommendation (SBAR) communication form, dated 3/15/2025, the SBAR communication form indicated on 3/15/2025, Resident 7 fell and was observed sitting on the floor. The SBAR communication form indicated there was a small red lump on Resident 7's forehead but no bleeding noted. Resident 7 stated she did not have pain. During a review of the facility's Census and Direct Care Service Hours Per Patient Day (DHPPD), dated 3/15/2025, the scheduled Certified Nursing Assistant (CNA) direct hours of care per patient day was 2.4 but the actual CNA direct hours of care per patient day was 1.75. During a review of the facility's staff assignments, dated 3/15/2025, the staff assignments indicated on 3/15/2025, only four CNAs worked the morning shift. During an interview on 3/23/2025 at 3:50 p.m. with the Director of Nursing (DON), the DON stated on 3/15/2025, there were supposed to be seven CNAs scheduled to work the morning shift but only had four CNAs working. The DON stated Resident 7's assigned CNA was with another resident at the time of the resident's fall. The DON stated another CNA was the one that saw Resident 7 on the floor. The DON stated the progress notes did not specify how long Resident 7 was on the floor, and by having only four CNAs, that could have led to a delayed response to tend to Resident 7. The DON stated Resident 7 had a bump on her head and was sent to the hospital but was negative for any findings. During a review of the facility's policy and procedure (P&P) titled, Resident Safety, dated 4/15/2021, the P&P indicated to observe the safety and well being of the residents, a resident check would be made at least every two hours around the clock by nursing service personnel and any staff member who identifies an unsafe situation, practice, or environmental risk factors should immediately notify their supervisor or charge nurse.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation practices in the kitchen when: 1. The cook (Cook 1) and dietary aid (DA) were not ...

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Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation practices in the kitchen when: 1. The cook (Cook 1) and dietary aid (DA) were not wearing a mask while plating breakfast trays. 2. The DA did not change gloves when returning to the tray line (a system of food preparation, used in hospitals, in which trays move along an assembly line) after touching non-food items. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness for residents who received food from the kitchen. 3. Expired foods were stored in the kitchen and accessible for use while preparing foods. This deficient practice had the potential to result in the residents ingesting expired food and the potential for foodborne illnesses leading to symptoms such as nausea, vomiting, stomach cramps, and diarrhea, and a decrease in food flavoring and taste. Findings: a. During an observation of the tray line service for breakfast on 3/22/2025 at 7:12 a.m., [NAME] 1 and the DA were observed plating breakfast trays without wearing a mask. b. During a concurrent observation and interview on 3/22/2025 at 7:30 a.m. with the DA, the DA was observed at the tray line wearing gloves. The DA was then observed touching items from the dry food storage and returning to the tray line to plate food without washing his hands or changing gloves. The DA stated it was important to change gloves while in contact with food items during the tray line due to cross contamination. c. During an observation on 3/22/2025 at 11:00 a.m., of the bread rack, one package of sliced bread was observed with an expiration date of 3/18/2025 and one package of sliced bread had no labeled expiration date. During an observation on 3/22/2025 at 11:05 a.m., in the dry food storage, observed two bags of mini marshmallows with an expiration date of 3/6/2025, ground cumin spice container with an expiration date of 2/16/2025, pumpkin pie spice container with an expiration date of 8/31/2024, mustard flour container with an expiration date of 11/27/2024 and one box containing 12 cartons of 1% Low-fat chocolate milk with an expiration date of 3/19/2025. During an interview on 3/22/2025 at 10:30 a.m. with the DA, the DA stated during breakfast on 3/22/2025, [NAME] 1 and the DA forgot to use a face mask while plating breakfast trays. The DA stated it was necessary to use a face mask while food handling for the prevention of the transmission of any contagious diseases. The DA stated a face mask should be always used during food handling. The DA stated he did not change his gloves when he left the tray line to get more items from the storage room. The DA stated it was important to change gloves due to cross contamination. The DA stated every time he went to another zone, he must wash his hands and change his gloves to prevent food contamination and prevent the risk of acquiring any diseases. During an interview on 3/23/2025 at 1:34 p.m. with the Kitchen Supervisor (KS), the KS stated staff that work in the kitchen need to wear a face mask while serving food. The KS stated gloves were changed after finishing any tasks. The KS stated hands needed to be washed and clean gloves applied for infection control prevention and cross contamination. The KS stated if the staff failed to follow the guidelines the residents could be at risk of gastrointestinal (GI) problems, such as abdominal pain or loose stool. The KS stated it was the facility's responsibility to protect the residents' health. The KS stated when food products are received, the products are stamped with the date that was received. The KS stated she usually checked the products for expiration dates. The KS stated giving expired products to residents could cause GI problems and infection. During an interview on 3/23/2025 at 3:25 p.m. with the Director of Nursing (DON), the DON stated the facility policy was to wear a face mask while preparing food due to infection control. The DON stated the if the food must be clean and uncontaminated from any foreign particles. The DON stated the expired food concussion will cause a health hazard. The DON stated residents can developed nausea, vomiting, diarrhea symptoms of food poisoning. During a review of the facility's policy and procedure (P&P) titled Dry Goods Storage Guidelines, dated 2018, the P&P indicated do check expiration dates on boxes or containers to be sure the length of time is correct. During a review of the facility's P&P titled Gloves use Policy, dated 2020, the P&P indicated the appropriate use of gloves is essential in preventing food borne illness. The P&P indicated gloves need to be changed before beginning a different task. During a review of the facility's P&P titled Respiratory Protection Program, dated 5/30/2024, the P&P indicated the employee is responsible for being aware of the respiratory protection requirements for their work areas. The P&P indicated wearing the appropriate respiratory protection according to manufactures instructions.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to implement infection control interventions to prevent the spread of ge...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to implement infection control interventions to prevent the spread of germs in accordance with the facility's Respiratory Protection Program policy and procedure (P/P) impacting 57 of 57 residents and staff, with the improper wear of a N95 (a type of filtering facepiece respirator designed to provide protection from inhaling certain airborne particles) Respirator Mask while in a resident care area. This deficient practice had the potential to lead to the spread of COVID 19 (infectious disease caused by the SARS-CoV-2 virus) to residents and staff. Findings: During an observation on 3/22/2025 at 2:50 p.m., observed Certified Nurse Assistant (CNA 1) entering room [ROOM NUMBER] with a N95 respirator. The string was hanging to the front of the mask. During an interview on 3/22/2025 at 2:55 p.m., with CNA 1, CNA 1 stated she had entered room [ROOM NUMBER] wearing her mask improperly and that wearing the mask with the string to the front did not provide a proper seal and could lead to germs entering or escaping causing further spread of COVID 19. CNA 1 stated she was supposed to place the first string of the mask at the nape (back of the neck) of her head and the second string at the crown of her head. CNA 1 stated she needed to ensure there was a tight seal and blow air to ensure there was no air escaping. During an interview on 3/22/2025 at 3:09 p.m., with the Infection Prevention Nurse (IP), the IP stated she would do a re-in-service training for staff on the proper method of wearing an N95 respirator to prevent the spread of germs and COVID 19. During a review of the facility's policy and procedure (P&P) titled Respiratory Protection Program, dated 9/9/2021, P&P indicated the respirator shall not be used in a manner for which it is not certified by NIOSH ([National Institute for Occupational Safety and Health] federal agency that conducts research and makes recommendations to prevent work-related injuries and illnesses) or by its manufacturer. The P&P indicated all employees shall conduct positive and negative pressure user seal checks each time they wear a respirator.

Jan 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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect one of three sampled residents' (Resident 2) right to be fre...

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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 one of three sampled residents' (Resident 2) right to be free from physical abuse. This failure resulted in Resident 2 slapping Resident 1 on the left side of the face. Findings: During a review of Resident 1's admission Record, the admission Record indicted Resident 1 was admitted by the facility on 8/22/2017 and readmitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow imprecise movements), polyosteoarthritis (a progressive disorder of the joints caused by a gradual loss of cartilage) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool) dated 1/24/2025, the MDS indicated Resident 1's cognitive (ability to think and reason) skills for daily decision-making was moderately impaired (cues/supervision required). During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted by the facility on 10/30/2024 with diagnoses including schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and anxiety disorder (a mental health condition that causes excessive fear and worry). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision-making was moderately impaired (cues/supervision required). During an interview with Certified Nurse Assistant (CNA) 1 on 1/30/2025 at 11:57 a.m., CNA 1 stated Resident 2 became agitated about a week ago and tried to throw a book of files at her while at the nursing station. During an interview with Resident 1 on 1/30/2025 at 12:09 p.m., Resident 1 stated his roommate (Resident 2) hit him on the left side of his face . Resident stated the incident happened around 9:30 p.m. and there was a female nurse with him in the room at that time. Resident 1 stated he was scared when the incident happened. During an interview with Licensed Vocational Nurse (LVN) 1 on 1/30/2025 at 1:02 p.m., LVN 1 stated Resident 2 would have moments of outbursts before the incident, off and on. LVN 1 stated Resident 2 got aggressive to the point he would push things, and he threw a pitcher prior to the incident. During a concurrent interview and record review with the Minimum Data Set (MDS) nurse on 1/30/2025 at 1:33 p.m., the MDS nurse stated Resident 2 was reported berating Resident 1 stating he stole my girlfriend . Resident 2's Medication Administration Record (MAR) dated 1/2025 was reviewed. The MDS nurse stated, there was no documented evidence of the number of episodes of outbursts of anger for Resident 2. The MDS nurse stated staff should have monitored to prevent incidents like resident-to-resident altercations and should have called the doctor to assess the resident and adjust the medications. During a telephone interview with Registered Nurse (RN) 3 on 1/30/2025 at 4:25 p.m., RN 3 stated she was making her rounds when she saw Resident 1 in his wheelchair going to the bathroom. When Resident 1 passed Resident 2's bed, RN 3 saw Resident 2 telling Resident 1 he stole his girlfriend. RN 3 walked into the residents' room to assist Resident 1, that's when Resident 2 slapped Resident 1 . RN 3 stated she witnessed the slapping of Resident 1. During a review of Resident 1's Progress Notes and Interdisciplinary Team (IDT) notes dated 1/21/2025 indicated Resident 2 without provocation, suddenly berated and accused Resident 1 of stealing his girlfriend. This accusation was unfounded and nor based in reality .while Resident 1 was being assisted to the toilet by a staff member, Resident 2 approached and slapped him (Resident 1) in the face. During a review of the facility's policy and procedure (P&P), titled Abuse Prevention and Management, revised on 5/30/2024, the P&P indicated, The facility does not condone any forms of resident abuse, neglect, misappropriation of property, exploitation and/or mistreatment. The facility develops policies, procedures, training programs, and screening and prevention systems.

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

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to: a. Monitor one of three sampled resident ' s (Resident 2) behaviors...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to: a. Monitor one of three sampled resident ' s (Resident 2) behaviors while the resident was on Risperidone (a psychotropic medication, used to treat certain mental/mood disorders). b. Document one of three sampled resident ' s (Resident 2) indication for an increased dose of Depakote [medication used to treat (bipolar disorder, a chronic mental health condition characterized by significant and persistent shifts in mood, energy, and activity levels)] These failure had the potential to result in inconsistent behavior monitoring and placed Resident 2 at risk for not receiving the necessary interventions for increased psychiatric behaviors. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a mental illness that is characterized by disturbances in thought), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), bipolar type (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), and anxiety (excessive worry). During a review of Resident 2 ' s Minimum Data Set (MDS- resident assessment tool), dated 10/01/2024, the MDS indicated Resident 2's cognitive skills for daily decision-making was moderately impaired (decisions poor; cues/supervision required). a. During a review of Resident 2 ' s Order Summary Report, from1/7/2025 to 1/21/2025, the report indicated: Risperidone 3 milligrams (mg, unit of weight) one tablet by mouth two times a day for mood disorder manifested by behavioral aggression as evidenced by destroying facility property, going into other resident ' s room/belongings and taking them. During an interview with Certified Nurse Assistant (CNA) 1 on 1/30/2025 at 11:57 a.m., CNA 1 stated Resident 2 became agitated about a week ago and tried to throw a book of files at her while at the nursing station. During an interview with Licensed Vocational Nurse (LVN) 1 on 1/30/2025 at 1:02 p.m., LVN 1 stated Resident 2 would have moments of outbursts before the incident, off and on. LVN 1 stated Resident 2 got aggressive to the point he would push things, and he threw a pitcher prior to an incident with his roommate. During a concurrent interview and record review on 1/30/2025 at 1:33 p.m. with the Minimum Data Set (MDS) nurse, Resident 2 ' s Medication Administration Record (MAR), dated 1/2025 was reviewed. The MAR indicated, to monitor target behaviors for use of Risperidone due to schizophrenia manifested by recurrent episodes of outbursts of anger, indicate the number of behavior occurrences. The MDS nurse stated, there was no documented evidence of the number of episodes of outbursts of anger. The MDS nurse stated staff should have monitored to prevent behavioral outbursts and should have called the doctor to assess the resident and adjust the medications. During an interview on 1/30/2025 at p.m., with Registered Nurse (RN) 2 at 5:08 p.m., RN 2 stated, when residents are on psychotropic medications the facility should monitor for behaviors manifested and document the number of episodes on the MAR. RN 2 stated, monitoring behaviors was important to prevent increase in behaviors and track if medication is working. b. During a review of Resident 2 ' s Order Summary Report, from 1/7/2025 to 1/21/2025, the report indicated: Depakote 750 mg by mouth two times a day for mood disorder manifested by sudden mood changes ranging from depressed to euphoric and vice versa. During a concurrent interview and record review on 1/30/2025 at 3:26 p.m., with Registered Nurse (RN) 1, Resident 2 ' s Medication Order Summary Report, dated 1/13/2025 was reviewed. The Medication Order Summary Report indicated an increase in Depakote from 500 mg to 750 mg twice a day. RN 1 stated, the increase in dose was not documented on a Situation, Background, Assessment, and Recommendation (SBAR) form, nor was there documentation on the indications for the increase. RN 1 stated, documentation of the indication was a standard of practice. During a phone interview on 1/30/2025 at 5:06 p.m., with the Nurse Practitioner (NP), the NP stated, the criteria for increasing Depakote were for increased behaviors. The NP stated the medication was adjusted to decrease behavior outbursts. During a review of the facility ' s policy and procedure (P&P) titled, Behavior/Psychoactive Medication Management revised 1/25/2024, indicated, Evaluation: a. The Behavior Management/Psychoactive Review Committee will review the following and make recommendations based on resident ' s need: ii) continued use of psychoactive medication; c. Documentation Requirements: i) Monthly. The occurrence of behavior will be tallied and entered on the Monthly Psychoactive Medication Management Form in addition to any occurrence of adverse reaction

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement intervention in a resident's care plan title...

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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 intervention in a resident's care plan titled Comprehensive Person-Centered Care Planning, which indicated hourly visual monitoring should be conducted to one of seven sampled residents (Resident 2), who was at risk for wandering(walking aimlessly)/ eloping (when a resident who is cognitively, physically, mentally, emotionally, and/or chemically impaired leaves a care-giving facility or environment unsupervised, unnoticed, and/or prior to their scheduled discharge). This deficient practice resulted in Resident 2 wandering into other resident ' s rooms and placed Resident 2 at risk for an altercation with another resident. Findings: During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including polyneuropathy (a condition where the nerves that are located outside of the brain and spinal cord are damaged), paranoid schizophrenia (a brain disorder where a person experiences paranoia that feeds into delusions and hallucinations), and cognitive communication deficit (a disorder in which a person has difficulty communicating because of an injury to the brain that controls the ability to think). During a review of Resident 2 ' s History and Physical (H&P), dated 7/8/2024, 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 standardized assessment and care screening tool, dated 7/19/2024, the MDS indicated Resident 2 sometimes understood and was able to sometimes understand others. The MDS indicated Resident 2 required partial assistance from staff for activities of daily living such as eating, oral hygiene, upper body dressing, and personal hygiene, substantial assistance from staff for toileting hygiene, lower body dressing, and putting on and taking off footwear, and was dependent on staff for showering. The MDS indicated Resident 2 required set up assistance from staff for walking 150 feet, supervision from staff for rolling left and right, sit to lying, lying to sitting on side of bed, sit to stand, and bed to chair transfer, and partial assistance for toilet transfer and shower transfer. During a review of Resident 2 ' s care plan, titled, Risk for wandering/elopement identified related to disturb thought processes secondary to internal stimuli as evidenced by restlessness, bizarre behavior and resident wandering aimlessly, dated 7/8/2024, the interventions indicated checking wander guard ((a system used in healthcare facilities to prevent residents with a tendency to wander from leaving monitored areas) functioning and placement every shift, and visual hourly monitoring for safety. During a review of Resident 2 ' s order summary report, dated 8/5/2024, the order summary report indicated to monitor for number of elopements every shift. The order summary report dated 3/11/2024 indicated to apply wander guard bracelet due to elopement precautions. The order summary report dated 8/5/2024 indicated to check for wander guard placement and function every shift for elopement. During a concurrent observation and interview on 8/2/2024 at 1:35 p.m. with Resident 1 in Resident 1 ' s room, Resident 1 stated Resident 2 came into Resident 1 ' s room at least three times that day and attacked Resident 1. Resident 1 stated Resident 2 took off Resident 1 ' s blanket and hit Resident 1. Resident 1 stated she told the Registered Nurse Supervisor (RN 1) about the incident. Resident 1 was observed lying in bed with no obvious bruises or markings. During an observation on 8/5/2024 at 2:01 p.m. in the hallway, Resident 2 was observed going into another resident ' s room, laid down on another resident ' s bed, and went to sleep. During a concurrent observation and interview on 8/5/2024 at 2:04 p.m. with Registered Nurse (RN 2) in the hallway, RN 2 redirected Resident 2 back to her room. RN 2 stated that was not Resident 2 ' s room and Resident 2 tends to wander into other resident ' s rooms. RN2 stated the intervention would have been to do frequent redirection. During an interview on 8/5/2024 at 2:06 p.m. with LVN 2, LVN 2 stated Resident 2 would wander from room to room because of her dementia (a loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life). LVN 2 stated the interventions would be to redirect Resident 2 back to her room and do frequent monitoring every two hours. LVN 2 stated Resident 2 would wander into Resident 1 ' s room because Resident 1 ' s room was Resident 2 ' s previous room and when Resident 2 wandered into Resident 1 ' s room, Resident 1 would scream so they know they had to get Resident 2 out of Resident 1 ' s room. LVN 2 stated she had never seen Resident 2 hit Resident 1 and Resident 1 did not tell LVN 2 that Resident 2 hit Resident 1. During an observation on 8/5/2024 at 2:14 p.m. in the hallway, Resident 2 was observed leaving Resident 1 ' s room. Resident 1 was sleeping in bed. During an observation on 8/5/2024 at 2:18 p.m. in the hallway, Resident 2 was observed leaving and entering two other residents ' rooms. During an interview on 8/5/2024 at 2:28 p.m. with RN 1, RN 1 stated Resident 1 never told him about Resident 2 attacking her. RN 1 stated Resident 2 was very confused and was always wandering into other resident ' s rooms and staff would try to redirect Resident 2. During a concurrent interview and record review on 8/5/2024 at 3:52 p.m. with the Director of Nursing (DON), Resident 2 ' s care plan, dated 7/8/2024, and order summary report, dated 8/5/2024, were reviewed. The care plan indicated, on 7/8/2024, the intervention for Resident 2 ' s risk for wandering and elopement included visual hourly monitoring. The DON stated there were no visual hourly monitoring done for Resident 2 from 7/6/2024 through 8/5/2024. The DON stated Resident 2 ' s care plan which indicated to conduct hourly visual monitoring was not followed. The DON stated the facility placed Resident 2 at risk for altercation if Resident 2 wandered into a resident ' s room. During a review of the facility ' s policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 11/2018, the P&P indicated the facility should ensure to develop a comprehensive person-centered for each resident to provide a person-centered, comprehensive, and interdisciplinary care that reflected best practice standards for meeting resident ' s needs. The P&P indicated the baseline care plan should address resident-specific health and safety concerns and would identify needs for supervision as necessary.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the call light for one of seven sampled resi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the call light for one of seven sampled residents (Resident 1) was placed within reach while Resident 1 was in bed. This deficient practice had the potential to cause Resident 1 to not be able to get the help she needed in a timely manner. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including polyneuropathy (a condition where the nerves that are located outside of the brain and spinal cord are damaged), dementia (the loss of memory, language, problem-solving, and other thinking abilities that are severe enough to interfere with daily life), and paranoid personality disorder (a mental disorder characterized by exaggerated distrust and suspicion of other people). During a review of Resident 1 ' s history and physical (H&P), dated 2/29/2024, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 4/30/2024, the MDS indicated Resident 1 was usually understood and was usually able to understand others. The MDS indicated Resident 1 required supervision from staff for activities of daily living such as eating, partial assistance from staff for oral hygiene, substantial assistance from staff for personal hygiene, and was dependent on staff or toileting hygiene, upper and lower body dressing, and putting on and taking off footwear. The MDS indicated Resident 1 was dependent on staff for mobility such rolling left and right, sit to lying, lying to sitting on edge of bed, toilet transfer, and shower transfer. During an observation on 8/2/2024 at 1:30 p.m. at Resident 1 ' s room, Resident 1 ' s call ligha ws behind the bedside table. During an interview on 8/2/2024 at 1:35 p.m. with Resident 1, Resident 1 stated she did not have a call light at bedside and she did not have a phone so she had to yell to get help from staff. During a concurrent observation and interview on 8/2/2024 at 4:03 p.m. with the Director of Nursing (DON) in Resident 1 ' s room, Resident 1 ' s call light was on the floor behind Resident 1 ' s bed. The DON stated the call light was supposed to be within reach of the residents. The DON stated the call light on the floor was not within reach of the resident and if the resident needed help, they would not be able to get help if the call light was not within reach. During a review of the facility ' s policy and procedure (P&P) titled, Communication-Call System, dated 1/1/2012, the P&P indicated the purpose of the call light system was to provide a mechanism for residents to promptly communicate with nursing staff. The P&P indicated call cords will be placed within the resident ' s reach in the resident ' s room.

Jul 2024 2 deficiencies 2 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

Comprehensive Care Plan (Tag F0656)

Someone could have died · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a comprehensive person-centered care plan (a wr...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a comprehensive person-centered care plan (a written plan of care developed by the resident's medical provider, the interdisciplinary team ([IDT] group of healthcare professionals working together to provide residents with needed care), and the resident to help resident achieve his or her treatment goals) was developed and implemented for the safe storage of smoking materials (cigarettes and lighters) for three of three sampled residents (Residents 3, 2 and 1), who were smokers by failing to ensure: 1). Resident 3 was not holding a lighter while coming out of his room on 7/2/2024 at 2 p.m. 2). Resident 2 did not have a lighter on her wheelchair seat while in the room, on 7/2/2024 at 1:50 p.m. 3). Resident 1 did not have a cigarette lighter in her purse on 7/2/2024 at 1:45 p.m. 4). Its Nursing Manual-Resident Rights, titled, Smoking Residents, which indicated the IDT will develop an individualized plan of care for safe storage, use of smoking materials, assistance and/or required supervision, for residents who smoke, was implemented. These failures had the potential for Residents 3, 2, and 1 to turn on the lighters, cause a fire and affect the health, safety, and wellbeing of all 56 residents in the facility, staff and visitors and result in serious injuries, hospitalization, and death. Findings: 1). During an observation and interview on 7/2/2024 at 2 p.m., Resident 3 was observed coming out of his room, holding a lighter. Resident 3 refused to answer what could happen if he lost his cigarette lighter and/or someone stole his cigarette lighter. During an observation on 7/2/2024 at 3:45 p.m., in the smoking patio, Resident 3 was observed smoking a cigarette by himself, and unsupervised. During a concurrent interview and record review on 7/3/2024 at 1:55 p.m. with the DON, Resident 3 ' s Smoking Safety Evaluation, dated 6/6/2024 was reviewed. The DON stated, the Smoking Safety Evaluation indicated Resident 3 smoked cigarettes and required supervision during designated smoking times. The DON stated the Activity ' s Department kept the lighters and cigarettes in an unlocked, unsecured tacklebox (utility box). The DON stated she was unaware if residents were stealing cigarettes and lighters from the tacklebox. The DON stated unsecured cigarettes and lighters were a safety concern in case residents light cigarettes and smoked in a room where other residents might be using oxygen. A review of Resident 3 ' s admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 3 ' s admitting diagnoses included schizoaffective disorder, suicidal ideations (act of thinking about or a state of preoccupation with taking one's own life) and homicidal ideations (a thought pattern characterized by the desire to kill another person or persons, along with a mental plan for a method of doing it). A review of Resident 3 ' s Smoking Safety form, dated 6/6/2024, indicated Resident 3 utilized (used) cigarettes and supervision was required during designated smoking times. A review of Resident 3 ' s MDS, dated [DATE] indicated Resident 3 had severe cognitive impairment (ability to think and reason). The MDS indicated Resident 3 was independent with eating, toileting, and personal hygiene. A review of Resident 3 ' s IDT Conference Review, dated 6/14/2024, indicated Resident 3 was safe to smoke independently. The IDT Conference Review indicated staff interventions included to store smoking materials per facility protocols, explain facility smoking policy to Resident 3, and assist Resident 3 to and from the designated smoking area. A review of Resident 3 ' s care plan titled At risk for injury related to smoking, an assisted smoker requiring supervision and refusing to wear apron, dated 6/14/2024, indicated staff will enforce supervised smoking hours in the designated smoking patio. The care plan did not indicate if Resident 3 required his cigarettes and lighter stored. 2). During an observation and interview on 7/2/2024 at 1:50 p.m., Resident 2 was observed lying in bed and a wheelchair next to his bed. An orange cigarette lighter was observed on the seat of the wheelchair. Resident 2 stated he kept his cigarettes and lighter and smoked as needed without staff ' s supervision. Resident 2 stated he would feel horrible if someone stole his cigarette lighter and use the lighter to start a fire in the facility. During a concurrent interview and record review on 7/3/2024 at 1:45 p.m. with the DON, Resident 2 ' s IDT Conference Review, dated 1/16/24 was reviewed. The DON stated the IDT conference review goals and outcomes indicated staff will give Resident 2 smoking related material per facility ' s protocol and supervise the resident per his smoking assessment. The DON stated smoking materials were supposed to be stored by the activities department. The DON stated all residents were supposed to be supervised during smoking to prevent burn related injuries. The DON stated the care plan did not indicate a safe storage of Resident 1 ' s cigarettes and lighter. A review of Resident 2 ' s admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnosis of metabolic encephalopathy (alteration in consciousness due to brain dysfunction), urinary tract infection ([UTI] infection in urinary system, which may include kidneys, ureters, bladder, or urethra), and unsteadiness on feet. A review of Resident 2 ' s IDT Conference Review, dated 1/16/2024, indicated Resident 2 was safe to smoke independently. The IDT Conference Review indicated staff will explain the facility ' s smoking policy, store smoking related materials per facility policy and supervise Resident 2, per the smoking assessment. A review of Resident 2 ' s Smoking and Safety form dated 4/20/2024, indicated Resident 2 used tobacco and required assistance and supervision when smoking. The Smoking and Safety form indicated staff will apply a smoking apron on Resident 2, extinguish (blow out) the resident ' s cigarette, and refer to the IDT, if Resident 2 was deemed unsafe to smoke. The form did not indicate how Resident 2 ' s cigarettes and lighter were stored. A review of Resident 2 ' s MDS, dated [DATE], indicated Resident 2 had a clear speech and had the ability to express ideas and wants, and understood. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, shower/bathe self, and personal hygiene. A review of Resident 2 ' s care plan titled, Risk for injury related to smoking, an assisted smoker requiring supervision, and refusing to wear an apron, dated 7/1/2024, indicated staff will keep offering and encouraging Resident 2, to use an apron, to protect the resident. The care plan interventions indicated staff will enforce supervised smoking hours at scheduled times in the designated smoking patio. The care plan interventions indicated staff will light Resident 2 ' s cigarette and bring the cigarette to his mouth for assistance. The care plan did not indicate how Resident 2 ' s cigarettes and lighter were stored. 3). During a concurrent observation and interview on 7/2/2024 at 1:45 p.m., Resident 1 was observed sitting on her bed with a cigarette lighter in her purse. Resident 1 stated cigarette breaks were scheduled several times a day and she did not have to ask for a lighter or cigarette from anyone since she already had hers. Resident 1 stated she was unsupervised during some cigarette breaks. Resident 1 stated staff did not check her belongings for the presence of cigarettes or lighters. Resident 1 stated she would feel horrible (fearful) if someone stole her lighter and set a fire, in the facility. During a concurrent interview and record review on 7/3/2024 at 1:40 p.m. with the DON, Resident 1 ' s Smoking and Safety form dated 6/5/2024 and Resident 1 ' s care plan titled Risk for injury related to smoking dated 6/5/2024 were reviewed. The DON stated Resident 1 ' s Smoking and Safety form indicated Resident 1 was able to smoke cigarettes without supervision but did not indicate how the smoking materials will be stored. The DON stated Resident 1 ' s care plan titled Risk for injury related to smoking, indicated Resident 1 was an assisted smoker and required supervision. The DON stated the care plan interventions did not indicate how Resident 1 ' s cigarettes and lighter will be stored. The DON stated the care plan and smoking, and safety form were misleading, and staff could not implement appropriate interventions to prevent negative outcomes due to the inconsistency of the documents. The DON stated the care plan did not indicate a safe storage of Resident 1 ' s cigarettes and lighter. A review of Resident 1 ' s admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 1 ' s diagnoses included schizoaffective disorder (a mental illness that causes a person to experience dramatic changes in their thoughts, moods, and behaviors), generalized anxiety disorder (persistent worrying), and nicotine dependence (addiction of). A review of Resident 1 ' s care plan titled Risk for injury related to smoking, dated 6/5/2024, indicated Resident 1 was an assisted smoker and required supervision. The care plan interventions indicated staff will enforce (implement) supervised smoking hours during scheduled times in the designated smoking patio. A review of Resident 1 ' s IDT Conference Review, dated 6/10/2024, indicated the purpose of the conference was to ensure Resident 1 smoked safely. The IDT goals indicated staff will keep offering Resident 1 an apron (burn protector for smokers) and encourage it ' s (apron) use. The interventions indicated staff will enforce the facility ' s smoking hours and supervise residents while smoking. The IDT Conference Review did not indicate a safe storage of Resident 1 ' s cigarettes and lighter. A review of Resident 1 ' s Minimum Data Set ([MDS] an assessment and care planning tool), dated 6/12/2024, indicated Resident 1 had clear speech and had the ability to express ideas and wants, and understood. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, shower/bathe self, and upper body dressing. A review of the facility ' s Nursing Manual-Resident Rights, titled, Smoking Residents, dated 8/18/2023, indicated the licensed nurse will assess residents who express a desire to smoke upon admission, quarterly, annually and upon significant change of condition, and present to the interdisciplinary team (IDT) for review. The manual indicated, the IDT will develop an individualized plan of care for safe storage, use of smoking materials, assistance and/or required supervision, for residents who smoked.

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

Accident Prevention (Tag F0689)

Someone could have died · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure three of 11 residents (Residents 1, 2 and 3) wh...

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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 11 residents (Residents 1, 2 and 3) who were smokers, had an environment free of accident hazards (risk) by failing to ensure: 1). Resident 3 was not holding a lighter while coming out of his room on 7/2/2024 at 2 p.m. 2). Resident 2 did not have a lighter on her wheelchair seat while in the room, on 7/2/2024 at 1:50 p.m. 3). Resident 1 did not have a cigarette lighter in her purse on 7/2/2024 at 1:45 p.m. These failures had the potential for Residents 3, 2, and 1 to turn on the lighters, cause a fire and affect the health, safety, and wellbeing of all 56 residents in the facility, staff and visitors and result in serious injuries, hospitalization, and death. On 7/3/2024 at 4:32 p.m., an Immediate Jeopardy ([IJ] a situation in which the facility's noncompliance with one or more requirements of participation has cause, or is likely to cause serious injury, harm, impairment, or death to a resident) was called in the presence of the Administrator and Director of Nursing (DON) due to the facility ' s failure to ensure Residents 3, 2 and 1 ' s lighters were stored in a secured area which had the potential to cause a fire affecting the health, safety and wellbeing of all 56 residents in the facility including staffs and visitors. On 7/5/2024 at 4 p.m., the facility submitted an acceptable IJ Removal Plan ([IJRP] a plan with interventions to correct the deficient practice). After validating the IJRP's implementation onsite, the IJ was removed on 7/5/2024 at 4:18 p.m. in the presence of the Administrator, DON, and Clinical consultant. The IJRP included the following immediate actions: 1). On 7/3/24, the Administrator Immediately removed the lighter from Residents 3, 2 and 1. 2). On 7/3/2024, the DON/designee immediately reassessed and completed the Smoking Safety Evaluations for Residents 3, 2 and 1 who smoked and included in the assessment, the safe storage of their smoking paraphernalia (material), the supervision and/or assistance required during smoking. Person-centered care plans were updated to address residents' current assessments including their supervision needs, and safe storage of smoking materials. 3). On 7/3/24, the Administrator met with Residents 3, 2 and 1 and discussed the Smoking Policy and Procedures including the process for safe storage and safekeeping of smoking materials. The smoking materials will be kept in a locked box and will be supervised by the activity and nursing staff. 4). Resident 3 will be supervised by the activity/nursing staff during smoking outside smoking scheduled times. 5). On 7/3/2024, the DON/designee conducted an audit of current residents who smoke to ensure accurate Smoking Safety Evaluations and Person-Centered Care Plans were in placed, including assessment for safe storage of smoking materials, supervision or assistance required during smoking. There were 12 residents that smoke. 12 out 12 residents identified as smokers, would be supervised by the facility staff during smoking break. These residents' smoking materials will be kept in a locked box by the Activity Department in daytime and at the nurse's station after office hours. Person centered care plans have been updated to reflect residents' smoking needs. 6). On 7/3/2024, the Administrator/Designee conducted rounds and observations on current residents to identify any other residents who kept smoking materials in their possession and ensure safekeeping. 7). On 7/3/2024, the DON/Designee conducted rounds and observation in the smoking area to ensure that residents who required supervision while smoking, were supervised. 8). On 7/3/2024, the Administrator/DON initiated in -service education to the Licensed Nurses, Certified Nurse Assistants (CNA), Department Managers and the rest of the facility staff on the Smoking Policy and Procedures, with emphasis on: -Accurate Smoking Safety Evaluations and Person -Centered Care Plans -Monitoring and safe storage of smoking materials for the residents. Smoking paraphernalia will be kept in the locked box in the activity department during activity hours and at the nursing station thereafter. -Residents who smoke will be supervised and assisted by the designated staff during smoking. This education was completed 7/4/2024. Staff who were on leave or were unscheduled, will be provided with education by the DON or designee upon return to work. 9). During morning Clinical Meetings on Mondays to Fridays, the IDT will review residents newly admitted /readmitted , residents due for quarterly assessments and residents with significant change in condition. The review was to ensure that Smoking Safety Evaluations and Person-Centered Care Plans were accurately completed for those residents who currently smoke, and those who have expressed the desire to smoke. Identified concerns will be immediately addressed and reported to the Administrator and DON for resolution, as warranted. 10). The Department Managers will conduct rounds and observe residents who smoke, weekly for 4 weeks, then bimonthly for 2 months, to ensure residents who smoke adhere to smoking policy and procedures. 11). Lighting and smoking materials were safely stored according to the residents' care plan and residents were provided supervision/assistance by the staff accordingly. Identified concerns during the observation will be immediately addressed and reported to the Administrator and DON for resolution, as warranted. 12). The Administrator and DON will present the results of the Smoking Monitoring Audits to the Quality Assurance and Performance Improvement Committee for monthly review, for the next 3 months and quarterly thereafter, until substantial compliance is achieved. The Administrator and DON were responsible for monitoring and sustaining compliance. Findings: 1). During an observation and interview on 7/2/2024 at 2 p.m., Resident 3 was observed coming out of his room, holding a lighter. Resident 3 refused to answer what could happen if he lost his cigarette lighter and/or someone stole his cigarette lighter. During an observation on 7/2/2024 at 3:45 p.m., in the smoking patio, Resident 3 was observed smoking a cigarette by himself, and unsupervised. During a concurrent interview and record review on 7/3/2024 at 1:55 p.m. with the DON, Resident 3 ' s Smoking Safety Evaluation, dated 6/6/2024 was reviewed. The DON stated, the Smoking Safety Evaluation indicated Resident 3 smoked cigarettes and required supervision during designated smoking times. The DON stated the Activity ' s Department kept the lighters and cigarettes in an unlocked, unsecured tacklebox (utility box). The DON stated she was unaware if residents were stealing cigarettes and lighters from the tacklebox. The DON stated unsecured cigarettes and lighters were a safety concern in case residents light cigarettes and smoked in a room where other residents might be using oxygen. A review of Resident 3 ' s admission Record indicated Resident 3 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 3 ' s admitting diagnoses included schizoaffective disorder, suicidal ideations (act of thinking about or a state of preoccupation with taking one's own life) and homicidal ideations (a thought pattern characterized by the desire to kill another person or persons, along with a mental plan for a method of doing it). A review of Resident 3 ' s Smoking Safety form, dated 6/6/2024, indicated Resident 3 utilized (used) cigarettes and supervision was required during designated smoking times. A review of Resident 3 ' s MDS, dated [DATE] indicated Resident 3 had severe cognitive impairment (ability to think and reason). The MDS indicated Resident 3 was independent with eating, toileting, and personal hygiene. A review of Resident 3 ' s IDT Conference Review, dated 6/14/2024, indicated Resident 3 was safe to smoke independently. The IDT Conference Review indicated staff interventions included to store smoking materials per facility protocols, explain facility smoking policy to Resident 3, and assist Resident 3 to and from the designated smoking area. A review of Resident 3 ' s care plan titled At risk for injury related to smoking, an assisted smoker requiring supervision and refusing to wear apron, dated 6/14/2024, indicated staff will enforce supervised smoking hours in the designated smoking patio. The care plan did not indicate if Resident 3 required his cigarettes and lighter stored. 2). During an observation and interview on 7/2/2024 at 1:50 p.m., Resident 2 was observed lying in bed and a wheelchair next to his bed. An orange cigarette lighter was observed on the seat of the wheelchair. Resident 2 stated he kept his cigarettes and lighter and smoked as needed without staff ' s supervision. Resident 2 stated he would feel horrible if someone stole his cigarette lighter and use the lighter to start a fire in the facility. During a concurrent interview and record review on 7/3/2024 at 1:45 p.m. with the DON, Resident 2 ' s IDT Conference Review, dated 1/16/24 was reviewed. The DON stated the IDT conference review goals and outcomes indicated staff will give Resident 2 smoking related material per facility ' s protocol and supervise the resident per his smoking assessment. The DON stated smoking materials were supposed to be stored by the activities department. The DON stated all residents were supposed to be supervised during smoking to prevent burn related injuries. The DON stated the care plan did not indicate a safe storage of Resident 1 ' s cigarettes and lighter. A review of Resident 2 ' s admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnosis of metabolic encephalopathy (alteration in consciousness due to brain dysfunction), urinary tract infection ([UTI] infection in urinary system, which may include kidneys, ureters, bladder, or urethra), and unsteadiness on feet. A review of Resident 2 ' s IDT Conference Review, dated 1/16/2024, indicated Resident 2 was safe to smoke independently. The IDT Conference Review indicated staff will explain the facility ' s smoking policy, store smoking related materials per facility policy and supervise Resident 2, per the smoking assessment. A review of Resident 2 ' s Smoking and Safety form dated 4/20/2024, indicated Resident 2 used tobacco and required assistance and supervision when smoking. The Smoking and Safety form indicated staff will apply a smoking apron on Resident 2, extinguish (blow out) the resident ' s cigarette, and refer to the IDT, if Resident 2 was deemed unsafe to smoke. The form did not indicate how Resident 2' s cigarettes and lighter were stored. A review of Resident 2 ' s MDS, dated [DATE], indicated Resident 2 had a clear speech and had the ability to express ideas and wants, and understood. The MDS indicated Resident 2 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, shower/bathe self, and personal hygiene. A review of Resident 2 ' s care plan titled, Risk for injury related to smoking, an assisted smoker requiring supervision, and refusing to wear an apron, dated 7/1/2024, indicated staff will keep offering and encouraging Resident 2, to use an apron, to protect the resident. The care plan interventions indicated staff will enforce supervised smoking hours at scheduled times in the designated smoking patio. The care plan interventions indicated staff will light Resident 2 ' s cigarette and bring the cigarette to his mouth for assistance. The care plan did not indicate how Resident 2 ' s cigarettes and lighter were stored. 3). During a concurrent observation and interview on 7/2/2024 at 1:45 p.m., Resident 1 was observed sitting on her bed with a cigarette lighter in her purse. Resident 1 stated cigarette breaks were scheduled several times a day and she did not have to ask for a lighter or cigarette from anyone since she already had hers. Resident 1 stated she was unsupervised during some cigarette breaks. Resident 1 stated staff did not check her belongings for the presence of cigarettes or lighters. Resident 1 stated she would feel horrible (fearful) if someone stole her lighter and set a fire, in the facility. During a concurrent interview and record review on 7/3/2024 at 1:40 p.m. with the DON, Resident 1 ' s Smoking and Safety form dated 6/5/2024 and Resident 1 ' s care plan titled Risk for injury related to smoking dated 6/5/2024 were reviewed. The DON stated Resident 1 ' s Smoking and Safety form indicated Resident 1 was able to smoke cigarettes without supervision but did not indicate how the smoking materials will be stored. The DON stated Resident 1 ' s care plan titled Risk for injury related to smoking, indicated Resident 1 was an assisted smoker and required supervision. The DON stated the care plan interventions did not indicate how Resident 1 ' s cigarettes and lighter will be stored. The DON stated the care plan and smoking, and safety form were misleading, and staff could not implement appropriate interventions to prevent negative outcomes due to the inconsistency of the documents. The DON stated the care plan did not indicate a safe storage of Resident 1 ' s cigarettes and lighter. A review of Resident 1 ' s admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 1 ' s diagnoses included schizoaffective disorder (a mental illness that causes a person to experience dramatic changes in their thoughts, moods, and behaviors), generalized anxiety disorder (persistent worrying), and nicotine dependence (addiction of). A review of Resident 1 ' s care plan titled Risk for injury related to smoking, dated 6/5/2024, indicated Resident 1 was an assisted smoker and required supervision. The care plan interventions indicated staff will enforce (implement) supervised smoking hours during scheduled times in the designated smoking patio. A review of Resident 1 ' s IDT Conference Review, dated 6/10/2024, indicated the purpose of the conference was to ensure Resident 1 smoked safely. The IDT goals indicated staff will keep offering Resident 1 an apron (burn protector for smokers) and encourage it ' s (apron) use. The interventions indicated staff will enforce the facility ' s smoking hours and supervise residents while smoking. The IDT Conference Review did not indicate a safe storage of Resident 1 ' s cigarettes and lighter. A review of Resident 1 ' s Minimum Data Set ([MDS] an assessment and care planning tool), dated 6/12/2024, indicated Resident 1 had clear speech and had the ability to express ideas and wants, and understood. The MDS indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) with toileting hygiene, shower/bathe self, and upper body dressing. A review of the facility's manual titled Resident Safety, dated 4/15/2021, indicated the facility will provide residents a safe and hazard free environment.

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Implement its abuse policy and procedure titled Reporting Abuse...

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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. Implement its abuse policy and procedure titled Reporting Abuse, indicated the facility should report any resident-to-resident altercations to the State Survey Agency and Ombudsman within 2 hours for one of three sampled residents (Resident 1). This deficient practice placed Resident 1 and other residents in the facility at risk for further abuse. Findings: a. A review of Resident 1's admission Record (Face Sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included cerebral infarction (a disrupted blood flow to the brain due to problems with the blood vessels that supply it), atrial fibrillation (abnormal heartbeat), and celiac disease (a chronic digestive and immune disorder that damages the small intestine). A review of Resident 1's History and Physical (H&P), dated 6/6/2024, the H&P indicated Resident 1 had fluctuated capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 6/17/2024, the MDS indicated Resident 1's cognition (ability to learn, reason, remember, understand, and make decisions) was able to recall information when asked to repeat information after queuing. The MDS indicated Resident 1's activities of daily living (ADL) required partial/moderate assistance with personal hygiene, showering, and dressing. During an interview on 7/3/24 at 1:15 pm, Resident 1 stated he and Resident 2 got into a fight over the TV being too loud. Resident 1 stated, Resident 2 blocked the door with his wheelchair and grabbed his private parts. Resident 1 further stated they fought. b. A review of Resident 2's admission Record (Face Sheet), the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 2's diagnoses included cardiomegaly (the heart has a hard time pumping the blood), dementia (developed difficulties with reasoning, judgment, and memory), and schizoaffective disorder (loss of contact with reality and mood problems). During a review of Resident 2's History and Physical (H&P), dated 4/24/2024, the H&P indicated Resident 2 does not have the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set ([MDS] a comprehensive assessment and care-screening tool), dated 5/6/2024, the MDS indicated Resident 2's cognition (ability to learn, reason, remember, understand, and make decisions) was not able to recall information when asked to repeat information. During an interview on 6/25/2024 at 5:19 p.m. with Director of Nursing (DON), The DON stated I am not aware of an altercation on 6/16/2024 at 12:00 p.m. with Resident 1 and Resident 2. The DON further stated the incident was not reported and our abuse policy was not followed by staff. A review of the facility's policy and procedure (P&P) titled, Abuse-Reporting & Investigations, dated 3/2018, the P&P indicated, The facility will report all allegations of abuse and to the appropriate agencies promptly .Abuse is to be reported to the Administrator (the Abuse Prevention Coordinator) .Upon allegations of abuse the Administrator or designated representative will notify law enforcement immediately within two hours of serious body injury .Administrator or designated representative will notify the Ombudsman, and CDPH by telephone and in writing (SOC-341) within two hours of initial report.

May 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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to notify the physician for one of six sampled residents (Reside...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to notify the physician for one of six sampled residents (Resident 2), when Resident 2 continued to refuse to take her medications: 1. Remeron (antidepressant, medication used to treat depression) 2. Buspirone (antianxiety, medication used to treat anxiety) 3. Seroquel (antipsychotic, medication used to treat schizophrenia) This deficient practice resulted in Resident 2's physician being unaware of Resident 2's change of condition, delayed medical intervention and Resident 2 experienced unnecessary hostile behavior. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including schizophrenia (mental illness that effects how person thinks, feels, and behaves) bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels), metabolic encephalopathy (problem in the brain), depression (loss of pleasure or interest), and anxiety (feeling fear, afraid, and worry). During a review of Resident 2's admission Assessment, the admission assessment indicated Resident 2's cognition status was sometimes able to makes himself-understood and sometimes understood others. During a review of Resident 2's H&P dated 5/10/2024, the H&P indicated Resident 2 had fluctuating(changing) capacity to understand and make decisions. During a review of Resident 2's Order Summary Report for the month of 5/2024, the order summary report indicated: 1. Remeron (antidepressant medication) (15 milligram ([mg]- a unit of measurement of weight), give one tablet at bedtime for depression. 2. Buspirone HCL (antianxiety medication) 15 mg, give one tablet two time a day for anxiety. 3. Seroquel (antipsychotic medication)25 mg, give one tablet two times a day for schizophrenia. During a review of Resident 2's Care Plan initiated 5/9/2024, the care plan indicated Resident 2 had an alteration in neurological status related to metabolic encephalopathy. The care plan goals were to give medications as ordered. The care plan also indicated Resident 2 was on psychotropic medications (drug that affects behavior, mood, and thoughts) and to administer psychotropic medications as ordered by physician. During a concurrent interview and record review on 5/22/2204 at 2:35 PM with Licensed Vocational Nurse (LVN1), Resident 2's progress notes for the month of 5/2024 was reviewed. The progress notes dated 5/9/2024 indicated Remeron 15 mg one tablet at bedtime, Buspirone 15 mg one tablet two times a day, and Seroquel 25 mg one tablet two times a day. The progress notes also indicated Resident 2 refused all three medications, when offered three (3) times by the licensed nurse. The progress notes dated 5/11/2024 indicated Resident 2 kept on refusing psychotropic(drug that affects behavior, mood, and thoughts) medications and became agitated. The progress notes dated 5/12/2024 indicated Resident 2 was hospitalized for behavioral evaluation. During a concurrent interview and record review on 5/22/2024 at 2:44 PM with LVN 1, Resident 2's Electronic Medical Record (EMR) was reviewed. The EMR did not indicate a Change of Condition (COC) was completed, or the physician was notified. LVN1 stated licensed nursing staff should have completed a COC, and the physician should have been notified after Resident 2 had refused the medications for three consecutive times. LVN 1 stated licensed nurses should have notified the physician for further interventions for Resident 2. During a concurrent interview and record review on 5/22/2024 at 3:25 PM with the Director of Nursing (DON), Resident 2's EMR was reviewed. The DON stated the COC was not completed. The DON stated there was no documented evidence the physician was notified when Resident 2 refused psychotropic medications. The DON stated the physician must be notified timely if Resident 2 had a change of condition. The DON stated Resident 2's COC was not addressed on time and would not get resolved which puts Resident 2 at risk for health complications, and hospitalization. During a review of facility's Policy and Procedure (P&P) titled Change of Condition Notification , revised 4/1/2015, the P&P indicated: 1. Change of Condition related to Attending physician notification is defined as when the Attending Physician must be notified when any sudden and marked adverse change in the resident's condition. 2. Facility will promptly inform the resident's Attending Physician when the resident endures a significant change. 3. A licensed nurse will notify the resident's Attending Physician a significant change in the resident's physical, mental or psychosocial status. During a review of facility's P&P titled Refusal of Treatment , revised 1/1/2012, the P&P indicated: 1. When a resident refuses treatment, the Charge Nurse, or Director of Nursing Services (DNS) will document information related to the refusal in the resident's medical record: a) The date and time Nursing staff tried to give a medication. b) The medication refused. c)The residents' response and reason(s) for refusal. d)The date and time the Attending Physician was notified and his or her response. e) The Attending Physician will be notified of refusal in a time frame determined by the resident's condition and potential serious consequences of the refusal. During a review of facility's P&P titled Medications-Administration , revised 1/1/2012, the P&P indicated, if resident is refusing to take medication the licensed nurse will attempt to give medications several times, but if resident continue to refuse after one-hour, licensed nurse will notify physician and document in the 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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was free from verbal abuse for one of six sampled...

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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 was free from verbal abuse for one of six sampled residents, (Resident 1). This deficient practice had the potential for Resident 1 to have psychological distress and caused Resident 1 to experience feelings of humiliation and disrespect. Finding: A. A review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes (high blood sugar), hypertension (high blood pressure), dysphagia (difficulty swallowing), depression (loss of pleasure or interest), and anxiety (feeling fear, afraid, and worry). A review of Resident 1's History and Physical (H&P) dated 4/18/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS] a comprehensive standardized assessment and care-screening tool) dated 4/11/2024, the MDS indicated Resident 1 was totally dependent (helper does all the effort) from staff for oral, toileting, and personal hygiene. The MDS also indicated Resident 1was self-understood and able to understand others. B. A review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including schizophrenia (mental illness that effects how person thinks, feels, and behaves) bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels), depression, and anxiety. A review of Resident 2's H&P dated 5/10/2024, the H&P indicated Resident 2 had fluctuating (changing) capacity to understand and make decisions. During a concurrent observation and interview on 5/22/2024 at 10:00 AM at, Resident 1's bedside, Resident 1 stated on 5/12/2024 early morning hours, doesn't remember the time, she had a verbal altercation (argument) with her roommate, Resident 2. Resident 1 stated Resident 2 was calling her (Resident 1) bad names like n*gg*r , using curse words, and profanity (a type of language that include dirty words). Resident 1 stated she felt angry, sad, upset, and disrespected. During an interview on 5/22/2024 at 11:22 AM with Certified Nursing Assistant 1(CNA1), CNA1 stated she was aware of the verbal altercation between Resident 1 and Resident 2. CNA1 stated on 5/12/2024 around 7:00 AM she was passing breakfast trays for Resident 1 and Resident 2. CNA1 stated, Resident 1 told her that Resident 2 was verbally aggressive and was calling her (Resident 1) bad words, using curse words and profanity. CNA1 stated she did not report right way to change nurse. CNA1 stated verbal altercation is abuse and should be reported immediately. CNA1 stated all staff, facility employees are mandated to report abuse immediately to change nurse, Director of Nursing (DON), and Administrator (ADM). During an interview on 5/22/2024 at 11:30 AM with CNA1, CNA1 stated on 5/12/2024 at 7:30 AM was passing breakfast trays for residents at the facility and heard yelling and screaming coming from across the hallway from Resident 1's and Resident 2's room. CNA1 stated she went into Resident 1's and Resident 2's room right way and saw Resident 2 standing by Resident 1's bed and was yelling n*gg*r word, and profanity. CNA1 stated she should have reported verbal abuse when Resident 1 told her earlier on 5/12/2024 at 7:00 AM. CNA1 stated was important to report abuse timely, to be investigated timely to prevent from happening again. During an interview on 5/22/2024 at 11:43 AM with Licensed Vocational Nurse1 (LVN1), LVN1 stated she was made aware of verbal altercation between Resident 1 and Resident 2 by CNA1 on 5/12/2024 around 7:30 AM. LVN stated on 5/12/2024 at 7:35 AM she checked Resident 2 status and was observed Resident 2 lying in bed, talking to herself. LVN1 stated she did not transfer Resident 2 to a different room. LVN 1 stated upon her assessment at that time, Resident 2 did not appear aggressive, or hostile, and so she did not transfer Resident 2 into a different room in the facility. During an interview on 5/22/2024 at 11:47 AM with LVN1, LVN1 stated on 5/22/2024 around 9:30 AM heard a commotion and loud yelling coming out of Resident 1's and Resident 2's room. LVN1 stated she went into Resident 1's and Resident 2's room and observed CNA1 redirecting Resident 2 to her (Resident2) bed. LVN1 stated Resident 2 became very agitated, and verbally abusive toward Resident 1 and staff. LVN 1 stated she should have transferred Resident 2 into a different room earlier to prevent verbal altercation for happening again. LVN 1 stated not separating Resident 1 from Resident 2 right way was safety issues and placed Resident 1 at risk for continue verbal abuse. During an interview on 5/22/2024 at 1:35 PM with the Director of Nursing (DON), The DON stated she was made aware by LVN 1 of the verbal altercation between Resident 1 and Resident 2 on 5/12/2024 at 9:30 AM. The DON stated was not aware that Resident 2 was not transferred right way from Resident 1's room. The DON stated facility staff should have separate both residents' right way, transfer Resident 2 into different available room at the facility. The DON stated facility staff failed to take appropriate actions for verbal abuse and failed to prevent verbal abuse for happening again to Resident 1. The DON stated residents should be treated with respect, and free from abuse. During a review of facility's Policy and Procedure (P&P) tiled Abuse-Prevention, Screening, & Training Program , revised 7/2018, the P&P indicated: 1. Abuse is defined as the willful, deliberate infliction of injury, unreasonable confinement, involuntary seclusion, physical or chemical restraint not required to treat symptoms and/or imposed for the purposes of discipline or convenience, intimidation, exploitation, misappropriation of resident property, mistreatment, and injuries of unknown source or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the neglect and deprivation of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. It includes verbal abuse, sexual abuse, physical abuse, mental abuse, or abuse facilitated or enabled by the use of technology that causes physical harm, pain, or mental anguish. 2. Verbal abuse is defined as any use of oral, written, gestured communication, or sounds that willfully includes disparaging and derogatory terms directed to residents within their hearing distance, regardless of age, ability to comprehend, or disability. During a review of facility's P&P titled Resident -To-Resident Altercations , revised 11/1/2015, the P&P indicated: 1. To protect the health and safety of residents ensuring altercations between residents are promptly reported, investigated, and addressed by the facility: a) Facility staff observes residents for aggressive or inappropriate behavior toward other residents. b) Any occurrence of such behavior is promptly reported to the Charge Nurse, the Director of Nursing Services, and the Administrator. c) Separate the residents, and institute measures to calm the situation. d) Review the events with the Change Nurse and Director of Nursing Services, including interventions staff can take to prevent additional incidents.

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the State Survey Agency (Bureau of Health Facility Licensin...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the State Survey Agency (Bureau of Health Facility Licensing, Certification and Resident Assessment, within the Department of Public Health), a written report of findings for the investigation of an allegation of abuse within five (5) working days for an incident of verbal abuse for one of six samples residents, (Resident 1). This deficient practice had the potential to result in unidentified abuse in the facility and failure to protect residents from further abuse. Findings: A.A review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including diabetes (high blood sugar), hypertension (high blood pressure), dysphagia (difficulty swallowing), depression (loss of pleasure or interest), and anxiety (feeling fear, afraid, and worry). A review of Resident 1's History and Physical (H&P) dated 4/18/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS] a comprehensive standardized assessment and care-screening tool) dated 4/11/2024, the MDS indicated Resident 1 was totally dependent (helper does all the effort) from staff for oral, toileting, and personal hygiene. B.A review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including schizophrenia (mental illness that effects how person thinks, feels, and behaves) bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels), depression, and anxiety. A review of Resident 2's H&P dated 5/10/2024, the H&P indicated Resident 2 had fluctuating capacity to understand and make decisions. During an interview on 5/22/2024 at 11:47 AM with LVN, LVN1 stated on 5/22/2024 around 9:30 AM heard a commotion and loud yelling coming out of Resident 1's and Resident 2's room. LVN1 stated she went into Resident 1's and Resident 2's room and was observed CNA1 redirecting Resident 2 to her (Resident 2) bed. LVN1 stated Resident 2 became very agitated, and verbally abusive toward Resident 1. LVN1 stated Resident 2 was calling Resident 1 bad name n*gg*r , using curse words, and profanity (a type of language that include dirty words). A review of an SOC 341 (this form, as adopted by the California Department of Social Services CDSS, is required under Welfare and Institutions Code WIC, to report suspected dependent adult/elder abuse), indicated that the incident was reported to the State Survey Agency on 5/12/2024 via email. During a concurrent interview and record review on 5/22/2024 at 2:14 PM with LVN1, Resident 2's progress note dated 5/12/2024 was reviewed. The progress note indicated Resident 2 was verbally aggressive and calling Resident 1 a n*gg*r repeatedly. The progress notes also indicated Resident 2 was transferred to the hospital for a behavioral evaluation. During a telephone interview on 5/22/2024 at 2:28 PM with the Administrator (ADM), the ADM stated, I will be honest with you regarding the five days investigation report, it was not reported to the Health Department. A review of facility's Policy and Procedure (P&P), titled Reporting Abuse , revised 1/8/2018, the P&P indicated: 1. Ensure compliance with federal and state laws and regulations regarding reporting of incidents and suspected incidents of abuse. 2. Facility will ensure that resident has the right to be free from verbal abuse. 3. Facility will report known or suspected abuse. 4. The Administrator, or his or her designee, shall provide the appropriate agencies or individuals with written report of the findings of the investigation within five (5) working days of the incident.

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to implement the baseline care plan for one of six sampled 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 implement the baseline care plan for one of six sampled residents, (Resident 2) by failing to: 1. Monitor Resident 2's psychotropic (drug that affects behavior, mood, and thoughts) medications side effects every shift. 2. Monitor Resident 2's mental status closely and report changes to the physician. 3. Assess Resident 2's for signs of distress or anxiety (feeling fear, afraid, and worry). These deficient practices had the potential to result in inconsistent implementation of the care plan that could lead to a delay or lack of delivery of care and services. Findings: A review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including schizophrenia (mental illness that effects how person thinks, feels, and behaves) bipolar disorder (mental illness that causes unusual shifts in a person's mood, energy, activity levels), metabolic encephalopathy (problem in the brain), depression (loss of pleasure or interest), and anxiety. A review of Resident 2's admission Assessment, the admission assessment indicated Resident 2's sometimes makes himself-understood and sometimes understood others. A review of Resident 2's H&P dated 5/10/2024, the H&P indicated Resident 2 had fluctuating (changing)capacity to understand and make decisions. A review of Resident 2's Care Plan initiated 5/9/2024, the care plan indicated Resident 2 had an alteration in neurological (damage to the brain) status related to metabolic encephalopathy. The care plan indicated Resident 2 was on psychotropic medications (drug that affects behavior, mood, and thoughts) and to administer psychotropic medications as ordered by physician, monitor for side effects and effectiveness every shift. The care plan interventions indicated to monitor and record occurrence of behavior symptoms (inappropriate response to verbal communication, physical and verbal aggression) and document in the Medication administration Record (MAR). During a concurrent interview and record review on 5/22/2024 at 2:44 PM with LVN 1, LVN 1 stated medication side effects and behavior monitoring should be documented in the MAR. Resident 2's MAR for month of 5/2024 was reviewed. LVN 1 stated there were no documented evidence that licensed staff monitored and recorded Resident 2's medications side effects or behaviors. LVN 1stated if it was not documented, that means it was not done. During a concurrent interview and record review on 5/22/2024 at 3:25 PM with the Director of Nursing (DON), Resident 2's EMR was reviewed. The DON stated care plan was resident specific to care, needs, goals, and interventions. The DON stated there was no documentation for Resident 2's medication side effects, or behavior monitoring as indicated on care plan. The DON stated licensed staff did not implement interventions in accordance with the care plan. The DON stated not implementing care plan interventions, put Resident 2 at risk for delay of care and treatment. During a review of facility's Policy and Procedure (P&P) titled Comprehensive Person-Centered Care Plan , revised 11/2018, the P&P indicated: 1. This facility to provide person-centered care that reflects best practice standards for meeting health, safety, psychosocial, behavioral needs of residents to obtain or maintain the highest physical, mental, and psychosocial well-being. 2. The baseline Care Plan should address resident-specific health and safety concerns to prevent decline or injury, and would identify needs for supervision, behavioral interventions. 3. The Baseline Care Plan will be developed and implemented using the necessary combination of problem specific care plans.

Apr 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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents have the right to be free from verbal abuse fo...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the residents have the right to be free from verbal abuse for one of three sampled residents (Resident 1). This deficient practice had the potential for Resident 1 to have psychological distress. Findings: A review of Resident 1's admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure), muscle weakness (a lack of strength in the muscles), diabetes (high blood sugar), and heart failure (a condition in which the heart doesn't pump enough blood to meet the body needs). A review of Resident 1's History and Physical (H&P) dated 11/15/2023, indicated Resident 1 could make needs known but could not make medical decisions. A review of Resident 1's Minimum Data Set ([MDS] a comprehensive standardized assessment and care-screening tool) dated 3/20/2024, indicated Resident 1 could make himself understood, and understand others. The MDS indicated Resident 1 required moderate assistance from staff for dressing, toilet use, personal hygiene, and bathing. A review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR) Communication form dated 4/5/2024, indicated Resident 1 was threatened by staff on 4/3/2024. A review of Resident 1's Psychiatric Evaluation dated 4/6/2024, indicated Resident 1 reported being threatened by staff and that the staff member cursed at Resident 1 on 4/3/2024. During a concurrent observation and interview on 4/15/2024 at 1:05 PM, with Resident 1, in Resident 1's room, Resident 1 was observed seating on the bed, well groomed, and dressed appropriately. Resident 1 stated in the morning of 4/3/2024, he exited his room to go the outdoor patio. Resident 1 stated Housekeeper 1 was in front of Resident 1's room and the resident cut off Housekeeper 1. Resident 1 stated Housekeeper 1 verbally threatened Resident 1 using curse words and profanity. Resident 1 stated he felt frustrated and scared. During an interview on 4/15/2024 at 2:15 PM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated he did not witness the verbal altercation between Resident 1 and Housekeeper 1. LVN 1 stated on 4/3/2024 during the morning shift (7:00 AM- 3:30 PM), he heard a loud verbal altercation in the hallway. LVN 1 stated he went to the hallway and saw Resident 1 wheeling himself to the outside patio as Housekeeper 1 stood in the hallway. LVN 1 stated he was told by Housekeeper 1 that there was a verbal altercation between Resident 1 and Housekeeper 1. LVN 1 stated Resident 1 was evaluated and did not see, or suspect that abuse occured. LVN 1 stated verbal altercations were not reported or documented. During a telephone interview on 4/15/2024 at 3:38 PM, with Housekeeper 1, Housekeeper 1 stated on 4/3/2024 around 8:30 AM, Housekeeper 1 was preparing laundry cards in front of Resident 1's room. Housekeeper 1 stated Resident 1 came out of his room and cut me off . Housekeeper 1 stated there was a loud verbal altercation with Resident 1, in which curse words and profanity were used. Housekeeper 1 stated he reported the incident to an unidentified certified nursing assistant (CNA) and his supervisor. Housekeeper 1 stated two days after the incident he was suspended. During an interview on 4/15/2024 at 4:11 PM, with the Director of Nursing (DON), the DON stated she was made aware of the verbal altercation between Housekeeper 1 and Resident 1 on 4/5/2024 and an investigation was started right way. The DON stated Resident 1 informed the ADM of the incident. During an interview on 4/15/2024 at 4:30 PM with Housekeeper 3, Housekeeper 3 stated on 4/3/2024 around 8: 30 AM, he was in his office and heard yelling, screaming, and cursing in the hallway. Housekeeper 3 stated he came out of his office and saw Resident 1 and Housekeeper 1 in the hallway having a loud conversation. Housekeeper 3 stated Resident 1 was yelling at Housekeeper 1 and Housekeeper 1 was talking back at Resident 1 with a loud voice and cursing. Housekeeper 3 stated he told Housekeeper 1 and Resident 1 to go their separate ways, then Resident 1 went to the outside patio. Housekeeper 3 stated Housekeeper 1 was asked what happened, and stated nothing had happened. Housekeeper 3 stated he asked Resident 1 if he was OK and Resident 1 stated, Yes, I am OK . Housekeeper 3 stated he reported the incident to the facility's Social Services Designee (SSD) on 4/3/2024, but was not sure what was done after that. Housekeeper 3 stated all staff were responsible for reporting alleged abuse, verbal abuse, or any other types of abuse must be reported immediately to the ADM and DON. Housekeeper 3 stated he should have reported the incident to the ADM, but he did not. During an interview on 4/15/2024 at 4:40 PM with the ADM, the ADM stated he was made aware of the verbal altercation between Resident 1 and Housekeeper 1 on 4/5/2024 by Resident 1. The ADM stated he started an investigation right way. The ADM stated Housekeeper 1 was suspended and the SSD resigned. The ADM stated residents should be treated with respect, dignity, and free from abuse. A review of the facility's Policy and Procedure (P&P) titled, Reporting Abuse revised 1/8/2014, indicated the following: 1. Facility will ensure that the resident has the right to be free from verbal, sexual, physical, and mental abuse. 2. Facility staff are mandatory reporters. 3. Facility staff will report known or suspected instances of abuse to the Administrator, or his/her designee. A review of the facility's P&P tiled, Abuse-Prevention, Screening, & Training Program , revised 7/2018, indicated: 1. Abuse is defined as the willful, deliberate infliction of injury, unreasonable confinement, involuntary seclusion, physical or chemical restraint not required to treat symptoms and/or imposed for the purposes of discipline or convenience, intimidation, exploitation, misappropriation of resident property, mistreatment, and injuries of unknown source or punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the neglect and deprivation of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. It includes verbal abuse, sexual abuse, physical abuse, mental abuse, or abuse facilitated or enabled by the use of technology that causes physical harm, pain, or mental anguish. 2. Verbal abuse is defined as any use of oral, written, gestured communication, or sounds that willfully includes disparaging and derogatory terms directed to residents within their hearing distance, regardless of age, ability to comprehend, or disability.

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to timely report the allegation of verbal abuse regarding one of...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to timely report the allegation of verbal abuse regarding one of three sampled Residents (Resident 1) to the facility Administrator (ADM), and to other officials including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities. These deficient practices had the potential to place Resident 1 at risk of further abuse, and neglect. Findings: A review of Resident 1's admission Record (Face Sheet), indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure), muscle weakness (a lack of strength in the muscles), diabetes (high blood sugar), and heart failure (a condition in which the heart doesn't pump enough blood to meet the body needs). A review of Resident 1's History and Physical (H&P) dated 11/15/2023, indicated Resident 1 could make needs known but couldnot make medical decisions. A review of Resident 1's Minimum Data Set ([MDS] a comprehensive standardized assessment and care-screening tool) dated 3/20/2024, indicated Resident 1 could make himself understood, understand others. The MDS indicated Resident 1 required moderate assistance from staff for dressing, toilet use, personal hygiene, and bathing. A review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR) Communication form dated 4/5/2024, indicated there was an altercation where Resident 1 was threatened by staff (Housekeeper 1) on 4/3/2024. A review of Resident 1's Psychiatric Evaluation dated 4/6/2024, indicated Resident 1 reported, I was threatened by staff (Housekeeper 1) and the staff member cursed at Resident 1. During a concurrent observation and interview on 4/15/2024 at 1:05 PM, with Resident 1, in Resident 1's room, Resident 1 was observed sitting on the bed, well groomed, and dressed appropriately. Resident 1 stated on the morning of 4/3/2024, he was exiting out of his room to go the outdoor patio, Resident 1 stated Housekeeper 1 verbally threatened Resident 1 using curse words and profanity. During an interview on 4/15/2024 at 2:15 PM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 4/3/2024 during the morning shift (7:00 AM- 3:30 PM), he heard a loud verbal altercation in the hallway. LVN 1 stated he went to the hallway and saw Resident 1 wheeling himself to the outside patio and saw Housekeeper 1 standing in the hallway. LVN 1 stated Housekeeper 1 stated that there was a verbal altercation between him and Resident 1. LVN 1 stated the verbal altercation between Resident 1 and Housekeeper 1 was not reported or documented. LVN 1 stated all staff were mandated to report alleged abuse immediately to the Administrator (ADM), ombudsman, and California Department of Public Health (CDPH). LVN 1 stated it was important to report alleged abuse timely, and to be investigated timely to prevent the incident from happening again and to ensure residents ' safety. During a telephone interview on 4/15/2024 at 3:38 PM with Housekeeper 1, Housekeeper 1 stated on 4/3/2024 during the morning shift (7:00 AM- 3:30 PM) around 8:30 AM, there was a verbal altercation with curse words and profanity between he and Resident 1. Housekeeper 1 stated he reported the incident to an unidentified certified nursing assistant (CNA), and his supervisor. Housekeeper 1 stated he was not aware he needed to report the incident to the ADM. During an interview on 4/15/2024 at 4:11 PM with the Director of Nursing (DON), the DON stated she was made aware of the verbal altercation between Housekeeper 1 and Resident 1 on 4/5/2024. The DON stated the ADM was made aware of the incident by Resident 1 , and the ADM reported immediately within two hours to the ombudsman, and (CDPH). The DON stated all alleged abuse must be reported immediately within two hours to the ADM, ombudsman, police, and CDPH per facility policy. The DON stated the verbal altercation between Housekeeper 1 and Resident 1 should have been reported immediately to the ADM, DON or change nurse. The DON stated facility staff failed to report the alleged verbal abuse timely. The DON stated was important to report abuse to ensure timely investigation and to prevent future abuse, and resident safety. During an interview on 4/15/2024 at 4:30 PM with Housekeeper 3, Housekeeper 3 stated on 4/3/2024 around 8: 30 am, he was in his office and heard yelling, screaming, and cursing in the hallway. Housekeeper 3 stated Resident 1 was yelling at Housekeeper 1 and Housekeeper 1 was cursing at Resident 1. Housekeeper 3 stated he report the incident to the Social Services Designee (SSD) on 4/3/2024, but not sure what was done after that. Housekeeper 3 stated all staff were responsible to report alleged abuse, verbal abuse, or any other types of abuse immediately to the ADM, and DON. Housekeeper 3 stated he should have reported the incident to the ADM, but he did not. During an interview on 4/15/024 at 4:40 PM with the ADM, the ADM stated he was made aware of the verbal altercation between Resident 1 and Housekeeper 1 on 4/5/2024 by Resident 1. The ADM stated he started the investigation right away and reported to the ombudsman, and CDPH within two hours. The ADM stated the facility staff should have reported the alleged verbal altercation immediately to him on 4/3/2024 so the incident could have been investigated timely but he was not aware until 4/5/2024. A review of facility's Policy and Procedure (P&P) titled, Reporting Abuse revised 1/8/2014, indicated facility staff will report known or suspected instances of abuse to the Administrator, or his/her designee. The P&P indicated facility staff members shall be notified that the Administrator, or his/her designee, has the responsibility, and that inquiries concerning resident abuse and reporting requirements should be referred to the Administrator, or his/her designee

Mar 2024 3 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure Resident 1 was being monitored for wandering (a person t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure Resident 1 was being monitored for wandering (a person that roams around and becomes lost or confused about their location) throughout the facility. 2. Ensure staff followed Resident 1's Care Plan (CP) titled Resident is an elopement risk/wanderer related to dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person ' s ability to perform everyday activities) with intervention requiring a sitter for constant monitoring for safety purposes. 3. Ensure staff followed Resident 1's CP titled Risk for harm, other directed behavior potentially causing harm (episodic). Resident 1 enters other residents rooms, takes, and moves their personal items. 4. Follow their policy and procedure (P&P), titled, Reporting Abuse, indicated the facility will ensure residents are free from physical harm. These deficient practices resulted in Resident 1 sustaining a hematoma (a bruise) under the right eye. During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect your thoughts, mood, and behavior), Type 2 diabetes mellitus ([DM] - a disease characterized by an impairment of the body's ability to control blood sugar levels), and dementia. During a review of Resident 1's History and Physical (H&P), dated 2/18/2024, the H&P indicated, Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] resident assessment and care screening tool), dated 2/18/2024, the MDS indicated, Resident 1 had wandering behavior. The MDS indicated, Resident 1 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene and upper body dressing (the ability to dress and undress above the waist), and lower body dressing (the ability to dress and undress below the waist). During a review of Resident 2's admission Record, the admission Record indicated, Resident 2 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including bipolar disorder (a mental illness that causes unusual shifts in a person ' s mood, energy, activity levels, and concentration), depression (feeling sadness and loss of interest), and chronic obstructive pulmonary disease ([COPD] - a group of lung disease conditions that causes breathing difficulties). During a review of Resident 2's History and Physical (H&P), dated 1/11/2024, 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] resident assessment and care screening tool), dated 3/4/2024, the MDS indicated, Resident 2 needs supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with oral hygiene and toileting hygiene. During a review of Resident 3's admission Record, the admission Record indicated, Resident 3 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses of Type 2 diabetes mellitus ([DM] - a disease characterized by an impairment of the body ' s ability to control blood sugar levels), end stage renal disease (a medical condition in which a person ' s kidneys cease functioning on a permanent basis leading to the need for a regular course of long term dialysis or a kidney (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) transplant to maintain life), and right eye blindness (lack of vision). During a review of Resident 3's History and Physical (H&P), dated 10/4/2023, the H&P indicated, Resident 3 had the capacity to understand and make decisions. During a review of Resident 1's Situation, Background, Assessment, and Recommendation form ([SBAR] a communication tool used by licensed staff after a resident has a change of condition), dated 3/13/2024 at 6:30 p.m., the SBAR indicated CNA 1 saw Resident 2 on his wheelchair hitting Resident 1 who was lying on the bed of Resident 2 with a wooden back scratcher. The SBAR indicated Resident 1 sustained a hematoma (bad bruise that happens when an injury causes blood to collect and pool under the skin) on the right eye. During a review of Resident 1's Wound Assessment, dated 3/13/2024, the Wound Assessment indicated Resident 2 had hematoma on right periorbital area (around the eye) with intervention to cleanse with normal saline, pat dry, leave open to air and apply cold compress thereafter. During a review of Resident 1's Psychiatric Evaluation, dated 2/21/2024, the Psychiatric Evaluation indicated Resident 2 had assigned sitter due to confused behavior, restless, agitation and unable to follow commands. During a review of Resident 1's CP, titled The resident is an elopement risk/wanderer related to dementia, dated 12/20/2023 and revised on 3/4/2024, with goal of resident ' s safety will be maintained through the review date. The CP intervention indicated the resident is capable of being redirected. She requires a sitter for constant monitoring. During a review of Resident 1's CP, titled Risk for harm-directed behavior potentially causing harm (episodic) she enters other resident ' s rooms and rummages through their belongings. This behavior puts her in harm ' s way, dated 3/10/2024 and revised on 3/13/2024, the CP intervention indicated if wandering or pacing, initiate visual supervision during acute episode. During a review of Resident 1's emergency room (ER General Acute Care Hospital (GAHC) report, dated 3/13/2024, the GAHC report indicated Resident 1 had a diagnosis of periorbital ecchymosis of right eye (bruising and discoloration around a person ' s eye). During an interview on 3/15/2024 at 12:03 p.m. with Resident 3, stated he remembers the incident that happened with Resident 1 and Resident 2. Resident 3 stated his roommate Resident 2 just came back from smoking patio and entered the room screaming and yelling and informing Resident 1 to get out of his bed and room. Resident 3 stated he heard Resident 1 telling Resident 2 to stop hitting her. Resident 3 stated definitely Resident 2 was hitting Resident 1 with something and then someone came and grab Resident 1 outside of the room. Resident 3 stated he is blind but can recognized the voice of Resident 1 because she screams a lot. Resident 3 stated that night Resident 1 came to their room twice. Resident 3 stated the nurse were aware of Resident 1 ' s behavior of going into their room but they don ' t do anything about it. During a phone interview 3/15/2024 at 12:38 p.m., with LVN 2, LVN 2 stated Resident 1 had a sitter assigned to her the morning shift on 3/13/2024 but no assigned sitter that night. LVN 2 stated he did not know the reason why Resident 1 had no sitter that evening. LVN 2 stated she was passing medication to other residents when the incident happened. LVN 2 stated the incident could had been avoided if the facility had provided a sitter that could keep an eye on Resident 1 whereabouts especially Resident 1 had a wandering behavior and goes to other residents room. During an interview on 3/15/2024 at 1:12 p.m., with LVN 1, LVN 1 stated the incident between Resident 1 and Resident 2 happened on 3/13/2024 at 6:30 p.m. and was witnessed by CNA 1. LVN 1 stated it was essential for Resident 1 to have a sitter so they can follow, monitor, and redirect her behavior. LVN 2 stated Resident 2 had an anxiety (is an emotion characterized by feelings of tension and worried thoughts) behavior and easily get agitated. LVN 2 stated there were a sitter provided to Resident 2 on 3/13/2024 day shift but not on evening shift. During an interview on 3/15/2024 at 2:10 p.m., with the Director of Nursing (DON), the DON stated the facility provides only a sitter to Resident 1 only if they have an extra nurse. DON stated sitter is responsible for monitoring resident to prevent accidents and to redirect residents behavior from wandering into other residents room. DON stated safety is the paramount goal of the facility to prevent any accident of residents. DON stated interventions for wandering residents includes redirection of behavior, 1:1 monitoring (staff that are immediately at hand can help prevent a fall or redirect a patient from engaging in a harmful act), and frequent visual checks monitoring. DON stated frequent visual checks meaning you have to check the resident more frequently like every hour. DON stated the facility did not provide visual monitoring for Resident 1 because the incident happened. DON stated it was the facility ' s responsibility to provide 1:1 monitoring for resident. DON stated when a resident was put on 1:1 monitoring, staff should observe resident, redirect resident and staff should be always with resident. DON stated constant monitoring means all the time (24 hours, 7 days a week). DON could not provide visual monitoring logs of Resident 1 ' s whereabouts. DON stated the facility must provide appropriate supervision to meet the needs of the residents. DON stated regardless of any situation, all residents have the right to be free from abuse. During an interview on 3/15/2024 at 2:45 p.m., with the Director of Staff Development (DSD), DSD stated she is responsible for assigning a sitter for Resident 1. DSD stated she provides only a sitter for Resident 1 only if necessary and to accommodate the staff who are on modified light duty (an offer of a work assignment made to an employee who is recovering from an injury, and who has received clearance from a physician to return to work with specific medical limitations). DSD stated a sitter was provided to Resident 2 on 3/13/2024 at day shift and no sitter provided at evening shift because there were no modified light duty staff available. During an interview on 3/15/2024 at 3:21 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she witnessed the incident of Resident 1 and 2. CNA 1 stated she was in other residents room, and she heard a voice coming from Resident 2 ' s room and she immediately responded. CNA 1 stated she saw Resident 2 sitting on his wheelchair inside his room and Resident 1 was lying on Resident 2's bed awake and yelling for help. CNA 1 stated she saw Resident 2 hitting Resident 1 on her right side of her face with a wooden back scratcher. CNA 1 stated she saw Resident 1 with a big bruise around her right eye and slight bleeding on her right side of the face. CNA 1 stated she put herself in front of Resident 2 to block him from further hitting Resident 1. During an interview on 3/15/2024 at 3:45 p.m., with the Administrator (ADM), the ADM stated he was informed about the incident that Resident 2 struck Resident 1 with a wooden back scratcher. ADM stated Resident 1 sustained a big bruise on her right eye and it was a big concern and was considered as major bodily injury. ADM stated the behavior of Resident 1 should had been redirected by the staff before she went to Resident 2 ' s room. ADM stated the facility failed to keep track of Resident 1 ' s whereabouts to prevent her from going to Resident 2 ' s room and it was unfortunate for Resident 1 got physically abused by Resident 2. During an interview on 3/18/2024 at 10:17 a.m., with Certified Nursing Assistant 2 (CNA 2), CNA 2 stated she was assigned to Resident 1 on 3/13/2024 at evening shift. CNA 2 stated she was busy feeding and passing dinner trays to other residents when the incident happened. CNA 2 stated Resident 1 had a behavior of screaming and yelling and it needs two staff to talk to her and was not easy to redirect her behavior. CNA 2 stated she had seen Resident 1 in the past going to Resident 2 ' s room but Resident 1 had a sitter that follows her. During an interview and concurrent record review on 3/18/2024 at 10:57 a.m., with the Minimum Data Set Nurse (MDS Nurse), the CP titled The resident is an elopement risk/wanderer related to dementia and Risk for harm-directed behavior potentially causing harm (episodic) she enters other resident ' s rooms and rummages through their belongings. This behavior puts her in harm ' s way, were reviewed. MDS Nurse stated the CP goal for Resident 1 for safety to be maintained were not met. MDS Nurse stated visual monitoring means to monitor resident every hour. MDS Nurse stated all nurses were responsible in visual monitoring. During an interview and concurrent record review on 3/18/2024 at 11:20 a.m. with the DON, the daily staff assignment sheet from 3/1/2024 to 3/14/2024 were reviewed. The DON stated the facility did not provide a sitter to Resident 1 on the following days: 3/1/2024 7-3 shift, 3-11 shift, 11-7 shift. 3/2/2024 3-11 shift and 11-7 shift. 3/3/2024 3-11 shift and 11-7 shift. 3/4/2024 3-11 shift and 11-7 shift. 3/5/2024 3-11 shift and 11-7 shift. 3/6/2024 7-3 shift, 3-11 shift, 11-7 shift. 3/7/2024 7-3 shift, 3-11 shift, 11-7 shift. 3/8/2024 3-11 shift and 11-7 shift. 3/9/2024 7-3 shift, 3-11 shift, 11-7 shift. 3/10/2024 11-7 shift 3/11/2024 3-11 shift and 11-7 shift. 3/12/2024 3-11 shift and 11-7 shift. 3/13/2024 3-11 shift 3/14/2024 7-3 shift and 11-7 shift. During an interview on 3/18/2024 at 1:50 p.m., with the ADM, the ADM stated there were lapse within that specific time period when Resident 1 entered Resident 2 ' s room. ADM stated there were some sorts of lack of supervision provided to Resident 1 in that period. ADM stated since Resident 1 sustained an injury, the facility did not prevent Resident 1 from physical abuse by Resident 2. ADM stated constant monitoring means to know where the resident at all the time to make sure she is safe. During a review of the facility's Policy and Procedure (P&P) titled, Reporting Abuse, dated 1/8/2014, the P&P indicated The facility will ensure that the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. During a review of the facility's P&P titled, Abuse-Prevention, Screening, and Training Program, dated 7/2018, the P&P indicated The facility conducts resident pre-admission, admission and ongoing assessments and care planning for appropriate interventions and monitoring of residents with needs and behaviors that might lead to conflict or neglect. During a review of the facility's undated P&P titled, Wandering and Elopement, the P&P indicated To enhance the safety of residents of the facility. During a review of the facility ' s P&P titled, Resident Rights-Quality of Life, dated 3/2017, the P&P indicated To ensure that each resident receives the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being, consistent with the resident ' s comprehensive assessment and plan of care. During a review of the facility ' s P&P titled, Resident Safety, dated 4/15/2021, the P&P indicated To provide a safe and hazard free environment. The IDT will establish a person-centered observation or monitoring systems for the resident to address the identified risk factors.

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

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled Abuse-Prevention, Screening, and Training Program, which indicated facility did not condone any form of resident abuse or neglect, for one of three sampled residents (Resident 1), after Resident 2 hit Resident 1. This deficient practice placed Resident 1 at risk for further abuse. Findings: a. A review of Resident 1's admission Record, indicated, Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnosis included schizoaffective disorder (a mental illness that affects person's thoughts, mood, and behavior), Type 2 diabetes mellitus ([DM] abnormal blood sugar), and dementia. A review of Resident 1's History and Physical (H&P), dated 2/18/2024, indicated, Resident 1 did not have the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set ([MDS] an assessment and care screening tool), dated 2/18/2024, indicated, Resident 1 had wandering behaviors. The MDS indicated, Resident 1 required partial or moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene and upper body dressing (the ability to dress and undress above the waist), and lower body dressing (the ability to dress and undress below the waist). A review of Resident 1's Situation, Background, Assessment, and Recommendation form ([SBAR] a communication tool used to communicate a resident's change of condition), dated 3/13/2024, at 6:30 p.m., indicated a Certified Nursing Assistant (CNA) 1 observed Resident 1 lying on Resident 2's bed and Resident 2 sitting on a wheelchair. The SBAR indicated CNA 1 observed Resident 2, hitting Resident 1 on the right eye with a wooden back scratcher. The SBAR also indicated Resident 1 sustained a hematoma on the right eye. b. A review of Resident 2's admission Record, indicated, Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included bipolar disorder (a mental illness that causes unusual shifts in a person ' s mood, energy, activity levels, and concentration), depression (feeling of sadness and loss of interest in daily activities). A review of Resident 2's H&P, dated 1/11/2024, indicated, Resident 2 had the capacity to understand and make decisions. A review of Resident 2's MDS dated [DATE], indicated, Resident 2 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with oral hygiene and toileting hygiene. During a review of Resident 1's Situation, Background, Assessment, and Recommendation form ([SBAR] a communication tool used by licensed staff after a resident has a change of condition), dated 3/13/2024 at 6:30 p.m., the SBAR indicated CNA 1 saw Resident 2 on his wheelchair hitting Resident 1 who was lying on the bed of Resident 2 with a wooden back scratcher. The SBAR indicated Resident 1 sustained a hematoma (bad bruise that happens when an injury causes blood to collect and pool under the skin) on the right eye. During an interview on 3/15/2024 at 2:10 p.m., with the Director of Nursing (DON), the DON stated she was fully aware of the incident between Resident 1 and Resident 2. The DON stated the facility did not condone any form of resident abuse and residents had the right to be free from abuse. During an interview and concurrent record review on 3/18/2024 at 1:50 p.m., with the Administrator (ADM), the facility's P&P titled, Abuse-Prevention, Screening, and Training Program, dated 7/2018 was reviewed. The ADM stated the facility did not follow and implement facility's P&P for abuse since Resident 1 sustained an injury and did not prevent Resident 1 from physical abuse by Resident 2.

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report within two (2) hours, resident to resident allegation of phy...

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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 within two (2) hours, resident to resident allegation of physical abuse (Resident 2 hitting Resident 1 on the face and right eye with a wooden back scratcher) to the Department of Public Health, Licensing and Certification unit (CDPH), for one of three sampled residents (Resident 1). This failure resulted in the delay of investigation by the Department of Public Health and placing Resident 1 at risk for further abuse and psychosocial harm. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated, Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including schizoaffective disorder (a mental illness that can affect your thoughts, mood, and behavior), Type 2 diabetes mellitus ([DM] - a disease characterized by an impairment of the body ' s ability to control blood sugar levels), and dementia (a decline in memory, language, problem-solving and other thinking skills that affect a person ' s ability to perform every day activities). During a review of Resident 1 ' s History and Physical (H&P), dated 2/18/2024, the H&P indicated, Resident 1 does not have the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS] resident assessment and care screening tool), dated 2/18/2024, the MDS indicated, Resident 1 had wandering (a person that roams around and becomes lost or confused about their location) behavior. The MDS indicated, Resident 1 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene and upper body dressing (the ability to dress and undress above the waist), and lower body dressing (the ability to dress and undress below the waist). During a review of Resident 2 ' s admission Record, the admission Record indicated, Resident 2 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including bipolar disorder (a mental illness that causes unusual shifts in a person ' s mood, energy, activity levels, and concentration), depression (feeling sadness and loss of interest), and chronic obstructive pulmonary disease ([COPD] - a group of lung disease conditions that causes breathing difficulties). During a review of Resident 2 ' s History and Physical (H&P), dated 1/11/2024, 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] resident assessment and care screening tool), dated 3/4/2024, the MDS indicated, Resident 2 needs supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with oral hygiene and toileting hygiene. During a review of Resident 1 ' s Situation, Background, Assessment, and Recommendation form ([SBAR] a communication tool used by licensed staff after a resident has a change of condition), dated 3/13/2024 at 6:30 p.m., the SBAR indicated CNA 1 saw Resident 2 on his wheelchair hitting Resident 1 who was lying on the bed of Resident 2 with a wooden back scratcher. The SBAR indicated Resident 1 sustained a hematoma (bad bruise that happens when an injury causes blood to collect and pool under the skin) on the right eye. During an interview on 3/15/2024 at 2:10 p.m., with the Director of Nursing (DON), the DON stated she was fully aware of the incident between Resident 1 and Resident 2. The DON stated based on her investigation and the report she received from the license nurses the allegation of physical abuse involving Resident 1 and Resident 2 occurred on 3/13/2024 at 6:30 p.m. The DON stated any allegation of abuse should be reported to the CDPH immediately within 2 hours. The DON stated it was important to report to the licensing agency so the department can conduct their own investigation and the risk of not immediately reporting any allegation of abuse would result in monetary fines. During a concurrent interview and record review on 3/15/2024 at 3:45 p.m., with the Administrator (ADM), the SOC 341 (a report for any suspected dependent adult/elder abuse) sent by ADM to CDPH online on 3/13/2024 at 9 p.m. were reviewed. The SOC 341 indicated CNA 1 witnessed Resident 2 hitting Resident 1. The ADM stated Resident 1 bruise on her right eye was a big concern and considered as serious bodily injury. The ADM stated he is the abuse coordinator and he prefers completing the SOC 341 and reporting to the licensing agency. The ADM stated it was a late reporting based on the fact that the incident happened on 3/13/2024 at 6:30 p.m. The ADM stated he made the online report to CDPH after 2 hours of the incident. The ADM stated it was essential to report to the licensing agency within 2 hours as required by law for the safety and well-being of all residents in the facility. During a review of the facility ' s policy and procedure (P&P) titled, Reporting Abuse, dated 1/8/2014, the P&P indicated, The facility will report known or suspected instances of physical abuse to the proper authorities by telephone or through a confidential internet reporting tool as required by state and federal regulations. If the reportable event results in serious bodily injury, a telephone report shall be made to the local law enforcement agency immediately and no later than two (2) hours of the observation, knowledge or suspicion of the physical abuse, in addition, a written report shall be made to the local Ombudsman (an agency who investigates, reports on, and helps settle complaints against the facility), The California Department of Public Health, and the local law enforcement agency within 2 hours of the observation, knowledge, or suspicion of the physical abuse.

Mar 2024 5 deficiencies

CONCERN (D)

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

Deficiency F0694 (Tag F0694)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Ensure a peripheral catheter ([IV], a thin tube in...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Ensure a peripheral catheter ([IV], a thin tube inserted into a vein for therapeutic purposes such as administration of medications, fluids and/or blood products) dressing was dated and kept clean for one of one sample resident (Resident 24). This deficient practice had the potential for the IV insertion site to develop an infection and/or hospitalization for Resident 24. Findings: During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 24's diagnoses included sepsis (a serious condition that happens when the body's immune system has an extreme response to an infection. The body's reaction causes damage to its own tissues and organs), hypoxemia (a low level of oxygen in the blood), and dementia (loss of the ability to think, remember, and reason to levels that affect daily life and activities). During a review of Resident 24's History and Physical (H&P), dated 2/29/2024, the H&P indicated Resident 24 had fluctuating capacity to understand and make decisions. During a review of Resident 24's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 3/5/2024, the MDS indicated Resident 24 comprehends (ability to think and reason) most conversation. The MDS indicated Resident 24 required partial assistance from staff for activities of daily living (ADLs) such as eating and was dependent on staff for toileting hygiene, showering, putting on and taking off footwear, and to roll left and right. During a review of Resident 24's physician's order dated 3/5/2024, MD orders indicated start date of 2/28/2024 for ceftriaxone (a medication used to treat certain infections) 1gram intravenously (the infusion of liquid substances directly into a vein) every 24 hours for infection until 3/1/2024. During a concurrent observation and interview on 3/5/2024 at 3:01 p.m. with RN 1 in Resident 24's room, Resident 24 had an IV where the dressing was soiled and not dated to the left forearm. RN 1 stated no, there is no date on the IV site. RN 1 stated the IV is also dirty with some kind of sauce on it. RN stated there the IV dressing should not be dirty. RN 1 stated as soon as IVs are placed you need to date and initial the dressing. RN 1 stated Resident 24's IV should have been removed after calling the physician, and as soon as the IV antibiotics were completed, which were four days ago. RN 1 stated there is risk to the resident for infection, or sepsis. During an interview on 3/8/2024 at 5:02 p.m. with Director of Nursing (DON), DON stated when IVs are inserted, the procedure is then documented in the resident's medical record. DON stated an IV needs to be dated, if not you would not know when it was placed. DON stated the IV insertion site is a point of entry for microorganisms. DON stated there is a risk if infection, pressure injury and irritation to the tape.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Ensure respiratory care consistent with professi...

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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 respiratory care consistent with professional standards of practice when two of three sampled residents Resident 21 and Resident's 24 oxygen (air) nasal cannula (a device used to deliver supplemental oxygen) tubing, and humidifier (liquid that moistens the air) bottle was not labeled with the date of change. These failures had the potential to result in unsafe use or storage of oxygen equipment, respiratory infection, and/or hospitalization for Resident 21 and Resident 24. 2. Ensure oxygen precaution sign was posted on the door for one of three sampled residents (Resident 21) who was receiving oxygen. This failure had the potential to place residents at risk of injury due to a fire hazard. Findings: During a review of Resident 21's admission Record, the admission Record indicated Resident 21 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 21's diagnoses included acute respiratory failure (a serious condition that makes it difficult to breathe on your own), chronic obstructive pulmonary disease (COPD, lung disease that causes blocked airflow from the lungs), and type 2 diabetes mellitus (abnormal blood sugar). During a review of Resident 21's History and Physical (H&P), dated 1/5/2024, the H&P indicated Resident 21 had the capacity to understand and make decisions. During a review of Resident 21's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 12/16/2023, the MDS indicated Resident 21 had clear cognition (ability to think and reason). The MDS indicated Resident 21 required set up assistance from staff for activities of daily living (ADLs) such as eating and was dependent on staff for personal hygiene, toileting hygiene, showering, putting on and taking off footwear, and to roll left and right. During a review of Resident 21's physician order summary report (MD orders), MD orders indicated Resident 21 had an active order dated 12/16/2023 for O2 t 2 liters/minute via nasal cannula. During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 24's diagnoses included sepsis (a serious condition that happens when the body's immune system has an extreme response to an infection. The body's reaction causes damage to its own tissues and organs), hypoxemia (a low level of oxygen in the blood), and dementia (loss of the ability to think, remember, and reason to levels that affect daily life and activities). During a review of Resident 24's H&P, dated 2/29/2024, the H&P indicated Resident 24 had fluctuating capacity to understand and make decisions. During a review of Resident 24's MDS, a standardized assessment and care planning tool), dated 3/5/2024, the MDS indicated Resident 24 comprehends (ability to think and reason) most conversation. The MDS indicated Resident 24 required partial assistance from staff for ADLs such as eating and was dependent on staff for toileting hygiene, showering, putting on and taking off footwear, and to roll left and right. During a concurrent observation and interview on 3/6/2024 at 9:15 a.m. with Licensed Vocational Nurse (LVN) 1 in Resident 21's room, oxygen tubing and humidifier was not dated with the change date. LVN 1 stated no, the oxygen was not dated. LVN 1 stated the oxygen tubing and humidifier should be dated with the date it was changed. LVN 1 stated this is an infection control issue, the tubing could get bacteria in it. LVN 1 stated the resident could potentially get an infection. During a subsequent concurrent observation and interview on 3/6/2024 at 9:15 a.m. with LVN 1 outside the door in Resident 21's room, signage indicating oxygen was running was not placed on the outside of room. LVN 1 stated no, there is not a sign showing oxygen is running. LVN 1 stated yes there should be a sign. LVN 1 stated the sign on the door is for protection, oxygen is flammable, anyone entering the room needs to know oxygen is running. During an interview on 3/6/2024 at 4:22 p.m. with LVN 3, LVN 3 stated oxygen tubing and humidifier are changed every Sunday and as needed. LVN 3 stated that it is labeled with the date and initials. LVN 3 stated if no dated, there is no way of knowing when it was last changed. LVN 3 stated it can potentially lead to residents getting an infection. During an interview on 3/8/2024 at 5:02 p.m. with Director of Nursing (DON), DON stated the oxygen tubing and humidifier should have the date on them when they are changed. The DON stated if not dated, there would be no way of knowing when it was last changed. The DON stated there is risk for infection to the resident. DON stated the signage for oxygen should be displayed outside the room. The DON stated this is for safety precautions, oxygen is flammable. DON stated no one entering rood would know oxygen is being used, that is a safety issue. During a review of the facility's policy and procedure (P&P) titled, Oxygen Therapy, dated November 2017, the P&P indicated, the humidifier and tubing should be changed no more than every 7 days and labeled with the date of change. No smoking signs will be prominently displayed wherever oxygen is being stored or administered.

CONCERN (D)

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

Deficiency F0710 (Tag F0710)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to: 1. Ensure there was a physician's order for oxygen (a...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to: 1. Ensure there was a physician's order for oxygen (air) therapy for one of three sampled residents (Resident 24). 2. Ensure there was a physician order for the placement, and assessment of a peripheral catheter ([IV], a thin tube inserted into a vein for therapeutic purposes such as administration of medications, fluids and/or blood products) for one of one sampled resident (Resident 24). These failures had the potential to result in unnecessary procedures and/or hospitalization for Resident 24. Findings: During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 24's diagnoses included sepsis (a serious condition that happens when the body's immune system has an extreme response to an infection. The body's reaction causes damage to its own tissues and organs), hypoxemia (a low level of oxygen in the blood), and dementia (loss of the ability to think, remember, and reason to levels that affect daily life and activities). During a review of Resident 24's History and Physical (H&P), dated 2/29/2024, the H&P indicated Resident 24 had fluctuating capacity to understand and make decisions. During a review of Resident 24's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 3/5/2024, the MDS indicated Resident 24 comprehends (ability to think and reason) most conversation. The MDS indicated Resident 24 required partial assistance from staff for activities of daily living (ADLs) such as eating and was dependent on staff for toileting hygiene, showering, putting on and taking off footwear, and to roll left and right. During a concurrent interview and record review on 3/6/2024 at 4:22 p.m. with Licensed Vocational Nurse (LVN) 3, Resident 24's medical records - physician orders were reviewed. LVN stated there is no oxygen order for Resident 24. LVN 3 stated it was an oversite on our part. LVN 3 stated yes, there needs to be a physician order for oxygen to be able to administer it. LVN 3 if oxygen is given, and it was not needed I can lead to respiratory distress or respiratory issues. LVN 3 stated the resident may be getting something not appropriate for them. During an interview on 3/8/2024 at 5:02 p.m. with Director of Nursing (DON), DON stated there should always be an order for oxygen. DON stated that if there is not an order and oxygen is given the resident could have respiratory problems. DON stated there can be a risk and the resident could potentially get over oxygenated and get sick. During a review of the facility's policy and procedure (P&P) titled, Oxygen Therapy, dated November 2017, the P&P indicated, Administer oxygen per physician orders. During a concurrent interview and record review on 3/5/2024 at 3:01 p.m. with Registered Nurse Supervisor (RN) 1, Resident 24's medical records- physician orders were reviewed. RN 1 stated no, there was not a physician order for IV placement. RN 1 stated that you cannot place an IV without a physician order it is an invasive procedure. RN 1 stated it is not working under your scope of practice. RN 1 further stated it is important to make sure resident is safe, to follow maintenance of the physician order. During an interview on 3/8/2024 at 5:02 p.m. with Director of Nursing (DON), DON stated no, there is no order for IV placement or assessment. DON stated you cannot put in an IV without a physician order, this is working out of our scope of practice. During a review of the facility's policy and procedure (P&P) titled, Physician Orders, dated August 21, 2020, the P&P indicated, Treatment orders will include the following: A description of the treatment - including the treatment site (if applicable). The frequency of the treatment and duration of order (when appropriate). The condition or diagnosis for which the treatment is ordered. Medication and treatment orders will be transcribed onto the appropriate resident administration record (e.g., medication administration record (MAR) or treatment administration record (TAR))

CONCERN (E)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure a care plan (the process of identifying a patient's need...

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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 a care plan (the process of identifying a patient's needs and facilitating holistic care and ensures collaboration among nurses, patients, and other healthcare providers) was formulated for three of 15 sampled residents (Residents 17, 24, 27 and 54). This deficient practice had the potential for the affected residents not to receive the care and services needed and the provision of a poor-quality care. Findings: a. During a review of Resident 17's admission record, the admission record indicated Resident 17 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses that included major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy), metabolic encephalopathy (a problem in the brain, when the imbalance affects the brain, it can lead to personality change), schizoaffective disorder (a mental disorder with symptoms of hallucinations or delusions and mood disorder like depression) and bipolar disorder (a mental illness characterized by extreme mood swings). During a review of Resident 17's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 2/15/2024, indicated the resident was assessed to have a severe cognitive impairment in daily decision making and required dependent assistance with transfer, dressing, and toilet use. b. During a review of Resident 27's admission record, the admission record indicated Resident 27 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy, muscle weakness (a decrease in muscle strength), Chronic Obstructive Pulmonary Disorder (A group of lung diseases that block airflow and make it difficult to breathe) and bipolar disorder. During a review of Resident 27's MDS, dated [DATE], indicated the resident was assessed to be cognitively intact in daily decision making and required moderate to maximum assistance with transferring, dressing, and toilet use. During a review of Resident 24's admission Record, the admission Record indicated Resident 24 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 24's diagnoses included sepsis (a serious condition that happens when the body's immune system has an extreme response to an infection. The body's reaction causes damage to its own tissues and organs), hypoxemia (a low level of oxygen in the blood), and dementia (loss of the ability to think, remember, and reason to levels that affect daily life and activities). During a review of Resident 24's History and Physical (H&P), dated 2/29/2024, the H&P indicated Resident 24 had fluctuating capacity to understand and make decisions. During a review of Resident 24's MDS, dated [DATE], the MDS indicated Resident 24 comprehends (ability to think and reason) most conversation. The MDS indicated Resident 24 required partial assistance from staff for activities of daily living (ADLs) such as eating and was dependent on staff for toileting hygiene, showering, putting on and taking off footwear, and to roll left and right. During a concurrent interview and record review on 3/6/2024 at 4:22 p.m. with Licensed Vocational Nurse (LVN) 3, Resident 24's medical records - care plans were reviewed. LVN 3 stated no, there is not a care plan for oxygen therapy. During a review of Resident 54's admission Record, the admission Record indicated Resident 54 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 54's diagnoses included major depressive disorder, metabolic encephalopathy, psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality.) and dementia. During a review of Resident 54's H&P, dated 11/6/2023, the H&P indicated Resident 54 had fluctuating capacity to understand and make decisions. During a review of Resident 54's MDS, dated [DATE], the MDS indicated Resident 54 comprehends most conversation. The MDS indicated Resident 54 required partial assistance from staff for ADLs such as toileting hygiene, showering, and upper body dressing, and rolling left to right.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observation, interview and record review, the facility failed to: 1. Ensure expired diced tomatoes and candy sprinkles discarded after expiration date. 2. Ensure produce, seasonings, milk, m...

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Based on observation, interview and record review, the facility failed to: 1. Ensure expired diced tomatoes and candy sprinkles discarded after expiration date. 2. Ensure produce, seasonings, milk, mocha mix, tomato sauce, lemon juice, mayonnaise, mustard, dressings, ice cream, shakes, frozen vegetables, and pasta were labeled with received date and use by date. 3. Ensure personal staff food items were not stored in the refrigerator and dry storage room. 4. Ensure the ice machine was clean. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization. Findings: During a concurrent observation and interview on 3/5/2024 at 8:15 a.m. with Dietary Supervisor (DS) 1 in the kitchen's: 1. Refrigerator 1, was produce that was not dated. DS 1 stated I didn't think it needed to be labeled. 2. Staff Seasoning was observed on a shelf. 3. Milk and mocha mix was opened without labels and dates. 4. Staff personal cake was in the kitchen refrigerator. 5. Open containers with tomato sauce, lemon juice, mayonnaise, mustard, dressings with no labels. 6. Expired diced tomatoes with a use by date of 3/4/2024. 7. A black thick substance was seen on the shoot in the ice machine. During a concurrent observation and interview on 3/8/2024 at 11:57 a.m. with the DS 1 in the dry storage room, staff food was in a bag on a cart and lasagna noodles not labeled was observed. DS 1 further stated, stated labeling is to make sure food is safe used after the use by date the residents can get sick. During an interview on 3/8/2024 at 12:08 p.m. with the Dishwasher (DW) 1, DW 1 stated no, you should not put your lunch in the storage area, refrigerator, or freezer. DW 1 stated that these areas are not staff food zone. DW stated staff food should not be in the kitchen refrigerator. During a review of the facility's policy and procedure (P&P) titled, Food Storage, dated July 25, 2019, the P&P indicated, Food items will be stored, thawed, and prepared in accordance with good sanitary practice. All items will be correctly labeled and dated. During a review of the facility's policy and procedure (P&P) titled, Ice Machine - Operation and Cleaning, dated October 1, 2014, the P&P indicated, The dietary staff will operate the ice machine according to the manufacturer's guidelines. The ice machine will be cleaned routinely. Sanitation of equipment: on no less than a monthly basis, remove the ice to wash the inside of the machine. Wash the inside of the machine using pot and pan washing solution and rinse well. Sanitize the inside of the machine using a sanitizing solution and a clean cloth. Allow the inside of the machine to air dry, then refill the machine with ice.

Feb 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its abuse policy and procedure (P&P) titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating to ensure an allegation of abuse was reported to the California Department of Public Health (CDPH) within two hours, for one of three sampled residents (Resident 1). This deficient practice resulted to the delay in the abuse (monies) investigation by the CDPH and placed Resident 1 at risk for continuous abuse at the facility. Findings: During a review of Resident 1's admission record, the admission record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Chronic Obstructive Pulmonary Disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe), Metabolic encephalopathy (an alteration in brain function caused by an underlying illness causing a chemical imbalance in the bloodstream), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). During a review of the Minimum Data Set (MDS - a standardized assessment and care planning tool), dated 1/16/2024, indicated Resident 1 was cognitively intact (process of acquiring knowledge and understanding through thought, experience, and the senses) in daily decision making and had the capacity to understand and make decisions for himself. Resident 1 required substantial assistance with putting on/taking off footwear, lower body dressing, and toilet use. During a review of Resident 1's physician orders, dated 1/13/2024, the physician orders indicated Resident 1 was able to go 'out on pass' (a planned and supervised leave for a few hours from a health care facility ordered by the patient's treating doctor as a part of the patient management plan) independently. During an interview on 2/28/2024 at 8:45 a.m., with Resident 1, Resident 1 stated he cashed a check in the amount of $2,500 on 2/22/2024. Resident 1 stated the facility's Activities Director (AD 1) escorted him to cash his check. Resident 1 stated the check he received and cashed was due to his brother passing away recently. Resident 1 stated the $2,500 was missing by 12:00pm on 2/23/2024. Resident 1 stated he kept the money in his bedside drawer, and no one knew the money was there except for staff members. Resident 1 stated he believed a staff member had taken the money and felt as if he lost another family member stating, I don't trust the staff anymore. During an interview on 2/28/2024 at 11:06 a.m., with Certified Nurse Assistant 1 (CNA 1), CNA 1 stated she was the nurse on 2/23/24 for Resident 1 from 3:00 p.m-11:00 p.m. CNA 1 stated she did not know Resident 1 left with the Activities Director (AD 1) on the evening of 2/23/24. CNA 1 stated she did not see Resident 1 with any money during her shift. CNA 1 stated she assisted Resident 1 to bed at 10:00 pm and finished her shift at 10:57 p.m. During an interview on 2/28/2024 at 11:50 a.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated although he did not work at Resident 1's nursing station, he overheard Resident 1 screaming and yelling about not being able to find his money on the morning of 2/23/24. LVN 1 stated he did not know the exact amount of the money Resident 1 was missing. LVN 1 stated if a resident is to receive any new clothing, money, or items while out on pass, the facility's protocol Is to have all items reported to a staff member upon returning so it can be documented on their inventory list. During an interview on 2/28/2024 at 12:30 p.m., with Activities Director 1 (AD 1), AD 1 stated he took Resident 1 out of the facility to cash a check on the evening of 2/15/24. AD 1 stated Resident 1 cashed a check across the street from the facility. AD 1 stated he did not know the amount of Resident 1's check. AD 1 stated upon returning to the facility, Resident 1 said he will not be reporting the money to the facility and told the AD 1 to not report any of his money to staff members also. AD 1 stated no other staff members knew he had taken Resident 1 to cash his check and did not document leaving the facility with Resident 1. AD 1 stated he did not report Resident 1's money to any staff members due to Resident 1 being alert and he told me not to tell anyone. That is my biggest regret: not telling anyone. He was very aggravated when I told him it may be best to inform the staff of the money. AD 1 stated the risk of not reporting funds to a staff member or resident's inventory could result in incidents like this. It appears as if a staff member could have stolen his money. During an interview on 2/28/2024 at 11:50 a.m., with Social Services Director 1 (SSD), SSD 1 stated if a resident has any missing property, it is to be reported so a Lost and Theft form can be completed. SSD stated if a resident has any money, it is placed in the Administrator's office due to not having a safe in the SSD office. SSD stated the protocol for resident's money is all incoming money should be reported to a nurse and SSD to be documented and safeguarded. SSD 1 stated No one knew he had any money except for the Activities Director who took him. It should have been reported. During an interview on 2/28/2024 at 2:00 p.m., with Administrator (Admin), Admin stated the protocol for residents with cash and valuables are to be reported to the charge nurse and SSD. Admin stated if a resident has over a few hundreds of dollars, residents are encouraged to keep it in a bank or the Administrator's office. Admin stated he was aware of Resident 1's missing money when Resident 1 told him about it. Admin stated he was aware that the Activities Director took Resident 1 to cash the $2,500 check. Admin stated, I do not plan to reimburse the resident, to be honest. A review of the facility's policy and procedure, titled Theft and Loss Policy dated 07/2017, indicated, Money and other valuables should be taken to the business office for safe keeping. The staff will strongly urge resident/resident representative that some valuables be taken home by the resident representative in which case these items are not to be listed on the resident inventory. and Upon the request of the resident/resident representative, the Maintenance Department provides for a secured area for the safekeeping of the resident's property. This may include the placement of a lock on the resident's bedside drawer or closet. The provision of a secured area is at the expense of the resident. The Facility does not cover any cost associated with this accommodation.

Dec 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

Deficiency F0637 (Tag F0637)

Could have caused harm · This affected 1 resident

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Set ([MDS] a standardized care assessment and care screening tool) significant change in status was completed within the required time frame for one of three sampled residents (Resident 3) This deficient practice had the potential to negatively affect the provision of necessary care and services. Findings: During a review of Residents 3 ' s Face Sheet (admission record), indicated Resident 3 was originally admitted to the facility on [DATE], with diagnoses that included muscle weakness, and dysphagia oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat). During a review of Resident 3 ' s Change of Condition Report dated 11/9/2023, it indicated Resident 3 was having aggressive behavior with complain of increasing pain. During a review of Residents 3 ' s Psychiatric Evaluation Team Assessment Form dated 11/9/2023 it indicated Resident 3 had violent behavior and was threatening to hurt the staff. During a review of Resident 3's most recent MDS dated [DATE], the MDS indicated Resident 3 usually had the ability to understand and be understood by others. The MDS indicated Resident 3 did not exhibited any physical behavioral symptoms directed toward others and he did not exhibit any behavioral symptoms toward others. During a review of Resident 3 ' s History and Physical (H/P) dated 11/15/2023, the H/P indicated Resident 3 had the capacity to make needs known but could not make medical decisions. During an interview with Reassessment Coordinator (RS) on 12/4/2023 at 3:50 p.m., RS stated the MDS should have been updated on 11/10/2022 since the behavioral incident occur prior to the assessment. RS stated the assessment should had been captured on the MDS to make an appropriate care plan and address the behavior. During a review of the facilities Change of Condition Notification (P/P) Revised 4/1/2015, indicated the purpose was to ensure residents, family, legal representatives, and physicians are informed of changes int the resident ' s condition in a timely manner. It further indicated that a new MDS assessment should be completed within 14 days if there was a significant change of 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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to develop a comprehensive person-centered plan of care...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to develop a comprehensive person-centered plan of care for three of twelve sampled residents (Resident 10, Resident 11, Resident 12) to monitor oxygen used via nasal cannula {(medical device that provides oxygen (colorless, odorless, tasteless gas essential to living organisms)}, whom had an order for continuous and as needed oxygen used. This deficient practice had the potential to decrease blood oxygen leading to possible re-hospitalization. Findings: a.During a review of Resident 10 ' s admission Record, the admission record indicated Resident 10 was admitted on [DATE] and readmitted on [DATE] with a diagnosis that included Chronic obstructive Pulmonary Disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs.), Acute Bronchitis (airways of the lungs swell and produce mucus in the lungs.), Congestive Heart Failure (heart muscle has become less able to contract over time or has a mechanical problem that limits its ability to fill with blood). During a review of Resident 10 ' s minimum data set ([MDS] a standardized care assessment and care screening tool), dated 10/14/2023, the MDS indicated Resident 10 ' s cognitive skills (thought process) was capable to understand and be understood by others. The MDS indicated Resident 10 required extensive assistance with activities of daily living such as dressing, toilet use, personal hygiene, supervision with bed mobility (how resident moves from lying to turning side to side). During a review of Resident 10 ' s physician orders dated 9/14/2023, the physician orders indicated Resident 10 had an order for Oxygen at 3l/min (liter per minute) via nasal cannula (NC), continuous to keep oxygen saturation above 94% diagnosis Congestive heart failure. During a review of Resident 10 ' s care plans dated 12/1/2023, there is no care plan indicating Resident 10 had an order for continuous oxygen used. During a concurrent observation and interview on 11/30/2023 at 2:00 p.m., in Resident 10's room. Resident 10 was laying on bed with head of the bed elevated. Observed Resident 10 with oxygen used 3l/min via NC. Resident 10 stated, I am okay, I do not feel shortness of breath. Resident 10 stated, I need to use the oxygen all the time. b.During a review of Resident 11 ' s admission Record, the admission record indicated Resident 11 was admitted on [DATE] and readmitted on [DATE] with a diagnosis that included Chronic obstructive Pulmonary Disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs.), Pneumonia (infection of one or both of the lungs caused by bacteria, viruses, or fungi), Morbid obesity (complex chronic condition in which a person has a body mass index of 40 or higher). During a review of Resident 11 ' s minimum data set ([MDS] a standardized care assessment and care screening tool), dated 9/15/2023, the MDS indicated Resident 11 ' s cognitive skills (thought process) was capable to understand and be understood by others. The MDS indicated Resident 11 required limited assistance with activities of daily living such as dressing, toilet use, personal hygiene, supervision with bed mobility (how resident moves from lying to turning side to side). During a review of Resident 11 ' s physician orders dated 8/18/2023, the physician orders indicated Resident 11 had an order for Oxygen at 2l/min via NC may titrate to keep oxygen saturation above 93% as needed. During a review of Resident 11 ' s care plans dated 12/1/2023, there is no care plan indicating Resident 11 had an order for a needed oxygen used. During a concurrent observation and interview on 12/1/2023 at 12;35 p.m., in Resident 11's room. Resident 11 was sitting on the side of the bed. Resident 11 with portable oxygen used on the side of the bed. Resident 11 in room air now. Resident 11stated, I am okay with my breathing. Resident 11 stated, I used the oxygen when I needed it. c. During a review of Resident 12 ' s admission Record, the admission record indicated Resident 12 was admitted on [DATE] and readmitted on [DATE] with a diagnosis that included Encephalopathy (Brain dysfunction can appear as confusion, memory loss, personality changes and/or coma in the most severe form), Atherosclerotic heart disease (is the buildup of fats, cholesterol and other substances in and on the artery walls), muscle weakness (commonly due to lack of exercise, ageing, muscle injury). During a review of Resident 12 ' s minimum data set ([MDS] a standardized care assessment and care screening tool), dated 10/10/2023, the MDS indicated Resident 12 ' s cognitive skills (thought process) was severely impaired to understand and be understood by others. The MDS indicated Resident 12 required substantial/maximal assistance with activities of daily living such as dressing, toilet use, personal hygiene, supervision with bed mobility (how resident moves from lying to turning side to side). During a review of Resident 12 ' s physician orders dated 9/24/2023, the physician orders indicated Resident 12 had an order for Oxygen at 2l/min via NC to keep oxygen saturation above 92% every shift for shortness of breath. During a review of Resident 12 ' s care plans dated 12/2/2023, there is no care plan indicating Resident 12 had an order for a needed oxygen used. During a concurrent observation and interview on 12/1/2023 at 1:00 p.m., in Resident 12's room. Resident 12 was laying on bed. Resident 12 with oxygen used 2l/min via NC. Resident 12 denies any complications with oxygen. During a concurrent record review and interview on 12/1/2023 at 2:30 p.m., with Licensed Vocational Nurses (LVN) 3, LVN 3 stated, care plans are done at admission and residents change of condition. LVN 3 stated, if a resident received an order for oxygen used it must be caring plan. LVN 3 stated, there is no care plan for Resident 10, Resident 11, and Resident 12. LVN 3 stated, the care plan is important because is our guide in monitor residents in oxygen. LVN 3 stated, the care plan interventions are developed for resident wellbeing. LVN 3 stated, if there is not a care plan to follow for resident ' s care, it can be in exacerbation or deterioration of condition because the care is not done. LVN 3 stated, the resident can be at risk of hospitalization and respiratory distress. During an interview on 12/1/2023 at 3:10 p.m., with Assistance Director of Nursing (ADON), ADON stated, when a resident comes from the hospital with oxygen, nurses must assess resident the used of oxygen. ADON stated if resident need oxygen used continuously or as needed it must be caring plan. ADON stated, care plan is a documentation done to resident conditions, problem, goal interventions and evaluation. ADON stated, all the nurses should be involved in the care plan. ADON stated, if we do not have a care plan it means the problem was not address and is no action taking to resolve the problem. ADON stated, Resident 10, 11 and 12 can be at risk of harm such as respiratory distress and hospitalization. During a review of the facility ' s policies and procedures (P&P) titled Comprehensive Person-Centered care Planning, dated 8/24/2023 the P&P indicated additional changes or updates to the resident ' s comprehensive care plan will be made based on the assessed needs of the resident. The comprehensive care plan will also be reviewed and revised at the following times: onset of new problems and change of 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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to provide knowledgeable treatment following profes...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to provide knowledgeable treatment following professional standards of practice by failing to: 1.Verbalized the amount of chest compression per minute for a Cardiopulmonary resuscitation (CPR) (emergency procedure consisting of chest compressions to manually preserve intact brain flow) and ambu bag (provide positive pressure ventilation to patients who are not breathing or not breathing adequately) used according to American Heart Association (AHA) recommendations of 100-120 chest compressions per minute 2. Following the facility policy and procedure to document assessments and interventions during a CPR provide to one of fourteen sampled residents (Resident 4) on [DATE] These deficient practices had the potential to negatively affect the delivery of care and services necessary for patient ' s occupant at the facility. Findings: a.During an interview on [DATE] at 1:40 p.m., with Certified Nurse Assistance (CNA) 4. CNA 4 stated, the crash card for CPR is at the front of the nurse station. CNA 4 stated, when a resident became unresponsive, the first thing is to assess for breathing and pulse and start CPR. CNA 4 stated, the chest compression is 20 compressions, to 5 breaths with the ambu bag. CNA 4 stated, I do not know how many compressions per minute and breaths I need to give using the ambu bag CNA 4 stated, it is important to know how to provide CPR because of resident safety. CNA 4 stated, knowing how to provide CPR, can save residents life. CNA 4 stated, nurses need to act fast and know what the amount of chest compression is to give while a code. During an interview on [DATE] at 3:02 p.m., with Assistance Director of Nursing (ADON) ADON stated, when resident gets unconscious, nurses ask resident for respond and check pulse and start CPR. ADON stated, the chest compressions are 30 to 2 oxygen pumps with the ambu bag. ADON stated, I am not sure of how many chest compressions per minute. ADON stated, it is 30 compression per minute, in total of 30 compression and 2 breath pumps. ADON stated, checking the AHA recommendations I found that that is 100 to 120 compressions per minute. ADON stated, it is vital to know how to provide CPR because it is residents life. ADON stated, if nurses are not knowledgeable on the CPR steps, residents can be at risk of dying, so nurses must know how to administrate CPR. During an observation and interview on [DATE] at 3:40 p.m., with CNA 7 CNA 7 stated, procedure of CPR is 30 compressions, and 2 breathing, heart rate is 60 to 100 beats per minute. CNA 7 stated, first, we check for resident respond and check the pulse and ask for help. CNA 7 demonstrate where the crash cart was and unknowledgeable on the position of the ambu bag. CNA 7 was unable to verbalize the breaths per minute when using the ambu bag. CNA 7 stated, I forgot how many breathings are in total CNA 7 stated, I remember the 30 compressions and 2 breaths, but I do not remember, how many compressions per minute. During an interview on [DATE] at 4:20 p.m., with Licensed Vocational Nurses (LVN) 8, LVN 8 stated, the steps in following a code first, assess the patient for consciousness, if not responds, I will cheek the pulse and started chest compressions. LVN 8 stated, the chest compressions are 30 compressions to 2 breaths. The heart rate is 60 to 100. LVN 8 stated I do not know many compressions; I need to do in one minute. During an observation and interview on [DATE] at 10:30 a.m., with ADON, ADON able to identify how to place the ambu-bag mask on resident when giving rescue breaths but when placing and holding the mask ADON held the mask from the bottom, cupping mask from the chin up. ADON states it would not be effective holding the ambu-bag in that manner because it does not give a good seal and it can cause air to scape losing oxygen being delivered to resident. ADON stated, normal heart rate for an adult is 60-80 beats per minute. ADON stated, giving 30 compressions per minute would not be effective to properly oxygenate a patient who is actively coding. b. During a review of Resident 4 ' s admission record, the admission record indicated Resident 4 was admitted on [DATE], with a diagnosis that included Chronic Obstructive Pulmonary Disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), Morbid obesity (complex chronic condition in which a person has a body mass index of 40 or higher) and diabetes (DM-high blood sugar). During a review of Resident 4 ' s history and physical (H&P) dated [DATE], the H&P indicated Resident 4 had fluctuating mental capacity to understand and make medical decisions. During a review of Resident 4 ' s minimum data set ([MDS] a standardized care assessment and care screening tool), dated [DATE], the MDS indicated Resident 4 ' s cognitive skills (thought process) was moderately impaired and could understand and be understood by others. The MDS indicated Resident 4 required some assistance with activities of daily living (ADL) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). During a review of Resident 4 ' s change in condition (COC) dated [DATE], the COC indicated, Resident 4 become unresponsive. The COC indicated Resident 4 was administrate immediately CPR and paramedics was called. During a review of Residents 4 CPR flowsheet on [DATE] at 10:30, there was not documentation indicating Resident 4 coding on [DATE]. During an interview on [DATE] at 4:20 p.m., with LVN 8, LVN 8 stated, the facility policy was for the nurses who have the patient to document the CPR flowsheet LVN 8 stated, I did not document anything of the code. LVN 8 stated, I just when home after 5:00 p.m. During an interview on [DATE] at 10:30 am with ADON, ADON stated, nurses did not do a code run sheet that day because they forgot. ADON stated, it is important to do a run sheet to ensure they documented all the interventions during the code that needed to be done to safe the residents life. DON stated, it is part of their policy to do a code sheet. During a review of the facility ' s policies and procedures (P&P) titled Cardiopulmonary Resuscitation, dated [DATE] the P&P indicated initiate CPR in accordance with AHA guidelines, continue CPR until the EMS arrives and assumes care of the resident. Utilize CPR flowsheet to record the events of the resident emergency. The P&P LVN staff Nurse Job Description undated, the P&P indicated initiates emergency procedures (including basic CPR) and provide emergency patient 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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to: 1. Ensure a Licensed Vocational Nurse (LVN) 1 had an active professional nursing license before the start of his employment orientation. 2...

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Based on interview and record review, the facility failed to: 1. Ensure a Licensed Vocational Nurse (LVN) 1 had an active professional nursing license before the start of his employment orientation. 2. Ensure a Licensed Vocational Nurse (LVN) 1 had a competency skill (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual need to perform work roles or occupational functions successfully) check prior to orientation or upon hire. 3. Ensure a Licensed Vocational Nurse (LVN) 1 did not sign the Individual Narcotic (a drug that in moderate doses dulls the senses, relieves pain, and induces profound sleep but in excessive doses causes stupor, coma, or convulsions) Record form without a valid professional nursing license. 4. Follow facility ' s Policies and Procedures of Pre-Employment Activities and Resources, Job Description Manual of LVN, Staff Competency Assessment and Facility Assessment Tool. For one of three randomly selected staff. This deficient practice had the potential for the facility not be able to assess the skills necessary to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident will not be performed within the acceptable standards of practice. Findings: During an interview on 11/21/2023 at 11:15 a.m. with LVN 1, LVN 1 stated he observed licensed nurses passing medication and had an orientation on the floor prior to getting his LVN license. During a concurrent interview and record review on 11/21/2023 at 11:20 a.m. with the Assistant Director of Nursing (ADON), Licensed/CNA (Certified Nursing Assistant)/RNA (Restorative Nursing Assistant) assignment sheet from October 15, 2023, to November 21, 2023, was reviewed. The Licensed/CNA/RNA assignment sheet indicated LVN 1 had an orientation on October 19, 2023 7-3 shift at station 2, October 20, 2023 7-3 shift at station 1, October 21, 2023 7-3 shift at station 1 as treatment nurse, October 22, 2023 3-11 shift at station 2, October 23, 2023 7-3 shift as treatment , October 24, 2023 7-3 shift as treatment, October 25, 2023 7-3 shift station 1, October 26, 2023 7-3 shift station 2, October 28, 2023 11-7 shift station 2, October 29, 2023 11-7 shift station 2, November 2, 2023 3-11 shift station 2, November 10, 2023 7-3 shift station 2, November 13, 2023 7-3 shift station 2, and November 17, 2023 7-3 shift station 2. ADON stated LVN 1 passed his National Council Licensure Examination for Practical Nurses (NCLEX), refers generally to one of the two standardized test nurses need to pass in order to become either a licensed practical nurse (LPN) or a registered nurse (RN), on October 6, 2023 and his LVN license was issued on November 13, 2023 by Board of Vocational Nursing Psychiatric Technicians, agency that regulates the education, practice and discipline of licensed vocational nurses (LVN) and psychiatric technicians (PT). ADON stated the facility hiring process for licensed nurse is to conduct background check and to verify the status of license if it is active or inactive. ADON stated she put LVN 1 on the orientation schedule as instructed by the DON (Director of Nursing) and Administrator (ADM) as a way of gratitude of LVN 1 long term service with the company. During a concurrent interview and record review on 11/21/2023 at 2:40 p.m. with ADON, Employee file of LVN 1 and Station 2 Individual Narcotic Record were reviewed. Station 2 Individual Narcotic Record for Resident 4 indicated on October 19, 2023, at 9 a.m. lorazepam (a drug used to treat anxiety) 1 mg was signed by LVN 1. ADON confirmed the signature of LVN 1 based on Medical Record Signature Log. Employee file of LVN 1 indicated his original hire date was October 28, 2019, as housekeeping supervisor. ADON stated LVN 1 had no competency check when he had an orientation and hired as an LVN on November 13, 2023. ADON stated the competency skills training should be done upon hire or prior to orientation, yearly or as needed. ADON stated it is important to have it done to make sure licensed staff can provide the standard of care and practice to all residents within the regulations, prevent malpractice and to give highest quality of care to all residents. ADON stated license nurse can ' t practice without an active license. During a concurrent interview and record review on 11/21/2023 at 3:26 p.m. with ADM. ADM acknowledged LVN 1 signature on the station 2 Individual Narcotic Record form on October 19, 2023, at 9 a.m. for Resident 4. ADM stated facility had a failure by putting LVN 1 on the orientation without a valid professional active nursing license. ADM stated LVN 1 should not administer and signed the Individual Narcotic Record since his LVN license was not active yet at that time. ADM stated facility did not follow their Pre-Employment Activities and Resources procedure and Facility Assessment Tool. During a review of facility ' s undated policy and procedure (P&P) titled, Pre-Employment Activities and Resources, the P&P indicated, After recruitment and candidate selections are complete, a job offer and other pre-employment activities must occur before formal orientation begins such as interview process, candidate selection process, pre-employment background and license/certificate verification process and employee health exam process. During a review of facility ' s policy and procedure (P&P) titled, Medication Administration nursing manual, revised January 1, 2012, the P&P indicated, Medications and treatments will be administered only by licensed medical or licensed nursing staff. During a review of facility ' s policy and procedure (P&P) titled, Staff Competency Assessment, revised March 17, 2022, the P&P indicated, the purpose of completing competency assessments is to determine knowledge and/or performance of assigned responsibilities based on standard of practice, policy and procedure and regulatory requirement. Competency assessments will be performed upon hire during the employee ' s 90-day employment period, annually, or anytime new equipment or a procedure is introduced and as needed. During a review of facility ' s Licensed Vocational Nurse Job Description, the LVN Job Description indicated must have a current nursing licensure in good standing with the State licensing board. During a review of facility ' s document titled Facility Assessment Tool (a tool for the facility to evaluate its resident population and identify the resources needed to provide necessary person-centered care and services the facility residents require), dated July 3, 2023, indicated Facility staff must be thoroughly educated on their responsibilities, general facility policies and procedures which are applicable to them. Their required licenses/certifications must be kept current and continuing educations requirements must be fulfilled. Staff must be able to pass an annual competency check and appropriate, educated as necessary.

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

Based on interview and record review, the facility failed to: 1. Ensure a Licensed Vocational Nurse (LVN) 1 had an active professional nursing license before the start of his employment orientation. 2...

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Based on interview and record review, the facility failed to: 1. Ensure a Licensed Vocational Nurse (LVN) 1 had an active professional nursing license before the start of his employment orientation. 2. Ensure a Licensed Vocational Nurse (LVN) 1 had a competency skill (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics in performing that an individual need to perform work roles or occupational functions successfully) check prior to orientation or upon hire. 3. Ensure a Licensed Vocational Nurse (LVN) 1 did not sign the Individual Narcotic (a drug that in moderate doses dulls the senses, relieves pain, and induces profound sleep but in excessive doses causes stupor, coma, or convulsions) Record form without a valid professional nursing license. 4. Follow facility ' s Policies and Procedures of Pre-Employment Activities and Resources, Job Description Manual of LVN, Staff Competency Assessment and Facility Assessment Tool. For one of three randomly selected staff. This deficient practice had the potential for the facility not be able to assess the skills necessary to assure resident safety and to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident will not be performed within the acceptable standards of practice. Findings: During an interview on 11/21/2023 at 11:15 a.m. with LVN 1, LVN 1 stated he observed licensed nurses passing medication and had an orientation on the floor prior to getting his LVN license. During a concurrent interview and record review on 11/21/2023 at 11:20 a.m. with the Assistant Director of Nursing (ADON), Licensed/CNA (Certified Nursing Assistant)/RNA (Restorative Nursing Assistant) assignment sheet from October 15, 2023, to November 21, 2023, was reviewed. The Licensed/CNA/RNA assignment sheet indicated LVN 1 had an orientation on October 19, 2023 7-3 shift at station 2, October 20, 2023 7-3 shift at station 1, October 21, 2023 7-3 shift at station 1 as treatment nurse, October 22, 2023 3-11 shift at station 2, October 23, 2023 7-3 shift as treatment , October 24, 2023 7-3 shift as treatment, October 25, 2023 7-3 shift station 1, October 26, 2023 7-3 shift station 2, October 28, 2023 11-7 shift station 2, October 29, 2023 11-7 shift station 2, November 2, 2023 3-11 shift station 2, November 10, 2023 7-3 shift station 2, November 13, 2023 7-3 shift station 2, and November 17, 2023 7-3 shift station 2. ADON stated LVN 1 passed his National Council Licensure Examination for Practical Nurses (NCLEX), refers generally to one of the two standardized test nurses need to pass in order to become either a licensed practical nurse (LPN) or a registered nurse (RN), on October 6, 2023 and his LVN license was issued on November 13, 2023 by Board of Vocational Nursing Psychiatric Technicians, agency that regulates the education, practice and discipline of licensed vocational nurses (LVN) and psychiatric technicians (PT). ADON stated the facility hiring process for licensed nurse is to conduct background check and to verify the status of license if it is active or inactive. ADON stated she put LVN 1 on the orientation schedule as instructed by the DON (Director of Nursing) and Administrator (ADM) as a way of gratitude of LVN 1 long term service with the company. During a concurrent interview and record review on 11/21/2023 at 2:40 p.m. with ADON, Employee file of LVN 1 and Station 2 Individual Narcotic Record were reviewed. Station 2 Individual Narcotic Record for Resident 4 indicated on October 19, 2023, at 9 a.m. lorazepam (a drug used to treat anxiety) 1 mg was signed by LVN 1. ADON confirmed the signature of LVN 1 based on Medical Record Signature Log. Employee file of LVN 1 indicated his original hire date was October 28, 2019, as housekeeping supervisor. ADON stated LVN 1 had no competency check when he had an orientation and hired as an LVN on November 13, 2023. ADON stated the competency skills training should be done upon hire or prior to orientation, yearly or as needed. ADON stated it is important to have it done to make sure licensed staff can provide the standard of care and practice to all residents within the regulations, prevent malpractice and to give highest quality of care to all residents. ADON stated license nurse can ' t practice without an active license. During a concurrent interview and record review on 11/21/2023 at 3:26 p.m. with ADM. ADM acknowledged LVN 1 signature on the station 2 Individual Narcotic Record form on October 19, 2023, at 9 a.m. for Resident 4. ADM stated facility had a failure by putting LVN 1 on the orientation without a valid professional active nursing license. ADM stated LVN 1 should not administer and signed the Individual Narcotic Record since his LVN license was not active yet at that time. ADM stated facility did not follow their Pre-Employment Activities and Resources procedure and Facility Assessment Tool. During a review of facility ' s undated policy and procedure (P&P) titled, Pre-Employment Activities and Resources, the P&P indicated, After recruitment and candidate selections are complete, a job offer and other pre-employment activities must occur before formal orientation begins such as interview process, candidate selection process, pre-employment background and license/certificate verification process and employee health exam process. During a review of facility ' s policy and procedure (P&P) titled, Medication Administration nursing manual, revised January 1, 2012, the P&P indicated, Medications and treatments will be administered only by licensed medical or licensed nursing staff. During a review of facility ' s policy and procedure (P&P) titled, Staff Competency Assessment, revised March 17, 2022, the P&P indicated, the purpose of completing competency assessments is to determine knowledge and/or performance of assigned responsibilities based on standard of practice, policy and procedure and regulatory requirement. Competency assessments will be performed upon hire during the employee ' s 90-day employment period, annually, or anytime new equipment or a procedure is introduced and as needed. During a review of facility ' s Licensed Vocational Nurse Job Description, the LVN Job Description indicated must have a current nursing licensure in good standing with the State licensing board. During a review of facility ' s document titled Facility Assessment Tool (a tool for the facility to evaluate its resident population and identify the resources needed to provide necessary person-centered care and services the facility residents require), dated July 3, 2023, indicated Facility staff must be thoroughly educated on their responsibilities, general facility policies and procedures which are applicable to them. Their required licenses/certifications must be kept current and continuing educations requirements must be fulfilled. Staff must be able to pass an annual competency check and appropriate, educated as necessary.

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

Deficiency F0655 (Tag F0655)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four sampled residents (Residents 3) had develop a ba...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four sampled residents (Residents 3) had develop a baseline care plan addressing vaginal bleeding. This deficient practice had the potential to negatively affect the delivery of nursing care and medical interventions to Residents 3. Findings: During a review of Resident 3 ' s admission Record (facesheet), dated 10/6/2023, the face sheet indicated Resident 3 was admitted to the facility on [DATE] with the diagnoses that include type 2 diabetes mellitus (abnormal blood sugar), abnormal uterine and vaginal bleeding, legal blindness, and schizoaffective disorder. During a review of Resident 3 ' s History and Physical (H&P), dated 8/20/2023, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3 ' s Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 8/25/2023, the MDS indicated Resident 3 required setup or clean-up assistance for personal hygiene, eating. Resident 2 required partial/moderate assistance with transfer, walk in corridor, dressing. During a concurrent interview and record review on 10/6/2023 at 3:50 p.m. with licensed Vocational Nurse (LVN) 2, Resident ' s 3 Care plan, dated 8/2023 was reviewed. LVN 2 stated there was no care plan developed addressing Resident 3 ' s vaginal bleeding. LVN 2 stated yes, a care plan should have been made for this diagnosis. LVN 2 stated that if a care plan is not developed it could be harmful to the resident, and they would not get the interventions they needed. During an interview on 10/6/2023 at 4:03 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated that care plans are important for treatment, it shows interventions goals and outcomes. LVN 3 stated If a care plan is not done it could jeopardize the treatment of a resident. During a concurrent interview and record review on 10/6/2023 at 4:13 p.m. with Director of Nursing (DON), Resident ' s 3 Care plan, 8/2023 was reviewed. DON stated there was no care plan on abnormal vaginal bleeding. DON stated a care plan for this diagnosis should have been created. DON stated that if a care plan is not created the resident could potentially miss getting treatment or interventions they need. During a review of the facility ' s policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated November 2018, the P&P indicated, To ensure that a comprehensive person-centered care plan is developed for each resident. the baseline care plan must reflect the resident ' s stated goals and objectives and include interventions that address his or her needs.

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its policy and procedure titled Abuse Reporting and Inves...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its policy and procedure titled Abuse Reporting and Investigations dated March 2018 by failing to submit a conclusion report of an alleged abuse investigation within five days for two of four sampled residents (Resident 1 and 2). This deficient practice had the potential to place the residents at risk for further abuse. Findings: During a review of Resident 1 ' s Face sheet (admission record) dated 1/30/2023, the face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including cerebral infarction (brain damage due to a loss of oxygen), repeated falls, and depression (mental illness characterized by persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities). During a review of Resident 1 ' s History and physical (H&P), dated 4/1/2022, 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 standardized assessment and care screening tool), dated 11/1/2022, the MDS indicated Resident 1 was able to understand and be understood by others. During a review of Resident 1 ' s and Resident 2 ' s Change of Condition (COC), dated 1/12/2023, the COC indicated Resident 1 had a physical altercation with Resident 2 outside, in the smoking patio on 1/12/2023. During a review of Resident 1 ' s Interdisciplinary Team notes (IDT), dated 1/18/2023, the IDT indicated the incident between Resident 1 and Resident 2 occurred on 1/12/2023 at 6:30 p.m. During a review of Resident 2 ' s face sheet dated 1/30/2023, the face sheet indicated Resident 2 was originally admitted on [DATE] and readmitted on [DATE]. Resident 2 ' s diagnosis included Parkinson ' s disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), chronic kidney disease (a gradual loss of kidney function), and dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning). During a review of Resident 2 ' s H&P, dated 11/11/2022, the H&P indicated Resident 2 did not have the capacity to understand and make decisions. During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 ' s ability to express ideas and wants was limited. The MDS indicated Resident 2 was able to comprehend most conversations. During an interview on 1/30/2023 at 1:50 p.m. with Resident 1, Resident 1 stated Resident 2 called Resident 1 a couple names and then Resident 1 hit Resident 2. Resident 1 stated nurses were in the smoking patio, and he told them what happened. Resident 1 stated the nurses assessed and separated them and he was interviewed the next day. During an interview on 1/30/2023 at 4:30 p.m., with the Administrator (Admin), the Admin stated he investigated the incident between Resident 1 and Resident 2 and sent in the initial report within two hours. The Admin stated Resident 1 was noncompliant with the smoke break schedule and Resident 2 followed Resident 1 out into the smoking patio. The Admin stated he spoke to the nurses involved and no staff witnessed the incident between the two residents because the occurrence happened between smoke breaks. The Admin stated he did not do the five day follow up report because he was under the impression that the initial report was the complete investigation since all the facts related to the abuse incident were investigated the day the incident happened. During a review of the facility ' s P&P titled, Abuse-Reporting & Investigations, dated 3/2018, the P&P indicated the administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey agency within five working days of the reported allegation.

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop an individualized plan of care for the use of Oxygen (O2) f...

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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 an individualized plan of care for the use of Oxygen (O2) for one of one sampled resident (Resident 1). This deficient practice had the potential to result in delayed or missed interventions to meet Resident 1 ' s oxygenation (addition of O2 to the body) needs. Findings: During a review of Residents 1 ' s Face Sheet (admission Record), the admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including acute respiratory failure with hypoxia (low O2 levels) and cognitive communication deficit (difficulty with thinking and how someone uses language). During a review of Resident 1's Minimum Data Set ([MDS], a standardized care assessment and care screening tool) dated 8/4/2022, the MDS indicated Resident 1 ' s cognitive (thought process) skills was moderately impaired. The MDS also indicated Resident 1 required limited (resident highly involved in activity; staff provide guided maneuvering of limbs) assistance for bed mobility, dressing, eating, toilet use and personal hygiene. During a review of Resident 1 ' s physician order dated 12/15/2022, the order indicated the resident should be administered O2 at 3 liters/minute via nasal canula (N/C, tube which delivers O2 to the resident) to keep O2 saturation [blood oxygen level]) at or above 92% as needed for shortness of breath. During a concurrent observation and interview on 12/29/2022 at 11:59 a.m. with Licensed Vocational Nurse (LVN 2), Resident 1 was observed with the O2 N/C dangling off the resident. LVN 2 stated the resident ' s O2 saturation was 87% and resident was refusing to keep the O2 on. Resident 1 agreed to place the O2 back on after several attempts and education by LVN 2. During a subsequent interview with LVN 2 on 12/29/2022 at 1:56 p.m. LVN 2 stated Resident 1 had an order to check the resident ' s oxygen level once a shift and to maintain her O2 saturation above 92%. LVN 2 stated the facility did not create a care plan for Resident 1 ' s use of O2 and address the resident ' s non-compliance to include frequent monitoring for the resident. During a review of the facilities Policy and Procedure (P&P) titled, Comprehensive Person-Centered Care Planning revised 11/2018, the P&P indicated the facility should provide person-centered, comprehensive and interdisciplinary care that reflected best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 2 and...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 2 and Resident 3) were treated with respect and dignity by: 1. Failing to ensure call light (device used to signal resident ' s need for assistance from facility staff) was within reach for Resident 2. 2. Failing to respond to Resident 3 ' s request for assistance to the restroom in a timely manner. These deficient practices resulted in Resident 2 feeling sad, angry and frustrated and had the potential to result in psychosocial harm and decline for Resident ' s 2 and 3. Findings: During a review of Residents 2 ' s Face Sheet (admission Record), the admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses including muscle weakness and abnormalities of gait (manner of walking) and mobility. During a review of Resident 2 ' s Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 12/23/2022, the MDS indicated Resident 2 had the ability to understand and be understood by others. The MDS also indicated the Resident required extensive assistance (resident involved in activity, staff provide weight-bearing support) for activities of daily living (ADL) including bed mobility, transfer, dressing, personal hygiene and was completely dependent on staff for eating and toilet use. During an observation and concurrent interview 12/22/2022 at 1:03 p.m. with Resident 2, Resident 2 was observed not being able to locate and reach his call light. Resident 2 stated it made him feel sad, angry and frustrated to not be able to use his call light for assistance. During a review of Residents 3 ' s admission record, the admission record indicated Resident 3 was admitted to the facility on [DATE] with diagnoses including repeated falls and legal blindness. During a review of Resident 3's MDS dated [DATE], the MDS indicated Resident 3 required extensive assistance for ADL ' s including bed mobility, transfer, walking, locomotion (moving from place to place), dressing, toilet use and personal hygiene. During a concurrent observation on 12/22/2022 at 1:20 p.m. with Licensed Vocational Nurse (LVN 1), Resident 3 ' s roommate (Resident 4) was yelling for help stating Resident 3 needed help to use the restroom. During an observation on 12/22/2022 at 1:35 p.m., Physical Therapist (PT) walked by Resident 3 ' s room and walked away without assisting the resident. During an observation on 12/22/2022 at 1:46 p.m., LVN 2 was notified that Resident 3 needed help to the restroom and the resident was not assisted by LVN 2. During a concurrent observation and interview on 12/22/2022 at 1:53 p.m. with Certified Nurse Assistant (CNA 2), CNA 2 was observed assisting Resident 3 to the restroom. CNA 2 stated she was busy with another resident and was not able to assist Resident 3. During an interview on 12/22/2022 at 1:53 p.m. with Receptionist (RP), RP stated she heard Resident 4 scream for help to assist Resident 3 and should have called someone to assist the resident however did not because she was waiting for the assigned CNA to be able to assist. During an interview on 12/22/2022 at 2:05 p.m. with LVN 2, LVN 2 stated he did not assist Resident 4 because was busy and should have looked for someone to assist the resident however did not. LVN 2 stated it was everyone ' s responsibility to assist the residents. During an interview on 12/29/2022 at 11:18 a.m. with Resident 3, Resident 3 stated most of the time she was left without assistance when she called for help. Resident 3 stated staff would tell her they are going to help her but then they would walk away and not return to help her. Resident 3 stated Resident 4 was trying to help her get assistance to the restroom, however felt the staff did not care. During an interview on 1/19/2023 at 1:20 p.m. with Assistant Director of Nursing (ADON), ADON stated staff should respond to resident ' s call for help immediately and if unable to help should notify the resident and get another staff to assist. ADON also stated failing to respond to resident ' s request for help affects the resident ' s emotional well-being and can lead to the resident feeling worthless. During a review of the facility ' s Policy and Procedure (P&P) titled, Communication - Call System revised 1/1/2012, the P&P indicated the facility would provide a call system to enable residents to alert the nursing staff from their rooms and toileting/bathing facilities. It also indicated nursing staff would answer call bells promptly, and in a courteous manner. During a review of the facility ' s undated P&P titled, Resident Rights, the P&P indicated staff should treat all residents with kindness, respect and dignity

Dec 2022 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

Quality of Care (Tag F0684)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide necessary care to a resident who was residing in the isolat...

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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 necessary care to a resident who was residing in the isolation area (an area that keeps residents with certain medical conditions separate from other people while they receive medical care) due to the corona virus ([COVID-19] deadly virus that easily spreads from person to person) for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure licensed nurses monitored (checked) Resident 1 ' s vital signs (measurementsof the body's most basic functions such as blood pressure [pressure of the circulating blood against the walls of the blood vessels], temperature [measurement of the heat inside the body], pulse (the rate at which the heart beats), respiration (breathing rate) and oxygen saturation (the measure of how much oxygen is traveling through your body) every four (4) hours for COVID-19 symptoms. 2. Ensure licensed nurses implemented Resident 1 ' s care plan titled At risk for COVID-19, dated 9/2/2022, to monitor (check) the resident ' s vital signs every 4 hours. These deficient practices resulted in Resident 1 becoming unresponsive and later expiring (dying) on 11/28/2022 at 11:50 a.m., at the facility, seven (7) hours after the last vital signs were checked on 11/28/2022 at 4:30 a.m. Findings: During a review of Resident 1 ' s Face Sheet (admission record), the face sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included dysphagia (difficulty swallowing), diabetes (abnormal blood sugar) and dementia (loss of memory, language, problem-solving and other thinking abilities). During a review of Resident 1 ' s care plan titled At risk for COVID-19 dated 9/2/22, the care plan interventions indicated staff will monitor Resident 1 for signs and symptoms of COVID-19 including respiratory rate, lung sounds, vital signs and oxygen saturation, every four (4) hours. During a review of Resident 1 ' s history and physical (H/P) dated 10/21/2022, the H/P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized assessment and care-screening tool) dated 11/11/2022, the MDS indicated, Resident 1 had the ability to understand and be understood by others usually. The MDS indicated Resident 1 required limited assistance (the resident was highly involved in activity, staff provided guided maneuvering of limbs or other non-weight bearing assistance) for bed mobility. The MDS indicated, Resident 1 required extensive assistance (the resident was involved in activity, staff provided weight bearing support) for transfer, dressing, toilet use, and locomotion (moving between locations). During a review of Resident 1 ' s physician order dated 11/25/2022, the physician order indicated monitor the resident ' s temperature, pulse, respiration, blood pressure, and oxygen saturation every 4 hours for COVID-19 screening/monitor for 10 days. During an interview on 12/2/2022, at 2:08 p.m., Certified Nurse Assistant (CNA) 2 stated on 11/28/2022 Resident 1 expired in the morning. CNA 2 stated she (CNA 2) attempted to feed Resident 1 breakfast (morning), but the resident only ate three bites of food and refused to eat more. CNA 2 stated, the facility had so many staffing problems and she sometimes worked in the isolation area (designated area for COVID-19 positive residents) without a designated licensed nurse. CNA 2 stated licensed nurses were responsible for checking the residents ' vital signs. During an interview on 12/12/2022 at 1:20 p. m., Licensed Vocational Nurse (LVN) 1 stated on 11/28/2022(during the day shift, 7a.m to 3p.m. shift), the facility called her (LVN 1) to work because the assigned LVN called off (did not report to work). LVN 1 stated, she clocked in to work at 10:30 a.m., (on 11/28/2022), went to Resident 1 ' s room at approximately 10:50 a.m., and found the resident unresponsive. LVN 1 stated, she verified Resident 1 ' s code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) in his chart and started cardiopulmonary resuscitation ([CPR] aprocedure designed to restore normal breathing after a person ' s heart stops beating) while another staff called 911(a telephone number used to contact the emergency services). During an interview on 12/12/2022 at 1:20 p.m., LVN 1 stated, she did not know which licensed nurse was assigned to Resident 1 before her shift that started at 10:30a.m. (on 11/28/2022). LVN 1 stated CNA 2 was assigned to Resident 1 but CNA 2 left the faciity on [DATE] at approximately10:30 a.m., before the end of her shift because she was sick. LVN 1 stated she did not receive report from anyone about Resident 1 prior to starting her shift. LVN 1 also stated licensed nurses were responsible for checking residents ' vital signs every 4 hours in the isolation area. During an interview on 12/12/2022 at 2:10 p.m., with the Director of Staff Development (DSD), the DSD stated, Resident 1 was diagnosed with COVID-19 on 11/25/2022. The DSD stated vital signs for all COVID-19 positive residents in the isolation area (designated area for COVID-19 positive residents) were supposed to be checked by the licensed nurses every four hours. During a concurrent interview and record review of Resident 1 ' s Medication Administration Record (MAR) dated November 2022 on 12/12/2022 at 2:30 p. m., with the Infection Preventionist (IP) the IP stated the MAR indicated, to monitor Resident 1 ' s vital signs such as temperature, pulse, respirations, and oxygen saturation every 4 hours. The IP stated Resident 1 ' s vital signs were not taken and not recorded on 11/28/22 at 8 a. m., when they (licensed nurses) were supposed to have been taken. The IP stated according to the MAR, Resident 1 ' s vital signs were last taken was on 11/28/2022 at 4:30 a.m. and again at 11:30a.m., (7 hours later), when the resident was found unresponsive. During an interview on 12/20/2022 at 9:15 a. m., the DSD stated on 11/28/2022 the assigned LVN called off and LVN 4 was supposed to monitor residents in the isolation area, until LVN 1 arrived at the facility. During an interview on 12/21/2022 at 9:50 a. m., LVN 4 stated, when Resident 1 expired in the facility on 11/28/2022 (at 11:50 a.m.), he (LVN 4) was working in Station 1 and Resident 1 was in Station 2 (non-isolation area). LVN 4 stated, he did not take care of Resident 1 and did not check the resident ' s vital signs at any point on 11/28/2022. During an interview on 12/27/2022 at 2pm, the IP stated it was important to monitor Resident 1 ' s vital signs every 4 hours. The IP stated if Resident 1 ' s vital signs were checked every 4 hours, nurses could have intervened promptly on 11/28/2022 at 11:30a.m., when the resident was found unresponsive. During a review of the facility ' s policy and procedure (P&P) titled Obtaining Vital Signs, dated 8/22/2019, the P &P indicated vital signs will be taken as ordered by the physician, and before giving medication or treatments when there were conditional parameters of administration. During a review of the facility ' s infection control P&P for mitigating COVID-19, with a revision date of 10/8/2022, the P&P indicated resident ' s positive for COVID-19 with or without symptoms will be isolated (separating residents with a contagious disease from people who are not sick) and their vital signs taken and recorded in the resident ' s clinical record every 4 hours, the resident will be observed for worsening or improvement of symptoms of COVID-19.

Dec 2022 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for o...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for one out of three sampled residents (Resident 2). Resident 2 who was exposed to COVID-19 (a deadly virus that easily spreads from person to person). This deficient practice had the potential to result in Resident 2 not being monitored for COVID-19 signs and symptoms and delayed COVID-19 interventions. Findings: During a review of Resident 2 ' s admission record (Face Sheet), the face sheet indicated Resident 2 was admitted to the facility on [DATE]. Resident 2 ' s diagnosis included major depression (mood disorder that causes a persistent feeling of sadness and loss of interest with daily activities), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear) and essential hypertension ([HTN] high blood pressure). During a review of Resident 2 medical records, the Initial History and Physical dated 8/26/22, indicated Resident 2 had fluctuating capacity to understand and make decisions. During a review of Resident 2 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 9/2/2022, the MDS indicated Resident 2 was able to understand and be understood by others. The MDS indicated Resident 2 required oversight, encouragement or cueing with dressing, toilet use and personal hygiene. During a review of Resident 2 ' s Change of Condition ([COC] an internal communication tool) dated 11/12/2022, the COC indicated Resident 2 roommate tested positive for covid-19. During a review of Resident 2 ' s progress notes dated 11/17/2022 and timed 8:57 a.m., the notes indicated Resident 2 required monitoring for skilled nursing services for management of medically complex conditions related to Covid19. During a record review on 11/16/22, at 2:25 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 was unable to find a care plan for Resident 2 about the exposure to Covid-19. During an interview on 10/16/20222, at 2:36 p.m., with LVN 3, LVN 3 stated the care plan was developed to reflect the condition of the residents. LVN 3 stated the care plans included the resident's problem, goal, interventions, and evaluations based on Resident ' s diagnosis. LVN 3 stated the care plan was a plan created for the resident to help the nurses evaluate the problem and monitor the effectiveness of the interventions. LVN 3 stated the licensed nurses were responsible for the development of a personalized resident care plan. LVN 3 stated not developing a care plan for Resident 2 could result in resident 2 not receiving the proper interventions. LVN 3 stated Resident 2 was in yellow zone (area in the facility to house residents who are under investigation for COVID-19) and should have had a care plan developed for the COVID-19 exposure. During an interview on 11/17/2022, at 12:34 p.m., with Registered Nurse Supervisor (RN), RN stated when there was a new problem or diagnosis with residents, nurses developed a care of plan and created interventions to help improved the resident's outcome. RN stated the care plan was important to communicate to the licensed nurses what needed to be done for the resident. The RN stated Resident 2 should have had a care plan with interventions developed to ensure the nurses knew how to provide care for Resident 2. RN stated not having a care plan cold result on the staff not knowing of what and how to monitor Resident 2. During a review of the facility ' s policy and procedure (P/P) titled, LVN Staff Nurse Job Description undated, indicated LVNs assisted in developing, reviewing, revision, and updating the residents plan of care. The P/P indicated the LVNs contributed to the evaluation to the patient ' s progress towards specific goals and the adjustment of nursing plan of care as necessary. During a review of the P/P titled, Comprehensive Person-Centered Care Planning dated 11/2018, indicated a purpose to ensure that a comprehensive person centered care plan was developed for each resident. The P/P indicated the facility would provide person-centered, comprehensive, and interdisciplinary care that reflected best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial wellbeing.

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's d...

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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 in a manner that maintained or enhanced a resident's dignity and respect for one (1) out of four sampled residents (Resident 2). This failure had the potential to negatively affect Resident 2's self-worth and dignity, and cause skin breakdown. Findings: During a review of Resident 2 ' s admission record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included 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), heart failure (heart doe not pump enough blood for your body's needs), muscle weakness, chronic pain syndrome (pain lasting longer than three months), left and right artificial knee joint, and unspecified artificial hip joint. During a review of Resident 2 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool), indicated Resident 2 had the capacity to be understood and to understand others. The MDS indicated Resident 2 required extensive assistance from staff members with transfer, locomotion on and off the unit, toilet use, personal hygiene, and bathing. The MDS indicated Resident 2 had impairment on one side of the upper extremities (the part of the body that includes the arm, wrist, and hand) and both sides on the lower extremities (the part of the body that includes the leg, ankle, and foot). The MDS indicated Resident 2 also used a wheelchair to help with mobility. During an interview with Resident 2 on 10/27/2022, at 2:07 p.m., Resident 2 stated Certified Nurse Assistants (CNA) did not attended to her needs. Resident 2 stated the CNAs took their time to answer the call light. Resident 2 stated she had to wait and stayed dirty for a while and she felt like she was not treated with respect or dignity. During an interview with CNA 1, on 10/27/2022, at 3:32 p.m., CNA 1 stated Resident 2 was a total care and sometimes it took two to three people to help Resident 2 . CNA 1 stated was important to answer the call lights and attend to the resident ' s needs, the resident could get mad if we did not answered the call lights in a timely matter. During an interview with CNA 2, on 10/27/2022, at 3:38 p.m., with CNA 2 stated that it is important to answer call lights because that is that way that residents can communicate with staff, the residents can be calling for an emergency, so it is important to answer them promptly and attend to their needs. During an interview with the Director of Nursing (DON) on 10/27/2022 at 4:25 p.m., the DON stated it is important for staff to answer the call lights, residents can become anxious and upset if the call lights aren ' t answered in a timely matter. The DON stated that she would be upset also if my needs were not being met. During a review of the facility ' s policy and procedure (P/P) titled Resident Rights and revised on January 1, 2012, the P/P indicated that employees are to treat all residents with kindness, respect and dignity and honor the exercise of the residents ' rights.

Dec 2021 16 deficiencies

CONCERN (D)

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

Comprehensive Assessments (Tag F0636)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the PASAAR assessment information for one of 16 sample resid...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the PASAAR assessment information for one of 16 sample residents (Resident 45) was included in the MDS assessment. Therefore, the MDS assessment was not complete and accurate. This deficient practice had the potential to result in Resident 45 being inappropriately treated at the facility, and not receiving the needed personalized care and services to improve health. Findings: A review of Resident 45's admission Record indicated Resident 45 was admitted to the facility on [DATE]. Resident 45's diagnosis included metabolic encephalopathy (problem in the brain that may lead to personality changes), bipolar disorder (a mental condition marked by alternating periods of happiness). A review of Resident 45's History and Physical (H/P) dated, 7/30/2021, indicated the resident did not have the capacity to understand and make medical decisions. A review of Resident 45's History and Physical (H/P) dated, 7/30/2021, indicated the resident did not have the capacity to understand and make medical decisions. A review of Resident 45's Minimum Data Set (MDS) a resident assessment and care screening planning tool, dated 10/18/2021, indicated Resident 44 was able to make needs known and understood others. The MDS indicated Resident 44 resident was unable to recall year, month, and day of the week. Resident was also unable to recall words. A review of Resident 45's Letter from the Department of Health Care Services dated, 7/28/2021, indicated the resident was Positive Level I screening, indicating a Level II Mental Health Evaluation required. The letter stated, Once the level II Mental Health Evaluation was completed, she would receive a report that would provide recommendations for specialized services. During an interview with Minimum Data Set Nurse (MDS) on 12/2/2021, at 1:17 p.m., MDS stated, they were supposed to enter and update the MDS assessment sheet to include the PASSAR II information dated 7/28/2021, but they did not. Furthermore, the MDS stated she did not know the importance of including PASSAR II in the MDS assessment tool. The facility's undated Policy titled Medicare/MDS Coordinator Job Description, indicated its purpose was to: 1. Under the supervision of the Director of Nursing Services, the Medicare/MDS Coordinator is responsible for MDS assessment completion in accordance with State and Federal Law. 2. Ensures all documentation is maintained as required by Federal and State regulations and Company Policy. 3. Provide resident assessments that accurately depict and identify resident-specific issues and objective as required, while meeting state and federal guidelines and data submission requirements.

CONCERN (D)

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to conduct follow-up on the status of the PASSAR Level II recommendati...

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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 follow-up on the status of the PASSAR Level II recommendations for one of 16 sampled residents (Resident 45), to ensure the recommendations were included in the resident's assessment and care plan. This deficient practice had the potential to result in Resident 45 being inappropriately treated at the facility, and not receiving the needed personalized care and services to improve her health. Findings: A review of Resident 45's admission record indicated Resident 45 was admitted to the facility on [DATE], with diagnoses that included metabolic encephalopathy (problem in the brain that may lead to personality changes), bipolar disorder (a mental condition marked by alternating periods of happiness). A review of Resident 45's history and physical dated, 7/30/2021, indicated the resident did not have the capacity to understand and make medical decisions. A review of Resident 45's Minimum Data Set (MDS) a resident assessment and care screening planning tool, dated 10/18/2021, indicated Resident 44 was able to make needs known and understood others, was unable to recall year, month, and day of the week and was unable to recall words. A review of Resident 45's Letter from Department of Health Care Services dated, 7/28/2021, indicated Resident 45 was Positive for a Level I screen, which indicated a Level II Mental Health Evaluation (Level II mental illness evaluation is an in-depth psychosocial evaluation of the individual. A Level II mental illness evaluation is required when the individual is identified with a suspected or diagnosed mental illness on the Level I Screening) was required. The letter stated, once the level II Mental Health Evaluation was completed, the facility would receive a report that would provide recommendations for specialized services for Resident 45. During an interview with the Director of Nursing (DON) on 12/1/2021, at 2:34 p.m., the DON stated, they did not follow up on the PASSAR II, and they do not document the status of the evaluation after a resident is tested positive on PASSAR II. During an interview with Social Services (SS) on 12/1/2021, at 2:43 p.m., Social Services stated, they do not follow up on PASSAR II and she did not think there would be a problem if the PASSAR II evaluation was not done. There was no documentation to indicate the facility staff followed up or incorporated the Level II determination and recommendations into the resident's assessment and care plan.

CONCERN (D)

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

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a preadmission screening assessment was done for one of...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a preadmission screening assessment was done for one of four sampled residents (Resident 14), who was diagnosed with a mental illness, prior to admission to the facility. This deficient practice had the potential to result in Resident 14 to not receive the necessary and appropriate psychiatric level of treatment and evaluation in the facility. Findings: A review of the admission record indicated Resident 14 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included schizoaffective (chronic mental condition characterized by hallucinations [sensations that are not real] and delusion [false belief]), psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions) and major depressive disorder (persistent feeling of sadness and loss of interest). The Preadmission Screening and Resident Review (PASRR) is a State required assessment to ensure that every person entering a Medicaid certified Nursing Facility (NF) receives a Level I screen, and if necessary, a Level II evaluation to ensure their Nursing Facility (NF) residence is appropriate and to identify what specialized services a resident may need. During a concurrent interview and record review with the Director of Nursing (DON) on 11/30/21 at 2:57 p.m., the DON stated she is the facility's PASARR coordinator. The DON stated Resident 45 was negative for a Level I, assessment dated [DATE], because he did not have mental problems. This Surveyor pointed out to the DON a physician's order to administer Seroquel for Schizoaffective diagnosis. The DON then made changes to the Level I PASARR which triggered the required Level II mental health evaluation. During an interview with the DON on 12/01/21 at 02:09 p.m., DON stated PASARR screening is done before admission. The admission coordinator does the initial part of the screening and the DON will assess the clinical part of the PASARR screening. The DON stated she based the answers on the records that the admission coordinator had provided her. The DON verbalized that she had missed the Schizophrenia diagnosis on the diagnosis list, and it was looked over upon PASARR screening. DON stated she can correct the PASRR right away if a mistake is identified after reassessing the resident. DON stated complete initial assessment is important to give the proper help the residents need. The facility's policy and procedure titled Pre-admission Screening Resident Review (PASRR) revised on July 2018, indicated to ensure that all Facility applicants are screened for mental illness and intellectual disability (ID) or a related condition (RC) prior to admission.

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 5 sampled residents (Resident 41), had ...

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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 5 sampled residents (Resident 41), had a comprehensive and resident-centered care plan developed with the interdisciplinary team and implemented for cast care. This deficient practice had the potential to put the resident at risk for complications such as skin infection, numbness or tingling in the affected limb, increased pain or swelling, weakness with movements, cold & pale skin with a bluish tinge, pressure sore, or compartment syndrome (a painful and dangerous condition caused by pressure build up from internal bleeding or swelling of tissues). Findings: During a review of Resident 41's admission record indicated Resident 41 was admitted to the facility on [DATE]. Resident 41's diagnosis includes Type II Diabetes Mellitus (a long-lasting health condition that affects how your body turns food into energy), Hemiplegia (paralysis on one side of the body following cerebral infarction (a blockage or narrowing in the arteries supplying blood and oxygen to the brain), metabolic encephalopathy (damage or disease that affects the brain leading to confusion and not acting like you usually do), and repeated falls. During a review of Resident 41's history and physical completed on October 1, 2021 indicated, Resident 41 was recently hospitalized due to generalized weakness with a fall out of bed. During a review of Resident 41's MD indicated memory is severely damaged. During a concurrent observation and interview on December 2, 2021, at 09:46 AM, with Licensed Vocational Nurse (LVN 1) charge nurse, states, The importance of doing circulation checks for a resident that has a cast on is to check to make sure the circulation is not being impeded by swelling and also capillary refill, pain, skin, movement of fingers, pulses, and pain must be checked. The circulation checks should be checked every shift and as needed. That is the standard of practice. No, I do not see any circulation checks documented for Resident 41. During a concurrent observation and interview on 12/02/21, at 10:02 AM, with LVN 2 charge nurse, states, I'm unable to find where the assessments for her wrist is documented. For a resident with a cast, it is important to assess for odor, pain, skin, numbness and infection. During a review of the facility's policy and procedure titled, Cast Care (January 1, 2012), indicated, Cast care is provided to enhance resident healing and prevent complications secondary to restricted mobility. Procedure II. Inspect casted extremity every shift for first 48 hours, then every day, for adequate circulation. II. A. Check extremity for swelling coldness, blanching, and excessive pain, and/or odor or drainage on cast. During a review of the facility's policy and procedure titled, Comprehensive Person-Centered Care Planning (November 2018), indicated, III. D. If the comprehensive assessment and comprehensive care plan identified a change in the resident's goals, or physical, mental, or psychosocial functioning, which was not previously identified on the problem specific care plan used for the baseline care plan, those changes must be updated on each specific care plan used and incorporated, as applicable, into the initial and/or updated baseline care plan summaries.

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of one certified nurse assistants (CNA 5) d...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of one certified nurse assistants (CNA 5) did not work outside of her scope of practice, by turning off the feeding tube of Resident 33, which was only to be turned off by a licensed nurse in accordance with the facility's policy. This deficient practice had the potential to result in Resident 33 not receiving the proper assessment to ensure the tube feeding was safe to be turned off for resident 33. Findings: During a review of the clinical record for Resident 33's admission Facesheet, Resident 33 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnosis that included dysphasia (difficulty swallowing), dementia (memory loss), urinary tract infection ([UTI] a clinically detectable condition associated with invasion by disease causing microorganisms of some part of the urinary tract), functional quadriplegia (a complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the spinal cord), right and left hip contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). During a review of the history and physical examination dated 7/31/21, Resident 33 did not have the capacity to understand and make medical decisions. Resident 33's Care Plan dated 8/31/21, indicated Resident 33 required a tube feeding due to dysphagia. The listed interventions included to maintain the head of the bed elevated at 45 degrees during and thirty minutes after the tube feeding. According to the Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 10/6/2021, Resident 33 sometimes had the ability to understand others and to make herself understood. The MDS indicated Resident 33 was totally dependent and required one-person physical assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident 33 had a tube feeding. During an observation on 11/30/21, at 2:53 p.m., Certified Nurse Assistant (CNA 5) turned off Resident's 33 tube feeding and lowered the head of the bed to provide care. During a review of the physician orders dated 12/2021, indicated Resident 33 received Jevity 1.2 (source of nutrition) via tube feeding at 55 milliliters ([ml] unit of measure) an hour. The order indicated the tube feeding may be turned off during care. During a concurrent observation and interview on 11/30/21, at 3:31 p.m., Licensed Vocational Nurse (LVN 4) stated the CNAs were not allowed to turn off the tube feeding because it was out of their scope of practice. During an interview on 11/30/21 at 3:14 p.m., CNA 5 stated she had to call the LVN to turn off the tube feeding prior to providing care. CNA 5 stated sometimes she would call the LVN to turn off the tube feeding and sometimes she turned the tube feeding off out of habit. CNA 5 stated she should not have turned off the tube feeding for resident 33. During an interview on 12/1/21 at 9:18 a.m., the Director of Nurses (DON) stated the CNAs were not allowed to turn the tube feeding on or off as that was out of their scope of practice. The facility's policy titled Closed Enteral Feeding revised 1/1/2012, indicated the nursing staff would administer a tube feeding via an enteral pump as ordered by the physician. The policy indicated nursing staff would review the order for feeding, calculate, assemble equipment, check tube placement, set dose, and start machine. The facility's undated job description titled LVN Staff Nurse indicated the LVN would provide nursing care as prescribed by the physician in accordance with the legal scope of practice, and within established standards of care, policies, and procedures.

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility staff conducted a wound dressing change in an unsanitary manner for one of thre...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility staff conducted a wound dressing change in an unsanitary manner for one of three sampled residents (Resident 50). This deficient practice exposed resident 50 to infection and delay in healing of stage 3 pressure ulcer. Findings: During an observation of wound care treatment done on 12/1/21 at 11:20 a.m., with Treatment nurse licensed vocational nurse LVN 2. Resident 50 had a bowel movement while LVN 2 was cleaning the wound. LVN 2 did not clean out the feces, but covered the wound with gauze and there was some feces observed at the edges of the wound. During a review of Resident 50 medical records Faces Sheet, the face sheet indicated that resident 50 was admitted to the facility on [DATE], with diagnoses that included acute kidney failure (disease of the Kidney), diabetes mellitus (high level of sugar in the blood) and Dysphagia (difficulty in swallowing). During a review of Resident 50's comprehensive Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 11/2/21, indicated Resident 50 was admitted to the facility with a stage 3 pressure ulcer on the sacrococcygeal area During a review of the physician's order sheet indicated resident 50 had an order dated 10/26/21, to clean the Stage 3 pressure ulcer with normal saline, apply Santyl ointment and cover the wound with bordered foam dressing. During an interview on 12/1/21 at 12:04 P.m., with LVN 2, LVN 2 stated that she is sorry that she should have cleaned the feces before covering the wound and that she would change Resident 50's wound dressing again after the certified nursing assistant has cleaned him up. A review of the facility undated Policy and Procedure P&P titled Pressure injury and skin integrity treatment -Dressing Application indicated staff are to ensure cleanliness and prevention of infection by protecting the skin's surfaces and to promote resident comfort and wound healing.

CONCERN (D)

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide restorative nursing assistance ([RNA] care fo...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide restorative nursing assistance ([RNA] care for one out of three sampled residents (Resident 33), who was contracted, had limited mobility, and depended on staff for care. The deficient practice had the potential to result in further decline in mobility for Resident 33. Findings: During a review of the clinical record for Resident 33, the Facesheet indicated Resident 33 was originally admitted on [DATE] and readmitted on [DATE]. Diagnosis included dysphasia (difficulty swallowing), dementia (memory loss), urinary tract infection ([UTI] a clinically detectable condition associated with invasion by disease causing microorganisms of some part of the urinary tract), functional quadriplegia (a complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the spinal cord), right and left hip contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). During a review of the clinical records for Resident 33, the history and physical Examination dated 7/31/21, indicated Resident 33 did not have the capacity to understand and make medical decisions. During an observation on 11/30/21, at 2:53 p.m., Resident 33 was lying on the bed, her left hand was contracted, her left fingers were closed, and her left leg was contracted into a knee bending position. During an interview on 12/2/21, at 7:27 a.m., restorative nursing assistant (RNA 1) stated the reason residents received RNA services was to lessen their contractures and to help them maintain flexibility. RNA 1 stated Resident 33 was discharged from RNA services when she was hospitalized approximately three months ago. RNA 1 stated when Resident 33 returned from the hospital the facility did not resume her RNA services. RNA 1 stated she thought the facility forgot to add Resident 33 back into the RNA services and Resident 33 should have received RNA services because her hands and legs were contracted. During an interview on 12/2/21, at 7:37 a.m., Occupational Therapist (OT 1) stated residents who were contracted, had hemiparesis, or weakness were candidates to receive RNA services. OT 1 stated when the residents returned from the hospital, she reassessed their needs for therapy services. OT 1 stated she was going to reevaluate Resident 33 for RNA services needs today. During an interview on 12/2/21, at 1:48 p.m., Physical Therapist Assistant (PTA) stated the purpose for RNA services was to prevent the residents from having functional decline. PTA stated RNA services helped to prevent further contractures. During an interview on 12/2/21, at 1:51 p.m., Physical Therapist (PT) stated she was going to reevaluate Resident 33's function today. PT stated she did not know the reason why Resident 33 was not reassessed for RNA earlier. During a review of the clinical record for Resident 33, the Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 10/6/2021, indicated Resident 33 sometimes had the ability to understand others and made herself understood. The MDS indicated Resident 33 was totally dependent on one-person physical assistance with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident 33 was impaired on one side of her upper extremity and both sides of her lower extremities. The MDS indicated Resident 33 did not receive restorative nursing services. The facility's policy titled Restorative Nursing Program Guidelines revised 9/19/19, indicated the program included nursing interventions that promoted the patient's ability to attain and maintain his or her optimal functional potential. The policy indicated restorative care implied there was a risk of imminent decline which could be prevented. The policy indicated the program actively focused on achieving or maintaining optimal physical, mental, and psychosocial functioning unless a decline was unavoidable based on the resident's clinical condition. The policy indicated a resident with restorative nursing needs may be started on a restorative nursing program upon admission to the facility.

CONCERN (D)

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure that one of three sampled residents (Resident 50) activities o...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure that one of three sampled residents (Resident 50) activities of daily living (ADL) care was provided in a comfortable and safe manner. Staff cleaned resident 50, who had bowel movement, with a dry towel without soap and water. This practice caused Resident 50 to experience pain and discomfort during care and had the potential to cause more skin irritation and possible skin tear, or breakdown to an already irritated area. Findings: During wound care observation on 12/1/21 at 11:30 a.m., Resident 50 had a bowel movement and needed perineal care. The Restorative Nurse Assistance (RNA 1) was observed cleaning resident 50's perineal area with a dry towel that was on the resident's bed. RNA 1 was rubbing repeatedly on Resident 50's perineal area and smearing the feces around resident's anal area. During a review of Resident 50's Faces Sheet, the face sheet indicated that resident 50 was admitted to the facility on [DATE] with diagnoses that included acute kidney failure, diabetes mellitus (high level of sugar in the blood) and dysphagia (difficulty in swallowing) A review of Resident 50's comprehensive Minimum Data Set (MDS- a standardized assessment and care-screening tool), dated 11/2/21 indicated that Resident 50 was admitted to the facility with stage 3 pressure ulcer on the sacrococcygeal area, was incontinent of bowel and bladder and was totally dependent to two staff for ADL care in the area of toileting and personal hygiene. During an interview on 12/1/21 at 12:10 p.m., with RNA 1, RNA1 stated that she made a mistake, and should have used a wipe or wash cloth with soap and water to clean resident 50's perineal area. RNA 1 stated that by using a dry towel she caused pain and discomfort to resident 50. During an interview on 12/3/21 at 2 p.m., with director of staff development (DSD), DSD stated that all staff were educated to use wet wipes to clean resident who has a bowel movement. DSD stated that dry towels are not be used to wipe resident's perineal areas because it causes pain and discomfort to the residents. A review of Facility undated policy and procedure (P&P) titled Resident Rights-Quality of Life. P&P indicated that each resident shall be cared for in a manner that promotes and enhances the quality of life.

CONCERN (D)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and record reviews, the facility failed to ensure the medication error rate of less than five (5) percent,...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and record reviews, the facility failed to ensure the medication error rate of less than five (5) percent, due to improper medication administration for three (3) of four (4) residents during medication administration. The outcome was three (3) medication errors out of twenty- nine opportunities for errors, which resulted in a medication administration error rate of ten (10) percent (%), that exceeded the five (5) percent threshold. Findings: a. During a review of Resident 51's admission record indicated Resident 51 was originally admitted on [DATE]. Resident 51 diagnosis included primary hypertension (high blood pressure), chronic embolism and thrombosis of deep veins of lower extremity bilateral (occurs when a blood clot forms in one or more of the deep veins in your body usually in your legs), gastro-esophageal reflux disease, unspecified dementia without behavioral disturbance (a broad term that describes a loss of thinking, ability, memory, attention, logical reasoning, and other mental abilities), malignant neoplasm of the prostate (Prostate cancer) During a review of the Minimum Data Set (MDS), a standardized assessment tool, indicated Resident 51 had severely cognitive impairment (ability to think, understand and make decisions). During a concurrent observation and interview on 11/30/21, at 11:38 a.m., with Licensed Vocational Nurse (LVN) 4, at station 1 medication cart, a low strength chewable aspirin 81 milligrams (mg) (unit of measure) tablet was observed in the prepared medication cup. This surveyor asked LVN 4 if the tablet was supposed to be chewable and LVN 4 responded No, the doctor order says enteric coated. During a review of Resident 51's Medication Administration Record (MAR), the physician order dated 9/02/21 was reviewed. The MAR indicated, on 11/30/21, at 11:38 a.m. administration time, there were staff initials in the box for Resident 51's Aspirin enteric coated (coated with a substance that prevents the medication from being released until it reaches the small intestine where it can be absorbed) 81 mg one tablet by mouth which indicated medication was given when actually it was a chewable aspirin. b. During a review of Resident 153's admission record indicated Resident 153 was admitted on [DATE]. Resident 153 diagnosis included cerebral infarction (an area of dead tissue in the brain caused from a blockage or narrowing in the arteries supplying blood and oxygen to the brain), Type II Diabetes Mellitus ((a long-lasting health condition that affects how your body turns food into energy), polyneuropathy (multiple peripheral nerves becomes damaged and affects all other parts of your body) During a review of Resident 153's MDS indicated intact understanding. 1. During a concurrent observation and interview on 11/30/21 at 9:41 a.m., with LVN 7, at station 2 medication cart, multivitamin with minerals one tablet was observed in the medication cup for Resident 153. LVN 7 handed over one bottle of multivitamins with minerals to me to write down. The Surveyor intervened and asked LVN 7 was multivitamins ordered with or without minerals? LVN 7 stated, without minerals, and then proceeded to retrieve one bottle of multivitamins without minerals to administer. c. During a review of Resident 38's admission record indicated Resident 38 was admitted on [DATE]. Resident 38's diagnosis included Cerebral infarction (an area of dead tissue in the brain caused from a blockage), and Type II diabetes. During a concurrent observation and interview on 11/30/21, at 12:34 p.m., with LVN 7, at station 2 medication cart, Resident 38's medication Metformin 1000mg was to be administered with meals but was almost administered to Resident 38 without meals until the surveyor intervened. During a review of the facility's policy and procedure titled Medication-Administration, dated January 1, 2012, indicated, Medication will be administered as directed by a Licensed Nurse and upon the order of a physician or licensed independent practitioner.

CONCERN (D)

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

Deficiency F0790 (Tag F0790)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to refer one of one resident (Resident 30) who had a bro...

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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 refer one of one resident (Resident 30) who had a broken denture, was referred to the dentist for evaluation and treatment. The deficient practice had the potential to result in Resident 30 losing weight and decline in health. Findings: During a review of the clinical record for Resident 30, the admission Record indicated Resident 30 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Diagnosis included dysphasia (difficulty swallowing), type 2 diabetes (abnormal sugar), and dependence on renal dialyses (a treatment that does some of the things done by healthy kidneys) During a review of the clinical record for Resident 30, the Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 8/13/2021, indicated Resident 30 had the ability to understand others and to make himself understood. The MDS indicated Resident 30 received mechanically altered diet (food texture that is smoother and easier to swallow than regular foods). The MDS further indicated Resident 30 did not have broken dentures. During a review of the clinical record for Resident 30, the Care Plan has Nutritional Problem or Potential for Nutritional Problem revised on 10/2/21, indicated a goal to maintain an adequate nutritional status daily. The care plan interventions included monitoring, documenting, and reporting any signs and symptoms of dysphagia and concerns during meals. During a concurrent observation and interview on 11/30/21, at 10:16 a.m., Resident 30 stated his lower dentures were broken. Resident 30 stated he told the staff, but no one had done anything about his broken dentures. Resident 30 opened a plastic container, that contained his broken lower dentures. Resident 30 lower denture was broken in half. Resident 30 stated he could not use his dentures. During an interview on 12/1/21, at 11:34 a.m., CNA 1 stated Resident 30 had told her about his broken dentures. CNA 1 stated the Director of Social Services (DSS) had already scheduled a dentist appointment for Resident 30. During an interview on 12/1/21, at 3:50 p.m., DSS stated she was not notified that Resident 30's dentures had been broken. DSS stated the CNAs were to notify her or the charge nurses about Resident 30's broken dentures, but they did not notify her. During an interview on 12/2/21, at 7:49 a.m., CNA1 stated on 11/30/21, she notified the DSS about Resident 30's dentures being broken. CNA 1 stated CNA 6 notified her about Resident 30 broken dentures. During an interview on 12/2/21, at 7:54 a.m., CNA 6 stated approximately three days ago she had notified CNA1 about Resident 30's dentures being broken. CNA 6 stated CNA 1 told her that she was going to notify the DSS. CNA 6 stated she did not notify the DSS. CNA 6 stated it was important to replace Resident 30's dentures to ensure Resident 30 could properly eat his food and not lose weight and have a health decline. The facility's policy titled Oral Healthcare & Dental Services revised 7/14/17, indicated the facility would provide oral healthcare and dental services as needed or requested by each resident. The policy indicated residents with lost or damage dentures were referred to a dentist within three business days. The policy indicated the social services staff are responsible for assisting with arranging necessary dental appointments and all requests for dental services should be directed to the social services staff to ensure that appointment was made in a timely manner.

CONCERN (D)

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

QAPI Program (Tag F0867)

Could have caused harm · This affected 1 resident

Based on interview, and record review the facility's Quality Assessment and Assurance and Quality Assurance Performance Improvement committee failed to develop and implement appropriate plans of actio...

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Based on interview, and record review the facility's Quality Assessment and Assurance and Quality Assurance Performance Improvement committee failed to develop and implement appropriate plans of action to ensure the QAA/QAPI committee systematically implemented and evaluated the plan of action facility wide to ensure the facility had standardized documentation of administration and discontinuation of Narcotics. These deficient practices resulted in inconsistencies and discrepancies in documentation and have the potential for Narcotic diversion. Findings: The QAA([QAA] develop and implement appropriate plans of action to correct identified quality deficiencies) /QAPI([QAPI] takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving) committee failed to ensure the licensed nurses monitored and properly documented narcotic administration on the Medication Administration Record (MAR). The facility did not have a standardized process and documentation of verified discontinued narcotics. The licensed nurses inconsistently documented narcotic use on the MAR. During a QAPI interview with the Administrator (Admin) on 12/3/21 at 3:36 p.m., the Admin stated the problem with inconsistencies in documentation involving Narcotics was already brought to his attention and he would bring up the topic on the next QAPI meeting. The Admin stated the facility will discuss ways on how to improve and prevent errors in the future. The facility's policy titled Quality Assurance Performance Improvement (QAPI) Program revised on 09/19/21, indicated the facility was to implement and maintain ongoing, facility-wide Quality Assurance and Performance Improvement (QAPI) Program designed to monitor and evaluate the quality of resident care, pursue methods to improve quality of care and resolve identified problems. The policy also indicated a systemic analysis and approach is used when an in-depth analysis is needed to understand the problem, cause, and implications. A focus on continued learning and improvement is included.

CONCERN (E)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Ensure a large wheelchair, bedside commode, mat, a...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Ensure a large wheelchair, bedside commode, mat, and walker did not clutter the entryway of Resident 44's room. 2. Provide supervision during smoking sessions for Resident 6 and Resident 46. These deficient practices had the potential to result in harm such as burns, fires, falls, injury and accidents to residents, staff, and visitors. Findings: 1. A review of Resident 44's admission Record indicated Resident 44 was admitted to the facility on [DATE], with diagnosis that included anxiety (a feeling of worry, nervousness, or unease), repeated falls and abnormal posture. A review of Resident 44's History and Physical (H/P) dated, 4/28/2021, indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 44's Minimum Data Set (MDS) a resident assessment and care screening planning tool, dated 10/14/2021, indicated Resident 44 was able to make needs known and understand others. The MDS indicated Resident 44 required supervision for transfers and for set up for bed mobility. A review of Resident 44's undated Care Plan titled Risk for Falls, indicated the resident goals were to maintain Resident 44 free from falls the listed interventions and tasks included to: a. Ensure the call light is within reach. Prompt response to all requests for assistance. b. Follow facilities protocol. c. Treat and evaluate as ordered. During an interview and concurrent observation with Resident 44 on 11/30/2021, at 2:15 p.m., the entryway had a large wheelchair facing bed 1A, a bedside commode, a mat, and a walker. These items left limited space to move from one area to another. Resident 44 was having an extremely difficult time exiting the room, because her feet could not go through between the wheels of the chair and the footboard. Resident 44 stated, staff had removed the mat because she fell a long time ago. She tripped on the fall mat and her feet got caught up. During an observation on 12/1/2021, at 8:55 a.m., there was a mat at the bedside of bed 1A, which was noticeably raised from the floor. The mat was detached from the base of the mat with stitching undone. During an interview and concurrent observation with Certified Nurse Assistant (CNA 4) on 12/1/2021, at 2:13 p.m., CNA 4 stated, some of the interventions to prevent falls included: a. Responding to call lights in a timely manner. b. Ensure wheelchairs are locked and the bed is in the lowest position. c. Keep call light within reach d. Ensure the room is free from clutter [bedside commodes, IV (medication) poles, and wheelchairs]. e. Ensure the mat is close to the bed and flat on the floor CNA 4 noted the condition of the mat and stated that ambulatory residents were at risk of falling due to the mat's condition. The facility's Policy titled Communication dated 1/1/12, indicated the facility is to provide residents with a safe, clean, comfortable, and homelike environment. Facility Staff should aim to create a personalized, homelike atmosphere, paying close attention to cleanliness and order. 2. A review of the admission record indicated Resident 6 was admitted to the facility on [DATE], with diagnosis that included history of substance abuse, paraplegia (paralysis of the legs and lower body), and right above the knee amputation (damage limb removed). A review of Resident 6's Smoking Safety Evaluation, dated 8/25/21, indicated Resident 6 had balance problems when sitting or standing and had total or limited range of motion in the arms or hands. The evaluation further indicated Resident 6 would follow the facility's policy on location and time of smoking. A review of the admission Minimum Data Set (MDS- standardized assessment and care planning tool), dated 8/31/21, indicated Resident 6 has moderately impaired cognition (moderate problems with reasoning, memory, knowledge, and understanding), able to understand and be understood, requires limited assistance in bed mobility, transfers (from bed to chair), dressing, toilet use, and personal hygiene. Resident 6 is wheelchair bound. A review of Resident 6's Smoking Care plan, initiated on 9/9/21, indicated Resident 6 was a smoker and was non-compliant with smoke breaks and smoked whenever he wanted to. 3. A review of the admission record indicated Resident 46 was admitted to the facility on [DATE], with diagnosis that include multiple sclerosis (a long-lasting disease that can affect brain, spinal cord, and the optic nerves of the eyes), depression (a common and serious medical illness that negatively affects how you feel, the way you think and how you act), and Cognitive communication deficit (impairment in organization/thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness.) A review of the admission Minimum Data Set (MDS - standardized assessment and care planning tool), dated 10/30/21, indicated Resident 46 has moderately impaired cognition (moderate problems with reasoning, memory, knowledge, and understanding), was able to understand and be understood, required limited assistance in bed mobility, transfers (from bed to chair), dressing, toilet use, and personal hygiene. The MDS indicated Resident 46 is wheelchair bound, has unsteady balance and only able to stabilize self with staff assistance. A review of Resident 46's care plan for Smoking, initiated on 11/30/21, indicated Resident 46 was a smoker. The goal indicated Resident 46 would not smoke without supervision. The interventions included to instruct Resident 46 about the facility policy for smoking regarding locations, times, and safety concerns. Another listed intervention indicated Resident 46 could smoke unsupervised which contradicted the goal of the care plan. During an observation on 11/30/21 at 1:58 p.m., two residents sat in their wheelchairs smoking without staff supervision. Ashtray, fire extinguisher, and fire blanket were available. Resident 46 stated the staff keep the cigarettes to give to them. During an observation on 12/01/21 at 9:35 a.m., Resident 6 and 46 wheeled themselves to the patio to smoke without staff supervision. Both residents had their own lighter and were able to light their own cigarettes. During a concurrent interview, Resident 6 and 46 stated they are allowed to have their own lighter and had been lighting their own cigarettes since admission. Resident 6 stated only two of them smoke without staff watching but some residents need chaperone (a company to look after) to smoke. Resident 6 stated sometimes they (Residents 6 and 46) watch other residents for the staff because he can call if something happens. Resident 6 stated he can come out to smoke at any time he wants if it is 5:00 a.m. in the morning, no one can stop him., Resident During the interview 6 threw the unextinguished cigarette filter on the ground, next to the ashtray. Resident 6 verbalized it is even a bad habit to throw a cigarette filter without extinguishing it and verbalized he should use the ashtray to dispose of the cigarette. A review of the smoking schedule and location indicated the smoking location is the patio area between the Director of Staff Development (DSD) office and employee break room. The smoking schedule indicated the smoking hours are strictly enforced (8:30 a.m., 10:30 a.m., 1:00 p.m., 3:00 p.m., 6:00 p.m., and 8:00 p.m.) and supervised at scheduled times, and smoking minutes not to exceed more than 10 minutes each smoking time. During a concurrent observation and interview with Activities Director (AD) on 12/01/21 at 09:43 a.m., AD stated three of the Activities staff, including her, supervise weekend smoking breaks. AD stated Activities staff cover the nurses when they are unable to supervise smoking, nurses let them know if coverage is needed. AD stated there is only one resident who needs supervision (Resident 41). AD stated she thought the cigarettes were lighted up by the staff. AD stated she does not think they should smoke unsupervised and verbalized they could catch on fire and get something on fire. During an interview with LVN 3 on 12/01/21 at 10:01 a.m., LVN 3 stated all residents who smoke go to the patio and staff must watch the residents, even the alert residents. LVN 3 stated some alert residents go outside and smoke anytime they want. LVN 3 stated she is not sure if residents have their own lighter and stated they should not. LVN 3 stated If residents are not supervised and do not put out cigarettes properly, there can be fire. During an interview with DSD (Director of Staff Development) on 12/01/21 at 10:10 a.m., DSD stated the Activities Director (AD) is responsible for residents who are smoking. DSD stated the facility has a schedule to follow and the list of facility staff who are scheduled to watch the residents. DSD stated sometimes the residents do not follow the schedule. DSD stated some smokers are alert and oriented but still need supervision. During an interview and record review with DSD on 12/01/21 at 10:25 a.m., DSD stated Resident 6 is alert and able to light his own cigarettes. Smoking assessment dated [DATE] indicated Resident 6 can use the ashtray and extinguish fire. DSD stated ability and willingness is different when it comes to following smoking protocols. DSD verbalized Resident 6 is defiant. A review of Resident 46's Care Plan for Smoking, initiated on 11/30/21, indicated Resident 46 is a smoker. The goal indicated Resident 46 would not smoke without supervision through the review date. The interventions included to instruct the resident about the facility policy regarding smoking, locations, times, and safety concerns. Another listed intervention indicated Resident 46 could smoke unsupervised which contradicted the goal of the care plan.

CONCERN (E)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During observation on 11/30/21, Resident 50 was observed sleeping from 8 :30 a.m., to 4:30 p.m. On 12/1/21 Resident 50 was ob...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. During observation on 11/30/21, Resident 50 was observed sleeping from 8 :30 a.m., to 4:30 p.m. On 12/1/21 Resident 50 was observed awake from 9 a.m. to 3:40 p.m. On 12/2/21 at 11 a.m. Resident 50 was agitated and yelling out loud and exchanging words with another resident in the same room. During an interview 12/2/21 at 11: 05 a.m., with Charge nurse, license Vocational Nurse (LVN 2), LVN 2 stated that resident 50 has a behavior problem and that she has given him Ativan (a medication uses in the treatment of anxiety) to calm him down. During a review of Resident 50 medical records Faces Sheet, face sheet indicated that resident 50 was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia (a mental health disorder), major depressive disorder (a mental health disorder that affect ones feeling thinking and action), acute kidney failure and diabetes mellitus (high level of sugar in the blood. A review of physician's order sheet 10/26/21, indicated that resident 50 is being treated for schizophrenia manifested by screening yelling and getting out of bed without help. The physician order dated 11/1/21, indicated Resident 50 had an order for Ativan 1 milligram (mg) every 12 hours as needed for the treatment of anxiety manifested by restlessness and agitation. A review of the narcotic and hypnotic count sheet indicated that Ativan was taken out on 11/12/21, 11/19/21, 11/26/21, and 11/27/21. A review of Resident 50's MAR for the month of November 2021, indicated there was no initial on the MAR to indicate that the Ativan was administered to Resident 50. During an interview on 12/2/21 at 1:30 p.m., with LVN 2, LVN 2 stated that she signed out the Ativan from the narcotic count sheet, and administered them to resident 50 on those days but forgot to sign the MAR. LNV 2 stated that by not signing on the MAR indicated that the Ativans were not administered to resident 50. During an interview on 12/2/21 at 2 p. m., with director of Nursing (DON), DON stated that all licensed staff were educated to document in the MAR each time a medication was administered to residents, and by not documenting on the MAR indicated that the medication was not given to the residents. DON stated that she will in-service all the staff on documenting on the MAR each time medication was given to residents. A review of the facility Policy and Procedure (P&P) titled Medication Administration indicated that to ensure that accurate administration of medications for the residents. 1. Medications must be given to the resident by the licensed Nurse preparing the medication. 2. The licensed nurse will verify the resident' identity before administering the medication. 3. The Licensed nurse will chart the drug, time administered and initial his/her name with each medication administration and sign full name and title on each page of the medication administration record (MAR). Based on observations, interviews, and record reviews, the facility failed to: 1. Ensure that the change of shift narcotics reconciliation records were not missing ten (10) licensed nurse signatures in the designated nurse signature boxes over a two (2) month period, for one (1) out of two (2) medication carts at the facility. This deficient practice had the potential for loss of accountability, which affected the controls against drug loss, diversion, or theft. 2. Ensure that the narcotics records for individual residents were consistently signed by the director of nursing and licensed nurses upon initial custody of discontinued narcotic medications by the director of nursing, over a two (2) month period, at one (1) out of one (1) locked narcotic cabinet at the facility. 3. Ensure that a control medication administered to resident 50 was documented in the medication administration record (MAR). This deficient practice had the potential for loss of accountability, which affected the controls against drug loss, diversion, or theft and double dosing. Findings: 1. During an observation, on 12/1/21, at 3:05 p.m., Station 2 Medication Cart's controlled drugs (narcotics, drugs with the potential for abuse and addiction controlled by the government) logbook indicated ten (10) missing licensed nurse signatures on shift change narcotics reconciliation records (Controlled Drug Count Records) dated October 2021 and November 2021. A review of the Controlled Drugs-Count Record, dated October 2021, indicated missing nurse signatures in the signature boxes shown by Date, Shift, Nurse Off, and Nurse On: 10/10/21, 7-3 (7 a.m. to 3 p.m.) Shift, Nurse On 7-3; 10/10/21, 3-11 (3 p.m. to 11 p.m.] Shift, Nurse Off 7-3; 10/13/21, 3-11 Shift, Nurse On 3-11; 10/13/31, 11-7 (11 p.m. to 7 a.m.) Shift, Nurse Off 3-11; 10/15/21, 7-3 Shift, Nurse On 7-3; 10/15/21, 3-11 Shift, Nurse Off 7-3; 11/2/21, 7-3 Shift, Nurse On 7-3; 11/2/21, 3-11 Shift, Nurse Off 7-3; 11/9/21, 3-11 Shift, Nurse On 3-11; and, 11/9/21 11-7 Shift, Nurse Off 3-11. During an interview, on 12/1/21, at 3:06 p.m., the licensed vocational nurse, LVN 4, acknowledged the ten (10) missing nurse signatures. A review of the facility's pharmacy policy and procedures, titled, Controlled Medication Storage, effective date, 2/23/2015 (February 23, 2015), indicated, Procedures .At each shift change, a physical inventory of all controlled medications, including the emergency supply, is conducted by two licensed nurses and is documented on the controlled medication accountability record. 2. A review of the controlled drugs disposition process indicated that, in the beginning, the discontinued narcotic medications were removed from the medication carts by the licensed vocational nurses, LVNs, and brought into the director of nursing's, DON's, office for reconciliation of narcotic counts, processing, and storage in the locked cabinet while awaiting the destruction process with the facility's pharmacist. A review of the individual residents' narcotic records, titled, Narcotic and Hypnotic Record, during an inspection of the locked narcotics cabinet in the DON's office, indicated inconsistencies in documentation of the narcotics count and the LVNs' signatures. Also, there were no DON co-signatures next to the LVN signatures upon reconciliation. During an interview, on 12/1/21, at 1:32 p.m., the DON stated that she did not sign the form when confirming the narcotics count with the LVN. The LVN either signed the form in the top section of the form, signed the form next to the last time dispensed, or did not sign it at all, based on a random check of the November 2021 forms. Regarding inconsistency with the signatures of LVN and DON not signing off, the DON stated, [Need to] be consistent. A review of the facility's pharmacy policy and procedures, titled, Controlled Medication Disposal, effective date, 02/23/2015, indicated, Policy .Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

Based on observations, interviews, and record reviews, the facility failed to: 1. Ensure that a digital room thermometer was functioning, and the room temperature monitoring record was in place to ens...

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Based on observations, interviews, and record reviews, the facility failed to: 1. Ensure that a digital room thermometer was functioning, and the room temperature monitoring record was in place to ensure that storage of medications was within the specified manufacturers' temperature ranges, in one (1) out of two (2) medication storage rooms at the facility. This deficient practice had the potential to cause harm to residents due to the potential loss of strength of the medications, and the potential for the residents to receive ineffective medication dosages. 2. Ensure that the refrigerator temperature log had spaces for the times when temperatures were taken during each work shift, in one (1) out of two (2) medication storage rooms at the facility. This deficient practice had the potential to cause harm to residents due to a potential undetected temperature excursion, the potential loss of strength of the medications, and the potential for the residents to receive ineffective medication dosages. 3. Ensure that unauthorized, non-licensed personnel did not have the key to access the medication storage room, in one (1) out of two (2) medication storage rooms at the facility. This deficient practice had the potential to cause a loss of accountability, which affected the controls against drug loss, diversion, or theft. 4. Ensure that the facility's emergency kit policy and procedures had the correct time interval for checking emergency kits by the provider pharmacy. This deficient practice had the potential to cause harm to residents receiving potentially expired medications, due to potential loss of strength and ineffective medication dosages. Findings: 1. During an observation, on 11/30/21, at 3:23 p.m., of the Station 1 Medication Room, the digital room thermometer was not functioning, indicated by no temperature readings on the display panel. The Station 1 Medication Room did not have a room temperature log, and there was no record of the room temperatures being monitored. During an interview, on 11/30/21, at 3:24 p.m., the director of staff development, DSD, who was also a licensed vocational nurse, stated, We don't take room temperatures, and we don't have a room thermometer log. I will call Maintenance to get a thermometer and a room temperature log. A review of the facility's pharmacy policy and procedures, titled, Storage of Medications, effective date, 2/23/2015 (February 23, 2015), indicated. Procedures .Medications requiring storage at 'room temperature' are kept at temperatures ranging from .59 degrees F to 86 degrees F. 2. During an observation, on 11/30/21, at 3:31 p.m. of the Station 1 Medication Room, the refrigerator temperature record (log) indicated the temperature readings were documented, but not the times that the temperatures were taken. The refrigerator log sheet had the columns and spaces for dates and work shifts, but not for the times. During an interview, on 11/30/21, at 3:31 p.m., the DSD acknowledged that the refrigerator log sheet had no spaces for the times of temperature readings. A review of the facility's pharmacy policy and procedures, titled, Storage of Medications, effective date, 02/23/2015 (February 23, 2015), indicated. Procedures .Medications requiring storage at 'refrigeration' or 'temperatures between .36 degrees F to 46 degrees F are kept in a refrigerator with a thermometer at allow temperature monitoring . 3. During an observation, on 11/30/21, at 4:29 p.m., of the Station 1 Medication Room, the Environmental Director walked into the open Station 1 medication room, went to the shelf, and took one (1) bottle of the over-the-counter medication Calcium 600 mg (strength in milligrams) with Vitamin D 10 mcg (strength in micrograms) (equivalent to 400 IU [strength in international units]), quantity 180 tablets. During an interview, on 11/30/21, at 4:29 p.m., the DSD stated, Only licensed personnel should have access to the med room. The DSD named the person as [environmental director, a non-licensed person]. During an interview, on 11/30/21, at 4:38 p.m., with the Environmental Director, ED, regarding if he always goes to this medication room, he stated, Yes, I handle ordering and stocking of the over-the-counter medications. I do not have access to the controlled substances cabinet or the medication refrigerator. Regarding if he has possession of a key to this medication room to access the medication room at all times, ED stated, Yes, I handle over-the-counter stuff. A review of the facility's pharmacy policy and procedures, titled, Storage of Medications, effective date, 02/23/2015, indicated. Policy .Medications and biologicals are stored safely, securely, and properly .The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 4. A review of the facility's pharmacy emergency kit policy and procedures, titled, Emergency Pharmacy Service and Emergency Kits, effective date, 02/23/2015 (February 23, 2015), indicated, Procedures .The kits are inventoried by the provider pharmacy quarterly for completeness and expiration dating of the contents ., instead of monthly. During an interview, on 12/2/21, at 1:22 p.m., the facility's corporate consultant, CC1, regarding the emergency kit policy and procedures, stated, I'll take a note of that. It's a generic [policy and procedures). Let me make sure that this gets e-mailed to pharmacy so they can revise this (from 'quarterly' to 'monthly'). A review of the facility's pharmacy policy and procedures, titled, Emergency Pharmacy Service and Emergency Kits, effective date, 02/23/2015, indicated, Policy .An emergency supply of medications, including emergency drugs, antibiotics, controlled substances and products for infusion is supplied by the provider pharmacy in limited quantities in portable, sealed containers, in compliance with applicable state regulations. A review of the state regulation, titled, California Code of Regulations (Title 22), section 72377(b)(4), indicated, 72377. Pharmaceutical Service-Equipment and Supplies .(b) .Emergency drug supplies shall meet the following requirements: (4) The supply shall be checked monthly by the pharmacist.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observation, staff interviews, review of facility policy, the facility failed to ensure safe and sanitary food storage and food preparation and service practices in the kitchen when: 1. One ...

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Based on observation, staff interviews, review of facility policy, the facility failed to ensure safe and sanitary food storage and food preparation and service practices in the kitchen when: 1. One staff working in the dish machine area did not wash hands and change gloves when removing the clean and sanitized dishes from the dish machine. This failure had the potential to cross contaminate dishes and cause food borne illness to residents who eat from the facility's kitchen. 2. Several food items were not labeled or dated in the reach in freezer and refrigerator to identify food content and discarded prior to use by date. Two cantaloupe that looked old and sunken and had areas with green and black color mold like substance, stored in the reach in refrigerator. One box containing about 10 green bell peppers that was old with black spots on the peppers was stored in the reach in refrigerator. 3. Nutritional supplement labeled store frozen with manufacture's instruction to use within 14 days of thawing, were not monitored for the date they were thawed to ensure expired shakes were discarded after this timeframe. One box of chocolate flavor shake, and two boxes of strawberry flavor nutritional shakes were stored in reach in refrigerator with an open date of 11/11/21 exceeding storage periods for the nutrition supplements. This deficient practice had the potential to result in food borne illness in five residents who receive nutritional supplements at the facility. 4. One dietary staff did not wear gloves when preparing ready to eat food. 5. Food brought to residents from outside of the facility, including leftovers, were stored in the resident food refrigerator in the nurses' station were not clearly identified, labeled, or dated. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness for 53 out of 54 medically compromised residents who received food from the kitchen. Findings: 1.During an observation in the dish machine area on November 30, 2021, at 8:45 a.m. Dishwasher (DW) had gloves on and rinsing soiled dishes. After rinsing soiled dishes DW loaded the dirty dishes in the dish machine. DW proceeded to wash then rinse the food carts with soap and water. When the dish machine stopped DW proceeded to remove the clean and sanitized dishes from the dish machine. DW did not wash hands, or change gloves. During a concurrent observation and interview, DW stated she did not know she was supposed to change gloves. DW added that she moved from a dirty task to clean task, and she should've wash hands and change gloves. DW stated she forgot to change gloves. DW stated not washing hands can contaminate clean dishes. A review of facility policy titled Dishwashing procedures (Dish machine) (dated 2012) indicated, To avoid cross contamination, it is recommended two employees handle dishwashing .If only one employee is available to wash and handle clean and soiled dishes, the employee must wash hands thoroughly before handling clean dishes, trays and carts. A review of 2017 U.S. Food and Drug Administration Food Code 2-301.14 indicated, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils and unwrapped single service and single use articles and after handling soiled equipment or utensils. 2. During an observation in the kitchen on November 30, 2021 at 9:21 a.m. one large bag of turkey and one bag of chicken patty were stored in the reach in freezer with no date or label to identify the product. During a concurrent observation and interview, Dietary Supervisor (DS) stated that he didn't know if the large poultry is chicken or turkey. He also stated that all items out of its original container should be labeled with name of product and date. During the same observation there were two whole cantaloupe fruits that looked dry, had sunken spots that had large greenish and black parts on them. In the same reach in refrigerator there was a box that contained 8-10 green bell peppers that had black spots and moldy areas on the entire pepper. During a concurrent interview with DS and [NAME] 1, DS stated the cantaloupe is bad and discarded it in the trash. Cook1 verified that the green bell peppers were bad and couldn't be used. Cook1 discarded the green peppers. During the same observation in the kitchen, there were four plastic pouches of sea moss vegan product for a resident stored in the reach in refrigerator with no date. During the same interview and review of storage instructions of the Sea moss vegan product, DS verified that the product should be discarded after three weeks in the fridge. DS also stated if there is no date staff would not know if item is expired. DS also stated that he will provide Inservice to staff on labeling and dating and rotating products to discard the expired items. A review of facility policy and procedure title food storage (revised 7/2019) indicated, All items will be correctly labeled and dated, and Rotate fruits/produce so that oldest produce is used first 3.During an observation in the kitchen on November 30, 2021 at 9:26 a.m. there was one box of chocolate flavored nutrition supplements with a date of 11/11/21 and two boxes of strawberry flavored shakes stored in the reach in refrigerator with a date of 11/18/21. During a concurrent interview with Dietary Supervisor (DS), he stated the shakes come in frozen and were stored in the refrigerator. He added that the date indicates the day the boxes were stored in the refrigerator and thawed. A concurrent review of the shakes manufactures storage instruction, Dietary supervisor verified that the storage period for the shakes had expired. He added that the shakes will be discarded. He also stated that he will provide in-service regarding labeling and discarding expired items. According to the 2017 U.S. Food and Drug Administration Food Code, Ready-to-eat, Time/Temperature control for safety food should be marked by date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed, sold or discarded. The U.S. Food Code further states Time/Temperature control for safety refrigerated food must be consumed, sold or discarded by the expiration date. 4. During an observation in the food preparation area on November 30, 2021 at 12:20PM, Dietary Aide (DA1) was preparing sandwiches and snacks for residents. DA1 was not wearing gloves. DA1 was touching diet orders sheets and labeling sandwich bags. DA1 opened the refrigerator door and picked up a container of turkey ham deli meat (a ready to eat food). DA1 took two slices using bare hands and placed them in small plastic bag. DA1 labeled the bags with the resident's name and date. During a concurrent interview with DA1 he stated that he wore gloves when he made sandwiches. DA1 stated that he forgot to wear gloves when he picked up slices of turkey ham and placed it in bags. DA1 stated that he should wash hands and wear gloves when touching or working with ready to eat food (food that does not require heating or cooling) to prevent cross contamination of bacteria from his hands to the food. A review of facility policy titled infection control for dietary employees (dated11/2016), indicated proper handwashing by personnel will be done as follows: .G. During food preparation, as often as necessary to remove soil and contamination and to prevent cross-contamination when changing tasks. A review of the 2017 U.S. Food and Drug Administration Food Code 3-301.11 indicated, Except when washing fruits and vegetables, Food employees may not contact exposed, ready to eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. 5.During an observation of the resident's refrigerator in the nurse's station on November 30, 2021 at 1:30 p.m., there was one bottle of orange soda, one carton of eggnog drink with no resident name or date and one plastic bag with food container that had no date. During a concurrent interview with Director of staff development (DSD), he stated that all resident's food brought by family or leftovers from takeout has to be labeled with resident name, room number and date. He also stated that resident food from outside is stored for 48 hours and will be discarded after that date. He stated that he doesn't know when the food was brought in because there is no date on the food. A review of facility's policy titled Food Brought in by visitors (dated 6/2018), indicated When food is brought into a nursing home prepared by others, the nursing home is responsible for ensuring that the food container is clearly labeled with the resident name and date received and stored in a refrigerator designated for this purpose. And Perishable food requiring refrigeration will be discarded after two hours at bedside, and if refrigerated it will then be labeled, dated and discarded after 48 hours.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F. During a review of Resident 5's admission record indicated, Resident 5 was admitted on [DATE]. Resident 5's diagnosis include...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F. During a review of Resident 5's admission record indicated, Resident 5 was admitted on [DATE]. Resident 5's diagnosis included Paranoid schizophrenia (a type of brain disorder especially characterized by delusions of persecutions or jealousy and hearing voices), defects in walking and mobility, and one-sided paralysis. During an observation on 12/1/21 at 10:02 a.m., in room [ROOM NUMBER], Certified Nurse Assistant (CNA 2) entered the room and used hand sanitizer then went to bed 6C with gloves on and pulled the resident's curtain. After pulling 6C's curtain while wearing the same gloves, CNA2 went to bed 6A to change Resident 5's diaper. CNA 2 used the same gloves to give Resident 5 a bed bath and change the diaper. CNA 2 used the same gloves to put on clean diaper and clean clothes on Resident 5, and comb resident Resident 5's hair, and then remove the gloves and use hand sanitizer. During an interview on 12/1/21, with CNA 2, at 1030 a.m., CNA2 stated, I knock on the door, enter the room, and go to the resident who called. I ask the resident what kind of help they need, and explain for example, I'm going to change your diaper. I wash my hands, put on gloves, and change the diaper, give a bath, and clean the resident. When are you supposed to change gloves? Going from one resident to another, when going from dirty to clean areas? Was that done? No, I'm supposed to wash my hands and change gloves when touching clean items. During an interview on 12/02/21, with DSD, at 10:29 A.M., DSD stated, When a staff member has gloves on for one resident and then goes to another resident or needs a diaper change, going from dirty to clean, you must remove your gloves and wash your hands and put on new pair of gloves before going to the next resident. I do ongoing in services on handwashing and donning and doffing of gloves several times a month. Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program by failing to: a. Ensure one out of four resident (Resident 33), who had a Foley catheter (a flexible plastic tube inserted into the bladder to provide continuous urinary drainage) and urine with sediment was assessed for signs and symptoms of urinary tract infection (UTI). b. Ensure one out of four residents (Resident 403) Foley catheter drainage bag did not touch the floor. c. Ensure one out of two wash machines were maintained and cleaned. d. Ensure three out of three used face shields were properly stored in the laundry room. e. Ensure one out of one Certified Nurse Assistant (CNA 1) kept her nails trimmed. f. Ensure one out of one staff (certified nurse assistant [CNA 2]) changed gloves and performed hand hygiene in between providing care for two residents 5 and 39. g. Ensure the urinal of one out of one resident (Resident 153) was not kept next to the meal tray during lunch time. The findings for this Resident were not found in the findings below. Please include. These deficient practices had the potential to expose residents, to bacteria and other microorganism that could cause the residents to become infected and sick. Findings: a. During a review of the clinical record for Resident 33, the Facesheet indicated Resident 33 was originally admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included dysphasia (difficulty swallowing), dementia (memory loss), urinary tract infection ([UTI] a clinically detectable condition associated with invasion by disease causing microorganisms of some part of the urinary tract), functional quadriplegia (a complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the spinal cord), right and left hip contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints). During a review of the clinical records for Resident 33, the history and physical dated 7/31/21, indicated Resident 33 did not have the capacity to understand and make medical decisions. During a review of the clinical records for Resident 33, the Care Plan for Foley catheter revised 8/30/21, indicated a goal that Resident 33 would show no signs and symptoms of urinary infection. The care plan interventions included to monitor, record, and report to the physician signs and symptoms of urinary infection such as pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, and chills. During a review of the clinical record for Resident 33, the Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 10/6/2021, indicated Resident 33 sometimes had the ability to understand others and made herself understood. The MDS indicated Resident 33 was totally dependent on one-person physical assistance with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident 33 had a Foley catheter. During a review of the clinical record for Resident 33, the Treatment Administration Record (TAR) dated 11/2021, indicated Resident 33 received Foley catheter care daily. During a review of the clinical record for Resident 33, the physician orders dated 12/2021, indicated Resident 33 had orders to provide daily Foley catheter care. During an observation on 11/30/21, at 2:53 p.m., Resident 33's Foley catheter tube had thick and cloudy urine with particles. During an observation and interview on 11/30/21, at 3:14 p.m., Certified Nurse Assistant (CNA 5) stated Resident 33 urine had particles in it. CNA 5 stated Resident 33 urine usually had particles. During a concurrent observation and interview on 11/30/21, at 3:31 p.m., Licensed Vocational Nurse (LVN 4) stated Resident 33's Foley catheter had particles but that was normal for Resident 33. LVN 4 stated he did not notify anyone about Resident 33 having particles in her urine. During an interview on 12/1/21 at 9:18 a.m., the Director of Nurses (DON) stated the LVNs who assessed residents whose Foley catheter has sediments (particles) in their urine, is required to notify the findings to the physician. The DON stated sediment in the urine for resident 33 was not a normal finding and the physician should have been notified. During an interview on 12/2/21, at 9:50 a.m., the infection Preventionist ([IP] stated when the urine appeared cloudy and had particles the physician needed to be notified to identify if the resident was having an infection. The facility's policy titled Care of catheter revised 6/10/2021, indicated the purpose of the policy is to prevent catheter associated urinary tract infections. The policy indicated licensed nurses must periodically reassess any complications associated with catheter use. The policy indicated the nursing staff would assess urinary drainage for signs and symptoms of infection, noting cloudiness, color, sediment, blood, odor, and amount of urine. The policy indicated a licensed nurse would notify the attending physician of any signs and symptoms of infection for clinical interventions. b. During observation rounds on 11/30/21 at 11:19 a.m., Resident 403 was lying on the bed, eyes unopened, and no verbal communication at that time. Resident 403's Foley catheter drainage bag was touching the floor, anchored to the left side of the low bed. The urinary catheter drainage bag was inside a dignity bag (a pouch in which an indwelling catheter is placed to provide dignity for a resident by not allowing others to see the contents of the urine container bag) but not protected from the floor contamination inside a wash basin. The bag was full of urine. During a concurrent observation and interview on 12/1/21 at 2:20 p.m., at Resident 403's bedside, PTA 2 stated the urinary bag should not touch the floor. PTA 2 stated he would ask for help to position the bed in the lowest position without the bag touching the floor. PTA 2 stated the urinary bag should not touch the floor to prevent infection. During an interview on 12/01/21 at 3:43 p.m., LVN 6 stated the bag should not touch the floor for infection control as bacteria would travel to resident 403 and could cause Resident 403 to become sick. LVN 6 stated she always put a clean basin under the catheter drainage bag, so the bag did not touch the ground, but the staff often would throw out the basin. A review of the admission record indicated Resident 403 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included cerebral infarction (also known as a stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area), diabetes mellitus Type 2 (an impairment in the way the body regulates and uses sugar (glucose) as a fuel), and Stage 3 pressure ulcer wound (full-thickness tissue loss with visible subcutaneous fat), and Stage 3 pressure ulcer is the indication for urinary catheter placement. A review of the Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 11/11/21, indicated Resident 403 has a severe cognitive impairment (process of acquiring knowledge and understanding through thought, experience, and the senses) in daily decision making and needed one-person extensive assistance with bed mobility, dressing, and two-person physical assist in toilet use and personal hygiene. The MDS indicated Resident 403 is always incontinent (no ability to control) with bowel and bladder. A review of Resident 403's Care Plan for Indwelling Catheter, initiated on 11/23/21, indicated a goal that the resident would show no signs and symptoms of urinary infection through review date. However, there was no intervention to address keeping the drainage bag from coming in direct contact with a potentially infectious area such as the floor. A review of the policy and procedure titled Care of Catheter revised on 6/10/21, indicated the catheter bag, tubing, and spigot (a small peg or plug) would be anchored to not touch the floor. c. During a concurrent observation and interview on 12/1/21, (Time?) in the laundry room, the wash machine had a brown and whitish, stain looking area, approximately three inches wide, by the washing machine door. The Laundry Supervisor (ED) stated the laundry machine was supposed to be cleaned to prevent contaminating the clean laundry. The facility's policy titled Laundry services revised 1/1/2012, indicated the facility would provide laundry services that meet the needs of the residents. The policy indicated the laundry equipment was maintained in a clean and sanitary condition. The facility's policy titled Route & Process Laundry revised 1/1/2012, indicated the facility laundry room was to be cleaned on a consistent basis, to always maintain a clean and safe environment, and to disinfect washing machines after using them. d. During an observation and concurrent interview on 12/1/21, in the laundry room clean area three face shields were on top of the shelf. The Laundry Supervisor (ED) stated he did not know who the face shields belong to because they did not have a name. ED stated the used face shields should not have been stores on the shelf as could lead to cross contamination. During an interview on 12/2/21 at 9:50 a.m., the infection preventionist stated the face shields used by staff should have been properly stored. The IP stated the face shields could not be lying around because they were dirty. The IP stated the dirty face shields could contaminate the resident's clean clothes and spread infection to the residents. The facility's policy titled Infection Control revised 1/1/2012, indicated the facility intended to maintain a safe, sanitary, and comfortable environment and helped to prevent and manage transmission of disease and infections. The California Department of industrial relations (Cal-OSHA) Title 8, section 3380, titled Cal/OSHA Interim General Guidelines on Protecting Workers from COVID-19 dated 5/14/2020, indicated Personal Protective Equipment ([PPE] was needed to protect employees from hazards that were present or were likely to be present in the workplace, including health hazards. Employers must ensure the appropriate PPE was provided to and used by employees who use cleaners and disinfectants. e. During a concurrent observation and interview on 12/1/21, certified Nurse Assistant (CNA 1) had nails approximately one inch long. CNA 1 stated she was not allowed to have long nails because germs could grow underneath the nails and spread germs for the residents. CNA 1 stated she should have cut her nails. During an interview on 12/2/21, at 12:38 p.m., the IP stated the staff was not supposed to have long nail due to the risk of spreading infection to the residents. The facility's policy titled Infection Control revised 1/1/2012, indicated the facility intended to maintain a safe, sanitary, and comfortable environment and helped to prevent and manage transmission of disease and infections. The Center for Diseases Control and Prevention (CDC) titled Healthcare Providers updated 1/8/2021, indicated all healthcare providers should not wear artificial fingernails and should keep natural nails less than one quarter inch long if they care for patients at high risk of acquiring infections. The CDC indicated germs could live under artificial fingernails both before and after using an alcohol-based hand sanitizer and handwashing. g. During observation on 11/30/21 at 12: 45 p.m., Resident 153 was alert and oriented in his room sitting up on his bed. He had a urinal with urine on the bed table. Resident 153 turned on the call light. Certified nursing assistance CNA 1 responded to the call light, Resident 153 stated to CNA 1 that he wanted to know when his lunch would be served. CNA 1 responded that it will be soon and left the room. During a concurrent observation and interview on 11/30/21 at 1:04 p.m., CNA 1 brought in the lunch tray into resident 153's room, sat the tray on the bed table while the urinal with urine were on the table. CNA 1 positioned the table within reach for resident 153 and left the room. CNA 1 stated that she should have removed the urinal with urine from the bed table, that it is unhygienic for resident to eat food with urine on the same table. CNA 1 took the urinal away from the table and emptied the urine in the bathroom. A review of the admission record indicated Resident 153 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction, type 2 diabetes mellitus, and large B-cell lymphoma. A review of the physician document resident assessment history and physical examination (H&P), dated 11/19/21, indicated that Resident 153 has the capacity to understand and make decisions. During an interview on 12/30/21 at 1:30 p.m., with resident 153, Resident 153 stated that it is embarrassing to eating while looking at the urine. He further stated that the nurses do not care about them, and usually leave his urinal with urine at his bed side for a long time and he has to call for it to be emptied. During a review of the facility's policy titled Infection Control revised 1/1/2012, indicated the facility intended to maintain a safe, sanitary, and comfortable environment and helped to prevent and manage transmission of disease and infections.

LAWNDALE HEALTHCARE & WELLNESS CENTRE LLC

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