How many inspection deficiencies does COSTA DEL SOL HEALTHCARE have?

COSTA DEL SOL HEALTHCARE has 82 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at COSTA DEL SOL HEALTHCARE?

COSTA DEL SOL HEALTHCARE has a two-star staffing rating from CMS with 0.23 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 COSTA DEL SOL HEALTHCARE located?

COSTA DEL SOL HEALTHCARE is located in LOS ANGELES, CA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does COSTA DEL SOL HEALTHCARE have?

COSTA DEL SOL HEALTHCARE has 99 certified beds.

Who owns COSTA DEL SOL HEALTHCARE?

COSTA DEL SOL HEALTHCARE is a for profit - limited liability company facility and is part of the PACS GROUP chain.

What questions should families ask when visiting COSTA DEL SOL HEALTHCARE?

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

How does COSTA DEL SOL HEALTHCARE compare to other nursing homes?

COSTA DEL SOL HEALTHCARE has a 3-star overall rating, which is average compared to other nursing homes in CA. Consider visiting multiple facilities before making a decision.

COSTA DEL SOL HEALTHCARE

Name: COSTA DEL SOL HEALTHCARE
Address: 1016 S. RECORD ST., LOS ANGELES, CA, 90023, US
Telephone: (323) 268-0106
Rating: 3.0

1016 S. RECORD ST., LOS ANGELES, CA 90023 · (323) 268-0106

For profit - Limited Liability company 99 Beds PACS GROUP Data: November 2025

Trust Grade

45/100

#556 of 1155 in CA

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Last Inspection: May 2025

Inspected within the last 6 months. Data reflects current conditions.

Overview

Costa Del Sol Healthcare has a Trust Grade of D, indicating below average performance with some concerns for potential residents and their families. It ranks #556 out of 1155 facilities in California, placing it in the top half, and #99 of 369 in Los Angeles County, suggesting that while it has some local competition, there are better options available. The facility's trend is improving, as the number of issues decreased from 26 in 2024 to 14 in 2025, which is a positive sign. However, staffing is a weakness, with a rating of 2 out of 5 stars and a turnover rate of 43%, which is average but may affect the continuity of care. Additionally, the facility faced concerning fines of $38,181, higher than 77% of California facilities, and has less RN coverage than 93% of state facilities, which could impact the quality of care. Specific incidents include failing to ensure proper discharge planning for residents needing assistance and neglecting to address significant weight loss and dehydration for another resident, highlighting some serious areas for concern. Overall, while there are strengths, such as a decent quality measures rating of 5 out of 5, families should carefully consider these weaknesses when making their decision.

Trust Score: D
In California: #556/1155
Safety Record: Moderate
Inspections: Getting Better
Staff Stability: 43% turnover. Near California's 48% average. Typical for the industry.
Penalties: $38,181 in fines. Lower than most California facilities. Relatively clean record.
Skilled Nurses: Each resident gets only 13 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 82 deficiencies on record. Higher than average. Multiple issues found across inspections.

★★★☆☆

3.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★★★★★

5.0

Care Quality

★★☆☆☆

2.0

Inspection Score

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Stable

2024: 26 issues

2025: 14 issues

The Good

5-Star Quality Measures · Strong clinical quality outcomes
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover below average (43%)
5 points below California average of 48%

Facility shows strength in quality measures, fire safety.

The Bad

3-Star Overall Rating

Near California average (3.1)

Meets federal standards, typical of most facilities

Staff Turnover: 43%

Near California avg (46%)

Typical for the industry

Federal Fines: $38,181

Above median ($33,413)

Moderate penalties - review what triggered them

Chain: PACS GROUP

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 82 deficiencies on record

2 actual harm

Jul 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0627 (Tag F0627)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one out of three residents (Resident 1), was re-admitted to the facility within the seven (7)- day bedhold (a policy where a facility reserves a bed for a resident who has been temporarily transferred to a hospital or for therapeutic leave, ensuring the resident can return to the same facility when they are ready) period. This deficient practice resulted in Resident 1 not readmitted to the facility as of 7/15/2025.Findings:During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of morbid obesity (severe overweight) and muscle weakness. During a review of Resident 1's Care Plan titled, Discharge Care Plan, dated 4/5/2023, the care plan interventions indicated to discuss with resident/family/representative discharge planning process. During a review of Resident 1's History and Physical (H&P) dated 5/26/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS], a resident assessment tool), dated 5/28/2025, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 required moderate supervision (Helper does less than half the effort. Helper lifts, holds, or supports trunks or limbs, but provides less than half the effort) for eating, and oral hygiene. The MDS indicated Resident 1 was dependent (Helper does none of the effort to complete the activity or require the assistance of two or more helpers to complete the activity) with toileting hygiene, showering/bathing, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 1 required maximal assistance (helper does more than half the effort) with upper body dressing. The MDS indicated Resident 1 was dependent with rolling from left to right side and sitting to lying/lying to sitting on side of bed. During a review of Resident 1's Order Listing Report dated 5/29/2025, the report indicated Resident 1 was transferred to a General Acute Hospital (GACH) via 911 (medical emergency phone number) due to desaturation (low oxygen level. Normal is 92-100 percent [%]) with a seven (7)- day bedhold (from 5/29/2025 to 6/6/2025). During a review of Resident 1's Progress Notes dated 6/10/2025 at 10:25 a.m., the progress notes indicated the facility's Admissions Director (AD) spoke with Resident 1 over the phone (date not indicated on note) while Resident 1 was still in GACH indicating that he (Resident 1) was ready to return to the facility (date not indicated). The progress notes indicated the facility was not contracted with Resident 1's health insurance anymore and could not readmit Resident 1 back to the facility. During an interview on 7/2/2025 at 8:33 a.m. with the Complainant, the Complainant stated Resident 1 was admitted to GACH on 5/28/2025 due to low oxygen saturation. The complainant stated Resident 1 was stable with orders to go back to the facility on 5/31/2025. The Complainant stated she called and notified the facility's AD on 6/3/2025, 6/5/2025, 6/11/2025, and 6/20/2025 Resident 1 was ready to be discharged back to the facility. The Complainant stated the facility's AD denied Resident 1's readmission 1 due to no coverage from the health insurance. During a concurrent interview and record review on 7/2/2025 at 2:18 p.m. with the facility's AD, the policy and procedure (P&P) titled, Bed-holds and Returns, dated 10/2022, was reviewed. The facility's AD stated the facility's P&P indicated residents should be permitted to return to the facility, following hospitalization regardless of payer source. The facility's AD stated residents who seek to return to the facility within the bed-hold period should be allowed to return to their previous room, if available. The facility's AD stated the facility denied Resident 1's readmission to the facility because the facility was no longer contracted with Resident 1's health insurance. The facility's AD stated GACH made several attempts to send Resident 1 back for readmission (AD could not recall dates she was called by GACH), but the facility could not accept Resident 1. The facility's AD stated they failed to follow the facility's P&P indicating to re-admit residents regardless of payment source by not accepting Resident 1. During an interview on 7/2/2025 at 2:51 p.m. with the Director of Nursing (DON), the DON stated Resident 1's health insurance was not contracted with the facility, and was not sure if they could readmit Resident 1despite their P&P indicating residents should be readmitted to the facility regardless of payer source. During an interview on 7/14/2025 at 1:18 p.m. with the DON, the DON stated they did not receive a letter from Resident 1's health insurance company indicating the facility had not contract with the resident's health insurance. During an interview on 7/15/2025 at 12:52 p.m. with the Complainant, the Complainant stated Resident 1 is still in GACH as of 7/15/2025 and had not been readmitted back to the facility. During a review of the facility's P&P titled, Bed-holds and Returns dated 10/2022, the P&P indicated residents should be permitted to return to the facility following hospitalization regardless of payer source. The P&P indicated residents who seek to return to the facility within the bed-hold period defined in the state plan should be allowed to return to their previous room, if available.

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 F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to notify the physician when one of three sampled residents (Resident 1) missed a session of dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). This deficient practice had the potential for Resident 1 to experience a delay in treatment or services due to possible unidentified complications associated with the physician not being aware of a missed session of dialysis. 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 originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included idiopathic neuropathy (a type of nerve damage where the origin is unknown), acute respiratory failure (a condition where you don't have enough oxygen in the tissues in the body) , asthma (a chronic respiratory disease that affects the airways in the lungs, causing inflammation, swelling, and muscle tightening, leading to breathing difficulties), end stage renal disease (End Stage Renal Disease-irreversible kidney failure), dependence on dialysis, cardiomegaly (condition where the heart is bigger than normal) , pneumonia (an infection/inflammation in the lungs), and pleural effusion (a condition where there is fluid buildup in the area between the lungs and chest wall). During a review of Resident 1 ' s Care Plan dated 3/27/2025, the Care Plan indicated Resident 1 required dialysis related to ESRD, and interventions included to provide dialysis on Monday, Wednesday, and Friday for 3 hours and 30 minutes. During a review of Resident 1 ' s Order Summary Report, the Order Summary Report indicated Resident 1 had an order placed on 4/23/2025 for Resident 1 to receive dialysis on Monday, Wednesday, and Friday from 1:45pm to 5:15pm. During a review of Resident 1 ' s History and Physical (H&P) dated 4/25/2025, the H&P indicated Resident 1 had the ability to make medical decisions. During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool) dated 4/26/2025, the MDS indicated Resident 1 had moderately impaired cognition (ability to learn, reason, remember, understand, and make decisions), received dialysis, and was dependent on staff for activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily). During a review of Resident 1 ' s Progress Notes dated 4/25/2025, the Progress Notes indicated Resident 1 was being monitored for signs and symptoms of fluid overload due to a missed dialysis session on 4/25/2025 that was rescheduled for the next day on 4/26/2025. During an interview on 5/14/2025 at 2:01 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated transportation for residents to their dialysis appointments were made by the social service director and if there were any issues with cancellation or delay, they would communicate with the transport company and the dialysis center to make them aware of the situation. LVN 1 stated Resident 1 received dialysis on Monday, Wednesday, and Friday. On 4/25/2025, Resident 1 was supposed to have dialysis, but the transportation company was late and when they ultimately arrived, the dialysis company called and said they could no longer take Resident 1 because they couldn ' t accommodate her any longer due to how late she was. At this time, Resident 1 was already on the gurney, so they had to place her back in bed. LVN 1 stated they informed the dialysis center the transportation was running behind, and they also followed up with the transport company to see approximately how late they would be. LVN 1 stated she did not notify Resident 1 ' s physician that Resident 1 missed her scheduled dialysis appointment because her dialysis session was already rescheduled for the following day. LVN 1 further stated that the doctor should have been notified because the doctor could give additional orders such as monitoring, interventions or the doctor could even send Resident 1 to a general acute care hospital (GACH) for dialysis if necessary to reduce complications from a missed session of dialysis. During an interview on 5/15/2025 at 11:30 with the Director of Nursing (DON), the DON stated they have never had any issues with a resident missing a dialysis appointment and this was the first time a scenario like this had happened. He stated the facility had other transportation companies the facility could use but the transportation company just arrived late, and the dialysis center was not able to accommodate Resident 1 due to how late she was. He stated the staff communicated with the transportation company and the dialysis center to keep them all informed but ultimately the dialysis center had to reschedule Resident 1 ' s dialysis to the following day. The DON stated if a resident were to miss a dialysis session, the staff should inform the resident ' s doctor to notify them of the situation because the doctor needs to be aware and if necessary, they could give additional orders or to transfer the resident out to a hospital for dialysis if needed. During a review of the facility ' s policy and procedure (P&P) titled Change in a Resident ' s Condition or Status dated 10/2024, the P&P indicated the facility will promptly notify the resident, his or her physician, and the resident representative of changes in the resident ' s medical/mental condition and/or status and when there is a need to alter the resident ' s medical treatment significantly.

May 2025 11 deficiencies

CONCERN (D)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure informed consent for psychotropic medication (any drug that affects brain activities associated with mental processes and behavior) was obtained in accordance with the facility's policy and procedures for one of five sampled residents (Resident 6). This deficient practice placed Resident 6 at risk for experiencing unexpected and/or unwanted adverse effects or complications of the medications, including increased cognitive impairment (problems with a person's ability to think, learn, remember, use judgment, and make decisions), over sedation (excessive drowsiness, loss of response to verbal command, inappropriate movement, hearing abnormalities, visual disturbances, sweating, or nausea), and tardive dyskinesia (a chronic movement disorder that causes involuntary, repetitive movements in the body). Findings: During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE]. Resident 6's admitting diagnoses included dementia (a progressive state of decline in mental abilities) and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 2/25/2025, the MDS indicated Resident 6 had severe cognitive impairments. The MDS indicated Resident 6 required partial to moderate assistance from staff for activities of personal hygiene and mobility while in bed. During a review of Resident 6's History and Physical (H&P), dated 3/12/2025, the H&P indicated Resident 6 did not have the capacity to understand and make decisions. During a review of Resident 6's discontinued physician order, dated 12/10/2024, the physician order indicated Resident 6 received 50 milligrams (mg, a unit of dose measurement) of Seroquel (quetiapine fumarate, an antipsychotic medication that treats several kinds of mental health conditions) twice a day for psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality). The order was discontinued on 5/7/2025. During a review of Resident 6's physician order, dated 5/7/2025, the physician order indicated Resident 6 was to receive 100 mg of Seroquel twice a day for psychosis. During a review of Resident 6's medical record titled Informed Consent - Psychoactive Medication, dated 5/7/2025, the record indicated informed consent for administration of Seroquel 100 mg twice a day was obtained from Resident 6. During an interview on 5/8/2025 at 2:10 p.m., with Nurse Practitioner (NP) 1, NP 1 stated informed consent for psychotropic medication was necessary prior to their administration because the resident/responsible party needed to be informed of their potential adverse effects (an unwanted and potentially harmful effect that occurs because of a medical treatment). NP 1 stated this included extrapyramidal symptoms (EPS, involuntary movements, muscle stiffness, and tremors), over sedation, and possible falls and accidents. NP 1 stated psychotropics were also particularly high-risk for elderly residents (residents [AGE] years of age or older). During an interview on 5/8/2025 at 1:58 p.m., with the Assistant Director of Nursing (ADON), the ADON stated that when a dose of psychotropic medication was increased, the ordering provider (i.e., physician, nurse practitioner) was required to obtain a new informed consent for the increased dose. During a concurrent interview and record review, on 5/8/2025 at 2 p.m., with the ADON, Resident 6's record titled Informed Consent - Psychoactive Medication, dated 5/7/2025, was reviewed. The ADON stated the informed consent for Seroquel 100 mg twice a day was obtained from Resident 6. During a concurrent interview and record review, on 5/8/2025 at 2 p.m., with ADON, Resident 6's H&P dated 3/12/2025 was reviewed. The ADON stated the H&P indicated Resident 6 did not have decision making capacity and could not give informed consent for the increased dose of Seroquel. The ADON stated informed consent was required to be obtained because there were side effects of psychotropics, including dehydration, sedation, and accidents. During a review of the facility's policy and procedure (P&P) titled Psychoactive/Psychotropic Medication Use, dated 4/2025, the P&P indicated the resident or resident representative had the right to be informed, in advance, by the physician or other practitioner, of the risks and benefits of proposed care. The P&P indicated prior to administration of the psychotropic medication, the prescribing clinician (i.e. physician, NP) were to obtain informed consent prior to administration.

CONCERN (D)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the needs and preference of two of 22 sampled residents (Resident 66 and Resident 50) were accommodated by failing to: 1. Ensure Resident 66's call light was kept within his reach. 2. Ensure Facility staff used a language interpreter when communicating with Resident 50. This deficient practice removed Resident 66's ability to exercise his right to request assistance from staff and removed Resident 50's ability to understand the care being provided to him. Findings: 1. During a review of Resident 66's admission Record, the admission Record indicated Resident 66 was originally admitted on [DATE] and was most recently readmitted on [DATE]. Resident 66's admitting diagnoses included dementia (a progressive state of decline in mental abilities), anxiety disorder (mental health conditions characterized by excessive fear and worry that can significantly impact daily life), and history of falling. During a review of Resident 66's Minimum Data Set (MDS, a resident assessment tool), dated 4/8/2025, the MDS indicated Resident 66 had severe cognitive impairments (a decline in mental processes like memory, attention, language, and reasoning). The MDS indicated Resident 66 was dependent on staff for activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily), and was dependent on staff for repositioning while in bed. During a concurrent observation and interview, on 5/5/2025 at 1:48 p.m., while at Resident 66's bedside, Resident 66's call light was observed resting on the left side of his bed, near his feet. Resident 66 was lying in a right-facing position. Resident 66 stated he could not reach his call light. During a concurrent observation and interview, on 5/5/2025 at 1:49 p.m., with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 66 should be able to reach the call light to ensure he can ask for help. CNA 1 stated he could yell for help if he could not reach his call light. During a concurrent observation and interview, on 5/7/2025 at 8:24 a.m., while at Resident 66's bedside, Resident 66's call light was observed resting on the left side of his bed, below his hip near his feet. Resident 66 was lying in a right-facing position. Resident 66 stated he could not reach his call light. During an interview on 5/7/2025 at 3:25 p.m., with the Assistant Director of Nursing (ADON), the ADON stated the purpose of the call light was to allow residents to call for help. The ADON stated call lights should be within reach of the resident. The ADON stated nursing staff should ensure the call light is within the resident's reach before leaving the room. The ADON stated if the call light was not within reach, it could lead to accidents and potential delays in the provision of care. The ADON stated it could also lead to the residents' needs not being met. The ADON stated it was not acceptable for a resident to yell for help and stated yelling for help was not a dignified way to live. The ADON stated yelling could also negatively impact the quality of life for the resident's roommates because it would disrupt their sleep and did not create a homelike environment. During a review of the facility's policy and procedure (P&P) titled Answering the Call Light, revised 10/2010, the P&P indicated staff were to ensure the call light was within easy reach of the resident while they are in bed. 2. During a review of Resident 74's admission Record, the admission Record indicated Resident 50 was originally admitted on [DATE] and most recently readmitted on [DATE]. Resident 50's admitting diagnoses included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), generalized muscle weakness, reduced mobility, and depression. During a review of Resident 50's History and Physical (H&P), dated 10/5/2024, the H&P indicated Resident 50 had the capacity to understand and make decisions. During a review of Resident 50's MDS, dated [DATE], the MDS indicated Resident 50's preferred language was Cambodian and indicated Resident 50 needed or wanted an interpreter to communicate with doctors and healthcare staff. The MDS indicated Resident 50 had severe cognitive impairments and required substantial/maximal assistance from staff for ADLs and mobility. During an observation on 5/6/2025 at 8:49 a.m., while at Resident 50's bedside, Resident 50 was observed with slurred speech but was able to state he spoke Cambodian. No communication board (a sheet of symbols, pictures or photos that a person points to, to communicate with those around them) was readily observed at Resident 50's bedside. During a telephone interview on 5/7/2025 at 1:03 p.m., with Resident 50's Emergency Contact (EM) 1, EM 1 stated Resident 50 spoke Cambodian and only spoke a few words of English. EM 1 stated she sometimes came to visit Resident 50, and when she spoke to him in Cambodian, he understood what was being said. EM 1 stated it was hard for Resident 50 to talk, but he preferred for facility staff to speak to him in Cambodian. During an observation on 5/7/2025 at 1:21 p.m., at Resident 50's bedside, Resident 50 was observed sitting up in bed, holding a fork in his right hand and feeding himself lunch. No communication board was readily observed at Resident 50's bedside. During an interview on 5/7/2025 at 1:26 p.m., with CNA 2, CNA 2 stated she explained and provided all of Resident 50's care in English. CNA 2 stated she thought Resident 50 spoke English because she heard him say yes, no, and here while providing care. CNA 2 stated staff looked at his facial expressions to determine if he was accepting of the care being provided and stated Resident 50 often appeared frustrated. CNA 2 stated the Charge Nurse (Licensed Vocational Nurse [LVN] 3) did not mention Resident 50 had any language needs. CNA 2 stated she had not used a communication board or an interpreter with Resident 50 during her shift. During an observation on 5/7/2025 at 1:33 p.m., while at Resident 50's bedside, CNA 2 spoke to Resident 50 in English to ask about collecting his lunch tray. Resident 50 looked at CNA 2 and did not respond. CNA 2 walked away without using an interpreter, communication board, or other interpretation method. CNA 2 walked away without collecting Resident 50's tray and exited the room. During an interview on 5/7/2025 at 1:44 p.m., with LVN 3, LVN 3 stated Resident 50 spoke Vietnamese. LVN 3 stated she did not use an interpreter to speak with Resident 50 or explain the care being provided. LVN 3 stated they did not provide Resident 50 with a communication board because he had left-sided weakness and might not be able to point to things. LVN 3 stated it was important to speak to residents in their preferred language to ensure that nursing assessments were accurate, and to ensure staff could adequately identify the residents' needs and address them. During an observation on 5/8/2025 at 9:46 a.m., while at Resident 50's bedside, Restorative Nurse Aide (RNA) 1 approached Resident 50's bedside. RNA introduced himself in English and asked Resident 50, Do you want to do exercises? in English. Resident 50 grunted in response to RNA 1's question but did not verbalize a clear Yes or No and did not nod his head to gesture Yes or No. During a concurrent interview and record review, on 5/7/2025 at 3:28 p.m., with the ADON, Resident 50's MDS dated [DATE] was reviewed. The ADON stated the MDS indicated Resident 50's preferred language was Cambodian and indicated he preferred to have an interpreter when communicating with doctors and healthcare staff. The ADON stated it was important to communicate with residents in their preferred language to ensure they could understand what healthcare staff were saying and explaining to them. The ADON stated accommodation of language preferences was required to provide dignified and resident-centered care. The ADON stated speaking a different language than what the resident preferred could result in them feeling like they were not understood, or that staff could not understand them. The ADON stated this could result in frustration and refusal of care. The ADON stated it was the resident's right to be informed of the care they were receiving and participate in the care being provided. The ADON stated that even if Resident 50 had left-sided weakness, a communication board could be offered and used. During a review of the facility's policy and procedure (P&P) titled Resident Rights, dated 2001, the P&P indicated residents had a right to be informed of, and participate in, their care planning and treatment. During a review of the facility's P&P titled Communication Language Barrier, revised 3/2017, the P&P indicated it was the facility's policy to assist and provide appropriate communication for residents who have barriers to communicate. The P&P indicated staff were to provide an interpreter or utilize visual aids such as communication boards, white boards, or tablets. During a review of the facility's P&P titled Dignity, dated 2001, the P&P indicated residents were to be cared for in a manner that promoted and enhanced their sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The P&P indicated staff were to honor resident goals, choices, preferences, values, and beliefs.

CONCERN (D)

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, Licensed Vocational Nurse (LVN) 3 failed to notify the physician when one of 22 sampled residents (Resident 74) experienced seizures (sudden, uncontrolled electrical disturbances in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) on 2/13/2025, 2/16/2025, 2/20/2025, 2/28/2025, 3/1/2025, and 3/14/2025. This deficient practice prevented Resident 74's physician from being able to make adjustments to Resident 74's plan of care to prevent recurring seizure activity. Findings: During a review of Resident 74's admission Record, the admission Record indicated Resident 74 was originally admitted on [DATE] and was most recently readmitted on [DATE]. Resident 74's admitting diagnoses included seizures (sudden, uncontrolled electrical disturbances in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 74's MDS, dated [DATE], the MDS indicated Resident 74 had severe cognitive impairment (a significant decline in thinking, learning, remembering, and other mental functions, to the point where individuals struggle with daily activities and may require assistance or supervision). The MDS indicated Resident 74 required substantial/maximal assistance from staff for mobility while in bed. During a review of Resident 74's active physician order, dated 2/12/2025, the physician order indicated Resident 74 was receiving Ativan (lorazepam, an anti-anxiety medication) as needed for seizures. During a review of Resident 74's Medication Administration Record (MAR), dated 2/1/2025 to 2/28/2025, the MAR indicated Resident 74 received Ativan on 2/13/2025, 2/16/2025, 2/20/2025, and 2/28/2025. During a review of Resident 74's Medication Administration Record (MAR), dated 3/1/2025 to 3/31/2025, the MAR indicated Resident 74 received Ativan on 3/1/2025 and 3/14/2025. During an interview on 5/7/2025 at 3:04 p.m., with LVN 3, LVN 3 stated Resident 74 had a history of seizures. LVN 3 stated that when a seizure occurs, they ensure the residents' safety then immediately report the seizure activity to the physician. During a concurrent interview and record review, on 5/7/2025 at 3:12 p.m., with LVN 3, Resident 74's MAR dated 2/1/2025 to 2/28/2025, and MAR dated 3/1/2025 to 3/31/2025, were reviewed. LVN 3 stated the MARs indicated Resident 74 received Ativan on 2/13/2025, 2/16/2025, 2/20/2025, 2/28/2025, 3/1/2025, and 3/14/2025. LVN 3 stated the Ativan was given for seizures. During an interview on 5/7/2025 at 3:17 p.m., with LVN 3, LVN 3 stated she did not document the seizure activity anywhere in Resident 7's medical record aside from the documented administrations of Ativan on the MAR. LVN 3 stated she followed the medication administration orders for Ativan but did not notify Resident 74's physician or complete Change of Condition (COC) assessments for the seizures. During an interview on 5/7/2025 at 3:21 p.m., with the Assistant Director of Nursing (ADON), the ADON stated a COC assessment should be completed each time a resident has a seizure. The ADON stated there should be a COC assessment because if seizures were occurring despite the resident taking medication to prevent them, notification from LVN 3 would likely prompt the physician to order blood tests to identify if the resident's anti-seizure medication needed to be adjusted. During a review of the facility's policy and procedure (P&P) titled Change in a Resident's Condition or Status, dated 2001, the P&P indicated the facility was to notify the physician of changes in the resident's medical/mental condition and/or status.

CONCERN (D)

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

Deficiency F0605 (Tag F0605)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the following were indicated for two of five sampled residents (Resident 6 and Resident 73): 1. Non-pharmacological interventions were attempted, and behavioral indications were present and documented prior to administering psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) for Resident 6. 2. Specific behavioral indications were documented and monitored from 3/1/2025 to 5/7/2025 for Resident 73 before the administration of clonazepam (a medication used to treat anxiety disorder [a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities]) three times a day. These deficient practices placed Resident 6 and Resident 73 at risk for experiencing unwanted adverse effects or complications from the psychotropic medications, including increased cognitive impairment (problems with a person's ability to think, learn, remember, use judgment, and make decisions), over sedation (excessive drowsiness, loss of response to verbal command, inappropriate movement, hearing abnormalities, visual disturbances, sweating, or nausea), and tardive dyskinesia (a chronic movement disorder that causes involuntary, repetitive movements in the body). Findings: a. During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was admitted to the facility on [DATE]. Resident 6's admitting diagnoses included dementia (a progressive state of decline in mental abilities) and anxiety disorder. During a review of Resident 6's Minimum Data Set (MDS, a resident assessment tool), dated 2/25/2025, the MDS indicated Resident 6 had severe cognitive impairments. The MDS indicated Resident 6 required partial to moderate assistance from staff for activities of personal hygiene and mobility while in bed. During a review of Resident 6's Change of Condition Assessment, dated 9/18/2024, the COC indicated Resident 6 exhibited episodes of anxiety manifested by agitation and restlessness. The COC did not indicate non-pharmacological interventions were provided to address the behaviors of agitation and restlessness. The COC indicated orders were received to administer 0.5 milligrams (mg, a unit of dose measurement) of Ativan (an anti-anxiety medication) every 12 hours as needed for anxiety. During a review of Resident 6's Medication Administration Record (MAR), dated 9/1/2024 to 9/30/2024, the MAR indicated Resident 6 received Ativan 0.5 mg on 9/25/2024 and 9/26/2024. During a review of Resident 6's MAR, dated 10/1/2024 to 10/31/2024, the MAR indicated Resident 6 displayed one episode of anxiety manifested by agitation and/or restlessness on 10/18/2024. No other episodes of anxiety were documented for the month of 10/2024, however the MAR indicated staff administered Ativan 0.5 mg for anxiety on 10/1/2024, 10/2/2024, 10/4/2024, 10/5/2024, 10/18/2024, 10/30/2024, and 10/31/2024. During a review of Resident 6's MAR, dated 11/1/2024 to 11/30/2024, the MAR indicated Resident 6 displayed no episodes of anxiety manifested by agitation and/or restlessness during the month of 11/2024, but indicated staff administered Ativan 0.5 mg for anxiety on 11/5/2024, 11/24/2024, and 11/25/2024. During a review of Resident 6's COC Assessment, dated 12/5/2024, the COC indicated Resident 6 was having episodes of outbursts and yelling. The COC did not indicate any non-pharmacological interventions were provided to address the behaviors of outbursts and yelling. The COC indicated an order was received for Seroquel (quetiapine fumarate, an antipsychotic medication that treats several kinds of mental health conditions) 100 mg twice a day for psychosis manifested by outbursts. During a review of Resident 6's MAR, dated 12/1/2024 to 12/31/2024, the MAR indicated Resident 6 displayed no episodes of outbursts. The MAR indicated Resident 6 received seven (7) doses of Seroquel 100 mg from 12/5/2024 to 12/10/2024, and received 41 doses of Seroquel 50 mg from 12/10/2024 to 12/31/2024. During a review of Resident 6's MAR, dated 1/1/2025 to 1/31/2025, the MAR indicated Resident 6 displayed one episode of outbursts on 1/22/2025. No other episodes of outbursts were documented for 1/2025. The MAR indicated Resident 6 received 62 doses of Seroquel 50 mg from 1/1/2025 to 1/31/2025. During a review of Resident 6's MAR, dated 2/1/2025 to 2/28/2025, the MAR indicated Resident 6 displayed no episodes of outbursts for the month of 2/2025. The MAR indicated Resident 6 received 56 doses of Seroquel 50 mg from 2/1/2025 to 2/28/2025. During a review of Resident 6's MAR, dated 3/1/2025 to 3/31/2025, the MAR indicated Resident 6 displayed one episode of outbursts on 3/9/2025. No other episodes of outbursts were documented for 3/2025. The MAR indicated Resident 6 received 62 doses of Seroquel 50 mg from 3/1/2025 to 3/31/2025. During a review of Resident 6's MAR, dated 4/1/2025 to 4/30/2025, the MAR indicated Resident 6 displayed no episodes of outbursts for the month of 4/2025. The MAR indicated Resident 6 received 59 doses of Seroquel 50 mg from 4/1/2025 to 4/30/2025. During a review of Resident 6's MAR, dated 5/1/2025 to 5/31/2025, the MAR indicated Resident 6 displayed two episodes of outbursts on 5/5/2025. No other episodes of outbursts were documented for 5/2025. The MAR indicated Resident 6 received 14 doses of Seroquel 50 mg from 5/1/2025 to 5/7/2025. During a review of Resident 6's COC Assessment, dated 5/7/2025, the COC indicated Resident 6 had an episode of outburst. The COC did not indicate any non-pharmacological interventions were provided to address the outburst. The COC indicated Nurse Practitioner (NP) 1 ordered Seroquel 100 mg twice a day for psychosis manifested by outbursts which was twice the amount of Resident 6's previous Seroquel order. During an observation on 5/6/2025 at 9:52 a.m., at Resident 6's bedside, Resident 6 was observed lying in bed, awake, alert. Resident 6 was calm and was not agitated or restless. During an observation on 5/8/2025 at 1:19 p.m., at Resident 6's bedside, Resident 6 was observed sitting up in a wheelchair feeding himself lunch. Resident 6 was calm, and was not observed as agitated, restless, or yelling. During an interview on 5/8/2025 at 1:27 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 6's mood was generally calm, but he was occasionally confused. LVN 1 stated he could become disoriented to where he was and would call for his brother. LVN 1 stated Resident 6 was easily re-oriented and stated that after staff re-oriented him he was ok and did not have any other mood or behavior issues. LVN 1 stated this behavior was likely due to his dementia diagnosis. LVN 1 stated non-pharmacological interventions, such as re-orientation, should be attempted to address Resident 6's behaviors before administering medication. During a concurrent interview and record review, on 5/8/2025 at 1:37 p.m., with the Assistant Director of Nursing (ADON), Resident 6's COC assessments, dated 9/18/2024 and 12/5/2024, were reviewed. The ADON stated the COC, dated 9/18/2024, indicated Resident 6 displayed agitation and restlessness and Ativan was ordered. The ADON stated there was no documentation prior to the COC assessment on 9/18/2024 indicating other occurrences of agitation and/or restlessness. The ADON stated there was no documentation indicating non-pharmacological interventions were attempted prior to getting orders for and administering Ativan. The ADON stated the COC, dated 12/5/2024, indicated Resident 6 had outbursts and Seroquel was ordered. The ADON stated there was no documentation prior to the COC assessment indicating other occurrences of outbursts. The ADON stated there was no documentation indicating non-pharmacological interventions were attempted prior to getting orders for and administering Seroquel. During an interview on 5/8/2025 at 1:45 p.m., with the ADON, the ADON stated Resident 6 had a diagnosis of dementia, and stated dementia could cause Resident 6's behaviors of agitation, restlessness, and outbursts. The ADON stated non-pharmacologic interventions could be taken to address these behaviors prior to the administration of psychotropics, including reorienting the resident, providing distractions, and ensuring a calm environment. The ADON stated non-pharmacological interventions should be attempted before psychotropic medications because the behaviors might be addressable without medications. The ADON stated Resident 6's was receiving Ativan and Seroquel as chemical restraints to control his behaviors. During a concurrent interview and record review, on 5/8/2025 at 1:49 p.m., with the ADON, Resident 6's COC assessment dated [DATE] was reviewed. The ADON stated the COC indicated Resident 6 had an episode of psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality) manifested by an outburst. The ADON stated the COC did not indicate non-pharmacological interventions were attempted to address the episode. The ADON stated the COC indicated NP 1 ordered Seroquel 100 mg twice a day for the episode of outburst. During a concurrent interview and record review, on 5/8/2025 at 1:52 p.m., with the ADON, Resident 6's physician order for Seroquel 100 mg twice a day, dated 5/8/2025, was reviewed. The ADON stated the physician order indicated Resident 6 was to receive 100 mg of Seroquel twice a day, and stated his previous order was for 50 mg of Seroquel twice a day. The ADON stated an increase in dose would require a behavioral indication, and stated this behavior would be documented in Resident 6's MAR. During a concurrent interview and record review, on 5/8/2025 at 1:56 p.m., with the ADON, Resident 6's MARs dated 4/2025 and 5/2025 were reviewed. The ADON stated the MARs indicated Resident 6 had two episodes of outbursts on 5/5/2025, and no other documented outbursts for 4/2025 and 5/2025. The ADON stated there was no documentation indicating non-pharmacologic interventions were attempted. The ADON stated that administration of psychotropic medications, without a behavioral indication or without attempting non-pharmacological intervention first, could cause adverse effects in the resident, including oversedation and accidents. During an interview on 5/8/2025 at 2:10 p.m., with NP 1, NP 1 stated psychotropic medications were particularly high-risk for elderly residents (residents [AGE] years of age or older), and caution was needed when increasing the dose. NP 1 stated there should be behavioral indications for increasing the dose, and stated non-pharmacological interventions should be attempted first. NP 1 stated Resident 6's behaviors of agitation, restlessness, and yelling could be attributed to his diagnosis of dementia. During an interview on 5/8/2025 at 2:21 p.m., with NP 1, NP 1 stated he increased Resident 6's Seroquel dose from 50 mg twice a day to 100 mg twice a day based on a verbal report he received from the ADON. NP 1 stated the ADON told him Resident 6 was having episodes of yelling at others. NP 1 stated he did not review Resident 6's records, including the MAR and COC assessments, to verify the frequency of the behavior. NP 1 stated he did not review Resident 6's records to determine if non-pharmacological interventions had been attempted prior to increasing Resident 6's Seroquel dose. NP 1 could not state if he directly observed Resident 6 displaying any episodes of yelling prior to increasing Resident 6's dose of Seroquel. During an interview on 5/8/2025 at 3:16 p.m., with the ADON, the ADON stated that on 5/7/2025 she told NP 1 Resident 6 was screaming. The ADON stated this was based on reports she received from nursing staff. The ADON stated she did not review Resident 6's records to validate the frequency of the behaviors. The ADON stated there was no documentation in the medical record to indicate the necessity of Resident 6's current orders for Seroquel, or previous orders for Ativan. During a review of the facility's policy and procedure (P&P) titled Psychoactive /Psychotropic Medication Use, dated 4/2025, the P&P indicated residents were only to receive psychotropic medications when necessary to treat a specifically diagnosed condition that is documented in the medical record. The P&P indicated staff were to identify person-centered, non-pharmacological interventions, unless contraindicated, to meet the individual needs of the resident, and minimize or discontinue the use of psychotropic medication. The P&P indicated that before initiating or increasing a resident's dose of psychotropics, the medical record must contain clear documentation that the resident's distress persists and his or her quality of life is negatively affected and, unless contraindicated, that multiple, non-pharmacological approaches have been attempted and evaluated. b. During a review of Resident 73's admission Record, the admission Record indicated Resident 73 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included anxiety, depression (overwhelming feeling of hopelessness and sadness), insomnia (inability to sleep), and paraplegia (loss of movement and/or sensation, to some degree, of the legs). During a review of Resident 73's MDS, dated [DATE], the MDS indicated Resident 73's cognitive skills (ability to think and reason) for daily decision making was intact. The MDS indicated Resident 73 required substantial assistance (helper does more than half of the effort) from staff for toileting hygiene, bathing, and lower body dressing personal and chair to bed transfers. During a review of Resident 73's History and Physical (H&P), dated 2/28/2025, the H&P indicated Resident 73 had the capacity to make medical decisions. The H&P indicated Resident 73 was a known psychoactive substance (drugs that alter a person's brain function and results in a change in perception, mood or behavior) abuser. During a review of Resident 73's Order Summary Report, dated 5/6/2025, the Order Summary Report indicated Resident 73 was ordered clonazepam oral tablet 1 milligram (mg- a unit of measurement) one tablet by mouth three times a day for anxiety disorder manifested by multiple concerns on 2/27/2025. During a review of Resident 73's Medication Administration Record (MAR), dated 3/2025 to 5/2025, the MAR indicated Resident 73 received clonazepam 1mg by mouth three times a day for anxiety manifested by multiple concerns from 3/1/2025 to 5/7/2025. The MAR indicated Resident 73 was monitored for anxiety manifested by multiple concerns from 3/1/2025 to 5/7/2025. During a concurrent interview and record review on 5/7/2025 at 9:50 a.m. with LVN 4, Resident 73's MAR, dated 5/2025, was reviewed. The MAR indicated Resident 73 was monitored for anxiety manifested by multiple concerns from 5/1/2025 to 5/7/2025. LVN 4 stated psychotropic medication orders were normally inputted into the electronic medical record (EMR) with a specific indication of use, or diagnosis, and specific behavioral manifestations (behavioral symptoms that are persistent or repetitive behaviors that are unusual, disruptive, inappropriate, or cause problems). LVN 4 stated that it was important to ensure specific behavioral manifestations were included in the orders so that the licensed nursing staff could monitor for an increase or a decrease of the frequency of specific behaviors. LVN 4 stated Resident 73's MAR did not indicate the licensed nurses had adequately documented the monitoring of specific behaviors. LVN 4 stated she was familiar with Resident 73's behaviors and had known Resident 73 to constantly ask repetitive questions. LVN 4 stated she would have revised Resident 73's orders to monitor for anxiety manifested by constant and repetitive questioning. LVN 4 stated the lack of monitoring for specific behaviors and the frequency of these behaviors placed Resident 73 at risk for being treated with a psychotropic medication for a prolonged duration of time. During a concurrent interview and record review on 5/8/2025 at 8:57 a.m. with the Director of Nursing (DON), Resident 73's Order Summary Report, dated 5/6/2025, was reviewed. The Order Summary report indicated Resident 73 was ordered clonazepam 1 mg three times a day for anxiety disorder manifested by multiple concerns on 2/27/2025. The Order Summary indicated Resident 73 was ordered monitoring for anxiety manifested by multiple concerns. The DON stated the licensed nurse, along with the physician, was to ensure the indication and specific behavioral manifestations were documented and monitored once an order for a psychotropic drug was transcribed. The DON stated he transcribed Resident 73's order for clonazepam into the EMR. The DON stated the current orders for the use of and behavioral monitoring of clonazepam did not specify exact behavioral manifestations because the phrase multiple concerns could have different interpretations. The DON stated the lack of specificity placed Resident 73 at risk for inappropriate care planning interventions and goals, inadequate behavioral monitoring, and had increased the potential for Resident 73 to be receiving the medication unnecessarily. During a review of the facility's Policy and Procedure (P&P), titled, Psychoactive, Psychotropic Medication Use, dated 4/2025, the P&P indicated the following: 1. The facility was to administer medications by following federal and state regulations if the medication was necessary to treat specifically diagnosed conditions and was appropriately documented in the medical record. 2. The Attending Physician and other staff will gather and document information to clarify, as possible, the resident's behavior, mood, function, and medical condition, specific symptoms, and risks to the resident and others. 3. Before initiating a psychotropic medication, the resident's symptoms must be clearly and specifically identified and documented.

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Minimum Data Sets (MDS, a resident assessment tool) for two of 22 sampled residents (Resident 38 and 74) accurately reflected the care and services they received. This deficient practice resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS) regarding the above residents' health status and unique healthcare needs. This deficient practice also created the potential for Residents 38 and 74 to not receive the interventions needed to monitor the effectiveness of the care received. Findings: 1. During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was originally admitted on [DATE] and most recently readmitted on [DATE]. Resident 38's admitting diagnoses included congestive heart failure (CHF, a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). During a review of Resident 38's physician order, dated 3/18/2024, the order indicated Resident 38 was to receive oxygen therapy, as needed, for shortness of breath. During a review of Resident 38's MDS, dated [DATE], the MDS indicated Resident 38 did not have cognitive impairments (a decline in mental abilities like memory, language, problem-solving, and attention). The MDS indicated Resident 38 required supervision and/or touch assistance from staff for dressing herself, performing activities of personal hygiene, and movement while in and out of bed. The MDS did not indicate Resident 38 received oxygen therapy while a resident. During an observation on 5/5/2025 at 10:11 a.m., while at Resident 38's bedside, Resident 38 was observed receiving oxygen therapy through a nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen). During an interview on 5/7/2025 at 10:42 a.m., with the Minimum Data Set Nurse (MDSN), the MDSN stated the purpose of the MDS was to create a profile of the resident. The MDSN stated the MDS guided the resident's plan of care. The MDSN stated the information indicated in the MDS allowed the interdisciplinary team to identify the necessary interventions to provide care to the resident. During a concurrent interview and record review, on 5/7/2025 at 10:48 a.m., with the MDSN, Resident 38's physician order for oxygen therapy, dated 3/18/2025, and MDS, dated [DATE], were reviewed. The MDSN stated the physician order indicated Resident 38 was on oxygen therapy and stated the MDS did not indicate Resident 38 was on oxygen therapy. The MDSN stated it was important to have an accurate MDS to ensure proper care can be provided to the residents. 2. During a review of Resident 74's admission Record, the admission Record indicated Resident 74 was originally admitted on [DATE] and was most recently readmitted on [DATE]. Resident 74's admitting diagnoses included seizures (sudden, uncontrolled electrical disturbances in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 74's active physician order, dated 8/22/2024, the physician order indicated Resident 74 was receiving levetiracetam (an anticonvulsant medication). During a review of Resident 74's active physician order, dated 2/12/2025, the physician order indicated Resident 74 was receiving Ativan (lorazepam, an anti-anxiety medication) as needed for seizures During a review of Resident 74's MDS, dated [DATE], the MDS indicated Resident 74 had severe cognitive impairment (a significant decline in thinking, learning, remembering, and other mental functions, to the point where individuals struggle with daily activities and may require assistance or supervision). The MDS indicated Resident 74 required substantial/maximal assistance from staff for mobility while in bed. The MDS did not indicate Resident 74 received anticonvulsants (medication used to prevent seizures) or anti-anxiety medications. During a review of Resident 74's Medication Administration Record (MAR), dated 3/1/2025 to 3/31/2025, the MAR indicated Resident 74 received levetiracetam every day of 3/2025. The MAR indicated Resident 74 received Ativan on 3/1/2025 and 3/14/2025. During a concurrent interview and record review, on 5/8/2025 at 8:57 a.m., with the MDSN, Resident 74's MDS dated [DATE] was reviewed. The MDSN stated the MDS did not indicate Resident 74's use of anti-anxiety and anticonvulsant medication. The MDSN stated it was important to know the medications Resident 74 was taking to monitor their effectiveness and to monitor for possible side effects. During a review of the facility's policy and procedure titled Resident Assessments, dated 2001, the P&P indicated information documented in the MDS assessments was to consistently reflect information in the progress notes, plans of care, and resident observations/interviews.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 74) had orders to monitor for seizures (sudden, uncontrolled electrical disturbances in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) following his first seizure on 2/12/2025. This deficient practice placed Resident 74 at risk of experiencing injuries related to unwitnessed and/or undocumented seizures (e.g., falls, choking, low oxygen levels). Findings: During a review of Resident 74's admission Record, the admission Record indicated Resident 74 was originally admitted on [DATE] and was most recently readmitted on [DATE]. Resident 74's admitting diagnoses included seizures. During a review of Resident 74's Minimum Data Set (MDS), dated [DATE], the MDS indicated Resident 74 had severe cognitive impairment (a significant decline in thinking, learning, remembering, and other mental functions, to the point where individuals struggle with daily activities and may require assistance or supervision). The MDS indicated Resident 74 required substantial/maximal assistance from staff for mobility while in bed. During a review of Resident 74's Change of Condition (COC) assessment, dated 2/12/2025, the COC indicated Resident 74 had a seizure lasting three minutes. During a review of Resident 74's active physician orders, dated 4/28/2025, the orders indicated staff were to monitor Resident 74 for seizure activity every shift. During a concurrent interview and record review, on 5/7/2025 at 3:21 p.m., with the Assistant Director of Nursing (ADON), Resident 74's order for seizure monitoring dated 4/28/2025, was reviewed. The ADON stated there should have been orders to monitor Resident 74 for seizure activity after the first seizure episode on 2/12/2025. The ADON stated nursing staff should have contacted the doctor for orders. The ADON stated it was important to have an order for seizure monitoring to ensure Resident 74's safety. During a review of the facility's policy and procedure (P&P) titled, Seizures and Epilepsy - Clinical Protocol, dated 2001, the P&P indicated staff were to monitor the progress of individuals with a new seizure or a seizure disorder and periodically document the presence or absence of seizure activity.

CONCERN (D)

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

Deficiency F0694 (Tag F0694)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow their Policy and Procedure (P&P) for Intravenous line ([IV] a thin, flexible tube placed inside a vein, usually in the arm or hand, to deliver fluids, medications, or nutrients directly into the bloodstream) care for one Of eight sampled residents (Resident 87) by failing to: 1. Ensure Resident 87's left arm IV and IV dressing was changed per the physician's order. 2. Ensure Resident 87's right arm IV was assessed. These deficient practices increased Resident 87's risk of developing an infection (the invasion and growth of germs in the body), and caused pain and discomfort to Resident 87. Findings: During an observation on 5/5/2025 at 9:50 a.m., Resident 87's left arm IV was dated 4/28/2025. Resident 87's right arm IV's dressing was dislodged from the skin and the IV had blood on the tubing. The dressing was not dated. During an observation on 5/6/2025 at 1:06 p.m., Resident 87's left arm IV was dated 4/28/2025. Resident 87's right arm IV's dressing was dislodged from the skin and the IV had blood on the tubing. The dressing was not dated. During an observation on 5/7/2025 at 12:18 p.m., Resident 87's left arm IV was dated 4/28/2025. Resident 87's right arm IV's dressing was dislodged from the skin and the IV had blood on the tubing. The dressing was not dated. During a review of Resident 87's admission Record, the admission Record indicated Resident 87 was admitted to the facility on [DATE] with diagnoses including end stage of 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 transplant to maintain life) and diabetes mellitus ([DM] a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 87's History and Physical (H&P) dated 5/2/2025, the H&P indicated Resident 87 had the mental capacity to understand and make medical decisions. During a review of Resident 87's Minimum Data Set ([MDS] a resident assessment tool), dated 4/10/2025, the MDS indicated Resident 87's cognitive skills for daily decision making was intact (ability to think and reason). The MDS indicated Resident 87 required moderate assistance (helper does less than half the effort) for toileting hygiene, shower/bathing, dressing, and personal hygiene. The MDS indicated Resident 87 required supervision for eating and oral hygiene. During a review of Resident 87's Order Summary Report, dated 4/30/2025, the order summary report indicated to check Resident 87's IV line every shift until 5/19/2025. The order summary report indicated to change the IV line, IV dressing and IV cap every three days. During a review of Resident 87's Comprehensive Skin Evaluation/Assessment, dated 4/30/2025, the Comprehensive Skin Evaluation/Assessment indicated Resident 87 had a right and left antecubital (area in front of the elbow) IV with bruising. The Comprehensive Skin Evaluation/Assessment indicated Resident 87's left antecubital was noted with bright purple bruising. The Comprehensive Skin Evaluation/Assessment indicated the right antecubital was noted with a dressing that appeared to be coming undone and appeared to be worn out. During an interview on 5/5/2025 at 10:42 a.m. with Resident 87, Resident 87 stated he had a right arm IV for a month. Resident 87 stated the IV caused him pain and discomfort especially when dressing. Resident 87 stated staff never changed the IV or IV dressing. Resident 87 stated staff did not use the IV for medication administration. Resident 87 stated he did not know why he still had a right arm IV. Resident 87 stated no one had assessed his right arm IV and he thought it looked dirty. During an interview on 5/7/2025 at 3:54 p.m. with the Assistant Director of Nursing (ADON), the ADON stated Registered Nurses (RNs) are responsible for assessing IV sites, changing IV site dressings and administering IV medication. The ADON stated RNs assessed the IV site for redness, dressing placement, infiltration (when IV fluids or medications leak out of the vein and into the surrounding tissues) and bleeding. The ADON stated IV lines and dressings must be changed according to the physician's orders. The ADON stated IV's lines and dressing must be changed every three to seven days. The ADON stated it was important to change the IV lines and IV dressings to prevent IV infections. The ADON stated licensed nurses must inform the physicians if an IV line or IV dressing was not changed every 3 days and document the reason why it was not changed. During a concurrent interview and record review on 5/7/2025 at 4:15 p.m. with the ADON, Resident 87's IV Administration Record was reviewed. The ADON stated the IV Administration Record indicated she (ADON) assessed Resident 87's IV site from 5/1/2025 to 5/2/2025 and 5/5/2025 to 5/7/2025. The ADON stated from 5/1/2025 to 5/7/2025, Resident 87's IV line and dressing had not been changed. During an interview on 5/7/2025 at 4:21 p.m. with the ADON, the ADON stated she assessed Resident 87's left IV line. The ADON stated she did not know the date the IV dressing was labeled. The ADON stated she was supposed to know the date the IV line was placed because that was part of her assessment. The ADON stated she did not know when she should change the IV line or IV dressing. The ADON stated she did not inform the physician that she did not change Resident 87's IV line and dressing. The ADON stated she did not verify with Resident 87's physician that it ok to keep the IV line and dressing for nine days. The ADON stated Resident 87 returned from the hospital on 4/29/2025 and he had an IV line on the left arm. The ADON stated Resident 87 had a right IV line before he was transferred (4/25/2025) to the hospital but it was removed at the hospital. During an interview on 5/8/2025 at 10:47 a.m. with the ADON, the ADON stated Resident 87 only had a left IV line. The ADON stated it was acceptable to have the same IV line up to three weeks without changing it or changing the IV dressing. The ADON stated when Resident 87's antibiotic medication was administered, licensed nurses must date and initial the IV tubing to indicate when the medication was given to Resident 87. During a concurrent observation and interview on 5/8/2025 at 11:02 a.m. with the ADON, in Resident 87's room, Resident 87 was observed with an IV on his right arm. The ADON stated she did not know Resident 87 had an IV on his right arm. The ADON stated she thought the IV was removed when he was transferred to the hospital. The ADON stated the right arm IV had not been assessed or had a dressing change. The ADON stated the Treatment Nurse (TN) did not notify her of Resident 87's right arm IV. The ADON stated the TN must notify her of all IVs that residents have. The ADON stated she did not know how long Resident 87 had the right arm IV but he had it before he was transferred to the hospital on 4/25/2025. The ADON stated Resident 87 had the right arm IV for at least two weeks. The ADON stated the IV site did not look good, the IV tubing had blood, the IV site had bruising, the IV dressing was dirty and the IV dressing was peeling off and was hanging off the skin. The ADON states based on the IV appearance it had to be removed especially because the IV had not been flushed (injecting a small amount of saline solution (mixture of sterile water and salt) into the IV line to push out any residual medication or fluid). The ADON stated the staff missed Resident 87's right arm IV and someone should have noticed how bad it looked. During an interview on 5/8/2025 at 11:30 a.m. with the TN, the TN stated she did Resident 87's skin assessment when he returned to the facility from the hospital. The TN stated she documented Resident 87's left and right antecubital IV. The TN stated she assessed the right IV dressing and it looked old and worn out. The TN stated she documented her findings and informed the Director of Nursing (DON). The TN stated she did not inform the ADON about the right IV because registered nurses must do their own IV assessments. During an interview on 5/8/2025 at 3:49 p.m. with the DON, the DON stated on admission nurses must identify all IVs and document the location of the IVs. The DON stated it was important to document all IVs for continuity of communication and for the IVs to be monitored. The DON stated if an IV was not monitored it increased the chances of an infection. The DON stated it was a lack of communication Resident 87's right arm IV was missed. The DON stated if nursing staff did not know about the right arm IV, it meant that it was not monitored for infiltration, infection or if it was functioning. The DON stated the admitting nurse should have identified the right arm IV and documented the finding. The DON stated all IVs had to be changed every three days and seven days if the resident was a hard stick (a patient whose veins are difficult to access, leading to multiple attempts and potential complications). The DON stated IVs and IV dressings needed to be changed to prevent infection and for hygienic purposes. The DON stated if an IV or IV dressing was not changed as ordered, nurses must notify the physician. During a review of the facility's Policy and Procedure (P&P) titled Peripheral and Midline IV dressing changes, dated 3/2024, the P&P indicated the purpose for this procedure was to prevent complications associated with intravenous therapy, including catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings. The P&P indicated to perform IV site care and dressing change at established intervals or immediately if the integrity of the dressing is compromised (damp, loosened or visibly soiled). The P&P indicated to change the dressing at least every seven days. The P&P indicated to assess the peripheral/midline access device at least every 8 hours, check for expiration dates of the infusion, dressing and administration set.

CONCERN (E)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to initiate a care plan or have resident-centered interventions for three of six sampled residents (Residents 50, 8, and 16) when: 1. Resident 50's preference for an interpreter when communicating with doctors and healthcare staff was not included in his communication care plan. 2. Resident 8 did not have a care plan for the use of oxygen. 3. Resident 16 did not have a care plan for the use of oxygen. These deficient practices resulted in staff being unaware of Resident 50's preference for a Cambodian-speaking interpreter. These deficient practices had the potential for Resident 8 and 16 oxygen administration and potentially caused a delay and negatively affected the delivery of care. Findings: 1. During a review of Resident 50's admission Record, the admission Record indicated Resident 50 was originally admitted to the facility on [DATE] and most recently readmitted on [DATE]. Resident 50's admitting diagnoses included Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), generalized muscle weakness, reduced mobility, and depression (feeling of sadness). During a review of Resident 50's History and Physical (H&P), dated 10/5/2024, the H&P indicated Resident 50 had the capacity to understand make decisions. During a review of Resident 50's Minimum Data Set (MDS, a resident assessment tool) dated 3/18/2025, the MDS indicated Resident 50 had severe cognitive impairment (ability to think and reason. The MDS indicated Resident 50 required substantial/maximal assistance from 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 mobility. The MDS indicated Resident 50's preferred language was Cambodian and indicated Resident 50 needed or wanted an interpreter to communicate with doctors and healthcare staff. During a review of Resident 50's care plan titled [Resident 50] has a communication problem .speaks a foreign language (Cambodian), dated 6/20/2023, the care plan indicated interventions included encouraging the resident to state his thoughts, and to anticipate and meet the resident's needs. The care plan did not address the need for the use of an interpreter. During an observation on 5/6/2025 at 8:49 a.m., at Resident 50's bedside, Resident 50 was observed with slurred speech but able to state he spoke Cambodian. During a telephone interview on 5/7/2025 at 1:03 p.m., with Resident 50's Emergency Contact (EM) 1, EM 1 stated Resident 50 spoke Cambodian and only spoke a few words of English. EM 1 stated she sometimes visited Resident 50, and when she speaks to him in Cambodian, the resident understands what is being said. EM 1 stated it was hard for him to speak, but he would prefer the staff to speak to him in Cambodian. During a interview on 5/7/2025 at 1:26 p.m., with Certified Nursing Assistant (CNA) 2, CNA 2 stated she explained and provided all of Resident 50's care in English. CNA 2 stated she thought Resident 50 spoke English because she heard him say yes, no, and here while providing care. CNA 2 stated staff looked at his facial expressions to determine if he was accepting of the care being provided and stated Resident 50 often looked frustrated. CNA 2 stated Licensed Vocational Nurse (LVN) 3 did not state Resident 50 required an interpreter. CNA 2 stated she had not used an interpreter to communicate with Resident 50. During an observation on 5/7/2025 at 1:33 p.m., at Resident 50's bedside, observed CNA 2 speaking to Resident 50 in English. Resident 50 did not respond. CNA 2 walked away without collecting Resident 50's tray and exited the room. During an interview on 5/7/2025 at 1:44 p.m., with LVN 3, LVN 3 stated Resident 50 spoke Vietnamese. LVN 3 stated she did not use an interpreter to speak with Resident 50 or explain care. LVN 3 stated it was best and important to speak to residents in their preferred language to ensure that assessments were accurate and to ensure staff could identify the resident's needs and address them. During an observation on 5/8/2025 at 9:46 a.m., at Resident 50's bedside, observed Restorative Nurse Aide (RNA) 1 approach Resident 50's bedside. RNA 1 introduced himself in English and asked Resident 50, Do you want to do exercises? in English. Resident 50 grunted in response to RNA 1's question but did not verbalize a clear yes or no and did not nod his head yes or no. During a concurrent interview and record review, on 5/7/2025 at 3:28 p.m., with the Assistant Director of Nursing (ADON), Resident 50's MDS dated [DATE] and care plan titled [Resident 50] has a communication problem .speaks a foreign language (Cambodian), dated 6/20/2023, were reviewed. The ADON stated the MDS indicated Resident 50's preferred language was Cambodian and indicated the resident preferred to have an interpreter when communicating with doctors and healthcare staff. The ADON stated the preference for an interpreter was not documented in Resident 50's care plan. The ADON further stated the current care plan interventions could not be implemented without the use of an interpreter as there were no staff who spoke Cambodian. The ADON stated accommodation of language preferences were required to provide resident-centered care. 2. During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was originally admitted to the facility on [DATE] and readmitted on [DATE] with chronic obstructive pulmonary disease ([COPD], a chronic lung disease causing difficulty in breathing)) and diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 8's History and Physical (H&P) dated 4/3/2025, the H&P indicated Resident 8 was alert (awake and alert to surroundings). During a review of Resident 8's MDS dated [DATE], the MDS indicated Resident 8's cognitive skills for daily decision making was intact. The MDS indicated Resident 8 required supervision for eating. The MDS indicated Resident 8 required moderate assistance (helper does less than half the effort) for oral hygiene. The MDS indicated Resident 8 was dependent on staff for toileting hygiene, and shower/bathing. The MDS indicated Resident required maximal assistance (helper does more than half the effort) for upper body dressing and personal hygiene. During a review of Resident 8's electronic medical record, unable to locate a care plan for Resident 8's oxygen administration. During a review of Resident 8's Order Summary Report, dated 4/27/2025, the order summary report indicated to administer oxygen at two liters per minute via nasal cannula (a small plastic tube, which fits into residents' nostrils for providing supplemental oxygen). During an interview on 5/7/2025 at 3:42 p.m. with the ADON, the ADON stated oxygen administration should be care planned. The ADON stated a care plan would provide an outline for Resident 8's care. During a concurrent interview and record review on 5/8/2025 at 3:37 p.m. with the Director of Nursing (DON), Resident 8's care plans were reviewed. The DON stated Resident 8 did not have a care plan for oxygen administration. The DON stated the care plan would serve as a plan of care for proper care, to prevent a decline, and maintain proper function. The DON stated if there was no care plan, Resident 8 would not have any interventions to maintain safe oxygen administration. The DON stated a care plan would outline how many liters per minute would be delivered to Resident 8, what was Resident 8's oxygen saturation (measurement of how much oxygen blood is carrying), the goal, and the side effects of receiving oxygen. 3. During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was originally admitted to the facility on [DATE] and readmitted on [DATE] with heart failure (progressive heart disease that affects pumping action of the heart muscles, causes fatigue and shortness of breath) and peripheral vascular disease ([PVD], a slow progressive narrowing of the blood flow to the arms and legs). During a review of Resident 16's History and Physical (H&P) dated 3/12/2025, the H&P indicated Resident 16 did not have the capacity to understand and make decisions. During a review of Resident 16's MDS, dated [DATE], the MDS indicated Resident 16's cognitive skills for daily decision making was intact. The MDS indicated Resident 16 required moderate assistance for eating. The MDS indicated Resident 16 required maximal assistance for oral hygiene, toileting hygiene, shower/bathing, dressing and personal hygiene. During a review of Resident 16's Order Summary Report, dated 12/19/2023, the order summary report indicated Resident 16 had an order to administer oxygen at two liters per minute via nasal cannula. During a concurrent interview and record review on 5/8/2025 at 3:42 p.m. with the Director of Nursing (DON), Resident 16's care plans were reviewed. The DON stated Resident 16 did not have a care plan for oxygen administration. The DON stated Resident 16 needed a care plan for oxygen administration because it would inform licensed nurses why the resident needed oxygen, what to do if the oxygen saturation was lower than Resident 16's goal, and outline interventions to make oxygen therapy beneficial and safe. During a review of the facility's policy and procedure (P&P) titled Comprehensive Assessments, dated 2001, the P&P indicated comprehensive assessments (MDS) were conducted to assist in developing the comprehensive resident-centered care plans. During a review of the facility's P&P titled Care Plans, Comprehensive Person-Centered, dated 2001, the P&P indicated care plan interventions were to be derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

CONCERN (E)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received necessary respiratory care and services consistent with the resident's plan of care for three of 26 sampled residents (Resident 8, 16, 39). For Resident 8, who had a diagnosis of chronic obstructive pulmonary disease (COPD, a chronic lung disease causing difficulty in breathing), there was no assessment of the oxygen saturation (measurement of the amount of oxygen in the blood). For Residents 8, 16 and 39, the prescribed liters of oxygen were not administered to the residents per the physician's order. These deficient practices had the potential to cause a negative respiratory outcome and placed residents at risk of injury due to fire hazard. Findings: 1. During a review of Resident 8's admission Record, the admission Record indicated Resident 8 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including COPD and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 8's Minimum Data Set (MDS, a resident assessment tool), dated 3/21/2025, the MDS indicated Resident 8's cognitive skills for daily decision making was intact and required supervision for eating. The MDS indicated Resident 8 required moderate assistance (helper does less than half the effort) for oral hygiene and was dependent on staff for toileting hygiene, shower/bathing. The MDS indicated Resident 8 required maximal assistance (helper does more than half the effort) for upper body dressing and personal hygiene. During a review of the Physician's Order Summary Report, dated 4/27/2025, the order summary report indicated Resident 8 was to receive oxygen at two liters per minute via nasal cannula (a small plastic tube, which fits into residents' nostrils for providing supplemental oxygen), may titrate oxygen if saturation was less than 92%. During a review of Resident 8's Vital Signs Summary, dated 1/1/2025 to 4/29/2025, the Vital Signs Summary indicated Resident 8's oxygen saturations were between 96% - 98%. The Vital Signs Summary did not indicate Resident 8's oxygen saturations were less than 92%. During a review of Resident 8's electronic medical record, there was no documentation of the Vital Signs Summary for oxygen saturations dated from 5/1/2025 - 5/8/2025. During an observation on 5/5/2025 at 12:45 p.m., an observation on 5/6/2025 at 12:04 p.m., an observation on 5/7/2025 at 12:10 p.m., and an observation on 5/8/2025 at 9:02 a.m., in Resident 8's room, Resident 8 received four liters of oxygen per minute and there was no Oxygen in Use sign placed outside of Resident 8's room. During an interview on 5/8/2025 at 11 a.m., the Assistant Director of Nursing (ADON) stated to titrate oxygen meant to increase the oxygen liters delivered to a resident to maintain oxygen saturation at a certain level. The ADON stated it was important to check oxygen saturation to make sure residents received enough oxygen, because residents' oxygen saturation could drop, even though they were receiving oxygen. During a concurrent interview and record review on 5/8/2025 at 11:06 a.m. with ADON, Resident 8's Vital Signs Summary, dated 4/1/2025 - 4/29/2025 was reviewed. The ADON stated that on 4/29/2025, Resident 8's oxygen saturation was 97% and she should receive two liters of oxygen instead of the four liters. The ADON stated the licensed nurse should have checked Resident 8's oxygen saturation during medication pass and documented it. During a concurrent interview and record review on 5/8/2025 at 11:10 a.m. with ADON, Resident 8's Vital Signs Summary, dated 5/1/2025 - 5/8/2025 was reviewed. The ADON stated Resident 8 oxygen saturation was not monitored on 5/1 - 5/8/2025. The ADON stated Resident 8's oxygen should have been monitored every day to ensure Resident 8 was receiving enough oxygen. During a concurrent observation and interview on 5/8/2025 at 11:15 a.m. with ADON, in the hallway in front of Resident 8's room, there was no Oxygen in Use sign outside of Resident 8's room. The ADON stated and agreed Resident 8 did not have an Oxygen in Use sign outside the room and all residents with oxygen therapy must have one to alert residents, visitors and staff to not smoke. The ADON stated all licensed nurses were responsible for placing this sign in the designated areas. The ADON stated Certified Nursing Assistants (CNA) were also responsible to report it to their charge nurse when they did not see the sign. During a concurrent interview and record review on 5/8/2025 at 3:37 p.m. with the Director of Nursing (DON), Resident 8's care plans were reviewed. The DON stated Resident 8 did not have a care plan for oxygen administration as the care plan would serve as a plan of care for proper care, to prevent a decline, and maintain proper function. The DON stated that since there was no care plan, Resident 8 did not have any interventions to maintain safe oxygen administration. The DON stated a care plan would outline the goal and the side effects of the resident receiving oxygen. 2. During a review of Resident 16's admission Record, the admission Record indicated Resident 16 was readmitted to the facility on [DATE] with diagnoses including heart failure (progressive heart disease that affects pumping action of the heart muscles, causes fatigue and shortness of breath) and peripheral vascular disease (PVD, a slow progressive narrowing of the blood flow to the arms and legs). During a review of the Physician's Order Summary Report, dated 12/19/2023, the order summary report indicated Resident 16 was to receive oxygen at two liters per minute via nasal cannula. During a review of Resident 16's History and Physical (H&P) dated 3/12/2025, the H&P indicated Resident 16 did not have the capacity to understand and make decisions. During a review of Resident 16' MDS, dated [DATE], the MDS indicated Resident 16's cognitive skills for daily decision making were intact and the resident required moderate assistance for eating. The MDS indicated Resident 16 required maximal assistance for oral hygiene, toileting hygiene, shower/bathing, dressing and personal hygiene. During an observation on 5/5/2025 at 10:36 a.m., and an observation on 5/6/2025 at 8:21 a.m., in Resident 16's room, Resident 16 received one liter of oxygen per minute and there was no Oxygen in Use sign placed outside of Resident 16's room. During an observation on 5/7/2025 at 3:21 p.m., in Resident 16's room, Resident 16 received 2.5 liters of oxygen per minute. During a concurrent interview and record review on 5/8/2025 at 3:42 p.m. with the DON, Resident 16's care plans were reviewed. The DON stated Resident 16 did not have a care plan for oxygen administration. The DON stated Resident 16 needed a care plan for oxygen administration because it would inform licensed nurses why the resident needed oxygen, what to do if the oxygen saturation was lower than Resident 16's goal, and outline interventions to make oxygen therapy beneficial and safe. 3. During a review of Resident 34's admission Record, the admission Record indicated Resident 34 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including COPD and sequelae of cerebral infarction (the long-term consequences or lasting effects of a stroke). During a review of the Physician's Order Summary Report, dated 3/27/2025, the order summary report indicated Resident 34 had an order for oxygen at two liters per minute via nasal cannula for COPD. During a review of Resident 34's H&P dated 3/28/2025, the H&P indicated Resident 34 had fluctuating capacity to understand and make decisions. During a review of Resident 34' MDS, dated [DATE], the MDS indicated Resident 34's cognitive skills for daily decision making were severely impaired and was dependent on staff for all activities of daily living. During a review of Resident 34's care plan titled, Oxygen Therapy, dated 6/27/2024, the care plan indicated the goal was for Resident 34 not to have signs and symptoms of poor oxygen absorption (process where oxygen, typically from inhaled air, enters the bloodstream within the lungs). The care plan interventions indicated to monitor signs and symptoms of respiratory distress (difficulty breathing, with signs like rapid or shallow breathing, and a low oxygen level in the blood), change resident position every two hours to facilitate lung secretion movement and drainage, and promote lung expansion and improve air exchange by positioning with proper body alignment. During an observation on 5/5/2025 at 11:37 a.m. in Resident 34's room, Resident 34 received three liters of oxygen per minute and there was no Oxygen in Use sign was placed outside of Resident 34's room. During an observation on 5/6/2025 at 12:49 p.m., and on 5/7/2025 at 11:56 a.m., in Resident 34's room, Resident 34 received 2.5 liters of oxygen per minute and there was no Oxygen in Use sign was placed outside of Resident 34's room. During an interview on 5/7/2025 at 3:42 p.m., the ADON stated if a resident received less oxygen than what the physician ordered, the resident would not receive appropriate oxygen perfusion and may cause a change in the resident's mental status. The ADON stated when a resident received more oxygen than what the physician ordered, resident lungs could hyperinflate (air trapped in the lungs, causing shortness of breath, chest tightness and fatigue) and cause the resident to work harder to breathe. The ADON stated it was important to deliver the correct liters of oxygen to a resident, to follow the physician's order, and for oxygen therapy to be beneficial to the residents. The ADON stated all residents on oxygen therapy should have an Oxygen is Use sign outside their room to notify all resident, visitors and staff not to smoke to prevent a fire. The ADON stated if there was no sign outside of the residents' room it could potentially be a hazard to residents' safety. During an interview on 5/8/2025 at 3:19 p.m., the DON stated it was important to deliver the correct amount of oxygen to residents to make them comfortable and stabilize them when in respiratory distress. The DON stated not providing the correct liters of oxygen to a resident was not following the physician's order. The DON stated it was important to follow physician's orders to keep residents healthy and maintain residents at their normal functional level. The DON stated the facility provided an Oxygen in Use sign when a resident was on oxygen therapy to inform staff, residents and visitors not to smoke because oxygen was combustible and can cause a fire. During a review of facility's policy and procedure (P&P) titled, Oxygen Administration, dated 2/2024, the P&P indicated its purpose was for a safe oxygen administration, staff would verify the physician's orders for oxygen administration and review the resident care plan. The P&P indicated an Oxygen in Use sign would be placed outside of resident's room entrance door and an Oxygen in Use sign would be placed over resident's bed.

CONCERN (E)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the licensed nursing staff failed to ensure the physician's orders to hold medications were followed, medications were administered timely, and medications administered were accurately documented for four of six sampled residents (Resident 5, 93, 84, and 89) when: 1. Resident 89's order to hold medications on scheduled dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) days was clarified with Nurse Practitioner (NP) 2. 2. Resident 93's newly prescribed dose of fluconazole (a medication used to treat fungal infections) was administered timely from 5/4/2025 to 5/6/2025. 3. Resident 93's Antibiotic (medication used to treat infection) Medication Count Sheet was accurate and complete to account for all 10 doses of Resident 93's ordered doses of fluconazole. 4. Resident 5's Pregabalin (a medication used to treat nerve pain) Medication Count Sheet was accurate and complete to account for all 28 doses. 5. Resident 84's Pregabalin Medication Count Sheet was accurate and complete to account for all 30 doses. These failures had the potential to result in a hypotensive crisis ([low blood pressure]- a condition in which the force of the blood pushing against the artery walls is too low) and hospitalization or death for Resident 89. These failures resulted in a two-day delay in the treatment of Resident 93's fungal infection. These failures also had the potential to result in missing or unaccounted doses of Fluconazole and Pregabalin, drug diversion (the illegal distribution or abuse of prescription drugs or their use for unintended purposes), medication errors, and overdose (receive higher than the prescribed amount). Findings: a. During a review of Resident 89's admission Record, the admission Record indicated Resident 89 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease (ESRD- irreversible kidney failure), dialysis, and muscle weakness. During a review of Resident 89's Minimum Data Set ([MDS], a resident assessment tool), dated 4/22/2025, the MDS indicated Resident 89's cognitive skills (ability to think and reason) for daily decision making was intact. The MDS indicated Resident 89 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). During an interview on 5/6/2025 at 9:17 a.m. with Resident 89, Resident 89 stated his normal dialysis days were Tuesdays, Thursdays, and Saturdays. Resident 89 stated he was getting ready to go to his dialysis treatment session and the session was scheduled for 10 a.m. that morning. During a concurrent interview and observation on 5/6/2025 at 9:18 a.m. with Licensed Vocational Nurse (LVN) 6, Resident 89's medication administration pass was observed. LVN 6 administered Resident 89 his ordered dose of nifedipine (a medication used to lower blood pressure) extended release (ER- drug is released slowly over time) tablet 30 milligrams (mg-a unit of measurement), carvedilol (a medication used to lower blood pressure) tablet 6.25 mg, and isosorbide mononitrate (a medication used to lower blood pressure) ER tablet 60 mg. During a concurrent interview and record review on 5/6/2025 at 9:30 a.m. with LVN 6, Resident 89's Physician Orders, dated 5/6/2025, were reviewed. The Physician Orders indicated medications were to be held on dialysis days, every Tuesday, Thursday and Saturday. LVN 6 stated she administered Resident 89's blood pressure (the pressure of circulating blood against the walls of blood vessels) medications and she should have held the medications and clarified the order with Nurse Practitioner (NP) 2. LVN 6 stated her interpretation of the order was to hold Resident 89's medications while Resident 89 was out of the facility for dialysis. During an interview on 5/06/2025 at 1:40 p.m. with NP 2, NP 2 stated he ordered to hold all medications on Resident 89's dialysis days. NP 2 stated the order was not clear and the order should have been clarified to read to hold blood pressure medications on dialysis days. NP 2 stated he would have expected the nurses to clarify the order with him to hold Resident 89's blood pressure medications on dialysis days. NP 2 stated it was the standard of practice for nurses to hold blood pressure medications prior to a resident's dialysis session. NP 2 stated there was potential for Resident 89 to lose too much fluid and to have his blood pressure significantly lowered. During a concurrent interview and record review on 5/8/2025 at 8:57 a.m. with the Director of Nursing (DON), Resident 89's Physician Orders, dated 5/6/2025, were reviewed. The DON stated LVN 6 should have held Resident 89's blood pressure medications and clarified the medication order with NP 2. The DON stated the administration of the blood pressure medications placed Resident 89 a risk for his blood pressure to drop significantly and for Resident 89 to become sick. b. During a review of Resident 93's admission Record, the admission Record indicated Resident 93 was originally admitted to the facility on [DATE] with diagnoses that included methicillin resistant staphylococcus aureus (MRSA - a bacteria that does not respond to antibiotics) infection, urinary tract infection (UTI- an infection in the bladder/urinary tract), and hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body). During a review of Resident 93's History and Physical (H&P), dated 5/4/2025, the H&P indicated Resident 93 did not have the capacity to make medical decisions. During a review of Resident 93's Order Summary Report, dated 5/2025, the Order Summary Report indicated Resident 93 was ordered to start Fluconazole Oral Tablet 200 mg one time a day for a fungal infection for 10 days on 5/4/2025. During a concurrent interview and record review on 5/6/2025 at 3:02 p.m. with LVN 5, Resident 93's Antibiotic Medication Count Sheet, dated 5/2025, was reviewed. The Antibiotic Medication Count Sheet indicated there were nine doses left in Resident 93's bubble pack supply of fluconazole. LVN 5 stated the normal process was to prepare the medication and document the remaining doses in the Antibiotic Medication Count Sheet to account for all doses of the medication. During a concurrent interview and observation on 5/6/2025 at 3:02 p.m. with LVN 5, Resident 93's bubble pack supply of fluconazole was completely intact and had 10 doses remaining. LVN 5 stated she signed and documented the preparation of Resident 93's dose of fluconazole in Resident 93's Antibiotic Medication Count Sheet, but she forgot to physically administer Resident 93's dose of fluconazole. LVN 5 stated Resident 93's Antibiotic Medication Count Sheet was inaccurate because 10 doses remained in the bubble pack. LVN 5 stated she did not administer the Fluconazole as ordered and should have ensured the Antibiotic Medication Count Sheet was accurate. LVN 5 stated this placed Resident 93 at risk for a medication error, a delay in treatment, and could have led to an undetected controlled medication discrepancy. During a concurrent interview and record review on 5/8/2025 at 7:47 a.m. with LVN 1, Resident 5's Order Summary Report, dated 5/2025, was reviewed. The Order Summary Report indicated Resident 93 was ordered to start Fluconazole Oral Tablet 200 mg one time a day for fungal infections for 10 days on 5/4/2025. LVN 1 stated she was Resident 93's assigned LVN for the 7 a.m. to 3 p.m. shift on 5/4/2025. LVN 1 stated Resident 93's dose of fluconazole had not been delivered to the facility during her shift. LVN 1 stated she should have taken the ordered dose of fluconazole from the facility's emergency kit (e-kit) to administer to Resident 93 instead of waiting for the medication to be delivered by the pharmacy. LVN 1 stated she forgot to consider removing the fluconazole from the e-kit, and this delayed the treatment of Resident 93's fungal infection. LVN 1 stated the delay in treatment placed Resident 93 at risk for her fungal infection to spread throughout her body. During an interview on 5/8/202 at 8:57 a.m. with the DON, the DON stated a newly prescribed anti-infective should be supplied within four hours of the order. The DON stated Resident 93 ordered dose of fluconazole should have been taken from the e-kit and administered right away (on 5/4/2025). The DON stated this placed Resident 93 at risk for an untreated infection. c. During a review of Resident 5's admission Record, the admission Record indicated Resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), peripheral vascular disease (PVD - a slow progressive narrowing of the blood flow to the arms and legs), and neuropathy (disease or dysfunction of one or more nerves, typically causing numbness or weakness in the hands and feet). During a review of Resident 5's MDS, dated [DATE], the MDS indicated Resident 5's cognitive skills for daily decision making was intact. The MDS indicated Resident 5 required supervision when performing activities of daily living. During a concurrent observation, interview, and record review on 5/6/2025 at 3:02 p.m. with LVN 5, Resident 5's Pregabalin Medication Count Sheet, dated 5/2025, was reviewed. Observed Resident 5's bubble pack of pregabalin. The bubble pack had 23 doses remaining. The Pregabalin Medication Count Sheet indicated 24 doses of pregabalin remained in the bubble pack. LVN 5 stated she forgot to document the preparation of Resident 5's dose of pregabalin on the Pregabalin Medication Count Sheet. LVN 5 stated this placed Resident 5 at risk for a medication error, accidental overdose, and could have led to an undetected controlled medication discrepancy. d. During a review of Resident 84's admission Record, the admission Record indicated Resident 84 was admitted to the facility on [DATE] with diagnoses that included spinal stenosis (a condition characterized by the narrowing of spaces in the spine, which can compress the spinal cord and nerves), post dysenteric arthropathy (a specific type of inflammatory joint disease that occurs following a dysentery [a stomach disease] infection), and muscle weakness. During a review of Resident 84's MDS, dated [DATE], the MDS indicated Resident 84's cognitive skills for daily decision making was intact. The MDS indicated Resident 84 was dependent on staff for toileting hygiene, showering, lower body dressing, and putting on footwear. The MDS indicated Resident 84 required substantial assistance (helper does more than half of the effort) for bed mobility. During a concurrent observation, interview, and record review on 5/7/2025 at 9:50 a.m. with LVN 4, Resident 84's Pregabalin Medication Count Sheet, dated 5/2025, was reviewed. Observed Resident 84's bubble pack of pregabalin. The bubble pack had three doses remaining. The Pregabalin Medication Count Sheet indicated four doses of pregabalin remained in the bubble pack. LVN 4 stated she forgot to document the preparation of Resident 84's dose of pregabalin on the Pregabalin Medication Count Sheet. LVN 4 stated this placed Resident 84 at risk for a medication error and could have led to drug diversion. During an interview on 5/8/202 at 8:57 a.m. with the DON, the DON stated the normal process for the administration of controlled drugs was to prepare the controlled drug and document the remaining doses on the medication count sheet. The DON stated if the medication count sheet for the controlled drug was inaccurate issues could arise. The DON stated this would increase the risk for drug diversion or for a resident to accidentally miss a dose or receive a double dose. During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, dated 2001, the P&P indicated the facility was to ensure medications were administered in a safe and timely manner and as prescribed. The P&P indicated medications were to be administered within one hour of their prescribed time, unless otherwise specified. The P&P indicated the person preparing a medication that was identified as having potential adverse consequences for the resident should contact the prescriber or the resident's attending physician to discuss the concerns. During a review of the facility's P&P titled, Charting and Documentation, dated 2001, the P&P indicated medications administered and treatments or services performed were to be documented in the resident's medical record.

CONCERN (E)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 83 and Resident 87) were free from significant medication errors (one which causes the resident discomfort or jeopardizes his or her health and safety) by failing to: 1. Ensure licensed nurses held medications for Resident 83 and Resident 87 on scheduled hemodialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed) days per the physician orders. The deficient practice had the potential to result in a hypotensive crisis (low blood pressure) leading to harm or hospitalization. Findings: a. During a review of Resident 87's admission Record, the admission Record indicated Resident 87 was admitted to the facility on [DATE] with diagnoses of end stage of renal disease (ESRD, 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 transplant to maintain life) and diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 87's History and Physical (H&P) dated 5/2/2025, the H&P indicated Resident 87 had the mental capacity to understand and make medical decisions. During a review of Resident 87's Minimum Data Set ([MDS] a resident assessment tool), dated 4/10/2025, the MDS indicated Resident 87's cognitive skills for daily decision making was intact (ability to think and reason). The MDS indicated Resident 87 required moderate assistance (helper does less than half the effort) for toileting hygiene, showering/bathing, dressing, and personal hygiene. The MDS indicated Resident 87 required supervision for eating and oral hygiene. During a review of Resident 87's Order Summary Report, dated 4/30/2025, the order summary report indicated to hold medications on dialysis days. During a review of Resident 87's Medication Administration Record (MAR), dated 5/1/2025 - 5/7/2025, the MAR indicated medications were to be held on Resident 87's dialysis days. The MAR indicated on 5/2/2025 and 5/5/2025 Resident 87 received the following: 1. Protonix 40 milligrams ([mg], unit of measurement) for gastroesophageal reflux disease ([GERD] digestive disease in which stomach acid or bile irritates the food pipe lining). 2. Docusate (stool softner) 100 mg. 3. Ferrous sulfate (supplement) 325 mg. 4. [NAME]-Vite (supplement). 5. Thiamine (supplement) 100 mg. 6. Furosemide (medication used to remove excess fluid from the body) 100 mg. During a concurrent interview and record review on 5/7/2025 at 4:15 p.m. with the Assistant Director of Nursing (ADON), Resident 87's MAR dated 5/1/2025 - 5/7/2025 was reviewed. The ADON stated when there was an order to hold medication on dialysis days it meant to hold blood pressure medications (drugs used to treat high blood pressure). The ADON stated she did not know Resident 87 was not ordered blood pressure medication. The ADON stated based on Resident 87's MAR, all medications should be held because the order did not identify which medication to hold. The ADON stated on Resident 87's dialysis days the resident received all his medications. The ADON stated based on the MAR, furosemide should have not been given to Resident 87 because it would lower Resident 87's blood pressure and his dialysis treatment would potentially lower his blood pressure as well. The ADON stated licensed nurses should have contacted Resident 87's physician to clarify which medication was ordered to be held. The ADON stated licensed nurses did not follow the physician order. The ADON stated it was important to follow the physician's order for resident safety, prevent health complications, and maintain a better quality of life. During an interview on 5/8/2025 at 11:47 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated when there was an order to hold medications on dialysis days it meant to hold all medications on the days a resident has dialysis. LVN 4 stated she was not aware Resident 87 had an order to hold his medications on his dialysis days. LVN 4 stated she administered medications to Resident 87 on his dialysis days. LVN 4 stated if she was aware of the order she would have held all of Resident 87's medications because the order did not specify which medications to hold. LVN 4 stated by not holding all medications she did not follow the physician's order. LVN 4 stated it was important to follow the physician's orders to prevent health complications. During an interview on 5/8/2025 at 3:28 p.m. with the Director of Nursing (DON), the DON stated when there was an order to hold medications on dialysis days, they must hold all medications. The DON stated if a nurse needed clarification on a medication order they must call the residents physicians. The DON stated nurses did not follow the physician's order because medications were administered to Resident 87 on his dialysis days. The DON stated if a medication was not held it could potentially lower the residents' blood pressure and cause complications while at dialysis. b. During a review of Resident 83's admission Record, the admission record indicated the facility admitted Resident 83 on 1/28/2025 with diagnoses including but not limited to ESRD, chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), and DM. During a review of Resident 83's MDS, dated [DATE], indicated Resident 83's cognitive skills for daily decision making were moderately impaired. The MDS indicated Resident 83 required hemodialysis. During a review of Resident 83's Dialysis Care Plan, initiated on 1/29/2025, the care plan indicated to hold blood pressure medications as ordered by the physician. During an interview on 5/7/2025 at 9:20 a.m. with Resident 83, Resident 83 stated he received his blood pressure medications and was getting ready to go to his dialysis appointment. During a concurrent interview and record review on 5/7/2025 at 9:31 a.m. with LVN 1, Resident 83's physician's orders dated 5/7/2025, and electronic Medication Administration Record (eMAR), dated 4/18/2025 to 5/7/2025, were reviewed. LVN 1 stated she administered carvedilol (used to treat heart failure and hypertension) oral tablet 12.5 milligram (mg, unit of weight), nifedipine (used to treat high blood pressure and to control chest pain) ER (externed release) oral tablet 60 mg, and hydralazine (used to treat high blood pressure) oral tablet 25 mg at 9:00 a.m. to Resident 83 on 4/19/2025, 4/22/2025, 4/26/2025, 5/3/2025 and 5/6/2025. LVN 1 stated she did not check the physician's orders before administering Resident 83's blood pressure medications. LVN 1 stated this error placed Resident 83 at risk for hypotension and bradycardia (slowed heart rate). During a concurrent interview and record review on 5/7/2025 at 9:33 a.m. with Registered Nurse (RN) 1, Resident 83's physician's orders dated 5/7/2025, and eMAR, dated 4/18/2025 to 5/7/2025, were reviewed. RN 1 stated LVN 1 should have held the blood pressure medications on 4/19/2025, 4/22/2025, 4/26/2025, 5/3/2025 and 5/6/2025 as ordered by the physician. During an interview on 5/7/2025 at 1:20 p.m. with the DON, the DON stated LVN 1 should have held the blood pressure medications on Resident 83's dialysis days. The DON stated the administration of blood pressure medications on Resident 83's dialysis days placed Resident 83 at risk for dizziness and passing out during his dialysis session. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 2001, the P&P indicated, Medications would be administered in a safe, timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame.

Jan 2025 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the State Survey Agency (Bureau of Health Facility Licensing, Certification and Resident Assessment, within the Department of Public Health), a written report of the findings of the investigation of an allegation of abuse within five (5) working days of the occurrence of an incident of physical abuse for two of four sampled residents (Residents 1 and 2). This deficient practice had the potential to result in a delay in the State Survey Agency's investigation, unidentified abuse in the facility, and placed Residents 1 and 2 at risk for elder abuse. Findings: a. 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 originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including dementia (a progressive state of decline in mental abilities), anxiety (feeling of fear), dysphagia (difficulty swallowing), and muscle weakness (loss of muscle strength). During a review of Resident 1's Minimum Data Set ([MDS]- a resident assessment tool), dated 12/31/2024, the MDS indicated Resident 1 ' s cognitive (the ability to think and process information) skills for daily decision making was moderately impaired. The MDS indicated Resident 1 was dependent (helper does all the effort) 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). During a review of Resident 1 ' s History and Physical (H&P), dated 12/3/2024, the H&P indicated Resident 1 did not have the capacity for medical decision making. During a review of Resident 1 ' s situation, background, assessment, recommendation ([SBAR]-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 1/9/2025, the SBAR indicated Resident 1 was monitored for emotional distress manifested by (m/b) a physical altercation (angry dispute) with Resident 2 on 1/9/2025. b. During a review of Resident 2 ' s Face Sheet, the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including altered mental status (change in person ' s mental function), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 2 ' s MDS, dated [DATE], the MDS indicated Resident 2 ' s cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 2 required supervision or touching assistance (helper provides verbal cues and /or touching/steadying assistance as resident completes activity) from staff for ADLs. During a review of Resident 2 ' s SBAR, dated 1/9/2025, the SBAR indicated on 1/9/2025 Resident 2 was physically aggressive toward Resident 1. The SBAR indicated Resident 2 was agitated (upset) and irritated (angry) and hit Resident 1. During an interview on 1/23/2025 at 9:50 a.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated on 1/9/2025 around 5:30 p.m., Resident 1 was lying in bed and talking loudly. LVN 1 stated Resident 2 asked Resident 1 if he (Resident 1) could stop talking so loudly. LVN 1 stated while Resident 1 continued talking loudly Resident 2 became irritated and agitated, stood up from his bed approached Resident 1 and hit Resident 1 on the face. During a review of a 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), dated 1/9/2025 indicated the incident between Residents 1 and 2 was reported to the Los Angeles County Department of Public Health, Health Inspection Division on 1/9/2025 via fax (an image of a document made by electronic scanning). During an interview on 1/23/2025 at 2:45 p.m., with the Director of Nursing (DON), the DON stated, I will be honest with you regarding the 5- days Investigation Report, it was completed on 1/16/2025 but was not faxed to CDPH within 5 days. During a review of the facility ' s policy and procedure (P&P) titled Abuse, Neglect, exploitation or Misappropriation-Reporting Investigating, revised 9/2022, the P&P indicated reports of resident abuse would be reported to local and federal agencies. The P&P indicated facility shall provide a written report of the findings of abuse investigations within five (5) working day of the reported allegations. 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 the findings of the investigation of an allegation of abuse within five (5) working days of the occurrence of an incident of physical abuse for two of four sampled residents (Residents 1 and 2). This deficient practice had the potential to result in a delay in the State Survey Agency's investigation, unidentified abuse in the facility, and placed Residents 1 and 2 at risk for elder abuse. Findings: a. 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 originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including dementia (a progressive state of decline in mental abilities), anxiety (feeling of fear), dysphagia (difficulty swallowing), and muscle weakness (loss of muscle strength). During a review of Resident 1's Minimum Data Set ([MDS]- a resident assessment tool), dated 12/31/2024, the MDS indicated Resident 1's cognitive (the ability to think and process information) skills for daily decision making was moderately impaired. The MDS indicated Resident 1 was dependent (helper does all the effort) 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). During a review of Resident 1's History and Physical (H&P), dated 12/3/2024, the H&P indicated Resident 1 did not have the capacity for medical decision making. During a review of Resident 1's situation, background, assessment, recommendation ([SBAR]-a communication tool used by healthcare workers when there is a change of condition among the residents), dated 1/9/2025, the SBAR indicated Resident 1 was monitored for emotional distress manifested by (m/b) a physical altercation (angry dispute) with Resident 2 on 1/9/2025. b. During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including altered mental status (change in person's mental function), diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and seizure (a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness). During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognitive skills for daily decision making was severely impaired. The MDS indicated Resident 2 required supervision or touching assistance (helper provides verbal cues and /or touching/steadying assistance as resident completes activity) from staff for ADLs. During a review of Resident 2's SBAR, dated 1/9/2025, the SBAR indicated on 1/9/2025 Resident 2 was physically aggressive toward Resident 1. The SBAR indicated Resident 2 was agitated (upset) and irritated (angry) and hit Resident 1. During an interview on 1/23/2025 at 9:50 a.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated on 1/9/2025 around 5:30 p.m., Resident 1 was lying in bed and talking loudly. LVN 1 stated Resident 2 asked Resident 1 if he (Resident 1) could stop talking so loudly. LVN 1 stated while Resident 1 continued talking loudly Resident 2 became irritated and agitated, stood up from his bed approached Resident 1 and hit Resident 1 on the face. During a review of a 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), dated 1/9/2025 indicated the incident between Residents 1 and 2 was reported to the Los Angeles County Department of Public Health, Health Inspection Division on 1/9/2025 via fax (an image of a document made by electronic scanning). During an interview on 1/23/2025 at 2:45 p.m., with the Director of Nursing (DON), the DON stated, I will be honest with you regarding the 5- days Investigation Report, it was completed on 1/16/2025 but was not faxed to CDPH within 5 days. During a review of the facility's policy and procedure (P&P) titled Abuse, Neglect, exploitation or Misappropriation-Reporting Investigating , revised 9/2022, the P&P indicated reports of resident abuse would be reported to local and federal agencies. The P&P indicated facility shall provide a written report of the findings of abuse investigations within five (5) working day of the reported allegations.

Dec 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents ' (Resident 1) muscle relaxant medication was readily available for use when needed and the injection medication for physician ' s administration to manage resident ' s pain was available. This failure placed the resident at risk for discomfort and severe pain, which can affect in maintaining the resident ' s highest practicable physical, mental, and psychosocial well-being. 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 osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), hereditary and idiopathic neuropathy (nerve damage), and chronic pain syndrome (pain that lasts longer than three months). During a review of Resident 1 ' s History and Physical (H&P) dated 11/23/2024, the H&P indicated Resident 1 had the mental capacity to understand and make medical decisions. During a review of Resident 1 ' s Minimum Data Set (MDS – a resident assessment tool) dated 11/28/2024, the MDS indicated Resident 1 had intact cognitive skills (thought process). The MDS indicated Resident 1 required partial to moderate assistance with activities of daily living (ADLs) 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). 1). During a review of Resident 1 ' s physician ' s order dated 11/26/2024, the order indicated Metaxalone Oral Tablet 800 mg give 1 tablet by mouth every eight (8) hours as needed (PRN) for muscle relaxant. During a review of Resident 1 ' s Medication Administration Record (MAR) for 12/ 2024, the MAR indicated Metaxalone 800 mg was last administered on 12/8/2024. 2). During a review of Resident 1 ' s physician ' s order dated 12/3/2024, the physician ordered two (2) vials of lidocaine (a medication to numb area of the body to reduce pain or discomfort) 1% (one [1] cubic centimeter [cc, unit of measurement] needed for each injection) and 2 vials of Kenalog (medicine to reduce inflammation) 40 mg/ milliliter ([ml] a unit of measurement, 1 cc will be used for each injection) for bilateral shoulder osteoarthritis. During a review of Resident 1 ' s December 2024 MAR, the MAR did not indicate the physician ' s order on 12/3/2024 for the lidocaine 1% and Kenalog 40 mg orders. During an interview on 12/10/2024 at 10:00 a.m., Resident 1 stated the doctor had prescribed Resident 1 muscle relaxant (Metaxalone) when needed. Resident 1 stated when she needed the muscle relaxant (Metaxalone) in the last 2 days ago, the nurse (unidentified) had told her that the medication (Metaxalone) was not available, and the pharmacy had not delivered the medication. Resident 1 stated she also gets the pain medicine injection Kenalog for her shoulder pain due to osteoarthritis. Resident 1 stated the doctor had ordered the medication Kenalog injection one or two weeks ago. Resident 1 stated, when the physician came today (12/10/2024) to give the injection (Kenalog), the medication was not available. Resident 1 stated the nurse had told her, that the pharmacy had not delivered the medication. During an interview on 12/10/2024 at 12:31 p.m., License Vocational Nurse 1 (LVN 1) stated Resident 1 ' s refill for the muscle relaxant medication (Metaxalone) was sent to the pharmacy on 12/9/2024. LVN 1 stated, the Metaxalone had not been delivered yet. The LVN 1 stated if medications were not received timely, the nurse should follow up from the pharmacy. The LVN 1 stated nurses should have ordered refills for the medications when there were 3 to 4 pills left. LVN 1 stated the Kenalog vials for injection ordered by the physician last 12/3/2024, was not delivered as well. LVN 1 stated it was important to follow up the delivery of the medications from the pharmacy so it will be available for Resident 1. LVN 1 stated, if Resident 1 was in pain, Resident 1 would not be comfortable and would be at risk of being anxious due to uncontrolled pain. During an interview on 12/10/2024 at 3:00 p.m., the Director of Nursing (DON) stated nurses should order medication refills by faxing the medication sticker when there are 2 or 3 tablets left and call the pharmacy to make sure the refill request was received. The DON stated pharmacy usually delivers refill medications within 24 hours. The DON stated regardless of if it ' s a PRN order, the medication should always be available for the resident. The DON stated the Kenalog vials ordered 12/3/2024 did not show in the facility ' s order system. During a review of the facility ' s policy and procedures (P&P) titled Medications and treatment orders, dated 7/2016, the P&P indicated drugs and biologicals that requiring to be refilled, should be reordered from the pharmacy not less than three (3) days prior to the last dosage administered, to ensure that refills are readily available.

Nov 2024 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

Deficiency F0624 (Tag F0624)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure two of three sampled residents (Residents 1 and 2) were prepared for a safe discharge from the facility when the following occurred: 1. On [DATE], facility staff discharged Resident 1, who required extensive assistance with activities of daily living (ADLs, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) and mobility, without arrangements for home health services (a wide range of health care services that you can get in your home for an illness or injury), as ordered by the physician. 2. On [DATE], facility staff discharged Resident 2, who had physician orders for continuous oxygen therapy (a treatment that provides you with extra oxygen to breathe in), without ensuring Resident 2 had the required equipment and instructions for continuous oxygen therapy. These deficient practices resulted in Resident 1 confined in her wheelchair from [DATE] through [DATE], resulting in macerated (skin condition that occurs when skin is exposed to moisture for an extended period), red skin to her buttocks and perineum (tiny patch of sensitive skin between the genitals) from sitting in her stool and urine. Emergency services [NAME] Resident 1 general acute care hospital (GACH) 1 on [DATE] and diagnosed with bilateral lower extremity venous stasis rash (a skin condition where blood pools in the lower legs due to poor circulation causing the skin to become swollen, itchy, discolored, dry, cracked, and inflamed). These deficient practices also placed Resident 2 at risk for harm of low oxygen levels, respiratory distress, and death due to lack of education and preparation regarding her orders for continuous oxygen therapy. Findings: 1. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's admitting diagnoses included generalized muscle weakness, unsteadiness on feet, history of falling, lack of coordination, heart attack (life-threatening emergency where blood flow to the heart is blocked), chronic embolism and thrombosis (a condition where blood clots form in a vein, usually in the legs, potentially breaking off and traveling to the lungs) of the right lower extremity. During a review of Resident 1's History and Physical (H&P), dated [DATE], the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's discharge Minimum Data Set (MDS, a resident assessment tool required by the federal government), dated [DATE], the MDS indicated Resident 1 did not have cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 1 required set-up and/or clean-up assistance for brushing her teeth, upper body dressing, and personal hygiene, and required supervision or touch assistance for toileting hygiene, showering or bathing, and lower body dressing. The MDS indicated Resident 1 required partial to moderate assistance to move 50 feet and 150 feet while in a manual wheelchair. The MDS also indicated Resident 1 was frequently incontinent (inability to control) of bowel and bladder function. During a review of Resident 1's Nurse Practitioner (NP, an Advanced Practice Registered Nurse with advanced clinical training) progress note, dated [DATE], written by NP 1, the progress note indicated Resident 1 was at high risk for health complications due to her comorbidities (simultaneous presence of two or more diseases or medical conditions), including her diagnoses of lack of coordination, obesity, chronic embolism and thrombosis, and activities of daily living (ADL, routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) dysfunction. The progress note indicated Resident 1 required frequent evaluation. The progress note indicated neglecting regular monitoring and management could result in an acute increase in severity of symptoms, complications, and possible rehospitalization. During a review of Resident 1's physician orders, dated [DATE], the orders indicated to discharge Resident 1 home with a Home Health Agency (HHA) 1. During a review of Resident 1's Discharge summary, dated [DATE], the Discharge Summary indicated on [DATE] Resident 1 was discharged home with home health services through HHA 1. The Discharge Summary indicated Resident 1 required extensive assistance for ADLs and mobility and indicated Resident 1's skin was intact at the time of discharge. During a review of the email correspondence between HHA 1 and the Social Services Director (SSD), dated [DATE], the email correspondence indicated the SSD received the referral documents on [DATE] at 1:11 PM and sent the referral to HHA 1 on [DATE] at 1:47 PM. During a review of Resident 1's physician's order, dated [DATE] (4 days after being discharged home), the order indicated May [discharge] with [HHA 2] . The SSD entered the order. During a review of Resident 1's social services progress note, dated [DATE] at 4:24 PM, the note indicated Home health referral was sent to [HHA 3] . waiting for response . During an interview on [DATE] at 9:30 AM, with Resident 1, Resident 1 stated she was confined to her wheelchair in the entryway of her apartment since she was discharged home from the facility on [DATE]. Resident 1 stated she slept in the wheelchair and urinated and had bowel movements into the incontinence brief because she could not get up on her own. Resident 1 stated that prior to leaving the facility, the Social Services Director (SSD) informed her she would receive help from HHA 1. Resident 1 stated the SSD instructed her to contact HHA 1 upon discharge. Resident 1 stated that when she contacted HHA 1 at the number provided by the SSD, HHA 1 informed her they did not receive a referral or orders for her to receive home health services. During an interview on [DATE] at 10:19 AM, with Case Manager (CM) 1 from HHA 1, CM 1 stated that when a resident was referred for home health services, the discharging facility would send a referral along with information about the resident. CM 1 stated she never spoke with anyone from the facility regarding Resident 1, and HHA 1 never received any referrals or faxes from the facility for Resident 1. During an interview on [DATE] at 11:23 AM, with Resident 1, Resident 1 stated she had not showered or bathed since returning home on [DATE]. Resident 1 stated she had trouble walking and could not do anything for herself by herself. Resident 1 stated she was handicapped and could not stand. Resident 1 stated her Family Friend (FF 1) came to help her change her incontinence brief on [DATE], but FF 1 was not available all the time because she worked. Resident 1's speech was rapid and frantic during the interview. Resident 1 stated she had no family to help her because they were all deceased . Resident 1 stated she was all alone . During an interview on [DATE] at 12:30 PM, with FF 1, FF 1 stated she lived in the same apartment complex as Resident 1 and had been helping Resident 1 for a few years. FF 1 stated Resident 1 used to be able to walk with a walker, do her own laundry, and only needed help with errands requiring her to drive. FF 1 stated Resident 1 did not require a wheelchair before the resident's admission to the facility. FF 1 stated she was surprised the facility discharged Resident 1 in her current condition because Resident 1 could not care for herself and was not receiving help from anyone else. FF 1 stated Resident 1 had been confined to her wheelchair since arriving home, from the facility on [DATE]. FF 1 stated Resident 1 had not bathed or slept, and urinated, and had bowel movements in her wheelchair, because she was unable to get up on her own. FF 1 stated she had to help Resident 1 change her incontinence brief on [DATE] because Resident 1 was soiled and could not change the brief by herself. During an interview on [DATE] at 4:59 PM, with Resident 1, Resident 1 stated she was suffering from severe pain in her left leg, extending from her knee to her ankle. Resident 1 also stated her right ankle was swollen. Resident 1 stated she was supposed to elevate her legs, but she could not elevate them while in the wheelchair. During an interview on [DATE] at 5:31 PM, with FF 1, FF 1 stated she went to help Resident 1 change her incontinence brief and stated Resident 1's perineum and buttocks were red and raw . During an interview on [DATE] at 8:45 AM, with CM 1 from HHA 1, CM 1 stated she received a referral via email from the facility's SSD, around 2:00 PM on [DATE], for Resident 1 to receive home health services. CM 1 stated this was the first referral received for Resident 1, and stated the physician order for discharge and referral for home health services was dated [DATE]. CM 1 stated home health services were not provided due to the delayed receipt of the referral. During an interview on [DATE] at 9:17 AM, with the Administrator (ADM) for HHA 2, the ADM stated the SSD sent a referral via email on [DATE] requesting home health services for Resident 1. The ADM stated HHA 2 sent a Registered Nurse to see Resident 1 on [DATE], and the SSD called on [DATE] and informed HHA 2 that HHA 1 would be seeing Resident 1, and HHA 2's services were no longer needed. During a concurrent interview and record review, on [DATE] at 9:47 AM, with the SSD, Resident 1's physician orders, progress notes, and Discharge summary dated [DATE], were reviewed. The SSD stated the Discharge summary, dated [DATE], indicated Resident 1 was discharged home on [DATE] and Resident 1 was supposed to receive home health services through HHA 1. The SSD stated she did not confirm that HHA 1 would be providing services prior to discharging Resident 1 on [DATE]. The SSD stated the progress notes indicated from [DATE] to [DATE], Resident 1 had not received home health services as originally indicated in the physician order dated [DATE]. The SSD stated it was important for residents to have confirmed arrangements for home health services prior to discharge to ensure the residents received the care needed once they left the facility. The SSD stated it was not safe to discharge Resident 1 without ensuring home health services would be provided, as ordered by the physician. The SSD stated Resident 1 required extensive assistance with ADLs (routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) at the time of discharge and home health services were necessary to carry out those tasks. During a concurrent interview and record review, on [DATE] at 10:11 AM, with Licensed Vocational Nurse (LVN) 1, Resident 1's Discharge summary, dated [DATE], was reviewed. LVN 1 stated Resident 1's Discharge Summary indicated Resident 1 required extensive assistance with ADLs and could not stand up or walk by herself. LVN 1 stated the Discharge Summary indicated Resident 1 was incontinent of bowel and bladder and Resident 1's skin was intact at time of discharge. LVN 1 stated it was not safe for Resident 1 to be discharged home without someone available to help her, or arrangements for home health services. LVN 1 stated Resident 1 was at risk for injury, skin breakdown and urinary tract infection (UTI, an infection in the bladder/urinary tract) from her incontinence and inability to perform hygiene tasks on her own, hospitalization, and death. During an interview on [DATE] at 12:32 PM, with FF 1, FF 1 stated Resident 1 called emergency personnel due to increasingly severe pain in her legs. FF 1 stated emergency personnel assessed Resident 1 took her to GACH 1 on [DATE]. During a concurrent interview and record review on [DATE] at 1:32 PM, with the Director of Nursing (DON), Resident 1's admission Record and NP progress notes dated [DATE] were reviewed. The DON stated Resident 1's admission Record indicated a diagnosis of a heart attack, chronic embolism, and thrombosis of the right lower extremity. The DON stated Resident 1's prolonged confinement to her wheelchair from [DATE] to [DATE] placed her at risk for repeat formation of a thrombosis, which could lead to another heart attack. The DON stated Resident 1 would also be unable to apply compression to her lower extremities or elevate her lower extremities due to obesity if she was confined to her wheelchair. During a review of Resident 1's GACH 1 records, dated [DATE], the records indicated Resident 1 was brought to the emergency department on [DATE] with complaints of severe lower extremity pain and injury. The records indicated Resident 2 had bilateral grade 4 pitting edema (the most severe type of swelling, where a deep indentation remains in the skin for more than 30 seconds after pressure is applied). The records indicated Resident 2 had an anxious affect (a feeling of fear, dread, and uneasiness) and weak strength in both legs. The records indicated Resident 2 was diagnosed with bilateral lower extremity venous stasis rash and the emergency department physician recommended hospitalization for further evaluation and management. 2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted on [DATE]. Resident 2's admitting diagnoses included, but were not limited to, chronic obstructive pulmonary disease (COPD, chronic lung disease causing difficulty in breathing), and heart failure (a heart disorder which causes the heart to not pump the blood efficiently). During a review of Resident 2's H&P, dated [DATE], the H&P indicated Resident 2 had capacity for medical decision making. The H&P further indicated that prior to admission to the facility, Resident 2 had been hospitalized due to COPD exacerbation and difficulty breathing. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had moderate cognitive impairment (a stage of cognitive decline where a person has difficulty with complex tasks and navigating to new places), The MDS indicated Resident 2 required supervision and/or touching assistance for picking up small objects. During a review of Resident 2's physician's order, dated [DATE], the order indicated Resident 2 was to be discharged home with HHA 3. During a review of Resident 2's NP Progress Note, dated [DATE], the NP progress note indicated Resident 2's primary diagnosis was COPD, and Resident 2 was at high risk for complications, including increased likelihood of hospital readmission due to complications from pulmonary dysfunction (a general term for diseases that affect the lungs or respiratory system). During a review of Resident 2's physician orders, dated [DATE], the orders indicated Resident 2 was supposed to receive continuous oxygen therapy for desaturation (when blood oxygen levels drop below normal) related to her COPD diagnosis. The order did not specify an oxygen flow rate (the measurement of how much oxygen is delivered to a patient per minute). During a review of Resident 2's care plan titled, Altered Respiratory Status/Difficulty Breathing related to COPD , dated [DATE], the staff's interventions indicated to administer oxygen therapy as ordered to prevent complications related to difficulty breathing or poor oxygen absorption. During a review of Resident 2's Interdisciplinary (IDT, group of different disciplines working together towards a common goal of a resident) Conference Note, dated [DATE], the note indicated Resident 2 informed the SSD that she had a portable oxygen delivery device in her personal possession. The note indicated Resident 2's orders for oxygen therapy were not for continuous oxygen and only as needed. The IDT note did not indicate that any teaching was provided to Resident 2 about her orders for continuous oxygen therapy, or if the personal oxygen delivery device Resident 2 had in her possession was assessed for functionality or the resident's ability to self-administer oxygen. During a review of Resident 2's Discharge summary, dated [DATE], the Discharge Summary indicated on [DATE], Resident 2 was discharged home from the facility with FF 2. The Discharge Summary indicated Resident 2 required oxygen equipment after her discharge from the facility. The Discharge Summary did not indicate that any instructions or teaching were provided to Resident 2 or FF 2 at the time of discharge related to her orders for continuous oxygen therapy. The Discharge Summary did not indicate Resident 2's portable oxygen delivery device was checked for functionality. During an interview on [DATE] at 1:01 PM, with FF 2, FF 2 stated on [DATE], he assisted Resident 2 with her discharge from the facility because Resident 2 did not have any living children. FF 2 stated at discharge, the facility informed Resident 2 that her oxygen equipment would not be delivered until Tuesday, [DATE], at the earliest. FF 2 stated Resident 2 informed staff that she had a portable oxygen delivery device in her possession at the facility she would be taking home. FF 2 stated the facility did not check the functionality of the portable oxygen delivery device in Resident 2's possession. FF 2 stated the facility did not provide any instructions or teaching about how much oxygen Resident 2 required, or whether the oxygen therapy was needed continuously. During a concurrent interview and record review, on [DATE] at 1:41 PM, with LVN 1, Resident 2's IDT Conference Note and Discharge Summary, both dated [DATE], were reviewed. LVN 1 stated the IDT Conference Note and the Discharge Summary did not indicate Resident 2 or FF 2 were provided any teaching related to the resident's orders for continuous oxygen therapy. LVN 1 further stated the IDT Conference Note and Discharge Summary did not indicate that Resident 2's portable oxygen delivery device was checked by facility's staff to ensure it was able to provide continuous oxygen as ordered. LVN 1 stated Resident 2 was at risk for difficulty breathing, desaturation, hospitalization, and death from not receiving teaching related to oxygen administration, and assessment of her portable oxygen delivery device to ensure it worked and could meet the resident's needs. During a review of the facility's policy and procedure (P&P) titled, Discharge Summary and Plan , dated 10/2022, the P&P indicated the staff was supposed to ensure the post-discharge plan included arrangements that had been made for follow-up care and services. The P&P indicated the resident (or their representative) was supposed to be involved in the post-discharge planning process and informed of the final post-discharge plan.

Oct 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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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 unusual occurrence from one of four sampled residents (Resident 1) to the state agency California Department of Public Health (CDPH), when Resident 1 was noticed with a large bruise on her left side of the breast and left rib cage on 9/5/2024. This deficient practice resulted in a delay of an onsite inspection by CDPH to investigate Resident 1 ' s injury in a timely manner, a delay in prevention of further injuries and possible abuse. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis that included adult failure to thrive (a decline caused by chronic diseases and functional impairments which can cause weight loss, decreased appetite, poor nutrition, and inactivity), unspecified protein-calorie malnutrition (The lack of sufficient energy or protein to meet the body's metabolic demands), and type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control.) During a review of Resident 1 ' s History and Physical (H&P) dated 6/22/2024, 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 care assessment and care screening tool), dated 9/13/2024, the MDS indicated Resident cognitive skills were severe impaired never/rarely make decisions. The MDS indicated Resident 1 required substantial maximum assistance with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene. The MDS indicated Resident 1 required partial to moderate assistance with eating and oral hygiene. The MDS indicated Resident 1 required dependent assistance with transfer from chair to bed. During a review of Resident 1 ' s Interdisciplinary meeting (IDT) dated 9/6/2024, the IDT meeting indicated, the IDT team met regarding the incident that happened 9/5/024 around 10AM. The IDT team meeting indicated Resident 1 was noted with bluish purplish discoloration the left breast and left rib cage. Resident 1 complained of pain when care was provided to the affected area. During a review of Resident 1 ' s care plan titled Potential for pressure ulcer development related to impaired mobility and anemia dated 5/9/2023, the care plan goals indicated Resident 1 would have intact skin, free of redness, blisters, or discolorations. The care plan interventions indicated to follow facility policies/protocols for the prevention/treatment of skin issues. During an interview on 10/9/2024 at 2:00 p.m. with the Restorative Nursing Assistance (RNA), the RNA stated the bruise on Resident 1's skin should have been reported to the Administrated (ADM) or Director of Nursing (DON) for investigation. During a concurrent interview and record review on 10/9/2024 at 3:45 p.m. with the DON, the DON stated on 9/5/2024 in the morning, she was notified of Resident 1's bruised left breast and rib cage. The DON stated stated it was injury of unknow origin and happened on 9/5/2024. The DON stated the injury of unknow origin reporting policy indicated any incident needed to be report it to CDPH within 24 hours, and an investigation started at the facility. During a review of the facility ' s policy and procedures (P&P) titled Abuse, Neglect, Exploitation or Misappropriation – Reporting and investigation, dated 2001, the P&P indicated If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law within 24 hours of an allegation.

Aug 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure three of eight sampled residents (Resident 2, Resident 5 and Resident 6) call lights were placed within residents' reach. This deficient practice could result in residents ' needs not met and residents ' highest practicable physical, mental, and psychosocial wellbeing will not be maintained. Findings: a). During an observation on 8/23/2024 at 3:10 p.m., in Resident 2 ' s room, Resident 2 ' s call light was observed hanging on the left side of Resident 2 ' s bedside wall. Certified Nursing Assistant (CNA) 1 came and took the call light from the wall and gave it to Resident 2. During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses of muscle weakness (loss of muscle strength), lack of coordination (problem with balance, movement, or coordination), and other abnormalities of gait and mobility (abnormal walking pattern). During a review of Resident 2 ' s History and Physical (H&P) dated 2/18/2024, the H&P indicated Resident 2 had the mental capacity to understand and make medical decisions. During a review of Resident 2 ' s Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 5/31/2024, the MDS indicated Resident 2 ' s cognitive skills (thought process) usually understand and be understood by others. The MDS indicated Resident 2 required supervision or touching assistance with activities of daily living (ADLs) 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 2 ' s care plan titled, High risk for fall related to generalized weakness, gait/balance, dated 2/18/2024, the interventions indicated to place resident ' s call light within reach and encourage the resident to use the call light. b). During an observation on 8/23/2024 at 3:35 p.m., in Resident 5 ' s room, Resident 5 was observed laying on bed. Resident 5 ' s call light was observed stucked on the right side of the of the bed rail away from Resident 5 ' s reach. When Resident 5 was asked where his call light was, Resident 5 stated he did not know where his call light was. During a review of Resident 5 ' s admission Record, the admission Record indicated Resident 5 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 5 ' s diagnoses included muscle weakness, other lack of coordination, and other reduce mobility. During a review of Resident 5 ' s H&P dated 8/6/2024, the H&P indicated Resident 5 had no mental capacity to understand and make medical decisions. During a review of Resident 5 ' s MDS, dated [DATE], the MDS indicated Resident 5 ' s cognitive skills were intact. The MDS indicated Resident 5 was dependent with ADLs such as dressing, toilet use, personal hygiene, transfer, and bed mobility. c). During an observation on 8/23/2024 at 3:40 p.m., in Resident 6 ' s room, Resident 6 was observed laying on bed. Resident 6 ' s call light was observed hanging on the right side of the bed away from Resident 6's reach. During a review of Resident 6 ' s admission Record, the admission Record indicated Resident 6 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 6 diagnosis included Parkinson Disease (disorder of the central nervous system that affects movement, often including tremors), other lack of coordination, and other reduce mobility (lack of walking pattern). During a review of Resident 6 ' s H&P dated 6/27/2024, the H&P indicated Resident 6 did not have the mental capacity to understand and make medical decisions. During a review of Resident 6 ' s MDS, dated [DATE], the MDS indicated Resident 6 ' s cognitive skills was intact. The MDS indicated Resident 6 was dependent with ADLs such as dressing, toilet use, personal hygiene, transfer, and bed mobility. During a review of Resident 6 ' s care plan titled, High risk for Activity of Daily Living (ADL) self-care performance deficit related to Parkinson Disease, gait balance problems, dated 3/30/2023, the interventions indicated to encourage resident to use call light for assistance. During an interview on 8/27/2024 at 12:36 p.m., with CNA 2, CNA 2 stated call lights must always be placed within the residents ' easy reach and should not be placed on any of residents ' side rails. CNA 2 stated residents can use the call light to call staff when they are in danger of falling, or when needing incontinent care to prevent skin breakdown. During an interview on 8/27/2024 at 3:36 p.m., with the Director of Nursing (DON), the DON stated when call lights are not within in a resident ' s reach, the resident could not call and could not get their needs met right away. During a review of the facility ' s policy and procedure (P&P) titled, Answering Call Light, dated 10/2010, the P&P indicated residents ' call lights should be within easy reach when a resident is in bed or confined to a chair.

CONCERN (D) 📢 Someone Reported This

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

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of eight sampled residents (Resident 3 and Resident 4) who were on gastrostomy tube ([GT] a tube surgically inserted into the abdomen to administer medications and nutrition) feedings, received tube feedings (nutrition administered via GT) timely according to the physician ' s orders. This deficient practice had the potential to result in Resident 3 and Resident 4 ' s nutritional needs not met leading to weight loss and malnutrition (lack of proper nutrition). Findings: a) During an observation on 8/23/2024 at 3:25 p.m., in Resident 3 ' s room, Resident 3 was observed with GT feeding of Glucerna 1.2 calories (name of tube feeding formula) and a water bag with label, dated 8/23/2024 at 1:00 p.m., that was turned off. During a concurrent observation and interview on 8/23/2024 at 4:12 p.m., with Licensed Vocational Nurse 1 (LVN) in Resident 3 ' s room, Resident 3 ' s GT pump (machine used to deliver tube feeding) was turned off. LVN 1 reviewed Resident 3 ' s physician ' s order and stated, the GT feeding order had indicated tube feeding should have been turned on at 2 p.m. During a review of Resident 3 ' s admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE]. Resident 3 ' s diagnoses included adult failure to thrive (decreased appetite and poor nutrition), diabetes ([DM]high blood sugar), and gastrostomy (artificial openings of digestive tract). During a review of Resident 3 ' s History and Physical (H&P) dated 3/25/2024, the H&P indicated Resident 3 did not have the mental capacity to understand and make medical decisions. During a review of Resident 3 ' s Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 6/14/2024, the MDS indicated Resident 3 had intact cognitive skills (thought process). The MDS indicated Resident 3 was dependent with activities of daily living (ADLs) 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 3 ' s physician's order dated 8/19/2024, the order indicated, Glucerna 1.2 (type of tube feeding formula) at 60 milliliters/hour (mL/hr.) for 20 hrs. to provide 1200 ml/ 1440 kilocalorie (kcal) every shift, on at 2:00 p.m., off at 10:00 a.m., or until dose is completed. b) During an observation on 8/23/2024 at 3:27 p.m., in Resident 4 ' s room, Resident 4 was observed with a GT feeding of Glucerna 1.2 and a water bag with label dated 8/23/2024 at 6:00 a.m. The GT was observed disconnected from Resident 4. During a concurrent observation and interview on 8/23/2024 at 4:05 p.m., with Licensed Vocational Nurse (LVN) 1, inside Resident 4 ' s room, Resident 4 ' s GT was observed disconnected from Resident 4 and was confirmed (GT disconnected) by LVN 1. During a review of Resident 4 ' s admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4 ' s a diagnosis included adult failure to thrive, diabetes and gastrostomy status. During a review of Resident 4 ' s H&P dated 3/7/2024, the H&P indicated Resident 4 had the mental capacity to understand and make medical decisions. During a review of Resident 4 ' s MDS, dated [DATE], the MDS indicated Resident 4 had intact cognitive skills. The MDS indicated Resident 4 was dependent with ADLs such as dressing, toilet use, personal hygiene, and transfers and bed mobility. During a review of Resident 4 ' s physician's order dated 5/13/2024, the physician's order indicated Glucerna 1.2 at 65 ml/hr. for 20 hrs. to provide 1300 ml/ 1560 kcal., with water flush of 50 ml/hr. for 20 hrs. via kangaroo pump (type of tube feeding machine) daily, to start at 2:00 p.m., and stop at 10:00 a.m., or until dose is completed. During an interview on 8/27/2024 at 12:46 p.m., with LVN 1, LVN 1 confirmed Resident 3 ' s tube feeding was turned off and Resident 4 ' s tube feeding was disconnected. LVN 1 stated Residents 3 and 4 ' s tube feeding should have started at 2:00 p.m. per doctor ' s ' orders. LVN 1 stated when tube feedings were off, residents could suffer dehydration (loss of water), weight loss and malnutrition. LVN 1 stated diabetic residents could suffer hypoglycemia (low blood sugar levels). During an interview on 8/27/2024 at 1:45 p.m., with the Registered Nurse (RN), the RN stated charge nurses (LVNs) must follow physician ' s tube feeding orders. The RN stated tube feeding is the residents ' nutrition. The RN stated, it was not acceptable to start the GT feeding late than what was ordered. The RN stated the facility placed Resident 3 and Resident 4 at risk of losing weight, that could result in malnutrition. During an interview on 8/27/2024 at 3:36 p.m., with the Director of Nursing (DON), the DON stated it was important for the nurses to follow physician ' s tube feeding orders to meet residents ' nutritional needs. The DON stated not turning on the tube feedings on time could result in weight loss. During a review of the facility ' s policy and procedure (P&P) titled, Enteral Nutrition, dated 11/2018, the P&P indicated adequate nutritional support should be provided to the residents through enteral nutrition as ordered.

Aug 2024 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure effective infection control measures were practiced, by failing to ensure: 1. Cleaned and uncleaned oxygen concentrators (a medical device that takes air from the environment and filters it into purified oxygen) were not stored in the same storage room (Storage 1). 2. The oxygen concentrators were labeled to distinguish the cleaned oxygen concentrators from the uncleaned oxygen concentrators. These deficient practices had the potential to result in cross contamination and increase the risk of infection to residents receiving supplemental oxygen. Findings: During a concurrent observation and interview on 8/12/2024 at 4 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 pointed out the storage room used to store oxygen concentrators in the facility. LVN 1 stated all cleaned, used, and broken oxygen concentrators were placed in one storage room. The storage room held six oxygen concentrators, with one concentrator covered in plastic. The concentrators were unlabeled and facing in different directions, with some of the concentrators touching the others. LVN 1 stated when the oxygen concentrators were discontinued, the concentrators would be placed in the same storage area as the clean and dirty concentrators. LVN 1 stated once she removed the concentrator from the room a resident, she would bring the uncleaned concentrator to the storage room. LVN 1 stated did not place a label on the concentrator to indicate it was used, but she would attempt to separate the unclean concentrators from the clean ones. LVN 1 admitted the room was too small to separate the clean concentrators from the unclean ones and there was no way to indicate which concentrators were cleaned and which ones were uncleaned. LVN 1 stated someone comes to clean the concentrators and she would grab one from the storage area when she needed one. LVN 1 stated she was not familiar with how the facility maintains and cleans the concentrators. During an interview on 8/12/2024 at 4:16 p.m. with the Director of Maintenance (DOM), the DOM stated housekeeping staff was responsible for cleaning the concentrators in the storage area every Monday. The DOM stated he had nothing in writing regarding this policy, but the housekeeping staff was aware of their responsibility of cleaning the concentrators and placing them in Storage 1. During a concurrent observation and interview on 8/13/2024 at 8:25 a.m. with Housekeeper 1, Housekeeper 1 went to the storage room where the cleaned concentrators were kept. Housekeeper 1 initially stated that all concentrators stored in Storage 1 were cleaned before they were brought into the storage room. Housekeeper 1 stated when a resident was discharged and no longer used the equipment, the housekeeping staff was responsible for cleaning the room, cleaning all the equipment, and bringing it back to Storage 1. Housekeeper 1 then stated all concentrators in Storage 1 were not clean except for the concentrator that was covered in plastic. Housekeeper 1 proceeded to a small closet (Storage 2) with sliding doors located in another hallway of the facility. Housekeeper 1 stated, This is where the clean concentrators are kept, and the nursing staff should know this. Storage 2 was observed with one oxygen concentrator stored along with other equipment. Housekeeper 1 stated the clean concentrators should not be stored with the uncleaned concentrators in Storage 1 because storing clean and dirty concentrators together could contaminate the cleaned ones. During a concurrent observation and interview on 8/13/2024 at 9 a.m., with LVN 2, LVN 2 stated that she had dual roles as the desk nurse and respiratory therapist. Observed seven oxygen concentrators in Storage 1. Another concentrator had been placed in Storage 1 with a respiratory plastic bag hanging from the concentrator. The respiratory bag had the name of a resident written on the bag. LVN 2 stated that the concentrator had been used by a resident that had been transferred to the hospital the night before. LVN 2 stated Storage 1 was for clean concentrators and the concentrator that was used on the resident should not have been in Storage 1 because it had not been cleaned. LVN 2 removed the plastic bag and stated she would clean the concentrator immediately. LVN 2 stated the resident ' s respiratory bag should have been removed from the concentrator and the concentrator cleaned before storing in Storage 1. LVN 2 stated she did not know where the dirty concentrators were stored. LVN 2 stated whenever a concentrator was needed for a resident, nursing staff would retrieve the concentrator from Storage 1. LVN 2 stated she believed the DOM was responsible for cleaning the concentrators, but she was not sure of the cleaning process. LVN 2 was shown where Storage 2 was located. LVN 2 stated she unaware that Storage 2 contained clean concentrators. LVN 2 stated she had always gotten oxygen concentrators from Storage 1 and was never informed about Storage 2. LVN 2 stated there appeared to be a miscommunication amongst staff as to where the clean concentrators were kept. LVN 2 stated the uncleaned concentrator could have been used on another resident and caused cross contamination. LVN 2 stated, The resident that was transferred to the hospital could have had COVID and that concentrator would have been placed on another resident and passed COVID to that resident. During an interview on 8/13/2024 at 10:05 a.m., with the DOM, the DOM stated Storage 1 was called the dirty utility room. The DOM stated housekeeping staff would take the concentrators from the residents ' room and make sure they were disinfected before placing them in Storage 1. The DOM stated that the nursing staff were responsible for disinfecting the concentrators before placing them on another resident. The DOM stated the facility needed to have another room to separate the dirty equipment from the clean equipment. The DOM stated, If we are going to call Storage 1 the dirty utility room, we can not place clean equipment in that room. The DOM stated that the delivery persons also delivered the clean concentrators to Storage 1. The DOM stated that placing the clean and dirty concentrators was a problem because the facility did not label the concentrators that were clean. The DOM stated that the current process would cause everything in Storage 1 to be contaminated. During an interview on 8/13/2024 at 1:20 p.m. with the Infection Preventionist (IP) Nurse, the IP stated the clean oxygen concentrators were to be stored in Storage 1. The IP stated the concentrators were supposed to be disinfected by housekeeping at the bedside before they were placed in Storage 1. The IP stated uncleaned concentrators should not have been stored in Storage 1. The IP stated that a resident could mistakenly be given an unclean concentrator if they were stored in the same area as the clean concentrators. The IP stated that whatever infection the previous resident had could be passed on to another resident. The IP stated no equipment should leave the room dirty. The IP stated the concentrators should be disinfected, bagged, labeled clean and put away for the next resident. During a review of the facility ' s policy and procedure (P&P), titled Departmental (Respiratory Therapy) – Prevention of Infection, dated November 2011, the P&P indicated the following: 1. Transport respiratory therapy equipment to designated soiled utility area for decontamination. 2. Wash filters from oxygen concentrators every seven days with soap and water. Rinse and squeeze dry. 3. Nursing staff should perform a visual inspection of each Oxygen Concentrator daily, checking for dust, dirt, or visible contamination. If any issues are observed, the device should be cleaned immediately. 4. Use a clean, damp cloth to wipe down the exterior surfaces of the Oxygen Concentrator. 5. Apply an EPA-approved disinfectant to all exterior surfaces following the manufacturer ' s contact time recommendations. 6. Oxygen Concentrators should be stored in a clean and designated storage area if not in use. During a review of the facility ' s P&P, titled Infection Control and Prevention Program, revised October 2018, the P&P indicated, an infection prevention and control program (IPCP) was established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infections. The P&P indicated important facets of infection prevention included the following: 1. Identifying possible infections or potential complications of existing infections. 2. Instituting measures to avoid complications or dissemination. 3. Educating staff and ensuring that they adhere to proper techniques and procedures. 4. Communicating the importance of standard precautions and cough etiquette to visitors and family members. 5. Enhancing screening for possible significant pathogens.

May 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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Correctly use a Valve-bag-mask ([Ambu-bag] hand-held device commonly used to provide positive pressure ventilation [exchange of air between the lungs and the outside air] to residents who are not breathing or breathing inadequately) when one of one sampled resident (Resident 1) was in respiratory distress. 2. Ensure staff checked the Emergency Cart daily (cart with supplies used during emergencies) and ensure non-rebreather masks (device used to assist in the delivery of oxygen [O2] therapy) were stocked as per facility ' s policies and procedure (P&P). These deficient practices had the potential to result in residents not receiving emergency treatment and care needed in accordance with professional standards of practice. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses including respiratory failure (condition where there's not enough O2 or too much carbon dioxide in the body) and shortness of breath. A review of Resident 1 ' s History and Physical (H&P), dated 5/18/2024 indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 5/24/2024, indicated Resident 1 was able to understand and make self-understood. The MDS indicated Resident 1 required supervision for Activities of Daily Living (ADLs) such as eating, oral hygiene, personal hygiene, and moderate assistance (staff does less than half the effort)for toileting and showers. During a concurrent observation on 5/29/2024 at 9:30 a.m., with Licensed Vocational Nurse (LVN 1) and Respiratory Therapist (RT), Resident 1 was observed with respiratory distress, stating he could not breathe. Resident 1 ' s O2 saturation (measurement of oxygen in the blood) was 60% (normal range 92-100%) on 3 liters/min ([l/mi] unit of measurement) of O2. RT placed an Ambu-bag on Resident 1 without a full seal while providing ventilation to the resident. During an interview on 5/29/2024 at 11:26 a.m. with Registered Nurse (RN 1), RN 1 stated that an Ambu-bag was used during cardiac or respiratory arrest (when someone stopped breathing) and should go over the mouth and nose of the resident to form a C shape with a solid seal to prevent oxygen from escaping and to give effective ventilation to the resident. During a concurrent observation and interview on 5/29/2024 at 12:15 p.m. with RT, RT stated she looked for a non-rebreather mask in the emergency cart however could not find one, so she used the Ambu-bag instead. RT stated she could not get a complete seal while providing ventilation with the Ambu-bag because Resident 1 was moving and sitting up. The crash cart was observed with no non-rebreather mask and Emergency Cart checklist. RT stated she did not know if there was supposed to be an Emergency Cart checklist and she did not know if staff were supposed to check the emergency cart. During a concurrent observation and interview on 5/29/2024 at 12:57 p.m. with the Director of Nursing (DON), the DON stated, staff should have checked the Emergency Cart daily and placed a check on the cart, however staff had forgotten to do so. The DON stated, he did not remember when the Emergency Cart was last checked for completeness. DON also stated, not having supplies readily available for licensed personnel could have led to a delay in treatment and death for residents in an emergency situation. A review of the American Heart Association Advance Life Support Provider Manual 2020, indicated when providing ventilation with a Valve bag mask, the rescuer would tilt the patient ' s head and seal the mask against the patient ' s (resident) face, with the thumb and first finger of each hand creating a C, to provide a complete seal around the edges of the mask while using the third, fourth fingers forming an E to lift the jaw and with opposite hand slowly squeeze the bag over 1 second. A review of the facility ' s undated P&P titled, Emergency Cart Supplies and Equipment, indicated the facility must ensure that the emergency cart was checked daily for completeness and items were to be stocked including E-tank with regulator (a tank of oxygen the has a control and measures the flow of oxygen to ensure a safe and effective working pressure) and non-rebreather masks. The P&P indicated, licensed nurses or other designee would be responsible for the immediate replacement of all supplies, cleaning, and set-up of all equipment.

May 2024 18 deficiencies

CONCERN (D)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure staff provided assistance to one of two sampled residents (Resident 61), to accommodate the resident's preference for getting out of bed at least once a day to sit in his wheelchair. This deficient practice had the potential to cause avoidable psychosocial distress and frustration for Resident 61 from an inability to participate in his preferred activity. Findings: A review of Resident 61's admission Record indicated the facility originally admitted Resident 61 on 12/13/2022. Resident 61's admitting diagnoses included symptoms and signs involving the musculoskeletal system, reduced mobility, and difficulty or inability to move his right side following a stroke (interruption of blood flow to the brain). A review of Resident 61's H&P, dated 2/8/2024, indicated Resident 61 had the capacity to understand and make decisions. A review of Resident 61's MDS, dated [DATE], indicated Resident 61 had mild cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 61 had impairments to the upper extremities on both sides of his body (shoulder, elbow, wrist, and hands), and impairments to the lower extremity on one side of his body (hip knee, ankle, and foot). The MDS indicated Resident 61 required substantial/maximal assistance from staff (staff provide more than half the effort in lifting, holding, or supporting the resident's body) to get dressed and put on footwear. The MDS further indicated Resident 61 required substantial/maximal assistance from staff to roll from side to side, to transition from a lying position to a sitting position, and to transfer from the bed to a wheelchair. During an observation on 5/13/2024 at 11:00 a.m., in Resident 61's room, observed Resident 61 lying in bed watching TV. Resident 61's wheelchair was parked at his bedside. During a concurrent observation and interview on 5/13/2024 at 11:33 a.m., in Resident 61's room, observed Resident 61 lying in bed watching television. Resident 61 stated he suffered a stroke and had difficulty with his mobility on his own. During a concurrent observation and interview on 5/14/2024 at 9:56 a.m., observed Resident 61 lying in bed watching TV. Resident 61 stated he wanted to get dressed and get up to go outside. Resident 61 stated he required a wheelchair and help from staff to get dressed and transfer to his wheelchair. Resident 61 stated that when he asked staff to assist him, the certified nursing assistants (CNAs) repeatedly told him they had around 10 patients in their assignment, and if someone called off from work their assignment increased to 14 to 16 patients, and they did not have time to help him. Resident 61 stated that the last time he got out of bed was on 5/10/2024. During a concurrent observation and interview on 5/15/2024 at 2:06 p.m., in Resident 61's room, observed Resident 61 lying in bed and watching TV. Resident 61 stated he would like to get out of bed every day, but on average he gets out of bed twice a week. Resident 61 stated that before he can ask for assistance to get out of bed, staff tell him they are too busy or have too many patients, so he doesn't ask to get out of bed. During a concurrent observation and interview, on 5/16/2024 at 9:06 a.m., observed Resident 61 lying in bed and watching television. Resident 61's wheelchair was parked next to his bed. Resident 61 stated he wanted to get out of bed but did not ask because he was not sure who his nurse was. Resident 61 stated he had not been offered to get out of bed (on 5/16/2024). During an interview on 5/16/2024 at 9:22 a.m., with the Activity Director (AD), the AD stated the facility had a patio where residents could sit outside if they wanted. The AD stated that there were no restrictions on residents using the patio and that there just needed to be staff available to supervise. The AD stated it was important for residents to do activities that they preferred. During an interview on 5/16/2024 at 11:45 a.m., with the Director of Nursing (DON), the DON stated staff should assist with transferring residents to their wheelchairs and supervise them in the patio as needed. The DON stated that sitting in a wheelchair while out on the patio was not a hazardous activity, and stated it was not appropriate for staff to tell the resident that they were too busy to assist him. The DON stated that if staff were busy, they should come back once their task was completed to follow up on the resident's request or identify another staff member that could assist. A review of the facility policy and procedure (P&P) titled Accommodation of Needs, dated 3/2021, indicated the facility's environment and staff behaviors are directed towards assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. The P&P indicated the resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered.

CONCERN (D)

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility did not ensure the Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals with a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) screening was accurate, and determination for necessity of potential necessary services was completed for one of two sampled residents (Resident 10). This deficient practice had the potential for Resident 10 to not receive required services and care for her diagnosed mental disorders. Findings: A review of Resident 10's admission Record indicated the facility admitted Resident 10 on 3/15/2024. Resident 10's admitting diagnoses included anxiety disorder (intense, excessive, and persistent worry and fear about everyday situations), unspecified, schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and depression (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A review of Resident 10's Minimum Data Set (MDS, a comprehensive care-screening and care-planning tool), dated 3/21/2024, indicated Resident 10 had anxiety disorder, depression, and schizophrenia. A review of Resident 10's PASRR Level I Screening, dated 3/8/2024, indicated the individual completing the screening was to mark yes or no to indicate if Resident 10 had a serious diagnosed mental disorder. The PASRR was marked no, indicating Resident 10 did not have a serious mental disorder. During an interview on 5/15/2024 at 9:22 a.m., with the admission Coordinator (AC), the AC stated the PASRR Level I screenings were conducted in the hospital and sent to the facility, along with the resident's medical records, prior to the resident's admission. The AC stated that once the PASRR Level I screening and medical records were received, she reviewed the documents with the Director of Nursing (DON) for accuracy. The AC stated the PASRR was conducted to determine the presence of a mental illness or disorder. The AC further stated the PASRRs of all potential new admissions to the facility were reviewed to ensure that the facility had the resources needed, and could provide the required services, for residents with mental disorders. During a concurrent interview and record review, on 5/15/2024 9:46 a.m., with the DON, Resident 10's Level I PASRR dated 3/8/2024 and Resident 10's admitting diagnoses was reviewed. The DON stated Resident 10 had depressive disorder, anxiety disorder, and schizophrenia, and stated these diagnoses were not indicated on the resident's PASRR Level I dated 3/8/2024. The DON stated this discrepancy was not caught during the facility's review of the Resident 10's PASRR, and therefore Resident 10 was not referred to the appropriate state-designated mental health authorities for further evaluation and completion of a Level II evaluation. A review of the facility policy and procedure (P&P) titled admission Criteria, dated 3/2019, indicated all new admissions and readmissions are screened for mental disorders (MD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. The P&P indicated if the level I screen indicates that the individual may meet the criteria for a MD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. The P&P indicated upon completion of the Level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate.

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the licensed nursing staff failed to follow professional standards of practice and implement the physician's written order for the administration of routine medications to one of three sampled residents (Resident 13). This deficient practice had the potential to place Resident 13 at risk to have complications of high blood pressure, avoidable harm, heart attack (heart muscle begins to die because not getting enough blood flow), respiratory distress, and chronic obstructive pulmonary disease (COPD, a lung disease causing restricted airflow and breathing problem) exacerbation (worsening of symptoms). Findings: A review of Resident 13's admission Record (Face Sheet), indicated Resident 13 was admitted to the facility on [DATE]. Resident 13's diagnoses included COPD, hypertension (high blood pressure), dementia (a loss of brain function such as memory, language, thinking), and depression (feeling of sadness and loss of interest). A review of Resident 13's History and Physical (H&P), dated 3/21/2024, indicated Resident 13 had the capacity to understand and make decisions. A review of Resident 13's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 3/28/2024, indicated Resident 13 had the capacity to understand and make decisions. The MDS indicated Resident 13 required maximum assistance (helper does more than half the effort) from staff for toileting hygiene, shower, and moderate assistance (helper does less than half the effort) from staff for eating, oral hygiene, and personal hygiene. A review of Resident 13's care plan initiated 3/21/2024, indicated Resident 13 was at risk for complications related to not receiving medication on time. The staffs interventions indicated to administer medication as ordered and give anti hypertension medications as ordered. During an observation on 5/14/2024 at 8:30 a.m., in Resident 13's room, Resident 13 was observed lying in bed, covered with a blanket, eyes closed, and visibly sleeping. During an observation on 5/14/2024 at 9:44 a.m., in Resident 13's room, Resident 13 was observed in bed, eyes closed, and visibly sleeping. During a concurrent observation and interview on 5/14/2024 at 11:10 a.m., in Resident 13's room, Resident 13 was observed lying in bed, awake. Resident 13's breakfast tray was observed on the top of the resident's bedside table next to the bed. Resident 13 stated she just woke up and had not eaten her breakfast or received her morning medications. Resident 13 stated she was feeling dizzy. A review of Resident 13's Medication Administration Records (MAR) for the month of 4/2024 and 5/2024, indicated Resident 13 was to receive the following medications: a. Amlodipine Besylate (used to treat high blood pressure) oral tablet 5 milligrams([mg]- a unit of measurement of weight), give 5 mg by mouth one time a day at 9:00 a.m. b. Metoprolol Succinate (used to treat high blood pressure) oral tablet 25 mg, give 3 tablets of 25 mg (75mg) by mouth one time a day at 9:00 a.m. c. Aspirin (medication used to lower risk of heart attack) 81 mg oral tablet, give 81 mg by mouth one time a day at 9:00 a.m. d. Sertraline (used to treat depression) oral tablet 100 mg, give 100 mg by mouth one time a day at 9:00 a.m. e. Folic Acid (vitamin important in red blood cell formation and healthy cell growth and function) oral tablet 1 mg, give 1 mg by mouth one time a day at 9:00 a.m. f. Albuterol Sulfate (medication works by relaxing and opening the airways, used for COPD) Nebulization Solution 2.5 mg inhale (breathe) orally via nebulizer every four (4) hours at 8:00 a.m., 12:00 p.m., 4:00 pm., 8:00 p.m. During an interview on 5/14/2024 at 12:47 p.m. with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated she had not administered Resident 13's morning medications. LVN 3 stated Resident 13's morning medications should have been administered at 9:00 a.m. LVN3 stated Resident 13 was sleeping and she did not want to wake the resident. LVN 3 stated it was important to administer medications timely and follow the physician's orders. LVN 3 stated Resident 13 not receiving medications as scheduled placed Resident 13 at risk for high blood pressure, heart attack, and heart failure (condition when heart doesn't pump enough blood for your body). During an interview on 5/14/2024 at 2:07 p.m., with the Director of Nursing (DON), the DON stated licensed staff must follow the physician's orders and administer medications timely as scheduled. The DON stated not administering medications timely placed residents at risk for health complications, and hospitalization. A review of the facility's policy and procedure (P&P) titled Medication Administration, undated, indicated: 1. Medications are administered as prescribed in accordance with good nursing principles and practices. 2. Medications are administered in accordance with written orders of the attending physician. 3. Routine medications are administered according to the medication administration schedule.

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure fingernail care was provided, and grooming and personal hygiene was maintained for two of eight sampled residents (Resident 52 and 77), who were unable to carry out activities of daily living (ADLs, self-care activities performed daily). This deficient practice had the potential for a negative impact on Resident 52's and Resident 77's quality of life and self-esteem. Findings: 1. A review of Resident 52's admission Record (Face Sheet), indicated Resident 52 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 52's diagnoses included diabetes (high blood sugar), hypertension (high blood pressure), dementia (a loss of brain function such as memory, language, thinking), and dysphagia (difficulty swallowing). A review of Resident 52's Minimum Data Set ([MDS] a comprehensive standardized assessment and care-screening tool) dated 2/13/2024, indicated Resident 52 had the capacity to understand and make decisions. Resident 52 required maximum assistance (helper does more than half the effort) from staff for oral hygiene, toileting, dressing, bathing, and personal hygiene. A review of Resident 52's History and Physical (H&P), dated 3/27/2023, indicated Resident 52 had the capacity to understand and make decisions. During a concurrent observation and interview on 5/13/2024 at 9:58 a.m., with Resident 52, in Resident 52's room, Resident 52 was observed lying in bed watching television. Resident 52's fingernails were long with dark residue under the nail bed. Resident 52 stated he did not remember when the last time his fingernails were cleaned or cut. Resident 52 stated his fingernails looked long and dirty. Resident 52 stated he would like to have his fingernails clean and cut by staff. During a concurrent observation and interview on 5/13/2024 at 10:15 a.m., with Certified Nursing Assistant 10 (CNA 10), in Resident 52's room, CNA 10 stated CNAs were responsible for cleaning and trimming the residents' fingernails. CNA 10 acknowledged that Resident 52's fingernails were long and dirty. CNA 10 stated residents' fingernails should be cleaned daily and trimmed as needed. CNA 10 stated it was important that Resident 52's fingernails were cleaned and trimmed to prevent infection, cuts, and injuries. 2. A review of Resident 77's Face Sheet, indicated Resident 77 was admitted to the facility on [DATE]. Resident 77's diagnoses included diabetes, hypertension, dementia, and dysphagia. A review of Resident 77's MDS dated [DATE], indicated Resident 77 usually made self-understood and understood others. The MDS indicated Resident 77 required moderate assistance from staff for ADLs. During a concurrent observation and interview on 5/13/2024 at 11:07 a.m., with Resident 77, in Resident 77's room, Resident 77 was observed seated on the bed and brushing his hair. Resident 77's fingernails were long with dark residue under the nail bed. Resident 77 stated he did not remember when his fingernails were last cleaned and trimmed. During an interview on 5/13/2024 at 12:14 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated residents' fingernails should be checked daily to determine if they needed to be trimmed or cleaned. LVN 3 stated Resident 77's fingernails were an issue because Resident 77 could rub his eye and could end up with an eye infection. LVN 3 stated Resident 77 could touch other residents or other items and transfer any bacteria on his hands to others. LVN 3 stated Resident 77 could scratch himself and develop a wound that could get infected. During an interview on 5/14/2024 at 3:25 p.m., with Registered Nurse 1 (RN 1). RN 1 stated long and dirty fingernails was a safety risk and placed residents at risk for infection. RN 1 stated residents could scratch themselves, could get injured, and long fingernails could grow bacteria, fungus (living thing produce organisms), and infection. During an interview on 5/14//2024 at 3:43 p.m., with the Director of Nursing (DON), the DON stated it was the CNAs' responsibility to make sure the residents' fingernails were cleaned daily and trimmed as needed. The DON stated residents should be provided with care and services necessary to maintain good personal hygiene. A review of the facility's policy and procedure (P&P) titled Activities of Daily Living (ADLs), undated, indicated, residents who are unable to carry out activities of daily living independently will receive services necessary to maintain good grooming, personal hygiene. The P&P indicated appropriate care services will be provided for residents who are unable to carry out ADLs independently including hygiene (bathing, dressing, and grooming).

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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CONCERN (D)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, facility staff failed to administer enteral nutrition (the delivery of nutrients through a gastrostomy tube [a flexible plastic tube placed into the stomach wall]) as ordered for one of two sampled residents (Resident 27). This deficient practice had the potential to cause avoidable complications, such as malnutrition and/or delays in health promotion and maintenance for Resident 27. Findings: A review of Resident 27's admission Record indicated the facility originally admitted Resident 27 on 8/5/2021, and most recently readmitted Resident 27 on 3/30/2023. Resident 27's admitting diagnoses included gastrostomy status (the creation of an artificial external opening into the stomach for nutritional support), protein-calorie malnutrition (the state of inadequate intake of food [as a source of protein, calories, and other essential nutrients]), muscle wasting and atrophy (decrease in size of muscle tissue), dysphagia (difficulty or discomfort in swallowing). A review of Resident 27's active physician orders, dated 5/13/24, indicated Resident 27 was receiving enteral nutrition through a gastrostomy tube. A review of Resident 27's Minimum Data Set (MDS, a comprehensive care screening and care planning tool), dated 4/5/2024, indicated Resident 27 had a gastrostomy tube, and received 51 percent (%) or more of his total calories from enteral nutrition. A review of Resident 27's care plan, dated 3/31/2023, and revised on 8/3/2023, indicated Resident 27 required tube feeding [enteral nutrition] related to dysphagia. The care plan indicated the goals of care included Resident 27 remaining free of side effects or complications related to tube feeding and maintaining adequate nutritional and hydration status. The interventions indicated to achieve these goals staff were to administer GT [enteral nutrition] as ordered and indicated. During an observation on 5/13/2024 at 9:58 a.m., at Resident 27's bedside, observed Resident 27's enteral nutrition bottle connected to a feeding pump. The pump was programmed to infuse the enteral nutrition at a rate of 65 milliliters per hour (a unit for measuring the rate of administration). Resident 27's gastrostomy tube was connected to the feeding pump, and the opening of the gastrostomy tube was closed. Resident 27 was not receiving any enteral nutrition, and the enteral nutrition was observed flowing onto the floor and soaked into the towel and sheets of his bed. During a concurrent observation and interview, on 5/13/2024 at 10:16 a.m., at Resident 27's bedside, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 27 was supposed to be receiving enteral nutrition and stated the enteral nutrition was not being administered as ordered. LVN 1 stated the access to Resident 27's gastrostomy tube was closed. LVN 1 stated she was not sure how long it had been closed. LVN 1 stated there was a potential that Resident 27 would not meet his caloric needs. During an interview on 5/16/2024 at 10:53 a.m., with the Director of Nursing (DON), the DON stated that if a resident did not receive their enteral nutrition as ordered, the resident's condition could decline, and there was potential for the resident to suffer unwanted weight loss. The DON stated it was important for residents to receive their enteral nutrition as ordered to meet their nutritional needs. A review of the facility policy and procedure (P&P) titled Enteral Nutrition, dated 11/2018, indicated it was the facility's policy that adequate nutritional support through enteral nutrition is provided to residents as ordered. A review of the facility P&P titled Enteral Feedings - Safety Precautions, dated 11/2018, indicated the purpose of the P&P was to ensure the safe administration of enteral nutrition. The P&P further indicated staff were supposed to regularly inspect tubing for proper and secure connections.

CONCERN (D)

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

Deficiency F0694 (Tag F0694)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the licensed nurses failed to follow the facility policy and procedure (P&P) for initiation and maintenance of intravenous therapy ([IV] a way to give fluids, medicine, nutrition, or blood directly into the blood stream through a vein) for one of two residents (Resident 243) by: 1. Failing to label and date a peripheral intravenous catheter ([PIV] a short catheter inserted through a peripheral vein for the administration of solution or medication) site. 2. Failing to change the PIV site and dressing when the site appeared compromised. 3. Failing to remove the PIV after IV treatment was complete. This deficient practice had the potential to result in harm and lead to development of infection, infiltration (accidental leakage of non-vesicant solutions out of the vein into the surrounding tissue) and phlebitis (inflammation of a vein) for Resident 243. Findings: A review of Resident 243's admission Record (Face Sheet), indicated Resident 243 was admitted to the facility on [DATE] with diagnoses including diabetes (high blood sugar), urinary tract infection ([UTI]- infection in the bladder), hypertension (high blood pressure), and muscle weakness (a lack of strength in the muscles). A review of Resident 243's History and Physical (H&P), dated 5/11/2024, indicated Resident 243 did not have the capacity to understand and make decisions. A review of Resident 243's Order Summary Report, dated 5/9/2024, indicated IV site to the right forearm. The order summary report indicated Ceftriaxone Sodium (medication that works by killing bacteria [infection]), use two (2) grams ([GM]-a unit of measurement of weight) intravenously, one time a day for UTI until 5/10/2024. During a concurrent observation and interview on 5/13/2024 at 10:50 a.m. with Resident 243, in Resident 243's room, Resident 243 was observed lying in bed, well groomed, and dressed appropriately. Resident 243 was observed with a PIV to the right forearm. The dressing was visibly soiled (dirty), dislocated (to move from proper place), and undated. Resident 243 stated she felt discomfort at the PIV site. During a concurrent observation and interview on 5/13/2024 at 11:57 a.m., with Licensed Vocational Nurse 3 (LVN 3), in Resident 243's room, LVN 3 confirmed Resident 243's PIV dressing was soiled, dislocated, and undated. LVN 3 stated it was the LVNs responsibility to assess the resident's PIV site for signs and symptoms of infection, soiled dressings, or dislocation, and report to the registered nurse (RN). LVN 3 stated it was the RNs responsibility to change the PIV and dressing. During a concurrent observation and interview on 5/13/2024 at 3:45 p.m., with RN 1, in Resident 243's room, RN 1 stated she was not aware Residents 243's PIV dressing was soiled, dislocated, and undated. RN 1 stated she was not aware of Resident 243's having discomfort at the PIV site. RN 1 stated Resident 243's IV treatment was completed on 5/10/2024. RN 1 stated the PIV should have been removed to prevent infection. A review of facility's policy and procedure (P&P) titled Peripheral and Midline IV Dressing Changes, revised 3/2022, indicated: 1. To prevent complications associated with intravenous therapy, including catheter-related infections associated with contaminated, lessened, or soiled site dressings. 2. Perform site care and dressing change if the dressing is compromised (damp, loosened or visibly soiled). 3. Maintain sterile dressing (transparent semi-permeable membrane [TMS] dressing or sterile gauze) for all peripheral catheter sites. 4. Change dressing if it becomes damp, loosened, or visibly soiled every 2 days. 5. Change immediately if the dressing or site appears compromised. 6. Label dressing with the date and time of dressing change, and initials.

CONCERN (D)

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

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide timely pain management to two of two sampled residents (Resident 47 and 61). This deficient practice had the potential to cause avoidable discomfort and distress related to uncontrolled pain for Resident 47 and Resident 61. Findings: 1. A review of Resident 47's admission Record indicated the facility originally admitting Resident 47 on 7/22/2023. Resident 47's admitting diagnoses included lumbar spinal fusion (surgery to permanently join together two or more bones in the lower region of the spine), pain due to internal orthopedic prosthetic devices, implants, and grafts (a medical device manufactured to replace a missing joint or bone, or to support a damaged bone), and chronic pain. A review of Resident 47's History and Physical (H&P), dated 7/23/2023, indicated Resident 47 had the capacity to understand and make decisions. A review of Resident 47's Minimum Data Set (MDS, a comprehensive care planning and care screening tool), dated 4/26/2024, indicated Resident 47 did not exhibit any signs of disorganized thinking (rambling or irrelevant conversation, unclear or illogical now of ideas, or unpredictable switching from subject to subject) or delusions (misconceptions or beliefs that are firmly held, contrary to reality). The MDS indicated Resident 47 required setup assistance to supervision/touch assistance from staff for repositioning and activities of daily living (ADLs, self-care activities performed daily such as eating, getting dressed, personal hygiene). A review of Resident 47's physician orders indicated Resident 47 was receiving the following medications for pain: a. Bengay (topical analgesic [drug that reduces pain] used for temporary muscle and joint pain) Greaseless External Cream 10-15 percent (%) applied to the skin on his right shoulder and lower back every six (6) hours as needed for chronic pain, ordered on 7/22/2023. b. Hydrocodone-Acetaminophen (Vicodin, used to relieve moderate to severe pain) Oral Tablet 5-325 milligrams (mg, a unit of dose measurement) by mouth every six (6) hours as needed for moderate pain (pain rated from 7 to 10 in intensity, on a scale of 1 to 10), ordered on 8/16/2023. c. Acetaminophen (Tylenol, mild pain reliever) Oral Tablet 325 mg by mouth every four (4) hours as needed for mild pain (pain rated from 1 to 3 in intensity, on a scale of 1 to 10) ordered on 10/16/23. During a concurrent observation and interview, on 5/13/2024 at 10:32 a.m., in the hallway, Resident 47 approached State Agency Surveyor and requested pain medication for his back. An unidentified facility staff approached Resident 47, and Resident 47 requested pain medication from the unidentified staff. The unidentified facility staff escorted Resident 47 back to his room and stated they would report the request to Resident 47's nurse. During a concurrent observation and interview, on 5/13/2024 at 11:02 a.m., in Resident 47's room, Resident 47 was observed lying in bed. Resident 47 stated, Can you follow-up on my pain medications? My back hurt likes hell. Resident 47 stated he had not received any pain medication yet and stated he had reported his pain to his nurse. A review of Resident 47's Medication Administration Record (MAR), dated 5/2024, indicated Resident 47 received Hydrocodone-Acetaminophen on 5/13/2024 at 11:08 a.m., after initially reporting his back pain at 10:32 a.m. The MAR indicated that no other pain medication or non-medication pain interventions were provided prior to the administration Hydrocodone-Acetaminophen. A review of Resident 47's care plan, dated 7/23/2023 and revised on 7/24/2023, indicated Resident 47 suffered from chronic pain related to spinal fusion. The care plan indicated Resident 47's goals of care indicated Resident 47 will voice a level of comfort. The staff's interventions indicated to achieve this goal; staff were to respond immediately to any complaints of pain. A review of Resident 47's care plan, dated 7/24/2023, indicated Resident 47 had an alteration in musculoskeletal status related to spinal fusion. The care plan indicated Resident 47's goal of care included Resident 47 being free from pain or at a level of discomfort acceptable to the resident. The staff interventions indicated to achieve this goal; staff were to give analgesics as ordered by the physician. During an interview on 5/14/2024 at 2:26 p.m., with Certified Nursing Assistant (CNA) 10, CNA 10 stated that if a resident was reporting that they were in pain, it should be reported to the charge nurse right away. During an interview on 5/14/2024 at 2:47 p.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated that if a resident was reporting pain, or appeared to be in pain, the resident's pain level should be assessed and pain medication should be administered right away, along with non-medication interventions. 2. A review of Resident 61's admission Record indicated the facility originally admitted Resident 61 on 12/13/2022. Resident 61's admitting diagnoses included symptoms and signs involving the musculoskeletal system, reduced mobility, and difficulty or inability to move his right side following a stroke (interruption of blood flow to the brain). A review of Resident 61's H&P, dated 2/8/2024, indicated Resident 61 had the capacity to understand and make decisions. A review of Resident 61's MDS, dated [DATE], indicated Resident 61 had mild cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 61 required partial to maximal assistance from staff for assistance with ADLs. The MDS indicated Resident 61 required substantial assistance from staff with repositioning while in and out of bed (rolling from side to side, transferring from bed to chair and vice versa, and transitioning from a lying to sitting position and vice versa, etc.). A review of Resident 61's current physician orders, dated 5/14/2024, indicated Resident 61 was receiving Gabapentin (medication to treat nerve pain) by mouth three times a day for neuropathy (nerve pain). Further review of Resident 61's orders indicated that Resident 61 did not have any pain medication ordered for breakthrough pain (a sudden increase in pain that may occur in those who already have chronic pain from arthritis or other conditions). A review of Resident 61's care plan, dated 11/20/2023, indicated Resident 61 had the potential to experience pain due to his diagnoses of a stroke with subsequent right sided weakness, and neuropathy. The care plan indicated Resident 61's goals of care included verbalizing adequate relief of pain or ability to cope with incompletely relieved pain. The staff's interventions indicated to achieve this goal, staff were to anticipate the resident's need for pain relief and respond immediately to any complaint of pain. A review of Resident 61's care plan, dated 5/30/2023 and revised 8/10/2023, indicated Resident 61 had neuropathy and was at risk for pain. The care plan indicated Resident 61's goal of care was Resident 61 voicing a level of comfort. The staff's interventions indicated staff were to administer meds as ordered, including Gabapentin capsule 100 mg. A review of Resident 61's MAR, dated 5/2024, indicated Resident 61 did not receive his 6:00 p.m. dose of Gabapentin, as ordered, on 5/13/2024. During a concurrent interview and record review, on 5/14/2024 at 2:51 p.m., with LVN 4, LVN 4 reviewed Resident 61's current physician orders, progress notes, and MAR dated 5/2024. LVN 4 stated Resident 61 did not have any medication ordered for potential breakthrough pain. LVN 4 stated that if Resident 61 experienced breakthrough pain, staff would need to contact the physician for orders. LVN 4 stated the physicians usually responded quickly but it was not a guarantee. LVN 4 then stated Resident 61 had routinely scheduled Gabapentin ordered for his neuropathy and following a review of Resident 61's MAR dated 5/2024, LVN 4 stated Resident 61 did not receive his 6:00 p.m. dose of Gabapentin on 5/13/2024. LVN 4 reviewed Resident 61's progress notes and stated there was no documentation indicating why the medications was not administered. LVN 4 stated that not having pain medication ordered for breakthrough pain, and not administering Resident 61's Gabapentin as ordered, could cause unnecessary pain for Resident 61. During an interview on 5/16/2024 at 10:54 a.m., with the Director of Nursing (DON), the DON stated that if a resident's care plan indicated for staff to respond immediately to any complaints of pain, then immediately meant promptly or right away. The DON stated that when a staff was notified of a resident's complaint of pain, the staff should stop what they were doing and notify a charge nurse. The DON stated a licensed nurse should assess the resident's pain and perform an intervention, including administration of pain medication. The DON stated that delayed administration of pain medication could cause discomfort for the resident.

CONCERN (D)

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

Garbage Disposal (Tag F0814)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure the trash stored in the dumpster area was maintained in a sanitary manner when: One of three garbage dumpsters lid was open and overfilled with cardboard boxes. The ground around the trash dumpsters was not clean and had plastic utensils, gloves, and paper around and under the dumpsters. This deficient practice had the potential for harborage and feeding of pests. Findings: During a concurrent observation and interview with Maintenance Staff (MS 1) on 5/14/2024 at 9:00 a.m., there was one dumpster outside of the kitchen back exit that was not covered. The dumpster was overfilled with cardboard boxes and not covered. There was trash on the ground including plastic forks, gloves, and paper. MS 1 stated the cardboard boxes should be made flat so they could fit in the dumpster and the lids could close. MS 1 sated the trash on the floor was from the neighbor who lived next door to the facility who threw their trash into the facility's trash bins and on the ground. MS 1 stated the area should be clean and the trash bin should always stay covered to prevent attracting flies and other pests. A review of the facility policy and procedure (P&P) titled Food-Related Garbage and Refuse Disposal, revised 2017, indicated outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter. A review of the facility P&P titled Sanitation, revised 2022, indicated garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpsters/compactors with lids or otherwise covered. A review of the Food and Drug Administration (FDA) Food Code 2022, dated 1/18/2023, code number 5-501.113 titled Covering receptacles, indicated receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered with tight-fitting lids or doors if kept outside the establishment. The Food Code also indicated under code number 5-501.110 titled Storing Refuse, Recyclables, and Returnable indicated refuse, recyclables, and returnable shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents.

CONCERN (D)

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

Deficiency F0847 (Tag F0847)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to follow their policy when discussing binding arbitration agreements (a form of alternative dispute resolution in which both parties agree to have their case heard by a neutral party instead of a judge and jury) with three of three sampled residents and/or their responsible parties (Resident 73, 80, and 241). This deficient practice increased the risk that Resident 73, Resident 80, and Resident 241 and/or their responsible parties unknowingly forfeited their right to resolve any disputes with the facility in court, alongside a judge and/or jury. Findings: 1. A review of Resident 73's admission Record indicated the facility originally admitted Resident 73 on 1/27/2024. Resident 73's admission record indicated the resident had a responsible party (RP) making decisions on her behalf. A review of the facility document titled Arbitration Agreement, dated 1/20/2022, indicated Resident 73's RP (RP 1) signed the binding arbitration agreement on 3/5/2024, indicating Resident 73 no longer had the right to a jury or court trial in the event of medical malpractice (when a healthcare professional neglects to provide appropriate treatment, take appropriate action, or gives substandard treatment that causes harm, injury, or death to a person) or any other claim. During an interview on 5/15/2024 at 11:06 a.m., with RP 1, RP 1 stated he did not recall discussing binding arbitration agreements with the facility, and stated he did not know what it meant to enter into a binding arbitration agreement. 2. A review of Resident 80's admission Record indicated the facility originally admitted Resident 80 on 2/22/2024. Resident 80's admission record indicated he had an RP making decisions on his behalf. A review of the facility document titled Arbitration Agreement, dated 1/20/2022, indicated Resident 80's RP (RP 2) signed the binding arbitration agreement on 3/7/2024, indicating Resident 73 no longer had the right to a jury or court trial in the event of medical malpractice or any other claim. 3. A review of Resident 241's admission Record indicated the facility originally admitted Resident 241 on 5/4/2024. Resident 241's admission Record indicated Resident 241 was self-responsible. A review of the facility document titled Arbitration Agreement, dated 1/20/2022, indicated Resident 241 signed the binding arbitration agreement on 5/7/2024, indicating Resident 241 no longer had the right to a jury or court trial in the event of medical malpractice or any other claim. During an interview on 5/15/2024 at 11:39 a.m., with Resident 241, Resident 241 stated he had resided facility for less than two weeks. Resident 241 stated he did not recall entering into a binding arbitration agreement with the facility and stated, What is that? Can you tell me more?. Resident 241 stated he signed his own paperwork upon admission and stated that a binding arbitration was not explained to him prior to signing the agreement. During a concurrent interview and record review, on 5/15/2024 at 12:40 p.m., with the Admissions Coordinator (AC), the AC reviewed the facility policy and procedure (P&P) titled Binding Arbitration Agreements, dated 11/2023. The AC stated she did not document the Residents'/RPs' verbal acknowledgement of understanding what a binding arbitration agreement was prior to having them sign the document. During an interview on 5/15/2024 at 12:49 p.m., with the AC, the AC stated that she was trained on how to explain binding arbitration agreements, and stated the training curriculum was based on the facility policy and procedure titled Binding Arbitration Agreements, dated 11/2023. A review of the facility P&P titled Binding Arbitration Agreements, dated 11/2023, indicated residents (or representatives) are informed of the nature and implications of any proposed binding arbitration agreements so as to make informed decisions on whether to enter into such agreements. The P&P indicated the terms and conditions of a binding arbitration agreement are explained to the resident (or representative) in a way that ensures his or her understanding of the agreement and after the terms and conditions of a binding arbitration agreement are explained, the resident or representative must acknowledge that he or she understands the agreement before being asked to sign the document. The P&P further indicated a signature alone is not sufficient to acknowledgement of understanding and the resident (or representative) must verbally acknowledge understanding, and the verbal acknowledgement documented by the staff member who explains the agreement.

CONCERN (E)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately assess functional limitation (limited ability to move a joint that interferes with daily functioning) in range of motion ([ROM] full movement potential of a joint [where two bones meet]) for five of seven sampled residents (Resident 8, 27, 49, 61, and 63) with limited mobility (ability to move) and ROM limitations. This deficient practice had the potential to affect the provision of care. Findings: a. A review of Resident 8's admission Record, indicated Resident 8 was admitted to the facility on [DATE] with diagnoses including hemiplegia or hemiparesis (weakness or inability to move one side of the body) affecting the left non-dominant (used less often) side, dementia (decline in mental ability severe enough to interfere with daily life), contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness) to both knees, and muscle weakness. A review of Resident 8's Rehab - Joint Mobility Screen ([JMS] brief assessment of a resident's range of motion in both arms and both legs), dated 10/31/2023, indicated Resident 8 had ROM impairments, including severe impairment (approximately 25 percent [%] or less full ROM) in the left shoulder, left elbow, left wrist, and left hand and moderate impairment (approximately 50% full ROM) in both hips and both knees. A review of Resident 8's Minimum Data Set ([MDS] a comprehensive assessment and care planning tool), dated 11/29/2023, indicated Resident 8 had ROM limitations in one arm and one leg. A review of Resident 8's Rehab - JMS, dated 2/24/2024, indicated Resident 8 had ROM impairments, including severe impairment in the left shoulder, left elbow, left wrist, left hand, both hips, and both knees. A review of Resident 8's MDS, dated [DATE], indicated Resident 8 did not have any ROM limitations in both arms and had ROM limitations in both legs. During an observation on 5/13/2024 at 12:49 p.m., in Resident 8's room, Resident 8 was observed lying in bed with left shoulder rotated toward the body, the left elbow bent, the left wrist bent downward, and the left hand was in a closed fist. During a concurrent observation and interview on 5/14/2024 at 8:54 a.m., in Resident 8's room, Resident 8 was observed awake, lying in bed, and spoke clearly. Resident 8's left arm continued to be positioned with the left shoulder rotated toward the body, the left elbow bent, the left wrist bent downward, and the left hand in a closed fist. Resident 8 moved the left leg but stated the left leg was weak. During a concurrent interview and record review on 5/14/2024 at 4:38 p.m. with the MDS Coordinator (MDS 1), Resident 8's Rehab - JMS and MDS assessments were reviewed. MDS 1 stated Resident 8's MDS assessments, dated 11/29/2023 and 2/29/2024, was not accurate and should have indicated one arm and both legs had ROM limitations. MDS 1 stated the MDS provided an overall picture of the resident's status. MDS 1 stated it was important for the MDS assessments to be accurate to ensure the resident (in general) did not have any significant changes or decline and to ensure the resident was receiving care. b. A review of Resident 27's admission Record, indicated Resident 27 was initially admitted to the facility on [DATE] and re-admitted Resident 27 on 3/30/2023. The admission Record indicated Resident 27's diagnoses included Parkinson's disease (brain disorder that causes unintended or uncontrollable movements and difficulty with balance and coordination), contractures on both knees, and muscle weakness. A review of Resident 27's Rehab - JMS, dated 10/5/2023, indicated Resident 27 had ROM impairments including, moderate impairment (approximately 50 percent [%] full ROM) in both shoulders and minimal impairment (75% of full ROM) in the left elbow, both hands, and both knees. A review of Resident 27's MDS, dated [DATE], indicated Resident 27 did not have any ROM impairments in both arms and both legs. A review of Resident 27's Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation and Plan of Treatment, dated 10/10/2023, indicated Resident 27 had ROM impairments in both shoulders, both elbows, and both hands. A review of Resident 27's Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation, dated 10/12/2023, indicated Resident 27 had ROM impairments in both knees. A review of Resident 27's MDS, dated [DATE], indicated Resident 27 did not have any ROM impairments in both arms and both legs. A review of Resident 27's PT Discharge summary, dated [DATE], indicated Resident 27 had ROM limitations in both knees. A review of Resident 27's OT Discharge summary, dated [DATE], indicated Resident 27 had ROM limitations in both shoulders, both elbows, and both hands. A review of Resident 27's OT Evaluation and Plan of Treatment, dated 3/4/2024, indicated Resident 27 had ROM limitations in both shoulders, both elbows, both wrists, and both hands. A review of Resident 27's PT Evaluation and Plan of Treatment, dated 3/4/2024, indicated Resident 27 had ROM limitations in both knees. A review of Resident 27's MDS, dated [DATE], indicated Resident 27 did not have any ROM impairments in both arms and both legs. During an observation 5/13/2024 at 1:26 p.m., in Resident 27's room, Resident 27's shoulders were both rotated toward Resident 27's body, both elbows were bent, both wrists were bent downward, and both hands were in a closed first position. During an observation on 5/14/2024 at 11:46 a.m., in Resident 27's room, with Restorative Nursing Aide 1 (RNA 1), Resident 27's body was turned toward the right side of the bed. RNA 1 provided PROM exercises to both arms and both legs. During an interview on 5/14/2024 at 11:59 a.m., with RNA 1, RNA 1 stated Resident 27 had stiffness throughout both arms and both knees. During a concurrent interview and record review on 5/14/2024 at 4:28 p.m. with the MDS Coordinator (MDS 1), Resident 27's OT Evaluation and Discharge Summary, PT Evaluation and Discharge Summary, and MDS Assessments were reviewed. MDS 1 stated Resident 27's MDS assessments, dated 10/5/2023, 1/5/2024, and 4/5/2024, were inaccurate and should have indicated Resident 27 had ROM limitations in both arms and both legs in accordance with the OT and PT Evaluations. MDS 1 stated it was important for the MDS assessments to be accurate to ensure the resident (in general) did not have any significant changes or decline and to ensure the resident was receiving care. c. A review of Resident 49's admission Record, indicated Resident 49 was admitted to the facility on [DATE] with diagnoses including fracture (break in the bone) of the right femur (hip bone), presence of a right artificial hip joint, dementia, and contracture of the right elbow, both knees, and right hip. The admission Record also indicated Resident 49 was admitted to palliative care (specialized medical care that focuses on providing patients relief from pain and other symptoms of a serious illness) on 2/28/2024. A review of Resident 49's Rehab - JMS, dated 2/29/2024, indicated Resident 49 had ROM impairments in both arms and both legs, including moderate impairment (approximately 50 percent [%] full ROM) in the left shoulder, severe impairment (approximately 25% or less full ROM) in the right shoulder, minimal impairment (75% of full ROM) in the left elbow, severe impairment in the right elbow, moderate impairment in the right wrist, minimal impairment in the right hand, moderate impairments in both hip and the left knee, and severe impairment in the right knee. A review of Resident 49's MDS, dated [DATE], indicated Resident 49 did not have any ROM impairment in both arms and had a ROM impairment in one leg. During an interview on 5/14/2024 at 4:28 p.m. with MDS 1, MDS 1 stated it was important for the MDS assessments to be accurate to ensure the resident did not have any significant changes or decline and to ensure the resident was receiving care. During a concurrent interview and record review on 5/16/2024 at 9:51 a.m. with MDS 1, MDS 1 reviewed Resident 49's Rehab - JMS, dated 2/29/2024, and stated Resident 49 had ROM limitations in both arm and both legs. During a concurrent interview and record review on 5/16/2024 at 9:55 a.m. with MDS 1, MDS 1 reviewed Resident 49's MDS, dated [DATE], and stated the MDS was inaccurate and should have indicated Resident 49 had ROM impairments in both arms and both legs. d. A review of Resident 61's admission Record, indicated Resident 61 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis (weakness and inability to move one side of the body) following a cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the right dominant side, dysphagia (difficulty swallowing) following a cerebral infarction, history of falling, and reduced mobility. A review of Resident 61's Rehab - JMS, dated 3/8/2024, indicated Resident 61 had ROM impairments in both arms, including severe impairment (approximately 25 percent [%] or less full ROM) in both shoulders, the right elbow, and the right hand. A review of Resident 61's MDS, dated [DATE], indicated Resident 61 did not have any ROM limitations in both arms and both legs. During a concurrent observation and interview on 5/13/2024 at 1:05 p.m., in Resident 61's room, Resident 61 was observed awake and lying in bed. Resident 61 used the left hand to eat from the meal tray. Resident 61 had difficulty lifting both arms at the shoulder joint, had some active movement in the right elbow, and had difficulty moving the fingers on the right hand. During an observation on 5/14/2024 at 1:37 p.m., in Resident 61's room, with Restorative Nursing Aide 1 (RNA 1), Resident 61 required RNA 1's physical assistance to perform exercises to both arms and the right leg. Resident 61 moved the left leg without any physical assistance from RNA 1. During an interview on 5/14/2024 at 4:28 p.m. with the MDS 1, MDS 1 stated it was important for the MDS assessments to be accurate to ensure the resident (in general) did not have any significant changes or decline and to ensure the resident was receiving care. During a concurrent interview and record review on 5/16/2024 at 10:17 a.m. MDS 1, Resident 61's Rehab - JMS, dated 3/8/2024, and MDS, dated [DATE], were reviewed. MDS 1 stated Resident 61 has a diagnosis of hemiplegia, affecting the right arm and leg of Resident 61's body. MDS 1 stated Resident 61's MDS, dated [DATE], was inaccurate and should have indicated Resident 61 had ROM impairments to both arms and one leg. e. A review of Resident 63's admission Record, indicated Resident 63 was admitted to the facility on [DATE] and re-admitted Resident 63 on 12/12/2023. The admission Record indicated Resident 63 had diagnoses including muscle weakness, history of falling, and contracture to both elbows, both hands, both hips, and both knees. A review of Resident 63's Rehab - JMS, dated 12/16/2023, indicated Resident 63 had ROM limitations including, moderate impairment (approximately 50 percent [%] full ROM) in both shoulders, both elbows, both hips, and the right knee, minimal impairment (75% of full ROM) in both hands, and severe impairment (approximately 25% or less full ROM) in the left knee. A review of Resident 63's MDS, dated [DATE], indicated Resident 63 did not have any ROM limitations in both arms and had ROM limitations in both legs. During an interview on 5/14/2024 at 4:28 p.m. with MDS 1, MDS 1 stated it was important for the MDS assessments to be accurate to ensure the resident did not have any significant changes or decline and to ensure the resident was receiving care. During a concurrent interview and record review on 5/16/2024 at 10:08 a.m. with MDS 1, Resident 63's Rehab - JMS, dated 12/16/2023, and MDS assessment, dated 12/19/2023, were reviewed. MDS 1 stated Resident 63's MDS, dated [DATE], was inaccurate and should have indicated Resident 63 had ROM impairments to both arm and both legs. A review of the facility's undated Policy and Procedure (P&P) titled, Accuracy of the Resident Assessment, indicated any person completing the MDS must sign and certify the accuracy of that portion of the assessment.

CONCERN (E)

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure five of seven sampled residents (Resident 8, 27, 49, 61, and 65) with limited mobility (ability to move) and range of motion ([ROM] full movement potential of a joint [where two bones meet]) received services to maintain mobility and ROM by failing to: a. Apply Resident 8's left elbow extension splint (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) five times per week during 5/2024 in accordance with the physician orders and care plan. b. Provide Resident 61 with PROM to the right leg and active assistive range of motion (AAROM, use of muscles surrounding the joint to perform the exercise but required some help from a person or equipment) exercises to both arms and the left leg during 5/2024 in accordance with the physician orders and care plan. c. Provide Resident 27, 49, and 65 with passive range of motion (PROM, movement of joint through the ROM with no effort from the person) exercises during 5/2024 for both legs and both arms in accordance with the physician orders and care plan. These failures had the potential for Resident 8, 27, 49, 61, and 65 to develop ROM limitations, including but not limited to the development or worsening of contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness). Cross reference F725. Findings: a. A review of Resident 8's admission Record, indicated Resident 8 was admitted to the facility on [DATE] with diagnoses including hemiplegia or hemiparesis (weakness or inability to move one side of the body) affecting the left non-dominant (used less often) side, dementia (decline in mental ability severe enough to interfere with daily life), contractures to both knees, and muscle weakness. A review of Resident 8's Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation and Plan of Treatment, dated 1/27/2024, indicated Resident 8 had impaired ROM in the left shoulder, left elbow, left wrist, and left hand. The OT Evaluation indicated Resident 8's left elbow was bent at 90 degrees. A review of Resident 8's Order Summary Report which included physician orders, dated 2/21/2024, indicated the Restorative Nursing Aide ([RNA] certified nursing aide program that helps residents to maintain their function and joint mobility) program to apply the left elbow extension splint during the day for two hours, five days per week. A review of Resident 8's care plan, dated 2/21/2024, indicated Resident 8 was at risk for decline and/or complication in ROM, decreased mobility and movement, decreased muscle strength, and required an RNA ROM program to the left arm. The interventions indicated to provide Resident 8 with RNA to apply the left elbow extension splint two hours per day, five days per week. A review of Resident 8's Minimum Data Set ([MDS] a comprehensive assessment and care planning tool), dated 2/29/2024, indicated Resident 8 had clear speech, had difficulty communicating some words, usually understood others, and had severely impaired cognition (ability to think, understand, learn, and remember). A review of Resident 8's RNA Task Schedule (record of nursing assistant tasks) for 5/2024, indicated to apply the left elbow extension splint for two hours per day, five days per week was blank on 5/1/2024, 5/6/2024, 5/9/2024, 5/10/2024, and 5/15/2024. During an observation on 5/13/2024 at 12:49 p.m., in Resident 8's room, Resident 8 was observed lying in bed with left shoulder rotated toward the body, the left elbow bent, the left wrist bent downward, and the left hand was in a closed fist. An elbow splint was not applied to Resident 8's left arm. During a concurrent observation and interview on 5/14/2024 at 8:54 a.m. in Resident 8's room, Resident 8 was observed awake, lying in bed, and spoke clearly. Resident 8's left arm continued to be positioned with the left shoulder rotated toward the body, the left elbow bent, the left wrist bent downward, and the left hand in a closed fist. An elbow splint was not applied to Resident 8's left arm. Resident 8 stated a staff member (unknown) did place a splint on the left elbow, but Resident 8 stated the splint caused much pain when applied to the left arm. During an observation on 5/14/2024 at 11:34 a.m., in Resident 8's room, Resident 8 was observed with a splint applied to the left elbow. During a concurrent interview and record review on 5/16/2024 at 11:13 a.m. with the Director of Staff Development (DSD) and the Director of Rehabilitation (DOR), Resident 8's physician orders for RNA, dated 2/21/2024, and the RNA Task Schedule for 5/2024 was reviewed. The DSD reviewed Resident 8's RNA Task Schedule for 5/2024 and stated the splint was not applied to Resident 8's left elbow five times per week in accordance with the physician orders. The DSD stated Resident 8 did not receive RNA services five times per week in 5/2024 since there was only one RNA staff working. The DOR stated RNA services were important to prevent decline in ROM, function, and mobility. b. A review of Resident 61's admission Record, indicated Resident 61 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following a cerebral infarction (brain damage due to a loss of oxygen to the area) affecting the right dominant side, dysphagia (difficulty swallowing) following a cerebral infarction, history of falling, and reduced mobility. A review of Resident 61's physician orders, dated 2/8/2024, indicated for RNA to perform AAROM exercises to the left leg and PROM to the right leg, five times per week or as tolerated, to maintain current level of function. Another physician order, dated 3/8/2024, indicated for RNA to provide Resident 61 with AAROM exercises to both arms, five times per week or as tolerated. A review of Resident 61's Rehab - Joint Mobility Screen ([JMS] brief assessment of a resident's range of motion in both arms and both legs), dated 3/8/2024, indicated Resident 61 had ROM impairments in both arms, including severe impairment (approximately 25 percent [%] or less full ROM) in both shoulders, the right elbow, and the right hand. A review of Resident 61's MDS, dated [DATE], indicated Resident 61 had clear speech, had difficulty communicating some words, usually understood others, and had moderately impaired cognition. A review of Resident 61's undated care plan, indicated Resident 61 was at risk for decline and/or complication with ROM in joints, decreased mobility and movement, decreased muscle strength, and required an RNA program to provide ROM to both arms and both legs. The interventions indicated to provide Resident 61 with RNA for AAROM exercises to the left leg and both arms and PROM to the right leg, five times per week or as tolerated. A review of Resident 61's RNA Documentation Survey Report (record of nursing assistant tasks) for 5/2025, indicated to provide AAROM exercises to both arms and the left leg and PROM exercises to the right leg was blank for 5/1/2024, 5/6/2024, 5/9/2024, 5/10/2024, and 5/15/2024. During a concurrent observation and interview on 5/13/2024 at 11:33 a.m., in Resident 61's room, Resident 61 stated he had a stroke affecting the right side of the body. Resident 61's fingers of the right hand remained straight and unable to bend. Resident 61 stated a nurse (unknown) came once to assist with exercises on both hands but did not provide exercises to both legs. Resident 61 stated the nurse came once and had not returned in the past three to four weeks. During a concurrent observation and interview on 5/13/2024 at 1:05 p.m., in Resident 61's room, Resident 61 was observed awake and lying in bed. Resident 61 used the left hand to eat from the meal tray. Resident 61 stated he received exercises once a day every three to four weeks and did not receive exercises multiple times per week. Resident 61 had difficulty lifting both arms at the shoulder joint, had some motion in the right elbow, and had difficulty moving the fingers on the right hand. During an observation on 5/14/2024 at 1:37 p.m., in Resident 61's room, with Restorative Nursing Aide 1 (RNA 1), RNA 1 performed AAROM exercises to both arms and the left leg and PROM to the right leg. During a concurrent interview and record review on 5/16/2024 at 12:40 p.m. with the DOR and DSD, Resident 61's physician orders, dated 2/8/2024 and 3/8/2024, and the RNA Documentation Survey Report for 5/2024 was reviewed. The DSD stated Resident 61 did not receive RNA for AAROM to both arms and the left leg and PROM to the right leg, five per week in accordance with the physician orders since there was only one RNA staff working during 5/2024. The DOR stated RNA services were important to prevent decline in ROM, function, and mobility. c. A review of Resident 27's admission Record, indicated Resident 27 was initially admitted to the facility on Resident 27 on 8/5/2021 and re-admitted Resident 27 on 3/30/2023. The admission Record indicated Resident 27's diagnoses included Parkinson's disease (brain disorder that causes unintended or uncontrollable movements and difficulty with balance and coordination), contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness) on both knees, and muscle weakness. A review of Resident 27's MDS, dated [DATE], indicated Resident 27 had clear speech, had difficulty communicating some words, usually understood others, and had severely impaired cognition. A review of Resident 27's Occupational Therapy ([OT] profession aimed to increase or maintain a person's capability of participating in everyday life activities [occupations]) Evaluation and Plan of Treatment, dated 3/4/2024, indicated Resident 27 had impaired ROM in both shoulders, elbows, wrists, and hands. A review of Resident 27's Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Evaluation and Plan of Treatment, dated 3/4/2024, indicated Resident 27 had impaired ROM in both knees. A review of Resident 27's physician orders, dated 3/4/2024 and 3/5/2024, indicated for RNA to provide PROM exercises to both legs, four times per week as tolerated. Another physician order, dated 3/5/2024, indicated for RNA to provide Resident 27 with PROM exercises to both arms at all joints, four times per week as tolerated. A review of Resident 27's care plan, dated 3/4/2024, indicated Resident 27 was at risk for decline and/or complication with ROM in joints, decreased mobility and movement, decreased muscle strength, and required an RNA program for both arms and both legs. The interventions indicated to provide Resident 27 with RNA for PROM in both arms and both legs, four times per week. A review of Resident 27's RNA Task Schedule for 5/2024, indicated RNA to perform PROM to both arm and both legs was blank for 5/1/2024, 5/5/2024, 5/6/2024, 5/10/2024, and 5/15/2024. During an observation on 5/13/2024 at 9:44 a.m., in Resident 27's room, Resident 27 was observed lying in bed with both elbows bent and both hands positioned in a closed fist. During a concurrent observation and interview on 5/13/2024 at 1:26 p.m., in Resident 27's room, Resident 27's eyes were observed closed but the resident responded to questions. Resident 27 stated he rarely received exercises but was unable to specify how often exercises were performed. Resident 27's shoulders were both rotated toward Resident 27's body, both elbows were bent, both wrists were bent downward, and both hands were in a closed first position. During an observation on 5/14/2024 at 11:46 a.m., in Resident 27's room, with RNA 1, Resident 27's body was turned toward the right side of the bed. RNA 1 provided PROM exercises to both arms and both legs. During an interview on 5/14/2024 at 11:59 a.m., with RNA 1, RNA 1 stated Resident 27 had stiffness throughout both arms and both knees. During an interview on 5/14/2024 at 3:34 p.m. with the DOR, the DOR stated the purpose of the RNA program was to maintain a resident's ROM. The DOR stated Resident 27 was receiving PT, OT, and RNA services at the same time since Resident 27's diagnosis of Parkinson's disease placed Resident 27 at increased risk for decline in ROM. During a concurrent interview and record review on 5/16/2024 at 11:59 a.m. with the DOR and DSD, Resident 27's physician orders for RNA, dated 3/4/2024 and 3/5/2024, and RNA Task Schedule for 5/2024 was reviewed. The DSD stated Resident 27 did not receive RNA for PROM to both arms and both legs four times per week in accordance with the physician orders during 5/2024 since there was only one RNA staff working. The DOR stated RNA services were important to prevent decline in ROM, function, and mobility. d. A review of Resident 49's admission Record, indicated Resident 49 was admitted to the facility on [DATE] with diagnoses including fracture (break in the bone) of the right femur hip bone, presence of a right artificial hip joint, dementia, and contracture of the right elbow, both knees, and right hip. The admission Record also indicated Resident 49 was admitted to palliative care (specialized medical care that focuses on providing patients relief from pain and other symptoms of a serious illness) on 2/28/2024. A review of Resident 49's Rehab - JMS, dated 2/29/2024, indicated Resident 49 had ROM impairments in both arms and both legs, including moderate impairment (approximately 50 percent [%] full ROM) in the left shoulder, severe impairment (approximately 25% or less full ROM) in the right shoulder, minimal impairment (75% of full ROM) in the left elbow, severe impairment in the right elbow, moderate impairment in the right wrist, minimal impairment in the right hand, moderate impairment in both hips and the left knee, and severe impairment in the right knee. A review of Resident 49's physician orders, dated 3/1/2024, indicated for the RNA to provide gentle PROM exercises to both arms and both legs, five times per week as tolerated. A review of Resident 49's care plan, dated 1/3/2024, indicated Resident 49 was at risk for decline and/or complication with ROM in joints, decreased mobility and movement, decreased muscle strength, and required an RNA program for both legs. The interventions, initiated 3/1/2024, indicated to provide Resident 49 with RNA for PROM in both legs, five times per week. A review of Resident 49's MDS, dated [DATE], indicated Resident 49 had clear speech, had difficulty communicating some words, usually understood others, and had severely impaired cognition. A review of Resident 49's RNA Task for 5/2024, indicated to provide PROM to both arms and both legs was blank for 5/1/2024, 5/6/2024, 5/10/2024, and 5/15/2024. During a concurrent observation and interview on 5/14/2024 at 8:59 a.m., in Resident 49's room, Resident 49 was observed turned facing the left side of the bed. Resident 49's right shoulder was rotated toward the body, right elbow was bent, and the right wrist was bent. Resident 49's moved the fingers of the right hand without any assistance. Resident 49 stated he did not like the exercises due to pain. During an observation and interview on 5/14/2024 at 11:38 a.m., with RNA 1, in Resident 49's room, RNA 1 attempted to perform exercises with Resident 49, who refused the perform exercises with RNA due to pain. RNA 1 stated the nurse would be notified of Resident 49's pain and would attempt again after Resident 49 received pain medication. During a concurrent interview and record review on 5/16/2024 at 12:19 p.m. with the DOR and DSD, Resident 49's physician orders, dated 3/1/2024, and RNA Task Schedule for 5/2024 was reviewed. The DSD stated Resident 49 did not receive RNA for PROM to arms and both legs, five per week in accordance with the physician orders during 5/2024 since there was only one RNA staff working. The DOR stated RNA services were important to prevent decline in ROM, function, and mobility. e. A review of Resident 65's admission Record, indicated Resident 65 was admitted to the facility on [DATE] and readmitted Resident 65 on 9/6/2023. Resident 65's diagnoses included muscle weakness, encephalopathy (disease that affects the brain, causing changes in its function), anxiety disorder (feelings of worry or fear that are strong enough to interfere with one's daily activities), dementia, and dysphagia. The admission Record also indicated Resident 65 was admitted to palliative care on 10/25/2023. A review of Resident 65's physician orders, dated 11/17/2023 and 3/12/2024, indicated for the RNA to provide PROM exercises to both legs, seven times per week as tolerated. The order dated 3/12/2024, indicated for RNA to provide PROM exercises to both arms, five times per week as tolerated. A review of Resident 65's care plan, dated 11/17/2023, indicated Resident 65 was at risk for decline and/or complication with ROM in joints, decreased mobility and movement, decreased muscle strength, and required an RNA program. Interventions indicated to provide Resident 65 with PROM exercises to both arms, five times per week, and both legs, seven times per week, as tolerated. A review of Resident 65's Rehab - JMS, dated 2/2/2024, indicated Resident 65 had ROM impairments, including minimal impairment (75 percent [%] of full ROM) in both elbows and the right hand. A review of Resident 65's MDS, dated [DATE], indicated Resident 65 had clear speech, had difficulty communicating some words, usually understood others, and had severely impaired cognition. A review of Resident 65's RNA Documentation Survey Report for 5/2025, indicated to provide PROM to both arms, five times per week, and PROM to both legs, seven times per week, was blank on 5/1/2024, 5/4/2024, 5/5/2024, 5/6/2024, 5/9/2024, 5/10/2024, and 5/15/2024. A review of Resident 65's Rehab - JMS, dated 5/13/2024, indicated Resident 65 had ROM limitations in both arms and both legs. Resident 65's ROM impairments included moderate impairment (approximately 50% full ROM) in the left shoulder, severe impairment (approximately 25% or less full ROM) in the right shoulder, minimal impairment in both elbows, and moderate impairment in both wrists, the right hand, both hips, and both knees. The recommendations indicated Resident 65 will receive PT and OT evaluations due to the ROM decline which was anticipated due to Resident 65's palliative care status. During a concurrent observation and interview on 5/13/2024 at 12:54 p.m., in Resident 65's room, Resident 65 was observed awake, alert, and lying in bed. Resident 65's body was turned toward the right side and both hips and knees were in a bent position. Resident 65 slightly lifted both arms at the shoulder joint, bent both arms at the elbow joint, and slightly opened both hands. Resident 65 stated the RNA had just performed exercises with Resident 65. During a concurrent interview and record review on 5/16/2024 at 12:45 p.m. with the DOR and DSD, Resident 65's physician orders, dated 11/17/2023 and 3/12/2024, and RNA Documentation Survey Report for 5/2024 was reviewed. The DSD stated Resident 65 did not receive RNA for PROM to arms, five times per week, and both legs, seven times per week in accordance with the physician orders during 5/2024 since there was only one RNA staff working. The DOR stated RNA services were important to prevent decline in ROM, function, and mobility. A review of the facility's Policy and Procedure (P&P) titled, Resident Mobility and Range of Motion, revised 7/2017, indicated residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM.

CONCERN (E)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure a safe and hazard free environment was maintained for one of three sampled residents (Resident 75) when a pool of enteral nutrition (form of nutrition that is delivered as a liquid) was observed on the floor in Resident 75's room. This deficient practice had the potential to cause avoidable harm to Resident 75 related to slips, falls, and possible subsequent injury associated with a fall. Findings: A review of Resident 75's admission Record indicated the facility admitted Resident 75 on 1/15/2024. Resident 75's admitting diagnoses included abnormalities of gait (manner of walking) and mobility and generalized muscle weakness. A review of Resident 75's Minimum Data Set (MDS, a comprehensive care-screening and care-planning tool), dated 4/22/2024, indicated Resident 75 had intact cognitive skills for daily decision making (normal ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 75 required set-up or clean-up assistance with ambulation (walking), meaning staff assisted only prior to or following the activity. A review of Resident 75's care plan indicated Resident 75 was at high risk for falls related to generalized weakness, gait/balance problem and impaired mobility. Goals of Resident 75's care included not sustaining serious injury. During a concurrent observation and interview, on 5/13/2024 at 10:07 a.m., in Resident 75's room, Resident 75 was observed ambulating in his room without staff assistance. There was a pool of enteral nutrition (liquid nutrients) flowing from his roommate's bedside and extending into his side of the room. The pool of enteral nutrition was accumulating on the left side of Resident 75's bed, extending to the space underneath his bed. Resident 75 stated he usually ambulates in his room and around the facility without staff supervision. During a concurrent observation and interview, on 5/13/2024 at 10:16 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated there was a pool of enteral nutrition on the ground. LVN 1 stated this accumulation of liquid on the ground was a slipping hazard for Resident 75 and stated Resident 75 could sustain a fall. During an interview on 5/16/2024 at 10:52 a.m., with the Director of Nursing (DON), the DON stated that the floors and walkways in the facility should be clean and clear of spills and accumulated liquids because they created a risk for slips and falls. A review of the facility policy and procedure (P&P) titled Safety and Supervision of Residents, dated 7/2017, indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.

CONCERN (E)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 57's admission Record (Face Sheet), indicated Resident 57 was admitted to the facility on [DATE], with diagnoses of acute respiratory failure with hypoxia (a medical condition where you don't have enough oxygen in the body), shortness of breath, and pneumonia (an infection in the lungs). A review of Resident 57's MDS, dated [DATE], indicated Resident 57 was severely impaired (unable to) in making decisions regarding tasks of daily life. A review of Resident 57's Order Summary Report, dated as of 5/16/2024, indicated Resident 57 had an order for oxygen at 2 to 5 lpm as needed to maintain an oxygen saturation (measurement of how much oxygen is in the blood) above 90 percent (%) via nasal cannula or mask. During a concurrent observation and interview on 5/14/2024 at 12:32 p.m. with RT 1, in Resident 57's room, RT 1 stated a resident would need a humidifier when receiving oxygen at 4 lpm or more. RT 1 looked at Resident 57's oxygen machine and stated Resident 57 was receiving 4.5 lpm of oxygen and there was no humidifier. RT 1 stated a humidifier was important when a resident was receiving oxygen more than 4 lpm of oxygen because not doing so could dry out their nose and could cause a nosebleed. During an interview on 5/16/2024 at 11:41 a.m. with the Director of Nursing (DON), the DON stated when a resident was receiving oxygen above 4 lpm, they should have a humidifier to ensure the mucous membranes were kept moist. The DON stated not doing so could cause discomfort and nosebleeds for the resident. A review of the facility P&P titled Oxygen Administration, revised 10/2010, indicated when the staff is preparing to administer oxygen, they need to gather a humidifier bottle, ensure there is enough water in the humidifier bottle so that the water bubbles as oxygen flows through. The staff also needs to periodically re-check the water level in the humidifier bottle. 3. A review of Resident 69's admission Record, indicated Resident 69 was admitted to the facility on [DATE], with diagnoses including shortness of breath, fluid overload (too much fluid in the body), heart failure (condition where the heart does not pump blood as normal), and end stage renal disease (disease where the kidneys no longer work). A review of Resident 69's MDS, dated [DATE], indicated Resident 69 was cognitively intact (ability to reason, understand, remember, judge, and learn). A review of Resident 69's care plan, dated 4/26/2024 indicated Resident 69 was receiving oxygen therapy and had difficulty breathing due to pulmonary edema (water in the lung). The staff interventions included to provide Resident 69 with oxygen as ordered and to monitor for respiratory distress (condition where the body needs more oxygen) A review of Resident 69's Nursing Weekly Summary, dated 4/16/2024, indicated Resident 69 received oxygen as needed via nasal cannula. During an observation on 5/13/2024 at 9:37 a.m., Resident 1 was observed receiving oxygen at 3 lpm via a nasal cannula. During an interview on 5/14/2024 at 12:13 p.m. with LVN 3, LVN 3 stated Resident 69 was receiving oxygen via nasal cannula. LVN 3 confirmed after looking through Resident 69's medical records that there was no order for the resident to receive oxygen via nasal cannula. LVN 3 stated if a resident required oxygen, they needed a physician's order because nurses could not prescribe treatments for the residents. During an interview on 5/16/2024 at 11:41 a.m. with the DON, the DON stated oxygen administration required a physician order because oxygen was a treatment or medication and nurses did not have the ability to prescribe treatments or medications to residents. A review of the facility P&P titled Oxygen Administration, revised 10/2010, indicated the staff will first prepare to administer oxygen by verifying there is a physician's order. Based on observation, interview, and record review, the facility failed to provide respiratory services for three of four sampled residents (Resident 13, 57, and 69) by failing to: a. Ensure Resident 13 was provided a nebulizer machine (a device used to administer medication in the form of a mist inhaled into the lungs), incentive spirometer (device that measures the volume of the air inhaled into the lungs during inspiration), oxygen cylinder (medical device to provide supplemental oxygen to resident), nasal cannula (a device used to deliver supplemental oxygen placed directly on the resident's nostrils), respiratory treatment via nebulizer every four hours, and incentive spirometer treatment twice per day. This deficient practice had the potential to cause shortness of breath, avoidable harm, respiratory distress, and chronic obstructive pulmonary disease ([COPD]- a lung disease causing restricted airflow and breathing problems) exacerbation (worsening symptoms). b. Ensure Resident 57 was provided a humidifier (a device that adds moisture to the air to prevent dryness) while receiving more than 4 liters of oxygen via a nasal cannula. This deficient practice had the potential to cause discomfort and nosebleed associated with dry nasal mucous membranes (moist tissue that lines the inside of the nose). c. Ensure Resident 69 had a physician order for the administration of oxygen therapy. This deficient practice had the potential to cause complications associated with oxygen therapy. Findings: 1. A review of Resident 13's admission Record (Face Sheet), indicated Resident 13 was admitted to the facility on [DATE] with diagnoses including COPD, hypertension (high blood pressure), dementia (a loss of brain function such as memory, language, thinking), and depression (feeling of sadness and loss of interest). A review of Resident 13's History and Physical (H&P), dated 3/21/2024, indicated Resident 13 had the capacity to understand and make decisions. A review of Resident 13's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 3/28/2024, indicated Resident 13 required maximum assistance (helper does more than half the effort) from staff for toileting hygiene and showering, and moderate assistance (helper does less than half the effort) from staff for eating, oral hygiene, and personal hygiene. A review of Resident 13's Order Summary Report, dated 4/4/2024 and 5/1/2024, indicated to administer oxygen at 2 liters (l, unit of measurement) per minute (lpm) as needed for shortness of breath (SOB), incentive spirometer twice a day (BID) while awake, and Albuterol Sulfate Nebulization Solution (medication which works by relaxing and opening the airways) 2.5 milligram ([mg]-a measure of weight), inhale (breathe) orally via nebulizer every four (4) hours for COPD. During an observation on 5/13/2024 at 8:30 a.m., in Resident 13's room, Resident 13 was observed lying in bed, covered with a blanket, eyes closed, and visibly sleeping. There was no oxygen equipment, nebulizer machine, or incentive spirometer observed. During an observation on 5/13/2024 at 10:44 a.m., in Resident 13's room, there was no oxygen equipment, nebulizer machine, or incentive spirometer observed. During an observation on 5/13/2024 at 2:20 p.m., in Resident 13's room, there was no oxygen equipment, nebulizer machine, or incentive spirometer observed. During a concurrent interview and record review on 5/13/2024 at 4:30 p.m., with Registered Nurse 1 (RN 1), Resident 13's order summary reports, dated 4/2024, and 5/2024 was reviewed. The order summary reports indicated to administer oxygen at 2 lpm as needed for SOB, and incentive spirometer BID while awake. The order summary reports indicated Albuterol Sulfate Nebulization Solution 2.5 mg inhale orally via nebulizer every four (4) hours for COPD. During a concurrent observation and interview on 5/13/2024 at 4:35 p.m., with RN 1, in Resident 13's room. RN 1 confirmed there was no oxygen equipment, nebulizer, or incentive spirometer supplies in Resident 13's room. RN 1 stated Resident 13 should had been provided with the required respiratory treatment supplies per the facility's policy. RN 1 was not able to explain why Resident 13 was not provided with oxygen equipment, a nebulizer, and incentive spirometer supplies. RN 1 stated not having the required respiratory treatment supplies available when needed would mean the licensed staff would not be able to provide Resident 13 with respiratory treatment as ordered, which placed Resident 13 at risk for respiratory distress, avoidable SOB, COPD exacerbation, and hospitalization. During a concurrent observation and interview on 5/14/2024 at 10:10 a.m., with Resident 13, in Resident 13's room, Resident 13 was observed lying in bed reading a newspaper. There was no oxygen equipment, nebulizer machine, or incentive spirometer observed. Resident 13 stated she had resided in the facility for two months and did not remember receiving respiratory treatment since admission. During an interview on 5/14/2024 at 10:25 a.m., with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated she was the medication pass nurse. LVN 3 stated she did not provide Resident 13's respiratory treatment. LVN 3 stated Respiratory Therapist 1 (RT 1) was providing respiratory treatment for Resident 13. During an interview on 5/14/2024 at 1:45 p.m., with RT 1, RT 1 stated she was providing Resident 13's respiratory treatment during her work hours from 7:30 a.m., to 2:00 p.m., three times per week. RT 1 stated when she was not on duty, the licensed staff should provide Resident 13 's respiratory treatment. During a concurrent interview and record review on 5/14/2024 at 2:20 p.m., with RT 1, Resident 13's Medication Administration Record (MAR), dated 5/13/2024 was reviewed. The MAR indicated, on 5/13/2024, for the 8:00 a.m., and 12:00 p.m. administration time, there were no licensed staff initials in the box for Resident 13's Albuterol Sulfate Nebulization Solution 2.5 mg, to demonstrate the medication was administered. The MAR also indicated, on 5/13/2024, for 8:00 a.m., and 12:00 p.m. administration time, there were no licensed staff initials in the box for Resident 13's incentive spirometer, to demonstrate the treatment was provided. During a concurrent observation and interview on 5/14/2024 at 2:20 p.m., with RT 1, in Resident 13's room, RT 1 confirmed there was no oxygen equipment, nebulizer machine, and supplies, or incentive spirometer observed. RT 1 stated Resident 13 should had been provided needed respiratory treatment supplies and which should have been available in the resident's room. RT 1 stated if respiratory treatment supplies were not available in Resident 13 's room, licensed staff would not be able to provide Resident 13's respiratory treatment as ordered. RT 1 stated Resident 13 would not receive respiratory treatment as ordered. RT 1 stated it placed Resident 13 at risk for respiratory distress, avoidable COPD exacerbation, and hospitalization. A review of the facility's Policy and Procedure (P&P) titled Oxygen Administration revised 10/2010, indicated the following: 1. Provide safe oxygen administration. 2. Review physician's orders for oxygen administration. 3. Assemble the equipment and supplies. 4. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and nasal catheter. 5. Equipment and supplies necessary: a. Portable oxygen cylinder (medical device to provide supplemental oxygen to resident). b. Nasal cannula, nasal catheter, mask. c. Humidifier bottle. d. No Smoking/Oxygen in Use sign. e. Personal protective equipment (gowns, gloves, mask). A review of the facility's P&P titled Administering Medications through a Small Volume (Handheld) Nebulizer, revised 10/2010, indicated the following: 1. Review current orders. 2. Assemble the equipment and supplies: a. nebulizer kit, including nebulizer, medication cup, T- piece, mouthpiece (or face mask), and tubing. 3. Assemble equipment and supplies on the resident's overbed table. 4. Store equipment in a plastic bag with resident's name, date. A review of the facility's P&P titled Medication Administration, undated, indicated the following: 1. Medications are administered as prescribed in accordance with good nursing principles and practices. 2. Medications are administered in accordance with written orders of the attending physician.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and preparation practices when: 1. Nutritional supplements labeled store Frozen with manufactures instruction to use within 14 days of thawing, were not monitored for the date they were thawed to ensure expired shakes were discarded within the appropriate time frame. Four boxes containing 50 individual cartons of strawberry flavored nutrition supplements were stored in the walk-in refrigerator with no thaw date. This deficient practice had the potential to result in food borne illness in 24 residents who were on nutrition supplements at the facility. 2. One plastic bag of breaded cylinder-shaped food item was stored in the walk-in freezer with no label and date. One plastic bag of previously open ham with date 12/28/2023 and use by date of 3/28/2024 exceeding storage period for ham stored in the reach in freezer. The ham was covered in ice crystals. One plastic bag with previously open diced stew meat with date 10/25/2023 exceeding storage period for meat stored in the reach in freezer. The diced stew meat was covered in ice crystals and freezer burn. One large plastic container on the shelf next to the food preparation area holding dry food product (pasta) was dirty with food debris and pieces of toast. This deficient practice had the potential to result in expired food consumption. 3. One staff working in the dish washing area did not wash their hands before removing the clean and sanitized dishes from the dish machine. One cook did not their wash hands and change gloves before handling resident ready to eat cooked food. These deficiencies 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 food borne illness in 86 out of 89 residents who received food from the kitchen. Findings: 1. During an observation in the kitchen on 5/13/2024 at 9:15 a.m., there were four boxes stacked up on top of each other. Each box contained 50 individual cartons of strawberry flavored nutrition supplement stored in the walk-in refrigerator with no thaw date. During a concurrent interview with Dietary Aide (DA 1), DA 1 stated the nutrition supplements were delivered frozen and when thawed were good for 14 days. DA 1 stated there should be a thaw date on the supplements to monitor before they went bad. During a concurrent interview and review on 5/13/2024 at 10 a.m. with the Dietary Supervisor (DS), the labels on the box were reviewed. The DS stated that the supplements had delivery dates but not thaw dates. 2. During a concurrent observation and interview on 5/13/2024 at 9:30 a.m., with the DS, in the kitchen, the reach in freezer was overloaded with food items, stacked on top of each other. There was one plastic bag with leftover breaded food with no date or label. The DS stated the food items were leftover sausage and removed it from the freezer. The DS stated food should be labeled and dated. During the same observation in the reach in freezer there was one plastic bag of previously opened ham dated 12/28/2023 and use by date of 3/28/2024 exceeding the storage period for ham. There were ice crystals inside the bag and on the ham. One plastic bag with previously opened diced stew meat with dated 10/25/2023 exceeding the storage period for meat stored in the reach in freezer. The diced stew meat was covered with ice crystals and had freezer burn with dark and dried spots on the meat. The DS stated the ham, and the stewed meat should be discarded because they were old. The DS stated the freezer was overcrowded and old items were not rotated. The DS stated the facility had previously identified the need for more freezer space to organize food. During an observation on 5/13/2024 at 9:35 a.m., in the food preparation area, a container for holding open bags of pasta and open bags of marshmallow had food debris and pieces of dry toast. During a concurrent interview the DS, the DS stated the container was dirty with food debris. The DS stated sanitation in the kitchen was very important to keep everything clean. A review of the facility policy and procedure (P&P) titled Procedure for Refrigerated Storage, dated 2023, indicated, food items should be arranged so that older items will be used first and dating the packages or containers will facilitate this practice. The P&P indicated leftovers will be covered, labeled, and dated, and individual packages of refrigerated or frozen food taken from the original packaging box need to be labeled and dated. The P&P indicated freezer burn may occur before that and reduce the maximum shelf life. The P&P indicated food that has been freezer burned must be discarded. The P&P indicated supplemental shakes which are taken from the frozen state and thawed in the refrigerator must be dated as soon as they are placed in the refrigerator. A review of the facility Freezer Storage Guidelines, dated 2018, indicated all foods which need to be kept in the freezer can be stored frozen for six months with the following exceptions: processed meats, ham length of time in the freezer is one month. A review of the facility P&P titled Sanitization, dated 11/2022 indicated, all kitchen, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. 3. During an observation on 5/13/2024 at 9:40 a.m., in the dishwashing area, DA 2 was observed rinsing soiled dishes and loading the dirty dishes in the dish machine. DA 2 had several layers of gloves on his hands. DA 2 removed the outer layer of gloves and removed the clean and sanitized dishes from the dish machine. DA 2 had a disposable apron and was moving from the dirty dishes area to the clean dishes area are without washing his hands or changing aprons. During an interview on 5/13/2024 at 9:45 a.m. with DA 2, DA 2 stated he did not wash his hands before removing the clean and sanitized dishes. DA 2 stated the handwashing sink was far from his workspace. DA 2 stated he wore multiple gloves and removed the dirty glove on top before moving to the clean dishes area. DA 2 stated it was important to remove all disposable gloves and wash the hands in the handwashing sink before touching the clean dishes because the dirty hands and gloves could contaminate the clean dishes. During an interview on 5/13/2024 at 10 a.m. with the DS, the DS stated it was important to wash the hands and put on clean gloves before touching the clean and sanitized dishes to prevent cross contamination. The DS stated usually there were two people working in the dishwashing area to prevent cross contamination. During an observation of the lunch service on 5/13/2024 at 12 p.m., [NAME] 1 was observed wearing gloves and performing multiple tasks. [NAME] 1 left to open the oven, pick up food and returned. [NAME] 1 was also observed assisting with taking the food temperatures on the steam table. While standing, [NAME] 1 hands were touching the counters while waiting to start serving the food. [NAME] 1 did not change his gloves or wash his hands. During the same observation of the lunch service on 5/13/2024, at 12:15 p.m., [NAME] 1 was observed picking up roast turkey slices with gloved hands and serving them on the plates. [NAME] 1 was observed wearing the same gloves while performing multiple tasks since the beginning of lunch service at 12 p.m. [NAME] 1 left to grab utensils and pushed the plate warmer cart with gloved hands. During a subsequent interview with [NAME] 1, [NAME] 1 stated he should have changed his gloves and washed his hands when he returned from picking up the food from the oven. [NAME] 1 stated he should have used utensils to serve the food. [NAME] 1 stated dirty gloves could contaminate the food. A review of facility P&P titled Preventing foodborne illness-Employee Hygiene and Sanitary Practices, revised 11/2022, indicated, employees must wash their hands before coming in contact with any food surfaces, after handling soiled equipment or utensils, after engaging in other activities that contaminate the hands, during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. A review of the facility P&P titled Preventing foodborne illness-Employee Hygiene and Sanitary Practices, revised 11/2022, indicated gloves are considered single use items and must be discarded after completing the task for which they are used. The P&P indicated gloves are removed, hands are washed, and gloves are replaced between handling soiled and clean dishes. The P&P indicated the use of disposable gloves does not substitute for proper handwashing. The P&P indicated food service employees are trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness.

CONCERN (E)

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

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not provide accurate documentation for two of seven sampled residents (Resident 8 and 63) with limited mobility (ability to move) and range of motion ([ROM] full movement potential of a joint [where two bones meet]). a. Resident 8's clinical record for Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) tasks did not indicate both knee splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion) were applied from 11/2023 to 2/2024. b. Resident 63's clinical record for RNA tasks did not include passive range of motion (PROM, movement of joint through the ROM with no effort from the person) exercises to both legs from 12/16/2023 to 2/13/2024. These deficient practices provided inaccurate records of the RNA services provided to Resident 8 and 63. Findings: a. A review of Resident 8's admission Record, indicated Resident 8 was admitted to the facility on [DATE] with diagnoses including hemiplegia or hemiparesis (weakness or inability to move one side of the body) affecting the left non-dominant (used less often) side, dementia (decline in mental ability severe enough to interfere with daily life), contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness) to both knees, and muscle weakness. A review of Resident 8's Minimum Data Set ([MDS] a comprehensive assessment and care planning tool), dated 2/29/2024, indicated Resident 8 had clear speech, had difficulty communicating some words, usually understood others, and had severely impaired cognition (ability to think, understand, learn, and remember). A review of Resident 8's Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Discharge summary, dated [DATE], indicated recommendations for the RNA to provide PROM exercises to both legs followed by the application of both knee extension splints. A review of Resident 8's physician orders, dated 10/31/2023, indicated for the RNA to provide PROM exercise to both legs followed by the application of both knee extension splints with skin checks for two-and-a half (2.5) hours a day, seven days a week as tolerated. A review of Resident 8's RNA Task Schedule (record of nursing assistant tasks) for 11/2023, 12/2023, 1/2024, and 2/2024, indicated for RNA to provide Resident 8 with PROM to both legs but did not indicate the RNA applied both knee splints. A review of Resident 8's RNA Weekly Summary, dated 11/29/2023, 12/4/2023, 12/23/2023, 12/25/2023, 12/30/2023, 1/14/2024, 1/20/2024, and 2/27/2024, indicated the RNA performed PROM to both of Resident 8's legs and applied both knee extension splints. During a concurrent interview and record review on 5/16/2024 at 11:13 a.m. with the Director of Rehabilitation (DOR) and Director of Staff Development (DSD), Resident 8's PT Discharge Summary, physician orders, RNA Task Schedule from 11/2023 to 2/2024, and RNA Weekly Summary from 11/29/2023 to 2/24/2024 were reviewed. The DOR stated Resident 8 had physician orders, dated 10/31/2023, for the RNA to provide PROM to both legs and apply both knee extension splints for 2.5 hours, seven days per week. The DSD reviewed the RNA Weekly Summary from 11/29/2023 to 2/27/2024 and stated the RNA staff applied both knee extension splints. The DOR stated the RNA Task Schedule from 11/2023 to 2/2024 did not include the application of both knee splints since it was inputted into the electronic documentation system as an instruction. The DOR and the DSD stated Resident 8's RNA Task Schedule for 11/2023 to 2/2024 had documentation errors since the application of both knee splints should have been included as a separate RNA task instead of an instruction. b. A review of Resident 63's admission Record, indicated Resident 63 was admitted to the facility on [DATE] and re-admitted Resident 63 on 12/12/2023. The admission Record indicated Resident 63 had diagnoses including muscle weakness, history of falling, and contracture (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness) to both elbows, both hands, both hips, and both knees. A review of Resident 63's MDS, dated [DATE], the MDS indicated Resident 63 had clear speech, had difficulty communicating some words, usually understood others, and had severely impaired cognition. A review of Resident 63's Physical Therapy ([PT] profession aimed in the restoration, maintenance, and promotion of optimal physical function) Discharge summary, dated [DATE], indicated recommendations for the RNA to provide PROM to both legs. A review of Resident 63's physician orders, dated 12/16/2023, indicated for RNA to provide PROM exercises to both legs, five times per week. A review of Resident 63's Documentation Survey Report (record of nursing assistant tasks) for 12/2023, 1/2024, and 2/2024, did not indicate the RNA provided PROM exercises to both legs. A review of Resident 63's RNA Weekly Summary, dated 12/26/2023, 1/2/2024, 1/9/2024, 1/17/2024, 1/31/2024, and 2/7/2024, indicated the RNA provided PROM to both of Resident 63's legs. During an observation on 5/14/2024 at 12:39 p.m., in Resident 63's room, with Physical Therapist 1 (PT 1) and Occupational Therapist 1 (OT 1), Resident 63 was observed awake and lying in bed. Both of Resident 63's hips and knees were bent toward Resident 63's torso (part of the body that includes the chest and abdomen). During a concurrent interview and record review on 5/16/2024 ad 12:29 p.m. with the Director of Rehabilitation (DOR) and Director of Staff Development (DSD), Resident 63's PT Discharge Summary, physician orders, RNA Task Schedule from 12/2023 to 2/2024, and RNA Weekly Summary from 12/26/2023 to 2/7/2024 were reviewed. The DOR and DSD reviewed the physician orders, dated 12/16/2023, for RNA to provide Resident 65 with PROM to both legs, five times per week. The DSD and DOR stated the RNA task to provide Resident 65 with PROM to both legs was not created in the electronic documentation system. The DSD reviewed Resident 65's RNA Weekly Summary from 12/26/2023 to 2/7/2024 and stated PROM was provided. The DOR and DSD stated Resident 65's RNA Task Schedule from 12/2023 to 2/2024 had documentation errors since the RNA task to perform PROM to both legs was not included. A review of the facility's undated policy and procedure (P&P) titled, Documentation, indicated nursing personnel will maintain complete and accurate documentation. The P&P indicated documentation entries will be factual and specific.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not maintain infection control measures when: 1. Staff did not ensure enhanced barrier precautions (EBPs, an infection control intervention used to reduce transmission of multidrug-resistant organisms [MDROs, organisms resistant to at least one or more classes of antimicrobial agents]) were implemented for one of 18 sampled residents (Resident 27). This deficient practice increased the risk for spread of MDROs to vulnerable facility residents, and the potential incidence of preventable infection. 2. Clean one of one vinyl (type of plastic material) gait belt (assistive device used for lifting, transferring, and walking patients who have limited mobility issues) and front-wheeled walker (FWW, an assistive device with two front wheels used for stability when walking) after ambulation (the act of walking) with Resident 69. 3. Clean cloth gait belts in accordance with the manufacturer's recommendations for bleach sanitizing wipes (pre-moistened towelettes that contain a sanitizing or disinfecting formula that kill or reduce germs on surfaces). These deficient practices placed Resident 69, and other residents at risk for cross-contamination or contact with infectious agents. Findings: 1. A review of Resident 27's admission Record indicated the facility originally admitted Resident 27 on 8/5/2021, and most recently readmitted Resident 27 on 3/30/2023. Resident 59's admitting diagnoses included gastrostomy status (the creation of an artificial external opening into the stomach for nutritional support), protein-calorie malnutrition (the state of inadequate intake of food [as a source of protein, calories, and other essential nutrients]), muscle wasting and atrophy (decrease in size of muscle tissue), dysphagia (difficulty or discomfort in swallowing). A review of Resident 27's active physician orders, dated 4/23/24, indicated Resident 27 was on enhanced barrier precautions (EBP). A review of Resident 27's active physician orders, dated 5/13/24, indicated Resident 27 was receiving liquid nutrition through a gastrostomy tube (a flexible tube inserted into the abdomen for administration of nutrition and medications). A review of Resident 27's care plan, dated 5/13/24, indicated Resident 27 required EBP during high-contact resident care activities due to the presence of: feeding tubes [gastrostomy tube]. The goals of Resident 27's care included [EBP] will be appropriately utilized to reduce the risk of transmission of multidrug-resistant organisms and enhanced barrier precautions will be followed during high contact resident care activities. Interventions to achieve these goals required staff to utilize PPE [personal protective equipment] (gown and gloves .) during high contact resident care activities. During an observation on 5/13/2024 at 9:42 a.m., outside of Resident 27's room, signage was observed indicating Resident 27 was on EBP. Personal protective equipment (PPE, protective garments or equipment designed to protect the wearer's body from infection) was observed outside of or near Resident 27's room for staff use. During a concurrent observation and interview, on 5/13/2024 at 10:16 a.m., inside Resident 27's room, with Licensed Vocational Nurse (LVN) 1, LVN 1 performed hand hygiene prior to entering Resident 27's room and did not put on PPE. LVN 1 then touched Resident 27's gastrostomy tube to check it for complications. LVN 1 stated Resident 27 was on EBP, and stated she should have been wearing a gown and gloves while providing care to the gastrostomy tube. During an interview, on 5/16/2024 at 9:27 a.m., with the Infection Preventionist Nurse (IPN), the IPN stated EBP was used to prevent spread of MDROs. The IPN stated that EBP required staff to wear a gown and gloves while performing high contact activities such as handling indwelling medical devices, which included gastrostomy tubes. The IPN stated the purpose of implementing EBP was infection prevention and stated that not implementing EBP could increase the risk for spread of infection in the facility. A review of the facility policy and procedure (P&P) titled Isolation - Transmission-Based Precautions & Enhanced Barrier Precautions, dated 9/2022, indicated Enhanced Barrier Precautions are indicated for residents with .: wounds and/or indwelling medical devices. The P&P further indicated that staff were required to wear gowns and gloves while performing .high-contact tasks .such as: device care .feeding tube.Based on observation, interview, and record review, the facility did not maintain infection control measures when: 2. A review of Resident 69's admission Record, indicated Resident 69 was admitted to the facility on [DATE] and re-admitted Resident 69 on 11/21/2023. Resident 69's diagnoses included end stage renal (kidney) disease (progressive loss of kidney function), dependence on renal dialysis (process of filtering blood), and muscle weakness. A review of Resident 69's physician orders, dated 4/11/2024, indicated Restorative Nursing Aide (RNA, certified nursing aide program that helps residents to maintain their function and joint mobility) to provide ambulation using the FWW on non-dialysis days, three times per week as tolerated. During an observation on 5/14/2024 at 1:21 p.m. with Restorative Nursing Aide 1 (RNA 1), Resident 69 was observed alert, awake, and sitting up in the wheelchair. RNA 1 placed a vinyl gait belt around Resident 69's waist and placed a FWW in front of Resident 69. Resident 69 stood using the FWW and walked down the hallways throughout the entire facility. RNA 1 assisted Resident 69 to sit back into the wheelchair and removed the vinyl gait belt from Resident 69's waist. RNA 1 folded up the FWW and placed the walker against a wall near a weighing scale. RNA 1 fastened the vinyl gait belt around RNA 1's own waist and wheeled Resident 69 back to the bedroom. RNA 1 did not clean the FWW and the vinyl gait belt after use with Resident 69. During an interview on 5/14/2024 at 3:40 p.m. with RNA 1, RNA 1 stated the vinyl gait belt should be cleaned with bleach sanitizing wipes after every resident. RNA 1 stated she did not clean the vinyl gait belt after use with Resident 69 since Resident 69 was eager to return to the bedroom. During an interview on 5/15/2025 at 12:52 p.m. with the IPN, the IPN stated reusable equipment was supposed to be cleaned with the bleach sanitizing wipes before and after each resident use. The IPN stated it was important to disinfect surfaces in-between residents to prevent the spread of contamination (presence of unwanted substances) between residents. A review of the facility's P&P titled, Cleaning and Disinfecting Non-Critical Resident-Care and Multi-use Items, revised June 2011, indicated reusable items are cleaned and disinfected or sterilized between residents. 3. During an observation on 5/13/2024 at 12:29 p.m., Certified Nursing Assistant 1 (CNA 1) wore a cloth gait belt around CNA 1's waist. During an observation on 5/13/2024 at 12:57 p.m., CNA 2 wore a cloth gait belt around CNA 2's waist. During an observation on 5/13/2024 at 1:14 p.m., CNA 3 wore a cloth gait belt across the chest like a seatbelt. During an observation on 5/13/2024 at 1:16 p.m., CNA 4 wore a cloth gait belt around CNA 4's hips. During an observation on 5/14/2024 at 9:08 a.m., CNA 2 wore a cloth gait belt around CNA 2's waist. During an observation on 5/14/2024 at 9:52 a.m., CNA 6 wore a cloth gait belt around CNA 6's waist. During an observation on 5/14/2024 at 12:33 p.m. CNA 1 wore a cloth gait belt around CNA 1's waist. During a concurrent observation and interview on 5/15/2024 at 12:30 p.m. with CNA 7, CNA 7 wore a cloth gait belt around CNA 7's waist. CNA 7 stated the gait belts were used multiple times per day to transfer residents from the bed to wheelchair. During an observation on 5/15/2024 at 12:40 p.m., CNA 8 wore a cloth gait belt around CNA 8's waist. During a concurrent observation and interview on 5/15/2024 at 12:41 p.m. with CNA 2 and CNA 9, CNA 2 wore a cloth gait belt around CNA 2's waist and CNA 9 wore a vinyl gait belt around CNA 9's waist. CNA 9 stated the vinyl gait belt was cleaned using the bleach sanitizing wipes before and after use with a resident. CNA 2 stated the cloth gait belt was washed at home each day and used the bleach sanitizing wipes in-between use with residents. A review of the (undated) bleach sanitizing wipes' manufacturer recommendations, indicated the premoistened wipes can be used to clean, deodorize and disinfect hard, non-porous (water, air, or other fluids are unable to go through the material) healthcare and environmental surfaces. The manufacturer recommendation also indicated it was a violation of Federal Law to use the product in a manner inconsistent with its labeling. During an concurrent interview and review of the bleach sanitizing wipes' manufacturer recommendations on 5/15/2024 at 12:52 p.m. with the IPN, the IPN stated the manufacturer recommendations for the bleach sanitizing wipes indicated the wipes were for use on non-porous surfaces. The IPN stated the cloth gait belts were porous and should be washed. The IPN stated using the bleach sanitizing wipes on the cloth gait belts was ineffective since cloth gait belts were porous. The IPN stated it was important to disinfect surfaces in-between residents to prevent the spread of contamination (presence of unwanted substances) between residents. A review of an article entitled Rehabilitation Services published on October 3, 2014 by the Association for Professionals in Infection Control and Epidemiology, page 10 of the article indicated shared equipment must be cleaned and disinfected between each use. The article further states that gait belts should not be worn around the waist of staff or (if cloth) used on multiple patients due to the inability to clean the gait belt between patients.

CONCERN (F)

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

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 61's admission Record indicated the facility originally admitted Resident 61 on 12/13/2022. Resident 61's admitting diagnoses included symptoms and signs involving the musculoskeletal system, reduced mobility, and difficulty or inability to move his right side following a stroke (interruption of blood flow to the brain). A review of Resident 61's History and Physical (H&P), dated 2/8/2024, indicated Resident 61 had the capacity to understand and make decisions. A review of Resident 61's Minimum Data Set (MDS), dated [DATE], indicated Resident 61 had mild cognitive impairment (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 61 had impairments to the upper extremities on both sides of his body (shoulder, elbow, wrist, and hands), and impairments to the lower extremity on one side of his body (hip knee, ankle, and foot). The MDS indicated Resident 61 required substantial/maximal assistance from staff (staff provide more than half the effort in lifting, holding, or supporting the resident's body) to get dressed and put on footwear. The MDS indicated Resident 61 required substantial/maximal assistance from staff to roll from side to side, to transition from a lying position to a sitting position, and to transfer from the bed to a wheelchair. During an observation on 5/13/2024 at 11:00 a.m., in Resident 61's room, observed Resident 61 lying in bed watching TV. Resident 61's wheelchair was parked at his bedside. During a concurrent observation and interview, on 5/13/2024 at 11:33 a.m., in Resident 61's room, observed Resident 61 lying in bed watching television. Resident 61 stated he suffered a stroke and had difficulty with his mobility, on his own. During a concurrent observation and interview, on 5/14/2024 at 9:56 a.m., observed Resident 61 lying in bed watching TV. Resident 61 stated he wanted to get dressed and get up to go outside. Resident 61 stated he required a wheelchair and help from staff to get dressed and transfer to his wheelchair. Resident 61 stated when he asked staff to assist him, the certified nursing assistants (CNAs) repeatedly told him they had around ten (10) patients, and if someone called off from work, their assignment increased to 14 to 16 patients. Resident 61 stated the CNAs told him they did not have time to help him. Resident 61 stated that the last time he got out of bed was on 5/10/2024. During a concurrent observation and interview on 5/15/2024 at 2:06 p.m., in Resident 61's room, observed Resident 61 lying in bed and watching TV. Resident 61 stated he would like to get out of bed every day, but on average he gets out of bed twice a week. Resident 61 stated that before he can ask for assistance to get out of bed, staff tell him they are too busy or have too many patients, so he does not ask to get out of bed. During a concurrent observation and interview, on 5/16/2024 at 9:06 a.m., observed Resident 61 lying in bed and watching television, with his wheelchair parked next to his bed. Resident 61 stated he wanted to get out of bed but did not ask yet because he was not sure who his nurse was. Resident 61 stated he had not been offered to get out of bed that day (5/16/2024). During an interview on 5/16/2024 at 9:22 a.m., with the Activities Director (AD), the AD stated the facility had a patio where residents could sit outside if they wanted to. The AD stated that there were no restrictions on residents using the patio, there just needed to be staff available to supervise. The AD stated it was important for residents to do activities that they preferred. During an interview on 5/16/2024 at 11:45 a.m., with the Director of Nursing (DON), the DON stated staff should assist with transferring residents to their wheelchairs and supervise them in the patio as needed. The DON stated that sitting in a wheelchair while out on the patio was not a hazardous activity. The DON stated it was not appropriate for staff to tell the resident that they were too busy to assist him. The DON stated that if staff were busy, they should come back once their task was completed to follow up on the resident's request or identify another staff member that could assist. A review of the facility policy and procedure (P&P) titled Accommodation of Needs, dated 3/2021, indicated our facility's environment and staff behaviors are directed towards assisting the resident in maintaining and/or achieving safe independent functioning, dignity, and well-being. The P&P further indicated the resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered.Based on observation, interview, and record review, the facility failed to provide sufficient nursing staff to: 1. Provide range of motion ([ROM] full movement potential of a joint [where two bones meet]) exercises, apply splints (material used to restrict, protect, or immobilize a part of the body to support function, assist and/or increase range of motion), and perform ambulation (the act of walking) to 43 residents requiring a Restorative Nursing Assistant (RNA, nursing aide program that helps residents to maintain their function and joint mobility) program, including five of seven sampled residents (Resident 8, 27, 49, 61, and 63) with limited mobility (ability to move). This deficient practice had the potential for the 43 residents on RNA services, including Resident 8, 27, 49, 61, and 63, to experience a decline in range of motion and mobility, which could affect the residents' overall function. Cross reference F688. 2. Provide assistance to one of two sampled residents (Resident 61), to accommodate his preference for getting out of bed at least once a day to sit in his wheelchair. This deficient practice had the potential to cause avoidable psychosocial distress and frustration for Resident 61 from an inability to participate in his preferred activity. Findings: 1. A review of the Order Listing Report, dated 5/13/2024, for residents with physician orders for RNA, indicated 43 residents had physician orders for RNA. A review of the facility's sign in sheet for 5/2024, indicated there was no RNA on 5/1/2024, 5/4/2024, 5/5/2024, 5/6/2024, 5/9/2024, 5/10/2024, and 5/15/2024. During an interview on 5/13/2024 at 12:15 p.m. with the Director of Rehabilitation (DOR), the DOR stated the facility had two Restorative Nursing Aide staff, RNA 1 and RNA 2. The DOR stated the Director of Staff Development (DSD) oversaw the RNA program. During an interview on 5/13/2024 at 1:16 p.m. with RNA 1, RNA 1 stated she was the only RNA staff present in the facility today (5/13/2024). RNA 1 stated RNA 2 had been on leave for the past three weeks and no other staff assisted with RNA services. RNA 1 stated another staff (RNA 3) was currently being trained but was not independent to provide RNA services. RNA 1 stated residents on RNA program were divided by nursing stations - one RNA for Rooms 1 to 17 and another RNA for Rooms 18 to 30. RNA 1 stated she tried to provide RNA services to as many residents as possible during the workday. RNA 1 stated duties included applying splints, assisting with ambulation, assist with feeding, providing ROM exercises, helping the other nurses, and obtaining weights for newly admitted residents, resident requiring weekly weights, residents on dialysis (process of filtering blood), and monthly weights on all other residents. RNA 1 stated the RNA staff schedule included working four days and being off two days. During an interview on 5/14/2024 at 3:40 pm. with RNA 1, RNA 1 stated she was the only RNA staff present today (5/14/2024). RNA 1 stated she was unable to see all residents with physician orders for RNA on the same day. RNA 1 stated she had to provide RNA services to half of the residents one day and then provide RNA to the other half of the residents the next day. During an interview on 5/15/2024 at 1:25 p.m. with the DSD, DSD stated RNA 1 was not present at the facility (5/15/2024) since it was RNA 1's scheduled day off. a. A review of Resident 8's admission Record, indicated Resident 8 was admitted to the facility on [DATE] with diagnoses including hemiplegia or hemiparesis (weakness or inability to move one side of the body) affecting the left non-dominant (used less often) side, dementia (decline in mental ability severe enough to interfere with daily life), contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to joint stiffness) to both knees, and muscle weakness. A review of Resident 8's Order Summary Report which included physician orders, dated 2/21/2024, indicated RNA program to apply the left elbow extension splint for two hours per day, five day per week. A review of Resident 8's RNA Task Schedule (record of nursing assistant tasks) for 5/2024, indicated to apply the left elbow extension splint for two hours per day, five days per week was blank on 5/1/2024, 5/6/2024, 5/9/2024, 5/10/2024, and 5/15/2024. During a concurrent interview and record review on 5/16/2024 at 11:13 a.m. with the DSD and DOR, Resident 8's physician orders for RNA, dated 2/21/2024, and the RNA Task Schedule for 5/2024 was reviewed. The DSD stated reviewed Resident 8's RNA Task Schedule for 5/2024 and stated the splint was not applied to Resident 8's left elbow five times per week in accordance with the physician orders. The DSD stated Resident 8 did not receive RNA services five times per week in 5/2024 since there was only one RNA staff working. During an interview on 5/16/2024 at 12:45 p.m. with the DSD, the DSD stated the facility did not have adequate staff to provide RNA services during 5/2024 since RNA 2 had been on leave for the past three weeks. b. A review of Resident 27's admission Record, indicated Resident 27 was initially admitted to the facility on [DATE] and re-admitted Resident 27 on 3/30/2023. The admission Record indicated Resident 27's diagnoses included Parkinson's disease (brain disorder that causes unintended or uncontrollable movements and difficulty with balance and coordination), contractures on both knees, and muscle weakness. A review of Resident 27's physician orders, dated 3/4/2024, indicated for the RNA to provide PROM exercises to both legs, four times per week as tolerated. Another physician order, dated 3/5/2024, indicated to for RNA to provide Resident 27 with PROM exercises to both arms at all joints, four times per week as tolerated. A review of Resident 27's RNA Task Schedule for 5/2024, indicated to perform PROM to both arm and both legs was blank for 5/1/2024, 5/5/2024, 5/6/2024, 5/10/2024, and 5/15/2024. During a concurrent interview and record review on 5/16/2024 at 11:59 a.m. with the DOR and DSD, Resident 27's physician orders for RNA, dated 3/4/2024 and 3/5/2024, and RNA Task Schedule for 5/2024 was reviewed. The DSD stated Resident 27 did not receive RNA for PROM to both arms and both legs four times per week in accordance with the physician orders during 5/2024 since there was only one RNA staff working. During an interview on 5/16/2024 at 12:45 p.m. with the DSD, the DSD stated the facility did not have adequate staff to provide RNA services during 5/2024 since RNA 2 had been on leave for the past three weeks. c. A review of Resident 49's admission Record, indicated Resident 49 was admitted to the facility on [DATE] with diagnoses including fracture (break in the bone) of the right femur hip bone), presence of a right artificial hip joint, dementia, and contracture of the right elbow, both knees, and right hip. The admission Record also indicated Resident 49 was admitted to palliative care (specialized medical care that focuses on providing patients relief from pain and other symptoms of a serious illness) on 2/28/2024. A review of Resident 49's physician orders, dated 3/1/2024, indicated for the RNA to provide gentle PROM exercises to both legs and both arms, five times per week as tolerated. A review of Resident 49's RNA Task Schedule for 5/2024, indicated to provide PROM to both arms and both legs was blank for 5/1/2024, 5/6/2024, 5/10/2024, and 5/15/2024. During a concurrent interview and record review on 5/16/2024 at 12:19 p.m. with the DOR and DSD, Resident 49's physician orders, dated 3/1/2024, and RNA Task Schedule for 5/2024 was reviewed. The DSD stated Resident 49 did not receive RNA for PROM to arms and both legs, five per week in accordance with the physician orders during 5/2024 since there was only one RNA staff working. During an interview on 5/16/2024 at 12:45 p.m. with the DSD, the DSD stated the facility did not have adequate staff to provide RNA services during 5/2024 since RNA 2 had been on leave for the past three weeks. d. A review of Resident 61's admission Record, indicated Resident 61 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant (used more often) side, dysphagia (difficulty swallowing) following a cerebral infarction, history of falling, and reduced mobility. A review of Resident 61's physician orders, dated 2/8/2024, indicated for RNA to perform active assistive range of motion (AAROM, use of muscles surrounding the joint to perform the exercise but required some help from a person or equipment) to the left leg and PROM to the right leg, five times per week or as tolerated, to maintain current level of function. Another physician order, dated 3/8/2024, indicated for RNA to provide Resident 61 with AAROM exercises to both arms, five times per week or as tolerated. A review of Resident 61's RNA Documentation Survey Report for 5/2025, indicated to provide AAROM exercises to both arms and the left leg and PROM exercises to the right leg was blank for 5/1/2024, 5/6/2024, 5/9/2024, 5/10/2024, and 5/15/2024. During a concurrent observation and interview on 5/13/2024 at 11:33 a.m. in the bedroom, Resident 61 stated he had a stroke (cerebral infarction) affecting the right side of the body. Resident 61's fingers on the right hand remained straight and unable to bend. Resident 61 stated a nurse (unknown) came once to assist with exercises on both hands but did not provide exercises to both legs. Resident 61 stated the nurse came once and had not returned in the past three to four weeks. During a concurrent interview and record review on 5/16/2024 at 12:40 p.m. with the DOR and DSD, Resident 61's physician orders, dated 2/8/2024 and 3/8/2024, and the RNA Documentation Survey Report for 5/2024 was reviewed. The DSD stated Resident 61 did not receive RNA for AAROM to both arms and the left leg and PROM to the right leg, five per week in accordance with the physician orders during 5/2024 since there was only one RNA staff working. During an interview on 5/16/2024 at 12:45 p.m. with the DSD, the DSD stated the facility did not have adequate staff to provide RNA services during 5/2024 since RNA 2 had been on leave for the past three weeks. e. A review of Resident 65's admission Record, indicated Resident 65 was admitted to the facility on [DATE] and readmitted Resident 65 on 9/6/2023 with diagnoses including muscle weakness, encephalopathy (disease that affects the brain, causing changes in its function), anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), dementia, and dysphagia. The admission Record also indicated Resident 65 was admitted to palliative care on 10/25/2023. A review of Resident 65's physician orders, dated 11/17/2023, indicated for the RNA to provide PROM exercises to both legs, seven times per week as tolerated. Another physician orders, dated 3/12/2024, indicated for RNA to provide PROM exercises to both arms, five times per week as tolerated. A review of Resident 65's RNA Documentation Survey Report for 5/2025, indicated to provide PROM to both arms, five times per week, and PROM to both legs, seven times per week, was blank on 5/1/2024, 5/4/2024, 5/5/2024, 5/6/2024, 5/9/2024, 5/10/2024, and 5/15/2024. During a concurrent interview and record review on 5/16/2024 at 12:45 p.m. with the DOR and DSD, Resident 65's physician orders, dated 11/17/2023 and 3/12/2024, and the RNA Documentation Survey Report for 5/2024 was reviewed. The DSD stated Resident 65 did not receive RNA for PROM to arms, five times per week, and both legs, seven times per week in accordance with the physician orders during 5/2024 since there was only one RNA staff working. The DSD stated the facility did not have adequate staff to provide RNA services during 5/2024 since RNA 2 had been on leave for the past three weeks. A review of the facility's undated Policy and Procedure (P&P) titled, Restorative Nursing Services, indicated residents will receive restorative nursing care as needed to help promote optimal safety and independence. A review of the facility's undated P&P titled Staffing, Sufficient and Competent Nursing, indicated the facility provided sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents.

Jan 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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document information related to the resident ' s mental status or orientation when there was a significant change of condition in one of three residents (Resident 1). This deficient practice resulted in Resident 1 not having sufficient documentation regarding her mental status and orientation during a change in condition and before transferring to a higher level of care. This deficient practice had the potential to cause harm to Resident 1 due to poor communication of resident ' s health status which could cause inaccurate and delayed treatment to the resident. Findings: During a review of Resident 1 ' s admission Record, dated 1/4/2023, the admission record indicated Resident 1 was initially admitted to the facility on [DATE]. Resident 1's diagnoses included type 2 diabetes mellitus (condition that results in too much sugar circulating in the blood), chronic obstructive pulmonary disease (COPD - a lung disease characterized by long-term poor airflow), hypoxemia (an abnormally low concentration of oxygen in the blood), hyperlipidemia (an abnormally high concentration of fat particles in the blood) , hypertension (high blood pressure), atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), and congestive heart failure (CHF - a chronic condition in which a weakness of the heart leads to a buildup of fluid in the lungs). During a review of Resident 1 ' s Minimum Data Set (MDS - a standardized resident assessment care screening tool), dated 10/13/2023, the MDS indicated Resident 1 was moderately impaired with cognitive skills (ability to understand and make decision) for daily decision making. The MDS indicated Resident 1 required partial assistance with eating and oral hygiene and substantial assistance with toileting, bathing, transfers, and dressing. During a review of Resident 1 ' s History and Physical (H&P), dated 12/16/2023, the H&P indicated that Resident 1 had fluctuating capacity to understand and make decisions. During a review of Resident 1 ' s Nursing Progress Note - admission Summary Note dated 12/15/2023, the admission Summary Note indicated that upon admission to the facility, Resident 1 was alert and oriented times four (A&O x 4 - someone who is alert and oriented to person, place, time, and situation), was able to communicate in both Spanish and English and was able to make needs known. The admission Summary Note also indicated that Resident 1 was calm, cooperative, very pleasant, and polite to staff and was self-responsible. During a review of Resident 1 ' s care plan titled, [Resident] has impaired cognitive function/dementia or impaired thought processes related to confusion as evidenced by a Brief Interview for Mental Status (BIMS - a screening tool used to identify the cognitive condition of residents upon admission into a long term care facility) score of 12 out of 15, initiated on 12/18/2023, the care plan interventions indicated to monitor, document and report to medical doctor any changes in cognitive function, specifically changes in decision, difficulty understanding others, level of consciousness, and mental status. During a review of Resident 1 ' s Situation-Background-Assessment-Recommendation (SBAR, used to provide a framework for communication between members of the health care team) Communication Form, dated 12/19/2023, the SBAR Communication Form indicated Resident 1 started having abdominal pain on 12/18/2023, but was unable to determine if the abdominal pain was getting worse, better or stayed the same. The SBAR Communication Form also indicated that there were no changes to Resident 1 ' s mental status. During a review of Resident 1 ' s Nursing Progress Notes tilted, 72-hour monitoring for abdominal pain, dated 12/19/2023 at 7:01 a.m., the note indicated Resident 1 complained of abdominal pain. The note did not include documentation pertaining to Resident 1 ' s mental status or orientation. During a review of Resident 1 ' s Nursing Progress Note titled, 72-hour monitoring for abdominal pain, dated 12/19/2023 at 11:09 a.m., the note indicated Resident 1 had no complaints of abdominal pain. The note did not include documentation pertaining to Resident 1's mental status or orientation. During a review of Resident 1 ' s Nursing Progress Note titled, 72-hour monitoring for abdominal pain, dated 12/19/2023 at 10:19 p.m., the note indicated Resident 1 was being monitored for abdominal pain. The note did not include documentation pertaining to Resident 1 ' s mental status or orientation. During a review of Resident 1 ' s Nursing Progress Note titled, 72-hour monitoring for abdominal pain, dated 12/20/2023 at 7:44 a.m., the note indicated Resident 1 was being monitored abdominal pain. The note did not include documentation pertaining to Resident 1 ' s mental status or orientation. During a review of Resident 1 ' s Nursing Progress Note titled, 72-hour monitoring for abdominal pain, dated 12/20/2023 at 11:45 a.m., the note indicated Resident 1 was being monitored for abdominal pain. The note indicated Resident 1's family member (FM 1) came to visit Resident 1 and had concerns which were relayed to the physician. The note did not include documentation pertaining to Resident 1 ' s mental status or orientation. During a review of Resident 1 ' s Nursing Progress Note dated 12/20/2023 at 6:31 p.m., the nursing progress note indicated Resident 1 was being transferred to the general acute care hospital (GACH) in fair condition. The nursing progress note did not include documentation pertaining to Resident 1 ' s mental status or orientation. During a review of Resident 1 ' s Order Summary Report, dated 12/20/2023, the order summary report indicated an active order to transfer Resident 1 to the GACH for further evaluation per family request. During a telephone interview on 1/5/2023 at 9:33 a.m. with FM 1, FM 1 stated Resident 1 was alert and oriented when admitted to facility. FM 1 stated on 12/19/2023 and 12/20/2023, he attempted to call Resident 1 on her cell phone several times, but the resident never answered which concerned FM 1 because Resident 1 always answered her phone and would call him several times a day. FM 1 stated that on 12/19/2023 and 12/20/2023 he began calling the nurse ' s station to find out what was going on with Resident 1. FM 1 stated that he was told by the nursing staff that Resident 1 was sleeping. FM 1 stated he attempted to call the nurses station to contact Resident 1 over a period of 3 days. FM 1 stated each time he called, the nurse would say Resident 1 was sleeping and could not talk on the phone. FM 1 stated he went to visit Resident 1 on 12/20/2023 and knew something was wrong the minute he saw Resident 1. FM 1 stated Resident 1 was very drowsy and was mumbling and slurring her words. FM 1 stated that he immediately notified the nursing staff of Resident 1 ' s status change at 11 a.m. and asked the staff to call 9-1-1 because he felt Resident 1 was having a stroke (injury to the cells in the brain due to unusal electrical brain activity). FM 1 stated the nursing staff assured him that Resident 1 was not having a stroke. FM 1 stated ten hours later, the facility finally called for paramedics to take Resident 1 to the hospital. During an interview on 1/5/2024 at 1:50 p.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated she remembered Resident 1 being in the facility for a very short period before the resident was transferred to the hospital. CNA 1 stated she cared for Resident 1 the day she was transferred to the GACH on 12/20/2023. CNA 1 stated she remembered Resident 1 talking and having a conversation at the time and was able to communicate her needs. CNA 1 stated that Resident 1 complained she was not feeling well. CNA 1 stated that as a CNA, she was responsible for notifying the charge nurse immediately when there was a change in the resident ' s condition. CNA 1 stated that as a CNA she was not responsible for documenting the resident ' s condition, mental status, or orientation. CNA 1 stated that the charge nurse would be one that documented the resident ' s status including mental status changes. During a concurrent interview and record review on 1/5/2024 at 2:00 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that 72-hour monitoring was already in progress when he started his evening shift on 12/20/2024. LVN 1 stated that during his shift, Resident 1 was A&O x 2 or 3. LVN 1 stated that when he documented a resident on 72-hour monitoring, he must document the resident health status throughout the shift. Asked LVN 1 if he knew what Resident 1 ' s mental status and orientation was before sat the beginning of his shift and before she was transferred out to the hospital. LVN 1 stated that he did not remember Resident 1 ' s mental orientation, pain level or what Resident 1 ' s status was before she was transferred out. Asked LVN 1 if he documented Resident 1 ' s mental status and orientation in the electronic health record (EHR). LVN 1 stated that he documented on Resident 1 and the note should be in the nursing progress notes. Asked LVN 1 if he would locate the notes pertaining to Resident 1 ' s mental status in the EHR. LVN 1 began to look through Resident 1 ' s EHR and admitted that he could not find documentation pertaining to Resident 1 ' s mental orientation on 12/20/2023. LVN 1 stated that he only documented one note for Resident 1 on 12/20/2023 and the note did not include the resident ' s mental status or orientation. LVN 1 stated that he had so many residents that day, but he usually charted the status of the resident including their pain and mental orientation. LVN 1 stated, I just got busy. LVN 1 stated that documenting the resident ' s health status including mental status was important so that the status would be included in the record for other nurses to view. During an interview on 1/5/2023 at 3:39 p.m., with Registered Nurse Supervisor (RN 1), RN 1 stated that when a resident was on 72-hour monitoring due to a change in condition, the charge nurses were responsible for monitoring the status of the resident, documenting the status, the effects of any medications and any improvement or worsening in the resident ' s condition. RN1 stated that the charge nurses must notify her if there was any change in the resident ' s condition or if symptoms were worsening. RN 1 stated she was notified of Resident 1 ' s abdominal pain and she (RN 1) notified the physician. RN 1 stated Resident 1's physician wrote an order to give Resident 1 something to relieve nausea. RN 1 stated the mediation was given by the charge nurse. RN 1 stated that she saw Resident 1 briefly and that she was alert and oriented. RN 1 stated that Resident 1 had no indication of being transferred to the hospital at that time and the charge nurse never made her aware that Resident 1 ' s condition had worsened. During an interview on 1/5/2023 at 4:27 p.m. with LVN 2, LVN 2 stated that when there was a change of condition on a resident, the resident must be monitored for 3 days. LVN 2 stated the resident ' s condition was monitored for worsening or improvement in symptoms and the status must be documented every shift including the resident ' s mental status and orientation. LVN 2 stated that when a resident was being transferred to the hospital, a hospital transfer form and narrative regarding the transfer must be documented. LVN 2 stated the hospital transfer documentation should include the time, condition, and mental status of how the resident left the facility. During an interview on 1/5/2023 at 4:50 p.m. with the Director of Nursing (DON), the DON stated the nursing staff should document in more detail for residents that require 72-hour monitoring. The DON stated that when a resident has a change of condition, the resident was placed on 72-hour monitoring. The DON stated 72-hour monitoring should include the resident ' s condition and details regarding the resident ' s worsening or improving health status which includes the resident ' s mental status, orientation, and pain level. The DON stated this documentation was important so that the status of the resident was known by other health care providers and to communicate the resident ' s status to other shifts. The DON stated that the documentation would help communicate what was happening to the resident and the proper interventions to provide to the resident. When asked if the facility had a policy and procedure (P&P) for 72-monitoring, the DON stated he could not find the facility ' s P&P for 72-hour monitoring. During a review of the facility ' s P&P titled, Change in a Resident ' s Condition or Status, revised February 2021, the P&P indicated that the facility promptly notifies the resident, his or her attending physician and the resident representative of changes in the resident ' s medical/mental condition and/or status. The P&P also indicated that the nurse would record in the resident ' s medical record information relative to changes in the resident ' s medical/mental condition or status.

Dec 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 F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the licensed nurse failed to do the following for one of three sampled residents (Resident 1): 1. Follow facility established process when attempting to communicate with Resident 1 ' s medical doctor (MD). 2. Initiate an situation, background, assessment, and recommendation (SBAR- form of communication between staff) form during a sudden acute change in Resident 1 ' s health. These deficient practices had the potential for Resident 1 to have suffered life threatening complications and requiring a longer stay at a general acute care hospital (GACH). Findings: During a review of Resident 1 ' s admission Record, the admission record indicated Resident 1 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses that included end stage renal disease (ESRD- kidney failure), diabetes (high blood sugar), and hypertension (high blood pressure). During a review of Resident 1 ' s History and Physical (H&P) dated 11/11/2023, the H&P indicated Resident 1 had the capacity to understand and make medical decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 10/25/2023, the MDS indicated Resident 1 ' s cognitive skills (thought process) was intact and was able to understand and be understood by others. The MDS indicated Resident 1 was dependent on staff and required maximum assist with activities such as dressing, toilet use, and personal hygiene. The MDS indicated Resident 1 was dependent on a wheelchair for mobility. During a review of Resident 1 ' s Nursing Progress Notes dated 11/4/2023 at 11:07 p.m., the notes indicated, Resident 1 began complaining of rectal pain on 11/4/2023 at 3:40 p.m. The notes indicated during assessment, Licensed Vocational Nurse (LVN) 1 noted Resident 1 was having a bowel movement (BM) and there were no signs or symptoms of inflammation or blood noted in the rectum. The notes indicated pain medication was administered at 4:25 p.m. per Resident 1 ' s request. The notes indicated at 5:00 p.m. after dinner was served, Resident 1 reported she had 1 episode of emesis (vomit), and the medical doctor (MD) was notified of the changes. The notes indicated at 6:00 p.m., Resident 1 ' s family member (FM 1 ) expressed concerns regarding Resident 1 having difficulty and pain with having a BM. The notes indicated LVN 1 administered milk of magnesia (MOM- laxative medication) at 6:23 p.m., to help relieve Resident 1 ' s symptoms. The notes indicated FM 1 was still expressing concerns regarding Resident 1 ' s difficulty having a BM. FM 1 was re-assured the MD was notified and LVN 1 was currently awaiting further orders at the time. The notes indicated at 7:20 p.m. the paramedics arrived to the facility, and the facility was informed FM 1 dialed 911 without notifying the charge nurse. The notes indicated Resident 1 was transferred to a general acute care hospital (GACH) at 7:25 p.m. During a review of Resident 1 ' s GACH Emergency Department (ED) Physician Progress Notes dated 11/06/2023, the physician progress notes indicated Resident 1 presented to the ED complaining of rectal pain and inability to have a BM. The physician progress notes indicated the computed tomography ([CT]- a body scan that produces images of the inside of the body) scan of the abdomen (stomach) showed large fecal load in the rectum and fecal impaction (constipation). During an interview on 12/4/2023 at 11:19 a.m. with LVN 1, LVN 1 stated Certified Nursing Assistant (CNA) 1 reported that Resident 1 was complaining of rectal pain. LVN 1 stated as she was preparing to assess Resident 1, Resident 1 was observed passing a BM. LVN 1 stated upon observation, she made her assessment and did not observe redness, swelling, or bleeding in the rectum. LVN 1 stated the stool was fully formed and did not appear dry. LVN 1 stated Resident 1 continued to complain of pain even though she had a total of two (2) BM ' s and offered Resident 1 pain medication at around 4:25 p.m. LVN 1 stated when FM 1 arrived to the facility, FM 1 expressed concerns with the pain and discomfort Resident 1 was experiencing due to having a difficulty passing a BM. LVN 1 stated she communicated with FM 1 that Resident 1 was administered pain medication and had a total of 2 BMs and that the MD was notified and they were waiting his response. LVN 1 stated she notified the MD of Resident 1 ' s change in condition at 6:25 p.m., but did not follow up after the first attempt. LVN 1 stated she was not aware of the process that the MD needed to be called at least three (3) times, with a 20-minute response wait in between the attempts before taking it up to the medical director of the facility. LVN 1 also stated that she did not complete an SBAR because LVN 1 felt overwhelmed that day with everything happening and forgot to complete it. LVN 1 stated the importance of an SBAR form was to communicate with other nurses of a resident's change in condition, the interventions that were done, and the outcome of the interventions. During an interview on 12/4/2023 at 1:00 p.m. with the Director of Nursing (DON), the DON stated the nurses should make a total of 3 attempts with a 20 minute response wait in between the attempts, and if the MD did not respond after the last attempt, the facility ' s medical director should be notified. The DON stated because Resident 1 had a change in condition after expressing rectal pain and having one (1) episode of emesis, the nurse should have documented an SBAR form. The DON stated the SBAR was important because it served as a communication amongst the nurses to better understand the change in the residents condition, the interventions, and the outcomes of the interventions. The DON stated the SBAR was important because it focused on acute changes in the resident ' s health. During a review of the facility ' s policies and procedures (P&P) titled, Change in Resident ' s Condition or Status, with a revision date of February 2021, the P&P indicated Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant pertinent information for the provider, including information prompted by the Interact SBAR communication form. During a review of the facility ' s undated LVN job description, the LVN job description indicated LVNs are responsible for charting all reports of accidents/incidents involving residents and follow established procedures.

Aug 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to isolate (separation of a sick resident with a contagious disease from a resident who was not sick) one of six sampled residents (Resident 2) who tested positive for Coronavirus disease ([Covid-19], an infectious disease caused by the SARS-CoV-2 virus that affects the respiratory system) in a timely manner. This deficient practice had the potential to spread Covid-19 to other residents and staff throughout the facility. 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 hypothyroidism (defiency in thyroid hormones), hyperlipidemia (high cholesterol) and dementia (a decline in cognitive abilities such as memory and thinking). During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2 did not have the capacity to understand and make decisions. The MDS indicated Resident 2 required limited assistance with ADL's including bed mobility, transfer, walking, eating and toilet use. During a review of Resident 2's Situation, Background, Appearance, Review (SBAR) Communication Form dated 7/31/2023, the SBAR indicated Resident 2 tested positive for covid-19 via rapid (antigen) test. During a review of the facility's Resident Line Listing (table that contained key information about each case in an outbreak), the Listing indicated Resident 2 had covid-19 signs and symptoms including fever, nausea and fatigue on 7/31/2023. During a review of Resident 2's Census List Report, the Report indicated Resident 2 was in room [ROOM NUMBER]-D on 7/1/2023 and transferred to room [ROOM NUMBER]-B on 8/1/2023. During an interview on 8/1/23 at 1:55 p.m. with the Infection Preventionist Nurse (IPN), IPN stated Resident 1 should have been moved immediately after testing positive for covid-19 on 7/31/2023 however was not done due to a confusion with the guidelines and was waiting for PHN recommendations. During an interview on 8/2/23 at 3:55p.m. with the Public Health Nurse (PHN), PHN stated residents who tested positive for covid-19 on 7/31/2023 should have been moved to an isolation area immediately and should have stayed away from other residents to prevent further spread of covid-19. During a review of the facility's undated Covid-19 Mitigation Plan (MP), the MP indicated residents who test positive for Covid-19 should be housed in a separate area, building, unit or wing of the facility and have dedicated staff who no not provide care for residents in other cohorts if possible. During a review of the facility's Policy and Procedure (P&P) titled, Infection Prevention and Control Program dated 10/2018, the P&P indicated, Outbreak Management was a process that consisted of managing the affected residents, preventing the spread to other residents. The P&P also indicated medical staff would help the facility comply with pertinent state and local regulations concerning the reporting and management of those with reportable communicable diseases. During a review of All Facilities Letter 23-12 ([AFL]-A letter to licensed facilities containing new updates, enforcements, or general information) on Covid-19 Recommendations for Resident Placement/Movement dated 1/24/2023, the AFL indicated Skilled Nursing Facilities should continue to ensure residents identified with confirmed covid-19 were promptly isolated in designated covid-19 isolation area. The AFL also indicated the covid-19 isolation area may be a designated floor, unit or wing or a group of rooms at the end of a unit that was physically separate and ideally included ventilation measures to prevent transmission to other residents outside the isolation area.

Mar 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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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 two sampled residents (Resident 1) physician was notified after Resident 1 refused insulin (medication used to lower the blood sugar) administration on 3/20/2023 at 5:01 p.m., on 3/21/23 at 4:50 p.m., and on 3/23/2023 at 6:48 a.m. as per the facility's policy and procedure (P/P). This deficient practice had the potential to delay medical interventions and necessary care for Resident 1. Findings: During a record review of Resident 1's admission Record (AR), dated 3/24/2023, the AR indicated Resident 1 was admitted to the facility on [DATE] with diagnosis including type 2 diabetes mellitus (a chronic condition which affects the way the body processes blood sugar) and Alzheimer's disease (progressive disease which destroys memory and other important mental functions). During a record review of Resident 1's history and physical (H/P), dated 2/17/2023, the H/P indicated Resident 1 did not have the capacity to understand and make medical decisions. During a record review of Resident 1's Minimum Data Set (MDS), an assessment and care-screening tool, dated 2/22/2023, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene. During a record review of Resident 1's Blood Sugar Summary (BS), dated 3/20/2023 and timed at 5:01 p.m. indicated Resident 1's blood sugar level was 297 milligrams ([mg] metric unit of capacity, equal to one thousandth of a gram)/deciliter ([dL] a metric unit of capacity, equal to one tenth of a liter) and no insulin was documented administered. The BS dated 3/21/2023 and timed at 4:50 p.m. indicated Resident 1's blood sugar level was 346 mg/dL. and no documented insulin administered. The BS indicated not applicable (NA) for Resident 1's blood sugar on 3/23/2023 for 6:00 a.m. During a review of Resident 1's Order Summary Report (OSR), dated 3/23/2023, the OSR indicated Resident 1 was to receive Insulin Lispro (fast acting medication to treat high blood sugar) Injection (administering a liquid into a person's body using a needle and syringe) Solution 100 units (international unit)/milliliter (one thousandth of a liter) per sliding scale (dose of insulin based on blood sugar level): if blood sugar 140-170 give 2 units, if blood sugar 180-219 give 4 units, if blood sugar 220-259 give 6 units, if blood sugar 260-299 give 8 units, if blood sugar 300-340 give 10 units, if blood sugar 341-400 give 12 units, if blood sugar greater than 400 to call the physician. The OSR indicated to check blood sugar and give insulin subcutaneously (in the fatty tissue, under the skin) before meals and at bedtime. During a concurrent interview and record review on 3/23/2023 at 9:24 a.m. with the Licensed Vocational Nurse (LVN 1) of Resident 1's Nursing Progress Notes (NPN) dated, 3/20/2023 and timed at 5:01 p.m., the NPN indicated Resident 1 had refused insulin administration. The NPN dated, 3/21/2023 and timed at 4:50 p.m., the NPN indicated Resident 1 had refused insulin administration on three occasions. The NPN dated, 3/23/2023 and timed at 6:48 a.m., the NPN indicated Resident 1 refused blood sugar check and insulin administration. The LVN 1 stated there was no documentation in Resident 1's medical records to indicate Resident 1's physician was notified after Resident 1 refused his insulin administration on 3/20/2023, 3/21/2023 and on 3/23/2023. The LVN 1 stated Resident 1's physician must be notified if a resident refuses their medications after two attempts. During a concurrent interview and record review on 3/23/2023 at 1:45 p.m., with the Director of Nursing (DON) the facility's P/P revised 2/2022 and titled, Change in a Resident's Condition or Status, was reviewed. The P/P indicated the nurse will notify the resident's attending physician or physician on call when there has been a refusal of treatment or medications two or more consecutive times. The DON stated, Resident 1's physician should have been notified after Resident 1 refused his insulin administration after two occasions.

Feb 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow up on the refill of a narcotic pain medication Hydrocodone/Acetaminophen ([APAP] Norco, used for pain that is severe and is not helped by other types of painkillers) for one of five sampled residents (Resident 2). This deficient practice led to Resident 2 feeling frustrated and experiencing more pain to his back, legs, and hips which caused him to feel more restless and affected his quality of sleep. Findings: During a review of Resident 2's admission Record, the record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included paraplegia (the loss of the ability to move the legs and lower body) and reduced mobility. During the review of Resident 2's History and Physical (H&P), dated 8/24/2022, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's Minimum Data Set ([MDS], a standardized resident assessment and care screening tool), dated 11/29/2022, the MDS indicated Resident 2 had the capacity to understand and had the ability to express ideas and wants. The MDS indicated Resident 2 required extensive one-person assistance for bed mobility, transfers out of bed, dressing, toilet use, and personal hygiene. During a review of Resident 2's Care Plan for pain related to chronic physical pain, initiated 11/7/2022, the care plan indicated the following staff's interventions: a. Administer analgesia (pain medication) as per orders. b. Anticipate Resident 2's need for pain relief and respond immediately to any complaints of pain. c. Evaluate the effectiveness of pain interventions. Review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results . d. Identify and record previous pain history and management of that pain and impact on function. e. Monitor /record pain characteristics: Quality; Severity; Anatomical location; Onset; Duration; Aggravating factors; Relieving factors f. Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment During a review of Resident 2's Order Summary, dated 1/9/2022, the order summary indicated the resident had a physician's order for Norco tablet 5-325 milligrams (mg, unit of measurement). The order indicated to give one (1) tablet by mouth every six (6) hours as needed for severe pain seven (7) to 10 out of a pain scale of 0 (no pain) to 10 (severe pain), as needed. During a review of Resident 2's Interdisciplinary Team (IDT, group of different disciplines working together towards a common goal of a resident) Conference Summary, dated 11/14/2022, the summary indicated the resident's pain management was not reviewed. During a review of Resident 2's Controlled Drug Disposition Form for Norco, dated 12/16/2022 to 12/28/2022, the form indicated a Norco tablet was last signed as given on 12/28/2022. During a review of Resident 2's Medication Administration Record (MAR) for the months of December 2022 and January 2023, dated 12/2022 and 1/2023, the MAR indicated Resident 2 was last administered one Norco tablet on 12/26/2022. During a review of the fax transaction, dated 12/27/2022, the fax indicated Norco was ordered for Resident 2 from the pharmacy. During an interview on 1/6/2023, at 2:12 p.m., in Resident 2's room, Resident 2 stated he suffered from chronic pain to his back, legs, and hips. Resident 2 stated his legs felt restless due to the pain and Norco was the only thing that helped relieve his pain and helped him to relax. Resident 2 stated his pain was a seven (7) out of 10 on the pain scale. Resident 2 described the pain to his legs, back, and hips as throbbing and the resident stated he did not sleep well due to the pain. Resident 2 stated he had been waiting for his Norco order to be filled and received by the facility. Resident 2 stated the facility told him the Norco order needed to be signed off by his physician, but he had been waiting over a week for the Norco to be signed off. Resident 2 stated he was medicated with Tylenol (medication used to treat fever and mild pain) but it was not working to help with his pain level. Resident 2 stated he felt frustrated that it was taking so long for the Norco to be filled and it made him want to leave the facility. Resident 2 stated he had asked a nurse, who he could not recall, if he could get a Norco from the emergency kit and the nurse told him the facility did not do that. During a concurrent record review and interview on 1/6/2023, at 2:44 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 2's MAR, dated 12/2022, and Resident 2's Controlled Drug Disposition Form for Norco, dated 12/16/2022 to 12/28/2022, was reviewed. LVN 1 stated Resident 2 had an order for Norco and that the resident preferred Norco for pain management. LVN 1 stated Resident 2's last dose of Norco was administered on 12/26/2022. LVN 1 stated the Controlled Drug Disposition Form for Norco indicated she had administered Norco to Resident 2 on 12/27/2022 and 12/28/2022, but she had not documented it on Resident 2's MAR because she forgot. LVN 1 stated she was supposed to document administered medications on the resident's MAR. During an interview on 1/6/2023, at 2:50 p.m., with LVN 1, LVN 1 stated she ordered Resident 2's Norco from the pharmacy on 12/27/2022. LVN 1 stated the pharmacy usually filled medications in half a day, but Resident 2's Norco had not been filled yet. LVN 1 stated she spoke to the pharmacist on 12/28/2022 but she had not documented their conversation. LVN 1 stated Norco could be taken from the facility's emergency kit, but she did not know if every nurse was aware of that option if a medication refill was delayed. LVN 1 stated she had not offered the Norco from the emergency kit. LVN 1 stated she had not followed up on Resident 2's Norco refill because she was busy. LVN 1 stated she did not see any documentation that indicated any other nurse followed up on Resident 2's Norco refill. LVN 1 stated the Director of Nursing (DON) was aware Resident 2's Norco had not been filled. LVN 1 stated it was not okay for a resident to not have their pain medication for nine days. LVN 1 stated Resident 2's breathing, quality of sleep, and quality of life may be negatively affected if his pain was not well-managed. LVN 1 stated she should have reached out to the physician to have Resident 2's Norco order filled in a timely manner. During an interview on 1/6/2023, at 3:09 p.m., with the DON, the DON stated a narcotic medication should be ordered five to seven days before a resident runs out because the refill required the physician's authorization and that took time and may lead to resident running out of the pain medication. The DON stated the facility should have offered Resident 2 a Norco dose from the emergency kit if the refill was delayed. The DON stated he did not offer Resident 2 a Norco dose from the emergency kit because he forgot it was an option to medicate the resident. The DON stated he had spoken to Resident 2 regarding the delay of the Norco refill and stated he told the resident the nurses would follow up. The DON stated he did not know if the nurses had followed up with the pharmacy or the physician, but they should have to ensure the pain medication was filled in a timely manner. The DON stated he had not followed up the pharmacy or the physician regarding the Norco refill. The DON reviewed Resident 2's progress notes, dated 12/27/2022 to 1/5/2023, in the resident's electronic chart and verified there was no documentation indicating the nursing staff had followed up with the pharmacy and/or the doctor regarding the Norco refill. The DON stated Resident 2 may not be able to perform his normal day to day activities, it may affect his level of comfort, and affect his ability to sleep well if his pain was not well-managed. During a review of the facility's policy and procedure (P&P) titled, Medication Ordering and Receiving- Ordering and Receiving Controlled Medications, dated 2/23/2022, the P&P indicated, Schedule II (drugs with a high potential for abuse) refill requests must be called of faxed to the pharmacy when a five-day supply remains in the facility. During a review of the facility's P&P titled, Pain Assessment and Management, dated 10/2022, the P&P indicated the pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. The P&P indicated pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. The P&P indicated the medication regimen is implemented as ordered. Results of the interventions are documented and communicated directly to the provider when appropriate. Ongoing communication between the prescriber and the staff is necessary for the optimal and judicious use of pain medications.

CONCERN (E) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document all administered doses of Hydrocodone/Acetaminophen (Norco, used for pain that is severe and is not helped by other types of painkillers) for two of five sampled residents (Residents 1 and 2). This deficient practice increased the potential risk for a medication error and Residents 1 and 2 being overmedicated which may have led to respiratory distress, hospitalization, and death. Findings: During a review of Resident 1's admission Record, the record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Type 2 diabetes mellitus (a long-term condition that impairs the way the body regulates and uses sugar as a fuel) with diabetic polyneuropathy (affects multiple sensory and motor nerves in the arms, hands, legs, and feet causing weakness and a pins-and needles sensation or loss of sensation) and chronic obstructive pulmonary disease ([COPD] a group of diseases that cause airflow blockage and breathing problems). During a review of Resident 1's Minimum Data Set ([MDS], a standardized resident assessment and care screening tool), dated 12/14/2022, the MDS indicated Resident 1 had the capacity to understand and make decisions. The MDS indicated Resident 1 required limited one-person assistance with bed mobility, transfers out of bed, dressing, toilet use, and personal hygiene. During a review of Resident 1's Controlled Drug Disposition Form for Norco dated 12/14/2022 to 1/11/2023, the record indicated 53 tablets were signed out for administration to Resident 1 from 12/14/2022 to 1/9/2023. During a review of Resident 1's Medication Administration Record (MAR) for the months of December 2022 and January 2023, dated 12/2022 and 1/2023, the MAR indicated 17 doses of Norco were administered to Resident 1. The MAR indicated 36 tablets of Norco were not documented as being administered to Resident 1. During a review of Resident 2's admission Record, the record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including paraplegia (the loss of the ability to move the legs and lower body) and reduced mobility. During the review of Resident 2's History and Physical (H&P), dated 8/24/2022, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had the capacity understand and had the ability to express ideas and wants. The MDS indicated Resident 2 required extensive one-person assistance for bed mobility, transfers out of bed, dressing, toilet use, and personal hygiene. During a review of Resident 2's Controlled Drug Disposition Form for Norco, dated 12/16/2022 to 12/28/2022, the form indicated 24 tablets were signed out for administration to Resident 2. During a review of Resident 2's MAR for the month of December 2022, dated 12/2022, the MAR indicated 10 doses of Norco were administered to Resident 2 from 12/16/2022 to 12/31/2022. The MAR indicated 14 tablets of Norco were not documented as being administered to Resident 2. During a concurrent record review and interview on 1/6/2023, at 2:44 p.m., with Licensed Vocational Nurse (LVN) 1, Resident 2's MAR, dated 12/2022, and Resident 2's Controlled Drug Receipt/Record/ Disposition Form for Norco, dated 12/16/2022 to 12/28/2022, was reviewed. LVN 1 stated according to the MAR, Resident 2's last dose of Norco was administered on 12/26/2022. LVN 1 stated the Controlled Drug Receipt/Record/ Disposition Form for Norco indicated she had administered Norco to Resident 2 on 12/27/2022 and 12/28/2022. LVN 1 stated she had not documented both doses on the MAR because she forgot. LVN 1 stated she was supposed to document administered medications on the resident's MAR. During a concurrent record review and interview on 1/23/2023, at 10:25 a.m., with the Director of Nursing (DON), Resident 1's Controlled Drug Disposition Form for Norco, dated 12/14/2022-1/11/2023, and Resident 1's MAR for the months of December 2022 and January 2023, dated 12/2022 and 1/2023, was reviewed. The DON also reviewed Resident 2's Controlled Drug Disposition Form for Norco, dated 12/16/2022 to 12/28/2022, and Resident 2's MAR for the month of December 2022, dated 12/2022. The DON verified 36 doses of Norco for Resident 1 and 14 doses of Norco for Resident 2 were not documented on the MAR. The DON stated the licensed staff was supposed to immediately document medication on the resident's MAR at the time it was administered to the resident. The DON stated the disposition form was used to keep track of the narcotic count and the MAR was used to know when a medication was administered to the resident. The DON stated the licensed nurse was responsible for keeping track of both records for the safety of the resident. The DON stated the MAR also indicated the effectiveness of the pain medication and it should be documented to indicate the resident was assessed before and after the pain medication was administered. The DON stated it was important to document the administered narcotic medication on the MAR to identify when the resident was medicated and accurately determine when the next narcotic dose could be safely administered to the resident again. The DON stated the risk for the resident was that a medication error could have occurred if the medication was not documented on the MAR because the resident may be administered another dose at the wrong time and cause harm to the resident. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated 4/2019, the P&P indicated the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.

Jan 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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain records in accordance with accepted professional standards for one of three sampled residents (Resident 1) by failing to keep the investigation records of Resident 1's abuse allegations that occurred on 4/23/2020. Resident 1 reported a certified nurse assistant (CNA 2) twisted her thumb during a diaper change on 4/23/2020 and the resident sustained a fracture (broken bone) of the fifth finger of the left hand. This deficient practice had the potential to negatively impact the delivery of services. Findings: During a review of Resident 1's Face Sheet (admission records), the face sheet indicated Resident 1 was initially admitted to the facility on [DATE], and last readmitted on [DATE]. Resident 1's diagnoses included muscle weakness, dementia (a group of conditions characterized by impairment of memory loss and judgment), neuromuscular dysfunction of the bladder (when a person lacks bladder control due to brain problems), functional quadriplegia (complete immobility due to severe physical disability or frailty), and age related osteoporosis (bone loss that results from aging) without current pathological (not caused by force or impact) fracture (broken bones). During a review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 3/16/2020, the MDS indicated Resident 1's cognitive (the ability to understand or to be understood by others) skills for daily decision-making was moderately impaired. The MDS indicated Resident 1 required extensive assistance from one staff with bed mobility, transfers, and dressing. The MDS indicated Resident 1 required total dependence on one staff for personal hygiene, and was totally dependent on two staff members to assist her with toilet use. During a review of Resident 1's Progress Note dated 4/23/2020 at 3:05 p.m., the progress note indicated upon arriving on shift the resident (Resident 1) was observed crying in bed with left hand edema (swelling) and discoloration. The progress note indicated Resident 1 reported that CNA 2, during the 3 p.m. - 11 p.m. shift, broke her hand while changing her. The progress note indicated an X-ray (imaging which creates pictures of the inside of your body) was done and the results indicated a left fifth phalanx (little finger) fracture. The progress note indicated CNA 2 would be interviewed to gather more information. During an interview with the Social Services Designee (SS) on 12/9/2022 at 11:25 a.m., SS stated there were no records of Resident 1's injury noted, nor did she remember the incident. SS stated the Director of Nursing (DON) was the one responsible for filing incident reports and completing abuse investigations. During an interview with the DON on 12/9/2022 at 11:30 a.m., the DON stated CNA 2 no longer worked for the facility. The DON stated there was no documented evidence of Resident 1's incident or that investigation of the incident was completed. The DON stated he was hired with the facility in 2021, and did not receive any incident reports of any incidents prior to his employment at the facility. During a follow up phone interview with the DON on 1/19/2023 at 3:36 p.m., the DON stated records should have been retained for the investigation of the facility report incident and abuse allegations but it was not. During a review of the facility's policy and procedure (P&P) titled, Health Information/ Record Manual, revised 2/4/2004, the P&P indicated all records are completed promptly upon discharge and filed in a designated storage area on the premises and retained for a period of at least 7 years following the resident's last discharge. In the event of sale of the facility, records will remain on the premises and shall become the property of the successor who shall be required to retain said records for the balance of above stated duration.

Jan 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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three residents (Resident 4) was free from verbal abuse by Certified Nurse Assistant (CNA 2). This deficient practice had the potential to place Resident 4 at risk for psychosocial distress. Findings: During interview on 7/14/2022 at 9:50 a.m. with Resident 7, Resident 7 stated Certified Nurse Assistant (CNA 2) was witnessed speaking to Resident 4 in an aggressive and rough tone when cleaning or feeding Resident 4. Resident 7 stated CNA 2 spoke in a non-dominant language and could not understand the words spoken to Resident 4. Resident 7 stated he asked Resident 6 to translate the words related to the rough tone and Resident 6 stated CNA 2 was yelling at Resident 4 to shut up. Resident 7 stated, I was shocked by the way CNA 2 told Resident 4 to shut up. Resident 7 stated, if he was told to shut up, he would feel upset. During an interview on 7/14/2022 at 12:45 p.m., Resident 6 stated CNA 2 yells at Resident 4 during assistance with feeding. Resident 6 stated Resident 4 would ask for more food from CNA 2 and CNA 2 would tell Resident 4 to shut up. Resident 6 stated he had witnessed CNA 2 getting mad with Resident 4 when Resident 4 pulls off his gown and throws it on floor. Resident 6 stated, I felt shocked that CNA 2 would talk to Resident 4 that way. Resident 6 stated I would not like it if CNA 2 yelled at me and that would make me mad. During an interview on 7/14/2022 at 2:00p.m., Director of Staff Development (DSD), the DSD stated staff were trained regarding abuse upon hire, twice yearly, and after any incident. During an interview on 7/14/2022 at 3:15 p.m. with CNA 2, CNA 2 was able to identify forms of abuse and identified what constituted as verbal abuse. A review of Resident 4 ' s admission Record (Face Sheet), indicated Resident 4 was admitted to the facility on [DATE] with diagnoses including, dementia (chronic disorder of mental processes caused by brain disease), congestive heart failure (chronic condition the heart doesn ' t pump blood very well), type 2 diabetes mellitus(chronic condition that affects the body process sugar), hypertension (high blood pressure), paraneoplastic neuromyopathy with neuropath (sensorimotor associated with muscle atrophy), dysphagia (difficulty swallowing) with feeding difficulties, anxiety disorder, reduced mobility with muscle weakness. A review of Resident 4 ' s Minimum Data Set (MDS), a standardized care screening and assessment tool, dated 5/13/2022 indicated Resident 4 had severe cognitive (ability to think and understand) impairment. The MDS indicated Resident 4 had no verbal behavioral symptoms directed toward others, such as threatening, screaming, nor cursing at others and required extensive physical assistance from staff for mobility, feeding, bathing, dressing, and toileting. A review of Resident 4 ' s Care Plan titled ADL (Activities of Daily Living)/ Rehabilitation Potential dated 5/13/2022, the Care Plan indicated to allow adequate time for Resident 4 to complete task and praise efforts in participation. A review Resident 7 ' s admission Record (Face Sheet), indicated Resident 7 was admitted to the facility on [DATE] with diagnoses including, internal fixation device (used to internally set and stabilize fractured bones), chronic osteomyelitis (infection in the bone) left ankle and foot, end stage renal disease (kidneys cease functioning on a permanent basis), type 1 diabetes mellitus (pancreas does not make insulin). A review of Residents 7 ' s MDS dated [DATE], a standardized care screening and assessment tool, indicated Resident 7 ' s cognitive patterns (ability to think and understand) were intact and with no impairment. A review Resident 6 ' s admission Record (Face Sheet), indicated Resident 6 was admitted to the facility on [DATE] with diagnoses including cutaneous abscess (accumulation of pus) of buttock, type 2 diabetes mellitus (abnormal blood sugar), and acquired absence of left leg below the knee. A review of Residents 6 ' s MDS dated [DATE], a standardize care screening and assessment tool, indicated Resident 6 has cognitive patterns that indicate that Resident 6 ' s cognitive patterns (ability to think and understand) were intact and with no impairment. A review of in-service training records titled Abuse Training/Reporting indicated that CNA 2 had training in-services on 5/8/2022, 5/9/2022, 5/10/2022, 5/23/2022, and 5/24/2022 which included verbal abuse as part of the eight types of abuse. A review of the facility ' s policy and procedure (P&P) titled, Dignity dated February 2021, the P&P indicated, Staff speak respectfully to residents at all times .Staff are expected to treat cognitively impaired residents with dignity and sensitivity: for example: addressing the underlying motives or root causes for behavior; and not challenging or contradicting the resident ' s beliefs or statements. A review of the facility ' s policy and procedure (P&P) titled, Abuse Prevention Program dated December 2016, the P&P indicated to develop and implement policies and procedures to aid our facility in preventing abuse, neglect or mistreatment of our residents .require staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior . to implement measures to address factors that may lead to abusive situations . instruct staff regarding appropriate ways to address interpersonal conflicts.

Jan 2023 4 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

Deficiency F0692 (Tag F0692)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent weight loss and dehydration (dangerous loss of body fluid caused by illness, sweating, or inadequate intake) as per the resident ' s plan of care and the facility ' s policy and procedure (P&P) for one of four sampled residents (Resident 1) by failing to: 1. Ensure Resident 1 ' s nutritional status was assessed and addressed by the licensed staff from 8/20/2022 to 9/23/2022 and implement interventions such as honoring the resident ' s food preferences and likes/dislikes when Resident 1 began to refuse to eat. 2. Ensure the Registered Dietician (RD, health professional who has special training in diet and nutrition) was notified of Resident 1 ' s continued decreased oral intake and implement resident specific interventions to prevent further weight loss from 9/19/2022 to 11/23/2022, a total of 13 pounds. 3. Ensure a resident centered care plan was updated and implemented to address Resident 1 ' s decreased fluid and food intake and the nutritional needs to address significant weight change for Resident 1. 4. Notify Resident 1 ' s physician of continued decrease in appetite and refusal to eat from 10/10/2022 to 11/23/2022. As a result, Resident 1 had insidious (gradual unintended weight loss over time) weight loss leading to severe weight loss of 6.7 percent (%) in one month (September to October) due to lack of continuous monitoring and interventions. The resident lost a total of 13 pounds from 9/13/2022 to 11/23/2022. On 11/23/2022, Resident 1 was transferred to a general acute care hospital (GACH) and expired. 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 that included hemiplegia (paralysis [inability to move] of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body), dysphagia (difficulty in swallowing food or liquid), muscle weakness (a decrease in strength in one or more muscles), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Parkinson ' s disease (a degenerative condition of the brain associated with motor symptoms [slow movement, tremor, rigidity and imbalance]), and anxiety disorder (a mental health condition with frequently intense, excessive and persistent worry and fear about everyday situations). During a review Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 8/26/2022, the MDS indicated Resident 1 ' s cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired. The MDS indicated Resident 1 required extensive assistance from staff with bed mobility, dressing, supervision for eating, and was totally dependent on staff with toileting, personal hygiene, and bathing. The MDS indicated Resident 1 had no weight loss of 5 percent or more in the last month or loss of 10 percent or more in the last 6 months. During a review of Resident 1 ' s History and Physical (H&P), dated 9/17/2022, the H&P indicated Resident 1 had the capacity to understand and make decisions. The H&P indicated Resident 1 was admitted for 24-hour nursing care. The H&P indicated Resident 1 ' s weight was stable. A review of Resident 1 ' s Weights and Vitals Summary, dated from 8/23/2022 to 11/1/2022, indicated the following: On 8/23/2022 - 191 pounds (lbs) (2 days after admission) On 8/29/2022 - 193 lbs On 9/5/2022 - 193 lbs On 9/13/2022 - 193 lbs On 9/19/2022 - 189 lbs On 9/26/2022 - 186 lbs On 10/5/2022 - 184 lbs On 10/10/2022 - 180 lbs On 10/17/2022 - 180 lbs On 10/24/2022 - 181 lbs On 10/31/2022 - 180 lbs On 11/1/2022 - 180 lbs (last recorded weight at the facility) During a review of Resident 1 ' s Physician Order Summary Report, the order summary report indicated the following orders: 1. 8/20/2022 - weekly weights for 4 weeks was ordered. 2. 8/20/2022 - NAS (no added salt) diet, chopped texture, thin liquids consistency for breakfast, lunch, and dinner. 3. 8/20/2022 - monitor for side effects of Ativan (medication used to treat anxiety) use; drowsiness, dizziness, loss of coordination, headache, nausea, blurred vision, constipation, heartburn, and change of appetite. 4. 10/1/2022 - fortified diet (foods that have nutrients added that the food would not naturally contain), mechanical soft (a diet designed for people who have trouble chewing and swallowing), chopped texture, thin liquids consistency for breakfast, lunch, and dinner. 5. 10/4/2022 Megestrol Acetate Suspension (Megace, used to help raise feelings of hunger) 400 milligrams (mg, a unit of mass or weight), by mouth two times a day for poor appetite. During a review of Resident 1 ' s Nutrition (PO Intake) records, the records indicated from August to November 2022, the forms were incomplete. A review of Resident 1 ' s dietary records indicated there was no documentation that alternative foods, snacks, or supplements were offered or provided to Resident 1, from 8/21/2022 (day after admission) to 11/23/2022 (transfer to the GACH). During a review of Resident 1 ' s Weights and Vitals Summary, effective date range 8/20/2022 to 11/23/2022, the summary indicated Resident 1 lost 13 lbs, 6.7 percent (%) of her body weight within 27 days. Resident 1 ' s weight went from 193 lbs on 9/13/2022 to 180 lbs on 10/10/2022. During a record review of Resident 1 ' s Nutritional Risk Assessment (Admission/ Annual), dated 9/2/2022, the assessment indicated Resident 1 ' s diagnoses of depression and anxiety placed the resident at high risk for nutritional problems. The assessment indicated Resident 1 ' s weight was to not exceed more or less than 4% of her current body weight of 193 lbs. The assessment indicated Resident 1 ' s PO (oral) intake was consistently meeting greater than 75 % of needs and was on monitoring and evaluation of weight and oral (PO) intake changes. The assessment indicated the plan for Resident 1 was weight maintenance and not weight loss. The assessment also indicated for Resident 1 ' s food preferences (likes/dislikes), to refer to the Dietary Screening Report which identifies a resident ' s food preferences. A review of Resident 1 ' s clinical records indicated there was no Dietary Screening Report completed. During a review of Resident 1 ' s care plan titled, Hydration Risk: At risk for Fluid Volume deficit related to (R/T) advanced age, date initiated 9/13/2022, the care plan indicated Resident 1 would be well hydrated as evidenced by no weight loss, moist mucous membranes, good skin turgor (ability of skin to change shape and return to normal) and laboratory (labs) results within normal limits. The staff ' s interventions indicated to monitor Resident 1 ' s labs, weights, promote good nutrition and promote good PO intake. During a review of Resident 1 ' s care plan titled, Noted Recent Weight Change of nine (9) lbs. Weight Loss in a Week, initiated 9/19/2022 and revised on 10/6/2022, the care plan indicated Resident 1 would eat at least 50 percent of meals and drink adequate fluids. The staff ' s interventions included to monitor and record Resident 1 ' s weight, refer to the IDT for review and additional interventions, monitor lab work and provide supplements as ordered. During a review of Resident 1 ' s, Lab Results Report, dated 9/30/2022, the report indicated labs was completed and all results were in normal range including Albumin results (normal reference range [NRR] 3.0 to 5.0 grams per deciliter [(g/dL]) which is indicative of malnourishment. During a review of Resident 1 ' s Nutrition/Dietary Note dated 10/14/2022, the note indicated Resident 1 experienced a significant undesired weight loss of four (4) lbs in one week. The note indicated on 10/3/2022, Resident 1 ' s weight was 184 lbs and on 10/10/2022, the weight dropped to 180 lbs. The record indicated Resident 1 ' s weight loss was related to variable PO intake, urinary tract infection (UTI, bladder infection), and psychotropic medications (medications used to treat mental disorders), which may decrease appetite. The record further indicated Resident 1 was receiving Megace to stimulate appetite and would be monitored for improvement in PO intake and weight changes with a re-evaluation in 7 days. A review of Resident 1 ' s medical records indicated there was no re-evaluation addressing the resident ' s PO intake and weight changes after 7 days. A review of Resident 1 ' s Order Summary Report dated 12/1/2023, indicated there was a physician ' s order dated 10/16/2023, to administer multivitamin-minerals tablet, by mouth one time a day. During a review of Resident 1 ' s Nutrition note, and Nurses Progress note dated 11/22/2022, the notes indicated Resident 1 ate 0-25 % for breakfast and lunch. There was no documentation for dinner and no documented evidence a change of condition (COC) was initiated on this date regarding Resident 1 ' s poor PO intake. During a review of Resident 1 ' s Situation, Background, Assessment, and Recommendation (SBAR, communication form) dated 11/23/2022, the SBAR indicated on 11/23/2022 at 3:15 p.m., Resident 1 was found unresponsive with no pulse, and no breathing noted. 911 was called and Resident 1 was transferred to a general acute care hospital (GACH). During a review of Resident 1 ' s GACH ' s Emergency Department (ED) Note, dated 11/23/2022, the note indicated Resident 1 was transferred via emergency medical services (EMS) for unresponsiveness and cardiac arrest (when the heart stops beating suddenly). A review of Resident 1 ' s GACH ED laboratory results dated [DATE] indicated the following laboratory results: 1. Blood Urea Nitrogen (BUN, test to determine kidney function): elevated at a level of 49 milligrams (mg, unit of measurement) per (/) deciliter (dL, unit of measurement), indicative of dehydration. Normal Reference Range ([NRR] 7-20 mg/dL). 2. Creatinine (test to determine kidney function): elevated at a level of 5.3 mg/dL. NRR 0.50-1.30 mg/dL. 3. Sodium (electrolyte which plays a critical role in helping your cells maintain the right balance of fluid and used to help cells absorb nutrients in the body): elevated at a critically high level of 170 millimoles per liter (mmol/L). NRR 137-145 mmol/L. 4. Potassium (critical to your heart function, too much or too little can cause serious heart problems): elevated at a critically high level of 6.4 mmol/L. NRR 3.5-5.1 mmol/L. 5. Total Protein (test measures the amount of protein in your blood, which are important for the health and growth of the body's cells and tissues): low level of 3.1 grams (g)/dL. NRR 6.3-8.2 g/dL. 6. Albumin (responsible for transporting vitamins, enzymes (proteins that help speed up chemical reactions in our bodies), and hormones (substance made by glands in the body) throughout your body. Albumin makes up 50% of the proteins found in your plasma (fluid part of the blood that carries the blood cells). When your albumin levels are low, hormones and other important compounds are not able to get to where they need to go in your body to fulfill their duties): low level of 1.4 g/dL. NRR 3.0-5.0 g/dL. During a review of Resident 1 ' s GACH ED Note dated 11/23/2022, the note indicated per the EMS report, Resident 1 received 36 minutes of cardiopulmonary resuscitation (CPR, emergency life-saving procedure performed when the heart stops beating) at bedside at the facility followed by 10 minutes of CPR in route to the GACH. The note indicated at presentation to the ED, Resident 1 was apneic (breathing repeatedly stops and starts) and pulseless with CPR in progress. CPR was continued for approximately 35 minutes in the ED. Resident 1 was intubated (placement of a flexible plastic tube into the trachea to maintain an open airway) and regained perfusing pulse for approximately 10 minutes. CPR was re-initiated and after 10 minutes, Resident 1 was pulseless and without respiratory effort nor heart sounds. Resident 1 was declared deceased on [DATE] at 5 p.m. During a telephone interview with RD 1 on 12/29/2022 at 2:06 p.m., RD 1 stated there were no follow up notes after 10/14/2022, because Resident 1 ' s weight was stable at 180 lbs. RD 1 stated she did not look into Resident 1 ' s poor PO intake because the resident ' s weight was okay. RD 1 stated there were no nutrition labs recommended to Resident 1 ' s physician for October and November 2022 because September 2022 ' s lab results were good despite the resident ' s poor PO intake. RD 1 stated she did not make additional recommendations to address Resident 1 ' s continued poor PO intake. During an interview with Certified Nursing Assistant (CNA) 2 on 1/6/2023 at 1:05 p.m., CNA 2 stated Resident 1 was confused, needed help with eating, and was unable to eat on her own. During an interview with RD 1 on 1/6/2023 at 1:07 p.m., RD 1 stated she was not notified Resident 1 had poor PO intake. RD 1 confirmed snacks were not offered. RD 1 stated if she knew Resident 1 was not eating well, she would have recommended to order supplements to prevent losing more weight. RD 1 confirmed Resident 1 had multiple episodes of three or more episodes of poor meal intake in a two-day period. RD 1 was unable to provide documentation of Resident 1 ' s calorie count and measurement of the resident ' s fluid intake and output. RD 1 verified Resident 1 was not weighed after 11/1/2022, despite Resident 1 ' s continued poor PO intake. During an interview with Licensed Vocational Nurse (LVN) 7 on 1/6/2023 at 1:24 p.m., LVN 7 stated Resident 1 was alert and confused, and always needed prompting and assistance with eating and drinking. LVN 7 stated Resident 1 had water at the bedside but would not take the initiative to eat or drink by herself. LVN 7 stated Resident 1 ' s highly anxious state did not make eating and drinking her priority. LVN 7 stated Resident 1 refused her meals a lot and staff would try to soothe and relax her so she could eat. LVN 7 stated 10/11/2022 was the last documented date Resident 1 ' s physician was notified regarding the resident ' s poor oral intake. LVN 7 stated multivitamins (MVIs) were ordered. During a concurrent interview and record review on 1/6/2023 at 1:30 p.m. with LVN 7, Resident 1 ' s Weights and Vitals Summary, from 8/23/2022 to 10/17/2022, were reviewed. LVN 7 stated Resident 1 refused to eat, continued to have lose weight, and ultimately had an 11 lbs weight loss from 8/23/2022 to 10/17/2022. The weights reviewed were as follows: 1. 8/23/2022 weight was 191 lbs on admission. 2. 9/26/2022 weight was 186 lbs, a 5-lb weight loss since admission. 3. 10/5/2022 weight was 184 lbs, a 7-lb weight loss since admission. 4. 10/17/2022 weight was 180 lbs, an 11-lb weight loss since admission. During a subsequent interview, LVN 7 stated Resident 1 ' s care plan should have been updated to address the resident ' s unintended continuous weight loss from August to October 2022. LVN 7 stated each weight loss documented should have had new meaningful interventions. LVN 7 stated multivitamins should have been ordered sooner and oral nutritional supplements would have been helpful. LVN 7 stated Resident 1 ' s physician should have been notified on the dates the weight loss was noted and the interdisciplinary team (IDT, group of different disciplines working together towards a common goal for a resident) could have been more aggressive with interventions to aid in Resident 1 ' s nutritional status. During a concurrent interview and record review on 1/6/2023 at 2:03 p.m., with LVN 8, Resident 1 ' s clinical record was reviewed. LVN 8 stated when Resident 1 ' s health started to decline a change of condition (COC) was noted for a 4-lb weight loss on 9/19/2022. LVN 8 stated Resident 1 was confused and needed a lot of cues to drink water. LVN 8 stated there was no documented evidence Resident 1 was cued to drink water several times a day in the resident ' s clinical record. LVN 8 stated if staff knew what Resident 1 liked to eat, it would have helped encourage the resident to eat more. LVN 8 stated if snacks were also added in between meals, it could have helped prevent the decline of Resident 1 ' s health. LVN 8 stated there were multiple missed opportunities to intervene and help Resident 1 with increasing her PO intake more aggressively. During a subsequent concurrent interview and record review on 1/6/2023 at 2:03 p.m. with LVN 8, Resident 1 ' s clinical record was reviewed, LVN 8 stated there was no evidence Resident 1 ' s fluid intake was being monitored, and no record indicating RD 1 was notified of the resident ' s poor PO intake and refusals to eat and drink. During an interview with the Director of Nursing (DON) and Registered Nurse (RN) 1 on 1/6/2023 at 3 p.m., the DON and RN 1 stated the facility staff failed to notify Resident 1 ' s physician of the resident ' s continued poor PO intake, and refusal to eat and drink fluids from 10/15/2022, to 11/23/2022. The DON and RN 1 stated no additional interventions were made to address Resident 1 ' s continued poor PO intake from the last time the physician was notified of the resident ' s weight loss on 10/11/2022. The DON and RN 1 stated staff should have been notifying and updating Resident 1 ' s physician of the resident ' s continued poor PO intake and sought further guidance and medical interventions to prevent Resident 1 ' s health from declining. During an interview with Registered Dietician (RD) 1 on 1/6/2023 at 3:12 p.m., RD 1 stated Resident 1 ' s food preference assessment was not completed because the facility did not have a dietary staff supervisor (DSS) at the time. RD 1 stated a food preference assessment should have been completed upon Resident 1 ' s admission to the facility and when the resident began refusing to eat. RD 1 stated it was important to ask Resident 1 ' s food preferences and offer food the resident liked to help improve the resident ' s appetite and increase PO intake. During a telephone interview with Resident 1 ' s physician (Physician 1) on 1/11/2023 at 2:04 p.m., Physician 1 stated, If a resident is not eating or has poor intake and is losing weight, my expectations are for the nursing staff to contact me for the change in condition so that I may make appropriate medical decisions and provide orders to address the resident ' s issue. Physician 1 further stated the facility staff did not contact him nor his nurse practitioner (NP 1) about Resident 1 ' s poor oral intake and weight loss from 10/15/2022 to 11/23/2023. During a review of the facility ' s P&P titled, Calorie Counts, dated 4/2007, the P&P indicated nursing staff will document poor intake in the progress notes. Three or more episodes of poor meal intake in a two-day period will be reported in writing to the Dietitian. The P&P indicated the Dietitian will assess intake patterns. If unexpected weight loss or perceived decline in food intake warrants further investigation, a calorie count may be requested. A physician order is not required for the initiation of a calorie count. The P&P indicated the Dietitian will document results and assess adequacy of caloric intake in the medical record. If necessary, interventions will be initiated in accordance with current Standards of Practice. During a review of the facility ' s Policy and Procedure (P&P), titled, Food and Nutrition Services, revised 10/2017, the P&P indicated each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The P&P indicated the multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident ' s nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. A resident-centered diet and nutrition plan will be based on this assessment. During a review of the facility ' s P&P titled, Food and Nutrition Services, revised 10/2017, the P&P indicated nursing personnel, with the assistance of the food and nutrition services staff, will evaluate (and document as indicated) food and fluid intake of residents with, or at risk for, significant nutritional problems. a. Variations from usual eating or intake patterns will be recorded in the resident ' s medical record and brought to the attention of the nurse. b. A nurse will evaluate the significance of such information and report it, as indicated, to the attending physician and dietitian. During a review of the facility ' s P&P titled, Weight Assessment and Intervention, revised 3/2022, the P&P indicated resident weights are monitored for undesirable or unintended weight loss or gain. Unless notified of significant weight change, the dietitian will review the unit weight record monthly to follow individual weight trends over time. The P&P indicated the threshold for significant unplanned and undesired weight loss will be based on 1 month - 5% weight loss is significant; greater than 5% is severe. The P&P further indicated interventions for undesirable weight loss are based on careful consideration of nutrition and hydration 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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to immediately notify one of four sampled resident's (Resident 1) primary physician (MD 1) and responsible party (RP 1) regarding Resident 1 ' s poor oral intake and refusal of meals from 10/12/2022 to 11/23/2022. This deficient practice of not notifying MD 1 resulted in Resident 1 ' s continued poor oral hydration (the absorption of or combination with water) and poor nutritional intake which led to an unplanned and severe 13 pound weight loss (greater than 5 percent [%] weight difference) or a loss of 6.7 % body weight. The deficient practice of not immediately notifying RP 1 violated the residents/resident's RP ' s right to be informed of the care services provided. Findings: During a review of Resident 1 ' s admission Record, dated 12/1/2022, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis [inability to move] of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body), dysphagia (difficulty in swallowing food or liquid), muscle weakness (a decrease in strength in one or more muscles), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Parkinson ' s disease (a degenerative condition of the brain associated with motor symptoms [slow movement, tremor, rigidity and imbalance]), and anxiety disorder (a mental health condition with frequently intense, excessive and persistent worry and fear about everyday situations). During a review Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 8/26/2022, the MDS indicated Resident 1 ' s cognition (mental process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired. The MDS indicated Resident 1 required extensive assistance from staff with bed mobility and dressing, supervision with eating, and was totally dependent on staff with toileting, personal hygiene, and bathing. During a record review of Resident 1 ' s Nutritional Risk Assessment (Admission/ Annual), dated 9/2/2022, the assessment indicated: 1. Resident 1 ' s goal weight was to not exceed more or less than 4% of current body weight of 193 pounds; and 2. Plan for weight maintenance and not weight loss. During a review of Resident 1 medical records, the records indicated there was no documented evidence a Dietary Screening Report was completed, and there was no documented evidence Resident 1 ' s food preferences were assessed. During a review of Resident 1 ' s Physician Order Summary Report, dated 12/1/2022, the order summary report indicated on 10/1/2022, Resident 1 ' s meal regimen ordered consisted of a fortified diet (foods that have nutrients added to them that they wouldn ' t naturally contain), mechanical soft (a texture-modified diet that restricts foods that are difficult to chew or swallow), chopped texture, thin liquids consistency for breakfast, lunch, and dinner. The order summary report did not indicate to monitor Resident 1 ' s intake and output (measurement of the fluids that enter [input] and exit [output] the body). During a review of Resident 1 ' s Situation Background Assessment Recommendation ([SBAR] internal communication form), dated 10/10/2022, the SBAR indicated Resident 1 was noted with a 4 pound (lb) weight loss in a week and continued poor oral intake. The SBAR indicated MD 1 and RP 1 were notified on 10/11/2022 at 9 a.m. The SBAR was the last documented evidence of MD 1 and RP 1 ' s notification regarding Resident 1 ' s poor intake and meal refusals. During a review of Resident 1 ' s record titled, Nutrition (Oral Intake record), the record indicated the following: 1. From 10/12/2022 to 10/31/2022, out of 57 ordered meals, Resident 1 had no oral intake (resident refused or staff did not monitor and did not document how much the resident ate) with 20 of the meals, for 7 of the meals the resident consumed 0-25%, and resident consumed 26-50% for 10 of the meals. From 10/12/2022 to 10/31/2022 there were only three days where Resident 1consumed adequate oral intake (resident ate at least half of the three ordered meals per day). 2. From 11/1/2022 to 11/23/2022, out of 68 ordered meals, Resident 1 did not eat (from refusal or staff did not monitor and did not document how much the resident ate) 33 meals, consumed 0-25% for 4 meals, and ate 26-50% for 10 of the meals. From 11/1/2022 to 11/23/2022 Resident only had 4 days of adequate oral intake. During a review of Resident 1 ' s medical records, the records indicated there was no documented evidence Resident 1 ' s fluid intake was being monitored from admission on [DATE] to 11/23/2022. During a review of Resident1 ' s medical records, physician orders, and nurse progress notes, the records indicated that after 10/11/2022, there was no evidence MD 1 or RP 1 was notified of the resident ' s poor oral intake and meal refusals. During a review of Resident 1 ' s Weights and Vitals Summary, dated 12/28/2022, the summary indicated Resident 1 lost 13 lbs, and had a 6.7 percent (%) loss of body weight in 28 days, from 193 lbs on 9/13/2022 to 180 lbs on 11/1/2022. During a telephone interview with Resident 1 ' s family member (FM 1) on 12/30/2022 at 12:22 p.m., FM 1 stated she was the responsible party for Resident 1 as evidenced by the durable power of attorney for healthcare ([DPOA] a written authorization where the named person appoints a person to act in their behalf) and Resident 1 ' s Advance Healthcare Directive (document giving instructions about the resident ' s healthcare), dated 7/2022. FM 1 stated she was never contacted by the facility when Resident 1 was not eating her meals or when the resident experienced significant weight loss from September to October 2022. FM 1 stated she was also not contacted by MD 1 regarding the treatment plan for Resident 1. During an interview with Licensed Vocational Nurse (LVN) 7 on 1/6/2023 at 1:24 p.m., LVN 7 stated Resident 1 was alert and confused, and always needed assistance and prompting to eat or drink. LVN 7 stated Resident 1 ' s highly anxious state made eating and drinking not her priority. LVN 7 stated the last documented evidence MD 1 was notified regarding Resident 1 ' s poor oral intake was on 10/11/2022 after an SBAR for the resident ' s weight change was completed. LVN 7 stated Resident 1 continued to refuse eating and have poor oral intake after 10/12/2022. LVN 7 stated MD 1 and RP 1 should have been updated as Resident 1 continued to maintain poor oral hydration and intake. During an interview with LVN 8 and concurrent record review of Resident 1 ' s medical records on 1/6/2023 at 2:03 p.m., LVN 8 stated there was no documented evidence MD 1 and RP 1 was notified of Resident 1 ' s continued poor oral intake and meal refusals from 10/12/2022 to 11/23/2022. During a concurrent telephone interview with the Director of Nursing (DON) and Registered Nurse (RN) 1 and record review of Resident 1 ' s medical records, on 1/10/2023 at 3 p.m., the DON and RN 1 stated and confirmed the facility staff failed to notify MD 1 for Resident 1 ' s continued poor oral intake, refusal to eat and drink fluids, from 10/15/2022 to 11/23/2022. The DON and RN 1 stated there were no additional interventions to address Resident 1 ' s continued poor oral intake from the last time MD 1 was notified of the resident ' s weight loss and poor intake on 10/11/2022. The DON and RN 1 stated staff should have notified and updated MD 1 of Resident 1 ' s continued poor oral intake and requested further guidance and medical interventions to prevent Resident 1 ' s health from declining. During a telephone interview with MD 1 on 1/11/2023 at 2:04 p.m., MD 1 stated, If a resident is not eating or has poor intake and is losing weight, my expectations are for the nursing staff to contact me for the change in condition so that I may make appropriate medical decisions and provide orders to address the resident ' s issue. MD 1 stated the facility staff did not contact him nor his nurse practitioner (NP 1) about Resident 1 ' s poor oral intake and weight loss from 10/15/2022 to 11/23/2022. During a review of Resident 1 ' s care plan titled, Noted Recent Weight Change of nine (9) lbs Weight Loss in a Week, date initiated 9/19/2022 and revised on 10/6/2022, the care plan indicated Resident 1 would eat at least 50 percent of her meals and drink adequate fluids for weight loss. The staff ' s interventions included to notify MD 1 and RP 1 of significant weight changes. During a review of the facility ' s policy and procedure (P&P) titled, Food and Nutrition Services, revised 10/2017, the P&P indicated nursing personnel, with the assistance of the food and nutrition services staff, will evaluate (and document as indicated) food and fluid intake of residents with, or at risk for significant nutritional problems. The P&P indicated a nurse will evaluate the significance of such information and report it, as indicated, to the attending physician and dietitian. During a review of facility ' s P&P titled, Change in a Resident ' s Condition or Status, revised 2/2021, the P&P indicated the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident ' s medical/mental condition and/or status. The P&P indicated a significant change of condition was a major decline or improvement in the resident ' s status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b. impacts more than one area of the resident ' s health status; and c. requires interdisciplinary review and/or revision to the care plan.

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop comprehensive and resident-centered care plans in a timely manner for one of four sampled residents (Resident 1), who had decreased fluid and food intake, and who was receiving psychotropic medications (medications that affects behavior, mood, thoughts, or perception). These deficient practices resulted in an unplanned severe 13 pound weight loss or 6.7 percent (%) weight loss, and had the potential to result in poor care rendered which can negatively impact resident health and wellbeing. Findings: During a review of Resident 1 ' s admission Record, dated 12/1/2022, the admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis [inability to move] of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body), dysphagia (difficulty in swallowing food or liquid), muscle weakness (a decrease in strength in one or more muscles), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Parkinson ' s disease (a degenerative condition of the brain associated with motor symptoms [slow movement, tremor, rigidity and imbalance]), and anxiety disorder (a mental health condition with frequently intense, excessive and persistent worry and fear about everyday situations). During a review Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 8/26/2022, the MDS indicated Resident 1 ' s cognition (mental process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired. The MDS indicated Resident 1 required extensive assistance from staff with bed mobility and dressing, supervision with eating, and was totally dependent on staff with toileting, personal hygiene, and bathing. During a review of Resident 1 ' s general acute care hospital (GACH )1 Physician Progress Notes, dated 8/14/2022 at 9:35 a.m., the progress notes indicated the resident presented to GACH 1 dehydrated and was treated with intravenous (medical technique that administers fluids, medications, and nutrients directly into a person ' s vein) fluids for dehydration. During a review of Resident 1 ' s care plans dated from 8/20/2022 to 11/23/2022, the care plans indicated the following: 1. A care plan titled, Resident has potential nutritional problem related to poor appetite, was initiated on 11/22/2022, the day before Resident 1 ' s discharge to the GACH 2. 2. A care plan titled, Hydration risk: At risk for fluid volume deficit related to advanced age, was initiated on 9/13/2022, 24 days after Resident 1 ' s admission on [DATE]. 3. A care plan titled, Resident uses antidepressant medication (Sertraline, medication used to treat depression) related to depression, was initiated on 11/22/2022, 47 days after the physician ' s order. 4. A care plan titled, Resident uses anti-anxiety medications (Lorazepam, medication used to treat anxiety) related to anxiety disorder, was initiated on 11/22/2022, 47 days after the physician ' s order. There was no care plan for the administration of Seroquel (medication used to treat certain mental and/or mood disorders) noted. During a review of Resident 1 ' s Physician Order Summary Report, dated 12/1/2022, the order summary report indicated the following orders: 1. On 8/20/2022, no added salt diet, chopped texture, thin liquids consistency for breakfast, lunch, and dinner. 2. On 10/1/2022, fortified diet (foods that have nutrients added to them that they wouldn ' t naturally contain), mechanical soft (a diet designed for people who have trouble chewing and swallowing), chopped texture, thin liquids consistency for breakfast, lunch, and dinner. 3. On 10/6/2022, Lorazepam 1 milligram (mg, unit of measurement) by mouth every 4 hours as needed for anxiety until 1/06/2023 for three months then reevaluate. 4. On 10/6/2022, Sertraline 50 mg by mouth two times a day for depression, manifested by poor appetite and no interest in activities. 5. On 10/11/2022, Seroquel 25 mg by mouth two times a day for anxiety manifested by pulling at brief. During a review of Resident 1 ' s record titled, Nutrition (PO Intake record), the record indicated the following: 1. Resident 1 refused, had no intake, or no documented meal intake for 15 meals, ate 0-25% once, and consumed 26-50% for two meals during a 11-day period (8/21/2022 to 8/31/2022). 2. Resident 1 refused, had no intake, or had no documented intake for 30 meals, ate 0-25% for 3 meals and the resident consumed 26-50% for 20 meals during a 30-day period (9/1/2022 to 9/30/2022). 3. Resident 1 refused, had no intake, or no documented intake with 29 meals, consumed 0-25% for 15 meals, and resident consumed 26-50% for 21 meals during a 31-day period (10/1/2022 to 10/31/2022). 4. Resident 1 refused, had no intake, or no documented intake with 33 meals, consumed 0-25% for 4 meals, and ate 26-50% for 10 meals during a 23-day period (11/1/2022 to 11/23/2022). During an interview with Licensed Vocational Nurse (LVN) 7 and concurrent record review of Resident 1 ' s care plans, on 1/6/2023 at 1:24 p.m., LVN 7 stated Resident 1 was alert and confused and always needed assistance and prompting with eating and drinking. LVN 7 stated Resident 1 ' s highly anxious state made eating and drinking not her priority. LVN 7 stated and confirmed that a care plan for Resident 1 ' s poor oral intake was initiated on 11/22/2022. Resident 1 ' s care plan titled, Resident has potential nutritional problem related to poor appetite, was reviewed. LVN 7 stated the care plan addressing resident ' s poor oral intake of should have been initiated at the inception of the resident ' s poor intake in September 2022. During a concurrent interview with Registered Dietician 1 ([RD 1] food and nutrition expert) and record review of Resident 1 ' s clinical record, on 1/6/2023 at 3:12 p.m., RD 1 stated Resident 1 ' s food preference assessment was not completed upon Resident 1 ' s admission. RD 1 stated when Resident 1 began refusing meals, an assessment should have been initiated. RD 1 stated Resident 1 ' s food preference assessment was an important part of developing a resident-centered care plan. RD 1 stated a care plan initiated on 11/22/2022 was late and should have been initiated timely when the issue was first identified on 9/19/2022. RD 1 stated the care plan initiated on 11/22/2022 needed more interventions to help staff with care rendered. RD 1 stated she did not develop and revise care plans for Resident 1. During a concurrent interview with Registered Nurse (RN) 1 and record review of Resident 1 ' s Discharge Summary from GACH 1 dated 8/20/2022, on 1/10/2023 at 12 p.m., RN 1 stated Resident 1 had a previous history of dehydration in August 2022, immediately before Resident 1 was admitted to the facility on [DATE]. RN 1 stated Resident 1 was at high risk for dehydration. RN 1 stated although a care plan for fluid volume deficit related to advanced age was created on 9/13/2022, a plan of care should have been created upon Resident 1 ' s admission on [DATE] to ensure Resident 1 would not have repeat episodes of dehydration. During a concurrent interview with RN 1 and record review of Resident 1 ' s clinical record, on 1/10/2023 at 12:10 p.m., RN 1 stated when Resident 1 was admitted to the facility, Resident 1 did not have a strong appetite and needed encouragement to eat and drink with cuing from the staff. RN 1 stated a plan of care to address Resident 1 ' s poor oral intake should have been initiated upon the resident ' s admission or as soon as they have noticed the resident had decreased appetite and refusals of meals. RN 1 stated a plan of care should have addressed how to support Resident 1 ' s nutritional needs and prevent Resident 1 ' s health from declining. During a concurrent interview with RN 1 and record review of Resident 1 ' s clinical record, on 1/10/2023 at 12:10 p.m., RN 1 stated Resident 1 was receiving psychotropic medications and a plan of care should have been created as soon as the medication was ordered to ensure safe administration and to monitor for potential side effects. During a review of Resident 1 ' s Weights and Vitals Summary record from 8/23/2022 to 11/1/2022, the record indicated on 8/23/2022 (2 days after admission), Resident 1 weighed 191 pounds (lbs). On 11/1/2022, Resident 1 weighed 180 lbs, which was the last recorded weight at the facility. Resident 1 ' s weight of 191 lbs on 8/23/2022, and her weight of 180 lbs on 11/1/2022 revealed a 13-pound weight loss or 6.7 percent (%) weight loss. During a review of the facility ' s policy and procedure (P&P) titled, Change in a Resident ' s Condition or Status, revised 2/2021, the P&P indicated a change of condition required interdisciplinary review and/or revision to the care plan. During a review of facility ' s P&P titled, Care Plans, Comprehensive Person-Centered, revised 3/2022, the P&P indicated the interdisciplinary team (IDT) with the resident and RP, will develop and implement a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs for each resident. The P&P indicated care plans are revised as information about the residents and the residents' conditions change.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0806 (Tag F0806)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess one of four residents (Resident 1) food preferences and likes/dislikes upon admission and upon evidence of poor oral intake. This deficient practice resulted in Resident 1 ' s poor appetite which contributed to an unplanned severe 13 pound weight loss or loss of 6.7 percent (%) of body weight. 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 that included hemiplegia (paralysis [inability to move] of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body), dysphagia (difficulty in swallowing food or liquid), muscle weakness (a decrease in strength in one or more muscles), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Parkinson ' s disease (a degenerative condition of the brain associated with motor symptoms [slow movement, tremor, rigidity and imbalance]), and anxiety disorder (a mental health condition with frequently intense, excessive and persistent worry and fear about everyday situations). During a review of Resident 1 ' s Minimum Data Set (MDS, a standardized assessment and care-screening tool), dated 8/26/2022, the MDS indicated Resident 1 ' s cognition (mental process of acquiring knowledge and understanding through thought, experience, and the senses) was moderately impaired. The MDS indicated Resident 1 required extensive assistance from staff with bed mobility, dressing, supervision with eating, and was totally dependent on staff with toileting, personal hygiene, and bathing. During a record review of Resident 1 ' s Nutritional Risk Assessment (Admission/ Annual), dated 9/2/2022, the assessment indicated the section Food Preferences: (likes/dislikes) indicated to refer to a Dietary Screening Report. During a review of Resident 1 ' s medical records, the records indicated there was no documented evidence a Dietary Screening Report was completed nor were Resident 1 ' s food preferences assessed. During a review of Resident 1 ' s Physician Order Summary Report, dated 12/1/2022, the order summary report indicated the following orders: 1. On 8/20/2022, no added salt diet, chopped texture, thin liquids consistency for breakfast, lunch, and dinner. 2. On 10/1/2022, fortified diet (foods that have nutrients added to them that they wouldn ' t naturally contain), mechanical soft (a diet designed for people who have trouble chewing and swallowing), chopped texture, thin liquids consistency for breakfast, lunch, and dinner. During a review of Resident 1 ' s record titled, Nutrition (PO Intake record), the record indicated the following: 1. Resident 1 refused, had no intake, or no documented meal intake for 15 meals, ate 0-25% once, and consumed 26-50% for two meals during a 11-day period (8/21/2022 to 8/31/2022). 2. Resident 1 refused, had no intake, or had no documented intake for 30 meals, ate 0-25% for 3 meals and the resident consumed 26-50% for 20 meals during a 30-day period (9/1/2022 to 9/30/2022). 3. Resident 1 refused, had no intake, or no documented intake with 29 meals, consumed 0-25% for 15 meals, and resident consumed 26-50% for 21 meals during a 31-day period (10/1/2022 to 10/31/2022). 4. Resident 1 refused, had no intake, or no documented intake with 33 meals, consumed 0-25% for 4 meals, and ate 26-50% for 10 meals during a 23-day period (11/1/2022 to 11/23/2022). During an interview with Licensed Vocational Nurse (LVN) 7 on 1/6/2023 at 1:24 p.m., LVN 7 stated Resident 1 was alert and confused and always needed assistance and prompting with eating and drinking. LVN 7 stated Resident 1 ' s highly anxious state made eating and drinking not her priority. LVN 7 stated the facility needed to ensure the resident ' s food preferences were assessed so the resident ' s intake would improve. LVN 7 stated the interdisciplinary team (group of different disciplines working together towards a common goal of a resident) could have been more aggressive with the measures used to aid Resident 1 ' s nutritional status. During an interview with LVN 8 on 1/6/2023 at 2:03 p.m., LVN 8 stated if staff knew what Resident 1 liked to eat, it would have helped her eat more or if snacks were added in between meals it could have helped prevent the decline of her health. During a concurrent interview with Registered Dietician (RD) 1, and record review of Resident 1 ' s clinical record, on 1/6/2023 at 3:12 p.m., RD 1 stated Resident 1 ' s food preference assessment was not completed. RD 1 stated a food preference assessment should have been completed upon Resident 1 ' s admission and when the resident began refusing to eat. RD 1 stated it was important to ask Resident 1 ' s food preference and offer food the resident liked to help improve the resident ' s appetite and increase food and oral intake. During a review of Resident 1 ' s Weights and Vitals Summary record from 8/23/2022 to 11/1/2022, the summary record indicated on 8/23/2022 (2 days after admission) resident weighed 191 pounds (lbs). On 11/1/2022, Resident 1 weight was 180 lbs, which was the last recorded weight at the facility. Resident 1 ' s weight of 191 lbs on 8/23/2022, to her weight of 180 lbs on 11/1/2022 revealed a 13-pound weight loss or loss of 6.7 percent (%) bodyweight. During a review of facility ' s P&P titled, Resident Food Preferences, revised 7/2017, the P&P indicated individual food preferences will be assessed upon admission and communicated to the interdisciplinary team and modifications to diet will only be ordered with the resident ' s or representative ' s consent. The P&P indicated nursing staff will document the resident ' s food and eating preferences in the care plan. During a review of the facility ' s policy and procedure (P&P) titled, Food and Nutrition Services, revised 10/2017, the P&P indicated each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The P&P indicated the multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident ' s nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. A resident-centered diet and nutrition plan will be based on this assessment.

Dec 2022 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 1) was treated with dignity and respect by failing to provide necessary care in a timely manner when Resident 1 requested assistance with changing her wet and soiled brief. This deficient practice had the potential to negatively affect Resident 1's physical comfort and psychosocial well-being. Findings: During a review of Resident 1's admission Record (Face sheet), dated 12/21/2022, the face sheet indicated Resident 1 was admitted to the facility on [DATE], and re-admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus (high blood sugar), generalized muscle weakness, and chronic obstructive pulmonary disease ([COPD], a group of lung diseases that block airflow and make it difficult to breathe) with acute exacerbation. During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 12/13/2022, the MDS indicated the cognitive (the ability to think and process information) skills for daily decisions making was intact, and required extensive assistance with two or more-person physical assist for bed mobility, toilet use, and personal hygiene. The MDS also indicated Resident 1 was always incontinent (no episode of continent voiding) for urinary and bowel. During an observation on 12/20/2022, at 12:03 p.m., the call light was observed turned on in Resident 1's room. During a concurrent observation and interview on 12/20/2022, at 12:18 p.m., with Resident 1, Resident 1 was observed lying in the bed. Resident 1 stated she pushed the call light to ask for assistance to change her soiled brief. Resident 1 stated the last time the staff changed her brief was 2 hours ago, she had bowel movement and was currently lying on soiled and wet brief. Resident 1 stated Licensed Vocational Nurse (LVN) 2 answered the call light and told Resident 1 that her certified nursing assistant (CNA) was on break, and she would get the other CNA to help her. During an observation on 12/20/2022, at 12:40 p.m., LVN 2 was observed entering Resident 1's room. LVN 2 told Resident 2 that her CNA had gone home after break, and she was going to get another CNA to help her. During a concurrent observation and interview on 12/20/2022, at 1:15 p.m., with CNA 1, CNA 1 was observed entering Resident 1's room. CNA 1 stated Resident 1's previous CNA had left, and she was now assigned to provide Resident 1's care. CNA 1 was observed to bring clean supplies to the room to change Resident 1. During an interview on 12/20/2022, at 1:20 p.m., with LVN 2, LVN 2 stated Resident 1's CNA had to go home, and she let the other CNA know to help Resident 1. LVN 2 stated Resident 1 should not have been waiting to get changed and proper care was not provided to Resident 1. LVN 1 stated if CNA was not available, other licensed staff can help to change the resident. During a review of facility's policy and procedure (P&P) titled, Dignity, revised February 2021, the P&P indicated, each resident shall be care for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident who received dialysis (process of removing waste products and excess fluid from the body) received treatment in accordance with standards of practice of one of three sampled residents (Resident 2) by failing to assess the dialysis access site (Arteriovenous (AV) shunt or fistula, an access site formed by joining of a vein and artery in the arm) and removing the pressure dressing per physician order. This deficient practice had the potential to cause life threatening complications such as bleeding, infection, damage to the dialysis access site, and a lack of continuity of care. Findings: During a review of Resident 2's admission Record (Face sheet), dated 12/21/2022, the face sheet indicated Resident 2 was admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses which included end stage renal disease (permanent kidney failure that requires a regular course of dialysis) and hypertension (high blood pressure). During a review of Resident 2's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 10/17/2022, the MDS indicated Resident 2 had severely impaired cognitive (the ability to think and process information) skills for daily decision making. The MDS indicated Resident 2 required total dependence with two or more-person physical assist for bed mobility, transfer, dressing, toilet use, and personal hygiene. During an observation on 12/21/2022, at 10:58 a.m., in Resident 2's room, Resident 2 was observed sleeping in the bed. Resident 2 was observed with a right arm AV shunt with two cotton ball dressing taped to the dialysis access site. During a concurrent interview and record review on 12/21/2022, at 11:12 a.m., with Registered Nurse (RN) 1, RN 1 stated Resident 2's dialysis access site should have been assessed and pressure dressing for Resident 2's dialysis site should have been removed 4 hours after dialysis by the evening shift staff. RN 1 stated Resident 2 returned from dialysis on 12/20/22 at 2:20 p.m., and there was no documented note on why the pressure dressing was not removed after 4 hours. During a review of Resident 2's Dialysis Communication Form, dated 12/20/22, the form indicated Resident 2 returned to the facility and was stable with no distress. During a review of Resident 2's physician order, dated 11/17/2022, the order indicated Resident 2 to have dialysis on Tuesday, Thursday, and Saturday at the dialysis center and dialysis access site on the right AV shunt. During a review of Resident 2's physician order, dated 12/6/2022, the order indicated to remove the pressure dressing at dialysis site, 4 hours after the dialysis, every evening shift on Tuesday, Thursday, and Saturday. During a review of the facility's policy and procedure (P&P) titled, End-Stage Renal Disease, Care of a Resident with, revised September 2010, the P&P indicated, staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents.

CONCERN (E) 📢 Someone Reported This

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

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

Room Equipment (Tag F0908)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to document calibration (process of verifying the accuracy of a device to a known standard) of facility's four of four glucometers (device to measure and display the amount of sugar in the blood), in accordance with the manufacture's guidelines. This deficient practice had the potential to result in inaccurate glucometer readings for the residents which may lead to medical complications. Findings: During a concurrent interview and record review on 12/21/2022, at 12:55 p.m., with Licensed Vocational Nurse (LVN) 1, the LVN 1 stated there were total of four glucometers in the facility stored in each four medication carts. During a review of Station 2-medication cart 3's Assure Pro Blood Glucose Monitoring System: Daily Quality Control Record, for December 2022, the record indicated the quality control record was only completed on 12/2/2022, 12/3/2022, 12/5/2022, 12/9/2022 – 12/13/2022, 12/15/2022, and 12/16/2022. LVN 1 stated glucometers need to be calibrated every night by the evening shift staff. During a concurrent interview and record review on 12/21/2022, at 1:15 p.m., with Registered Nurse (RN) 1, Station 1 – medication cart 1 and 4 and Station 2 – medication cart 2's December 2022 record of Assure Pro Blood Glucose Monitoring System: Daily Quality Control Record were reviewed. The record for Station 1 - medication cart 1, indicated the control record was only completed on 12/2/2022, 12/3/2022, and 12/16/2022. There were no documented records found for Station 1 – medication cart 4 and Station 2 – medication cart 2. RN 1 stated that calibration of the glucometer should have been done by the by evening shift staff. RN 1 stated glucometer monitoring was done to make sure that glucometer was working properly. During a review of the facility's policy and procedure (P&P) titled, Blood Sampling – Capillary (Finger Sticks), revised September 2014, the P&P indicated, following the manufacturer's instructions, clean and disinfect reusable equipment, parts, and/or devices after each use. During a review of Assure Platinum, Blood Glucose Monitoring System's Quality Assurance/Quality Control (QA/QC) Reference Manual, Section E Regulatory Review and Guidelines for QA/QC Protocols, revised March 2014 indicated Quality control procedures are performed at least once each day on each instrument used for resident testing. On each day of use, two controls (high and normal) should be performed per instrument. Each operator to perform a quality control prior to the first patient test of the day. Additional checks should be performed when a new bottle of strips is opened, each time a reagent lot is changed and to ensure the strips and meter are functioning properly.

Dec 2022 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly prevent and/or contain COVID-19 (Coronavirus disease, a mild to severe respiratory illness that spread from person to person), and other communicable diseases and infections by failing to: 1. Ensure the visitor screening log sheet was completed and indicated the name of the resident that was visited, if the temperature was checked, and if the visitors had any symptoms of COVID-19 or were exposed to COVID-19. 2. Ensure one of one sampled resident (Resident 1's) oxygen nasal cannula tubing (a device used to deliver supplemental oxygen placed directly on a resident's nostrils) was off the floor and properly labeled with the date changed. These failures had the potential to result in transmission of communicable disease and infection for residents and staffs. Findings: a. During an interview with the Infection Prevention (IP) Nurse on 12/14/2022 at 11:15 a.m., the IP stated the screener must check the visitors' temperature, ask the COVID-19 screening questions, educate visitors on infection preventive practices and require to test all visitors. During a concurrent observation and interview with Receptionist 1 on 12/14/2022 at 1:42 p.m., Receptionist 1 was observed instructing a visitor to take his temperature, complete a section on the logbook, and take a COVID-19 test. Receptionist 1 informed the visitor he was COVID negative and informed he was cleared to enter the facility. Observed Receptionist 1 not asking the visitor any COVID-19 screening questions and not informing the visitor of the potential risk of visiting the facility during an outbreak. Receptionist 1 stated the visitor screening process was to have visitors take their own temperature, sign themselves in, answer the visitor log questions, and take a COVID test. Receptionist 1 stated she did not give visitors a N95 respirator mask (type of mask that filters airborne particles) because the facility had masks at the nurse's station and outside resident rooms. Receptionist 1 stated she did not inform the visitors of the facility's infection control practices, did not educate them about social distancing or hand-washing, or the need to keep a mask on during the visit. Receptionist 1 stated she was not aware she had to educate visitors on infection control practices to follow while they were at the facility. During a record review of the facility's Visitor Screen Log with Receptionist 1 on 12/14/2022 at 1:49 p.m., the visitor screen log indicated visitors did not completely fill out the log. The visitor screen log indicated the visitors did not indicate if their temperature was checked, who they were there to visit, if they have been exposed to COVID-19 or if they had any symptoms of COVID-19. Receptionist 1 stated she usually checked the visitor log at the end of her shift. Receptionist 1 stated she had been trained to make sure the visitors completely filled out the logs. Receptionist 1 stated it was important to have the visitor screen log filled out because it was part of the screening process and it was a way to know if there were any red flags. During a concurrent interview with the IP and record review on 12/14/2022 at 2:04 p.m., the IP reviewed the visitor screen log and stated the log sheet was unacceptable because it was not completely filled out. The IP stated based on the visitor screen log there was no way of knowing which resident was visited, if the visitor checked their temperature, and if the visitor had COVID-19 symptoms. During a review of the facility's policy and procedure (P&P) titled, Revised Visitation, updated 9/28/2022, the P&P indicated visitors will be provided with education that may include an explanation of the facility's infection control practices during visitation. The P&P indicated information pertaining to standard precautions hand hygiene, respiratory hand hygiene, social distancing, and signs and symptoms of COVID. The P&P indicated that visitors must be informed of the potential risk of visiting during an outbreak. P&P indicated that visitors will be screened for signs and symptoms of COVID-19 such as fever with temperature checks and other symptoms such as cough, sneeze, runny nose, shortness of breath or difficulty breathing. b. During a review of Resident 1's admission Record (Face sheet), dated 12/21/2022, the face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease (brain disorder that slowly destroys memory and thinking skills), type 2 diabetes mellitus (high blood sugar), and dysphagia (difficulty swallowing). During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 10/20/2022, the MDS indicated Resident 1 had severely impaired cognitive (the ability to think and process information) skills for daily decision making. The MDS indicated Resident 1 required total dependence with two or more-person physical assist with bed mobility, transfer, eating, toilet use, and personal hygiene. During a concurrent observation and interview with Registered Nurse (RN) 1 on 12/20/2022 at 1:15 p.m., in Resident 1's room, Resident 1 was observed sleeping in the bed with 2 liters (L) of oxygen infusing via a nasal cannula (thin flexible, plastic device used to deliver supplemental oxygen or increased airflow to a resident in need of respiratory help). The oxygen tubing attached to Resident 1's nasal cannula was observed touching the floor with no label and date. RN 1 stated the oxygen tubing should not be on the floor due to infection control issues. RN 1 stated oxygen tubing was to be changed every Sunday by the treatment nurse and it should have been labeled with the date. During a review of Resident 1's physician's order, dated 8/14/2022, the order indicated to administer oxygen two liters per minute via nasal cannula routine for period of shortness of breath related to Parkinson's disease (type of movement disorder) every shift. During a review of Resident 1's physician's order, dated 9/1/2022, the order indicated to change oxygen tubing and cannula every Sunday and write the date. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, revised October 2010, the P&P indicated, Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

Nov 2022 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview and record review, the facility failed to maintain potentially hazardous foods ([PHF] food that must be kept at a particular temperature [at or above 135 degrees Fahrenheit] to minimize the growth of food poisoning bacteria [a large group of single-cell microorganisms that cause infections and disease in animals and humans] that may be in the food, or to stop the formation of toxins [a naturally occurring organic poison produced by activities of living cells or organisms] at or above 135 degrees Fahrenheit (F) when the facility attempted to serve hot dog chili puree at 127 degrees F and pureed corn at 115 degrees F to nine out of 85 sampled residents during lunch. This deficient practice had the potential to cause food borne illness leading to diarrhea, dehydration (a condition that occurs when the body loses too much water and other fluids that it needs to work normally), infection, fever, pain, and loss of appetite. Findings: During an observation and concurrent interview on 10/21/2022, at 12:09 p.m., in the kitchen with [NAME] 1 (C1), C1 was observed checking the temperatures of the pureed foods on the steam table (table with slots to hold food containers which are kept hot by steam circulating beneath them) using a food thermometer. C1 stated the hot dog chili puree was at 127 degrees F and the pureed corn was at 115 degrees F. C1 was observed plating (scoop food onto resident ' s plates) the pureed hot dog chili and pureed corn with the assistance of other dietary staff. C1 stated the temperature of the hot dog chili puree, and the pureed corn was not at the right temperature. C1 stated the temperature of the pureed food should have been at 135 degrees. During an observation and interview on 10/21/2022, at 12:13 p.m., in the kitchen with the Dietary Manager (DM), the DM verified the temperatures of the pureed foods on the steam table using a food thermometer. The DM confirmed the hot dog chili puree was at 127 degrees F and the pureed corn was at 115 degrees F. The DM stated the temperature of the hot dog chili puree, and the pureed corn was not at the right temperature, they should be at least 135 degrees F, anything less than that could be dangerous to the residents. The DM was observed telling C1 not to give the food to the residents because the food was not at the right temperature. The DM stated serving food at the wrong temperature could cause residents to get sick due to bacteria in the food and stated it was concerning to him that C1 was going to serve the food to the residents, it was unacceptable. During a review of the facility's policy and procedure (P/P) titled, Food Preparation and Service, revised 4/2019, the P/P indicated the following: 1. Food and nutrition service employees prepare and service food in a manner that complies with safe food handling practices. 2. Danger zone for food temperatures is between 41 degrees Fahrenheit and 135 degrees Fahrenheit. This temperature range promotes rapid growth of pathogenic microorganisms that cause foodborne illness. 3. Fresh, frozen, or canned fruits and vegetables are cooked to a holding temperature of 135 degrees Fahrenheit. 4. Mechanically altered hot food prepared for modified consistency diet remain above 135 degrees Fahrenheit during preparation or they are reheated to 165 degrees for at least 15 seconds.

Nov 2022 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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a person-centered care plan for one out of eight sample residents (Resident 4) after Resident 4 slid out of her wheelchair and fell on her back. This deficient practice had a potential to place Resident 4 at risk for increased falls and injury. Findings: During a review of Resident 4's admission Record, dated 10/8/2022, indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included primary hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition) and acute angle-closure glaucoma (a sudden onset of severe unilateral eye pain or a headache associated with blurred vision, rainbow-colored halos around bright lights, nausea, and vomiting), abnormalities of gait and mobility (when a person is unable to walk in the usual way, which may be due to injuries, underlying conditions, or problems with the legs and feet), and muscle weakness (a decrease in strength in one or more muscles). During a review of Resident 4's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 7/30/2022, indicated Resident 4 was cognitively intact, and required total dependence with toilet, and extensive assistance with personal hygiene, bed mobility and transfer. During an interview with Licensed Vocational Nurse (LVN 2) on 9/27/2022 at 12:33 p.m., LVN 2 stated she observed Resident 4 was in so much pain and asked Resident 4 what was wrong because LVN 2 had never seen Resident 4 in pain. LVN 2 stated Resident 4 reported to LVN 2 that on 9/12/2022 during the 3:00-11:00 p.m. shift Resident 4 asked the CNA for a toothbrush, the CNA forgot to lock Resident 4 ' s wheelchair and left Resident 4 to get the toothbrush. Resident 4 slid from the wheelchair and fell on her back inside the room. LVN 2 stated she gave Resident 4 Tramadol (pain medication) to help with Resident 4 ' s pain and LVN 2 reported the incident to Registered Nurse (RN) 1 supervisor. During a review of Resident 4's record titled, SBAR (Situation, Background, Assessment) Communication Form (a communication tool that helps provide essential, and concise information), dated 9/13/2022, indicated Resident 4 fell on 9/12/2022. SBAR indicated primary care clinician was notified on 9/13/2022 at 10:00 a.m. and recommended x-ray (radiograph that creates pictures of bones and soft tissues) and PRN (as needed) pain medication. During a review of Resident 4's record titled, admission Fall Risk Assessment-John Hopkins Fall Risk Assessment Tool, dated 7/24/2022 indicated Resident 4 scored 11 points, which placed Resident 4 at moderate fall risk level. During an interview with LVN 6 on 11/10/22 at 12:15 p.m., LVN 6 stated she was familiar with Resident 4 because she previously provided care to her. LVN 6 stated when a resident fell, a care plan should be initiated for the fall to create plan of care to prevent further incident of fall and plan of care. During a review of Resident 4's medical records indicated the facility did not provide a care plan for the fall, and there was no post-assessment for a fall, nor any nursing notes from 9/14/2022 to 9/17/2022. During an interview and concurrent record review of Resident 4's medical record, with Medical Record, on 10/10/2022 at 4:54 p.m., Medical Records stated Resident 4 has no care plan for fall. During a review of the facility's policy and procedure, titled, Care Plans, Comprehensive Person-Centered, indicated the comprehensive, person centered describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The policy indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The policy further indicated the interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's 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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the resident remained free of accident hazards for one out of eight sample residents (Resident 4) by failing to lock Resident 4's wheelchair. This deficient practice resulted in Resident 4 sliding out of her wheelchair and fell on her back. Findings: During a review of Resident 4's admission Record, dated 10/8/2022, indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included primary hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition) and acute angle-closure glaucoma (a sudden onset of severe unilateral eye pain or a headache associated with blurred vision, rainbow-colored halos around bright lights, nausea, and vomiting), abnormalities of gait and mobility (when a person is unable to walk in the usual way, which may be due to injuries, underlying conditions, or problems with the legs and feet), and muscle weakness (a decrease in strength in one or more muscles). During a review of Resident 4's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 7/30/2022, indicated Resident 4 was cognitively intact, and required total dependence with toilet, and extensive assistance with personal hygiene, bed mobility and transfer. During an interview with Licensed Vocational Nurse (LVN) 2 on 9/27/2022 at 12:33 p.m., LVN 2 stated she observed Resident 4 was in so much pain and asked Resident 4 what was wrong because LVN 2 had never seen Resident 4 in pain. LVN 2 stated Resident 4 reported to LVN 2 that on 9/12/2022 during the 3:00-11:00 p.m. shift Resident 4 asked the CNA for a toothbrush, the CNA forgot to lock Resident 4 ' s wheelchair and left Resident 4 to get the toothbrush. Resident 4 slid from the wheelchair and fell on her back inside the room. LVN 2 stated she gave Resident 4 Tramadol (pain medication) to help with Resident 4's pain and LVN 2 reported the incident to Registered Nurse (RN) 1 supervisor. During a review of Resident 4's record titled, SBAR (Situation, Background, Assessment) Communication Form (a communication tool that helps provide essential, and concise information), dated 9/13/2022, indicated Resident 4 fell on 9/12/2022. SBAR indicated primary care clinician was notified on 9/13/2022 at 10:00 a.m. and recommended x-ray (radiograph that creates pictures of bones and soft tissues) and PRN (as needed) pain medication. During a review of Resident 4's, Medication Administration Record (MAR) for September 2022, indicated Resident 4 received Tramadol 50mg tablet for moderate pain on 9/12/2022 at 12:40 p.m. and on 9/13/2022 at 10:32 a.m. During a review of Resident 4's medical record titled, Order Recap for September 2022, indicated on 9/13/2022 there was a phone order for a STAT (immediate) x-ray of anterior posterior/lateral cervical spine related to pain status post fall. During a review of Resident 4's record titled, Final X-ray Report, dated 9/13/2022 indicated no acute fracture, there was a straightening of the cervical spine, which may indicate muscle spasm. During a review of Resident 4's medical records indicated the facility did not provide a care plan for the fall, and there was no post-assessment for a fall, nor any nursing notes from 9/14/2022 to 9/17/2022. During a review of Resident 4's record titled, admission Fall Risk Assessment-John Hopkins Fall Risk Assessment Tool, dated 7/24/2022 indicated Resident 4 scored 11 points, which placed Resident 4 at moderate fall risk level. During a review of the facility's policy and procedure (P&P), titled, Falls-Clinical Protocol, dated 3/2018, P&P the physician will help identify individuals with a history of falls and risk factors for falling. The staff and practitioner will review each resident ' s risk factors for falling and document in the medical record. Example of risk factors for falling include light headedness or dizziness, multiple medications, musculoskeletal abnormalities, peripheral neuropathy, gait and balance disorder, cognitive impairment, weakness, environmental hazards, confusion, visual impairment, hypotension, and medical conditions affecting the central nervous system. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try preventing subsequent falls and to address the risks of clinically significant consequences of falling. During a review of the facility's P&P, titled, Safety and Supervision for Residents, dated 7/2017, P&P indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards and try to prevent avoidable accidents.

CONCERN (E) 📢 Someone Reported This

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

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to accurately document the administration of medications in the residents ' treatment administration records for three of nine residents ( Resident 4, 5 and 7). This deficient practice had the potential to cause repeat doses of medication administration that could lead to life threatening complications such as overdose (consumes over the recommended or typical dose of a substance). Findings: a. During a review of Resident 4's admission Record, dated 10/8/2022, indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included primary hypertension (occurs when you have abnormally high blood pressure that's not the result of a medical condition) and acute angle-closure glaucoma (a sudden onset of severe unilateral eye pain or a headache associated with blurred vision, rainbow-colored halos around bright lights, nausea, and vomiting). During a review of Resident 4's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 7/30/2022, indicated Resident 4 was cognitively intact, and required total dependence with toilet, and extensive assistance with personal hygiene, bed mobility and transfer. During a review of Resident 4's Medication Administration Record (MAR) for September 2022, indicated the space for 9:00 p.m. dose for Lumigan Solution (eye drops, acute angle-closure glaucoma) was left blank on 9/14/2022 and 9/15/2022. During a review of Resident 4's MAR for September 2022, indicated the space for 5:00 p.m. dose for Metoprolol (used to treat angina [chest pain] and hypertension [high blood pressure] was left blank on 9/14/2022. b. During a review of Resident 5's admission Record, dated 10/8/2022, indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes mellitus (an impairment in the way the body regulates and uses sugar [glucose] as a fuel). During a review of Resident 5's MDS, dated [DATE], indicated Resident 5 was cognitively intact, and was independent with toilet, and limited assistance with personal hygiene, and required supervision with dressing, walking and transfer. During a review of Resident 5's MAR for September 2022, indicated the space for 6:30 a.m. dose for Basaglar KwikPen Solution Pen-injector - Insulin Glargine (Diabetes) was left blank on 9/2/2022, 9/5/2022, and 9/21/2022. During a review of Resident 5's MAR Record for September 2022, indicated the space for 6:30 a.m. dose for Humulin R Solution (Insulin Regular Human) (Diabetes) was left blank on 9/2/2022, 9/5/2022, and 9/21/2022. Also, the space for 9 p.m. on 9/15/2022 was left blank. c. During a review of Resident 7's admission Record, dated 10/8/2022, indicated Resident 4 was admitted to the facility on [DATE] with diagnoses that included heart failure (when the heart cannot pump enough blood and oxygen to support other organs in your body), and atherosclerotic heart disease of native coronary artery with angina pectoris (A disease in which plaque builds up in the arteries, causing them to narrow and reducing blood flow). During a review of Resident 7's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 10/1/2022, indicated Resident 7 was moderately impaired, and required extensive assistance with toilet, personal hygiene, bed mobility and required supervision with eating. During a review of Resident 7's MAR for September 2022, indicated the space for 9 a.m. dose for Acetazolmide (reduces the activity of a protein to help reduce the build-up of certain fluids in the body) was left blank on 9/19/2022 and 9/21/2022. During a review of Resident 7's MAR for September 2022, indicated the space for 9 a.m. dose for Lasix (used to reduce extra fluid in the body) was left blank on 9/19/2022, 9/21/2022 and 9/24/2022. During a review of Resident 7's Medication Administration Record for September 2022, indicated the space for 9:00 a.m. dose for Potassium Chloride ER Tablet Extended Release (Supplement) was left blank on 9/19/2022, 9/21/2022 and 9/24/2022. During a review of Resident 7's MAR for September 2022, indicated the space for 9 a.m. dose for Simvastatin Tablet (Cholesterol) was left blank on 9/15/2022, 9/19/2022 and 9/23/2022. During a concurrent interview and record review of Residents 4, 5, and 7's September 2022 - MAR, on 11/4/2022 at 9:46 a.m., with Director of Nursing (DON), DON stated he did not know why there were blanks on the MAR and licensed nurses should have documented date, time given and signed MAR after administering medication. DON stated they document medication administration on the computer. During a review of the facility's policy and procedure, titled, Documentation of Medication Administration, revised 2007, indicated a nurse or certified medication aide (where applicable) shall document all medications administered to each resident on the resident ' s medication administration record (MAR). The P&P indicated documentation must include, as a minimum: name and strength of the drug, dosage, method of administration, date and time of administration, reason why a medication was withheld, not administered, or refused, signature and title of the person administering the medication and resident response to the medication, if applicable (e.g., PRN, pain medication, etc.)

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Ensure opened insulin was labeled with open date affecting Resident 1 in one of one inspected medication cart. 2. Ensure medication refrigerator temperatures were monitored and documented on [DATE], [DATE], and [DATE] for one of one facility medication refrigerator inspected (Station 2 Refrigerator) These deficient practices increased the risk that residents could have received medications that had become ineffective or toxic due to improper storage or labeling possibly leading to health complications resulting in hospitalization or death. Findings: a. During a review of Resident 8's admission Record (Face sheet) dated [DATE], admission record indicate Resident 8 was admitted to the facility on [DATE] with a diagnosis not limited to type 2 diabetes (condition where the body cannot regulate sugar [glucose] properly). During a review of Resident 8's Medication Administration Record (MAR) for 9/2022, MAR indicated an order for Basaglar KwikPen Solution Pen-injector (a type of insulin used to treat high blood sugar) 100 unit/ milliliters, inject 42 unit subcutaneously two times a day for diabetes. Hold if blood sugar (BS) less than 100 milligrams/ deciliter and rotate injection sites. During a concurrent observation of medication storage room and interview with Licensed Vocational Nurse (LVN) 4, on [DATE] at 12:15 p.m., Resident 8 ' s Kwik pen was observed to be opened, used, and not labeled with an open date. The medication had 40 units left in the pen. LVN 4 stated Resident 8 ' s Kwik pen should have been labeled with an open date and failing to indicate date opened may cause resident to get sick if the medication was given expired. During a review of a medication insert titled, Basaglar Kwikpen instructions for use, revised 7/2021, instructions indicated in-use pen need to be disposed of after 28 days, even if it still has insulin left. b. During a concurrent interview and record review of the medication refrigerator log (for [DATE] to [DATE]) on [DATE] at 12:35 p.m., with LVN 4, the medication refrigerator log indicated that for [DATE], [DATE], and [DATE], no one monitored and signed the log for those dates. LVN 4 stated no signature, and no dates meant the refrigerator temperature was not checked and residents could have adverse reactions if the temperature was not monitored because improper storage of medication could make the medication toxic or less effective. During a review of the facility's policy, dated 4/2008, Medication Storage in the Facility, the policy indicated Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The policy further indicated medication requiring refrigeration or temperatures between 36 degrees Fahrenheit to 46 degrees Fahrenheit are kept in the refrigerator with a thermometer to allow temperature monitoring. The policy indicated medication storage conditions are monitored on a routine basis and corrective actions taken if problems are identified.

Mar 2022 22 deficiencies

CONCERN (D)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Develop and implement residents' rights policies and procedures, in accordance to state laws and regulations, related to psychotherapeutic (used to treat psychosis, which refers to a group of mental disorders such as depression, schizophrenia, and manic-depressive disorders, that affect mood and behavior) informed consent for one of 20 residents (Resident 34). 2. Have a policy and procedure (P/P) in place for psychotherapeutic medication informed consent usage. This deficient practice potentially affected the resident or responsible party to make informed health care decisions based on the resident's medical condition, changes in medical condition, benefits and reasonable risks of medications or treatment, and reasonable available alternatives. Findings: a. During a review of Resident 34's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 34's diagnoses included major depressive disorder (mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life, often with other symptoms such as disturbed sleep, feelings of guilt or inadequacy, and suicidal thoughts), anxiety disorder (persistent and excessive worry about activities or events - even ordinary, routine issues), insomnia (common sleep disorder that can make it hard to fall asleep, hard to stay asleep, or cause you to wake up too early and not be able to get back to sleep). During a review of Resident 34's Minimum Data Set ([MDS] a resident assessment tool), dated 1/31/2022, indicated resident was cognitively (ability to think and reason) intact, and had the ability to express ideas and wants, and was able to reason and understood others, During a concurrent interview with Registered Nurse 1 (RN 1) and review of Resident 34's, Physician Order Report (POR), dated 2/24/2022, on 3/24/2022 at 1:38 p.m., the POR indicated, on 11/22/2021, sertraline (antidepressant used to treat depression, obsessive-compulsive disorder, panic disorder and anxiety) was ordered. RN 1 indicated, A consent for sertraline is required this way resident can make own decisions. RN 1 confirmed the consent for sertraline was missing. During an interview with the Director of Nursing (DON) on 3/25/2022 at 8:56 a.m., the DON stated, If order for anti- psychotropic [any of the powerful tranquilizers (such as the phenothiazines and butyrophenones) used especially to treat psychosis and believed to act by blocking dopamine nervous receptors] medication then get consent so resident or family [if resident not alert] can be made aware of side effects risks and benefits from taking any psychotropic medication. b. During an interview with the DON on 3/25/2022 at 8:56 a.m., the DON stated the facility had no policy for psychotherapeutic therapy usage. During an interview with Medical Records Staff (MR) on 3/25/2022 at 3:17 p.m., MR stated the facility had no policy for psychotherapeutic therapy usage. A review of the California Code of Regulations, Title 22, Section 72527(a), Patient's Rights, indicated, Patients have the right .(5) To receive all information that is material to an individual patient's decision concerning whether to accept or refuse any proposed treatment or procedure. The disclosure of material information for administration of psychotherapeutic (drugs that are prescribed for their effects in relieving symptoms of anxiety, depression, schizophrenia, manic-depressive or other mental disorders) drugs .shall include the disclosure of information listed in Section 72528(b). A review of the California Code of Regulations, Title 22, Section 72528, Informed Consent Requirements, indicated, (b) The information material to a decision concerning the administration of a psychotherapeutic drug .shall include at least the following: (1) The reason for the treatment and the nature and seriousness of the patient's illness. (2) The nature of the procedures to be used in the proposed treatment including their probable frequency and duration. (3) The probable degree and duration (temporary or permanent) of improvement or remission, expected with or without such treatment. (4) The nature, degree, duration and probability of the side effects and significant risks, commonly known by the health professions. (5) The reasonable alternative treatments and risks, and why the health professional is recommending this particular treatment. (6) That the patient has the right to accept or refuse the proposed treatment, and if he or she consents, has the right to revoke his or her consent for any reason at any time.

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' medical records were updated to show documentation that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information was provided to the residents and/or responsible parties for one of 20 residents (Resident 37). This deficient practice violated Resident 37's and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care. Findings: During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 37's diagnoses included dysphagia (language disorder marked by deficiency in the generation of speech, and sometimes also in its comprehension, due to brain disease or damage), aphasia (condition that affects your ability to communicate), hemiplegia (paralysis [inability to move] of one side of the body), hemiparesis (weakness or inability to move on one side of the body), contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the right hand, and diabetes mellitus (a group of diseases that result in too much sugar in the blood). During a review of Resident 37's Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 2/4/22, indicated the resident was severely cognitively (relating to the process of acquiring knowledge and understanding) impaired, rarely/never understood. The MDS indicated Resident 37 was totally dependent on staff for bathing and was impaired on one side of the upper (arms) and lower (legs) extremities. During a concurrent interview and record review on 3/24/22 at 8:24 a.m., with the Social Service Director (SSD), the SSD stated there was no documentation that Resident 37 or the resident's representative was provided written information regarding the resident`s right to formulate an advance directive. The SSD verified there was no written information regarding an advance directive. During a review of the facility`s policy and procedure (P/P) titled, Advance Directives, dated 2016, the P/P indicated upon admission, the resident will be provided with information earning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to revise the care plan after one of two sampled residents sustained a fall (Resident 20). This failure had the potential to result in repeated falls, harm, and serious injury to Resident 20 due to a delay in developing cause-specific interventions to prevent further falls. Findings A review of Resident 20's facesheet indicated Resident 20 was originally admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included unspecified fall and unsteadiness on feet. A review of Resident 20's Minimum Data Set (MDS - a comprehensive assessment and screening tool) dated 1/18/2022, indicated Resident 20 was cognitively intact and independent in activities of daily living in the areas of transfers, dressing, eating, toilet use, personal hygiene, and bathing, and was continent (able to control) of bowel and bladder. During an interview on 3/22/2022 at 9:31 a.m. with Resident 20, Resident 20 stated he fell yesterday in the dining room as he were walking to the therapy room. Resident 20 stated he tripped over his own feet and his palms and knees hit the floor. A review of Resident 20's IDT (Interdisciplinary Team) Post Fall/Trauma note dated and timed 3/23/2022 at 2:12 p.m. indicated under the section titled Care Plan revised the box next to Yes was marked with a check indicating the care plan had been revised. During an interview with Registered Nurse 1 (RN 1), and a concurrent record review on 3/24/22 at 10:59 a.m. of Resident 20's care plan regarding falls, dated 1/17/2022, RN 1 stated there had been no revision of Resident 20's care plan since January. RN 1 stated after an IDT Post Fall/Trauma meeting, the care plan should be updated and change any interventions, if needed. During an interview on 3/24/22 at 2:48 p.m. with the Director of Nursing (DON), the DON stated any licensed staff can initiate a care plan, and a care plan should be updated post fall. A review of the facility's policy and procedure (P/P) titled, Falls and Fall Risk, Managing, revised March 2018 indicated after a fall, staff should reevaluate the current interventions and revise them if needed.

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services that meet professional standards of quality for three of three sampled residents (Residents 11, 52, and 18) by failing to ensure: a. Licensed Vocational Nurse 3 (LVN 3) did not administer Resident 11's medications via gravity through the resident's gastrostomy tube ([G-Tube] tube surgically inserted into the stomach for nutrition, hydration, and medication). This failure had the potential to cause clogging or damage to the G-Tube. b. The licensed nurse received an order to transfer Resident 52 to the hospital and provided adequate documentation upon the resident's transfer. This failure had the potential to cause miscommunication regarding Resident 52's change of condition. c. The facility failed to carry out the physician order to check Resident 18's oxygenation saturation and respirations every four hours for 14 days, and to ensure vital signs were taken every four hours in accordance with the facility's policy for Resident 18. These deficient practices had the potential to result in a delay in treatment and harm to Resident 18. Findings: a. During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 11's diagnoses included dysphagia (difficulty swallowing), oropharyngeal phase (difficulty swallowing), gastroesophageal reflux disease (the stomach contents sometimes flow backward, up into the esophagus), gastrostomy (a surgical operation for making an opening in the stomach), anxiety disorder (intense, excessive and persistent worry and fear about everyday situations), history of urinary tract infection (infection in any part of the urinary system), bipolar disorder (unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks) and Parkinson's disease (progressive nervous system disorder that affects movement). During a review of Resident 11's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 3/17/2022, the MDS indicated Resident 11 was rarely and never understood, was severely impaired in cognitive skills for daily decision making, (the ability to understand or to be understood by others) and required total dependence of one to two-person physical assist for activities of daily living. During a review of Resident 11's Physician Orders dated 2/24/2022 to 3/24/2022, the physician orders indicated to administer the following medications via the gastrostomy tube: 1. Buspirone 5 milligrams ([mg] unit of measurement) 1 tab via G-Tube for anxiety manifested by (m/b) feeling anxious, and inability to relax twice a day. 2. Carbidopa/levodopa 25-100 mg 1 tablet via G-Tube for Parkinson's disease. 3. Seroquel (quetiapine fumarate) 25 mg 1 tab via G-Tube twice a day for agitation m/b screaming. 4. Valproic acid 250mg/5 milliter ([ml] unit of measurement) per G-Tube for bipolar disorder m/b constant yelling for no apparent reason. 5. Cranberry 425mg capsule for urinary tract infection (UTI) prophylaxis. May cut open capsule and administer via G-Tube. During a medication administration observation on 3/24/2021 at 9:16 a.m., in Resident's 11 room, Licensed Vocational Nurse (LVN) 3 administered five individually crushed medication tablets into Resident 11's G-Tube. LVN 3 used a syringe and plunger to ensure the medications went through the tube. LVN 3 flushed the tube with 30 milliliters (ml) of water between each medication. During an interview with LVN 3 on 3/24/2022 at 12:15 p.m., LVN 3 stated she administered all medications by pushing the plunger of the syringe to ensure the medications went through the tube. LVN 3 stated she should not push the water or medication through the G-Tube because it could have damaged the G-Tube. LVN 3 stated she should have administered the medications via gravity (holding up a syringe to allow nutrition formula, water, or medications to flow by gravity). During an interview on 3/24/2022 at 12:39 p.m., with the Director of Nursing (DON), DON stated medications administered through a G-Tube should be administered through a syringe by gravity and not by pushing the syringe plunger because it can damage the G-Tube. During a review of the facility's policy and procedure (P&P) titled, Administering Medications through an Enteral Tube, dated 11/ 2018, the P&P indicated to administer medications through enteral tube included to: 1. Administer the medication by gravity flow. 2. Pour the diluted medication into the barrel syringe while holding the tubing slightly above the level of insertion. 3. Open the clamp and deliver the medication slowly and begin the flush before the tubing drains completely. b. A review of Resident 52's admission Record, indicated Resident 52 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included gastritis (inflammation of the lining of the stomach) with bleeding. A review of Resident 52's MDS dated [DATE], indicated that Resident 52 was sometimes understood, was severely impaired in cognitive (the ability to understand or to be understood by others) skills for daily decisions making, and required total dependence of one to two-person physical assist for activities of daily living. A review of Resident 52's SBAR Communication form (Situation, Background, Assessment and Recommendation) dated 11/29/2021 indicated Resident 52 vomited blood while eating lunch and was transferred to the acute hospital via emergency medical transport. During an interview and concurrent record review on 3/25/22 at 9:02 a.m. of Resident 52's SBAR Communication form dated 11/29/2021 with RN 1, RN 1 stated that there was not sufficient information regarding the assessment of the resident on the form, including how the resident was found, a description of the resident's condition and what interventions were provided. RN 1 also stated there was no order found in the electronic health record (EHR) to transfer Resident 52 to the hospital. RN 1 stated an order is required to transfer a resident to the acute hospital. During an interview and concurrent record review on 3/25/22 at 09:17 a.m. of Resident 52's SBAR Communication form date 11/29/2021 with LVN 2, LVN 2 stated more documentation was needed on the form. LVN 2 stated the change of condition should be documented including any observations of the resident. During an interview on 3/25/22 at 9:30 a.m. with the DON, the DON stated the process for transferring a resident to the hospital due to a change of condition included assessing the resident and obtaining an order from the physician. The DON stated it is important to include comprehensive documentation of the resident's status upon transfer to provide an accurate presentation of the resident's condition and the care that has been provided. A review of the facility's policy and procedure (P/P) titled, Change in a Resident's Condition or Status, updated February 2021, indicated when the resident experiences a change of condition, the nurse should gather relevant and important information, and make detailed observations to inform the provider. c. During a review of Resident 18's Vital Report, dated 2/3/22 to 2/7/22, the vital report indicated vital signs were inconsistently performed on an average of every four to 18 hours. A review of Resident 18's admission Record indicated the resident was admitted to the facility on [DATE], with diagnosis that included COVID-19 (predominantly a respiratory illness that can affect other organs), hypertension (abnormally high blood pressure), atrial fibrillation (An irregular heartbeat that occurs when the electrical signals in the atria [the two upper chambers of the heart] fire rapidly at the same time). A review of Resident 18's Quarterly MDS dated [DATE], indicated Resident 18 was cognitively severely impaired. A review of Resident 18's Physician's Order Report dated 2/2/22, indicated a physician's order to check Resident 18's oxygenation saturation ([O2] indicates that amount of oxygen traveling through your body with your red blood cells) every four hours for 14 days, and to check Resident 18's respirations every shift for 14 days. During a concurrent interview and record review, on 3/25/22, at 9:50 a.m., with Registered Nurse (RN 1), Vital Report, dated 2/3/22 to 2/7/22 was reviewed. The Vital Report indicated respirations were not taken as ordered every shift but were taken every five to 17 hours. Resident 29's temperature was not taken every four hours but was taken every four to 17 hours. His oxygen saturation was not taken every four hours but was taken every four to 18 hours. RN 1 stated, when in quarantine vital signs are to be taken every four hours, not limited to temperature, respirations, and O2. RN 1 further stated, If O2 is not taken the resident could have shortness of breath (SOB), or complications of breathing and we won't know. Additionally, the resident could potentially have complications from passing out due to not breathing or being sent to hospital or death. RN 1 also stated, VS from 2/3/22 to 2/7/22 were inconsistent varying from four hours and sometimes as long as 18. A review of Resident 29's VS record indicated the resident's vital signs were taken on the following dates and times: Respirations: 1. February 4, 2022, at 2:03 AM 2. February 4, 2022, at 6:54 PM 3. February 5, 2022, at 12:44 AM 4. February 5, 2022, at 1:56 PM 5. February 6, 2022, at 1:55 AM 6. February 6, 2022, at 8:36 AM 7. February 6, 2022, at 4:50 PM 8. February 6, 2022, at 10:38 PM 9. February 7, 2022, at 3:42 AM Oxygen Saturation (O2): 1. February 3, 2022, at 12:36 AM 2. February 3, 2022, at 6:26 PM 3. February 3, 2022, at 8:35 PM 4. February 4, 2022, at 12:40 AM 5. February 4, 2022, at 5:44 PM 6. February 5, 2022, at 12:44 AM 7. February 5, 2022, at 9:51 AM 8. February 5, 2022, at 5:20 PM 9. February 6, 2022, at 1:54 AM 10. February 6, 2022, at 10:37 PM 11. February 7, 2022, at 3:40 AM Temperature: 1. February 3, 2022, at 12:36 AM 2. February 3, 2022, at 8:22 AM 3. February 3, 2022, at 4:59 PM 4. February 3, 2022, at 8:35 PM 5. February 4, 2022, at 12:40 AM 6. February 4, 2022, at 10:22 AM 7. February 4, 2022, at 11:21 AM 8. February 4, 2022, at 8:28 PM 9. February 5, 2022, at 12:44 AM 10. February 5, 2022, at 9:51 AM 11. February 5, 2022, at 5:21 PM 12. February 6, 2022, at 1:02 AM 13. February 6, 2022, at 1:54 AM 14. February 6, 2022, at 8:37 AM 15. February 6, 2022, at 11:55 AM 16. February 6, 2022, at 4:50 PM 17. February 6, 2022, at 10:37 PM 18. February 7, 2022, at 3:41 AM During a record review of Resident 18's Care Plan, dated 2/3/22, the care plan indicated Resident 29 was under quarantine for 14 days, and was on contact/droplet precaution. The listed problem indicated, possible exposure to COVID-19 virus. During a review of the facility's policy and procedure (P/P) titled, COVID-19 Mitigation Plan/Policies and Procedures, dated 2021, the P/P indicated, Facility shall conduct symptom and temperature screening for all residents and perform twice a shift monitoring for residents in the yellow and red zone.

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately assess Resident 261's health status and initiate a change of condition (COC). This deficient practice had the potential to result in Residents 261 not receiving needed treatment and/or services. Findings: A review of Resident 261's admission Record (Face Sheet) indicated Resident 261 was admitted to the facility on [DATE]. Resident 261's diagnoses included iron deficiency anemia (a condition in which blood lacks adequate healthy red blood cells), congestive heart failure (occurs when the heart muscle doesn't pump blood as well as it should), pressure ulcer (an injury that affects areas of the skin and underlying tissue caused from prolonged pressure) of the right hip, muscle weakness, and cirrhosis of the liver (late-stage liver disease in which healthy liver tissue is replaced with scar tissue and the liver is permanently damaged). A review of Resident 261's Minimum Data Set (MDS), a comprehensive assessment and care screening tool, dated 3/16/2022 indicated Resident 261 had intact cognitive function (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). A review of Resident 261's care plan titled, Impaired Respiratory Status, dated 3/10/2022 indicated to provide breathing treatment as ordered. During observations on 3/22/2022 at 9:19 a.m., 10:33 a.m., and 11:49 a.m., observed Resident 261 with audible (related to hearing) congestion. During a concurrent observation and interview on 3/24/2022 at 10:11 a.m., observed Resident 261 lying in bed. An oxygen concentrator machine was on at 2 liters (a unit of measurement) per minute with a nasal cannula. The oxygen was not connected to Resident 261. Licensed Vocational Nurse 3 (LVN 3) stated that when oxygen was on and not being administered does not benefit the resident and was a fire hazard that could lead to injury. Observed LVN 3 checking Resident 261's lung sounds and stated that Resident 261 was congested, and the resident would benefit from oral suctioning. During an interview with Certified Nursing Assistant 2 (CNA 2) on 3/24/2022 at 12:54 p.m., CNA 2 stated when staff provide care to residents using oxygen via nasal cannula, CNA 2 would take the nasal cannula from the resident's nostrils when putting on a new gown and place it back right away to the resident's nostrils after changing the gown. CNA 2 stated she was not allowed to turn the resident's oxygen on and off because it was not part of the CNAs scope of practice. CNA 2 stated she did not know who left Resident 261's nasal cannula on the resident's bed while it was still on. During a concurrent interview and record review on 3/25/2022 at 10:40 a.m., LVN 3 stated the facility should have done a change of condition (COC) and informed the assigned physician regarding the resident's audible congestion because suctioning would be helpful to Resident 261. LVN 3 stated there was no COC done by the facility's staff, nor did the staff call and inform the resident's assigned physician and responsible party regarding Resident 261's COC of congestion. LVN 3 verified there was no order for oxygen administration even though Resident 261 was receiving oxygen without an order. During a concurrent observation and interview on 3/25/2022 at 11:06 a.m., the Director of Nursing (DON) was observed checking Resident 261's lung sounds with a stethoscope (a medical instrument for listening to the action of someone's heart or breathing, typically having a small disk-shaped resonator that is placed against the chest, and two tubes connected to earpieces). The DON stated that it was evident that you can really hear Resident 261's congestion even without using the stethoscope. During a concurrent observation and interview on 3/25/2022 at 12:27 p.m., Registered Nurse (RN 1) and (RN 2) were observed checking Resident 261's lung sounds with a stethoscope and acknowledged that lung congestion was evident even without using the stethoscope. RN 1 and RN 2 stated that suctioning and a breathing treatment would be beneficial to Resident 261. A review of the facility's policy and procedure (P/P) titled, Change in a Resident's Condition or Status, revised 2/2021, indicated: Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status (e.g., changes in level of care, billing/payments, resident rights, etc.).The nurse will notify the resident's attending physician or physician on call when there has been a(an): significant change in the resident's physical/emotional/mental condition.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the facility was free from clutter and accidental hazards and provided adequate supervision to prevent accidents for four of four sampled residents (Resident 3, 30, 38 and Resident 42). This deficient practice had the potential to result in serious harm and injury to residents, staff, and visitors. Findings: a. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 3's diagnoses included a history of falls, muscle weakness, abnormalities of gait and mobility, paranoid schizophrenia (altered perception of reality), blindness in one unspecified eye, and anxiety disorder (intense, excessive and persistent worry and fear about everyday situations). During a review of Resident 3's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 3/9/2022, the MDS indicated Resident 29's cognitive (the ability to understand or to be understood by others) skills for daily decisions making were intact, and the resident required limited assistance of one-person physical assist for transfers. The MDS indicated Resident 29 used a wheelchair and was not steady and was only able to stabilize with staff assistance when transferring from surface to surface (transfer between bed and chair or wheelchair) and walking. The MDS further indicated Resident 3 was independent with locomotion on the unit and off the unit and was self-sufficient once in a chair and was highly impaired in vision and had a history of falls in the last month prior to admission. During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was admitted to the facility on [DATE]. Resident 30's diagnoses included acute respiratory disease (breathing is difficult and the oxygen levels in the blood abruptly drop lower than normal), a history of unspecified fall, displaced fracture of medial malleolus of left tibia (inner side of the ankle), initial encounter for close fracture (broken bone that does not penetrate the skin), and morbid (severe) obesity (too much body fat). During a review of Resident 30's MDS, dated [DATE], the MDS indicated Resident 30's cognitive (the ability to understand or to be understood by others) skills for daily decisions making were intact. The MDS indicated Resident 30 was independent with locomotion on and off the unit and walking in the room and corridor and required help with set up only. During an observation on 3/22/2022, at 2:49 p.m., there were five (5) wheelchairs observed parked and stored in front of the entrance going into the patio. Resident 3 was observed being wheeled by Resident 30 and bumped into one of the wheelchairs stored by the entrance door of the patio. Licensed Vocational Nurse (LVN) 4 opened the door of the patio and allowed Resident 30 to wheel Resident 3 to the patio. During an observation on 3/23/2022, at 1:09 p.m., there were six (6) wheelchairs observed parked and stored in front of the entrance door leading to the patio. A coffee cart and a medication cart was observed blocking the entrance of the patio. During an interview with Resident 30 on 3/24/2022, at 3 p.m., Resident 30 stated on 3/22/2022, he was wheeling Resident 3, when he accidentally bumped Resident 3's wheelchair into another wheelchair parked by the entrance of the patio. Resident 30 stated there were so many wheelchairs cluttered by the entrance and it made maneuvering the wheelchair difficult. Resident 30 stated the staff where aware that the resident sometimes assists Resident 3 by pushing his wheelchair and was not told he could not longer wheel Resident 3 around the facility. Resident 30 stated he would no longer assist Resident 3 with his wheelchair to prevent another accident. During a review of Resident 3's care plan, dated 3/9/2022, the care plan indicated to provide Resident 3 with a safe, clutter-free, secure environment, well-lit room, and dry floor. During an interview on 3/24/2022, at 07:09 a.m., with LVN 4, LVN 4 stated, she saw Resident 30 was assisting Resident 3 pushing the wheelchair going to the patio and accidentally hit the wheelchair parked by the entrance of the patio. LVN 4 stated Resident 30 should not be pushing Resident 3's wheelchair because he was not trained on how to properly wheel the wheelchair and Resident 30 might trip and both residents could get hurt. LVN 4 stated they should not place the wheelchairs by the entrance to the patio and should have a designated area by the hallway where the wheelchairs can be securely stored. During an interview with the Director of Nursing (DON) on 3/24/2022, at 4:46 p.m., the DON stated a resident should not wheel another resident because the residents were not trained on how to safely maneuver another resident's wheelchair. The DON stated if staff saw the resident wheeling another resident, they should have stopped the resident and offered to assist because it could possibly cause an accident and could hurt both residents. The DON stated the environment should be free from clutter to avoid accidents and should not block the doors and entryway because it could be a hazard in case of an emergency. During a review of Resident 3's SBAR (Situation Background Communication Recommendation) communication form (a tool provided to aid in facilitating and strengthening communication between nurses and physicians), dated 3/24/2022, the SBAR indicated Resident 3 bumped his foot on another wheelchair while going to the patio on 3/22/2022. The SBAR indicated Resident 3 had no injuries. b. During a review of Resident 42's admission Record, the admission Record indicated Resident 42 was admitted to the facility on [DATE]. Resident 42's diagnoses included diabetes mellitus (body not produce enough insulin causing high blood sugar), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with behavioral disturbance, major depressive disorder (mood disorder that interferes with daily life), muscle weakness, unsteadiness on feet, and preglaucoma (elevated intraocular pressure but no detectable disc or visual field damage). During a review of Resident 42's MDS, dated [DATE], the MDS indicated Resident 42's cognitive (the ability to understand or to be understood by others) skills for daily decisions making were intact. The MDS indicated Resident 42 was independent with locomotion on and off the unit, and walking in the room and in the corridor. During a concurrent observation and interview on 3/22/2022, at 12:07 p.m. with Resident 42, in her room, Resident 42 was observed sitting on her bed with her feet resting on the floor. A reusable bed pad was observed on the floor right next to Resident 42's feet. Resident 42 stated she was using the bed pad as floor mat for her feet. c. During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 38's diagnoses included diabetes mellitus, acute respiratory disease, osteoarthritis (tissues in the joint break down over time), cardiomyopathy (affects heart muscle), anxiety disorder, and muscle weakness. During a review of Resident 38's MDS, the MDS indicated Resident 38's cognitive (the ability to understand or to be understood by others) skills for daily decisions making were intact. The MDS indicated Resident 38 required limited assistance of one-person physical assist for dressing, and supervision with toilet use and personal hygiene, and had impairment on both sides of the lower extremities (legs). According to the MDS Resident 38 used a wheelchair for mobility. During an observation on 3/22/2022 at 11:45 a.m. in Resident 38's room, wet towels and reusable bed pads were found on the floor under Resident 38's bed. During a concurrent observation and interview on 3/24/2022 at 10:45 a.m., in Resident 38's room, reusable bed pads were observed on the floor right next to the bed of Resident 38. Resident 38 stated he was using the reusable pad for his feet and to wipe the urine incase it spills on the floor when he uses the urinal. Resident 38 stated they do not come to mop the floor and clean his room when surveyors are not around. Resident 38 stated the facility has lots of clutter in the hallways like wheelchairs, lift machines, and carts which make it hard to travel around the facility and could be a risk for accidents for residents. During an interview with the DON on 3/24/2022 at 4:46 p.m., the DON stated the reusable pads should not be on the floor and not to be used as floor mat as residents might slip when they step on it and could get hurt. The DON stated the residents' room should be free from clutter to prevent any accident. During a review of the facility's policy and procedure (P/P) titled, Safety and Supervision of residents, dated 7/2017, the P/P indicated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. During a review of the facility's P/P titled, Homelike Environment, dated 2/2021, the P/P indicated Residents are provided with a safe, clean, comfortable, and homelike environment. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean, sanitary, and orderly environment.

CONCERN (D)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Certified Nurse Assistants (CNA) 2 performed indwelling catheter (a urethral catheter designed to be held in place to drain urine from the bladder) care that meets professional standards of quality. CNA 2 did not maintain clean technique (reduce the risk of introducing potentially pathogenic micro-organisms into susceptible sites) and caused pain and discomfort while providing indwelling catheter care to one of three Residents (Resident 59). This deficient practice had a potential to result in Resident 59 being at higher risk for developing a urinary tract infection (is an infection in any part of the urinary system) as well as other complications. Findings: During a review of Resident 59's undated admission record, the admission record indicated Resident 59 was admitted to the facility on [DATE], with diagnoses that included diabetes mellitus (ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine), hydronephrosis (excess urine accumulation in kidneys that causes swelling of kidneys) with renal and urethral calculous obstruction ( a blockage in one or both of the tubes that carry urine from the kidneys to the bladder), high blood pressure (the force of blood pushing against the walls of blood vessels, is consistently too high), history of urinary tract infections ([UTI] an infection in any part of urinary system) and presence of urogenital implants [an injection of material into the urethra used to control urine leakage caused by a weak urinary sphincter.]) During a review of Resident 59's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 3/4/2022, MDS indicated Resident 59's cognitive (the ability to understand or to be understood by others) skills for daily decisions making were intact, and Resident 59 required extensive assistance of one-person physical assist for activities of daily living and has an indwelling catheter. During a review of Resident 59's Physician Orders dated 2/23/2022 to 3/23/2022, the Physician Orders indicated Indwelling catheter care is to be done by the CNA and monitored by the license nurse every shift. During an indwelling catheter care observation on 3/25/2022, at 9:30 a.m., Resident 59 was observed lying in bed, in her room, with an indwelling catheter bag hanging on the right side of the bed. The indwelling catheter tubing was secured with a securement device on Resident 59's right upper thigh. CNA 2 was observed wiping Resident 59's outer labia with wet wipes towards the urinary meatus (the opening of the female urethra the duct by which urine is conveyed out of the body from the bladder to transport urine outside the body), and wipe the catheter tubing with wet wipes from the distal tubing going up towards the urinary meatus. CNA2 lifted the catheter tubing while the catheter was secured with a securement device and Resident 59 moaned and stated ouch. During the same observation, CNA2 turned Resident 59 to her left side while the indwelling catheter bag was hanging on the right side of the bed. Resident 59 stated I don't know why it was hurting so bad, and requested to be repositioned on her back. Resident 59 told CNA2 that it was probably better if she just turned on the right side since the catheter was hanging on the right side of the bed. CNA2 lowered the height of the bed, and the catheter bag and tubing were left touching the floor. The catheter tubing was curled, and the urine was unable to easily flow to the bag by gravity. During an interview on 3/25/2022, at 10:27 a.m. with CNA 2, CNA 2 admitted that she cleaned Resident 59's perineum area (an area between the thighs that marks the approximate lower boundary of the pelvis and is occupied by the urinary and genital ducts and rectum) from outer labia towards the urinary meatus and from distal tubing towards the urinary meatus because she was nervous. CNA 2 stated she should have moved the indwelling catheter bag to the left side of the bed to prevent the catheter from tugging when she turned Resident 59 to the left side. CNA 2 stated she made a mistake of lowering the height of the bed and did not realize the indwelling catheter bag and tubing was touching the floor. During an interview on 3/25/2022, at 10:30 a.m. with CNA 2, CNA 2 stated she did not receive any in service for the last 4 years regarding indwelling catheter care since after she initially completed her CNA class. CNA2 stated she did not work for the last 2 years, did not renew her license until November 2021, and took 48 hours of CEU (Continuous Education Unit) classes to renew her license but the classes she took did not addressed anything about indwelling catheter care and have not demonstrated indwelling catheter care to demonstrate competency. During an interview on 3/25/2022, at 11:00 p.m. with CNA 4, CNA4 stated she was taking care of residents with indwelling catheter but did not receive an in-service on how to take care of residents with indwelling catheters and stated it will be a good idea to have one so they will know how to properly care for the resident. During an interview on 3/25/2022, at 11:20 a.m., with the Director of Staff Developer (DSD), DSD stated CNAs should clean from the proximal to distal, from where the catheter goes to the urethra, making sure to separate the labia, and wipe from the front to the back toward the anus to keep from spreading germs into the urethra. DSD also stated to wipe the catheter from where it goes to the body and wipe down toward the drainage bag to prevent spreading germs into the urethra. DSD also stated staff should move the indwelling catheter bag to the side where the resident will be repositioned to prevent tugging and hurting the resident. During an interview on 3/25/2022, at 2:20 p.m., with Director of Nursing (DON), DON stated CNAs should clean from inner to outer, proximal to distal, making sure to separate labia and wipe from front to back toward the anus to keep from spreading germs into the urethra. DON also stated to wipe catheter from where it goes to the body and wipe down toward the drainage bag to prevent spreading germs into urethra. During a review of the facility's Lesson Plan titled, Incontinent Care, dated 11/24/2021, the lesson plan indicated at the end of the class caregivers will be able to verbalize and demonstrate proper perineal care. The record indicated to cleanse perineal from front to back, from inside to the outside, may fold towel once, then use another clean towel to continue peri care (female). Method of evaluation included verbalization, demonstration, rounds during care, and yearly CNA skills demonstration. During a review of the facility's policy and procedure (P&P) titled, Catheter care urinary, dated 9/2014, the P&P indicated, the purpose of the policy is to prevent catheter-associated urinary tract infections. The policy indicated to use standard precautions when handling or manipulating the drainage system, maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. Also be sure the catheter tubing and drainage bag are kept off floor and empty the drainage bag regularly. The urinary drainage bag must be always held or positioned lower than the bladder to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder.

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a licensed nurse did not administer medications via gravity (holding up a syringe to allow nutrition formula, water, or medications to flow by gravity) through a gastronostomy tube ([G-tube] a flexible tube placed into the surgical opening in the stomach that allows for nutrition, fluids, and medications) for one of three sampled residents (Resident 11). This failure had the potential to cause clogging and/or damaging Resident 11's G-tube. Findings: During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 11's diagnoses included dysphagia (difficulty swallowing), oropharyngeal phase (difficulty swallowing), gastroesophageal reflux disease (the stomach contents sometimes flow backward, up into the esophagus), attention to gastrostomy (surgical opening in the stomach), anxiety disorder (intense, excessive and persistent worry and fear about everyday situations), history of urinary tract infection (infection in any part of the urinary system), bipolar disorder (unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks) and Parkinson's disease (progressive nervous system disorder that affects movement). During a review of Resident 11's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 03/17/2022, the MDS indicated Resident 11 was rarely and never understood, cognitive (the ability to understand or to be understood by others) skills for daily decisions making was severely impaired, and required total dependence two-person physical assist with activities of daily living ([ADLs] self-care acitivites performed daily, such as grooming, personal hygiene, and bathing). During a review of Resident 11's Physician Orders dated 2/24/2022 to 3/24/2022, the physician orders indicated to administer the following: 1. Buspirone (used to treat anxiety orders) 5 milligrams ([mg] unit of measurement) 1 tab via g-tube for anxiety manifested by (m/b) feeling anxious, inability to relax twice a day. 2. Carbidopa/Levodopa (used to treat symptoms of Parkinson's disease) 25-100 mg 1 tablet via g-tube for Parkinson's disease. 3. Seroquel ([quetiapine] use to treat certain mental/mood disorders) fumarate 25 mg 1 tab via g-tube twice a day for agitation m/b screaming. 4. Valproic acid (used to treat seizures and bipolar disorder) 250mg/5 ml per g-tube for bipolar disorder m/b constant yelling for no apparent reason. 5. Cranberry (used to promote urinary and bladder health) 425mg capsule for urinary tract infection (UTI) prophylaxis. May cut open capsule and administer via g-tube During an observation of medication administration on 3/24/2021 at 9:16 a.m., Licensed Vocational Nurse (LVN) 3 was observed administering five individual crushed medication tablets into Resident 11's g-tube. LVN 3 used a syringed and plunger to ensure the medications went through the tube. She flushed the tube with 30 milliliters (ml) of water between each medication. During an interview with LVN 3 on 3/24/2022 at 12:15 p.m., LVN 3 stated she administered all of Resident 11's medications by pushing the plunger of the syringe to ensure the medications went through the tube. LVN 3 stated she should not have pushed the water or medication through the g-tube because it could have damaged the g-tube and should have administered the medications via gravity. During an interview with the Director of Nursing (DON) on 3/24/2022 at 12:39 p.m., the DON stated medications administered through a g-tube should be administered through a syringe by gravity and not by pushing the syringe plunger because it could damage the g-tube. During a review of the facility's policy and procedure (P/P) titled, Administering Medications through an Enteral Tube, dated 11/ 2018, the P/P indicated to administer medications through enteral tube: administer medication by gravity flow, pour diluted medication into the barrel syringe while holding the tubing slightly above the level of insertion, open the clamp and deliver medication slowly, and begin flush before the tubing drains completely.

CONCERN (D)

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

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer the influenza (flu) vaccine (substance to protect against influenza viruses [germ that infects people and attacks the respiratory system--nose, throat, lungs]) to one of five sampled residents (Resident 20). This deficient practice placed Resident 20 at higher risk for acquiring and transmitting the flu to other residents in the facility. Findings: During a review of Resident 20's admission Record, the admission Record indicated Resident 20 was admitted to the facility on [DATE]. Resident 20's diagnoses included type 2 diabetes mellitus (impairment in the way body regulates and uses sugar[glucose] as fuel), hypertension (high blood pressure [force it takes for blood to pump in body]), dementia (term for loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), heart failure (heart muscle doesn't pump as well as it should), failure to thrive (state of decline that is multifactorial causing weight loss, decreased appetite, poor nutrition, and inactivity), anemias (condition in which not enough healthy red blood cells to deliver oxygen to the body tissues). During a review of Resident 20's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 1/18/2022, the MDS indicated Resident 20 had the ability to express ideas and wants and had a clear comprehension and was able to understand verbal content. The MDS indicated Resident 20 had intact cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making. The MDS indicated Resident 20 ate independently and was independent with bed mobility, transfer, toilet use, personal hygiene, and dressing. The MDS indicated Resident 20 did not receive the influenza vaccine because of a medical contraindication. During a concurrent interview with the Infection Preventionist Nurse (IP) and record review of Resident 20's Preventative Healthcare Report, from 1/1/2019 to 3/25/2022, on 3/25/2022 at 11:20 a.m., IP confirmed that on 10/13/2020, Resident 20 did not receive the flu vaccine due to a medical contraindication and vaccine refusal. IP stated Resident 20 stated she was allergic to eggs, and it caused swelling of her face and lips. The report indicated on 10/13/2021, Resident 20 had a medical contraindication to the flu vaccine, and it was therefore not administered. During the continued interview with the IP and record review of the facility's Influenza Vaccinated residents' roster, IP confirmed Resident 20's responsible party (RP 1) refused to consent for Resident 20 to receive the influenza vaccine. During the same interview with the IP and record review of Resident 20's Immunization: consent or refusal on 3/25/2022 at 11:20 a.m., IP confirmed Resident 20's RP consented for Resident 20 to receive the influenza vaccine on 10/7/2021. IP stated there was no documented evidence of RP 1's refusal of the flu vaccination for Resident 20. IP stated Resident 20 should have received the influenza vaccination. During a review of the facility's policy and procedure (P/P), dated 8/2016 and titled, Influenza Vaccine, the P/P indicated residents with no medical contraindications were offered an influenza immunization annually. Resident refusal shall be documented on the informed consent for influenza vaccine for. Administration of the influenza vaccine will be made in accordance with current centers for disease control and prevention (CDC) recommendations at the time of vaccination. During a of the Centers for Disease Control and Prevention (CDC) article https://www.cdc.gov/flu/prevent/egg-allergies.htm#recommendations, the article indicated 1. Persons with a history of egg allergy who have experienced only hives (itchy rash or welts on skin) after exposure to egg should receive flu vaccine. 2. Persons who report having had reactions to egg involving symptoms other than hives, such as angioedema (hives with swelling under the skin) , respiratory distress, lightheadedness, or recurrent emesis; or who required emergency medical intervention, may similarly receive any licensed and recommended flu vaccine that is otherwise appropriate for the recipient's age and health status. The selected vaccine should be administered in an inpatient or outpatient medical setting (including, but not necessarily limited to hospitals, clinics, health departments, and physician offices). Vaccine administration should be supervised by a health care provider who is able to recognize and manage severe allergic conditions.

CONCERN (E)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the staff failed to ensure resident call lights were within reach for three of three sampled residents (Residents 27, 35 and 43), and failed to ensure one of 20 random selected residents (Resident 37) was provided with a communication board. This deficient practice had the potential for Residents 27, 35, and 43's needs to not be met timely, and Resident 37 not receiving a functional communication system to facilitate communication with staff. Findings: a. A review of Resident 27's admission Record (Face Sheet) indicated Resident 27 was admitted to the facility on [DATE]. Resident 27's diagnoses included bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), 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), history of falling, and dysphagia (difficulty swallowing). A review of Resident 27's Minimum Data Set (MDS), a comprehensive assessment and care screening tool, dated 1/24/2022 indicated Resident 27 had no cognitive (ability to learn, remember, understand, and make decisions) impairment and required extensive assistance for bed mobility and transfer. A review of Resident 27's care plan dated 3/15/2022, indicated Resident 27 had an ADL (activities of daily living) self-care performance deficit related to weakness and history of falling resulting in a fracture (broken bone). The care plan indicated Resident 27 required extensive assistance with a one-person assist for bed mobility and transfer. During a concurrent observation and interview with Resident 27 on 3/22/2022 at 10:04 a.m., Resident 27's call light was observed out of the resident's reach. Resident 27 stated, I have to scream to get their attention sometimes and my room is just across the nurse's station, and I feel like I'm not important at all. During an observation on 03/22/2022 at 12:01 p.m., Resident 27's call light was on top of her hear and resident unable to reach the call light. During an interview with the Infection Preventionist Nurse (IP) on 3/24/2022 at 11:00 a.m., IP stated if a resident cannot reach the call light, it was very frustrating and affects your whole being because you cannot get help by not being able to use the call light and your needs cannot be catered to or met. During an interview with Certified Nursing Assistant 5 (CNA 5) on 3/24/2022 at 11:45 a.m., CNA 5 stated it was very frustrating not to be able to use the call light to ask for help. CNA 5 stated the resident's needs not being met would really affect the resident's quality of living and psychosocial well-being. During an interview with Registered Nurse 1 (RN 1) on 3/24/2022 at 1:14 p.m., RN 1 stated it would make the resident anxious, frustrated, and mad for them not to be able to reach the call light to call for help and that would affect the psychosocial aspect of the resident's being. b. A review of Resident 35's admission Record (Face Sheet) indicated Resident 35 was admitted to the facility on [DATE]. Resident 35's diagnoses included dementia, history of falling resulted to fracture, essential hypertension (high blood pressure), and abnormalities of gait and mobility related to muscle weakness. A review of Resident 35's MDS dated [DATE], indicated Resident 35 had moderate cognitive impairment and required total assistance with bed mobility, transfer, eating, toilet use and personal hygiene. A review of Resident 35's care plan dated 2/1/2022, indicated Resident 35 had an ADL self-care performance deficit. The care plan indicated Resident 35 required total one-person assist for bed mobility, transfer, eating, toilet use and personal hygiene. During an observation on 3/22/2022 at 10:05 a.m., Resident 35's call light was observed at the head of bed out of the resident's reach. During an observation on 3/22/2022 at 12:03 p.m., Resident 35's call light was observed at the head of bed out of the resident's reach. c. A review of Resident 43's admission Record (Face Sheet) indicated Resident 43 was initially admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 43's diagnoses included dementia, history of falling resulting in a fracture, essential hypertension, diabetes mellitus (high blood sugar), hemiplegia (paralysis [inability to move] of one side of the body) and hemiparesis (weakness to one side of the body). A review of Resident 43's MDS dated [DATE], indicated Resident 43 had moderate cognitive impairment and required total assistance for bed mobility, transfer, eating, toilet use and personal hygiene. A review of Resident 43's care plan dated 2/8/2022, indicated Resident 43 had an ADL self-care performance deficit. The care plan indicated Resident 43 required total assistance for one-person assist for bed mobility, transfer, eating, toilet use and personal hygiene. During an observation on 3/22/2022 at 10:13 a.m., Resident 43's call light was observed out of the resident's reach. During a concurrent observation and interview on 3/22/2022 at 12:03 p.m., Resident 43 call light was observed out of the resident's reach. Resident 43 stated it was hard to ask for help if you cannot find the call light or if you cannot reach it. Resident 43 stated it was very helpful when you are able to use the call light to ask for assistance. During a review of the facility's policy and procedure (P/P) titled, Accommodation of Needs Positive Practice, revised on 1/2020, the P/P indicated: Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. The resident's individual needs and preferences will be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. In order to accommodate individual needs and preferences, staff attitudes and behaviors must be directed towards assisting the residents in maintaining independence, dignity and well-being to the extent possible and in accordance with the residents' wishes. d. During a concurrent observation and interview on 3/22/22 at 10:17 a.m., during an initial tour of the facility, Resident 37 was observed lying in bed in a supine (face up) position and crying. Licensed Vocation Nurse (LVN 1) stated Resident 37 was not very verbal and hard to understand. There was no communication board observed in Resident 37`s room to aid the resident in communicating her needs to staff. During a review of Resident 37's admission Record, the admission Record indicated Resident 37 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 37's diagnoses included dysphagia (language disorder marked by deficiency in the generation of speech, and sometimes also in its comprehension, due to brain disease or damage), aphasia (condition that affects your ability to communicate), hemiplegia (paralysis [inability to move] of one side of the body), hemiparesis (weakness or inability to move on one side of the body), contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) right hand, and diabetes mellitus (a group of diseases that result in too much sugar in the blood). During a review of Resident 37's MDS dated [DATE], the MDS indicated the resident was severely cognitively impaired and rarely/never understood. The MDS indicated Resident 37 was totally dependent on staff for bathing, and had impairment on one side of the upper and lower extremities (arms and legs). During a review of Resident 37's Care Plan initiated on 2/2/22, the care plan indicated Resident 37 had altered communication, never really understood related to aphasia. The staff's interventions included providing Resident 37 with a communication device. During a concurrent observation and interview with LVN 1 on 3/23/22 at 9:42 a.m., at Resident 37's bedside, LVN 1 confirmed there was no communication board at the bedside. LVN 1 stated a communication board was attempted prior but the resident threw it. LVN 1 stated there were no alternative means of communication attempted at that time. LVN 1 confirmed only one question was asked with no other follow- up questions to figure out why resident why still screaming and crying to get her accommodation needs met. LVN 1 stated more questions would have been appropriate and, I would feel frustrated if my needs are not being met. During an interview with the Director of Nursing (DON) on 3/25/22 at 8:56 a.m., the DON stated Resident 37 was non- verbal and expectations would be to communicate the resident's needs accordingly included asking resident a series of questions and a communication device per resident's current care plan. The DON stated, If the nurse only asks one question to this resident and no communication board or other communication mechanisms in place then not appropriate to just ask one question. During a review of the facility's P/P titled, Accommodation of Needs, dated 2020, the P/P indicated staff will interact with the residents in a way that accommodates the physical or sensory limitations of the residents, promotes communication, and maintains dignity.

CONCERN (E)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an uncluttered physical environment, and a safe, clean, comfortable and home-like environment for four of four sampled residents (Resident 3, 30, 38 and 42). This deficient practice created an unsafe environment for Resident 38 whose wheelchair was bumped by Resident 3 at the entrance door of the patio while being wheeled by Resident 30, and Resident 42 was using disposable bed pads as a floor mat. These failures had the potential for other residents, staff, and visitors to have an accident and get hurt. Findings: a. During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses not limited to history of fall, muscle weakness, abnormalities of gait and mobility, paranoid schizophrenia (altered perception of reality), blindness in one unspecified eye, and anxiety disorder (intense, excessive and persistent worry and fear about everyday situations). During a review of Resident 3's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 3/9/2022, the MDS indicated the cognitive (the ability to understand or to be understood by others) skills for daily decisions making was cognitively intact. The MDS indicated Resident 3 required limited assistance of a one-person physical assist for transfer. The MDS indicated Resident 3 used a wheelchair and was only able to stabilize with staff assistance when transferring from surface to surface (transfer between bed and chair or wheelchair) and walking. The MDS indicated Resident 3 was independent with locomotion on unit and off the unit and self-sufficient once in the chair, with highly impaired vision. The MDS indicated Resident 3 had a history of falls in the last month prior to the resident's admission to the facility. During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was admitted to the facility on [DATE], with diagnoses not limited to acute respiratory disease (breathing is difficult and the oxygen levels in the blood abruptly drop lower than normal), history of unspecified fall, displaced fracture of medial malleolus of left tibia (inner side of the ankle), initial encounter for close fracture (broken bone that does not penetrate the skin), morbid (severe) obesity (too much body fat). During a review of Resident 30's MDS, dated [DATE], the MDS indicated Resident 30's cognitive skills for daily decisions making was intact, and the resident was independent with locomotion on and off the unit, walking in the room and corridor however, required help with set up only. During an observation on 3/22/2022 at 2:49 p.m., there were five (5) wheelchairs observed parked and stored in front of the entrance leading to the patio. Resident 3 was observed being wheeled by Resident 30 and bumped into one of the wheelchairs stored by the entrance door of the patio. Licensed Vocational Nurse (LVN) 4 opened the door of the patio and allowed Resident 30 to wheel Resident 3 to the patio. During an observation on 3/23/2022 at 1:09 p.m., there were six (6) wheelchairs observed parked and stored in front of the entrance door leading to the patio. A coffee cart and medication cart were also observed blocking the entrance to the patio. During an interview with Resident 30 on 3/24/2022 at 3:00 p.m., Resident 30 stated on 3/22/2022, he was wheeling Resident 3 to the patio when he accidentally bumped Resident 3's wheelchair into another wheelchair parked by the entrance of the patio. Resident 30 stated there were so many wheelchairs cluttered by the entrance and it made maneuvering the wheelchair difficult. Resident 30 stated the staff were aware that he would sometimes assist Resident 3 by pushing his wheelchair and was not told that he cannot assist Resident 3 with his wheelchair until the accident happened. Resident 30 stated he would no longer assist Resident 3. During a review of Resident 3's care plan, dated 3/9/2022, the care plan indicated to provide Resident 3 with a safe, secure environment, clutter free, well-lit room, and dry floor. During an interview with Licensed Vocational Nurse 4 (LVN 4) on 3/24/2022 at 7:09 a.m., LVN 4 stated she saw Resident 30 assisting Resident 3 by pushing the resident's wheelchair to the patio and accidentally hit another wheelchair parked by the entrance of the patio. LVN 4 stated staff should not place the wheelchairs by the entrance to the patio and should have a designated area by the hallway where the wheelchair could be securely stored. During an interview with the Director of Nursing (DON) on 3/24/2022 at 4:46 p.m., the DON stated the resident's environment should be free from clutter to avoid accidents and should not block the doors and entryway because it could be a hazard in case of an emergency. The DON stated the facility should create a home-like environment for the residents where residents can be comfortable and feel safe. During a review of Resident 3's SBAR (Situation Background Communication Recommendation) communication Form (a tool provided to aid in facilitating and strengthening communication between nurses and physicians), dated 3/24/2022, the SBAR indicated Resident 3 bumped the foot of another wheelchair going to the patio on 3/22/2022 with no injuries reported. b. During a review of Resident 42's admission Record, the admission Record indicated Resident 42 was admitted to the facility on [DATE] with diagnoses not limited to diabetes mellitus (body not produce enough insulin causing high blood sugar), dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) with behavioral disturbance, major depressive disorder (mood disorder that interferes with daily life), muscle weakness, unsteadiness on feet, pre-glaucoma (elevated intraocular pressure but no detectable disc or visual field damage. During a review of Resident 42's MDS, dated [DATE], the MDS indicated Resident 42's cognitive skills for daily-decisions making was intact, and resident was independent with locomotion on and off unit, walking in room and in corridor. During a concurrent observation and interview with Resident 42 on 3/22/2022 at 12:07 p.m. in Resident 42's room, Resident 42 was observed sitting on her bed with her feet resting on the floor, there was a reusable bed pad found on the floor right next to Resident 42's feet. Resident 42 stated she was using the bed pad as floor mat for her feet. c. During a review of Resident 38's admission Record, the admission Record indicated Resident 38 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses not limited to diabetes mellitus, acute respiratory disease, osteoarthritis (tissues in the joint break down over time), cardiomyopathy (affects heart muscle), anxiety disorder, and muscle weakness. During a review of Resident 38's MDS, dated [DATE], the MDS indicated the cognitive skills for daily decisions making was intact, and required limited assistance of a one-person physical assist for dressing, supervision with toilet use, personal hygiene, has impairment on both sides of lower extremities (legs) and used a wheelchair for mobility. During an observation on 3/22/2022 at 11:45 a.m. wet towels and reusable bed pads were observed under Resident 38's bed. During an observation on 3/24/2022 at 10:31 a.m., Resident 38 was observed sitting on his wheelchair. A urinal with 300 milliliters ([ml] unit of measurement) of urine, a breakfast food tray, six jelly fruit spread, four creamers, six straws, resident's personal belongings, paper documents, and a plastic bag filled with trash was observed on Resident 38's bedside table. A reusable bed pad was observed on the floor. During an interview with Resident 38 on 3/24/2022 at 10:45 a.m., Resident 38 stated he was using the reusable pad for his feet and to wipe the urine in case it spilled on the floor when he used the urinal. Resident 38 stated the staff did not come to pick up his food tray right away, and the staff did not mop the floor and clean his room when surveyors were not around. Resident 38 stated his room and hallways have lots of clutter in the hallways like wheelchairs, lift machines, and carts which makes it hard to go travel around the facility and could be a risk for accidents for residents. Resident 38 stated the clutter bother and frustrate him. During an interview with the Director of Nursing (DON) on 3/24/2022 at 4:46 p.m., the DON stated the reusable pads should not be on the floor and should not be used as a floor mat as residents might slip when they step on it and could get hurt. The DON stated the residents' room should be clean, and free from clutter to prevent any accident and pest infestations. During a review of the facility's policy and procedure (P/P) titled, Safety and Supervision of residents, dated 7/2017, the P/P indicated the facility strive to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. During a review of the facility's P/P titled, Homelike Environment, dated 2/2021, the P/P indicated Residents are provided with a safe, clean, comfortable and homelike environment. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include clean, sanitary and orderly environment.

CONCERN (E)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Obtain an order to titrate the use of oxygen ([O2] the life supporting component of air), and date and label the oxygen nasal cannula tubing as ordered for Resident 49. 2. Obtain an order for the use of oxygen and perform a thorough assessment of Resident 261's lung sounds. These deficient practices had the potential for health complications associated with lack of guidance from the physician, delay in assessment, treatment plan and poor continuity of care and follow-up on the resident's status. Findings: a. During a review of Resident 49's admission Record, the admission Record indicated Resident 49 was admitted to the facility on [DATE]. Resident 49's diagnoses included heart failure (heart muscle doesn't pump blood as well as it should), acute kidney failure (when kidneys suddenly become unable to filter waste products from blood), muscle weakness, iron deficiency anemia (blood lacks adequate healthy red blood cells which carry O2 to the body tissues), hypertension (abnormally high blood pressure), obesity (having too much body fat), chronic atrial fibrillation (irregular and often very rapid rhythm that can lead to blood clots in the heart), shortness of breath, and anxiety disorder (intense, excessive and persistent worry and fear about everyday situations). During a review of Resident 49's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 2/24/2022, the MDS indicated Resident 49's cognitive (the ability to understand or to be understood by others) skills for daily decisions making was intact. The MDS indicated Resident 49 required total dependence of a one-person physical assist for activities of daily living such as bed mobility, locomotion on unit, toilet use, and personal hygiene. The MDS indicated Resident 49 was receiving oxygen therapy. During an observation on 3/22/2022 at 10:20 a.m., Resident 49 was observed with a nasal cannula in the nose with the tubing connected to an oxygen concentrator (an oxygen concentrator takes in air and separates the oxygen and delivers it into a person via a nasal cannula) at 4 liters per minute (L/min, unit of rate). During a review of Resident 49's Physician Orders dated 2/24/2022 to 3/24/2022, the Physician Orders indicated to administer O2 at 2 L/min. During a review of Resident 49's Physician Orders dated 2/24/2022 to 3/24/2022, the Physician Orders indicated Resident 49's O2 nasal cannula and tubing to be changed every Sunday and label the date it was changed. During a concurrent observation and interview on 3/22/2022 at 10:20 a.m., with Registered Nurse 1 (RN 1), Resident 49 was observed with a nasal cannula in the nose with the tubing connected to an oxygen concentrator. RN 1 stated Resident 49 was receiving 3.5 L/min of oxygen and stated that the oxygen tubing was not labeled. During a concurrent interview and record review of Resident 49's Physician Orders dated 2/24/2022 to 3/24/2022, on 3/23/22 09:39 a.m., RN 1 stated Resident 49's physician orders indicated an order for 2 L/min and O2 via nasal cannula. RN 1 verified the orders indicated the tubing should be changed every Sunday with the date it was changed. RN 1 stated that if Resident 49 required more O2, the nurse should call the physician to get an order to titrate the O2. During an interview with the Director of Nursing (DON) on 3/24/2022, at 4:46 p.m., the DON stated there should be an order for oxygen, including when titration was needed to get guidance from the physician, assessment, treatment plan and continuity of care and follow-up on the resident's status. The DON stated the resident's nasal cannula and tubing should labeled and dated when it was changed. During a review of the facility's policy and procedure (P/P) titled, Oxygen Administration, dated 3/2004, the P/P indicated to provide safe oxygen administration the facility should verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. b. A review of Resident 261's admission Record, indicated Resident 261 was admitted to the facility on [DATE]. Resident 261's diagnoses included iron deficiency anemia, congestive heart failure (occurs when the heart muscle doesn't pump blood as well as it should), pressure ulcer (an injury that affects areas of the skin and underlying tissue) of the right hip, muscle weakness, cirrhosis of the liver (is a late-stage liver disease in which healthy liver tissue is replaced with scar tissue and the liver is permanently damaged). A review of Resident 261's MDS dated [DATE], indicated Resident 261 had intact cognitive function. A review of Resident 261's care plan titled, Impaired Respiratory Status, dated 3/10/2022 indicated to provide breathing treatment as ordered. During observations on 3/22/2022 at 9:19 a.m., 10:33 a.m., and 11:49 a.m., observed Resident 261 with audible (referring to hearing) chest congestion. During a concurrent interview and observation on 3/24/2022 at 10:11 a.m., observed Resident 261's oxygen concentrator infusing at 2 L/m with the nasal cannula laying at Resident 261 bedside. Licensed Vocational Nurse 3 (LVN 3) stated that when oxygen was infusing and not being administered to the resident, it does not benefit to the resident and was also a fire hazard that can lead to injury. LVN 3 was observed assessing Resident 261's lung sounds and stated the resident was congested and would benefit from oral suctioning. During an interview with Certified Nursing Assistant 2 (CNA 2) on 3/24/2022 at 12:54 p.m., CNA 2 stated when staff provide care to the resident's using oxygen via nasal cannula, CNA 2 removed the nasal cannula from the resident's nostrils to place on a new gown. CNA 2 stated the nasal cannula was placed back onto the resident after changing the gown. CNA 2 stated she was not allowed to turn the oxygen on and off because it was not within the CNAs scope of practice. CNA 2 stated that she did not know who left Resident 261's oxygen infusing at the bedside. During a concurrent interview and record review on 3/25/2022 at 10:40 a.m., LVN 3 stated the facility should have done a change of condition (COC) and informed Resident 261's assigned physician regarding the resident's audible congestion. LVN 3 stated suctioning would be helpful to Resident 261. LVN 3 verified there was no COC completed by the facility's staff regarding Resident 261's chest congestion, nor did the staff call and inform the resident's physician and responsible party regarding Resident 261's COC. LVN 3 verified there was no order for oxygen administration and Resident 261 was receiving oxygen without a physician's order. During a concurrent observation and interview on 3/25/2022 at 11:06 a.m., the DON was observed assessing Resident 261's lung sounds with a stethoscope (a medical instrument for listening to the action of someone's heart or breathing, typically having a small disk-shaped resonator that is placed against the chest, and two tubes connected to earpieces). The DON stated it was evident that you can really hear Resident 261's congestion even without using the stethoscope. During a concurrent observation and interview on 3/25/2022 at 12:27 p.m., RNs 1 and 2 were observed assessing Resident 261's lung sounds and acknowledged that lung congestion was evident and could be heard without using a stethoscope. RNs 1 and 2 stated that suctioning and a breathing treatment would be beneficial to Resident 261.

CONCERN (E)

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three of three staff (Certified Nurse Assistants [CNA 2], CNA 3, and CNA 4) had the necessary knowledge and skills to care for residents with an indwelling catheter (a urethral catheter designed to be held in place to drain urine from the bladder). The deficient practice had the potential to result in infection and hospitalization for the residents Findings: During a review of Resident 59's admission Record, indicated Resident 59 was admitted to the facility on [DATE]. Diagnosis included diabetes mellitus (abnormal sugar), hydronephrosis (excess urine accumulation in kidneys that causes swelling of kidneys) with renal and urethral calculous obstruction ( a blockage in one or both of the tubes that carry urine from the kidneys to the bladder), high blood pressure (the force of blood pushing against the walls of blood vessels, is consistently too high), history of urinary tract infections ([UTI] an infection in any part of urinary system) and the presence of urogenital implants (an injection of material into the urethra used to control urine leakage caused by a weak urinary sphincter) During a review of Resident 59's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 3/4/2022, indicated Resident 59 cognitive (the ability to understand or to be understood by others) skills for daily decisions making was intact. The MDS indicated Resident 59 required one-person extensive assistance for activities of daily living. The MDS indicated Resident 59 had an indwelling catheter. During a review of Resident 59's, the Physician Orders dated 2/23/2022 to 3/23/2022, indicated indwelling catheter care to be done by the CNA and monitored by the license nurse every shift. During an indwelling catheter care observation on 3/25/2022, at 9:30 a.m., CNA 2 wiped Resident 59's outer labia (folds of skin around the vaginal opening) towards Resident 59 indwelling catheter and urethra (the duct by which urine is conveyed out of the body from the bladder). CNA 2 wiped the indwelling catheter tubing from the distal part of tube and moved up towards the urethra. CNA2 lowered the height of Resident 59 bed and left the catheter bag touching the floor. During an interview on 3/25/2022, at 10:27 a.m., CNA 2 stated she cleaned Resident 59's outer labia and indwelling catheter tubing moving towards the urethra because she was nervous. CNA 2 stated she made a mistake of lowering the height of the bed and did not realize the indwelling catheter bag touched the floor. During an interview on 3/25/2022, at 10:30 a.m. CNA 2 stated she did not receive indwelling catheter care in-services the last four years. CNA 2 stated she completed 48 hours of CEU (Continuous Education Unit) classes to renew her license 11/2021, but the classes did not include indwelling catheter care. During an interview on 3/25/2022, at 11:00 p.m., CAN 4 stated she was taking care of residents with indwelling catheter, but she did not receive training on how to take care for resident with an indwelling catheter. During an interview with the Director of Staff Development (DSD) on 3/25/2022 at 11:20 a.m., the DSD stated the CNAs should clean the resident's perineal (region between the thighs, and by the opening of the vagina and anus) by separating the labia and wiping from the front to the back, toward the anus to prevent germs from entering the urethra. The DSD stated the area where the indwelling catheter was closer to the urethra was cleaned first and moved away from the body to prevent spreading germs into the urethra. During a concurrent interview and record review of the employee files and in-services, on 3/25/2022, at 11:50 a.m., the DSD stated from 2020 to 3/25/2022 there was no records indicating indwelling catheter care in-services was provided to the CNAs. The DSD stated CNA 2, CNA 3, and CNA 4, who were assigned to take care of resident with indwelling catheter, did not have skills check documented for indwelling catheter care. During an interview with the Director of Nursing (DON) on 3/25/2022 at 2:20 p.m., the DON stated the facility should have provided in-service training's and performed a skills competency for the CNAs upon hire and at least annually to ensure they had the necessary skills prior to taking care of the residents with indwelling catheter care. A review of the facility's Lesson Plan titled, Incontinent Care, dated 11/24/2021, the lesson plan indicated at the end of the class caregivers would be able to verbalize and demonstrate proper perineal care, the record indicated to cleanse the perineal from front to back, from inside to the outside, may fold towel once, then use another clean towel to continue per care (female). Method of evaluation verbalization, demonstration, rounds during care, yearly CNA skills demonstration. The facility's policy and procedure (P/P) titled, Catheter Care Urinary dated 9/2014, indicated the purpose of the policy was to prevent catheter associated UTI. The policy indicated to use standard precautions (a technique that prevents or reduces the spread of microorganisms from one site to another) when handling or manipulating the drainage system and maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. The policy indicated the catheter tubing and drainage bag were kept off the floor. During a review of the Facility assessment dated [DATE], indicated skills competencies were conducted annually and as necessary to ensure the provision of levels and types of care to support and care for the residents. During a review of the facility's Corona Virus (COVID 19) Mitigation Plan [(MP) a plan to reduce the spread of the COVID-19 virus) dated 08/17/2021, indicated the facility would ensure and provide a sufficient number of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment.

CONCERN (E)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five (5) percent, due to improper medication administration for three (3) of four (4) randomly selected residents (Resident 56, 29, and 11) during the medication administration. The outcome was six (6) medication errors out of thirty (30) opportunities, which resulted in a medication administration error rate of 20 percent and exceeded the five (5) percent threshold. Findings: a). During a review of Resident 56's admission Record (face sheet), the admission Record indicated Resident 56 was admitted to the facility on [DATE]. Resident 56's diagnoses included hemiplegia (paralysis [inability to move] of one side of the body) following cerebral infarction (brain injury) affecting the right dominant side, arthritis (condition that causes swollen and painful joints), dementia (term for loss of memory, language, problem-solving and other thinking abilities severe enough to interfere with daily life), type 2 diabetes mellitus (impairment in the way body regulates and uses sugar [glucose] as fuel), anemia (condition in which not enough healthy red blood cells to deliver oxygen to the body tissues), peptic ulcer (sore in the stomach), and heart failure (heart muscle does not pump as well as it should). During a review of Resident 56's Minimum Data Set (MDS), a standardized assessment and care screening tool, dated 3/2/2022, the MDS indicated Resident 56 had the ability to express ideas and wants and had clear comprehension and was able to understand verbal content. The MDS indicated Resident 56 had moderately impaired cognitive (ability to learn, remember, understand, and make decision) skills for daily decision making, ate independently, needed extensive assistance with bed mobility and transfer and was totally dependent with toilet use, personal hygiene, and dressing. During a concurrent interview with Licensed Vocational Nurse 1 (LVN 1) and record review of Resident 56's medication bubble packs (card that package doses of medication within small clear plastic bubbles or compartments for medication to be taken at specific times of the day) and Resident 56's medication administration record (MAR) on 3/22/2022 at 9:45 a.m., LVN 1 confirmed, he needed to medicate Resident 56 with: 1. Metformin (medication for diabetes)1000 milligrams (mg) 1 tablet (tab) orally ([PO] by mouth) twice a day to be given with breakfast and dinner at 7:30 a.m. and 5:00 p.m. 2. Potassium chloride extended release (supplement) PO once a day with food and eight ounces of water at 7:30 a.m. 3. Aspirin ([ASA] medication used as a blood thinner) 81 mg PO daily with food. During a medication pass observation and an interview with LVN 1 on 3/22/2022 at 10:00 a.m., LVN 1 confirmed verbally and then administered Metformin 1000 mg 1 tab, Potassium Chloride extended release 10 milliequivalent 1 tab, and ASA 81 mg, 1 tab to Resident 56 with four ounces of water. Per LVN 1, Resident 56 ate breakfast at about 7:15 a.m., approximately one and a half hours ago. Per LVN 1, Resident 56 consumed twelve (12) medications with four ounces of water. During an interview with Registered Nurse 1 (RN 1) and review of Resident 56's physician's orders and Medication Administration Record (MAR), dated 3/22/2022, on 3/24/2022 at 2:13 p.m., RN 1 confirmed Metformin, Potassium Chloride, and Aspirin were all administered at 10:02 a.m. Per RN 1, Metformin should have been administered at 7:30 a.m., and the three medications should have been administered with food; and potassium chloride should have been administered with eight ounces of water. Per RN 1, not taking Metformin with food and at breakfast can adversely affect Resident 56's blood sugar levels. Per RN 1, potassium chloride should have been administered with eight ounces of water as it may affect the heart. b). During a review of Resident 29's admission Record, the admission Record indicated Resident 29 was admitted to the facility on [DATE]. Resident 29's diagnoses included acute respiratory disease (problems breathing), dementia, anemia, muscle weakness, dysphagia, and essential hypertension (abnormally high blood pressure [force it takes blood to pump in the body]) During a review of Resident 29's MDS, dated [DATE], the MDS indicated Resident 29 sometimes expressed ideas and wants and had a clear comprehension and sometimes understood verbal content. The MDS indicated Resident 29 had severely impaired cognitive skills for daily decision making. Resident 29 ate independently, needed supervision with bed mobility, walking and transfer and required extensive assistance with dressing and was totally dependent with personal hygiene. During a medication pass observation and concurrent interview with LVN 2, and record review of Resident 29's physician orders and MAR's, on 3/24/2022 at 9:12 a.m., LVN 2 confirmed a medication order written on 12/27/2020 for multivitamins with minerals (supplement) one tab daily for Resident 29. Per LVN 2, she did not administer it because it was not in the MAR. Per LVN 2, the order needed to be clarified with the physician since it has not been administered since 12/27/2020. During a concurrent interview with Registered Nurse 1 (RN 1) and record review of Resident 56's physician's records and MARs for 2021 and 2022, on 3/24/22 at 2:13 p.m., RN 1 confirmed multivitamin was ordered for Resident 29 since 12/27/2020. RN 1 stated the medication was not transcribed and had not been administered to Resident 29 since 12/27/2020. RN 1 stated vitamins should have been given because it can affect Resident 29's wound healing and well-being. Per RN 1, Resident 29 had not received multivitamins as ordered for over a year. A record review of the facility's policy and procedure titled, Administering Medications, revised 4/2019, indicated the following: 1. Medications were administered in accordance with prescriber orders, including any required time frame. 2. Medication administration times were determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication. b. Preventing potential medication or food interactions; 3. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). c). During a review of Resident 11's admission Record, the admission Record indicated Resident 11 was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 11's diagnoses included dysphagia (difficulty swallowing), oropharyngeal phase (difficulty swallowing), gastroesophageal reflux disease (the stomach contents sometimes flow backward, up into the esophagus), gastrostomy ( a surgical operation for making an opening in the stomach), anxiety disorder (intense, excessive and persistent worry and fear about everyday situations), history of urinary tract infection (infection in any part of the urinary system), bipolar disorder (unusual shifts in mood, energy, activity levels, concentration, and the ability to carry out day-to-day tasks) and Parkinson's disease (progressive nervous system disorder that affects movement). During a review of Resident 11's MDS, dated [DATE], the MDS indicated Resident 11 rarely and never understood, was severely impaired in cognitive skills for daily decisions making and required total dependence of one to two-person physical assist for activities of daily living. During a review of Resident 11's Physician Orders dated 2/24/2022 to 3/24/2022, the physician orders indicated to administer Resident 11 the following: 1. Buspirone (used to treat anxiety) 5 mg 1 tab via gastrostomy tube ([G-Tube] surgical opening in the stomach used for nutrition, hydration, and medications) for anxiety manifested by (m/b) feeling anxious, and inability to relax twice a day. 2. Carbidopa/levodopa (used to treat Parkinson's disease) 25-100 mg one tablet via G-Tube for Parkinson's disease. 3. Seroquel ([quetiapine fumarate] used to treat mental/mood disorders) 25 mg one tab via G-Tube twice a day for agitation m/b screaming. 4. Valproic acid (used to treat seizures and bipolar disorder) 250mg/5 ml per G-Tube for bipolar disorder m/b constant yelling for no apparent reason. 5. Cranberry (used for urinary and bladder health) 425mg capsule for urinary tract infection ([UTI] bladder infection) prophylaxis. May cut open capsule and administer via G-Tube. During an observation of the medication administration on 3/24/2021, at 9:16 a.m., in Resident's 11 room, Licensed Vocational Nurse (LVN) 3 was observed administering five individually crushed medication tablets into Resident 11's G-Tube. LVN 3 used a syringe and plunger to ensure the medications went through the tube. LVN 3 flushed the tube with 30 milliliters (ml) of water between each medication. During an interview with LVN 3 on 3/24/2022, at 12:15 p.m., LVN 3 stated she administered all of Resident 11's medications by pushing the plunger of the syringe to ensure the medications went through the tube. LVN 3 stated she should not push the water or medication through the G-Tube because it could have damaged the G-Tube and should have been administered via gravity. During an interview with the Director of Nursing (DON) on 3/24/2022 at 12:39 p.m., the DON stated medications administered through a G-Tube should be administered through a syringe by gravity and not by pushing the syringe plunger because it can damage the G-Tube. During a review of the facility's P/P titled, Administering Medications through an Enteral Tube, dated 11/ 2018, the P/P indicated to administer medications through the enteral tube (feeding tube). The P/P indicated to administer the medication by gravity flow. Pour the diluted medication into the barrel syringe while holding the tubing slightly above the level of insertion. Open the clamp and deliver the medication slowly and begin the flush before the tubing drains completely.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to remove and replace expired medical supplies and tube feeding formula in one of two Storage Rooms. This deficient practice had the potential to result in the use of ineffective or spoiled equipment and formula for the residents. Findings: During a concurrent observation and interview on 3/22/2022 at 11:40 a.m., with Licensed Vocational Nurse (LVN) 4, during an inspection of the Storage Room located at Nursing Station 1 there were expired medical supplies and tube feeding formula. LVN 4 stated, Anything expired should be disposed of. Every shift should be checking for expiration. The following medical equipment and tube feeding formula supplies were found: 1. Four Irrigation Trays (used in wound irrigation and bladder irrigation), REF DYND20300 with expired date of 12/2021. 2. One IsoSource HN Complete Nutrition 1.2 kcal/ml unflavored (liquid food mixture containing protein, carbohydrates [sugar], fats, vitamins, and minerals, given through a tube into the stomach or small intestine) with expired date of 4/2019. During an interview with LVN 3 on 3/22/2022 at 2:20 p.m., LVN 3 stated, Should not keep anything expired in Storage Room. Can be detrimental to resident if expired. Bacteria can grow and can be detrimental. Irrigation tray used for, such as, Foley catheter don't want to use expired because it can cause infection and can be harmful. During a review of the manufacturer's guide titled, Health Science Product Guide, dated 2019, the guide indicated, The expiration date is the date up to which the product maintains its quality as well as the nutrient content declared on the label. The product should not be consumed after the expiration date has passed. During an email correspondence on 3/31/22 at 10:42 a.m. with the facility's Vendor Customer Service, the email indicated, Please see the statement below from our Urology division, regarding your inquiry for item# Item DYND20300 'We do not recommend using the tray after the expiration date.'

CONCERN (E)

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

Deficiency F0802 (Tag F0802)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure dietary staff (Cook 1 and [NAME] 2) had appropriate skills set to carry out the duties of a cook. This deficient practice resulted in 69 residents, who were receiving regular, pureed, or mechanical diets, receiving an incorrect portion size for pureed carrots, mechanical soft chicken, and potato salad, and 13 residents who were on a pureed diet received pureed carrots and pureed bread made with water instead of broth and milk. Findings During an observation on 3/22/22 at 12:15 p.m. of the tray line, [NAME] 1 was observed using the following scoop colors: 1. [NAME] scoop for potato salad for Pureed, Regular and Mechanical Soft diets. 2. [NAME] scoop for BBQ chicken, and a gray ladle (4 oz) for carrots for Mechanical Soft and Regular diets. 3. Gray scoop for BBQ chicken and gray scoop for carrots for Pureed diets. During a concurrent observation and interview with [NAME] 1 on 3/22/22 at 12: 15 p.m., scoop numbers were reviewed and compared against the facility's menu spreadsheet. The following scoop sizes were used: 1. #8 scoop for the puree carrots. 2. #12 scoop for mechanical soft chicken. 3. #10 scoop for potato salad. Cook 1 verified that the scoops used did not match the scoops indicated on the menu spreadsheet. A review of the facility's [NAME] Spreadsheet dated 3/22/22 indicated the following: 1. #12 scoop for the puree carrots. 2. #10 scoop for mechanical soft chicken. 3. #8 scoop for potato salad for Pureed, Regular and Mechanical Soft. During an observation on 3/22/22 at 1139 a.m. , [NAME] 2 was observed making pureed carrots and pureed bread by adding water to the food processor. During an interview with [NAME] 2 on 3/23/22 at 12:56 p.m., [NAME] 2 stated that she used 1 pint of milk and two (2) cups of water to make the pureed bread. [NAME] 2 stated staff were taught to make the bread in that manner and to make it the consistency of nectar pudding. [NAME] 2 stated the pureed carrots were made by mixing two (2) parts carrots to 1 cup water. [NAME] 2 stated staff were taught to use a combination of water or broth. A review of the facility's recipe for pureed vegetables indicated that warm fluid such as milk or low sodium broth should be added to vegetables. A review of the facility's recipe for pureed bread indicated warm milk or cold milk to be added to bread mixture. During an interview on 3/23/22 at 12:58 p.m. with the Registered Dietician (RD), the RD stated that water should not be used when making the pureed food because it can remove the flavor of the food and lower the nutritive value of the food. The RD stated that the cooks were trained to follow the menu spreadsheet with scoop selection and the recipes when making the pureed food. During an interview 3/23/22 at 2:54 p.m. with the Dietary Manager (DM), the DM stated she had not completed the year competency checklist for [NAME] 2 which included the preparation of mechanically altered food.

CONCERN (E)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to: a. Follow its menu as written for residents on regular, pureed, and mechanical soft diets. 69 residents who were receiving regular, pureed, or mechanical diets received an incorrect portion size for puree carrots, mechanical soft chicken and potato salad. This deficient practice had the potential to affect the residents' weight resulting in weight loss when the menu was not followed for residents on regular, pureed, and mechanical soft diet. b. Follow the pureed recipe for making pureed carrots and pureed bread. 13 residents who were receiving a pureed diet received pureed carrots and pureed bread made with water instead of broth and milk. These deficient practices had the potential to affect the nutritive value of the pureed carrots and bread served to the residents. Findings a. During an observation on 3/22/22 at 12:15 p.m. of the tray line, [NAME] 1 was observed using the following scoop colors: 1. [NAME] scoop for potato salad for Pureed, Regular and Mechanical Soft diets. 2. [NAME] scoop for BBQ chicken, a gray ladle (4 oz) for carrots for Mechanical soft and Regular diets. 3. Gray scoop for BBQ chicken and gray scoop for carrots for puree diets. During a concurrent observation and interview with [NAME] 1 on 3/22/22 at 12: 15 p.m. [NAME] 1 reviewed the scoops numbers. The following scoop sizes were used by [NAME] 1: 1. #8 scoop for the puree carrots 2. #12 scoop for mechanical soft chicken 3. #10 scoop for potato salad A review of the facility's [NAME] Spreadsheet dated 3/22/22 indicated the following: 1. #12 scoop for the puree carrots 2. #10 scoop for mechanical soft chicken 3. #8 scoop for potato salad for Pureed, Regular and Mechanical Soft diets During an interview with [NAME] 1 on 3/22/22 at 12:15 p.m., [NAME] 1 stated it was important to follow the menu spreadsheet because residents were on different diets which may affect their weight gain or loss. During an interview with [NAME] 2 on 3/23/22 at 12:56 p.m., [NAME] 2 stated that using the correct scoop was important because they provide the correct portion for meals. [NAME] 2 stated that the spreadsheet should be referenced when choosing the correct scoop size. During an interview on 3/23/22 at 12:58 p.m. with the Registered Dietician (RD), the RD stated it was important to follow the menu because it provided the correct portions, and could affect if the resident either gains or losses weight. b. During an observation on 3/22/22 at 1139 a.m., observed [NAME] 2 making pureed carrots and pureed bread by adding water to the food processor. During an interview with [NAME] 2 on 3/23/22 at 12:56 p.m., [NAME] 2 stated she used one (1) pint of milk and 2 cups of water to make the pureed bread. [NAME] 2 stated they were taught to make the pureed bread in that manner to make it the consistency of nectar pudding. [NAME] 2 stated that the pureed carrots were made by mixing 2 parts carrots to 1 cup water. [NAME] 2 stated they were taught to use a combination of water or broth. A review of the facility's recipe for pureed vegetables indicated that warm fluid such as milk or low sodium broth should be added to vegetables. A review of the facility's recipe for pureed bread indicated warm milk or cold milk was to be added to bread mixture. During an interview with the RD on 3/23/22 at 12:58 p.m., the RD stated that water should not be used when making the pureed food because it could remove the flavor of the food and lower the nutritive value of the food.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety when: 1. Several food items were not dated and labeled after being placed in the reach-in freezer and walk-in refrigerator. 2. Vegetables were stored in open bags in the walk-in refrigerator. 3. The ice machine was not cleaned properly and there was pink residue inside the ice machine. This failure had the potential to result in germ exposure to residents and placed residents at risk for developing foodborne illness (food poisoning: any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food, as well as toxins) which can lead to other serious medical complications and hospitalization for 69 out of the 76 residents who received food from the kitchen. Findings During a concurrent interview and observation on 3/22/2022 at 8:15 a.m. with the Dietary Manager (DM), multiple items in the reach-in freezer (6 bags of yellow corn, 7 bags of sugar snap peas, and 4 bags of succotash) were not labeled with the use by date. The DM stated that they should be labeled with the date, but they were going to be used for lunch today and will not be in the freezer that long. Also observed ½ of a roast beef in reach-in freezer with no identifying label. The DM stated the name is not required because it was sitting next to the other piece of roast beef, and it could be assumed that it was roast beef. In the walk-in refrigerator, observed Mighty shakes and frozen juice labeled with only the delivery date but no use by date. The DM stated the Mighty shakes and frozen juice need to be defrosted right away when they are delivered because it takes a couple of days to defrost. The DM also stated that the facility uses the Mighty shakes and frozen juices before the 14-day expiration that they use the delivery date as their point of reference. Also observed in walk-in refrigerator, green onions and lettuce stored in open bags. The DM stated that the bag of green onions and lettuce should be closed. During a concurrent interview and observation on 3/22/2022 at 8:20 a.m. with [NAME] 1, observed a tray with juice and a container of mixed fruit with no label of the food item. [NAME] 1 stated every item placed in the refrigerator should have a label with the date prepared, use by date, and the name of the item. During a concurrent observation of the facility's ice machine and interview on 3/22/2022 at 8:30 a.m. with the Maintenance Director (MD), the ice machine was found to have a pinkish orange sticky residue when the inside of the machine was wiped with a white napkin. The MD stated that it should be cleaned. The MD stated that the ice was cleaned out every month. The MD stated if the ice machine was not cleaned properly, it could lead to illness among the staff and the residents. A review of the facility's policy and procedure (P/P) titled, Procedure for Refrigerated Storage, dated 2019, indicated that food should be labeled with the date to facilitate the practice of using the older items first. The P/P indicated that food and leftovers should be covered, labeled, and dated. A review of the facility's P/P titled, Ice Machine Cleaning Procedures, dated 2018, indicated that the machine should be cleaned monthly with a sanitizing agent per manufacturer's instructions for use.

CONCERN (E)

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

Deficiency F0838 (Tag F0838)

Could have caused harm · This affected multiple residents

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Based on interview and record review, the facility failed to ensure a facility-wide assessment was implemented when the facility failed to: a. Ensure the competency of kitchen staff when preparing meals for the pureed diet (food that does not need to be chewed) recipe and serving the correct amount of food to residents as specified in the menus. b. Ensure competency of nursing staff when providing residents with an indwelling catheter (flexible tube inserted to bladder to drain urine) care and when administering medications safely. c. Ensure sufficient nursing staff in the day-to-day operations. This deficiency had the potential to result in poor resident health outcomes and diminished quality of care for facility residents. Cross Reference F759, F725, F726, F801 Findings: During a concurrent interview with the Administrator (ADM) and record review of the facility's Facility Assessment Tool, dated 2/24/2022, on 3/25/2022 at 2:33 p.m., ADM confirmed ensuring staff competency was part of the facility assessment requirement and should have been implemented properly. The ADM stated the facility had opportunities for improvement regarding: a. Competency of kitchen staff when following recipes and menus; b. Competency of nursing staff when providing residents with indwelling catheter care and administering medications to residents safely; and c. Sufficient nursing staff in the day-to-day operations. During a record review of the Facility Assessment Tool, dated 2/24/2020, the assessment indicated staffing was planned and adjusted according to the acuity of residents and levels of care needed. The tool indicated ongoing training and education was provided to ensure provision of levels and types of care to support resident population including catheter care and medication administration.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective infection control and prevention program to prevent the development and transmission of communicable diseases by not ensuring the use of personal protective equipment ([PPE] protective clothing, garments or equipment designed to protect the wearer or the resident from infections) prior to entering a yellow zone room (designated area for residents exposed to COVID-19). This deficient practice placed the residents, staff, and the community at higher risk for cross contamination, and increased spread of COVID-19 (a potentially severe respiratory illness caused by a coronavirus and characterized by fever, coughing, and shortness of breath) in the facility and the community. Findings: During an observation on 3/22/2022 at 10:24 a.m., Certified Nursing Assistant 5 (CNA 5) was observed exiting a shower room in the yellow zone without changing gowns and gloves. CNA 5 was observed wheeling a resident back to their room in the yellow zone room without putting on new personal protective equipment (PPE). During a concurrent observation and interview on 3/22/2022 at 10:24 a.m., CNA 5 was observed inside room [ROOM NUMBER], which is the yellow zone room, without using the required PPE. CNA 5 stated she did not wear the required PPE because she was in a hurry to provide care to another resident. CNA 5 acknowledged not wearing appropriate PPE was an infection control issue. CNA 5 stated all staff must wear the required PPE to enter a yellow zone room to prevent the spread of infection. During an interview on 3/23/2022 at 1:46 p.m., the Infection Preventionist Nurse (IP) stated that when a staff provides a shower to a resident coming from the yellow zone, staff must wear all the required PPE, which included a fitted N95 (a respirator mask that provides a secure seal), goggles, gown and gloves. IP stated doffed (remove an item or clothing) properly and change a new gown and gloves when entering back to the yellow zone room. The IP stated when a staff provides direct care to a resident, staff must wear all the required PPE because if any staff who does not follow the requirement, violate the infection control practices. A review of the facility's policy and procedure (P/P) titled, Infection Prevention and Control Program, updated on 9/17/2021, indicated an infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

CONCERN (E)

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

Antibiotic Stewardship (Tag F0881)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure two of two residents (Resident 55 and Resident 51) were prescribed antibiotics appropriately by failing to develop a clear policy and implementing an antibiotic stewardship program. This deficient practice had the potential to increase antibiotic resistance and provide antibiotics without justification. Findings During a concurrent interview with the Infection Preventionist Nurse (IP) and record review of Resident 55's electronic health record (EHR) on 3/23/22 at 2:08 p.m., the IP stated that there was no completed McGeer's criteria (criteria used to determine appropriate use of antibiotics) in Resident 55's chart. During a concurrent interview with the IP and record review on 3/23/22 at 2:08 p.m. of Resident 51's EHR, the IP stated that there was no completed McGeer's criteria in Resident 51's chart. A review of Resident 55's admission Record indicated the resident was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 55's diagnoses included urinary tract infection ([UTI] a condition in which bacteria invade and grow in the urinary tract) and pneumonia (an infection of one or both of the lungs caused by bacteria, viruses, or fungi). A review of Resident 55's Minimum Data Set (MDS), a standardized resident assessment and care screening tool, dated 3/3/2022 indicated Resident 55's cognition (ability to think and reason) was severely impaired. The MDS indicated Resident 55 was totally dependent on staff for activities of daily living ([ADLs] transfer, dressing, eating, toilet use, personal hygiene, and bathing) and was incontinent (inability to control) of bowel function. A review of Resident 55's Physician Order, with a start date of 2/1/2022, indicated to administer Amoxicillin (used to kill certain bacterial infections) 875 milligrams ([mg] unit of measurement) every 12 hours for pneumonia for a duration of 5 days. A review of Resident 55's Physician Order, with a start date of 2/1/2022, indicated to administer Metronidazole (used to treat a variety of infections) 500 mg every 6 hours for pneumonia for a duration of 5 days. A review of Resident 51's admission Record, indicated the resident was originally admitted on [DATE] and readmitted on [DATE] with the diagnoses including acute respiratory disease (an infection that affects breathing and lower oxygen levels in the blood) and urinary tract infection. A review of Resident 51's MDS dated [DATE], indicated Resident 55's cognition was intact. According to the MDS, Resident 55 was totally dependent on staff for ADLs, was incontinent of bowel function, and had an indwelling catheter (drains urine from the bladder into a bag outside the body). A review of Resident 51's Physician Order, with a start date of 2/2/2022, indicated to administer Zithromax ([Azithromycin] used to treat bacterial infections) 250 mg once a day for cough for a duration of 4 days. During an interview with the IP and concurrent record review on 3/23/22 at 2:08 p.m., the IP stated that at the end of every month the facility runs a report to review the antibiotic usage and use the information to complete the infection control surveillance line listing. The IP stated the information placed on the infection control surveillance line listing form was the information used to track antibiotic use. The IP stated that during the monthly report, they verify in the resident's medical record if the McGeer's criteria has been completed for the residents on antibiotics. The IP stated the McGeer's criteria should be completed by the nurse who received the order for the antibiotics, and if the criteria was not completed, it should be followed up by the IP. The IP stated if the criteria was not done, it was unclear if the resident met the criteria for the antibiotic and the licensed staff were unable to inform the doctor if the criteria was met. The IP stated that this could lead to inappropriate use of antibiotics. During a concurrent interview with the IP and review of the facility's policy and procedure (P/P) on Antibiotic Stewardship on 3/23/22 at 2:08 p.m. the IP stated the facility's current policy did not include the criteria that was utilized to determine appropriate antibiotic use. A review of the facility's undated P/P titled, Infection Prevention and Control Program, indicated there was an evaluation of antibiotic usage and feedback was provided to practitioners. According to the Centers for Disease Control and Prevention (CDC) core elements that should be included in the Antibiotic Stewardship for Nursing Homes included developing and implementing algorithms for the assessment of residents and performing antibiotic time outs. Antibiotic time outs is a process designed to prompt a reevaluation of need and choice of an antibiotic once more data is available.

CONCERN (F)

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

QAPI Program (Tag F0867)

Could have caused harm · This affected most or all residents

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Based on interview and record review, the facility's Quality Assessment and Assurance (QAA) Committee failed to implement corrective actions to the systemic problems identified: a. Ensure the medication administration error rate was below five (5) percent; b. Ensure consistent implementation of the facility's antibiotic stewardship program (effort to measure and improve how antibiotics [medications that fight infections-- germs invade body and makes the body sick]were prescribed by clinicians and used by residents in the facility) c. Ensure the competency of kitchen staff when following a pureed diet [food that doe not need to be chewed] recipe and serving the correct amount of food to residents as specified in the menus; d. Ensure competency of nursing staff when providing residents with an indwelling catheter (flexible tube inserted to bladder to drain urine) care; and e. Ensure sufficient nursing staff in the day-to-day operations. As a result, the facility's deficient practices placed 76 out of 76 residents at risk for not receiving the quality treatment necessary to adequately meet their highest practicable well-being. Cross Reference F759, F881, F725, F726, F801 Findings: During an interview with the administrator (ADM) on 3/25/2022 at 2:33 p.m., ADM confirmed not being able to identify systemic issues identified during the survey. ADM stated QAA was supposed to identify systemic issues and address them. ADM acknowledged the facility had opportunities for improvement regarding: a. Medication administration error aversion; b. Implementation of the facility's antibiotic stewardship program (effort to measure and improve how antibiotics [medications that fight infections] are prescribed by clinicians and used by residents in the facility); c. Competency of kitchen staff when following recipes and menus; d. Competency of nursing staff when providing residents with an indwelling catheter (flexible tube inserted to bladder to drain urine) care; and e. Sufficient nursing staff in the day-to-day operations. During a record review of the facility's policy and procedure (P/P) titled, Administering Medications, revised 4/2019, the P/P indicated medication errors were documented, reported, and reviewed by the QAA committee to inform process changes and /or the need for additional staff training. During a record review of the facility's undated P/P titled, Quality Assessment and Assurance, the P/P indicated the QAA committee would identify quality issues and develop and implement appropriate plans of action to correct identified deficiencies within the facility through an interdisciplinary approach. Through the QAPI committee facility indicated the following goals: a. A decrease and prevention of the utilization of unnecessary antibiotics to improve resident outcomes and reduce antibiotic resistance (when germs develop the ability to defeat the drugs designed to kill them); b. Significant medication management and administration error rate of 0 percent; c. A decreased number of residents with urinary tract (body's drainage system for removing urine which is made up of wastes and extra fluid) infections, and maintain an average below the state average; and d. The facility will develop a stable work force by improving retention and recruitment reducing staff turnover (number of workers who leave the facility over a certain period of time) percentage and filling open positions.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• 43% turnover. Below California's 48% average. Good staff retention means consistent care.

Concerns

• 82 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
• $38,181 in fines. Higher than 94% of California facilities, suggesting repeated compliance issues.
• Grade D (45/100). Below average facility with significant concerns.

Bottom line: Trust Score of 45/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Costa Del Sol Healthcare's CMS Rating?

CMS assigns COSTA DEL SOL HEALTHCARE an overall rating of 3 out of 5 stars, which is considered average nationally. Within California, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.

How is Costa Del Sol Healthcare Staffed?

CMS rates COSTA DEL SOL HEALTHCARE's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 43%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Costa Del Sol Healthcare?

State health inspectors documented 82 deficiencies at COSTA DEL SOL HEALTHCARE during 2022 to 2025. These included: 2 that caused actual resident harm and 80 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Costa Del Sol Healthcare?

COSTA DEL SOL HEALTHCARE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by PACS GROUP, a chain that manages multiple nursing homes. With 99 certified beds and approximately 86 residents (about 87% occupancy), it is a smaller facility located in LOS ANGELES, California.

How Does Costa Del Sol Healthcare Compare to Other California Nursing Homes?

Compared to the 100 nursing homes in California, COSTA DEL SOL HEALTHCARE's overall rating (3 stars) is below the state average of 3.1, staff turnover (43%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.

What Should Families Ask When Visiting Costa Del Sol Healthcare?

Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.

Is Costa Del Sol Healthcare Safe?

Based on CMS inspection data, COSTA DEL SOL HEALTHCARE has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in California. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Costa Del Sol Healthcare Stick Around?

COSTA DEL SOL HEALTHCARE has a staff turnover rate of 43%, which is about average for California nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Costa Del Sol Healthcare Ever Fined?

COSTA DEL SOL HEALTHCARE has been fined $38,181 across 1 penalty action. The California average is $33,461. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Costa Del Sol Healthcare on Any Federal Watch List?

COSTA DEL SOL HEALTHCARE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 99
Avg. Residents: 86
Occupancy: 87.7%
Ownership: For profit - Limited Liability company
Chain: PACS GROUP
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
3-Star Rating: +20
2 Actual Harm citations: -10
82 Deficiencies: -10
Fines ($38,181): -5
Final Score: 45/100

Nearby Alternatives

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

View all in LOS ANGELES →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 055697