What is LONGWOOD MANOR CONV.HOSPITAL's CMS rating?

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

How many inspection deficiencies does LONGWOOD MANOR CONV.HOSPITAL have?

LONGWOOD MANOR CONV.HOSPITAL has 91 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at LONGWOOD MANOR CONV.HOSPITAL?

LONGWOOD MANOR CONV.HOSPITAL has a three-star staffing rating from CMS with 0.43 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 LONGWOOD MANOR CONV.HOSPITAL located?

LONGWOOD MANOR CONV.HOSPITAL is located in LOS ANGELES, CA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does LONGWOOD MANOR CONV.HOSPITAL have?

LONGWOOD MANOR CONV.HOSPITAL has 198 certified beds.

Who owns LONGWOOD MANOR CONV.HOSPITAL?

LONGWOOD MANOR CONV.HOSPITAL is a for profit - corporation facility and is part of the LONGWOOD MANAGEMENT CORPORATION chain.

Is LONGWOOD MANOR CONV.HOSPITAL safe?

LONGWOOD MANOR CONV.HOSPITAL has documented safety concerns including a substantiated abuse finding on record. Families should ask about corrective actions taken.

Do nurses at LONGWOOD MANOR CONV.HOSPITAL stick around?

LONGWOOD MANOR CONV.HOSPITAL has average staff turnover at 35%, which is typical for the nursing home industry.

Was LONGWOOD MANOR CONV.HOSPITAL ever fined?

Yes, LONGWOOD MANOR CONV.HOSPITAL has been fined $24,465 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is LONGWOOD MANOR CONV.HOSPITAL on any federal watch list?

No, LONGWOOD MANOR CONV.HOSPITAL is not on any federal watch list. It is not designated as a Special Focus Facility or SFF Candidate by CMS.

What have inspectors found at LONGWOOD MANOR CONV.HOSPITAL?

Medicare inspectors have found 91 deficiencies at LONGWOOD MANOR CONV.HOSPITAL: 2 serious, 87 moderate, 2 minor. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting LONGWOOD MANOR CONV.HOSPITAL?

Families visiting LONGWOOD MANOR CONV.HOSPITAL 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 LONGWOOD MANOR CONV.HOSPITAL compare to other nursing homes?

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

LONGWOOD MANOR CONV.HOSPITAL | 23/100 (Grade F)

Sept 2025 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure medications were administered as ordered by the physician fo...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure medications were administered as ordered by the physician for four (4) of 4 sampled residents' (Residents 1, 2, 3 and 4).This failure placed the affected residents at risk for ineffective disease management and had the potential to affect the recovery process of the residents.Findings:1). 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 diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing,) hypertension (HTN-high blood pressure) and cerebral edema (the swelling of the brain tissue due to an abnormal accumulation of fluid.) During a review of Resident 1's History and Physical (H&P) dated 2/5/2025, the H&P indicated Resident 1 does not have the capacity to understand and make medical decisions. During a review of Resident 1's doctors' orders dated 3/6/2025, the doctors' orders indicated gabapentin (anticonvulsant medication used to treat seizures and specific types of nerve pain) oral 300 milligrams (mg- a unit of measurement) three times (TID) a day for neuropathic pain (a type of chronic pain caused by damage or dysfunction in the nerves). During a review of Residents 1's Minimum Data Set (MDS - a resident assessment tool) dated 9/10/2025, the MDS indicated Resident 1 had severe cognition impairment. The MDS indicated Resident 1 was dependent with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, transfer and mobility. During a review of Resident 1's Medications Administration Record (MAR) for 9/2025, the MAR indicated gabapentin was scheduled to be administrated at 9:00 a.m., 1 p.m., and 5:00 p.m. daily. During a review of Resident 1's MAR Audit Report of gabapentin dated 9/22/2025 and 9/23/2025 timed 5:00 p.m., the audit report indicated the gabapentin was administrated on 9/22/2025 at 7:55 p.m., and at 8:59 p.m. on 9/23/2025 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 including DM, HTN and right artificial knee joint (surgical procedure that replaces the damaged cartilage and bone in the right knee joint with artificial components.) During a review of Resident 2's Clinical admission dated 9/23/2025, the clinical admission indicated Resident 2 can understand and be understood by others.a. During an observation on 9/24/2025 at 8:54 a.m. with Licensed Vocational Nurse (LVN) 1 in Resident 2's room, LVN 1 was observed preparing Resident 2's metformin (medication for diabetes) that was scheduled for 7:30 a.m. The metformin was administered at 9:08 a.m. During a review of Resident 2's MAR Audit Report of metformin dated 9/24/2025 timed 7:30 a.m., it was administrated at 9:08 a.m. During a review of Resident 2's doctors' orders dated 9/23/2025, the doctors' orders indicated metformin (medication type 2 DM) oral 500 mg two times (BID) a day. During a review of Resident 2's MAR for 9/2025, the MAR indicated metformin was scheduled to be administrated at 7:30 a.m., and 4:30 p.m., daily. During a review of Resident 2's care plan for hypoglycemia (low blood sugar) and hyperglycemia related to diabetes mellitus, dated 9/24/2025, the care plan interventions indicated to administer medications as ordered. During an interview on 9/24/2025 at 9:20 a.m. with Resident 2 in Resident 2's room, Resident 2 stated she take metformin medicine in the morning and at night. Resident 2 stated her blood sugar level is not usually high, but this morning (9/24/2025 time not specified), her blood sugar level was very high (level not specified) because she did not receive her medications last night. Resident 2 stated during her breakfast at around 7:30 a.m., she asked the metformin medicine from the nurse (unidentified) and was told the metformin was not available from the pharmacy. b. During a review of Resident 2's doctors' orders dated 9/23/2025, the doctors' orders indicated Acetaminophen oral tab 325 milligram (mg- a unit of measurement) , give 1 tablet by mouth every four (4) hours (Q4hrs) as needed (PRN) for mild pain, Hydrocodone-Acetaminophen (Norco- medication used to treat moderate to severe pain) oral tab 5-325 mg, to give 1 tablet by mouth Q6hrs PRN for moderate pain (4-6). During a review of Resident 2's MAR for 9/2025, the MAR indicated pain assessment (numeric rating scale- 0: No pain, 1-3: Mild pain, 4-6: Moderate pain, 7-9: Severe pain, and 10: Worst possible pain) every shift, day, evening and night. The MAR indicated on 9/23/2025 at night, the pain level was 0 (no pain). The MAR indicated on 9/23/2025 at 11:47 p.m., and at 6:44 a.m. Resident 2 was medicated with Tylenol oral tab 325 mg. The MAR did not indicate the pain level was assessed. During an interview on 9/24/2025 at 9:20 a.m. with Resident 2 in Resident 2's room, Resident 2 stated she was admitted to the facility on [DATE] around 5:30 p.m., for rehabilitation due to right total knee replacement. Resident 2 stated she requested pain medications 9/23/2025 at around 11 p.m. and was given Tylenol (amount unspecified). Resident 2 stated on 9/24/2025 around 6:00 a.m., Resident 2 stated the pain level was 10/10 and requested Norco. Resident 2 stated the nurses (unidentified) told her (Resident 2) that the Norco was not delivered by the pharmacy. Resident 2 stated the Tylenol helped her a little. Resident 2 stated after she took the Tylenol, the pain level was 9/10. During an interview on 9/24/2025 at 12:15 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated when a resident complained of pain, the resident's pain must be assessed and should be medicated according to the physician's order. LVN 2 stated the pain level should be documented in the MAR and the licensed nurses should medicate the residents based on their pain level. LVN 2 stated that when residents are in a lot of pain and medication is not available, the nurses should contact the doctor and pharmacy to remove the medication from the emergency kit (emergency medications supplies that allow healthcare staff to quickly respond to sudden medical needs). LVN 2 stated it was not acceptable to let Resident 2 suffer in pain. LVN 2 stated the risk of leaving Resident 2 in pain can cause her to feel anxious and respiratory distress. During an interview on 9/24/2025 at 2:36 p.m. with LVN 4 stated on 9/23/2025 at around 11:30 p.m., Resident 2 reported pain level of 3/10. LVN 4 stated Resident 2 was medicated with Tylenol for mild pain. LVN 4 stated that after medication was administrated, the nurses need to document the level of pain. LVN 4 stated it was important to enter the resident's pain level to indicate if pain was managed accurately. LVN 4 stated he did not enter Resident 2's pain level in the MAR on 9/23/2025 at 11:30 p.m. During an interview on 9/24/2025 at 3:32 p.m. with the Director of Nursing (DON), the DON stated pain assessment should be done every shift. The DON stated assessment for pain level was important so that the nurses will know which pain medications to administer and the pain will be managed. The DON stated nurses should document the pain level in the MAR when unable, nurses can document in the resident's progress notes. The DON stated if pain level was not documented, the pain could not be properly managed. The DON stated not managing Resident 2's pain can cause the resident stress and health status affected due to uncontrolled pain. 3). During a review of Resident 3's admission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses including DM, HTN and hyperlipidemia.During a review of Resident 3's H&P dated 3/20/2025, the H&P indicated Resident 3 had the capacity to understand and make medical decisions. During a review of Resident 3's doctors' orders dated 3/28/2025, the doctors' orders indicated hydrochlorothiazide (medication to treat high blood pressure and fluid retention) oral 25 mg 1 tablet by mouth one time a day for HTN and metformin oral 500 mg, to give one table by mouth with meals for DM, administered with breakfast. During a review of Resident 3's care plan for hypoglycemia and hyperglycemia related to diabetes mellitus dated 3/28/2025, the care plan interventions indicated to administer medications as ordered. During a review of Residents 3's MDS dated [DATE], the MDS indicated Resident 3' cognition was intact. The MDS indicated Resident 3 required supervision or touching assistance with ADLs. During a review of Resident 3's MAR for 9/25/2025, the MAR indicated hydrochlorothiazide 25 mg was scheduled to be administrated at 8:00 a.m. and the metformin 500 mg was scheduled to be administrated at 7:30 a.m. with breakfast. During a review of Resident 3's MAR Audit Report of metformin administration dated 9/23/2025 and 9/24/2025 timed 7:30 a.m., the audit report indicated the metformin was administrated at 10:38 a.m. on 9/23/2025 and at 9:35 a.m. on 9/24/2025. The audit report indicated the hydrochlorothiazide was administered at 10:39 a.m. on 9/23/2025 and at 9:35 a.m. on 9/24/2025. During a concurrent interview and record review on 9/24/2025 at 10:10 a.m., with LVN 2 in Resident 3's room, Resident 3's MAR for 9/2025 was reviewed. LVN 2 stated the metformin 500 mg and hydrochloride 25 mg daily were documented and administered late. During an interview on 9/24/2025 at 10:42 a.m. with Resident 3 in Resident 3's room, Resident 3 stated he take metformin in the morning and nighttime. Resident 3 stated he should have gotten the metformin when he was eating breakfast around 7:30 a.m. but did not receive it (metformin). 4). 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], with diagnoses including DM, HTN and epilepsy unspecified (type of seizure cannot be determined.) During a review of Resident 4's care plan for hypoglycemia and hyperglycemia related to diabetes mellitus, dated 8/14/2024, the care plan interventions indicated to administer medications as ordered. During a review of Resident 4's doctors' orders dated 7/17/2025, the doctor's orders indicated metformin oral 500 mg, to give one tablet by mouth with meals for DM and gabapentin 100 mg 2 capsule by mouth TID for neuropathic pain. During a review of Residents 4's MDS dated [DATE], the MDS indicated Resident 4's cognition was intact. The MDS indicated Resident 3 required substantial/ maximal assistance with ADLs. During a review of Resident 4's H&P dated 11/3/2024, the H&P indicated Resident 4 had the capacity to make decisions. During a review of Resident 4's MAR for 9/2025, the MAR indicated metformin 500 mg was scheduled to be administrated at 7:00 a.m. and 5 p.m. The MAR indicated gabapentin 100 mg was scheduled to be administrated at 9:00 a.m., 1:00 p.m., and 5:00 p.m. During a review of Resident 4's MAR Audit Report of metformin administration dated 9/22/2025, 9/23/2025 and 9/24/2025 timed 7:00 a.m., and 5 p.m., the audit report indicated the metformin was administered on 9/22/2025 at 7:55 p.m., on 9/23/2025 at 8:58 a.m. and 8:57 p.m., on 9/24/2025 at 8:53 a.m. The audit report indicated gabapentin administration dated 9/22/2025, and 9/23/2025 timed at 5 p.m., and 1:00 p.m., was administered on 9/22/2025 at 7:55 p.m., on 9/23/2025 at 8:57 p.m. and 3:01 p.m. During a concurrent interview and record review on 9/24/2025 at 10:20 a.m. with LVN 2 at nurse station 2, Resident 4's MAR for 9/2025 was reviewed. LVN 2 stated Resident 4's MAR indicated the metformin 500 mg daily should be administered at 7:30 a.m. LVN 4 stated the MAR indicated that medications were administered and documented at 8:53 a.m. During an interview on 9/24/2025 at 12:15 p.m. with LVN 1, LVN 1 stated the facility's protocol is to administer medications one hour before or one hour after the scheduled time. LVN 1 stated if a medication is scheduled at 7:30 a.m. it can be given the latest at 8:30 a.m. LVN 1 stated it is essential to pass medications on time to make sure parameters are met. LVN 1 stated if medication for blood glucose control is not given on time, residents can experience an episode of hyperglycemia and have the risk of being transferred to the hospital. LVN 1 stated the metformin for Resident 2 was administrated at 9:00 a.m., but the medications were scheduled for 7:30 a.m. LVN 1 stated I have a lot of residents to attend, that I do not always start on time. During an interview on 9/24/2025 at 1:02 p.m., with LVN 2, LVN 2 stated that after residents received their medications, nurses need to document the medications residents took. LVN 2 stated it is important because it is proof of the time medications were administered. During an interview on 9/24/2025 at 1:30 p.m. with Registered Nurses (RN) 1, RN 1 stated it is not acceptable to administer medications more than an hour late. RN 1 stated not administering medications on time is not following doctors' orders. RN 1 stated if metformin or gabapentin were not administrated on time, residents can be at risk of hyperglycemia or seizures. RN 1 stated the facility protocol is to document the medications given to the residents as nurses pass the medications. During a review of the facility's policy and procedure (P&P) titled, Pain Assessment and Management, dated 3/2020, 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 standard or practice, the comprehensive care plan, and the residents choices related to pain management. The P&P indicated pain management interventions should reflect the sources, type and severity of pain. The P&P indicated resident's reported level of pain with adequate detail should be documented as necessary and in accordance with the pain management program. The P&P indicated upon completion of the pain assessment, the person conducting the assessment should record the information obtained from the assessment in residents medical records. During a review of the facility's P&P titled, Medication Administration -General Guidelines, dated 3/7/2024, the P&P indicated medications should be administered in accordance with written orders of the attending physician. The P&P indicated medications should be administered within 60 minutes of schedule time (1 hour before and 1 hour after), except before or after meals orders, which are administrated based on mealtimes. The P&P indicated the individual who administers the medication dose records the administration on the resident's MAR directly after medication is given. The P&P indicated at the end of each medication pass, the person administrating the medications reviews the MAR to ensure necessary dose were administered and documented.

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 F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Novolin insulin (medication used to control blo...

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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 Novolin insulin (medication used to control blood sugar levels in residents with diabetes [DM- a disorder characterized by difficulty in blood sugar control and poor wound healing]) was stored in the medication cart with the correct label (information including resident name, medication name, dosage and directions of the medication) for one of three sampled residents (Resident 1). This deficient practice had the potential for medication administration errors that could lead to hypoglycemia (low blood sugar), altered mental status and hospitalization for Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including DM and hypertension (HTN- high blood pressure). During a review of Resident 1's History and Physical (H&P), dated 1/18/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Physician's Order dated 4/22/2025, the order indicated to administer Novolin 70/30 subcutaneous (SQ- method of administering medication by injecting into the fatty tissue layer beneath the skin) suspension 100 units/milliliter (u/ml- unit of measurement), inject 40 u SQ one time a day and inject 20 U SQ at bedtime for DM. During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 4/26/2025, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 required setup or clean-up assistance for eating. The MDS indicated Resident 1 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity) for oral hygiene, upper body dressing and bed mobility (the ability to roll from lying on back to left and right side and return to lying on back on the bed). During a review of Resident 1's Physician's Order dated 7/13/2025, the order indicated to administer Novolin 70/30 SQ suspension (70/30) 100 u/ml, inject 20 u SQ every 12 hours for DM. During a concurrent observation and interview on 7/16/2025 at 3:37 p.m., with Licensed Vocational Nurse (LVN) 1, Medication Cart 2 was observed with Resident 1's Novolin labeled with Resident 1's name and indications to administer Humulin (Novolin) 70-30 Kwikpen (prefilled insulin pen) 40 u SQ one time a day and 20 U at bedtime for DM. LVN 1 stated the order was discontinued by the physician on 7/13/2025. LVN 1 stated the nurse should have discarded the medication and called the pharmacy for the new prescription or asked the pharmacy for a new label with the new prescription for the resident. LVN 1 stated keeping the medication with the old label could lead to medication administration errors that could cause hypoglycemia, hospitalization and coma (state of prolonged unconsciousness, like a very deep sleep, where a person is alive but unresponsive to the world around them) for the resident. During an interview on 7/22/2025 with the Pharmacist (Pharm 1), Pharm 1 indicated Resident 1's order (for Novolin) was changed by the physician on 7/13/2025, to administer Novolin 20 u every 12 hours to the resident. Pharm 1 stated licensed nurses should have notified the pharmacy of the new physician's order on 7/13/2025. Pharm 1 stated, a new medication request was submitted to pharmacy and sent on 7/16/2025. Pharm 1 also stated, licensed nurse(s) should have put a direction change on the medication to ensure there were no errors. During a review of the facility's Policy and Procedure (P&P) titled, Medication Ordering and Receiving from Pharmacy Medication Labels dated 4/2014, the P&P indicated medications are labeled in accordance with facility requirements and state and federal laws. The P&P indicated only the dispensing pharmacy can modify or change prescription labels. The P&P also indicated if the physician's directions for use change or the label is inaccurate, the nurse may place a change of order label on the container indicating there was a change in direction for use, taking care not to cover important label information. When such a label appears on the container, the medication nurse checks the resident Medication Administration Record (MAR) or the physician's order for current information. During a review of the facility's P&P titled, Medication Storage in the Facility dated 1/2025, the P&P indicated, outdated medications are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists.

May 2025 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that one Registered Nurse had the specific com...

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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 that one Registered Nurse had the specific competencies, and skill sets necessary to assess a newly admitted resident for one of three sampled residents (Resident 1 and Resident 2). This deficient practice led to Resident 1 to received unnecessary medications and delayed wound treatment. Findings: During a review of Resident 1 ' s General Acute Care Hospital (GACH) Flowsheet Print Request dated 4/4/2025, the record indicated Seroquel 12.5 milligrams ([mg] unit of measurement), 0.5 tablets twice a day. 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 major depressive disorder (mental health condition characterized by persistent feelings of sadness, hopelessness, and a lack of interest or pleasure in activities) unspecified psychosis (psychotic symptoms like delusions [false belief that a person firmly holds onto, even when there's evidence to the contrary] or hallucinations [false perception of objects or events involving the senses] but they don't fit neatly into a more specific psychotic disorder diagnosis). During a review of Resident 1 ' s History & Physical (H&P) dated 4/4/2025, H&P indicated Resident 1 had the capacity to understand and make decisions and his rehabilitation potential was good. During a review of Resident 1 ' s Order Details dated 4/5/2025, the order indicated Seroquel oral tablet 12.5 mg, give via G-tube (a soft, flexible tube surgically inserted through the belly into the stomach) two times a day for bipolar disorder manifested by uncontrollable extreme mood swings causing anger interfering with daily living activities and tally hash-marks for Seroquel use. During a review of Resident 1 ' s Order Details dated 4/5/2025, the order indicated to monitor for potential side effects anti-psychotic Seroquel, sedation, drowsiness, dry mouth, constipation, shuffling gait, drooling, weight gain, photosensitivity, postural hypertension, urinary retention, blurred vision. Of special [NAME], traditive dyskinesia, seizure disorder, glaucoma, chronic constipation, diabetes, skin pigmentation and jaundice. During a review of Resident 1 ' s Order Details dated 4/10/2025, the order details indicated to monitor episodes of bipolar disorder M/B uncontrollable extreme mood swings causing anger interfering with daily living activities and tally by hashmarks for Seroquel use every shift. During a review of Resident ' s Psychiatric Evaluation dated 4/11/2025, evaluation indicated Resident was on psychotropic medication and was being seen for psychiatric evaluation and medication management. Evaluation indicated staff reported the patient was cooperative and compliant with care. The evaluation indicated Resident 1 denied any psychiatric complaints. During a review of Resident 1 ' s Minimum Data Set ([MDS], a resident assessment tool), dated 4/11/2025, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 did not exhibited physical behavioral symptoms directed to others. The MDS indicated there were no verbal behavioral symptoms directed to others. The MDS indicated there were no other be behavioral symptoms directed towards others. The MDS indicated Resident 1 required supervision for eating, and upper body dressing. The MDS indicated Resident 1 was dependent (helper does all the effort and resident does none of the effort to complete activity) with eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with rolling left to right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and dependent for tub/shower transfer. The MDS indicated Resident 1 was always continent. The MDS indicated Resident 1 had active diagnosis of depression and bipolar disorder. The MDS indicated Resident 1 was at risk of developing pressure ulcers/injuries and did not have any pressure ulcers. The MDS indicated Resident 1 was on antipsychotic (medications used to treat mental health conditions characterized by psychosis [mental health condition characterized by a loss of touch with reality], such as schizophrenia and bipolar [mental health condition characterized by extreme mood swings between periods of high energy, elevated mood, and low mood, loss of interest, and fatigue] disorder) medications. During a review of Resident 1 ' s Care Plan titled Seroquel resident has bipolar disorder manifested by uncontrollable extreme mood swings causing anger interfering with daily livings activities dated 4/30/2025, the care plan indicated to notify physician if behavior interferes with functioning, monitor and record episodes per policy. During a review of Resident 1 ' s admission Reassessment dated [DATE]; reassessment indicated Resident 1 had a sacrococcygeal (relating to the area where the lower hip bones meet and the tailbone) unstageable (a type of pressure ulcer where the extent of tissue damage cannot be determined because the wound bed is obscured by slough [yellow or white, often moist, tissue that is dead or damaged within a wound] or eschar [hick, leathery layer of dead tissue that forms over a wound]) pressure ulcer measuring 21.1 centimeters ([cm] unit of measure). During an interview on 5/21/2025 at 9:19 a.m. with Family Member 1 (FM 1), FM 1 stated she was worried about Resident 1 being overmedicated because he was very sleepy to do his therapy and instead of improving, he was getting worse. FM 1 stated Resident 1 was admitted to the hospital with a pressure ulcer on 5/12/2025. During a concurrent interview and record review on 5/21/2025 at 2:20 pm. with Treatment Nurse (TN), Resident 1 ' s admission assessment dated [DATE], Resident 1 ' s Treatment Administration Record dated May 2025 and Resident 1 ' s Skin admission Reassessment dated [DATE]. TN stated that the record indicated Resident was admitted on [DATE] and the admission assessment did not indicate Resident 1 had a pressure ulcer on his sacrum. TN stated on every admission the skin assessment should be done immediately to provide treatment and prevent worsening of skin injury. TN stated she did the admission reassessment on 5/2/2025 when she was told she had a new admission, and she recorded as a deep purple area measuring about 21.1 cm all around. TN stated it could take 24-48 hours for a deep tissue injury to develop if the resident was not being turned. TN stated she entered the treatment order on 5/2/2025 and the treatment started on 5/3/2025 three days after admission. TN stated she did not remember the reason she did not call FM 1 to inform of Resident 1 ' s pressure ulcer but she should have. During a concurrent interview and record review on 5/22/2025 at 2:41 pm. with Assistant Director of Nursing (ADON), ADON stated she did not know where the admitting nurse on 4/4/2025 got the bipolar diagnosis for Resident 1 and she did not know why the order for Seroquel ' s dose was higher than the discharge Seroquel orders from GACH dated 4/4/2025 but the registered nurse should have been more cautious when transcribing diagnosis and medication for Resident 1. ADON stated the admission notes on 4/30/2025 did not indicate there was a pressure ulcer in the sacrococcygeal. DON stated there was a note from the CNA on 5/1/2025 of skin injury but it was not assessed by wound care nurse until 5/2/2025 and treatment did not start until 5/3/2025. ADON stated admitting nurse should had done a better assessment upon admitting preventing delay in treatment. During a concurrent phone interview and record review on 5/28/2025 at 12:33 p.m. with Medical Doctor (MD), Resident 1 ' s General Acute Care Hospital (GACH) Flowsheet Print Request dated 4/4/2025, the record indicated Seroquel 12.5 mg, 0.5 tablets twice a day. MD stated the record indicated half a tablet twice a day and he had not entered the order, but he signed for the order. MD stated the person who entered the order might have made a mistake entering the order. MD stated Resident 1 did not have bipolar disorder and he did not know how the diagnosis was entered in the system. MD stated he review the chart from GACH 1, and he could not find a diagnosis of bipolar disorder. MD stated it was not good for the elderly to take Seroquel because it could lead to confusion and sleepiness and that was bad for the resident ' s recovery. During a review of the facility ' s Policies and Procedures (P&P) titled Job Description, dated January 27, 2022, the P&P indicated Registered Nurse was responsible for assuring physicians' orders are followed and quality care is provided on each shift in a skilled care facility. The P&P indicated essential duties and responsibilities included assessment of new admissions, skin care and/or changes of skin condition. During a review of the facility ' s P&P titled admission Notes, dated September 2012, the P&P indicated when a resident is admitted to the nursing unit, the admitting nurse must document the following information (as each may apply) in the nurses' notes, admission form, or other appropriate place general condition of the resident upon admission.

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and records review, the facility failed to ensure, 1 of 3 residents (Resident 1): 1). Had documented assessme...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and records review, the facility failed to ensure, 1 of 3 residents (Resident 1): 1). Had documented assessment to support the diagnosis of bipolar disorder in the resident ' s clinical records. 2). Had an adequate indication for the use of Seroquel (antipsychotic medications that treat several kinds of mental health condition including schizophrenia [a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions)] and bipolar disorder [a mental health condition characterized by extreme shifts in mood, energy, and behavior]) for 1 of 3 residents (Resident 1). This failure had the potential that resident received unnecessary drug, causing the resident to suffer altered mental state, affecting his participation with the rehabilitation services and the potential to cause adverse reactions from the medications. This failure had the potential to affect the resident in maintaining the highest practicable physical, mental and psychosocial well-being. Findings: During a review of Resident 1 ' s General Acute Care Hospital (GACH 1) History and Physical Report (HPR) dated 3/9/2025, the HPR indicated Resident 1 had a past medical history (PMH) of hypertension (high blood pressure). During a review of Resident 1 ' s GACH 1 Medication orders dated 3/25/2025, the order indicated Seroquel 12.5 milligrams (mg- a unit of measurement), 0.5 tablet via gastric tube gastric tube ([G-tube] a soft, flexible tube surgically inserted into the stomach for administration of medications and nutrition) once (one time) to treat acute agitation/ delirium. During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1 ' s diagnoses included major depressive disorder (mental health condition characterized by persistent feelings of sadness, hopelessness, and a lack of interest or pleasure in activities) and unspecified psychosis (psychotic symptoms like delusions [false belief that a person firmly holds onto, even when there's evidence to the contrary] or hallucinations [false perception of objects or events involving the senses]). During a review of Resident 1 ' s History & Physical (H&P) dated 4/4/2025, the H&P indicated Resident 1 had the capacity to understand and make decisions and his rehabilitation potential was good. During a review of Resident 1 ' s GACH 1 Flowsheet Print Request for 4/3/2025 to 4/5/2025, the GACH 1 flowsheet indicated Seroquel 12.5 mg., 0.5 tablet twice a day, with a stop date of 5/30/25. During a review of Resident 1 ' s facility Order Details dated 4/5/2025, the order indicated Seroquel oral tablet 12.5 mg, give via gastrostomy tube (G-tube- a surgical opening in the stomach for nutrition and medication administration), two times a day for bipolar disorder manifested by (M/B) uncontrollable extreme mood swings causing anger interfering with daily living activities. During a review of Resident 1 ' s facility Order Details dated 4/10/2025, the order details indicated to monitor episodes of bipolar disorder M/B uncontrollable, extreme mood swings causing anger, interfering with daily living activities. The order details indicated to tally behaviors by hashmarks for Seroquel use every shift. During a review of Resident 1 ' s MAR from 4/11/2025 to 4/24/2025, the monitoring of bipolar disorder behaviors did not indicate the resident had manifested any of the behaviors. During a review of Resident 1 ' s Minimum Data Set ([MDS], a resident assessment tool), dated 4/11/2025, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 did not exhibit physical behavioral symptoms directed to others. The MDS indicated there were no verbal behavioral symptoms directed to others. The MDS indicated there were no other behavioral symptoms directed towards others. The MDS indicated Resident 1 required supervision for eating, and upper body dressing. The MDS indicated Resident 1 was dependent (helper does all the effort and resident does none of the effort to complete activity) with eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. The MDS indicated Resident 1 required substantial assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with rolling left to right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and dependent for tub/shower transfer. The MDS indicated Resident 1 was always continent. The MDS indicated Resident 1 had active diagnosis of depression and bipolar disorder. The MDS indicated Resident 1 was on antipsychotic medications. During a review of Resident 1 ' s psychiatric evaluation dated 4/11/2025, the notes indicated the psychiatrist was asked to see Resident 1 for psychiatric evaluation and medication management. The evaluation indicated Resident 1 was currently on Seroquel. The evaluation indicated staff reported Resident 1 was cooperative and compliant with care. The evaluation indicated Resident 1 denied any psychiatric complaints, anxiety, depression, obsessive compulsive disorder (mental health condition characterized by persistent, intrusive thoughts [obsessions] and/or repetitive behaviors [compulsions]), panic attack, psychosis, suicidal ideation, or violent thoughts. During a review of Resident 1 ' s clinical records, the record indicated the resident had started Physical Therapy (PT) and Occupational Therapy (OT) on 4/7/2025 and Speech Therapy (ST) started on 4/9/2025. During an interview on 5/21/2025 at 9:19 a.m. with Family Member 1 (FM 1), FM 1 stated she was worried about Resident 1 being overmedicated because he was very sleepy to do his therapy and instead of improving, he was getting worse. During a concurrent interview and record review on 5/22/2025 at 12:44 p.m. with Director of Rehabilitation (DOR), Resident 1 ' s Occupational Therapy Evaluation and Plan of Treatment dated 4/7/2025 was reviewed. The DOR stated the note indicated Resident 1 was able to follow two step commands. The DOR stated Resident 1 used to follow commands but during the later therapies, Resident 1 was not following commands anymore. During a phone interview on 5/22/2025 at 1:00 p.m. with OT, the OT stated Resident 1 was able to follow two step commands upon initial assessment. The OT stated, as time went on, Resident 1displayed periods of confusion with difficulty answering questions, and he required cues to communicate. The OT stated he did not remember if he had reported to nursing but the DOR was aware. The OT stated that if a resident is too lethargic and unable to participate in rehabilitation, it interferes with improvement and recovery. During a phone interview on 5/22/2025 at 2:18 p.m. with ST, the ST stated Resident 1 was very lethargic and was not able to participate on his initial visit (date not specified). During a phone interview on 5/27/2025 at 2:40 pm. with Registered Nurse (RN 1), RN 1 stated Resident 1 was talking okay with moments of confusion upon admission. RN 1 stated Resident 1 was able to answer most of the questions. RN 1 stated she entered the order for Seroquel, but did not notice that the order was only for acute agitation. RN 1 stated she did not remember the indication on the discharge orders for Seroquel. RN 1 stated she believed the Seroquel was ordered for mood swings or bipolar. RN 1 stated she wrote down the list of diagnosis and orders but was needed to be verified from the doctor. RN 1 stated Resident 1 had no episodes of trying to get out of bed and have not attempted to pull out G-tube on admission. RN 1 stated, when she returned to work (date not specified) after few days, she received a report that Resident 1 tried to get out of bed. RN 1 stated she did not know if there was a note indicating Resident 1 ' s behavioral issues. RN 1 stated some side effects of Seroquel includes irritability, mood swings, lethargy, drowsiness and speech problems. RN 1 stated that given the side effects of medication (Seroquel) Resident 1 received, the medication could interfere with Resident 1 ' s rehabilitation and recovery. During a concurrent phone interview and record review on 5/28/2025 at 12:33 p.m. with the Medical Doctor (MD), Resident 1 ' s GACH 1 Flowsheet Print Request dated 4/3/2025 to 4/5/2025, was reviewed. The MD stated the GACH 1 flowsheet indicated Resident 1 should receive half tablet of Seroquel 12.5.mg, twice a day. The MD stated he did not enter the order but signed it. The MD stated he reviewed Resident 1 ' s chart from GACH 1 and could not find a diagnosis of bipolar disorder. The MD stated Resident 1 did not have bipolar disorder, and he did not know how the diagnosis was entered in the system. The MD stated Resident 1 did not demonstrate mania, or delirium when he saw him on 4/4/2025. The MD stated he had a full conversation with Resident 1 and determined that day (4/4/2025), Resident 1 was able to make decisions and can be self-responsible. The MD stated he wanted to continue the medication orders from GACH 1 because he is not a psychiatrist. The MD stated the nurse who entered the order might have mistakenly entered the order. The MD stated Resident 1's mental status was better on his first visit than his current mental status (5/28/2025). The MD stated Seroquel is not good for the elderly population because it could lead to confusion and sleepiness and was bad for the resident ' s recovery. During a review of the facility ' s policy and procedure (P&P) titled, Psychotropic Medication Use, dated 6/2021, the P&P indicated psychotropic drug is any medication that affects brain activities associated with mental processes and behavior, which included but was not limited to antipsychotics. The P&P indicated facility should not use psychotropic medications to address behaviors without first determining if there was a medical, physical, functional, psychological, social or environmental cause of the resident's behaviors. The P&P indicated all medications used to treat behaviors must have a clinical indication and be used in the lowest possible dose to achieve the desired therapeutic effect.

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

Quality of Care (Tag F0684)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Ensure call lights were placed within reach for 2 ...

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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 call lights were placed within reach for 2 of 3 residents (Residents 2 and 3). 2. Provide oral care to 1 of 3 residents, (Resident 3) This deficient practice had the potential for the residents to not be able to call for help and assistance when needed and could result to the delay in care and interventions needed for the residents' safety. This deficient practice had the potential to cause Resident 2 the feeling of neglect, affecting psychosocial well-being and the risk of developing tooth decay and infection. Findings: 1). During a review of Resident 2 ' s admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses of muscle weakness and hypertension (high blood pressure). During a review of Resident 2 ' s History & Physical (H&P) dated 1/6/2025, the H&P indicated Resident 2 had the capacity to understand and make decisions. During a review of Resident 2 ' s Minimum Data Set ([MDS], a resident assessment tool), dated 4/19/2025, the MDS indicated Resident 2 was able to understand and be understood by others. The MDS indicated Resident 2 required supervision for eating, and upper body dressing. The MDS indicated Resident 2 required moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for eating. The MDS indicated Resident 2 required maximal assistance (helper does more than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides more than half the effort) for oral hygiene, shower/bath, upper body dressing, and personal hygiene. The MDS indicated Resident 2 was dependent (helper does all the effort and resident does none of the effort to complete activity) with toileting hygiene, lower body dressing and putting on/taking off footwear. The MDS indicated Resident 2 required maximal assistance with rolling left to right, and dependent with sitting to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and for tub/shower transfer. The MDS indicated Resident 2 was always incontinent of bowel. The MDS indicated Resident 2 was at risk of developing pressure ulcers/injuries and had pressure ulcer/injury, scar over prominence or a non-removable dressing. During a review of Resident 2 ' s Care Plan titled Activities of Daily Living (ADL) Care Deficit dated 1/22/2018, the care plan indicated to assist Resident 1 with grooming and to place call light within reach. During a concurrent observation and interview on 5/21/2025 at 12:49 p.m. with Resident 2 and Certified Nurse Assistant 1 (CNA 1), Resident 2 stated he could not see the call light. Resident 2 sated it was frustrating not having the call light because when he needed someone, he could not get a hold of the staff. Resident 2 stated he did not remember the last time he received oral care. Resident 2 stated he did not have a toothbrush or toothpaste. CNA 1 stated Resident 2 could not reach the call light because he had a contracture on left arm and Resident 2 was facing away from the call light. CNA 1 stated the call light should have been placed in front of him so he can see and reach it (call light). CNA 1 stated that not having the call light at reach could lead to the resident ' s feelings of neglect. CNA 1 stated she should ensure the call light was placed within Resident 1 ' s reach. CNA 1 stated Resident 1 could fall, develop skin break down or worsen pressure on ulcers if they could not call for assistance when they needed to. CNA 1 stated she have not done Resident 1 ' s oral care today because Resident 1 was just transferred yesterday from another room. CNA 1 stated Resident 1 already had breakfast and lunch for the day and she (CNA) was supposed to perform oral care after each meal. CNA 1 stated not performing oral care could lead to infections and tooth decay. 2). During a review of Resident 3 ' sadmission Record, the admission Record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses of hemiplegia (condition causing paralysis on one side of the body, affecting either the right or left side, due to damage to the brain or spinal cord) affecting left non-dominant side and hypertension (high blood pressure). During a review of Resident 3 ' s H&P dated 8/8/2024, H&P indicated Resident 3 did not have the capacity to understand and make decisions. During a review of Resident 3 ' s MDS dated [DATE], the MDS indicated Resident 3 was rarely able to make self be understood by others and sometimes was understood by others. The MDS indicated Resident 3 was dependent (helper does all the effort and resident does none of the effort to complete activity) with oral hygiene, toileting hygiene, shower/bathing self, upper/lower body dressing, putting on/taking off footwear, and personal hygiene. The MDS indicated Resident 3 was dependent with rolling left to right, chair/bed-to-chair transfer, and for tub/shower transfer. The MDS indicated Resident 3 was always incontinent of urine and bowel. The MDS indicated Resident 3 was at risk of developing pressure ulcers/injuries and had pressure ulcer/injury, scar over prominence or a non-removable dressing. During a review of Resident 3 ' s Care Plan titled Resident has Self-Care Deficits Dependent ADLs and Needs dated 8/17/2022, the care plan indicated to assist Resident 1 with ADLs as needed and to place call light within reach. During a concurrent observation and interview on 5/21/2025 at 1:18 p.m. with Resident 3 and Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated Resident 3 could not reach the call light because it was hanging off the bed. LVN 3 stated the call light should always be within reach. LVN 1 stated Resident 3 was contracted from the left side and could not use the call light unless it was next to him. LVN 1 stated not having the call light at reach could cause delays in care and the staff wouldn ' t know if the resident needed help. During a review of the facility ' s policy and procedure (P&P) titled Call lights undated, the P&P indicated the policy ' s purpose was to assure residents receive prompt assistance. The P&P indicated all staff should know how to place the call light for residents. The P&P indicated nursing should ensure that the call lights are placed within residents ' reach when in their room. During a review of the facility ' s P&P titled ADL, supporting dated September 2012, the P&P indicated residents who are unable to carry out activities of daily living independently should receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

May 2025 23 deficiencies

CONCERN (D)

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

Comprehensive Assessments (Tag F0636)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to: 1. Ensure one out of seven sampled residents (Residen...

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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 one out of seven sampled residents (Resident 49) had an accurate assessment for the use of four bed rails. This deficient pracfailure had the potential for Resident 49 to not have received necessary care and services. Findings: During a review of Resident 49's admission Record, the admission Record indicated Resident 49 was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 49's diagnoses metabolic encephalopathy (a condition characterized by altered brain function due to a systemic or metabolic disturbance), dementia (a progressive state of decline in mental abilities), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 49's History and Physical (H&P), dated 4/15/2025, the H&P indicated Resident 49 did not have the capacity to understand and make decisions. During a review of Resident 49's Minimum Data Set ([MDS]- a resident assessment tool), dated 4/7/2025 the MDS indicated Resident 49's cognition (ability to learn, reason, remember, understand, and make decisions) sometimes understands. The MDS indicated Resident 49 was dependent (helper does all of the effort. Residents do none of the effort to complete the activity) on staff for showering, toileting hygiene, and dressing. During an observation on 5/6/2025 at 11:06 a.m. all four bed rails were up while Resident 49 was lying in the bed. During an observation on 5/7/2025 at 11:28 a.m. all four bed rails were up while Resident 49 was lying in bed. Resident 49 was not receiving activity daily living ([ADL] -routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) from staff. Resident 49 was able to slightly able to move in bed and was not using the bed rails for mobility or repositioning. Resident 49 was not able to remove bed rails easily. During an interview on 5/7/2024 at 2:09 p.m. with the Assistant Director of Nursing (ADON), the ADON stated Resident 49's needed to be assessed quarterly to evaluate the need for all four bed rails being up was not properly assessed. The ADON stated Resident 49 did not move that much and required assistance from staff. The ADON stated Resident 49 it was not fitting to have all bed rails up. The ADON stated it was important to assess Resident 49's needs to prevent complications such as risk of injury with the bed rails up. During a concurrent interview and record review on 5/8/2025 at 10:21 a.m. with Minimum Data Set Nurse (MDSN) 3, the facility's policy and procedure (P&P) titled, Bed Safety and Bed Rails, dated 8/2022 was reviewed. The P&P indicated prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted alternatives may include roll guards, foam bumpers, lowering the bed and the use of concave mattresses to reduce rolling off the bed. MDSN 3 was not able to locate any documentation of attempted alternatives prior to placing all four bed rails up. MDSN 3 stated there was no alternative initiated and if it was not documented it was not done. MDSN 3 stated Resident 49's assessment should have included the alternatives before all four bed rails were used. MDSN 3 stated it was important to attempt alternatives to manage and monitor the residents' comfort and safety. During a review of the facility's policy and procedure (P&P) titled, Bed Safety and Bed Rails, dated 8/2022 was reviewed. The P&P indicated prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted alternatives may include roll guards, foam bumpers, lowering the bed and the use of concave mattresses to reduce rolling off the bed. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Assessments, dated 3/2023, the P&P indicated comprehensive assessment are conducted to assist in developing person-centered care plans. The P&P indicated comprehensive assessments are conducted and coordinated by a registered nurse with appropriate participation. The P&P indicated completed assessments are maintained in the resident's active record for a minimum of 15 months.

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record, the facility failed to ensure a Minimum Data Set ([MDS] - a resident assessment tool) assessment was completed accurately for one of 35 sampled residents (Resident 40) by failing to: 1. Ensure Resident 40's diagnosis of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) was encoded under MDS section I5800 (Active Diagnoses). This deficient practice resulted in incorrect data being transmitted to the Center for Medicare and Medicaid Services (CMS) and had the potential to negatively affect the plan of care and delivery of care and services for Resident 40. Findings: During a review of Resident 40's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 40 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 40's diagnoses included depression, intracranial hemorrhage ([a type of stroke] - loss of blood flow to a part of the brain), and hypertension ([HTN] - high blood pressure). During a review of Resident 40's History and Physical (H&P), dated 3/23/2025, the H&P indicated, Resident 40 did not have the capacity to understand and make decisions. During a review of Resident 40's MDS assessment, dated 3/28/2025, the MDS indicated, Resident 40's cognitive (ability to think and reason) skills for daily decision making were severely impaired (never/rarely made decisions). The MDS indicated, Resident 40 was totally dependent (helper does all of the effort) upon staff for oral hygiene, upper and lower body dressing, and personal hygiene. During a review of Resident 40's Order Summary Report (a document containing active orders), dated 5/8/2025, the Order Summary Report indicated, the physician placed a telephone order on 3/22/2025 for Resident 40 to start on Sertraline HCL (medication used to treat depression) to give 12.5 milligrams ([mg) - metric unit of measurement, used for medication dosage and/or amount) one time a day (9 a.m.) for depression manifested by episodes of crying, yelling, and biting self. During a concurrent interview and record review on 5/7/2025 at 10:38 a.m., with MDS Nurse (MDSN 1), Resident 40's MDS assessment, dated 3/28/2025, was reviewed. MDSN 1 stated Resident 40's MDS assessment was completed inaccurately. MDSN 1 stated there was a wrong entry on MDS section I. MDSN 1 stated there should be a check marked on section I5800 diagnosis of depression. The MDSN stated Resident 40 was taking Sertraline HCL which is considered an anti-depressant medication. MDSN 1 stated by not coding accurate information on the MDS, facility staff would not be able to treat Resident 40's condition appropriately and provide the interventions needed to provide quality of care. During a review of the facility's policy and procedure (P&P), titled Certifying Accuracy of the Resident Assessment, dated 11/2019, the P&P indicated Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment.

CONCERN (D)

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete and re-submit the Preadmission Screening and Resident Revi...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete and re-submit the Preadmission Screening and Resident Review ([PASARR - a tool to determine if the person had, or was suspected of having a mental illness, intellectual disability, or related condition) Level one (I) screening and refer one of one sampled resident (Resident 175) who had a diagnoses of bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and major depressive disorder ([MDD] - a mood disorder that causes a persistent feelings of sadness and loss of interest) to the appropriate state-designated authority for PASARR Level two (II) evaluation and determination. This deficient practice had the potential to result in Resident 175 to not receive the appropriate medical treatments for mental illness diagnoses. Findings: During a review of Resident 175's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 175 was admitted to the facility on [DATE]. Resident 175's diagnoses included bipolar disorder, MDD, and generalized muscle weakness. During a review of Resident 175's History and Physical (H&P), dated 2/26/2025, the H&P indicated, Resident 175 had the capacity to understand and make decisions. During a review of Resident 175's Minimum Data Set ([MDS] - a resident assessment tool), dated 2/26/2025, the MDS indicated, Resident 175 was independent (decisions consistent/reasonable) in cognitive (ability to think and reason) skills for daily decision making. The MDS indicated, Resident 175 required substantial assistance (helper does more than half the effort) from staff with toileting hygiene and lower body dressing. During a concurrent interview and record review on 5/7/2025 at 2:54 p.m., with Minimum Data Set Nurse 2 (MDSN 2), Resident 175's PASARR level I Screening completed by another facility on 2/18/2025, was reviewed. MDSN 2 stated the PASARR Level 1 screening indicated, Resident 175 had no serious mental illness diagnoses. MDSN 2 stated the PASARR Level 1 screening also indicated, Resident 175's case was closed, and a PASARR level II mental health evaluation was not required. MDSN 2 stated the facility should have completed and resubmitted a new PASARR Level I screening based on Resident 175's diagnoses of bipolar disorder and MDD which were considered as mental illness. MDSN 2 stated once the PASARR Level I was resubmitted to indicate the mental illness diagnoses then PASARR level II would be triggered. MDSN 2 stated it was important to refer Resident 175 to the state mental health agency so she could avail other psychiatric treatment to manage her behavior and to determine appropriate placement. During a review of the facility's policy and procedure (P&P), titled Preadmission Screening and Resident Review (PASARR), dated 3/2023, the P&P indicated, The Preadmission Screening and Resident Review policy is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. The P&P also indicated if Level I is positive for SMI/DD/RC, it needs to be advanced to a level II evaluation. During a review of PASRR reference manual, dated 2/2023, the PASRR reference manual indicated, An additional requirement has been added for NF's to promptly notify the state mental health and/or intellectual or developmental disability authority, as applicable, if there is a significant change in the physical or mental condition of an individual who is mentally ill or has an intellectual or developmental disability. This would warrant a re-evaluation to determine if a NF is still the most appropriate setting and/or if the individual could benefit from specialized services for his/her mental illness or intellectual disability.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to: 1. Ensure one out of seven sampled residents (Residen...

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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 one out of seven sampled residents (Resident 106) had a revised care plan (a structure written document that outlines the care a nurse will provide to a patient based on their specific needs and goals) for the low air loss ([LAL] -a specialized medical mattress designed to prevent and treat pressure ulcers by reducing pressure and moisture buildup on the skin) mattress. This deficient practice of not having revised care plan for the use of the LAL mattress placed Resident 106 at risk for not being provided with the appropriate, consistent, and individualized care. Findings: During a review of Resident 106's admission Record, the admission Record indicated Resident 106 was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 106's diagnoses metabolic encephalopathy (a condition characterized by altered brain function due to a systemic or metabolic disturbance), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and cerebral infarction (the death of brain tissue due to a lack of blood flow). During a review of Resident 106's History and Physical (H&P), dated 2/17/2025, the H&P indicated Resident 106 did not have capacity to understand and make decisions During a review of Resident 106's Minimum Data Set ([MDS]- a resident assessment tool), dated 4/7/2025 the MDS indicated Resident 106's cognition (ability to learn, reason, remember, understand, and make decisions) rarely/never understands. The MDS indicated Resident 106 was dependent (helper does all of the effort. Residents do none of the effort to complete the activity) on staff for showering, toileting hygiene, and dressing. The MDS indicated Resident 106 was at risk for developing pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). During a review of Resident 106's care plan titled, Risk for developing pressure sore, and other types of skin breakdown (damage to the skin and underlying tissues caused by prolonged pressure, friction, or moisture) related to aging process, fragile skin, hemiplegia .dated 7/15/2024, the care plan indicated Resident 106 was to minimize the risk of skin breakdown/pressure sore daily. The staff interventions included 1. assess risk using Wound Risk Assessment on admission, quarterly and as need 2. Pressure relieving devices as needed. During a concurrent interview and record review on 5/8/2025 at 1:02 p.m. with Assistant Director of Nursing (ADON), Resident 106's care plan, dated 7/15/2024 was reviewed. The care plan indicated Resident 106 was to minimize the risk of skin breakdown/pressure sore daily. The staff interventions included 1. assess risk using Wound Risk Assessment on admission, quarterly and as need 2. Pressure relieving devices as needed. The ADON stated the care plan did not specify what type of device was needed for pressure relief for Resident 106. The ADON stated it was important to update the interventions so the interventions could be implemented to prevent skin breakdown. During a review of the facility's policy and procedures (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. The P&P indicated assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure one of seven sampled residents (Resident 56) received a ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure one of seven sampled residents (Resident 56) received a weekly weight per physician's order. This deficient practice resulted in inadequate monitoring of Resident 56's weight loss. Findings: During a review of Resident 56's admission Record, the admission Record indicated Resident 56 was initially admitted to the facility on [DATE], with a readmission on [DATE]. Resident 56's diagnoses included malnutrition (a condition caused by not getting enough calories or the right amount of key nutrients), diabetes mellitus ((DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and 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 56's History and Physical (H&P), dated 2/20/2025, the H&P indicated Resident 56 had the capacity to understand and make decisions. During a review of Resident 56's Minimum Data Set (MDS - a resident assessment tool), dated 2/25/2025, the MDS indicated Resident 56's cognition (ability to reason and understand) was intact. The MDS indicated Resident 56 needed maximal assistance with toileting and bathing and set up assistance with eating. During a review of Resident 56's Order Summary Report, dated 5/8/2025, the report indicated on 4/6/2025 the physician ordered weekly weights x4. During a review of Resident 56's Weight Summary, (no date), the summary indicated the last weight obtained for Resident 56 was on 4/5/2025. During a review of Resident 56's Change of Condition (COC) form, dated 4/6/2025, the COC indicated Resident 56 had an eight-pound weight loss in one month. The COC indicated Resident 56 was consuming 25-100% of meals and the physician ordered staff to complete weekly weights x4. During a review of Resident 56's care plan, dated 4/8/2025, the care plan indicated Resident 56 had an eight-pound weight loss related to malnutrition. The care plan indicated the facility would continue weekly weights x4 and report significant changes to the physician. During a concurrent interview and record review on 5/8/2025 at 12:39 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 56's weights were reviewed. LVN 2 stated Resident 56 had a physician's order placed on 4/6/2025 to complete weekly weights x4. LVN 2 stated the last weight was documented on 4/5/2025. The weekly weights were not completed as ordered. LVN 2 stated weekly weights are ordered to check for weight gain or loss. It's important to complete it as ordered to ensure the resident is at a healthy weight. During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, dated March 2022, the P&P indicated resident weights are monitored for undesirable or unintended weight loss or gain.

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with pro...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, by failing to: 1. Provide compression stockings (elastic garments that squeeze the legs to improve blood flow, circulation, and to reduce swelling) per physician's order for one of one sampled resident (Resident 170) who had an edema (swelling caused by an accumulation of excess fluid in the body's tissues) of bilateral (both) lower extremities. This deficient practice had the potential to result in a delay in reducing the swelling of bilateral lower extremities of Resident 170 that would result in medical complication requiring hospitalization. Findings: During a review of Resident 170's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 170 was admitted to the facility on [DATE]. Resident 175's diagnoses included cellulitis (a skin infection that causes swelling and redness) of left and right lower limb (body part), hypertension ([HTN] - high blood pressure), and generalized muscle weakness. During a review of Resident 170's History and Physical (H&P), dated 1/29/2025, the H&P indicated, Resident 170 had the capacity to understand and make decisions. During a review of Resident 170's Minimum Data Set ([MDS] - a resident assessment tool), dated 2/5/2025, the MDS indicated, Resident 170 was independent (decisions consistent/reasonable) in cognitive (ability to think and reason) skills for daily decision making. The MDS indicated, Resident 170 required supervision (helper provides verbal cues as resident completes activity) from staff with oral hygiene, upper and lower body dressing, and personal hygiene. During a review of Resident 170's Order Summary Report (a document containing active orders), dated 5/8/2025, the Order Summary Report indicated, the physician placed a telephone order on 3/7/2025 for Resident 170 to have compression stockings to bilateral lower extremities every day. During a concurrent observation and interview on 5/6/2025 at 10:58 a.m. with Resident 170 in her room, Resident 170 had edema on bilateral lower extremities with no compression stockings. Resident 170 stated she had no compression stockings on her lower extremities for 2 weeks. Resident 170 stated her old compression stockings were too long and too wide. Resident 170 stated the licensed nursing staff were aware that she does not have compression stockings for 2 weeks. Resident 170 stated she was concerned with the swelling of her legs. During an interview on 5/8/2025 at 8:45 a.m. with Treatment Nurse 2 (TN 2), TN 2 stated she was aware Resident 170 did not have compression stockings for 2 weeks. TN 2 stated Resident 170's old compression stockings were too big for her, and it would defeat its purpose. TN 2 stated licensed nursing staff did not follow the physician's order to monitor the application of Resident 170's compression stockings on bilateral lower extremities every day. TN 2 stated she ordered Resident 170's new compression stockings to the pharmacy but did not deliver. TN 2 stated untreated edema would result in hospitalization. During an interview on 5/8/2025 at 9:34 a.m., with the Director of Nursing (DON), the DON stated the purpose of the compression stockings for residents with edema was to reduce the swelling and improve the blood circulation. During a review of the facility's policy and procedure (P&P), titled Applying Anti-Emboli Stockings (TED Hose), dated 10/2010, the P&P indicated, Stockings that are sized incorrectly can increase the risk of pressure and skin irritation, causing harmful pressure gradients which impede blood flow.

CONCERN (D)

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

Deficiency F0687 (Tag F0687)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Ensure resident with long thick elongated (nail p...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Ensure resident with long thick elongated (nail plate grows longer than the nail bed) toenails received podiatry (profession dealing with specialized care of the feet) care services for one of one sampled resident (Resident 170). This deficient practice had the potential to result in discomfort and decline in physical mobility of Resident 170. Findings: During a review of Resident 170's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 170 was admitted to the facility on [DATE]. Resident 175's diagnoses included cellulitis (a skin infection that causes swelling and redness) of left and right lower limb (body part), hypertension ([HTN] - high blood pressure), and generalized muscle weakness. During a review of Resident 170's History and Physical (H&P), dated 1/29/2025, the H&P indicated, Resident 170 had the capacity to understand and make decisions. During a review of Resident 170's Minimum Data Set ([MDS] - a resident assessment tool), dated 2/5/2025, the MDS indicated, Resident 170 was independent (decisions consistent/reasonable) in cognitive (ability to think and reason) skills for daily decision making. The MDS indicated, Resident 170 required supervision (helper provides verbal cues as resident completes activity) from staff with oral hygiene, upper and lower body dressing, and personal hygiene. During a review of Resident 170's Non-Pressure Sore Skin Report, dated 4/8/2025, the Non-Pressure Sore Skin Report indicated, Resident 170 was seen by a wound consultant with recommendation to refer for podiatry care for onychomycosis (a common condition where fungi grow on or under the toenail, causing discoloration, thickening, and sometimes crumbling of the toenail). During a concurrent observation and interview on 5/6/2025 at 10:58 a.m. with Resident 170 in her room, Resident 170 had a long a long thick brownish yellowish toenails on both feet. Resident 170 stated she requested to see a foot doctor 1month ago because of her toenail fungal infection (also known as onychomycosis). Resident 170 stated until now he had not seen by a foot doctor. During an interview on 5/8/2025 at 8:10 a.m., with Treatment Nurse 1 (TN 1), TN1 stated she was fully aware that Resident 170 needed podiatry care, and she informed the Assistant Director of Nursing (ADON). TN 1 stated it was not her responsibility to refer Resident 170 to the podiatrist (a doctor who specializes in diagnosing and treating conditions that affect the foot, ankle, and lower leg). During an interview on 5/8/2025 at 8:54 a.m., with the ADON, ADON stated it was an oversight on her part by not informing the Social Service Department for Resident 170's referral to the podiatrist. The ADON stated it was important to refer Resident 170 immediately to the podiatrist because of the risk of further infection. During an interview on 5/8/2025 at 9:29 a.m., with the Director of Nursing (DON), the DON stated podiatry care is one of the services provided by facility to all residents. The DON stated Resident 170 needed to be seen as soon as possible by a podiatrist so he could assess any abnormality of her lower extremities and treat the existing condition in order to prevent any complications. During a review of the facility's policy and procedure (P&P), titled Foot Care, dated 10/2022, the P&P indicated, Residents are provided with foot care and treatment in accordance with professional standards of practice.

CONCERN (D)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure one of four sampled residents (Resident 175) was provide...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure one of four sampled residents (Resident 175) was provided with a scheduled toileting plan (a technique that involves using a set schedule to go to the bathroom) or bladder training (type of training that will help a person manage urinary incontinence), per bowel and bladder assessment. This deficient practice had the potential for decline in bladder function for Resident 175. Findings: During a review of Resident 175's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 175 was admitted to the facility on [DATE]. Resident 175's diagnoses included bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), major depressive disorder ([MDD] - a mood disorder that causes a persistent feelings of sadness and loss of interest) and generalized muscle weakness. During a review of Resident 175's History and Physical (H&P), dated 2/26/2025, the H&P indicated, Resident 175 had the capacity to understand and make decisions. During a review of Resident 175's Minimum Data Set ([MDS] - a resident assessment tool), dated 2/26/2025, the MDS indicated, Resident 175 was independent (decisions consistent/reasonable) in cognitive (ability to think and reason) skills for daily decision making. The MDS indicated, Resident 175 required substantial assistance (helper does more than half the effort) from staff with toileting hygiene and lower body dressing. The MDS also indicated that a trial of toileting program such as scheduled toileting or bladder training have not been attempted. During an interview on 5/7/2025 at 2:26 p.m., with Resident 175, Resident 175 stated she is willing to use the bedpan (a shallow, pan-shaped container used by individuals who are bedridden or unable to use a toilet due to illness or injury) or use a bedside commode (a portable toilet that can be used by people who are unable to walk to the bathroom but can get out of bed) because she does not want to have a urine infection, but no staff had offered it. Resident 175 stated nursing staff put a diaper on her every day. During an interview on 5/7/2025 at 2:37 p.m., with Certified Nurse Assistant 2 (CNA 2), CNA 2 stated Resident 175 could tell when she needed to urinate and change her diaper. CNA 2 stated she did not offer a bedpan or bedside commode to Resident 175. During a concurrent interview and record review on 5/7/2025 at 3:12 p.m., with Minimum Data Set Nurse 2 (MDSN 2), Resident 175's Bowel and Bladder Program Screener was reviewed. The Bowel and Bladder Program Screener indicated, Resident 175 had a total score of 16 (0-6 Poor candidate for retraining/scheduled toileting, 7-14 candidate for scheduled toileting, 15-21 good candidate for retraining). The Bowel and Bladder Program Screener indicated, Resident 175's mental status was alert and oriented and always aware of need to toilet. The Bowel and Bladder Program Screener also indicated Resident 175 had the ability to get to the bathroom/transfer to toilet/commode/urinal, adjust clothing and wipe with 1 person assist. MDSN 2 stated that Resident 175 would benefit from bladder retraining or scheduled toileting program to reduce problems with incontinence (inability to control the flow or urine or stool) and to prevent risk of skin breakdown. MDSN 2 stated a scheduled toileting plan is a set schedule every 2 hours for residents to be assisted to the bathroom, use a bedside commode or offer a bedpan, for 72 hours to identify Resident 175's pattern of bladder incontinence or continency. MDSN 2 stated the facility did not implement any toileting program for Resident 175. During a review of the facility's policy and procedure (P&P), titled Urinary Continence and Incontinence - Assessment and Management, dated 8/2022, the P&P indicated, The physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible. The P&P also indicated as appropriate, based on assessing the category and causes of incontinence, the staff will provide scheduled toileting, prompted voiding, or other interventions to try to manage incontinence.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

The facility failed to: 1. Ensure one of four sampled residents (Resident 62) oxygen (O2) tubing was labeled with date last changed. This failure resulted in Resident 62 not having a clean and patent ...

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The facility failed to: 1. Ensure one of four sampled residents (Resident 62) oxygen (O2) tubing was labeled with date last changed. This failure resulted in Resident 62 not having a clean and patent tubing and placed at risk for developing a respiratory infection. Findings: During an observation on 5/6/2025 and 5/7/2025 at 11:30 a.m., Resident 62 was observed receiving continuous oxygen at 4 L/minute (amount of oxygen delivered) with no date label on the O2 tubing. The O2 tubing was cloudy and contained clear thick fluid in the tubing around the nasal area. During a concurrent interview and record review on 5/7/2025 at 11: 45 a.m. with Licensed Vocational Nurse (LVN) 4, LVN 4 stated oxygen tubing needs to be changed daily as a routine. LVN 4 stated nursing staff are supposed to label the O2 tubing. During a review of Resident 62's admission Record (Face sheet), the admission Record indicated the facility admitted Resident 62 on 1/29/2025 with diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing). During review of the Minimum Data Set (MDS- a resident assessment tool) dated 3/27/2025 indicated the resident had no cognitive (ability to think and make decisions) impairment. During the review of the physician's (MD) order indicated, change nasal cannula/mask (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) every 7 days(s) and as needed when soiled, every night shift(s), every Sunday for O2 therapy. During a review of Resident 62's Care Plan on oxygen revised 1/10/2025 indicated the resident was receiving oxygen 4 L/min due to COPD with goals for the resident to be free of adverse effects related to use of oxygen daily. The interventions included to change oxygen tubing weekly or as needed.

CONCERN (D)

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

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review the facility failed to: 1. Ensure one out of seven sampled residents (Resident 49...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review the facility failed to: 1. Ensure one out of seven sampled residents (Resident 49) appropriate alternatives were used prior to installing all four bed rails. This deficient practice of having all four bed rails up had the potential for Resident 49 to feel entrapped. Findings: During a review of Resident 49's admission Record, the admission Record indicated Resident 49 was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 49's diagnoses metabolic encephalopathy (a condition characterized by altered brain function due to a systemic or metabolic disturbance), dementia (a progressive state of decline in mental abilities), and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 49's History and Physical (H&P), dated 4/15/2025, the H&P indicated Resident 49 did not have the capacity to understand and make decisions. During a review of Resident 49's Minimum Data Set ([MDS]- a resident assessment tool), dated 4/7/2025 the MDS indicated Resident 49's cognition (ability to learn, reason, remember, understand, and make decisions) sometimes understands. The MDS indicated Resident 49 was dependent (helper does all of the effort. Residents do none of the effort to complete the activity) on staff for showering, toileting hygiene, and dressing. During an observation on 5/6/2025 at 11:06 a.m. all four bed rails were up while Resident 49 was lying in the bed. During an observation on 5/7/2025 at 11:28 a.m. all four bed rails were up while Resident 49 was lying in bed. Resident 49 was not receiving activity daily living ([ADL] -routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves) from staff. Resident 49 was able to slightly move in bed and was not using the bed rails for mobility or repositioning. Resident 49 was not able to remove bed rails easily. During a review of Resident 49's physician orders titled, Order Summary Report, dated 3/29/2024, the Order Summary Report indicated to have bilateral upper and lower half side rails up and locked when in bed for ADL changes, mobility, positioning, and as enabler. This use of side rails is considered as non-restraint. During a concurrent interview and record review on 5/7/2025 at 12:20 p.m. with Licensed Vocational Nurse (LVN) 5, Resident 49's physician orders titled, Order Summary Report, dated 3/29/2024 was reviewed. The Order Summary Report indicated to have bilateral upper and lower half side rails up and locked when in bed for ADL changes, mobility, positioning, and as enabler. This use of side rails is considered as non-restraint. LVN 5 stated Resident 49 and the physician order was not appropriate for the resident because he was not able to pull himself up nor turn himself in bed. LVN 5 stated the physician orders were not matching with Resident 49 abilities. LVN 5 stated Resident 49 could become confused, could potentially slide down, and become stuck in the bed rails which could place the resident in danger. During an interview on 5/8/2025 at 11:03 a.m. with Registered Nurse (RN) 1, RN 1 stated Resident 49 was moving around in bed and that's why all four bed rails were up. RN 1 stated all the bed rails have been up since 3/2024 and she had not noticed that all the bed rails were still up. RN 1 was not able to locate documentation that alternatives were used prior to using all four bed rails. RN 1 stated instead of all four bed rails would bed to have the bed in low position or just the upper bed rails up. RN 1 stated Resident 49 was not moving all over the bed now and not able to remove the bed rails easily. RN 1 stated having all bed rails up could make the resident feel trapped. During a review of the facility's policy and procedures (P&P) titled, Bed Safety and Bed Rails, dated 3/2023, the P&P indicated resident beds meet the safety specifications established and the use of bed rails is prohibited unless the criteria for use of bed rails have been met. The P&P indicated safety measures are implemented for residents who have been identified as having a higher than usual risk for injury including bed entrapment. The P&P indicated physical restraints are any manual method, physical, mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement. The P&P indicated alternatives to the use of side or bed rails are attempted. The P&P indicated alternatives include roll guards, foam bumpers, lowering the bed, and use of concave mattresses to reduce rolling off the bed.

CONCERN (D)

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

Deficiency F0712 (Tag F0712)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure one of one sampled resident (Resident 170) was evaluated...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure one of one sampled resident (Resident 170) was evaluated by a physician at least once every 30 days for the first 90 days following admission and document his visit in resident's clinical records. This deficient practice had the potential for Resident 170's current medical condition not timely assessed by a physician that can lead to delay in necessary care and treatment. Findings: During a review of Resident 170's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 170 was admitted to the facility on [DATE]. Resident 175's diagnoses included cellulitis (a skin infection that causes swelling and redness) of left and right lower limb (body part), hypertension ([HTN] - high blood pressure), and generalized muscle weakness. During a review of Resident 170's History and Physical (H&P), dated 1/29/2025, the H&P indicated, Resident 170 had the capacity to understand and make decisions. During a review of Resident 170's Minimum Data Set ([MDS] - a resident assessment tool), dated 2/5/2025, the MDS indicated, Resident 170 was independent (decisions consistent/reasonable) in cognitive (ability to think and reason) skills for daily decision making. The MDS indicated, Resident 170 required supervision (helper provides verbal cues as resident completes activity) from staff with oral hygiene, upper and lower body dressing, and personal hygiene. During an interview on 5/6/2025 at 10:58 a.m., with Resident 170, Resident 170 stated she had seen her physician only once since she was admitted January this year. Resident 170 stated she would like to see and talk to her physician so he could discuss her medical condition and provide the reason why her blood pressure was always high. During a concurrent interview and record review on 5/8/2025 at 9:00 a.m., with the Assistant Director of Nursing (ADON), Resident 170's clinical records were reviewed. The ADON stated Resident 170 was visited by her physician on 1/29/2025. The ADON stated Resident 170 was visited by a Physician Assistant ([PA] - a licensed healthcare professional who provides patient care under the supervision of a physician) on 2/15/2025, 3/15/2025, and 4/19/2025. The ADON stated residents at the facility should be seen by a physician once a month so he could do a thorough assessment, evaluate and treat residents medical conditions and document his findings in the clinical records of the residents. During an interview on 5/8/2025 at 9:37 a.m., with the Director of Nursing (DON), the DON stated a physician is required to visit residents every month in the facility and if the physician has a PA or Nurse Practitioner ([NP] - a nurse who has advanced clinical education and training) then he could visit every 3 months. The DON stated a physician has a broader amount of education and extensive training to treat residents complex (complicated) medical condition compared to a PA or NP. The DON stated he could not find Resident 170's physician progress notes on February 2025, March 2025, and April 2025. The DON stated the physician of Resident 170's was not compliant with the physician's visit based on the state and federal regulations. During a review of the facility's policy and procedure (P&P), titled Physician Visits, dated 4/2013, the P&P indicated, The attending physician must visit his/her patients at least once every 30 days for the first 90 days following the resident's admission, and then at least every 60 days thereafter.

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Ensure the correct prescribed eyedrops were in the...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Ensure the correct prescribed eyedrops were in the Sub-Acute Medication Cart according to physician orders for Resident 84. This deficient practice had the potential to result in medication errors. Findings: During a review of Resident 84's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 84 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included respiratory failure (a condition where the lungs cannot adequately exchange oxygen and carbon dioxide in the blood), aphasia (difficulty speaking), dysphagia (difficulty swallowing), and brain damage. During a review of Resident 84's Minimum Data Set (MDS- a federally mandated resident assessment tool), the MDS indicated Resident 84's cognitive (thinking) skills were severely impaired. The MDS indicated Resident 84 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 a review of Resident 84's physician orders, dated 1/10/2025, Resident 84 had a physician order for Refresh Tears Ophthalmic Solution 0.5%. During an observation, on 5/8/2025, at 8:40 a.m., of Medication Administration pass, with Licensed Vocational Nurse 8 (LVN 8), LVN 8 was observed removing Polyvinyl Alcohol 1.4% eye drops from the Sub Acute medication cart. During a concurrent interview and record review, on 5/8/2025, at 8:43, with LVN 8, LVN 8 stated Resident 84's Refresh eye drops were not delivered by the pharmacy in time. LVN 8 stated the Polyvinyl Alcohol eye drops needed to be clarified by Resident 84's physician as there wasn't an order for Resident 84. LVN 8 stated Resident 84's eye drops were held. LVN 8 stated he would clarify the order and called the pharmacy to follow up on Resident 84's Refresh tears eye drops. LVN 8 stated the risk of not obtaining the correct eye drops as ordered could result in accidentally administering the medication causing a medication error. During a review of the facility's policy and procedures (P&P), the P&P, titled Medication Administration-General Guidelines, dated October 2017, indicated Prior to administration, the medication and dosage schedule on the resident's, medication administration record (MAR) is compared with the medication label. If the label and MAR are different and the container is not flagged indicating a change in directions or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule.

CONCERN (D)

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

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Act on the pharmacist consultant's (a professional responsible ...

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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. Act on the pharmacist consultant's (a professional responsible for reviewing each resident's medication profile monthly to identify and report changes) recommendations timely, for one of five sampled residents (Resident 39). This deficient practice placed Resident 39 at risk for unnecessary medication administration. Findings: During a review of Resident 39's admission Record (front page of the chart that contains a summary of basic information about the resident), the admission Record indicated, Resident 39 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 39's diagnoses included psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and Diabetes Mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 39's History and Physical (H&P), dated 4/8/2025, the H&P indicated, Resident 39 was able to make decisions for activities of daily living. During a review of Resident 39's Minimum Data Set ([MDS] - a resident assessment tool), dated 4/11/2025, the MDS indicated, Resident 39 was independent (decisions consistent/reasonable) in cognitive (ability to think and reason) skills for daily decision making. The MDS indicated, Resident 39 required setup assistance (helper sets up, resident completes activity) from staff with eating, oral hygiene, and toileting hygiene. During a review of Resident 39's Order Summary Report (a document containing active orders), dated 5/7/2025, the Order Summary Report indicated, the physician placed a telephone order on 4/6/2025 for Resident 39 to start on Olanzapine (medication used to treat psychosis) to give 10 milligrams ([mg) - metric unit of measurement, used for medication dosage and/or amount) by mouth one time a day (9 a.m.) for psychosis manifested by constantly worrying about medical condition causing stress. During a concurrent interview and record review on 5/8/2025 at 3:54 p.m., with Registered Nurse 1 (RN 1), Resident 39's Consultant Pharmacist's Medication Regimen Review (MRR), dated 4/9/2025, was reviewed. The MRR indicated Resident 39 has a new psychotropic medication (any drug that affects brain activities associated with mental process and behavior) of Olanzapine for psychosis manifested by constant worrying about medical condition causing stress. The MDD indicated pharmacy consultant's recommendation for Resident 39's physician to clarify and update order of Olanzapine with appropriate behaviors. RN 1 stated the psychiatrist (a medical doctor who specializes in the diagnosis, treatment, and prevention of mental health disorder) came and evaluated Resident 39 on 4/11/2025 and did not address the Consultant Pharmacist's MRR. RN 1 stated Resident 39's clinical records did not indicate documentation the licensed nursing staff followed up with the resident's physician to clarify and update the behavior manifestation for the use of Olanzapine. RN 1 stated Resident 39's target behavior was not meeting the criteria for use of psychotropic medications. RN 1 stated it was important for the licensed nursing staff to address and discuss pharmacist consultant's recommendation with the resident's physician to avoid the residents receiving unnecessary medication and to comply with the federal regulations. During a review of the facility's policy and procedure (P&P), titled Consultant Pharmacist Reports, dated 6/2021, the P&P indicated, Recommendations are acted upon and documented by the facility staff and or the prescriber.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Ensure insulin pens were discarded for Resident 21...

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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 insulin pens were discarded for Resident 21. 2. Ensure a valproic acid (to treat seizures) bottle had a legible label for Resident 64. Findings: a. During a review of Resident 21's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 21 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hemiplegia and hemiparesis (complete paralysis and weakness on one side of the body), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and epilepsy (seizures). During a review of Resident 21's Minimum Data Set (MDS- a federally mandated resident assessment tool), the MDS indicated Resident 21's cognitive (thinking) skills were moderately impaired. The MDS indicated Resident 21 required 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). During a concurrent observation and interview, on 5/8/2025, at 11:04 a.m., of Station 2's Medication Storage Room, with Licensed Vocational Nurse 2 (LVN 2), LVN 2 observed a bag of Resident 21's opened insulin pens sitting on top of a shelf. LVN 2 stated Resident 21's insulin pens should had been discarded. LVN 2 stated the risk of not discarding expired medications could result in an infection control issue. LVN 2 stated The insulin pens should had been discarded immediately. b. During a review of Resident 64's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 64 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included epilepsy (seizures), type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), schizophrenia (a mental illness that is characterized by disturbances in thought)), and aphonia (inability to produce voiced sound). During a review of Resident 64's Minimum Data Set (MDS- a federally mandated resident assessment tool), the MDS indicated Resident 64's cognitive (thinking) skills were severely impaired. The MDS indicated Resident 64 required moderate 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). During a concurrent observation and interview, on 5/8/2025, at 2:25 p.m., of Station 2's Medication Cart, with Licensed Vocational Nurse 2 (LVN 2), LVN 2 observed a bottle of Resident 64's valproic acid with an illegible label inside of the cart. LVN 2 stated all medication should have a legible label for each resident. LVN 2 stated the risk of having an illegible label in a medication cart could result in medication errors and not knowing which resident the medication belongs to. During a review of the facility's policy and procedures (P&P), the P&P, titled Storage of Medications, dated 1/2025, indicated Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier.

CONCERN (D)

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to: 1. Ensure licensed staff performed hand hygiene for o...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to: 1. Ensure licensed staff performed hand hygiene for one out of seven sampled residents (Resident 34) during a dressing change. This deficient practice had the potential to spread infections throughout the facility, which is transferred through direct contact from contaminated hands. Findings: During a review of Resident 34's admission Record, the admission Record indicated Resident 34 was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 34's diagnoses chronic respiratory failure ([COPD]- a chronic lung disease causing difficulty in breathing), transient ischemic attack ([TIA]- an interruption of blood flow to the brain), and diabetes mellitus ([DM]- a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 34's History and Physical (H&P), dated 10/3/2024, the H&P indicated Resident 34 did not have capacity to understand and make decisions During a review of Resident 34's Minimum Data Set ([MDS]- a resident assessment tool), dated 4/7/2025 the MDS indicated Resident 34's cognition (ability to learn, reason, remember, understand, and make decisions) rarely/never understands. The MDS indicated Resident 34 was dependent (helper does all of the effort. Residents do none of the effort to complete the activity) on staff for showering, toileting hygiene, and dressing. The MDS indicated Resident 34 was at risk for developing pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). During an observation on 5/8/2025 at 11:30 a.m. TN 3 removed the dressing from the right great toe of Resident 34, cleaned the wound, and placed a clean dressing on the right great toe without washing his hand in between care of the wound. During an observation on 5/8/2025 at 11:35 a.m. TN 3 continued to treat another wound an abrasion to the left heel of Resident 34 and did not change gloves nor washed his hands between wound care treatment. During an interview on 5/8/2025 at 11:40 AM with TN 3, TN 3 stated he did not remove his gloves and washed his hands after he removed dressing from Resident 34's right great toe and left heel abrasion. TN 3 stated he should have washed his hands after cleaning the wounds and put on new gloves after each wound treatment. TN 3 stated the purpose of washing his hands was to prevent the spread of infection and to prevent the wound from getting infected. During a review of facility's policy and procedures (P&P) titled, Wound Care, dated 10/2010, the P&P indicated the purpose of this procedure was to provide guidelines for the care of wounds to promote healing. The P&P indicated the steps in the procedure was put on exam glove, loosen tape and remove dressing, pull glove over dressing, and discard into appropriate receptacle. The P&P indicated to wash and dry your hands thoroughly, put on gloves. During a review of facility's P&P titled, Handwashing/Hand Hygiene, dated 5/2023, the P&P indicated the facility considers hand hygiene the primary means to prevent the spread of infections. The P&P indicated use an alcohol-based hand rub before handling clean or soiled dressings and gauze pads, after handling used dressings, after removing gloves, and the use of gloves does not replace hand washing/hand hygiene.

CONCERN (E)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d. During a review of Resident 106's admission Record, the admission Record indicated Resident 106 was admitted to the facility ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d. During a review of Resident 106's admission Record, the admission Record indicated Resident 106 was admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 106's diagnoses metabolic encephalopathy (a condition characterized by altered brain function due to a systemic or metabolic disturbance), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and cerebral infarction (the death of brain tissue due to a lack of blood flow). During a review of Resident 106's History and Physical (H&P), dated 2/17/2025, the H&P indicated Resident 106 did not have capacity to understand and make decisions During a review of Resident 106's Minimum Data Set ([MDS]- a resident assessment tool), dated 4/7/2025 the MDS indicated Resident 106's cognition (ability to learn, reason, remember, understand, and make decisions) rarely/never understands. The MDS indicated Resident 106 was dependent (helper does all of the effort. Residents do none of the effort to complete the activity) on staff for showering, toileting hygiene, and dressing. The MDS indicated Resident 106 was at risk for developing pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). During an observation on 5/6/2025 at 11:45 a.m. in Resident 106's room, the resident was lying on a LAL mattress. The LAL mattress was set at 150 pounds [lbs.]- a unit of weight). During a review of Resident 106's Vital Signs, dated 5/6/2025, the Vital Signs indicated, Resident 106 weight was 126lbs. During a concurrent interview and record review on 5/7/ 2025 at 11:38 a.m. with Licensed Vocational Nurse (LVN) 5, Resident 106's Vital Signs, dated 5/6/2025 was reviewed. The Vital Signs indicated on 5/6/2025 Resident 106 weight was 126lbs. LVN 5 stated Resident 106's current weight is 126lbs. and the LAL mattress is set at 150lbs and that was the incorrect mattress setting. LVN 5 stated the LAL mattress should be set closer to the residents' current weight of 126lbs. LVN 5 stated the purpose of the mattress is to prevent pressure sores (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). LVN 5 stated it was important to have the correct LAL mattress setting to prevent pressure sores. During a concurrent interview and record review on 5/7/ 2025 at 11:38 a.m. with Licensed Vocational Nurse (LVN) 6, Resident 106's Vital Signs, dated 5/6/2025 was reviewed. The Vital Signs indicated on 5/6/2025 Resident 106 weight was 126lbs. LVN 6 stated the LAL mattress was 24lbs over the proper pressure for the resident and was not the correct settings for the resident. LVN 6 stated the LAL mattress should match the residents' weight to prevent pressure sores. During a review of facility's policy and procedures (P&P) titled, Prevention of Pressure Injuries, dated 4/2020, the P&P indicated the purpose of this procedure it to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. The P&P indicated review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application and ability to secure the device. During a review of the manufacturer's operational manual for the LAL mattress, date unknown, the manufacturer's operational manual indicated users can adjust air mattress to a desired firmness according to patient's weight. e. During a review of Resident 145's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 145 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included malignant neoplasm of colon (colon cancer), type 2 diabetes (a disorder characterized by difficulty in blood sugar control and poor wound healing), congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 145's Minimum Data Set (MDS- a federally mandated resident assessment tool), the MDS indicated Resident 145's cognitive (thinking) skills were intact. The MDS indicated Resident 145 required maximal assistance form 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 observation, on 5/6/2025, at 11:32 a.m., in Resident 145's room, Resident 145's low air loss mattress weight settings was at 220 lbs. During a concurrent interview and record review, on 5/ 8/2025, at 9:48 a.m., with Licensed Vocational Nurse 7 (LVN 7), LVN 7 stated Resident 145's low air loss mattress was set at 220 lbs. LVN 7 stated Resident 145 weighed 137 lbs. LVN 7 stated the risk of setting a low air loss mattress at an inappropriate weight setting could result in further skin breakdown. During a review of the facility's policy and procedures, the P&P, titled Pressure Reducing Mattress, undated, indicated May adjust air mattress to a desired firmness according to patient's weight. b. During a review of Resident 68's admission Record, the admission Record indicated Resident 68 was initially admitted to the facility on [DATE], with a readmission on [DATE]. Resident 68's diagnoses included hypertension (HTN-high blood pressure), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and gout (severe pain, swelling, and redness in the joints caused by inflammation). During a review of Resident 68's History and Physical (H&P), dated 3/28/2025, the H&P indicated Resident 68 had the capacity to understand and make decisions. During a review of Resident 68's Minimum Data Set (MDS - a resident assessment tool), dated 4/4/2025, the MDS indicated Resident 68's cognition (ability to reason and understand) was intact. The MDS indicated Resident 68 needed maximal (helper does more than half the effort) assistance with toileting, showering, and dressing the lower body. Resident 68 was unable to walk 10 feet, stand, or transfer to a chair. The MDS indicated Resident 68 was at risk for a pressure injury. The MDS indicated Resident 68 was not on a pressure reducing device for the bed. During a review of Resident 68's care plan, dated 2/1/2025, the care plan indicated Resident 68 was at risk for developing a pressure injury. The care plan indicated the facility would provide a pressure relieving device. During a review of Resident 68's Braden Scale for Predicting Pressure Sore Risk, dated 2/2/2025, the scale indicated Resident 68 had a moderate risk for developing a pressure injury. During a review of Resident 68's Order Summary Report, dated 5/8/2025, the report indicated on 4/6/2025 the physician entered an order for a low air loss mattress. During a concurrent observation and interview on 5/8/2025 at 12:17 p.m. with Licensed Vocational Nurse (LVN) 1 at the bedside of Resident 68, LVN1 stated Resident 68 was not on a low air loss mattress. LVN1 stated low air loss mattresses are ordered for residents who are at risk for pressure injuries and those who have pressure injuries. LVN1 stated low air loss mattresses help prevent pressure injuries. LVN1 stated Resident 68 is at risk for pressure injury because she is not on the correct mattress. During a review of the facility's policy and procedure (P&P) titled, Prevention of Pressure Injuries, dated April 2020, the P&P indicated the facility would select appropriate support surfaces based on the resident's risk factors. During a review of the facility's P&P titled, Pressure-Reducing Mattresses, (no date), the P&P indicated the facility would provide mattresses that will prevent and/or minimize pressure on the skin. c. During a review of Resident 76's admission Record, the admission Record indicated Resident 76 was initially admitted to the facility on [DATE], with a readmission on [DATE]. Resident 76's diagnoses included traumatic brain injury (TBI- a brain injury that is caused by an outside force), dysphagia (difficulty swallowing), and respiratory failure (a condition where the lungs are unable to adequately exchange oxygen). During a review of Resident 76's H&P, dated 1/28/2025, the H&P indicated Resident 76 did not have the capacity to understand and make decisions. During a review of Resident 76's MDS, dated [DATE], the MDS indicated Resident 76's cognition was not tested because he was unable to complete the interview. The MDS indicated Resident 76 was dependent on staff for toileting, showering, and dressing. Resident 76 was unable to walk 10 feet, stand, or transfer to a chair. The MDS indicated Resident 76 was at risk for developing a pressure injury. During a review of Resident 76's Order Summary Report, dated 5/9/2025, the report indicated on 1/30/2025 the physician entered an order for a low air loss mattress. During a review of Resident 76's care plan, dated 11/7/2019 (revised 8/12/2024), the care plan indicated Resident 76 was at risk for developing a pressure injury. The care plan indicated the facility would provide pressure relieving devices as indicated (low air loss mattress, heel protectors). During a review of Resident 76's Braden Scale for Predicting Pressure Sore Risk, dated 2/11/2025, the scale indicated Resident 76 had a high risk for developing a pressure injury. During a concurrent observation and interview on 5/8/2025 at 12:19 p.m. with Licensed Vocational Nurse (LVN) 1 at the bedside of Resident 76, LVN1 stated Resident 76 was not on a low air loss mattress. LVN1 stated low air loss mattresses are ordered for residents who are at risk for pressure injuries and those who have pressure injuries. LVN1 stated low air loss mattresses help prevent pressure injuries. LVN1 stated Resident 76 is at risk for pressure injury because he is not on the correct mattress. During a review of the facility's policy and procedure (P&P) titled, Prevention of Pressure Injuries, dated April 2020, the P&P indicated the facility would select appropriate support surfaces based on the resident's risk factors. During a review of the facility's P&P titled, Pressure-Reducing Mattresses, (no date), the P&P indicated the facility would provide mattresses that will prevent and/or minimize pressure on the skin. Based on observation, interview, and record review the facility failed to: 1. Ensure three out of seven sampled residents (Residents 68, 76, and 177) had a low air loss([LAL] -a specialized medical mattress designed to prevent and treat pressure ulcers by reducing pressure and moisture buildup on the skin) mattress, as ordered. 2. Ensure two out of seven sampled residents (Resident 106 and 145) LAL mattress had the correct settings, as ordered. This deficient practice had the potential for Residents 68, 76, 106, 145 and 177 to develop pressure ulcers (injuries to the skin caused by prolonged pressure). Findings: a. During a concurrent interview and observation on 5/6/2025 at 10:42 a.m. with Resident 177, Resident 177 stated she is unable to walk and could not move her legs very much because they are very weak. Resident 177 was observed lying on a regular mattress. During a review of Resident 177's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 177 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included amyotrophic lateral sclerosis (ALS- a disease that affects nerve cells in the brain and spinal cord, leading to muscle weakness and eventually paralysis), and muscle weakness. During a review of Resident 177's Care Plan, dated 3/1/2025, the Care Plan indicated Resident 177 was at risk to develop pressure ulcers due to immobility, and ALS. Interventions included that staff would provide pressure-relieving devices such as a low air loss mattress. During a review of Resident 177's Minimum Data Set (MDS - a resident assessment tool), dated 4/29/2025, the MDS indicated Resident 177 was dependent on others if needed to roll left and right in bed. The MDS further indicated Resident 177 did not have any unhealed pressure ulcers. During a review of Resident 177's Order Summary Report, the Order Summary Report indicated Resident 177 had an order placed on 5/3/2025 for a pressure relieving mattress for skin integrity and management. During a review of Resident 177's History and Physical (H&P), dated 5/4/2025, the H&P indicated Resident 177 was able to understand and make decisions. During a concurrent interview and record review on 5/7/2025 at 2:50 p.m. with Treatment Nurse 3 (TN 3), TN 3 stated if a resident had an order for a low air loss mattress, they would notify maintenance to bring up the low air loss mattress and would place it on for the resident. TN 3 stated the purpose of having a low air loss mattress is to prevent a resident from developing a pressure ulcer. Resident 177's Order Summary Report was reviewed with TN 3 and stated she had an order for a pressure relieving mattress. During an observation on 5/7/2025 at 3:13 p.m. with TN 3, TN 3 stated Resident 177 was not on a low air loss mattress and was just on a regular mattress and is unsure why a low air loss mattress was not in use for her. During a review of the facility's P&P titled Policy: Pressure- Reducing Mattresses, undated, the P&P indicated the facility would provide mattresses that would prevent and/or minimize pressure on the skin, and to provide comfort if resident prefers. During a review of the facility's policy and procedure (P&P) titled Prevention of Pressure Injuries, dated 4/2020, the P&P indicated the staff would select appropriate support surfaces based on the resident's risk factors in accordance with current clinical practice.

CONCERN (E)

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure two of seven sampled residents (Residents 74 and 76) rec...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure two of seven sampled residents (Residents 74 and 76) received Restorative Nurse Assistant ([RNA]- a healthcare worker who helps residents improve and maintain function in physical abilities) services seven days a week as ordered by the physician. This deficient practice put Residents 74 and 76 at risk for decreased range of motion and contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion). Findings: a. During a review of Resident 74's admission Record, the admission Record indicated Resident 74 was initially admitted to the facility on [DATE], with a readmission on [DATE]. Resident 74's diagnoses included hypertension (HTN-high blood pressure), dysphagia (difficulty swallowing), and respiratory failure (a condition where the lungs are unable to adequately exchange oxygen). During a review of Resident 74's History and Physical (H&P), dated 12/31/2024, the H&P indicated Resident 74 had the capacity to understand and make decisions. During a review of Resident 74's Minimum Data Set (MDS - a resident assessment tool), dated 3/6/2025, the MDS indicated Resident 74 was dependent on staff for toileting, showering, and dressing. Resident 76 was unable to walk 10 feet, stand, or transfer to a chair. During a review of Resident 74's Order Summary Report, dated 5/9/2025, the report indicated on 1/8/2025 the physician entered an order for the RNA to apply bilateral (both sides) elbow splints 4-6 hours, seven times a week. During a review of Resident 74's care plan, dated 1/27/2021 (revised 6/14/2021), the care plan indicated Resident 74 was at risk for a decline in range of motion of the bilateral upper extremities (both arms). The care plan indicated the RNA would apply bilateral elbow splints seven times a week. During a review of the RNA task form for application of the bilateral elbow splints, dated 4/9/2025 through 5/6/2025, the task indicated the elbow splint was applied on the following dates: 4/9/2025 4/10/2025 4/11/2025 4/14/2025 4/15/2025 4/16/2025 4/17/2025 4/18/2025 4/22/2025 4/23/2025 4/24/2025 4/25/2025 4/29/2025 4/30/2025 5/1/2025 5/2/2025 5/5/2025 5/6/2025 During an interview on 5/8/2025 at 12:41 p.m. with Licensed Vocational Nurse (LVN) 2, LVN2 stated splints need to be placed to prevent contractures. Splints help with mobility. LVN2 stated splints prevent the resident from being in the same position for too long. During a concurrent interview and record review on 5/8/2025 at 2:29 p.m. with RNA1, Resident 74's RNA task form for application of the bilateral elbow splints was reviewed. RNA1 stated when RNA services are ordered seven times a week, they need to be done every day. RNA1 stated Resident 74 did not have his splints applied every day as ordered. RNA1 stated RNA services are provided to help prevent contractures and provide exercises. When splints are not applied as ordered a resident can become contracted. During a review of the facility's policy and procedure (P&P) titled, Restorative Nursing Services, dated July 2017, the P&P indicated residents will receive restorative nursing care as needed to help promote optimal safety and independence. During a review of the RNA Job Description, dated January 2022, the job description indicated the RNA will provide residents with routine restorative nursing care and services in accordance with the resident's assessment, care plan and as directed by supervisors. b. During a review of Resident 76's admission Record, the admission Record indicated Resident 76 was initially admitted to the facility on [DATE], with a readmission on [DATE]. Resident 76's diagnoses included traumatic brain injury (TBI- a brain injury that is caused by an outside force), dysphagia, and respiratory failure (a condition where the lungs are unable to adequately exchange oxygen). During a review of Resident 76's H&P, dated 1/28/2025, the H&P indicated Resident 76 did not have the capacity to understand and make decisions. During a review of Resident 76's MDS, dated [DATE], the MDS indicated Resident 76's cognition was not tested because he was unable to complete the interview. The MDS indicated Resident 76 was dependent on staff for toileting, showering, and dressing. Resident 76 was unable to walk 10 feet, stand, or transfer to a chair. During a review of Resident 76's Order Summary Report, dated 5/9/2025, the report indicated on 3/14/2025 the physician entered an order for the RNA to apply bilateral (both sides) elbow splints 4-6 hours, seven times a week. During a review of Resident 76's care plan, dated 6/14/2021, the care plan indicated Resident 76 was at risk for a decline in range of motion of the bilateral upper extremities. The care plan indicated the RNA would apply bilateral elbow splints seven times a week. During a review of the RNA task form for application of the bilateral elbow splints, dated 4/9/2025 through 4/30/2025, the task indicated the elbow splints were applied on the following dates: 4/9/2025 4/10/2025 4/11/2025 4/12/2025 4/15/2025 4/16/2025 4/17/2025 4/18/2025 4/19/2025 4/20/2025 4/22/2025 4/23/2025 4/24/2025 4/25/2025 4/26/2025 4/27/2025 4/29/2025 4/30/2025 During an interview on 5/8/2025 at 12:41 p.m. with LVN2, LVN2 stated splints need to be placed to prevent contractures. Splints help with mobility. LVN2 stated splints prevent the resident from being in the same position for too long. During a concurrent interview and record review on 5/8/2025 at 2:24 p.m. with RNA1, Resident 76's RNA task form for application of the bilateral elbow splints was reviewed. RNA1 stated when RNA services are ordered seven times a week, they need to be done every day. RNA1 stated Resident 76 did not have his splints applied every day as ordered. RNA1 stated RNA services are provided to help prevent contractures and provide exercises. When splints are not applied as ordered a resident can become contracted. During a review of the facility's policy and procedure (P&P) titled, Restorative Nursing Services, dated July 2017, the P&P indicated residents will receive restorative nursing care as needed to help promote optimal safety and independence. During a review of the RNA Job Description, dated January 2022, the job description indicated the RNA will provide residents with routine restorative nursing care and services in accordance with the resident's assessment, care plan and as directed by supervisors.

CONCERN (E)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to: 1. Ensure one of seven sampled residents (Resident 67...

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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 one of seven sampled residents (Resident 67) smoking paraphernalia (an electronic cigarette device that heats a liquid containing nicotine) had been properly stored. 2. Ensure one of seven sampled residents (Resident 124) bed rails were properly padded. 3. Ensure one of seven sampled residents (Resident 95) lighter was stored in a safe location. These deficient practices had the potential to cause serious injuries. Findings: a. During a review of Resident 67's admission Record, the admission Record indicated Resident 67 was admitted to the facility on [DATE] and was readmitted on [DATE] Resident 67's diagnoses multiple sclerosis (a chronic, unpredictable disease of the central nervous system), chronic obstructive pulmonary disease ([COPD]-a chronic lung disease causing difficulty in breathing), and acute kidney failure (a sudden and significant decline in the kidney function). During a review of Resident 67's History and Physical (H&P), dated 7/19/2024, the H&P indicated Resident 67 had the capacity to understand and make decisions During a review of Resident 67's Minimum Data Set ([MDS]- a resident assessment tool), dated 2/14/2025 the MDS indicated Resident 67's cognition (ability to learn, reason, remember, understand, and make decisions) able to understand. The MDS indicated Resident 67 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity) on staff for toileting hygiene. The MDS indicated Resident 67 was at risk for developing pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). The MDS indicated Resident 67 neurological (anything related to the nervous system, including the brain, spinal cord, and nerves) had a seizure disorder. During an observation on 5/6/2025 at 11:39 a.m. in Resident 67's room there were two vapes with the cannabis symbol (often green cannabis leaf within a triangle with an exclamation point, signifies that a product contains cannabis) on the bedside table. During an observation on 5/7/2025 at 11:04 a.m. in Resident 67's there were two vapes with the cannabis symbol on the bedside table. During an interview on 5/7/2025 at 11:04 a.m. with Resident 67, Resident 67 stated she uses the vapes weekly in her room. Resident 67 stated she had been using the vapes since January of 2025 and she keep them on her bedside table. Resident 67 stated the black vape is for sleep and the white vape is to stay awake. During a concurrent observation and interview on 5/7/2025 at 12:04 p.m. with Licensed Vocational Nurse (LVN) 5, in Resident 67's room, Resident 67 had two vapes on the bedside table. LVN 5 stated she does rounds daily and did not notice the vapes on the bedside table. LVN 5 stated the vapes could potentially negatively expose the other residents in the room and to Resident 67 for example be contraindicated to her medications. LVN 5 stated Resident 67's physician needed to be notified, and resident teaching needed to be done. LVN 5 stated it was important to teach Resident 67 about vaping cause over time had the potential to cause lung damage. During a concurrent observation and interview on 5/8/2025 at 9:43 a.m. with Staff Development Assistant, the Staff Development Assistant stated he does rounds daily and did not notice the vapes on the bedside table. The Staff Development Assistant stated the resident had the potential to burn herself if she was not supervised while using the vapes. During a review of the facility's policy and procedure (P&P) titled, Smoking Policy-Residents, dated 8/2022, the P&P indicated the facility had established and maintains safe resident smoking practices. The P&P indicated vape devices are not considered smoking devices with respect to the risk of ignition, but are considered a risk for residents related to potential health effects for the smoker such as respiratory illness (any disease of condition that affects the lungs and other parts of the respiratory system impacting breathing), second-hand aerosol exposure (a mix of tiny particles and droplets in the air containing harmful substances), and explosion or fire caused by the battery. b. During a review of Resident 124's admission Record, the admission Record indicated Resident 124 was admitted to the facility on [DATE] and was readmitted on [DATE] Resident 124's diagnoses seizures, encephalopathy (a condition that disrupts the brain's normal function a range of symptoms including altered mental status, confusion, and difficulty concentrating), and dysarthria (a motor speech disorder that occurs when the muscles involved in speech become weak, paralyzed, or lack coordination). During a review of Resident 124's History and Physical (H&P), dated 2/17/2025, the H&P indicated Resident 124 did not have capacity to understand and make decisions During a review of Resident 124's Minimum Data Set ([MDS]- a resident assessment tool), dated 2/14/2025 the MDS indicated Resident 124's cognition (ability to learn, reason, remember, understand, and make decisions) rarely/never understands. The MDS indicated Resident 124 was dependent (helper does all of the effort. The resident does none of the effort to complete the activity) on staff for showering, toileting hygiene, and dressing. The MDS indicated Resident 124 was at risk for developing pressure ulcers (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence). The MDS indicated Resident 124 neurological (anything related to the nervous system, including the brain, spinal cord, and nerves) had a seizure disorder. During an observation on 5/6/2025 at 11:55 a.m. the left bed rail pad was hanging off the bed rail. During an observation on 5/7/2025 at 8:15 a.m. the left bed rail pad was hanging off the bed rail. During a review of Resident 124's physician orders titled, Order Summary Report, dated 1/12/2025, the Order Summary Report indicated Resident 124 was to have a low bed with padded bilateral upper half side rails up with floor mat to decrease potential injury. During a concurrent interview and record review on 5/7/2025 at 12:34 p.m. with LVN 5, Resident 124's physician orders titled, Order Summary Report, dated 1/12/2025 was reviewed. The Order Summary Report indicated Resident 124 was to have a low bed with padded bilateral upper half side rails up with floor mat to decrease potential injury. LVN 5 stated Resident 124's left rail was not completely padded, and the staff is to keep the bed rails padded. LVN 5 stated keeping the side rails padded is to keep the resident safe from injury. During a concurrent observation and interview on 5/7/2025 at 1:59 p.m. with the Assistant Director of Nursing (ADON), the ADON stated Resident 124 had a seizure disorder and the left bed rail was not fully padded. The ADON stated the left bed rail should be fully padded and more secure on the rail. The ADON stated the bed rail was to be padded to prevent injury if the resident was to have a seizure. 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 our facility strives to make the environment as free from accident hazards as possible. The P&P indicated resident safety, supervision, and assistance to prevent are facility-wide priorities. The P&P indicated resident supervision may need to be increased when there are temporary hazards in the environment such as bed safety. During a review of the facility's policy and procedure (P&P) titled, Seizures and Epilepsy-Clinical Protocol, dated 3/2024, the P&P indicated the treatment and management to prevent injury during seizure activity, side rails, if in use, will be padded. c. During a review of Resident 95's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 95 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease (COPD- a chronic lung disease causing difficulty in breathing), hypertension (high blood pressure), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), and muscle weakness. During a review of Resident 95's Minimum Data Set (MDS- a federally mandated resident assessment tool), the MDS indicated Resident 95's cognitive (thinking) skills were intact. The MDS indicated Resident 95 required partial 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). During a concurrent observation and interview, on 5/6/2025, at 10:30 a.m., in Resident 95's room, Resident 95 stated he was a smoker and was able to keep his lighter in his room. Resident 95 presented a personal green lighter from his bedside table. During a concurrent interview and record review, on 5/8/2025, at 1:50 p.m., with Licensed Vocational Nurse 2 (LVN 2), LVN 2 stated Resident 95 was a supervised smoker. LVN 2 stated all supervised smokers were not allowed to have lighters in their rooms. LVN 2 stated Resident 95 had a lighter at his bedside. LVN 2 stated the risk of a supervised smoker keeping a lighter on them could result in a resident burning themselves, other residents or the facility. LVN 2 stated Resident 95 shouldn't have had a lighter as he is a supervised smoker. During a review of the facility's policy and procedures (P&P), the P&P, titled Smoking Policy, revised August 2022, indicated Resident without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etc., except under direct supervision.

CONCERN (E)

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

Laboratory Services (Tag F0770)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure one of seven sampled residents (Resident 123) had a Comp...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure one of seven sampled residents (Resident 123) had a Complete Blood Count ([CBC]- a blood test that measures the number and type of cells in your blood), Comprehensive Metabolic Panel ([CMP]- a blood test that measures fourteen different substances in the blood) and Ammonia (a waste product found in blood) level completed per physician's order. 2. Ensure one of two sampled residents (Resident 156) had weekly pre-albumin (a lab test measures the level of prealbumin in the blood, a protein made by the liver) laboratory order drawn as ordered by the physician. These deficient practices had the potential for a delay in healthcare services and interventions for Residents 123 and 156 . Findings: a. During a review of Resident 123's admission Record, the admission Record indicated Resident 123 was initially admitted to the facility on [DATE], with a readmission on [DATE]. Resident 123's diagnoses included malnutrition (a condition caused by not getting enough calories or the right amount of key nutrients), schizophrenia (a mental illness that is characterized by disturbances in thought), and bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 123's History and Physical (H&P), dated 12/19/2024, the H&P indicated Resident 123 had the ability to make decisions for activities of daily living. During a review of Resident 123's MDS, dated [DATE], the MDS indicated Resident 123's cognition (ability to reason and understand) was intact. The MDS indicated Resident 123 needed set up assistance with eating, toileting, and dressing. During a review of Resident 123's care plan, dated 4/6/2025, the care plan indicated the facility would complete lab work as ordered and notify the physician of abnormal results. During a review of Resident 123's Order Summary Report, dated 5/8/2025, the report indicated on 4/25/2025 the physician entered an order for a CBC, CMP, and Ammonia level. During a concurrent interview and record review on 5/8/2025 at 12:36 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 123's lab results were reviewed. LVN 2 stated there were no lab results for a CBC, CMP, and Ammonia level. LVN 2 stated the lab work was not completed. LVN 2 stated the physician ordered the lab work to monitor Resident 123 because she is on medications. Since the lab work was not completed, something may be out of range that needs to be addressed. During a review of the facility's policy and procedure (P&P) titled, Availability of Services, Diagnostic, dated December 2009, the P&P indicated clinical laboratory services to meet the needs of the residents are provided by the facility. b. During a review of Resident 156's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 156 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included encephalopathy (any disease, disorder, or damage that affects the brain's normal function or structure), and generalized edema (the accumulation of fluid in the body's tissues, affecting the entire body). During a review of Resident 156's History and Physical (H&P), dated 12/7/2024, the H&P indicated Resident 156 did not have the ability to understand and make decisions. During a review of Resident 156's Minimum Data Set (MDS - a resident assessment tool), dated 2/5/2025, the MDS indicated it was not appropriate for Resident 156 to have a brief interview for mental status (BIMS -an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) be done. The MDS further indicated Resident 156 was dependent on staff for all functional abilities (an individual's capacity to perform activities of daily living and other tasks). During a review of Resident 156'S Care Plan, dated 1/15/2025, the Care Plan indicated Resident 156 was at risk for alteration in hydration status due to history of vomiting, and not being able to eat by mouth and was also on gastrostomy tube feeding (GT feeding- a feeding tube surgically placed directly into the stomach to receive nutrition) and was at risk for weight gain and weight loss, and dehydration. Interventions included to have laboratory blood work done as ordered. During a review of Resident 156's Order Summary Report, the Order Summary Report indicated Resident 156 had an order placed on 1/18/2025, for a weekly laboratory order for pre-albumin. During a concurrent interview and record review on 5/7/2025 at 1:56 p.m. with Registered Nurse (RN) 2, RN 2 stated laboratory orders need to be entered into the laboratory company website so they would be aware there was blood work that needed to be done. RN 2 reviewed Resident 156's Order Summary Report and stated there was an order for a weekly pre-albumin blood draw since January. RN 2 reviewed the weekly pre-albumin blood draw and stated they have not been done weekly as ordered and have only been done on the following dates: 1/21/25, 2/20/25, 3/5/25, 4/3/25, 4/7/25, 4/21/25. RN 2 stated Resident 156 had these blood work because they wanted to ensure his protein levels are good and if it was abnormal, would report to the doctor and dietitian and see what further interventions the resident would need. During a review of the facility's P&P titled Availability of Services, Diagnostic, dated 12/2009, the P&P indicated clinical laboratory services to meet the needs of our residents are provided by the facility.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by failing to: 1. Ensure food item was lab...

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Based on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen by failing to: 1. Ensure food item was labeled in dry food storage 2. Ensure the outside compartment of ice machine was clean These deficient practices had the potential to result in foodborne illness and cross contamination (transfer of harmful bacteria from one place to another). Findings: 1. During a concurrent observation and interview on 5/6/2025 at 8:40 a.m., with the Dietary Service Supervisor (DSS) in the dry storage room, an opened box of spaghetti whole wheat pasta was noted with no label with an open date. The DSS stated all food items in the dry storage are once opened in the box, should be labeled with the date it was opened and follow the standard food guidelines when to be consumed. The DSS stated the risk of not labeling with an open date of food items could result in residents consuming expired food. During a review of the facility's undated policy and procedure (P&P), titled Storage of Canned and Dry Goods, the P&P indicated, Food items will be dated and labeled when placed in the containers. 2. During a concurrent observation and interview on 5/6/2025 at 8:51 a.m., with the DSS in the kitchen area, outside compartment of ice machine was observed dirty with thick hard water deposit. The DSS stated dietary staff was responsible in cleaning the outside compartment of the ice machine once a week. The DSS stated the facility did not keep a log to show weekly cleaning of the outside compartment of the ice machine. The DSS stated it was important to clean the outside compartment of the ice machine to preserve the integrity of the ice machine and for infection control purposes. During a review of the facility's undated P&P, titled Ice Machine Cleaning, the P&P indicated, Dietary staff to clean and sanitize the outside of the ice machine daily and as needed.

CONCERN (E)

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

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to: 1. Ensure two of five sampled residents (Resident 152 and Residen...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to: 1. Ensure two of five sampled residents (Resident 152 and Resident 441) was offered the flu vaccine for the 2024-2025 flu season. This deficient practice had the potential for Resident 152 and Resident 441 at higher risk of acquiring and transmitting the flu to other residents in the facility. Findings: During an interview on 5/8/2025 at 8:56 a.m. with Infection Prevention Nurse (IPN) 1, IPN 1 stated all residents of the facility are offered the flu vaccine during the flu season. If the resident or their representative received the flu vaccine, it would be documented in the resident's chart that they received the flu vaccine, if they declined, there would also be documentation they declined the flu vaccine. IPN 1 stated she was unable to find documentation to show if Resident 152 and Resident 441 declined or received the flu vaccine for the 2024-2025 flu season. During a review of Resident 152's Face Sheet (front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 152 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included respiratory failure (too little air or blood flow to the lungs), dependence on ventilator (a machine that helps support breathing), and pneumonia (an infection/inflammation in the lungs). During a review of Resident 152's History and Physical (H&P) dated 12/6/2024, the H&P indicated Resident 152 did not have the ability to understand and make decisions. During a review of Resident 152's Minimum Data Set (MDS - a resident assessment tool) dated 3/15/2025, the MDS indicated the flu vaccine was not offered to Resident 152. The MDS also indicated it was not appropriate for Resident 152 to have a brief interview for mental status (BIMS -an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) be done. The MDS further indicated Resident 156 was dependent on staff for all functional abilities (an individual's capacity to perform activities of daily living and other tasks). During a review of Resident 441's Face Sheet, the Face Sheet indicated Resident 441 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included respiratory failure, and chronic obstructive pulmonary disorder (COPD- a chronic lung disease causing difficulty in breathing). During a review of Resident 441's Care Plan dated 12/21/2023, the Care Plan indicated Resident 441was at high risk for infection and interventions included to offer and administer vaccines as needed. During a review of Resident 441's MDS dated [DATE], the MDS indicated the flu vaccine was not offered to Resident 441. The MDS also indicated it was not appropriate for Resident 441 to have a BIMS assessment be done. The MDS further indicated Resident 441 was dependent on staff for all functional abilities. During a review of Resident 441's H&P dated 5/2/2025, the H&P indicated Resident 441 did not have the ability to understand and make decisions. During a follow up interview on 5/9/2025 at 9:14 a.m. with IPN 1, IPN 1 stated all residents are offered the flu vaccine during the flu vaccine season. IPN 1 was not sure why they were not offered the flu vaccine. With IPN 1, reviewed the electronic health record for Resident 152 and Resident 441 again, but unable to find documentation that they were offered the flu vaccine and there was no declination from either one of the residents, and no documentation they received the flu vaccine. IPN 1 stated both residents are ventilator (a medical device to help support or replace breathing) dependent and they are more vulnerable if they get the flu and if they or their family consents to receiving the vaccine then it should be given to them to prevent complications. During a concurrent interview and record review on 5/9/2025 at 9:50 a.m. with IPN 2, Resident 152 and Resident 441's care plan, interdisciplinary team (IDT) meetings were reviewed. IPN 2 stated there were care plans for Resident 152 and Resident 441 that showed the flu vaccine was declined and reviewed both of their care plans but was unable to find a care plan for declining the flu vaccine. The MDS was shown to IPN 2 for Resident 152 and Resident 441 and showed the flu vaccine was not offered. IPN 2 stated there could also be a documented IDT meeting that showed the flu vaccine was declined but Resident 152 and Resident 441's electronic health record did not show this IDT meeting occurred. During a concurrent interview and record review on 5/9/2025 at 10:34 a.m. with IPN 1, the California Immunization Registry (CAIR- a secure, confidential, statewide computerized immunization information system for California residents), undated, was reviewed for Resident 152 and Resident 441. IPN 1 stated that according to the CAIR website, neither Resident 152 nor Resident 441 received the 2024-2025 flu vaccine. During a review of the facility's policy and procedure (P&P) titled Vaccination of Residents, dated 10/2019, the P&P indicated all residents would be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated (a reason not to do something) or the resident had already been vaccinated. During a review of the facility's policy and procedure (P&P) titled Influenza Vaccine, dated 3/2022, the P&P indicated between October 1 and March 31 each year, the vaccine shall be offered to residents unless the vaccine is medically contraindicated or had already been immunized (have already received the vaccine). The P&P further indicated a resident's refusal of the vaccine shall be documented on the informed consent for influenza vaccine and placed in the medical record and the infection preventionist will maintain surveillance data on influenza vaccine coverage and reported rates of influenza among residents.

MINOR (B)

Minor Issue - procedural, no safety impact

Deficiency F0912 (Tag F0912)

Minor procedural issue · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Ensure residents in rooms 1, 2, 3, 4, 5, 7, 8, 9,...

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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 residents in rooms 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, and 13 had at least 80 square feet ([sqft]- a unit of measure) of living space. This deficient practice had the potential to result in residents not being able to move around freely or store personal items. Staff may also have difficulty providing care due to a lack of space. Findings: During an observation on 5/6/2025 at 12:00 p.m. in room [ROOM NUMBER], room [ROOM NUMBER] was noted to contain three occupied beds. During a review of the Client Accommodation Analysis, dated 5/6/2025, the analysis indicated the facility had the following room measurements: Room # # of beds Floor square footage 1 3 211 2 3 210 3 3 210 4 3 210 5 3 211 7 3 211 8 3 211 9 3 211 10 3 212 11 3 212 12 3 212 13 3 214 During a review of the Room Variance Waiver request letter, dated 5/6/2025, the letter indicated rooms 1, 2, 3, 4, 5, 7, 8, 9, 10, 11, 12, and 13 do not have at least 80 sqft per resident. During an interview on 5/9/2025 at 11:48 a.m. with the Administrator (Adm), the Adm stated there have not been any complaints from residents or staff concerning the smaller rooms. The Adm stated due to the smaller room, staff could potentially not have enough room to provide care for residents. There may not be enough room to store medical equipment and personal items.

MINOR (C)

Minor Issue - procedural, no safety impact

Deficiency F0577 (Tag F0577)

Minor procedural issue · This affected most or all residents

Based on observation, interview, and record review, the facility failed to: 1. Ensure the results of their last recertification survey were in a place easily accessible and viewed by residents/the pub...

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Based on observation, interview, and record review, the facility failed to: 1. Ensure the results of their last recertification survey were in a place easily accessible and viewed by residents/the public. This deficient practice had the potential to result in residents/the public not being well informed about the quality-of-care residents receive at the facility. Findings: During a concurrent observation and interview on 5/6/20/25 at 9:15 a.m. with the Administrator (Adm) in the main lobby, the Adm stated she did not know where the binder with the last survey results were. The Adm stated the survey binder should be in a place where anyone can look at it. The survey results allow others to see what past deficiencies the facility had. During a review of the facility's policy and procedure (P&P) titled, Resident Rights, dated February 2021, the P&P indicated residents have a right to examine survey results.

Mar 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

Free from Abuse/Neglect (Tag F0600)

Could have caused harm · This affected 1 resident

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

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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) were free from verbal abuse by Certified Nursing Assistant (CNA) 1. This deficient practice had the potential for Resident 1 to feel upset and that his needs were not being met. Findings: a. During a review of Resident 1's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included partial amputation of the right foot (involves surgically removing part of the foot), functional quadriplegia (inability to move due a physical disability), and diabetes mellitus ([DM] - a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 1's History and Physical (H&P), dated 7/19/2024, the H&P indicated, Resident 1 had the capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set ([MDS] a resident assessment tool), dated 2/1/2025, the MDS indicated Resident 1's cognition (ability to learn, reason, remember, understand, and make decisions) was normally intact. The MDS indicated Resident 1's verbal behavioral symptoms directed toward others were not exhibited. The MDS indicated Resident 1 required supervision for dressing and personal hygiene. During a review of Resident 1's Progress Note, dated 2/19/2025, the Progress Notes indicated Resident 1 had a verbal disagreement with Certified Nursing Assistant (CNA) 1 regarding the placement of his roommate's (Resident 2) wheelchair. The Progress Note indicated Resident 1 expressed loudly that the wheelchair obstructs his passage on the way out of the room. The Progress note indicated CNA 1 loudly expressed the necessity of moving it to feed Resident 2. During a review of Resident 1's Change of Condition (COC) dated 2/19/2025, the COC indicated Resident 1 had a verbal disagreement with his caregiver regarding the placement of Resident 2's wheelchair. The COC indicated Resident 1 expressed that the wheelchair obstructs his passage to get out of the room. The COC indicated the disagreement escalated and CNA 1's voice started to get louder and louder and began yelling at the resident. During a review of CNA 1's Performance Correction Notice, dated 2/21/2025, the Performance Correction Notice indicated CNA 1 stated I am also a human being. I don't allow anyone to disrespect me in regards to the incident with Resident 1. The Performance Correction Notice indicated on 2/19/2025, CNA 1 was verbally aggressive and disrespectful towards Resident 1. The Performance Correction Notice indicated the incident was a direct violation of Resident Rights and the company's code of conduct was unacceptable and grounds for immediate termination. During an interview on 2/26/2025 at 11:25 a.m. with Resident 1, Resident 1 stated on 2/19/2025, Resident 2's wheelchair was blocking the bathroom door and he was not able to exit the bathroom door. Resident 1 stated as he was trying to exit out of the bathroom, CNA 1 began raising her voice at Resident 2 that she would leave the wheelchair at the bathroom door. Resident 1 stated when CNA 1 raised her voice he felt a bit upset. During an interview on 2/26/2025 at 12:33 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated on 2/19/2025 around 8:00 a.m., he heard CNA 1 yelling at Resident 1 about the placement of Resident 2's wheelchair. LVN 1 stated CNA 1 should have explained to the resident why she needed to move the wheelchair without yelling. LVN 1 stated it was verbal abuse when the staff yelled at the residents. LVN 1 stated when the staff yells at the residents it could make them feel guarded and unsafe. During an interview on 2/26/2025 at 1:56 p.m. with Registered Nurse (RN) 1, RN 1 stated on 2/19/2025, CNA 1 yelled at Resident 1, You're not the only one in this room! RN 1 stated CNA 1 was being verbally abusive and should have gone to tell the charge nurse their was an issue. During an interview on 2/26/2025 at 2:23 p.m. with the Assistant Director of Nursing (ADON), the ADON stated CNA 1 had yelled at Resident 1, You're not the only one in here! The ADON stated CNA 1 should have listened to the needs of the resident by moving the wheelchair out of his way. The ADON stated CNA 1 yelling at Resident 1 could affect him psychosocially (the emotional and social aspects of a patient's health). During an interview on 3/12/2025 at 3:00 p.m. with the Administrator (ADM), the ADM stated the staff had reported on 2/19/2025 around 8:30 a.m. they witnessed CNA 1 in Resident 1's room screaming and yelling at Resident 1. The ADM stated CNA 1 used the F word, while screaming at Resident 1. The ADM stated CNA 1 was suspended on 2/19/2025 and later was terminated on 2/21/2025 because of her conduct. The ADM stated the residents should not be yelled and cursed at any time and the primary goal of the facility was for the residents to feel safe. b. During a review of Resident 2's Face Sheet, the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included paraplegia (loss of movement and/or sensation, to some degree, of the legs), heart failure (a condition where the heart doesn't pump blood well), and DM. During a review of Resident 2's H&P, dated 1/6/2025, the H&P indicated, Resident 2 had the capacity to understand and make decisions. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2's cognition was normally intact. During an interview on 2/26/2025 at 12:26 p.m. with Resident 2, Resident 2 stated on 2/19/2025, CNA 1 was upset about his (Resident 2) wheelchair being in her way. Resident 2 stated CNA 1 moved the wheelchair in front of the bathroom door. Resident 2 stated he tried to explain to CNA 1 that Resident 1 was in the bathroom. Resident 2 stated CNA 1 was loud and yelling at Resident 1 about how the wheelchair was going to stay in front of the bathroom door. During a review of the facility's policy and procedure (P&P), Abuse & Mistreatment of Residents, date unknown, the P&P indicated to uphold a resident's right to be free from verbal abuse. The P&P indicated verbal abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents with the hearing distance, regardless of their age, ability to comprehend, or disability.

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

Transfer Notice (Tag F0623)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1). Provide a written notice of discharge to one of three sampled ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1). Provide a written notice of discharge to one of three sampled residents (Resident 1). 2). Provide a copy of the notice of discharge to the Office of the State Long-Term Care Ombudsman (Patient Advocate), for one of three sampled residents (Resident 1). These failures resulted in the resident not knowing the facility where he was going and unaware of his appeal rights. This failure also resulted in the Ombudsman not aware of the resident ' s discharge to another facility. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 1 ' s diagnoses included morbid (severe) obesity and schizophrenia (chronic mental illness that affects how people think, feel, and behave) During a review of Resident 1 ' s History and Physical (H&P), dated 12/11/2024, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 12/17/24, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 required set up assistance with eating, and supervision with oral hygiene, toileting hygiene, shower, dressing, and putting on/taking off footwear and maximal assistance with personal hygiene. During an interview on 1/24/2025 at 12:57 p.m. with the Ombudsman, the Ombudsman stated the facility did not provide the Ombudsman a copy of the Notice of Discharge when Resident 1 was discharged to a different facility (lower level of care) on 12/6/2024. During an interview on 1/24/2025 at 1:12 p.m. with Resident 1, Resident 1 stated the Social Services Director (SSD) told him (Resident 1) he was going to go another facility for lower level of care. Resident 1 stated he was not given any documents to sign regarding his discharge. During a telephone interview on 1/27/2025 at 11:46 a.m. with the Assistant Director of Nursing (ADON), the ADON stated Resident 1 ' s Notice of Proposed Transferred/ Discharge was not completed. During a telephone interview on 1/28/2025 at 2:26 p.m. with the SSD, the SSD stated the Notice of Proposed Transfer/ Discharge was not done. The SSD stated the Notice of Proposed Transfer/ Discharge would have provided Resident 1 the reasons of the discharge and provided him the information on how to appeal the discharge. The SSD stated the facility did not send a copy of the Notice of Proposed Transfer/ Discharge to the Ombudsman. During a review of the facility ' s policy and procedure (P&P) titled, Transfer or Discharge Notice, dated 3/2021, the P&P indicated a copy of the notice should be sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge was provided to the resident and representative.

Jul 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0557 (Tag F0557)

Could have caused harm · This affected 1 resident

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement its policy and procedure (P&P) titled, Personal Property, which indicated the facility would inventory and pack the personal property of a resident , place in a secure location to prevent its loss, during a resident's absence of undetermined length, for one of three sampled residents (Resident 1). This failure had the potential for the residents' belongings missing if not properly inventoried. Findings: During a review of Resident 1 ' s admission Record, dated July 24, 2024, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis of Type 2 Diabetes Mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) and Bipolar Disorder (a mental illness that causes unusual shifts in a person ' s mood, energy, activity levels, and concentration). During a review of Resident 1 ' s Minimum Data Set (Minimum Data Set [MDS] a standardized assessment and care screening tool), dated 12/13/2013, the MDS indicated Resident 1 was cognitively (the ability to think and reason) intact. Resident 1 ' s MDS indicated Resident 1 required substantial/maximal assistance (staff does more than half the effort) for Activities of Daily Living (ADLs) such as sitting to lying, showering, and bathing self, and personal hygiene. During an interview on 7/24/2024 at 12:15 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated if a resident were to be discharged to the hospital, staff would do an inventory of belongings and check if all belongings were accounted for. During an interview on 7/24/2024 at 12:35 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated it was important to keep track of resident belongings because they are resident's property. During an interview on 7/24/2024 at 2:56 p.m. with Director of Nursing (DON), the DON stated if a resident were to be transferred to the hospital, the belongings a resident left in the facility should be itemized (listing items separately and include details about each item). It was important to have resident belongings inventoried to make sure resident will have what they have for safe keeping. During a concurrent interview and record review on 7/24/2024 at 4:14 p.m. with Social Services Director (SSD), Resident 1 ' s belongings list dated 12/29/24 s reviewed. Resident 1 ' s belongings list diid not indicate who performed inventory check of Resident 1 ' s belongings upon discharge. The SSD stated if a CNA did not inventory belongings, it would fall under Social Services to perform an inventory check. During a concurrent interview and record review on 7/31/2024 at 1:46 p.m. with SSD, facility policy and procedure (P&P) titled, Personal Property, was reviewed. The P&P indicated, Social Services will be responsible, with the help of nursing personnel, to inventory and pack personal property of the resident and place in a secure location to prevent loss of personal property during absence of undetermined length. The SSD stated staff should sign a resident ' s inventory list whether the discharge is expected or unexpected because it acknowledges that belongings have been checked. The SSD stated, it was not acceptable to leave an inventory list unsigned because leaving it unsigned means that inventory was not checked. The inventory list is proof.

May 2024 13 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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure an informed consent was obtained from resident represen...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure an informed consent was obtained from resident representative for the use of psychotropic drug (any drug that affects brain activities associated with mental process and behavior) for one of one sampled resident (Resident 2). This deficient practice had the potential for the resident representative to have a lack of knowledge to make an informed consent and not knowing in advance the potential risk and benefits of the psychotropic drug. Findings: A review of Resident 2's admission record, the admission Record indicated, Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 2's diagnoses included hypertensive heart disease (heart condition caused by high blood pressure), acute kidney failure (a condition in which the kidneys can't filter waste from the blood), and anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread, and uneasiness). A review of Resident 2's History and Physical (H&P), dated 3/12/2024, indicated, Resident 2 did not have the capacity to understand and make decisions. A review of Resident 2's Minimum Data SET ([MDS] resident assessment and care screening tool) under Section GG (Functional Abilities and Goals), dated 3/15/2024, the MDS indicated Resident 2 was totally dependent (Resident does none of the effort to complete the activity) in oral hygiene, toileting hygiene, and personal hygiene. A review of Resident 2's Order Summary Report, dated 5/24/2024, indicated, Resident 2's physician prescribed lorazepam (medication used to relieve anxiety) oral solution to give 0.25 milliliter (ml, unit of fluid volume) twice a day for anxiety and agitation. During a concurrent interview and record review on 5/23/2024 at 9:22 a.m. with Registered Nurse (RN 3), Resident 2's clinical records were reviewed. RN 3 stated the facility had no documentation to indicate informed consent for the use of lorazepam was obtained and risks and benefits were explained by Resident 2's physician from resident representative regarding the use of lorazepam. RN 3 stated the facility staff can't initiate any psychotropic drug until the physician obtained an informed consent from the resident or resident representative. During an interview on 5/23/2024 at 12:32 p.m. with the Director of Nursing (DON), the DON stated it was an oversight by the facility staff for not verifying with the physician of Resident 2's if he called resident representative and obtained an informed consent for the use of lorazepam. The DON stated whoever was listed in the admission Record was the recognized resident representative. The DON stated psychotropic drugs have adverse reaction (an unintended effect of a medication that is harmful or unpleasant) that has negative outcome to the resident. A review of facility's policy and procedure (P&P) titled, Psychotherapeutic Medications, undated, the P&P indicated, Informed consent will be obtained by physician prior to administering psychotherapeutic drugs. A review of facility's policy and procedure (P&P) titled, Informing Residents of Health, Medical Condition and Treatment Options, revised 2/2021, the P&P indicated, Each resident is informed of his/her total health status and medical condition, including diagnosis, treatment recommendations and prognosis, in advance of treatment and on an on-going basis. If a resident has an appointed representative, the representative is also informed.

CONCERN (D)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to: 1. Ensure the low loss air mattress was in functionin...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to: 1. Ensure the low loss air mattress was in functioning condition for one of one sampled resident (Resident 177). This deficient practice resulted in Resident 177 sleeping in a bed that was not functioning and uncomfortable, which had the potential not to meet the resident's needs. Findings: A review of Resident 177's admission Record, the admission Record indicated, Resident 177 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 177's diagnoses included type 2 diabetes mellitus (abnormal blood sugar), acute respiratory failure (a serious condition that makes it difficult to breathe on your own), and anxiety disorder (persistent and excessive worry that interferes with daily activities). A review of Resident 177's History and Physical (H&P), dated 4/2/2024, indicated Resident 177 had the capacity to understand and make decisions. A review of Resident 177's Minimum Data Set ([MDS]- a standardized assessment and care screening tool), dated 4/14/2024, indicated Resident 177 was assessed to have a clear cognition in daily decision making. The MDS indicated Resident 177 required supervision or touching assistance from staff for activities of daily living (ADLs) such as sit to lying, sit to stand, toilet transfer, lying to sitting on side of bed. And roll left and right. During a concurrent observation and interview on 5/22/2024 at 10:00 a.m. with Resident 177 in Resident 177's room, the bed mattress was observed to be sunken in at the middle of the bed. Resident 177 stated the bed has been like this for a few weeks. Resident 177 stated the staff did try to fix it when first observed, the staff was unable to fix it, so it has been like this since. Resident 177 stated that my back does hurt after lying in the bed for too long, I try to get my butt in the hole so my back would not hurt so much. During a concurrent observation and interview on 5/23/2024 at 12:41 p.m. with Certified Nursing Assistant (CNA) 4, in Resident 177's room, observed the mattress sunken in on the middle of the bed. CNA 4 stated yes, the bed mattress is sunken in, it has been like this for about a week. CNA 4 stated maintenance did attempt to fix it but not sure what happened. CNA 4 stated, this could affect the resident by potentially hurting the back, not comfortable, and it is just not right for the resident's bed to look like that. During a concurrent observation and interview on 5/23/2024 at 12:45 p.m. with Licensed Vocational Nurse (LVN) 5, in Resident 177's room, observed the mattress sunken in on the middle of the bed. LVN 5 stated yes, the bed is sunken in the middle. LVN 5 stated that if the bed is not functioning properly, it would affect the resident. LVN 5 stated it would be very uncomfortable for the resident to lay in a bed not functioning. During an interview on 5/23/24 at 1:08 p.m. with the Director of Nursing (DON), the DON stated the mattress should not be sunken in the middle of the bed. The DON stated the after the staff unsuccessfully tried to fix the mattress, they should have reported the issue to me. The DON stated, a resident should never have to sleep in a bed that is in that condition. The DON stated it could potentially affect the resident by being uncomfortable, possible hurting the resident's back. The DON stated it is the resident's right to have a comfortable and functioning mattress to sleep on. During a review of the policy and procedure (P&P) titled, Accommodation of Needs, dated March 2021, the P&P indicated the facility's environment are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. in order to accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedroom and bathroom, as well as the common areas in the facility. Such adaptations may include: providing a variety of types , sizes , and firmness of furniture in rooms and common areas so that residents with varying degrees of strength and mobility can independently arise to a standing position.

CONCERN (D)

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to: 1. Ensure a Preadmission Screening and Resident Review (PASRR- a fe...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to: 1. Ensure a Preadmission Screening and Resident Review (PASRR- a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment screening was resubmitted to determine the facility's ability to provide special care and needs for one of 7 residents (Resident 38). This deficient practice has the potential to negatively affect the provision of necessary care and services. Findings: A review of Resident 38's admission record (face sheet) indicated Resident 38 was initially admitted on [DATE] and readmitted on [DATE], with diagnoses that include metabolic encephalopathy (a broad term for any brain disease that alters brain function or structure), heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), anxiety (a feeling of worry, nervousness or unease about everyday situations) and paranoid schizophrenia (a mental health condition where a person feels distrustful and suspicious of other people and acts accordingly). A review of Resident 38's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 5/6/2024, indicated Resident 38 was severely cognitively impaired, unable to make needs known, and required extensive assistance from staff in ADLs (activities of daily living- an individual's daily self-care activities) with toileting, showering, and upper/lower dressing. During a concurrent interview and record review, on 5/24/2024 at 10:31 a.m., with the MDS Coordinator, the MDS Coordinator stated PASRRs were to be completed while a resident was in the hospital. MDS Coordinator stated the facility could also do PASRR if not completed in the hospital. MDS Coordinator stated PASRRs were completed when a resident had a change in mental health behavior or change in a mental health medication. MDS Coordinator stated Resident 38 was in isolation (a precaution used to minimize spread of infection associated with health care) when the Level 2 PASRR was to be completed. MDS Coordinator stated once isolation was lifted, a new PASRR was to be resubmitted for Resident 38. MDS Coordinator stated the risk of not resubmitting a new PASRR could result in residents not receiving the care and services needed. MDS Coordinator stated, We will make corrections to have a system set in place to avoid missing things like this. During an interview, on 5/24/24 at 1:10 p.m., with the DON, the DON stated PASRRs were completed by a hospital prior to a resident's admission. The DON stated if a hospital did not complete a resident's PASRR, the facility was responsible for doing so. The DON stated if a resident's level 1 PASRR was positive (meaning a resident had been diagnosed with a mental illness or was developmentally delayed), the facility was required to contact the California Department of Health Care Services to conduct a Level 2 screening. The DON stated a PASRR was not resubmitted for Resident 38 due to being on isolation precautions. The DON stated once the isolation period for the resident was complete, the facility was to resubmit a PASRR screening for Resident 38. The DON stated the risk of not resubmitting a PASRR screening could result in a resident not receiving the required services and/or resources for their mental illness. The DON stated, We are looking into a system to track residents who may need a PASRR completed if they are in isolation. A resident would still need to be re-evaluated whether in isolation or not. A review of the facility's policy and procedures, titled Preadmission Screening and Resident Review (PASRR), dated 2001 and revised 3/2023, indicated, The Preadmission Screening and Resident Review (PASRR) policy is a federal requirement to help ensure that individuals arc not inappropriately placed in nursing homes for long term care. PASRR requires that: The Level II PASRR determination and the evaluation report specify services to be provided by the nursing home and/or specialized services defined by the State.

CONCERN (D)

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

Deficiency F0645 (Tag F0645)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Correctly fill out the Preadmission Screening and Resident Rev...

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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. Correctly fill out the Preadmission Screening and Resident Review ([PASRR], a tool to determine if the person had, or was suspected of having, a mental illness, intellectual disability, or related condition) level one screening and refer one of seven sampled residents (Resident 147) who had a diagnoses of schizoaffective disorder (a mental illness that can affect thoughts, mood and behavior) and anxiety disorder (a condition in which a person has excessive worry and feelings of fear, dread and uneasiness) to the appropriate state-designated authority for PASRR level two evaluation and determination. This deficient practice had the potential to result in Resident 147 not receiving appropriate treatment recommendations for schizoaffective and anxiety disorder. Findings: A review of Resident 147's admission record, the admission Record indicated, Resident 147 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 147's diagnoses included schizoaffective disorder and anxiety disorder. A review of Resident 147's History and Physical (H&P), dated 12/20/2023, indicated, Resident 147 did not have the capacity to understand and make decisions. A review of Order Summary Report, dated 5/1/2024, indicated, Resident 147's physician prescribed quetiapine fumarate (a antipsychotic medication that is used to improve mood, thoughts, and behavior for people with schizoaffective disorder) 50 milligrams (mg, unit of measurement) twice a day for schizophrenia manifested by paranoid (feeling of extreme fear and distrust of others) delusions (something that is believed to be true or real but that is actually false or unreal) causing extreme fear. During a concurrent interview and record review on 5/23/2024 at 11:26 a.m., with the Minimum Data Set (MDS) coordinator, Resident 147's PASRR Level 1 Screening, dated 12/21/2023, was reviewed. The MDS coordinator stated the PASRR Level 1 Screening did not indicate Resident 147 had a diagnosed mental disorder such as schizoaffective disorder and anxiety disorder. The PASRR Level 1 Screening also did not indicate Resident 147 on antipsychotic medication. The MDS coordinator stated Resident 147's case was closed due to no serious mental illness and a PASRR level two evaluation and determination were not required. The MDS coordinator stated Resident 147's PASRR Level 1 Screening was completed inaccurately. The MDS coordinator stated Resident 147's PASRR Level 1 Screening should had been marked as an individual with a diagnosed mental disorder of schizoaffective disorder and anxiety disorder to trigger PASRR Level 2 evaluation and redetermination so Resident 147 could be evaluated and possibly receive appropriate treatment recommendations for schizoaffective and anxiety disorder. A review of facility's policy and procedure (P&P) titled, Preadmission Screening and Resident Review (PASRR), revised 3/2023, the P&P indicated, If level 1 is positive for suspected mental illness/developmentally delayed in this case it needs to be advanced to a level II evaluation. The P&P also indicated All individuals seeking admission to Medicaid-certified nursing facility must be evaluated for mental illness and/or intellectual disability.

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Ensure the low air loss mattress ([LALM] a mattre...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Ensure the low air loss mattress ([LALM] a mattress designed to prevent and treat pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) was set and maintained at correct setting for one of three sampled residents (Resident 82). This deficient practice placed Resident 82 at risk for further skin breakdown. Findings: A review of Resident 82's admission record, the admission Record indicated, Resident 82 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 82's diagnoses included dysphagia (difficulty of swallowing), cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), and muscle weakness (lack of strength in the muscles). A review of Resident 82's History and Physical (H&P), dated 5/17/2024, indicated, Resident 82 was able to make decisions for activities of daily living. A review of Resident 82's Minimum Data Set ([MDS] resident assessment and care screening tool) under Section GG (Functional Abilities and Goals), dated 4/13/2024, the MDS indicated Resident 82 was totally dependent (Resident does none of the effort to complete the activity) in oral hygiene, personal hygiene, upper and lower body dressing and mobility. The MDS under Section M (Skin Conditions) also indicated, Resident 82 was high risk for developing pressure ulcer. A review of Resident 82's Order Summary Report, dated 5/20/2024, indicated, Resident 82's physician prescribed LALM for wound care and management. A review of Resident 82's Wound Risk Assessment (used to assess the risk of tissue damage due to pressure ulcer or shear forces), dated 5/17/2024, indicated total score of 14 (score of 8 or greater considered as high risk). A review of Resident 82's Skin Progress Report, dated 5/17/2024, the Skin Progress Report, indicated, Resident 82 had unstageable (full thickness tissue loss in which actual depth of the ulcer is completely obscured by necrotic or eschar (dead tissue) on Sacro-coccyx (tail bone), right heel, right lateral malleolus (bone on the outer side of the ankle), and stage 1 (intact skin with non-blanchable redness of a localized area usually over a bony prominence) on left knee. A review of Resident 82's Weights and Vitals Summary indicated, Resident 82 weighed 103 pounds (lbs.) on 5/18/2024. During an observation on 5/21/2024 at 11:00 a.m., Resident 82 was observed laying in bed on a LALM. The LALM was observed on and functioning with settings at 340 lbs. During a concurrent observation and interview on 5/22/2024 at 11:34 a.m., with Treatment Nurse (TN 1), Resident 82 was observed laying in bed. TN 1 stated Resident 82 was laying on LALM with settings at 340 lbs. TN 1 stated Resident 82 was not 340 lbs. and the setting should be based on the resident's weight. TN 1 stated Resident 82's current weight was 103 pounds. TN 1 stated incorrect or improper setting of the LALM would result in resident's delayed wound healing or possibly worsening of pressure ulcer. During an interview on 5/22/2024 at 1:59 p.m., with the Assistant Director of Nursing (ADON), the ADON stated it was important to follow the settings of the LALM which is based on resident's weight for the airflow and circulation. The ADON stated if the weight was set a lot higher than what the resident's weighs then it could cause extra pressure on the bony prominence of the resident. A review of facility's policy and procedure (P&P) titled, Pressure-Reducing Mattresses, undated, the P&P indicated, To provide mattresses that will prevent and/or minimize pressure on the skin. Adjust air mattresses to a desired firmness according to patient's weight.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Ensure Resident 164 did not have a cigarette ligh...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Ensure Resident 164 did not have a cigarette lighter in his possession. This failure had the potential to result in a fire being started in the facility. Findings: During a concurrent observation and interview on 5/23/24 at 8:10 a.m. on the smoking patio with Resident 164, Resident 164 stated he keeps his own cigarettes and lighter. A lighter was observed in Resident 164's hand. During a concurrent observation and interview on 5/23/24 at 1:55 p.m. in Resident 164's room, a lighter was observed on the nightstand. Resident 164 states staff is aware he has a lighter and they didn't say anything. Resident 164 states staff did not provide education on keeping a lighter in his room. During an interview on 5/23/24 at 2:08 p.m. with AA1, AA1 stated the Activity Assistants monitor the residents when they smoke. The Activity Assistant keeps the lighter. Residents can't keep lighters because they might smoke in their room or light things on fire. During an interview on 5/24/24 at 10:20 a.m. with AD1, AD1 stated the Activity Assistant keeps the lighters. Residents who are alert and oriented get to keep their cigarettes but can't keep their lighters. Residents can't keep the lighters because it's the facility policy. The policy is in place to protect residents from lighting a cigarette in the room, they could burn something or light something on fire. A review of Resident 164's admission Record (Face Sheet), the Face Sheet indicated Resident 164 was admitted to the facility on [DATE] with diagnoses of congestive heart failure (weak heart), hypertension (high blood pressure), and heart attack. A review of Resident 164's History and Physical (H&P) dated 2/9/2024, the H&P indicated Resident 164 has the capacity to understand and make decisions. A review of the facility's policy and procedure (P&P) titled Smoking Policy and Procedure, (no date), the P&P indicated residents may keep cigarettes but not lighters.

CONCERN (D)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to: 1. Remove opened expired medication of diltiazem sol...

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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. Remove opened expired medication of diltiazem solution (medication to treat high blood pressure and chest pain) in subacute medication refrigerator room storage for Resident 115. This deficient practice had the potential to result in prolonged use and loss of strength of the expired medication and can lead to ineffective treatment of Resident 115's hypertension ([HTN] high blood pressure) and possibly can cause severe adverse reactions (an unintended effect of a medication that is harmful or unpleasant) including hospitalizations. Findings: A review of Resident 115's admission record, the admission Record indicated, Resident 115 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 115's diagnoses included HTN, cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), and atrial fibrillation (irregular heartbeat). A review of Resident 115's History and Physical (H&P), dated [DATE], indicated, Resident 115 did not have the capacity to understand and make decisions. A review of Order Summary Report, dated [DATE], indicated, Resident 115's physician prescribed diltiazem 90 milligram (mg, unit of measurement)/7.5 milliliter (ml, measure of volume) solution every 8 hours, to hold if systolic blood pressure ([SBP] first number in blood pressure reading) less than 110 or heart rate (the number of times the heart beats per minute) less than 60. During a concurrent observation and interview on [DATE] at 3:50 p.m. of the subacute medication refrigerator room storage with Registered Nurse 2 (RN 2), found one bottle of opened expired diltiazem solution of Resident 115. RN 2 stated the diltiazem medication for Resident 115 indicates a pharmacy fill date of [DATE] and expiration date labeled on [DATE]. RN 2 stated expired diltiazem solution of Resident 115 should had been removed in the medication refrigerator and discarded immediately. RN 2 stated giving expired medication to Resident 115 could affect her blood pressure because of the loss of potency. During an interview on [DATE] at 12:14 p.m., with the Director of Nursing (DON), the DON stated expired medication should be placed immediately in a box labeled for destruction in medication room storage. The DON stated expired medication may not be functioning in its higher effect and Resident 115's blood pressure could not be controlled because of the expired medication. A review of facility's policy and procedure (P&P) titled, Storage of Medications, revised 11/2020, the P&P indicated, Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

CONCERN (D)

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

Food Safety (Tag F0812)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to: 1. Ensure the cook was wearing a beard restraint (device used to keep hair from falling onto food) while working in the kitc...

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Based on observation, interview, and record review, the facility failed to: 1. Ensure the cook was wearing a beard restraint (device used to keep hair from falling onto food) while working in the kitchen. This failure had the potential to result in food being contaminated with hair. Findings: During an observation on 5/23/24 at 11:35 a.m. in the kitchen, CK1 was standing at the steam table taking temperatures and stirring food. CK1 had a beard of approximately two inches long that was not covered with a beard restraint. During an interview on 5/23/24 at 11:40 a.m. with CK1, CK1 stated he should be wearing a beard restraint. CK1 stated since he did not have on a beard restraint he could have gotten hair in the food. During an interview on 5/23/24 at 11:45 a.m. with DM1, DM1 stated CK1 should be wearing a beard restraint or regular face mask. The beard restraint prevents cross contamination (movement of germs from one place to another). A review of the facility's policy and procedure (P&P) titled, Preventing Foodborne Illness- Food Handling, dated October 2017, the P&P indicated beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils, and linens.

CONCERN (E)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure medical records were updated to show documentation that ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure medical records were updated to show documentation that advance directive's (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 were provided to the residents and/or responsible parties for five of 36 sampled residents (Residents 55, 71, 74, 113, 124, 71 and 31). This deficient practice had the potential for the residents not to receive necessary information, treatments and care regarding the end-of-life issues according to their wishes. Findings: a. A review of Resident 74's admission record, the admission Record indicated, Resident 74 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 74's diagnoses included diabetes mellitus type 2 ([DM] a chronic condition that affects the way the body processes blood sugar), chronic obstructive pulmonary disease ([COPD] progressive lung disease that affects your ability to breathe), and epilepsy (a disorder of the brain characterized by repeated seizure). A review of Resident 74's History and Physical (H&P), dated 7/10/2023, indicated, Resident 74 had the capacity for medical decision making. A review of Resident 55's admission Record, the admission Record indicated, Resident 55 was initially admitted to the facility on /4/2014 and last readmitted on [DATE]. Resident 55's diagnoses included chronic obstructive pulmonary disease (COPD, lung disease that causes blocked airflow from the lungs), encephalopathy (damage or disease that affects the brain), and schizophrenia (a mental disorder that affects a person's ability to think, feel and behave clearly). A review of Resident 55's H&P, dated 3/29/2024, indicated Resident 55 did not have the capacity to understand and make decisions. A review of Resident 113's admission Record, the admission Record indicated, Resident 113 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 113's diagnoses included type 2 diabetes mellitus (abnormal blood sugar), hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing), and schizophrenia (a mental disorder that affects a person's ability to think, feel and behave clearly). A review of Resident 113's H&P, dated 8/24/2023, indicated Resident 113 did not have the capacity to understand and make decisions. A review of Resident 124's admission Record, the admission Record indicated, Resident 124 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 124's diagnoses included cognitive communication deficit (difficulty with thinking and language use), encephalopathy (damage or disease that affects the brain), and altered mental status (a change in mental function that stems from illnesses, disorders and injuries affecting your brain). A review of Resident 124's H&P, dated 7/20/2023, indicated Resident 124 had the capacity to understand and make decisions. During a concurrent interview and record review on 5/23/2024 at 8:48 a.m. with Social Service Director (SSD), Residents 55, 74, 113, and 124's advance directives were reviewed. The SSD stated, Residents 55 and 74 advance directive acknowledgements were not filled out, so it was not completed. The SSD stated, Residents 113 and 124 did not have an advance directive form in the chart. The SSD stated advance directive acknowledgements are to be done within 5 days of admission. The SSD stated, written information was given to the resident and/or family and everything on the document was explained. The SSD stated, an advance directive was to know the wishes of the resident when they are not able to voice their opinions anymore. The SSD stated, the residents have the right to be informed and make informed decisions. During an interview on 5/24/2024 at 1:10 p.m., with Director of Nursing (DON), the DON stated, if the advance directive information is not given and not discussed with resident and/or representative there was potential to give medical interventions when a resident may not have wanted certain interventions. A review of the policy and procedure (P&P) titled, Health, Medical Condition and Treatment Options, Informing Residents of, dated February 2021, the P&P indicated, every resident is informed of their total health status, medical condition, and options for treatment and/or care. The facility is responsible for informing the resident of his or her medical condition. Such information includes providing the resident/representative with information about the resident's right to formulate an advance directive. b. A review of Resident 71's admission Record (Face Sheet), dated 4/17/2024, the Face Sheet indicate Resident 71's was admitted to the facility on [DATE], and was re-admitted on [DATE], with a diagnosis including heart failure (a chronic condition in which the hear doesn't pump blood as well as it should), type 2 diabetes mellitus (a long term condition in which the body has trouble controlling blood sugar and using it for energy), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the heart), polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body). A review of Resident 71's History and Physical (H&P), dated 5/23/2024, the H&P indicated Resident 71 has the capacity to understand and make decisions. A review of Resident 71's Minimum Data Set ([MDS]a standardized assessment and care screening tool), dated 5/15/2024, the MDS indicated the cognitive (the ability to think and process information) skills for daily decision-making resident was not completed. Resident 71's functional abilities and goals were between helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort, and helper does all the effort. A review of Resident 31's admission Record (Face Sheet), dated 5/23/2024, the Face Sheet indicated Resident 31 was admitted to the facility on [DATE], and was re-admitted on [DATE], with a diagnosis including dementia (a group of thinking and social symptoms that interferes with daily functioning), anxiety (an intense, excessive, and persistent worry and fear about everyday situations), chronic obstructive pulmonary disease with exacerbation ([COPD- a group of lung diseases that block airflow and make it difficult to breathe), hypertension (when the pressure in your blood vessels is too high), gastro-esophageal reflux disease ([GERD]- a digestive disease in which stomach acid or bile irritates the food pipe lining). A review of Resident 31's History and Physical (H&P), dated 11/17/2023, the H&P indicated, Resident 3` does not have the capacity to understand and make decisions. A review of Resident 31's Minimum Data Set ([MDS]a standardized assessment and care screening tool), dated 3/15/2024, the MDS indicated the cognitive (the ability to think and process information) skills for daily decisions making was scored at 99 indicating the Resident 31 could not make decision. Resident 31's functional abilities and goals were dependent (helper does all the effort. Resident does none of the effort to complete the activity. During an interview on 5/24/2024 at 1:10 p.m., with Director of Nursing (DON), the DON stated, if the advance directive information is not given and not discussed with resident and/or representative there was potential to give medical interventions when a resident may not have wanted certain interventions. A review of the policy and procedure (P&P) titled, Health, Medical Condition and Treatment Options, Informing Residents of, dated February 2021, the P&P indicated, every resident is informed of their total health status, medical condition, and options for treatment and/or care. The facility is responsible for informing the resident of his or her medical condition. Such information includes providing the resident/representative with information about the resident's right to formulate an advance directive.

CONCERN (E)

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

Deficiency F0637 (Tag F0637)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure a change of condition was completed for two of seven sam...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to: 1. Ensure a change of condition was completed for two of seven sampled residents (Resident 117 and 7) skin assessments. This deficient practice has the potential to negatively affect the provision of necessary care and services. Findings: a. A review of Resident 7's admission Record (Face Sheet), dated 5/23/2024, the face sheet indicated Resident 7 was admitted to the facility on [DATE], and was re-admitted on [DATE], with a diagnosis including type 2 diabetes mellitus (a long term condition in which the body has trouble controlling blood sugar and using it for energy), muscle weakness (can have causes that aren't due to underlying disease), major depression (persistently depressed mood or loss of interest in activities), urinary tract infection (an illness in any part of the urinary tract, they system of organs that makes urine), thrombocytopenia (a disorder causes bleeding into the tissues, bruising). A review of Resident 7's History and Physical (H&P), dated 2/8/2024, the H&P indicated Resident 7 can make decisions for activities of daily living. A review of Resident 7's Minimum Data Set ([MDS]a standardized assessment and care screening tool), dated 2/27/2024, the MDS indicated the cognitive (the ability to think and process information) skills for daily decision-making resident is rarely/never understood. Resident 7's functional abilities and goals were impaired on both sides. During a concurrent interview and record review, on 5/23/24, at 2:17 p.m., with Treatment Nurse 2 (TN 2), TN 2 stated Resident 117 had redness on his left calf. TN 2 stated Resident 117 was contracted at both legs. TN 2 stated charge nurses were responsible for a resident's change of condition (COC- also known as a SBAR (Situation Background and Reassessment) is a sudden change from a patient's baseline in physical, cognitive, behavioral, or functional domains). TN 2 stated a COC form should had been completed for Resident 117. TN 2 stated she did not see a COC for Resident 117 left leg redness. TN 2 stated the risk of not documenting a change of condition in a resident could result in staff not knowing what was going on with a resident. During a concurrent interview and record review, on 5/24/24 at 9:45 p.m., with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated charge nurses were responsible for documenting any COC in a resident. LVN 4 stated she was not informed of nor had seen Resident 117's left leg redness. LVN 4 stated there wasn't a COC regarding Resident 117's left leg redness although there should had been completed. LVN 4 stated the risk of not documenting a change of condition in a resident could result in neglecting a resident's treatment, not knowing if a resident's physician or family was informed, staff not being informed of what was going on with a resident, and possibly progress wound/skin breakdown. During an interview, on 5/24/24 at 1:10 p.m., with the Director of Nursing (DON), the DON stated a COC for a resident should had been reported to the charge nurse. DON stated whichever staff member that witnessed the COC was responsible for initiating the form. DON stated when completing a COC, a charge nurse should've had evaluated the resident, notified the resident's doctor and document. DON stated the risk of not documenting a COC on a resident could result in not knowing if the resident's family or doctor was notified. DON stated COC's are critical as they are the licensed staff members guide to care for the resident. b. During observations, on 5/30/24 at 9:15 a.m., disclosed a large red excoriated area on Resident 117 upper buttocks area. A review of Resident 117's admission record (face sheet) indicated Resident 117 was initially admitted on [DATE] and readmitted on [DATE], with diagnoses that include metabolic encephalopathy (a broad term for any brain disease that alters brain function or structure), epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), urinary tract infection (an infection in any part of the urinary tract system) and hemiplegia (muscle weakness or partial paralysis on one side of the body). A review of Resident 117's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 5/2/2024, indicated Resident 117 was severely cognitively impaired, unable to make needs known, and required extensive assistance from staff in ADLs (activities of daily living- an individual's daily self-care activities) with toileting, showering, and upper/lower dressing. A record review of Resident 117's skin progress report, dated 5/7/2024, indicated Resident 117 had a Stage 1 pressure ulcer (a intact skin wound on a bony area of the body that does not lose color fast when pressing and removing a finger) on his lower left leg. A review of the facility's policy and procedures, titled Change in a Resident's Condition or Status, dated on 2001 and revised in [DATE], indicated prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR Communication Form.

CONCERN (E)

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

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide vision care services to two of two sampled residents (Resid...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide vision care services to two of two sampled residents (Resident 119 and 150) by failing to: 1. Arrange an ophthalmology (branch of medical science dealing with the anatomy, functions, and diseases of the eye) office visit for glaucoma (group of eye conditions that can cause blindness, gradual loss of sight) surgery evaluation for two of two sampled residents (Resident 119 and 150). These deficient practices had the potential for Resident 119 and 150's vision to continue to get worse, lose vision and negatively affect Resident 119 and 150's quality of life. Findings: a. A review of Resident 119's admission Record, the admission Record indicated, Resident 119 was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 119's diagnoses included type 2 diabetes mellitus ([DM] a chronic condition that affects the way the body processes blood sugar) and blindness in one eye (loss of vision in one eye as a result of reduced blood flow to the eye from the heart). A review of Resident 119's History and Physical (H&P), dated 8/13/2023, indicated, Resident 119 was able to make decision for activities of daily living. A review of Resident 119's Best Vision Care Report, dated 2/26/2024, indicated, to refer Resident 119 to ophthalmology eye clinic for glaucoma surgery evaluation. During an interview on 5/23/2024 at 10:02 a.m., with Registered Nurse (RN 1), RN 1 stated Resident 119's pre-approval authorization for referral to ophthalmology eye clinic for glaucoma surgery evaluation was denied by the insurance and that was the reason why no appointment was made. During an interview on 5/23/20243 at 11:26 a.m., with the Social Service Director (SSD), the SSD stated Resident 119's referral to ophthalmology eye clinic for glaucoma surgery evaluation was not made because she was not aware of the referral. The SSD stated the facility failed to provide Resident 119's vision care needs. During an interview on 5/24/2024 at 1:32 p.m., with the Director of Nursing (DON), the DON stated it was the facility's responsibility to schedule residents appointment regardless of medical insurance. b. During observations and interviews, on 5/22/2024 at 1:11 p.m., with Resident 150 in his room, Resident 150 stated he had difficulty in reading the newspaper and he had been asking the nursing staff to schedule him for eye surgery. Resident 150 further stated that he was anxious and afraid of losing his sight. A review of Resident 150's admission Record, the admission Record indicated, Resident 150 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 150's diagnoses included left eye visual loss and type 2 diabetes mellitus ([DM] a chronic condition that affects the way the body processes blood sugar). A review of Resident 150's History and Physical (H&P), dated 7/19/2023, indicated, Resident 150 had the capacity to understand and make decisions. A review of Resident 150's Minimum Data Set ([MDS]) resident assessment and care screening tool) under Section B (Hearing, Speech, and Vision), dated 5/3/2024, the MDS indicated Resident 150's vision was moderately impaired. A review of Resident 150's Order Summary Report, dated 5/1/2024, the Order Summary Report indicated for eye health vision consult with follow up treatment. A review of Resident 150's care plan, titled Impaired vision, dated 4/28/2023, the care plan indicated, Resident 150 had impaired vision and not able to see small and large prints but can identify objects in his environment. During an interview and record review on 5/22/2024 at 1:45 p.m., with the Social Service Assistant (SSA), Resident 150's Best Vision Care Report, dated 11/8/2023 and 2/26/2024 were reviewed. The Best Vision Care Report indicated, Resident 150 had a diagnosis of diabetic retinopathy and needs to be referred to ophthalmology eye clinic for surgery evaluation. The SSA stated he did not refer or scheduled an ophthalmology clinic appointment as recommended for Resident 150. During an interview on 5/22/2024 at 2:03 p.m., with the Assistant Director of Nursing (ADON), the ADON stated SSA was responsible in scheduling Resident 150's ophthalmology clinic appointment. The ADON stated there was no documentation in Resident 150's clinical records indicating he was referred to eye retina specialist (an ophthalmologist who has undergone additional training to become an expert in the diagnosis, management and treatment of disease and surgery of the vitreous body of the eye (watery gel between the lens and the retina) and the retina (back of the eye). The ADON stated progressive vision loss would cause permanent blindness. A review of facility's policy and procedure (P&P) titled, Accommodation of Needs, undated, the P&P indicated, The staff will assist the resident in maintaining and/or achieving independent functioning, dignity, and well-being to the extent possible in accordance with the resident's own needs and preference. A review of facility's P&P titled, Social Services Referrals, dated 12/2008, the P&P indicated, Social service will collaborate with the nursing staff or other pertinent disciplines to arrange for services and will document the referral in the resident's medical record.

CONCERN (E)

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to: 1. Provide a complete Restorative Nursing Assistant (...

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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. Provide a complete Restorative Nursing Assistant (RNA) treatment per physician's order by failing to provide hand rolls and splints seven days a week for three of 14 sampled residents (Residents 115, 124, and 145). This deficient practice had the potential to promote the worsening development of contractures (condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to the residents' extremities. Findings: a. A review of Resident 115's admission Record indicated Resident 115 was initially admitted on [DATE] and readmitted on [DATE], with diagnoses that include respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide), dysphagia (difficulty swallowing foods or liquids), fibromyalgia (a long-term condition that involves widespread body pain and tiredness) and epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures). A review of Resident 115's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated 4/7/2024, indicated Resident 115 was severely cognitively impaired, unable to make needs known, and required extensive assistance from staff in ADLs (activities of daily living) with toileting, showering, and upper/lower dressing. During an interview on 5/22/2024 at 2:43 p.m. with RNA 2, RNA 2 stated, Resident 115 had a hand roll, hand splint and right knee splint 7 days a week. RNA 2 stated not providing services as ordered could cause the resident to get worse. RNA 2 stated when I am not at the facility no one covers my resdients, the resdients are not getting services those days. b. During a concurrent observation, interview and record review on 5/23/2024 at 2:55 p.m. with RNA 3, Resident 124 Document Survey Report (POC), dated May 2024 was reviewed. The POC indicated, RNA to apply bilateral hand rolls for 4-6 hours every day 7 days a week. The POC indicated Resident 124 did not receive this service on 5/7/2024, 5/8/2024, 5/16/2024, 5/17/2024, 5/18/2024, 5/20/2024, and 5/21/2024. RNA 3 no it was not documented that the hand rolls were placed on the resident those days. RNA 3 stated if the order is for 7 days a week the hand roll should be placed on the resident or documented why it was not placed. RNA 3 stated the hand roll was to prevent further contractures, if the hand roll is not placed on the resident the contractures could potentially get tighter, increased pain. RNA 3 stated on the days I am not in the facility there was no RNA coverage for the resdients to receive services. A review of Resident 124's admission Record, the admission Record indicated, Resident 124 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 124's diagnoses included cognitive communication deficit (difficulty with thinking and language use), encephalopathy (damage or disease that affects the brain), and altered mental status (a change in mental function that stems from illnesses, disorders and injuries affecting your brain). A review of Resident 124's H&P, dated 7/20/2023, indicated Resident 124 had the capacity to understand and make decisions. A review of Resident 124's MDS, dated [DATE], indicated Resident 124 was dependent on staff for ADLs such as eating, oral hygiene, upper and lower body dressing, toileting, and showering. A review of Resident 124's Order Summary Report (physician orders), dated 11/21/2023, indicated, RNA to apply right bilateral (both sides) hand rolls for 4-6 hours every day 7 times a week. c. During an observation on 5/21/2024 at 12:30 p.m. in Resident 145's room, Resident 145 had a right-hand contracture, resident did not have a splint or hand roll to hand. A review of Resident 145's admission Record, the admission Record indicated, Resident 145 was initially admitted to the facility on [DATE] and last readmitted on [DATE]. Resident 145's diagnoses included type 2 diabetes mellitus (abnormal blood sugar), hemiparesis (weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing), and major depressive disorder (a mental health condition that causes a persistently low or depressed mood and a loss of interest in activities that once brought joy). A review of Resident 145's H&P, dated 5/11/2023, indicated Resident 145 had the capacity to understand and make decisions. A review of Resident 145's MDS, dated [DATE], indicated the resident was assessed to have a clear cognition in daily decision making. The MDS indicated Resident 145 required maximal assistance from staff for ADLs such as oral hygiene, upper body dressing, and dependent on staff for toileting, showering, and lower body dressing. A review of Resident 145's physician orders, dated 6/22/2023, indicated, RNA to apply right hand roll for 4-6 hours every day 7 times a week. During a concurrent interview and record review on 5/23/2024 at 2:55 p.m. with RNA 3, Resident 145's POC, dated May 2024 was reviewed. The POC indicated, RNA to apply right hand roll for 4-6 hours every day 7 days a week. The POC indicated Resident 145 did not receive this service on 5/4/2024, 5/5/2024, 5/7/2024, 5/8/2024, 5/11/20204, 5/12/2024, 5/16/2024, 5/17/2024, 5/18/2024, 5/19/2024, 5/20/2024, and 5/21/2024. RNA 3 no it was not documented that the right-hand roll was placed on the resident those days. During an interview on 5/23/2024 at 8:24 a.m. with Director of Staff Development (DSD), DSD stated splints and hand rolls are to prevent contractions or further contractions. DSD stated, if splints or hand rolls not placed everyday it could affect the resident, not getting care, the resdients function could decline, and contractures to the extremities could become worse. DSD stated, the staff should be documented daily when they put on the devices and if a resident refuses or not in the facility then that should be documented. DSD stated there have been times we do not have RNA coverage and the resdients may not have gotten services that day. During an interview on 5/24/2024 at 1:10 p.m., with Director of Nursing (DON), the DON stated, we do need more RNAs, we try to cover them when they are off but there are times there just is not enough staff for coverage. The DON stated, if splints are not put on as ordered by the physician it could affect the resident by potentially causing more contractures to the resident. A review of the policy and procedure (P&P) titled, Restorative Nursing Services, dated July 2017, the P&P indicated, residents will receive restorative nursing are as needed to help promote optimal safety and independence.

CONCERN (E)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review the facility failed to: 1. Ensure accurate destruction of all medications including narcotic (drug which relieves pain and induces drowsiness, stupo...

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Based on observation, interview, and record review the facility failed to: 1. Ensure accurate destruction of all medications including narcotic (drug which relieves pain and induces drowsiness, stupor, or unconsciousness) were conducted with the signature of licensed nurse, per facility's Policy and Procedure (P&P) titled, Discarding and Destroying Medications. This deficient practice increased the risk of loss or diversion of controlled medication. Findings: During a concurrent observation and interview on 5/23/2024 at 12:14 p.m., with the Director of Nursing (DON) in his office, controlled medication area inspection was conducted. The DON produced multiple Controlled and Antibiotic Drug Record sheets (a log containing the time, quantity, and nurse's signature each time a dose is administered) that had been destroyed by him and facility's pharmacy consultant. The DON stated the facility's Controlled and Antibiotic Drug Record dated 5/8/2024, there were twenty resident medications disposed without signature of licensed nurse witnessing the destruction of the medications. The disposed medications included the following: Lacosamide (medication used to treat seizure) 10 milligrams (mg, unit of measurement)/ per milliliter (ml, unit of volume). Lorazepam (medication used to relieve anxiety) 0.5 mg tablet. Lorazepam 1mg tablet. Lorazepam 1mg tablet. Zolpidem Tartrate (a sedative-hypnotic medication to help one sleep) 5mg tablet. Lorazepam 1mg tablet. Hydrocodone-Acetaminophen (narcotic medication used to treat pain) 5-325 mg tablet. Hydromorphone (narcotic medication used to treat pain) 2mg tablet. Lorazepam 0.5 mg tablet. Lorazepam 1 mg tablet. Morphine Sulfate (narcotic medication used to treat pain) extended release 15mg tablet. Doxycycline Hyclate (antibiotic medication that fight bacterial infection) 100mg tablet. Lorazepam 0.5 mg tablet. Lorazepam 1mg tablet. Lorazepam 1mg tablet. Lacosamide 200mg tablet. Lorazepam 1 mg tablet. Clonazepam (medication used for acute management of panic disorder and seizure) 1mg tablet. Hydrocodone-Acetaminophen 5-325 mg tablet. Hydrocodone-Acetaminophen 10-325 mg tablet. During an interview on 5/23/2024 at 12:30 p.m. with the DON, the DON stated the process of controlled substance destruction includes two signatures on the Controlled or Antibiotic Drug Record, one from the Registered Pharmacy (RPH) Consultant and from a Registered Nurse (RN). The DON stated, he was the only licensed nurse responsible for the controlled substance destruction. The DON stated he regret and should have signed the destruction form along with the RPH Consultant but he did not, the RPH Consultant was the only one signed the form for destruction of the medications. The DON stated he was busy with other tasks on 5/8/2024 and that was the reason why he was not able to sign the Antibiotic or Controlled Drug Record sheets. The DON stated if the narcotic/controlled substance destruction was not documented accurately, there was no validation that it was done and there was a risk for diversion and theft of the medications if the process was not completed accurately. During a phone interview with the RPH Consultant, the RPH Consultant stated by signing the Antibiotic or Controlled Drug Record, both parties agreed that the amount was matching with the record and the amount that were destroyed. The RPH stated the facility did not follow the policy for narcotic destruction. A review of facility's P&P titled, Discarding and Destroying Medications, revised 4/2019, the P&P indicated, For any unused, non-hazardous controlled substances, the destruction and disposal of the substance must include the signatures of at least two witnesses.

Mar 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 F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Physician ' s Order for Life Sustaining Treatment (POLST...

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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 Physician ' s Order for Life Sustaining Treatment (POLST, a written medical order from a physician, nurse practitioner or physician assistant that helps give people with serious illnesses more control over their own care by specifying the types of medical treatment they want to receive during serious illness) for 1 of 5 residents (Resident 1) was completed, discussed with resident ' s representative and followed up with the attending physician. This failure had violated Resident 1 ' s right to decide and request the preferred medical services in the event of medical emergencies. Findings: During a review of Resident 1 ' s admission record, the admissions record indicated Resident 1 was originally admitted to the facility on [DATE] and was re-admitted on [DATE], with diagnosis of gastrotomy (a tube surgically inserted into the stomach for nutrition and medication administration) infection, epilepsy (a disorder of the brain characterized by repeated seizures), and dysphagia (swallowing difficulties). The admission record indicated Resident 1 had listed two contact persons. During a review of Resident 1 ' s Minimum Data Set (MDS-an assessment and care planning tool) dated 2/16/2024, the MDS indicated Resident 1 had clear speech, the ability to express ideas and wants, and understands. The MDS indicated Resident 1 was dependent (helper does all of the effort) on staff for personal hygiene, toileting hygiene, and shower/bathe. During a concurrent record review and interview on 3/27/2024 at 12:20 p.m., with the social service designee (SSD), Resident 1 ' s POLST dated 5/23/2023, was reviewed. Sections A (Cardiopulmonary Resuscitation, medical emergency intervention to bring back to life from apparent death or from unconsciousness), B (Medical Interventions), C (Artificially Administered Nutrition), and D (Information and Signatures) of Resident 1 ' s POLST were blank. The SSD stated if the POLST forms were not filled up completely, the facility may not have followed Resident 1 ' s rights or wishes in the event of medical crisis. During a review of the social service progress note dated 5/3/2023 at 4:06 p.m., the progress notes indicated social service visited Resident 1 and the POLST was reviewed. Resident 1 was made aware of benefits, consequences and had verbalized understanding. However, Resident 1 did not sign the POLST. Resident 1 was considered a full code. The POLST was endorsed to nursing and was flagged in the chart for the physician to sign. During a review of the Interdisciplinary Team Narrative-Other Concerns report, dated 3/11/2024, the report indicated Resident 1 required total assistance with activities of daily life and due to multiple co-morbid diagnosis Resident 1 was highly at risk for decline. The meeting was attended by social services, nursing, administration, and the physician. During a review of the facility ' s undated policy and procedure (P&P) titled POLST, the P&P indicated the facility will provide residents with the updated POLST that is voluntary and includes physician orders for life-sustaining treatment. The P&P indicated, the POLST will be completed by a physician, nurse practitioner, or physician assistant and the resident or his/her legally recognized healthcare decision maker. During a review of the facility ' s policy and procedure titled Charting and Documentation, revised dated July 2017, indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident ' s medical, physical, functional, or psychosocial condition, shall be documented in the resident ' s medical record should facilitate communication between the interdisciplinary team regarding the resident ' s condition and response to care.

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

Based on interview and record review, the facility failed to monitor, document and inventory emergency crash cart supplies for 2 of 2 facility crash carts. This failure had the potential for the emerg...

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Based on interview and record review, the facility failed to monitor, document and inventory emergency crash cart supplies for 2 of 2 facility crash carts. This failure had the potential for the emergency crash cart supplies not completely available and a poor quality emergency medical intervention during an emergency. Findings: During a concurrent record review and interview on 3/15/2024 at 1:15 p.m. with the Registered Nurse (RN 1) in the facility ' s skilled nursing station, the monthly emergency crash cart supplies ' log was reviewed. The emergency crash cart log from February 25 through February 28, 2024, did not indicate that emergency supplies were present in the cart. RN 1 stated, if the crash cart was not checked, the facility may not have all the lifesaving equipment available in the crash cart when there is an emergency. During a concurrent record review and interview on 3/15/2024 at 1:50 p.m. with the Registered Nurse (RN 2) in the acute nursing station, the monthly emergency crash cart supplies log was reviewed. The emergency crash cart log on February 4, and 25, March 10 and 11th, 2024 had no staff initials. RN 2 stated the clinical manager was responsible for assessing the emergency equipment and documenting in the logs. RN 2 stated failure to assess the emergency equipment may leave staff unprepared to deal with an emergency in a timely manner. During a review of the undated facility ' s policy and procedure (P&P) titled Emergency Cart, the P&P indicated the emergency cart should be available for use in case of medical emergency. The medical supplies will be provided for emergency use in Emergency Cart that include, at a minimum: a. Intravenous (IV) start-up kit and D 5 1/2 Normal Saline (at least 500 cc) b. Cardiac Board c. Oxygen tank with oxygen mask and cannula available d. Yanker e. Suction machine and catheters f. Ambu bag (type of device known as a bag valve mask, which is used to provide respiratory support to patients).

Feb 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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

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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 five sampled residents (Resident 1) received treatment and care in accordance with the physician ' s orders by failing to: 1. Monitor and identify when the resident last had a bowel movement. 2. Administer medications as ordered by the physician. This deficient practice had the potential to cause fecal impaction in Resident 1. Findings: During a review of Resident 1 ' s admission Record (Face Sheet), the Face Sheet indicated Resident 1 was initially admitted to the facility on [DATE]. The Face Sheet indicated Resident 1 ' s diagnosis included difficulty in walking, acquired absence of left leg below knee, acquired absence of right leg above knee, hemiplegia (one-sided paralysis) and hemiparesis (one-sided muscle weakness) following cerebral infarction (disrupted blood flow to the brain) affecting right side. During a review of Resident 1 ' s Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 2/5/2024, the MDS indicated Resident 1 is always incontinent of bowel (inability to control passing feces) and the resident does not have any cognitive impairment (ability to reason, understand, remember, judge, and learn). During a review of Resident 1 ' s Care Plan, titled Risk for Constipation, dated 2/12/2024, the Care Plan indicated, Resident 1 was at risk for constipation. The goal is to have the resident have a bowel movement at least every three days. Additionally, the Care Plan ' s interventions include monitor frequency and amount of bowel movement, administer laxatives (medication to treat constipation) and stool softeners as ordered and to inform the doctor if interventions are not effective. During an interview on 2/23/2024 at 10:15 AM, Resident 1 stated he is worried because he has not had a bowel movement for about 12 days now. During an interview on 2/23/2024 at 12:14 PM, Certified Nurse Assistant 1 (CNA 1) stated, if a resident had or did not have a bowel movement, she would document it. If there are any changes in a residents normal bowel pattern, she would notify the charge nurse. She states she would notify the charge nurse if a resident did not have a bowel movement for 3 days. During a concurrent interview and record review on 2/23/24, at 12:53 PM, with Licensed Vocational Nurse 1 (LVN 1), Resident 1 ' s Bowel and Bladder Elimination dated 2/2024, the Care Plan titled Risk for Constipation dated 2/12/2024, and the Medication Administration Record (MAR) dated 2/2024 was reviewed. The Bowel and Bladder Elimination indicated Resident 1 had no bowel movements as of 2/12/24. The MAR indicated the resident received his scheduled stool softeners and laxatives during the month of February, but the ordered as needed laxatives, Dulcolax and Milk of Magnesia, were not given. The Care Plan titled Risk for Constipation indicated the resident will have a bowel movement at least every 3 days. LVN 1 stated she was not aware Resident 1 did not have a bowel movement for 12 days now, and Resident 1 should have been given one of the as needed laxatives for constipation and notify the physician. LVN 1 stated untreated constipation can lead to fecal impaction, headaches, and hemorrhoids. During an interview on 2/23/24 at 2:11 PM, the Director of Nursing (DON), stated it is concerning for a resident to go three days without having a bowel movement and if left untreated, it may lead to fecal impaction. DON also stated that Resident 1 should have been given an ordered as needed laxative but did not, and generally if a resident received as needed laxatives and is ineffective, the nurses need to inform the doctor. A review of the facility ' s policy and procedure titled, Bowel Management, undated, indicated the facility will provide measures to help eliminate and/or alleviate constipation. Interventions included monitoring for signs and symptoms of constipation including frequency, consistency and volume, and the administration of laxatives, suppositories (type of medication inserted into the rectum to relieve constipation), stool softeners, and/or enemas (injection of fluid to in the rectum to empty the bowel) as ordered.

Jan 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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report Coronavirus Disease ([Covid-19] a highly contagious infectio...

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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 Coronavirus Disease ([Covid-19] a highly contagious infection caused by a virus that could easily spread from person to person) outbreak (at least one confirmed case of COVID-19 who had resided in the facility for at least 7 days) to the California Department of Public Health (CDPH) District Office for 3 out of 4 residents (Residents 1, 2 and 3) as indicated in the All Facilities Letter (AFL, a letter to all nursing facilities informing of new changes or updates) 23-09. This deficient practice delayed the infection control investigation by the DO and had the potential for further residents to be infected and become ill requiring hospitalization. Findings: 1). During a review of Resident 1 ' s admission record (Face sheet), the face sheet indicated Resident 1, a [AGE] year-old male, was admitted to the facility on [DATE], with a diagnosis that included diabetes (high blood sugar), metabolic encephalopathy (neurological disorder), and muscle weakness. During a review of Resident 1 ' s history and physical (H&P) dated 9/9/2023, the H&P indicated, Resident 1 did not have the capacity to understand and make medical decisions. A review of the facility ' s undated resident line listing (spreadsheet to keep track of COVID-19 positive residents) indicated Resident 1 tested positive for COVID-19 on 1/1/2024. During a review of Resident 1's Licensed Nursing note dated 1/1/2024 at 12:30 p.m., the progress notes indicated Resident 1 had a positive COVID-19 antigen test result. 2). During a review of Resident 2 ' s face sheet, the face sheet indicated Resident 2, a [AGE] year-old male, was admitted to the facility on [DATE], with a diagnosis that included hepatitis C (a virus that attacks the liver), asthma (inflamed airways of the lung), and hypertension (high blood pressure). A review of Resident 2 ' s H&P dated 1/4/2024, the H&P indicated, Resident 2 had the capacity to understand and make medical decisions. A review of the facility ' s undated resident line listing (spreadsheet to keep track of Covid positive residents), indicated Resident 2 tested positive for Covid-19 on 1/1/2024. During a review of Resident 2's Administration note, dated 1/1/2024 at 3:43 p.m., the Administration note indicated Resident 2 was transferred to a different room due to COVID-19. 3). During a review of Resident 3 ' s face sheet, the face sheet indicated Resident 3, a [AGE] year-old male, was admitted to the facility on [DATE], with a diagnosis that included anoxic brain damage (lack of oxygen to the brain), anxiety disorder (feeling of impending doom), and hypertension. A review of Resident 3 ' s H&P dated 1/4/2024, the H&P indicated, Resident 3 did not have the capacity to understand and make medical decisions. A review of the facility ' s undated resident line listing (spreadsheet to keep track of Covid positive residents), indicated Resident 3 tested positive for Covid-19 on 1/5/2024. During a review of Resident 3's Administration note, dated 1/1/2024 at 4 p.m., the Administration note indicated Resident 3 was moved to a different station due to positive COVID-19 test result. 4). During areview of Resident 4 ' s face sheet, the face sheet indicated Resident 4, a [AGE] year-old female, was admitted to the facility on [DATE], with a diagnosis that included multiple sclerosis (an immune system disorder), depression (a mood disorder) and hypertension. A review of the facility ' s undated resident line listing (spreadsheet to keep track of Covid positive residents), indicated Resident 4 tested positive for Covid-19 on 12/29/2023. During an interview on 1/8/2024 at 9:00 a.m. with the Infection Prevention (IP) Nurse 1, the IP 1 nurse stated she was assigned to assist IP nurse 2 and she was not aware that the COVID-19 outbreak needed to be reported to the DO. IP 1 stated she came back to the position to assist during the outbreak and was not made aware of the new changes in the AFL 23-09. During an interview on 1/8/2024 at 11:00 a.m. with the IP 2, the IP 2 stated she was not aware of the new changes in the AFL 23-09 requiring the facilities to report COVID-19 positive cases to their local district office. IP 2 stated she only reported the outbreak to the local health department. During a review of the California Department of Public Health AFL 23-9 dated 1/18/2023, the AFL indicated a reminder to all licensed health facilities of the requirement to report outbreaks and unusual infectious disease occurrences to the local health department and license and certification district office. .

Dec 2023 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Safe Environment (Tag F0584)

Could have caused harm · This affected multiple residents

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

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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 four sampled residents (Resident 1, Resident 2, and Resident 3), were provided clean bed linens and Resident 1 with clean wheelchair and curtains. This deficient practice resulted to an unclean resident's environment and had the potential to affect the highest practicable mental, physical, and psychosocial wellbeing of the affected residents. Findings: a). During a review of Resident 1 ' s admission record, the admission record indicated Resident 1 was admitted on [DATE] and re-admitted on [DATE] with a diagnosis that included hemiplegia and hemiparesis cerebral infarct (paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one-sided weakness, but without complete paralysis), diabetes (DM-high blood sugar), and muscle weakness (reduced muscle strength). During a review of Resident 1 ' s history and physical (H&P) dated 12/6/2023, the H&P indicated Resident 1 does not have the mental 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 10/20/2023, the MDS indicated Resident 1 ' s cognitive skills (thought process) was adequate and could understand and be understood by others. The MDS indicated Resident 1 required substantial/maximal 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 1 ' s care plan for ADL/Self-care Deficit dated 10/23/2023, the care plan indicated Resident 1 require assistance with activities of daily living because of medical condition. Care plan goal indicated, Resident 1 will be kept clean and dry. Care plan interventions indicated, provide a safe environment, staff will follow bed mobility/ ADL standards of care, staff will maintain and respect Residents 1 ' s rights. During a concurrent observation and interview on 12/29/2023 at 10:00 a.m., in Resident 1 ' s room, Resident 1 ' s bed was unmade (not done), bed sheets, pillowcase, and blankets weredirty with black spots. Resident 1 stated, I believed the sheets were changed every time I take a shower. Resident 1 stated the sheets are dirty right now. They had not changed the bedsheets. I do not know why. Resident 1 stated, I would like the nurse to change my sheets. b). During a review of Resident 2 ' s admission record, the admission record indicated Resident 2 was admitted on [DATE], and re-admitted on [DATE] with a diagnosis that included hemiplegia and hemiparesis cerebral infarct (paralysis of partial or total body function on one side of the body, whereas hemiparesis is characterized by one-sided weakness, but without complete paralysis), diabetes (DM-high blood sugar), and muscle wasting and atrophy (wasting (thinning) or loss of muscle tissue). During a review of Resident 2 ' s history and physical (H&P) dated 10/19/2023, the H&P indicated Resident 1 has 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 11/17/2023, the MDS indicated Resident 2 ' s cognitive skills (thought process) was adequate and could understand and be understood by others. The MDS indicated Resident 2 required dependent 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 for ADL/Self-care Deficit dated 11/18/2023, the care plan indicated Resident 2 has selfcare deficits. Needs up to depended assistance in ADL. Care plan goal indicated, Resident 2 will be kept clean and dry. Care plan interventions indicated, respect residents ' rights, assist with ADLs as needed, provide a safe environment. During an observation on 12/29/2023 at 10:40 a.m., in Resident 2 ' s room. Resident 2 was laying on bed wearing a gown. Residents 2 ' s bed sheets were dirty with brown spots on the right-side of the sheets. c). During a review of Resident 3 ' s admission record, the admission record indicated Resident 3 was admitted on [DATE] and re-admitted on [DATE] with a diagnosis that included epilepsy (nerve cell activity in the brain is disturbed, causing seizures.), chronic obstructive pulmonary disease (inflammatory lung disease that causes obstructed airflow from the lungs), and chronic kidney disease (kidneys are damaged and cannot filter blood). During a review of Resident 3 ' s history and physical (H&P) dated 7/1/2023, the H&P indicated Resident 3 has 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 10/27/2023, the MDS indicated Resident 3 ' s cognitive skills (thought process) was sometimes understood and be understood by others. The MDS indicated Resident 3 required dependent 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 3 ' s care plan for ADL/Self-care Deficit dated 11/03/2023, the care plan indicated Resident 3 has selfcare deficits requires up to total assistance with ADLs. Care plan goal indicated, Resident 3 will be kept clean and dry. Care plan interventions indicated, respect residents ' rights, assist with ADLs as needed, provide a safe environment. During a concurrent observation and interview on 12/29/2023 at 11:00 a.m., in Residents 3 ' s room, Resident 3 was laying on bed partially covered with blankets. Residents 3 ' s bed sheets were dirty with brown spots. Resident 3 stated, It will be nice to have clean sheets to lay down. During a concurrent observation and interview on 12/29/2023 at 10:00 a.m. in Residents 1 ' s room, Resident 1 ' s wheelchair was dirty with dried food stains on the left side of the wheelchair. Resident 1 ' s room privacy curtain was brown and had food stains. Resident 1 stated, I would like the nurses to change my curtains. Resident 1 stated, I do not know when they cleaned my wheelchair. The wheelchair is dirty because sometimes food fell on the wheelchair. Resident 1 stated, I forgot to tell them to clean it. During an interview on 12/29/2023 at 12:00 p.m., with Certified Nursing Assistance (CNA) 1, CNA 1 stated, in shower days the sheets are changed, but if sheets are soaked or dirty, it needs to be changed. CNA 1 stated, she noted Residents 2 ' s sheets were dirty. CNA 1 stated the importance of changing the sheets is for Resident 2 to feel comfortable and clean. CNA 1 stated, it is not pleasant to lay down on dirty sheets and it is Resident 2 ' s rights to have clean sheets and to feel like this place is his home. During an interview on 12/29/2023 at 12:00 p.m., with CNA 2, CNA 2 stated, the linings are changed when dirty. CNA 2 stated, I am not sure if Resident 1 ' s bed sheets were dirty. CNA 2 stated, it is important to change the sheets to prevent any bacteria and it ' s Resident 2 ' s right to be in a clean environment. CNA 2 stated the wheelchair is cleaned once a week by the housekeeping. Resident 1 liked to eat by himself and sometimes food spill on his wheelchair. CNA 2 stated, the facility is Resident 1 ' s home, it is nurses ' responsibility to keep everything as Resident 1 likes. CNA 2 stated, I know the linings were dirty for Resident 3. CNA 2 stated, it was my mistake, I will change the sheets. During an interview on 12/29/2023 at 12:40 p.m., with Licensed Vocational Nurses (LVN) LVN stated, the sheets are changed every day. LVN stated, it is one of residents ' rights to keep their environment clean. LVN stated, it is importance to keep the lining cleaned to prevent develop bed sores. During an interview on 12/29/2023 at 1:40 p.m., with Housekeeping (HK), the HK stated, I am responsible in taking the curtains down if dirty. HK stated the curtains should be changed when they are dirty. HK stated curtains must be checked every time the resident ' s room is cleaned. HK stated, it is important to check the residents ' rooms, residents lives here so we need to keep their room nice and clean. HK stated, I did not check the curtains of Resident 1 I forgot to check it. HK stated the wheelchair were cleaned once a week and as needed it. HK stated, if HK or nurses noted the wheelchair is dirty, we need to clean the wheelchair. During an interview on 12/29/2023 at 2:00 p.m., with Assistance Director of Nursing (ADON) ADON stated, the CNA job duties includes changing the linens. If the linens are dirty or soiled, it must be changed every day. ADON stated, it is not appropriate for residents lay on a filthy sheet. ADON stated, the sheets are changed for infection control prevention and for residents ' dignity. ADON stated, it is residents ' rights to live in a clean and safe environment. ADON stated, if environment or sheets are not clean, resident can be affected psychologically. ADON stated, nurses need to provide residents with a homelike environment. ADON stated, HK duties are to change privacy curtains if dirty. ADON stated, the privacy curtains are checked while cleaning resident ' s room. ADON stated, wheelchair is being cleaned once a week by HK, but if wheelchair is dirty with dry food, it needs to be cleaned by the CNA. ADON stated, it is important to keep the place where residents sit and moved around clean. During an interview on 12/29/2023 at 2:213 p.m., with Director of Nursing (DON) DON stated, the bed linens needed to be changed every day and with any incontinent episodes. DON stated linens are changed often and as needed or when soil or dirty. DON stated, no resident wants to lay down on a dirty bed. DON stated, it is dignity and resident right to have the room and bed clean. DON stated, HK clean the wheelchairs weekly and privacy curtains, if soil or dirty, it must be washed. DON stated, if wheelchair not cleaned is a potential for infection. DON stated, resident can be affected for not having a homelike environment. During a review of the facility ' s Policy and Procedures (P&P) titled, Job Description- Certified Nursing Assistance dated 8/23/2021, the P&P indicated, the certified Nursing Assistants assist in providing a clean, safe, dignified, happy and healthy environment for residents. When making residents beds, provide the necessary measures to ensure the safety and comfort, performs infection control practices during resident care procedures. During a review of the P&P titled, Housekeeping dated 1/27/2022, the P/P indicated, housekeeping duties are to clean rugs, carpets, and draperies. During a review of the P&P titled, Resident Rights dated 3/2023, the P/P indicated Residents rights to dignified existence, be treated with respect, kindness, and dignity.

Dec 2023 3 deficiencies 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Free from Abuse/Neglect (Tag F0600)

A resident was harmed · This affected 1 resident

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled Abuse and Mistreatment of Residents, which indicated residents will be free from verbal, sexual, and mental abuse, corporal punishment, involuntary seclusion for two of three sampled residents (Resident 1 and Resident 2) by a License Vocational Nurse (LVN 1). LVN 1 cursed, yelled and pushed Resident 1 on to his bed. LVN 1 was rude and yelled at Resident 2. This deficient practice resulted in Resident 1 crying and feeling fearful. It also resulted in Resident 2 feeling inhuman, withdrawn and anxious (feeling uneasy). Findings: 1.A review of Resident 1 ' s admission record (Face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE], with a diagnosis that included diabetes (abnormal blood sugar), dementia (impairment of memory and judgement) with behavioral disturbance, and encephalopathy (disturbance of the brain function). A review of Resident 1 ' s history of physical (H&P) dated 7/20/2023, indicated Resident 1 was able to make decisions for activities of daily living. A review of Resident 1 ' s minimum data set ([MDS] a standardized care assessment and care screening tool), dated 10/24/2023, indicated Resident 1 ' s cognitive skills (thought process) was moderately impaired and was sometimes understood by others. The MDS indicated Resident 1 required extensive assistance of one to two people assist with activities 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). The MDS indicated Resident 1 was always of bowel and bladder incontinent (inability to control bladder and bowel function). A review of Resident 1 ' s care plan titled Resident with episodes of uncontrollable mood swings, easily gets agitated and prefers to be alone, dated 11/13/2023, indicated interventions including to approach resident in a calm and friendly manner, if the resident became hostile during care, stopped, and resume back when resident had calm down. A review of Resident 1 ' s change in condition (COC) form dated 11/20/2023 at 3:05 a.m., indicated Certified Nurse Assistant (CNA) reported that Resident 1 was standing at the door of his room and was unable to be re-directed to his bed. The COC indicated LVN 1 assigned to Resident 1 assisted the CNA ' s in re-directing Resident 1 back to his bed. The COC indicated Resident 1 became aggressive and was swinging his arms uncontrollably. The COC indicated LVN 1 was unable to control Resident 1 ' s movements and LVN 1 became agitated and pushed Resident 1 onto his bed. A review of Resident 1 ' s interdisciplinary team ([IDT]- team members from difference disciplines working together to meet residents ' needs) dated 11/20/2023, indicated the IDT a meeting was held due to staff mishandling Resident 1. The IDT notes indicated Resident 1 became aggressive when staff asked him to return to his bed. The IDT notes indicated LVN 1 became agitated with Resident 1 and pushed the resident on to his bed. The notes indicated Resident was alert and oriented by name, but confused and unable to recall incident. b. A review of Resident 2 ' s face sheet indicated Resident 2 was admitted to the facility on [DATE] and re-admitted on [DATE], with a diagnosis including muscular dystrophy (loss of muscle), quadriplegia (condition in which both arms and legs are paralyzed), and depression (a mental health disorder affecting how a person thinks, feels and behaves). A review of Resident 2 ' s H&P dated 10/3/2023, indicated Resident 2 had the capacity to understand and make medical decisions. A review of Resident 2 ' s MDS dated [DATE], the MDS indicated Resident 2 was able to understand and be understood by other. The MDS indicated Resident 2 required max assistance of two person assist for activities such as dressing, toilet use, personal hygiene, transfer, and bed mobility. The MDS indicated Resident 2 was always incontinent of bowel and bladder. A review of Resident 2 ' s IDT meeting notes, dated 12/12/2023, was held due to Resident 2 ' s allegations of verbal threats by LVN 1. The IDT notes indicated Resident 2 ' s alleged LVN 1 threatened him by stating don ' t you ever disrespect me. The IDT notes indicated Resident 2 felt frightened. A review of Resident 2 ' s physician psychiatric notes dated 12/13/2023, indicated Resident 2 was withdrawn during the interview and reported LVN 1 cursed at him when Resident 2 asked for his medication. The psychiatric notes indicated Resident 2 admitted to experiencing anxiety. During an interview on 12/11/2023 at 5:09 p.m. with CNA 1, CNA 1 stated Resident 1 was standing outside of his room [ROOM NUMBER]/202/2023 and even though he was not assigned to her (CNA 1), she was concerned that the resident would fall. CNA 1 stated she observed LVN 1 yelling and cursing at Resident 1 from the nursing station. CNA 1 stated LVN 1 walked over to Resident 1 and LVN 1 and CNA 1 grabbed Resident 1 by the arms and walked the resident back to his bed. CNA 1 stated LVN 1 was rushing Resident 1 back to his bed and Resident 1 became agitated and said, slow down I cannot walk that fast, I feel like I am going to fall. CNA 1 stated while at the edge of Resident 1 ' s bed, LVN 1 became agitated and pushed Resident 1 on the bed practically slamming the resident ' s body. CNA 1 stated LVN 1 proceeded to yell and curse at Resident 1 stating do not disrespect me. You will respect me and my nurses. CNA stated she observed LVN 1 place his right fist on Resident 1 ' s chest and the left fist inside Resident 1 ' s mouth as he continued to curse and yell at Resident 1. CNA 1 stated Resident 1 looked frightened and started crying stating please do not let that nurse hurt me. CNA 1 stated as soon as Resident 1 calmed down, she and CNA 2 reported the incident to the Registered Nurse (RN) Supervisor. CNA 1 stated this was not the first time she observed LVN 1 speaking harshly to Resident 1. CNA 1 stated Resident 2 also had encountered harsh treatments from LVN 1. CNA 1 stated Resident 2 had reported to her that LVN 1 had yelled at him stating you should be grateful that I am here. I could be at home with my family. During an interview on 12/11/2023 at 5:28 p.m. with CNA 2, CNA 2 stated she was walking towards the elevator to get linens with CNA 1 and noticed Resident 1 standing outside his room. CNA 2 stated she observed LVN 1 yelling and cursing at Resident 1 from the nursing station. CNA 2 stated LVN 1 and CNA 1 proceeded to re-direct Resident 1 back to his bed. CNA 2 stated when she walked into the room, she observed LVN 1 ' s right fist on Resident 1 ' s chest and his left fist on the resident ' s mouth yelling and cursing at Resident 1. CNA 2 stated LVN 1 was muzzling (preventing one from speaking freely) Resident 1 with his left fist. CNA 2 stated she pushed LVN 1 off of Resident 1 and told LVN 1 that he was not allowed to treat the residents is such manner. CNA 2 stated she observed Resident 1 crying and saying, please do not let that man hurt me. CNA 2 stated she and CNA 1 reported the incident to the RN Supervisor. CNA 2 stated at an unknown date and time, she observed Resident 2 crying after he was informed that LVN 1 was assigned to him. During an interview on 12/12/2023 at 1:45 p.m. with Resident 2, Resident 2 stated he experienced mistreatment from LVN 1 before. Resident 2 stated whenever he asked LVN 1 for assistance he would ignore him and when he yelled louder for LVN 1 to assist him, LVN 1 would tell him You should be grateful that I am helping you. LVN 1 stated Resident 2 reported LVN 1 made degrading remarks to him and would curse and yell at him. Resident 2 stated LVN 1 never hit him, but he would get in front of his face multiple times to the point where he felt afraid that one day, he would be physically hit by LVN 1. Resident 2 stated LVN 1 made him feel inhuman and his anxiety worsen whenever LVN 1 was assigned to him. Resident 2 stated he had expressed his concerns to various nurses at the facility including CNA 1 and CNA 2. During a concurrent interview the Administrator (Admin), and Assistant Director of Nursing (ADON) on 12/12/2023 at 2:25 p.m., the Admin stated it was difficult to substantiate the allegations against LVN 1 because the interviews with the CNAs were incongruent. The Admin and the ADON stated the facility was not aware Resident 2 experienced harsh treatment from LVN 1. The Admin stated LVN 1 was dismissed from the facility, and the facility will follow up and monitor Residents 1 and 2. A review of the facility ' s undated policy and procedure (P&P) titled Abuse and Mistreatment of Residents, indicated the facility will uphold the residents right to be free from verbal, sexual, and mental abuse, corporal punishment, and involuntary seclusion. The P&P indicated abuse was the willful infliction of injury, unreasonable conferment, or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual including a caretaker, of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being.

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report allegations and incidents of abuse for two of three sampled ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report allegations and incidents of abuse for two of three sampled residents (Resident 1 and Resident 2) to the California Department of Public Health (CDPH) within 24 hours, and failed to implement its policy and procedure by not reporting Resident 1's allegation of abuse to the State Survey Agency (SSA) within two hours after being made aware of the allegation when: 1. Licensed Vocational Nurse (LVN) 1 was observed yelling and being physically and verbally abusive to Resident 1. 2. Resident 2 disclosed to staff of receiving verbal mistreatment from LVN 1. These deficient practices delalyed the investigation of the abuse allegations by the CDPH, and had a potential to place Resident 1 and Resident 2 and other residents at risk for abuse. Findings: During a review of Resident 1 ' s admission Record (Face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included diabetes (high blood sugar), dementia (impairment of memory and judgement) with behavioral disturbance, and encephalopathy (disturbance of the brain function). During a review of Resident 1 ' s History and Physical (H&P) dated 7/20/2023, the H&P indicated Resident 1 was able to make decisions for activities of daily living (ADLs, daily self-care activities such as dressing, grooming, and toileting). During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 10/24/2023, the MDS indicated Resident 1 ' s cognitive skills (thought process) was moderately impaired and was sometimes understood by others. The MDS indicated Resident 1 required extensive assistance with one to two persons assist with ADLs, transfer, and bed mobility. The MDS indicated Resident 1 was always incontinent (inability to control) of bowel and bladder. During a review of Resident 1 ' s care plan titled, Resident with episodes of uncontrollable mood swings, easily gets agitated and prefers to be alone, with an initiation date of 11/13/2023, the staff's interventions indicated to approach Resident 1 in a calm and friendly manner. The care plan interventions indicated if Resident 1 became hostile during care, care would be stopped and resumed when the resident calmed down. During a review of Resident 1 ' s Change of Condition (COC) form dated 11/20/2023 at 3:05 a.m., the COC indicated on 11/20/2023, Certified Nurse Assistant (CNA) 1 reported Resident 1 was standing at the door of his room and was unable to be re-directed back to his bed. LVN 1 assisted the (unidentified) CNA ' s in re-directing Resident 1 back to his bed. Resident 1 became aggressive and was swinging his arms uncontrollably. The COC indicated LVN 1 was unable to control Resident 1's movements, and LVN 1 became agitated (feeling or appearing troubled) and pushed Resident 1 onto his bed. During a review of Resident 1 ' s Interdisciplinary Team ([IDT]- group of different disciplines working together towards a common goal of a resident) Meeting Note dated 11/20/2023, the IDT note indicated a meeting was held due to staff (LVN 1) mishandling Resident 1 on 11/20/2023. The IDT note indicated Resident 1 became aggressive when asked by staff to return to his bed. LVN 1 became agitated with Resident 1 and pushed him onto his bed. The IDT note indicated Resident 1 was alert and oriented by name, but confused and unable to recall the incident. During a review of Resident 2 ' s admission Record (Face sheet), the face sheet indicated Resident 2 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included muscular dystrophy (loss of muscle), quadriplegia (condition in which both arms and legs are paralyzed [unable to move]), and depression (a mental health disorder affecting how you feel and how you live). During a review of Resident 2 ' s H&P dated 10/3/2023, the H&P indicated Resident 2 had the capacity to understand and make medical decisions. During a review of Resident 2 ' s MDS dated [DATE], the MDS indicated Resident 2 ' s cognitive skills was intact and was able to understand and be understood by other. The MDS indicated Resident 2 required maximum assistance with two persons assist with ADLs, transfer, and bed mobility. The MDS indicated Resident 2 was always incontinent of bowel and bladder. During a review of Resident 2 ' s IDT Meeting Note, dated 12/12/2023, the IDT note indicated a meeting was held due to Resident 2 ' s allegations of verbal threats by LVN 1. The IDT note indicated Resident 2 alleged that LVN 1 threatened him by stating ,don ' t you ever disrespect me. The IDT note indicated Resident 2 felt frightened. During a review of Resident 2 ' s Physician Psychiatric Notes dated 12/13/2023, the psychiatric notes indicated Resident 2 reported LVN 1 cursed at the resident when Resident 2 would ask for his medication. The psychiatric notes indicated Resident 2 admitted to experiencing anxiety (feelings of unease, excessive worry). The psychiatric notes indicated Resident 2 was withdrawn during the interview. During an interview on 12/11/2023 at 5:09 p.m. with CNA 1, CNA 1 stated on 11/20/2023, Resident 1 was standing outside of his room and was concerned the resident would fall. CNA 1 stated she observed LVN 1 yelling and cursing at Resident 1 from the nursing station. CNA 1 stated LVN 1 walked over to Resident 1 and they (CNA 1 and LVN 1) each grabbed Resident 1 by the left and right arm and walked the resident back to his bed. CNA 1 stated LVN 1 was rushing Resident 1 back to his bed and Resident 1 became agitated and said slow down I cannot walk that fast, I feel like I am going to fall. CNA 1 stated when they arrived at the edge of Resident 1 ' s bed, LVN 1 became agitated and pushed Resident 1 on the bed practically slamming the resident's body. CNA 1 stated LVN 1 proceeded to yell and curse at Resident 1 stating do not disrespect me. You will respect me and my nurses. CNA 1 stated she observed LVN 1 place his right fist on Resident 1 ' s chest and the left fist inside of the resident's mouth as he continued to curse and yell at Resident 1. CNA 1 stated this was not the first time she observed LVN 1 speaking harshly to Resident 1. CNA 1 stated Resident 2 disclosed to her that LVN 1 yelled at him and stated you should be grateful that I am here. I could be at home with my family. CNA 1 stated she did not report the incidents because she did not feel confident and was afraid of retaliation. CNA 1 also stated she was new to the facility and did not know the process of reporting abuse allegations. During an interview on 12/11/2023 at 5:28 p.m. with CNA 2, CNA 2 stated on 11/202/2023, she was walking towards the elevator to grab bed linens with CNA 1 and noticed Resident 1 standing outside his room. CNA 2 stated she observed LVN 1 yelling and cursing at Resident 1 from the nursing station. CNA 2 stated LVN 1 and CNA 1 proceeded to re-direct Resident 1 back to his bed and she walked away to grab the linen. CNA 2 stated when she walked into the room she observed LVN 1 with his right fist on Resident 1 ' s chest and his left fist on the resident's mouth yelling and cursing at Resident 1. CNA 1 stated LVN 1 was muzzling Resident 1 with his left fist. CNA 2 stated this was the first time she observed LVN 1 mistreat Resident 1, however CNA 2 stated she observed Resident 2 crying after he was informed that LVN 1 was assigned to his care. CNA 2 stated she asked Resident 2 why he was crying and Resident 2 stated, He is so mean, I do not like him, he always gives me a hard time with my medication. CNA 2 stated she did not report her observations to management because Resident 2 did not disclose that he was afraid or felt threatened by LVN 1. During an interview on 12/12/2023 at 1:45 p.m. with Resident 2, Resident 2 stated he experienced mistreatment with LVN 1 before. Resident 2 stated that whenever he (Resident 2) asked LVN 1 for assistance he would ignore him and when he yelled louder for LVN 1 to assist him, LVN 1 would tell Resident 2, You should be grateful that I am helping you. Resident 2 stated LVN 1 made degrading remarks to him and would curse and yell at him. Resident 2 stated LVN 1 never hit him, but he would get in front of his face multiple times to the point where he felt afraid that one day he would be physically hit by LVN 1. Resident 2 stated LVN 1 made him feel un-human and he felt his anxiety worsened when LVN 1 was assigned to him. Resident 2 stated he expressed his concerns to various nurses at the facility including CNA 1 and CNA 2. During an interview with the Administrator (Admin) and Assistant Director of Nursing (ADON) on 12/12/2023 at 2:25 p.m., the Admin and ADON stated they were not aware Resident 2 experienced harsh treatment from LVN 1. The Admin stated all nurses and staff were mandated reporters and CNA 1 and CNA 2 should have reported the abuse allegations from Resident 2. The ADON stated she would speak to the Director of Staff Development (DSD) to conduct in-service trainings on abuse. During a review of the facility ' s undated policies and procedures (P&P) titled, Abuse and Mistreatment of Residents, the P&P indicated Abuse is defined as the willful infliction of injury, unreasonable conferment, or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual including a caretaker, of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. During a review of the facility's undated P&P titled, Reporting, the P&P indicated It is the facility ' s policy for any mandated reporter working in a facility to report all alleged and substantiated violations to their supervisors.

CONCERN (D) 📢 Someone Reported This

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

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

Investigate Abuse (Tag F0610)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its policy and procedure (P&P) by not placing Licensed Vocat...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its policy and procedure (P&P) by not placing Licensed Vocational Nurse (LVN) 1 on immediate suspension after he was observed mishandling one of three sampled residents (Resident 1). This deficient practice had the potential to expose other residents to the same harsh treatment and care, potentially causing physical, emotional, and psychosocial injury and requiring hospitalization. Findings: During a review of Resident 1 ' s admission Record (Face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses that included diabetes (high blood sugar), dementia (impairment of memory and judgement) with behavioral disturbance, and encephalopathy (disturbance of the brain function). During a review of Resident 1 ' s History and Physical (H&P) dated 7/20/2023, the H&P indicated Resident 1 was able to make decisions for activities of daily living (ADLs, daily self-care activities such as dressing, grooming, and toileting). During a review of Resident 1 ' s Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 10/24/2023, the MDS indicated Resident 1 ' s cognitive skills (thought process) was moderately impaired and was sometimes understood by others. The MDS indicated Resident 1 required extensive assistance with one to two persons assist with ADLs, transfer, and bed mobility. The MDS indicated Resident 1 was always incontinent (inability to control) of bowel and bladder. During a review of Resident 1 ' s care plan titled, Resident with episodes of uncontrollable mood swings, easily gets agitated (feeling or appearing troubled) and prefers to be alone, with an initiation date of 11/13/2023, the staff's interventions indicated to approach Resident 1 in a calm and friendly manner. The care plan interventions indicated if Resident 1 became hostile during care, care would be stopped and resumed when resident calmed down. During a review of Resident 1 ' s Change of Condition (COC) form dated 11/20/2023 at 3:05 a.m., the COC indicated on 11/20/2023, a certified nurse assistant (CNA 1) reported Resident 1 was standing at the door of his room and was unable to be re-directed back to his bed. The COC indicated LVN 1 assisted the CNA ' s in re-directing Resident 1 back to bed. Resident 1 became aggressive and was swinging his arms uncontrollably. LVN 1 was unable to control Resident 1's movements and LVN 1 became agitated and pushed Resident 1 onto his bed. During a review of Resident 1 ' s Interdisciplinary Team ([IDT]- a group of different disciplines working together towards a common goal of a resident) Meeting Note dated 11/20/2023, the IDT note indicated a meeting was held due to staff (LVN 1 ) mishandling Resident 1. The IDT note indicated Resident 1 became aggressive when asked by staff to return to his bed. The IDT note indicated LVN 1 became agitated with Resident 1 and pushed him onto his bed. The IDT note indicated Resident 1 was alert and oriented by name, but confused and unable to recall the incident. During a review of LVN 1 ' s time sheet for the month of November 2023, LVN 1 ' s time sheet indicated LVN 1 clocked in to work on Sunday 11/19/2023 at 11:35 p.m., and clocked out on Saturday 11/20/2023 at 7:37 a.m. During an interview on 12/11/2023 at 5:09 p.m. with CNA 1, CNA 1 stated on 11/20/2023, Resident 1 was standing outside of his room and was concerned the resident would fall. CNA 1 stated she observed LVN 1 yelling and cursing at Resident 1 from the nursing station. CNA 1 stated LVN 1 walked over to Resident 1 and they (CNA 1 and LVN 1) each grabbed Resident 1 by the left and right arm and walked the resident back to his bed. CNA 1 stated LVN 1 was rushing Resident 1 back to his bed and Resident 1 became agitated and said slow down I cannot walk that fast, I feel like I am going to fall. CNA 1 stated when they arrived at the edge of Resident 1 ' s bed, LVN 1 became agitated and pushed Resident 1 on the bed practically slamming the resident's body. CNA 1 stated LVN 1 proceeded to yell and curse at Resident 1 stating, Do not disrespect me. You will respect me and my nurses. CNA 1 stated she observed LVN 1 place his right fist on Resident 1 ' s chest and the left fist inside of Resident 1 ' s mouth while he (LVN 1) continued to curse and yell at Resident 1. CNA 1 stated she and CNA 2 reported the incident to the Registered Nurse (RN) Supervisor, however, LVN 1 continued to work the entire shift. During an interview on 12/11/2023 at 5:28 p.m. with CNA 2, CNA 2 stated on 11/20/2023, she was walking towards the elevator to grab bed linens with CNA 1 and noticed Resident 1 standing outside his room. CNA 2 stated she observed LVN 1 yelling and cursing at Resident 1 from the nursing station. CNA 2 stated LVN 1 and CNA 1 proceeded to re-direct Resident 1 back to his bed and walked away to grab the linen. CNA 2 stated when she walked into the room she observed LVN 1 with his right fist on Resident 1 ' s chest and his left fist on the resident's mouth yelling and cursing at Resident 1. CNA 1 stated LVN 1 was muzzling Resident 1 with his left fist. CNA 2 stated after the incident was reported to the RN Supervisor, LVN 1 continued to work his shift. During an interview with the Administrator (Admin) and Assistant Director of Nursing (ADON) on 12/12/2023 at 2:25 p.m., the Admin stated the RN Supervisor should have sent LVN 1 home pending investigation. The Admin stated the RN Supervisor placed all the residents under LVN 1 ' s care at risk for abuse and mistreatment by not sending him home. During a review of the facility ' s undated policies and procedures (P&P) titled, Abuse and Mistreatment of Residents, the P&P indicated Abuse is defined as the willful infliction of injury, unreasonable conferment, or punishment with resulting physical harm or pain or mental anguish, or deprivation by an individual including a caretaker, of goods and services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Furthermore the P&P indicated if the suspected perpetrator is a staff member, the staff member is to be placed immediately on administrative suspension.

Nov 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of 3 residents (Resident 1) was evaluated for Physical T...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of 3 residents (Resident 1) was evaluated for Physical Therapy ([PT], treatment of disease, injury, or deformity by methods such as exercises to relieve pain, help resident move better or strengthen weakened muscles) in a timely manner per physician ' s order and facility policy and procedure (P&P). This deficient practice had the potential to cause harm to Resident 1 ' s newly amputated right lower limb and placed him at risk for decline in health and delay in recovery. Findings: During a review of Resident 1 ' s admission record (Face sheet), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including diabetes (high blood sugar), hypertension (high blood pressure), acquired absence of right leg below the knee (amputation). During a review of Resident 1 ' s history of physical (H&P) dated 11/26/2023, the H&P indicated Resident 1 had the capacity to understand and make medical decisions. During a review of Resident 1 ' s physician order summary dated 11/2023, the physician order summary indicated Resident 1 had PT evaluation and treatment with an order date of 11/25/2023. During a review of Resident 1 ' s baseline care plan for impairment in function requiring PT and occupational therapy (OT) dated 11/25/2023, the baseline care plan interventions indicated Resident 1 would have rehabilitation (rehab, PT) therapy as ordered. During a review of Resident 1 ' s self-care deficit care plan related to muscular weakness, poor balance, poor coordination, and medical condition, dated 11/26/2023, the care plan interventions indicated Resident 1 would have a rehab screening on admission, quarterly and as needed. During an interview on 11/29/2023 at 9:35 a.m. with Resident 1, Resident 1 stated he was admitted to the facility on Friday 11/24/2023 in the evening. Resident 1 stated he was under the impression that he would receive PT at least five (5) times a week and had not received any treatments. Resident 1 stated he did not want to delay his treatment further and was afraid his health would decline. During an interview on 11/29/2023 at 9:55 a.m., with the PT Director, PT Director stated he did not schedule Resident 1 for an initial assessment on 11/27/2023 and 11/28/2023 because he was catching up with administrative duties. The PT Director stated Resident 1 should have been assessed immediately upon admission because his below the knee amputation was new, and Resident 1 needed to be educated about his safety awareness and how to safely move around without hurting the stump. The PT Director stated not starting the PT evaluation sooner had the potential to cause Resident 1 to decline in his physical health and he could have injured the stump. During a review of the facility ' s undated P&P titled, Screening, the P&P indicated admissions and re-admission rehabilitation screening was completed within 72 hours of admission or re-admission.

Sept 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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview and record review the facility failed to maintain complete and accurate medical records in accordance with ac...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Interview and record review the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards and practices for one out of three sampled residents (Resident 2) by failing to accurately document administration of medications in the residents Medication Administration Record (MAR). This deficient practice placed Resident 2 at risk for medication errors and of not receiving appropriate medication due to incomplete medication administration documentation. Findings: During a review of Resident 2 ' s admission Record (face sheet), the face sheet indicated Resident 2 was admitted to the facility on [DATE] with diagnoses that included cervical disc disorder with myelopathy (compression of the spinal cord), human immunodeficiency virus [(HIV) a virus that attacks the body ' s immune system), paranoid schizophrenia (a mental disorder that affects a person ' s ability to think, feel and behave clearly with feelings of distrustfulness and suspicious of others). During a review of Resident 2 ' s History and Physical (H&P), dated 10/12/2022, the H&P indicated Resident 2 did have the capacity to understand and make decisions. During a review of Resident 2 ' s Minimum Data Set ([MDS] a standardized assessment and care screening tool) dated 7/20/2023, The MDS indicated Resident 2 was independent setup help only from staff for toileting and personal hygiene and dressing. During a review of Resident 2 ' s Medication Administration Record (MAR) dated August 2023 and September 2023 the document indicated on the dates of 8/24/2023, 8/25/2023, 8/29/2023, 8/30/2023, 8/31/2023, 9/2/2023, 9/5/2023, 9/7/2023, 9/8/2023, and 9/9/2023 for the medication Amlodipine (medication for high blood pressure), Multivitamin (supplement), Symtuza (medication for HIV), Vitamin D3 (supplement), Colace (stool softener) and Gabapentin (medication for nerve pain) due at 9:00am, Licensed Vocational Nurse (LVN) 1 documented a chart code of 9 on the MAR. Chart code of 9 indicates other/see progress notes. During a review of Resident 2 ' s progress notes dated 8/24/2023, 8/25/2023, 8/29/2023, 8/30/2023, 8/31/2023, 9/2/2023, 9/5/2023, 9/7/2023, 9/8/2023, and 9/9/2023 documented by LVN1, indicated medication administered by 11-7 charge nurse. During an interview on 9/14/2023 at 12:14 p.m. with Licensed Vocational Nurse (LVN)1, LVN 1 stated that medication is administered to all the residents assigned except for Resident 2. LVN 1 stated medication is pulled by LVN 1 and then administered by another licensed nurse. LVN 1 placed a chart code in the MAR to refer to the progress notes, a note was placed in the progress note stating, medication given by charge nurse. During an interview on 9/14/2023 at 2:57 p.m. with Director of Nursing (DON), DON stated a nurse should not pull the medication and have another nurse pull it. The nurse who is to administer a resident ' s medication should be the one who pull it from the medication cart, give it to the resident and document in the system under the MAR. If not documented correctly in the system, it could affect and potentially harm the resident. A review of the facility ' s policy and procedure (P&P) titled, Preparation and General Guidelines IIA2: Medication Administration – General Guidelines, dated April 2008, the P&P indicated, The person who prepares the dose for administration is the person who administers the dose .Medications are administered within 60minutes of scheduled time (1 hour before and 1 hour after) . The individual who administers the medication dose records the administration on the resident ' s MAR directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented. In no case should the individual who administered the medication report off-duty without first recording the administration of any medications . The resident ' s MAR is initialed by the person administering the medication .

Sept 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had bilateral (both) bed rails up and padded to prevent injuries according to the physician's order, the bed in lowest position and the bedside table within reach according to the facility's policy and procedures (P&P). These deficient practices had the potential to cause further falls and accidents with injury for Resident 1. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted on [DATE], and re-admitted on [DATE] with a diagnoses including hemiplegia (complete paralysis) and hemiparesis (weakness or partial paralysis) following a cerebral infarction (disrupted blood flow to the brain causing lack of oxygen causing parts of the brain to die off), nontraumatic intracerebral hemorrhage (brain bleed) and epilepsy (disorder which causes seizures [uncontrolled electrical activity in brain which can cause changes in behavior and movements). During a review of Resident 1's Careplan for fall risk dated 6/7/2023, the Careplan indicated Resident 1 was a high risk for falls/injury because of history of falls, osteoporosis, poor body balance/control, seizure disorder and use of medications). The Careplan indicated interventions included nursing to ensure frequently used items would be placed within reach and would provide a safe environment. During a review of Resident 1's Fall Risk Assessment (FRA) dated 6/25/2023, the FRA indicated Resident 1 was a high risk for fall, with an unsteady gait (manner of walking) and had poor sitting or standing balance. During a review of Resident 1's History and Physical (H&P) dated 6/26/2023, the H&P indicated Resident 1 did not have the capacity to understand and make medical decisions. During a review of Resident 1's Physician Order dated 6/28/2023, the Order indicated Resident 1 to have bilateral full side rails up and rail pads when in bed for safety, balance and positioning secondary to seizure disorder. During a review of Resident 1's Minimum Data Set ([MDS] a standardized care assessment and care screening tool), dated 7/20/2023, the MDS indicated Resident 1 required extensive assistance (resident involved in activity, staff provide weight-bearing support) with activities of daily living (ADL) such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how resident moves from lying to turning side to side). The During a concurrent observation and interview on 9/6/2023 at 9:00 a.m. with Resident 1 in Resident 1's room. Resident 1 was observed lying down with his bed in high position with the right siderail in the down position and both side rails unpadded. Resident 1's bedside table was also observed not being within reach of the resident. During a concurrent observation and interview on 9/6/2023 at 9:30 a.m., with Certified Nurse Assistant (CNA) 1 in Residents 1's room, CNA 1 stated Resident 1's bedside table should've been close to the resident so he could reach his water. CNA 1 stated, Resident 1's bed should have been in the lowest position with bilateral side rails been up and padded however was not. During an interview on 9/6/2023 at 3:10 p.m., with the Director of Nursing (DON), the DON stated, Resident 1 had a fall recently and sustained a laceration to the left eyebrow. DON stated, Resident 1 should have had the side rails up and padded with his bedside within reach for safety. During a review of the facility's undated P&P titled, Promoting Safety, Reducing Falls , the P&P indicated because of aging changes, underlying processes; and psychological, social and economic stresses, the elderly population was at increased risk of accident and injury. By focusing on fall preventions, caregivers could enhance the quality of life for residents to promote their independence and maintain their highest practicable level of functioning. The P&P also indicated caregivers should keep frequently used items within reach of residents and make sure that beds were in the lowest position to the floor and that the wheels were locked.

Sept 2023 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report an injury of unknown origin for one of three s...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to report an injury of unknown origin for one of three sampled residents (Resident 1) within two hours after being made aware of the injury. This deficient practice had the potential to result in unidentified abuse in the facility and a failure to protect residents from 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 admitting diagnoses that included acute respiratory failure (a condition where the lungs can't get enough oxygen into the blood), dependence on a ventilator (a machine or device used to support or replace a person's breathing), chronic pain syndrome (persistent pain that lasts weeks to years), and aphasia (a language disorder that affects a person's ability to communicate). During a review of Resident 1's History and Physical (H&P), dated 3/10/23, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. Durinag a review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 6/8/23, the MDS indicated Resident 1 had severely impaired cognition (an impaired ability to remember things or make decisions that affect everyday life, the loss of the ability to understand the meaning or importance of things, and the inability to talk or write). The MDS further indicated Resident 1 had total dependence on staff and required one- to two- person physical assistance with movement in his bed, getting dressed, eating, toileting, and performing activities of personal hygiene. The MDS indicated Resident 1 had impairments on both sides of the body to his upper and lower extremities which interfered with Resident 1's daily functions. During aA review of Resident 1's radiology report, dated 8/16/23, the radiology report indicated Resident 1 had a fracture (broken bone) to the mid patella (a flat bone that protects the front of the knee joint), and indicated the fracture appears recent . During a review of Resident 1's Change of Condition Assessment Form (COC), dated 8/16/23, documented by the Registered Nurse Supervisor (RNS), the COC indicated the radiology report indicating Resident 1's mid patella fracture was received by nursing staff on 8/16/23 at 1:50 PM and Medical Doctor (MD) 1 was notified. The COC further indicated the RNS contacted MD 1 again at 3:00 PM, because she had not been able to reach MD 1. The COC indicated that at 4:00 PM, the RNS received a call from MD 1 ordering Resident 1 to be transferred to the general acute care hospital (GACH) for further evaluation. During a review of Resident 1's H&P from the GACH, dated 8/17/23, documented by MD 1, the GACH H&P indicated the left knee was warm, swollen with .ecchymosis (bruising) in the frontal portion of the knee . The GACH H&P indicated [Resident 1] has unexplained fracture of the left patella, trauma . During an observation in Resident 1's room on 8/31/23 at 12:23 PM, observed Resident 1 lying in bed and connected to a ventilator. Resident 1 did not make eye contact when spoken to. Resident 1 moved his head and was not observed independently moving any extremities. During an interview on 8/31/23 at 1:42 PM, with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 1 did not move on his own and required staff assistance with all care. CNA 2 stated she identified Resident 1's left knee was red and swollen on 8/15/23, and reported it immediately to the licensed staff assigned to Resident 1, including the RNS. During an interview on 8/31/23 at 2:55 PM, with the RNS, the RNS stated she was familiar with Resident 1 and stated Resident 1 did not follow commands and could not communicate with staff. The RNS stated after the redness and swelling of Resident 1's left knee was reported to her by CNA 2, MD 1 was notified, and a radiograph (a type of medical imaging that creates pictures of your bones) was ordered. The RNS stated the radiograph identified Resident 1 had a fractured left knee. The RNS stated that fractures needed to be reported for possible abuse, and stated she was unsure of whether Resident 1's fracture was reported. The RNS stated injuries of unknown origin needed to be reported to rule out any possibility of abuse and stated that not reporting increased the risk that additional abuse could occur. During an interview on 8/31/23 at 3:17 PM, with the Clinical Care Coordinator (CCC), the CCC stated she was responsible for overseeing the care of the residents on the unit where Resident 1 resided. The CCC stated that on 8/16/23, the day the fracture was identified and reported to the nursing staff, nursing staff also observed bruising to Resident 1's left knee that had not been present when the radiograph was ordered on 8/15/23. The CCC stated that these injuries were reported to MD 1 but had not been reported to any outside agencies, including CDPH or law enforcement. During an interview on 8/31/23 at 4:09 PM, with the Director of Staff Development (DSD), the DSD stated all injuries of unknown origin were reported, and stated they should be reported immediately, and not later than two hours after they were identified. The DSD stated all staff were mandated reporters and required to report. The DSD stated the purpose of reporting injuries of unknown origin was to investigate and rule out abuse, and to prevent additional abuse from happening. The DSD stated if abuse or injuries of unknown origin were not reported, there was the potential that additional abuse could happen to the same resident or other residents in the facility. During an interview on 9/1/23 at 12:30 PM, with the Assistant Director of Nursing (ADON), the ADON stated injuries of unknown origin should be reported within two hours after they were identified. The ADON stated Resident 1's fracture was considered an unusual occurrence and was of unknown origin. The ADON stated the fracture had not been reported and should have been. The ADON then stated that if not reported, there was potential that the incident could re-occur, and Resident 1 and other residents could be harmed. During a review of the facility's policy and procedure (P&P) titled, Abuse and Mistreatment of Residents , undated, the P&P indicated, the facility shall institute procedures of identifying unusual occurrences and events, such as suspicious bruising of residents, .fractures, etc., which may constitute abuse . The P&P further indicated the facility shall report the incident by notifying the CDPH within two hours of the knowledge of such incident . During a review of the facility's P&P titled, Reporting , undated, the P&P indicated the facility shall ensure reporting of all alleged and substantiated violations to the state agency and all other agencies as required , and the facility shall report the incident by notifying the CDPH and local law enforcement no later than 2 hours .if the event .result in serious bodily injury .

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the bed was in a low position, with a fall mat...

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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 bed was in a low position, with a fall mat at the bedside, for one of three sampled residents (Resident 2), who was at risk for falls. This deficient practice had the potential to cause avoidable harm to Resident 2 from falling onto the floor from an elevated height and landing onto the floor without a fall mat in place. 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 hemiplegia (inability to move one side of the body) and hemiparesis (muscle weakness on one side of the body) affecting Resident 2's left side of the body, and legal blindness. During a review of Resident 2's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 7/19/23, the MDS indicated Resident 2 required limited, one-person physical assistance from staff for transfers between surfaces (e.g. moving from the bed to a wheelchair or from the bed to a chair) and movement within the facility. The MDS indicated Resident 2 required extensive, one-person physical assistance from staff to get dressed, use the bathroom, and perform activities of personal hygiene. During a review of Resident 2's care plan (a tool that summarizes a person's health conditions, specific care needs, and current treatments), dated 7/26/23, the care plan indicated Resident 2 experienced a fall in the facility related to decreased strength, poor safety awareness/judgement, unsteady gait, and visual deficits. The staff's interventions for preventing further falls and potential injuries, included keeping the resident's bed in a low position. During a review of Resident 2's Physician's Orders, dated 7/26/23, the orders indicated low bed .with floor mat to decrease potential injury . During a concurrent observation and interview with Resident 2, at Resident 2's bedside, on 9/1/23 at 10:37 AM, Resident 2 was observed lying in bed with no fall mats at the bedside. Resident 2 stated he recalled falling twice while in the facility and that he could not see well. Certified Nursing Assistant (CNA) 3 was at Resident 2's bedside and stated she was unaware Resident 2 had fallen in the past and stated there were no current fall precautions in place for Resident 2. During a concurrent interview and record review on 9/1/23 at 10:45 AM, with Licensed Vocational Nurse (LVN) 3, Resident 2's Physician's Orders were reviewed. LVN 3 stated Resident 2 recently fell in the facility. LVN 3 stated interventions were being implemented to prevent additional falls and potential injury, including keeping Resident 2's bed in a low position and keeping fall mats at the bedside. LVN 3 stated there a physician's order to keep Resident 2's bed in a low position and place fall mats at the bedside. During a concurrent observation and interview, at Resident 2's bedside, on 9/1/23 at 10:46 AM, LVN 3 verified there were no fall mats at Resident 2's bedside. When asked if Resident 2's bed was in a low position, LVN 3 stated Resident 2's bed was not in a low position and proceeded to lower Resident 2's bed. LVN 3 stated that not keeping the bed in a low position or having fall mats at the bedside created a risk for falls and injuries to Resident 2. During an interview on 9/1/23 at 12:30 PM, with the Director of Nursing (DON), the DON stated that fall precautions included keeping the residents' beds in a low position and using fall mats at the bedside to minimize potential injury from a fall. The DON stated not implementing these interventions, especially if ordered by the physician, created a higher risk for falls and injury to the facility residents. During a review of the facility's policy and procedure (P&P) titled, Promoting Safety, Reducing Falls , undated, the P&P indicated major risk factors for falls included a history of falls and gait and balance disturbances. The P&P further indicated staff should always make sure that beds are in the lowest position to the floor . During a review of the facility's P&P titled, Safety and Supervision of Residents , dated 7/2017, the P&P indicated that an individualized and resident-centered approach to safety included ensuring that interventions are implemented to reduce accident risks and hazards.

CONCERN (D) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, Licensed Vocational Nurse (LVN) 2 failed to implement infection control meas...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, Licensed Vocational Nurse (LVN) 2 failed to implement infection control measures for one of three sampled residents (Resident 3), when the following occurred: 1. LVN 2 did not perform hand hygiene (cleaning one's hands by washing hands with soap and water or antiseptic hand rub [i.e. alcohol-based hand sanitizer]) prior to or after providing direct patient care to Resident 3. 2. LVN 2 did not don (put on) the required personal protective equipment (PPE, specialized clothing or equipment worn by an employee for protection against infectious materials) while providing care to Resident 3, who required enhanced standard precautions (ESPs, a resident-centered and activity-based approach for preventing transmission of multi-drug resistant organisms [MDROs] in skilled nursing facilities [SNFs]). These deficient practices had the potential to spread disease-causing pathogens from one resident to another, and from facility staff to residents, causing avoidable infections in both residents and staff. Findings: During a review of Resident 3's admission Record, the admission record indicated Resident 3 was initially admitted to the facility on [DATE], and last readmitted on [DATE] with diagnoses that included urinary tract infection (UTI, infection of the bladder). During a review of Resident 3's Minimum Data Set (MDS, a standardized assessment and screening tool), dated 7/25/2023, the MDS indicated Resident 3 had two venous and/or arterial ulcers (open sores that often form on the legs and feet resulting from damage to the blood vessels). During a review of Resident 3's Physician's Orders, dated 8/7/2023, the orders indicated enhanced standard precautions due to open wound . During an observation on 9/1/2023 at 10:25 AM, signage posted above Resident 3's bed indicated Resident 3 required staff to implement enhanced standard precautions (ESPs). The sign indicated staff were required to perform hand hygiene upon entry to the room, and don required PPE (gloves and a gown) when giving medical treatments or performing activities of daily living, such as feeding. During an observation on 9/1/2023 at 10:28 AM, LVN 2 entered Resident 3's room wearing a pair of gloves and carrying a glucometer (a small, portable machine used to measure the amount of sugar in the blood). LVN 2 was not wearing a gown. LVN 2 obtained a blood specimen from Resident 3 while wearing the gloves. LVN 2 then exited Resident 3's room while wearing the same gloves. LVN 2 disposed of her gloves in a trash receptacle attached to the Station 1 medication cart outside of Resident 3's room. LVN 2 did not perform hand hygiene after removing her gloves. LVN 2 then removed Resident 3's insulin pen (a prefilled syringe containing insulin [a medicine to treat high blood sugar]) from the Station 1 medication cart. LVN 2 then donned a new pair of gloves without performing hand hygiene and entered Resident 3's room. LVN 2 was not wearing a gown. LVN 2 administered insulin into Resident 3's right arm with gloves on, then exited Resident 3's room with the same gloves on. LVN 2 disposed of the gloves outside of the room and did not perform hand hygiene. LVN 2 then touched a pitcher of juice on top of the medication cart and poured a cup of juice for Resident 3. LVN 2 then re-entered Resident 3's room without a gown or gloves on and gave the cup of juice to Resident 3. LVN 2 did not perform hand hygiene before entering the room or before handing the juice to Resident 3. During an interview on 9/1/2023 at 10:32 AM, with LVN 2, LVN 2 stated she did not wear a gown while providing care to Resident 3 because it was not needed. When asked about the signage posted at Resident 3's bedside indicating the need for ESPs, LVN 2 stated the signage did not apply to Resident 3. LVN 2 stated only gloves were required while providing patient care to Resident 3. LVN 2 then stated hand hygiene was supposed to be performed prior to and after providing patient care. LVN 2 stated she did not perform hand hygiene prior to and after providing patient care to Resident 3. LVN 2 stated this was an infection risk to the facility residents. During a concurrent interview and record review on 9/1/2023 at 10:55 AM, with the Infection Prevention Nurse (IPN), the IPN stated she was responsible for posting signage related to ESPs and stated the purpose of implementing ESPs was for infection prevention and control in the facility. The IPN stated ESPs were implemented for residents who had open wounds. The IPN then stated that if ESPs were not required, hand hygiene should still be implemented to prevent the spread of infection between facility residents and staff. The IPN stated that ESPs require staff to wear a gown and gloves when administering medications and when checking residents' blood sugar levels. The IPN reviewed Resident 3's physician orders and stated Resident 3 had active orders for ESPs, stating they were ordered because Resident 3 had open wounds. The IPN stated that if ESPs were not implemented and hand hygiene was not performed, there was risk of spreading infection between residents. During a review of the facility's policy and procedure (P&P) titled, Hand Washing , undated, the P&P indicated the hand washing must be performed before and after direct care of individual patients and in between performance of routine procedures (i.e .collecting specimens) .

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed provided one-on -one supervision to prevent one of three sampled resid...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed provided one-on -one supervision to prevent one of three sampled residents (Resident 2), who had a history of inappropirately touching a female resident from entering another resident's room (Resident 1) without permission from the staff as indicated in Resident 2's care plan. This deficient practice resulted in Resident 2 entering Resident 1 ' s room at night and was accused of raping Resident 1. Findings: 1.During a review of Resident 1 ' s admission Record (face sheet), the face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a disorder in the brain that can lead to personality changes), epilepsy (a disorder in the brain that causes recurring seizures), bipolar (a disorder associated with episodes of mood swing), anxiety disorder (a disorder associated with feeling of worries and fear) and schizoaffective disorder (a mental health condition where one experiences psychosis as well as mood symptoms). During a review of Resident 1 ' s Minimum Data Set [(MDS] a standardized assessment and care screening tool), dated 7/7/2023, the MDS indicated Resident 1 had the ability to understand and to be understood by others. The MDS indicated Resident 1 required Limited assistance with activities of daily living ([ADL] daily self-care) like dressing, eating and personal hygiene. 2. During a review of RT 2 ' s facesheet, the facesheet indicated RT 2 was admitted to the facility on [DATE] with diagnoses including schizophrenia (a disorder that affects a person ' s ability to think, feel, and behave clearly), osteomyelitis (infection of the bone) of right ankle and right foot, and absence of left upper limb and absence of left leg. During a review of RT 2 ' s MDS dated [DATE], the MDS indicated RT 2 had the ability to understand and be understood by others. The MDS indicated RT 2 required limited assistance with transfer, mobility, and dressing. During a review of RT 2 care plan titled Resident was accused of allegedly inappropriately touching a female resident dated on 6/5/2023, the interventions indicated to monitor RT 2 closely by providing one on one sitter. The interventions indicated RT 2 will not be allowed to other residents ' rooms without permission from the resident and the licensed nurse in change. During a review of the facility ' s Final Report dated 7/24/2023, the report indicated on 7/20/2023 at approximately 5:15am, RT 1 reported to a Certified Nursing Assistant (CNA 1) that RT 2 came into her room at about 2am and raped her. The report indicated the facility completed the investigation and concluded the allegation was unsubstantiated with the absence of the rape kit test results. The report indicated RT 1 was not consistent with her statement because she told the psychiatrist that RT 2 only attempted to rape her, and requested to return to the facility after her rape kit test was done at a general acute care hospital (GACH). According to the report, RT 3 stated, RT 2 asked RT 1 to come out of the room and when RT 1 declined, RT 2 left. The report also indicated, RT 3 did not witness any physical contact between RT 1 and 2. 3. During a review of RT 3 ' s facesheet, the facesheet indicated RT 3 was admitted to the facility on [DATE] with diagnoses including hypertension (high blood pressure) and cocaine abuse. During a review of RT 3 ' s history and physical (H/P) dated 11/18/2022, the H/P indicated RT had the capacity to understand and make decisions. During a review of RT 3 ' s MDS, the MDS indicated RT 3 could understand and be understood by others. During an interview on 7/21/2023 at 10:26 a.m., with Resident 1, (RT 1) RT 1 stated on 7/20/2023, Resident 2 came to her room at night and raped her. RT 1 stated RT 2 could have chocked her to death while he was on top of her. RT 1 stated RT 2 held her around the neck. During an interview on 7/21/2023 at 11:36 a.m., with Rt 3 (RT 1 ' s roommate), Rt 3 stated on 7/20/2023, Rt 2 came to their room two times at night and spoke with Resident 1. RT 3 after speaking with RT 1, RT 2 left. Rt 3 stated that she did not witness any rape. During an interview on 7/21/2023 at 12:00 p.m., with RT 2, RT 2 stated On 7/20/2023, he went to RT 1 ' s room two times during the night. The first time, he went to ask RT 1 for a cigarette and the second time was to ask her to come out so they could talk. RT 2 refused inappropriately touching or raping RT 1. During a review of the facility ' s video camera footage on 7/21/2023, in the presence of the Director of Nursing (DON), on 7/20/2023 at 11:00 p.m., RT 2 was observed wheeling himself in a wheelchair towards RT 1 ' s room. At 11:15 p.m., RT 2 was seen wheeling himself away from Rt 1 ' s room. At 1:27 a.m., RT 2 was observed with two other residents in the patio smoking. There was no staff in the patio at that time. At 1:36 a.m., RT 2 wheeled himself towards RT 1 ' s room, and at 1:56 a.m., he wheeled himself away from resident 1 ' s room. During an interview on 8/3/2023 at 10:35 a.m., with Licensed Vocational Nurse (LVN 2), LVN 2 stated she was aware RT 2 was accused of inappropriately touching a female resident, several weeks ago. LVN 2 Stated RT 2 was place on one-on-one monitoring for 72 hours during the investigation and after the investigation was completed, the allegation was not substantiated. LVN 2 stated RT 2 was place back on monitoring every 2 hours. LVN 2 stated she was not aware of the care plan indicating RT 2 was not allowed to enter other residents ' rooms without permission from licensed nurses. LVN 2 stated the cut off time for residents to go out and was 10:00 p.m., and residents were supposed to be monitored during smoking. During a review of the facility ' s policy and procedure (P&P) titled, Safety and Supervision of Residents dated July 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. During a review of the facility ' s P&P titled, Smoking dated July 2017, the P&P indicated, to ensure the safety of all residents, the designated smoking area will be under periodic observation by the facility staff.

Jun 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0573 (Tag F0573)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a copy of the medical records upon written request from an ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a copy of the medical records upon written request from an authorized representative for one of three sampled residents (Resident 1). This deficient practice violated the rights of Resident 1's Representative (Rep) 1 to obtain a copy of the resident's medical records. Findings: During a record review of Resident 1's Face Sheet, dated 6/14/2023, the face sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1 had an admission diagnosis of pneumonia (an infection of the lung). During a record review of Resident 1's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 11/24/2022, the MDS indicated Resident 1's cognitive decision-making was moderately impaired (ability to think and reason). The MDS indicated Resident 1 required extensive assistance (staff provides weight -bearing support) for personal hygiene. During an interview on 6/14/2023, at 9:03 a.m. with Medical Records Assistant (MRA) 1, MRA 1 stated the facility had 2 business days to submit records requested from residents or representatives after a written request for release of records. MRA 1 stated he had trouble submitting the requested records to Rep 1's Legal Representative (LR) 1 via e-mail so he asked MDS Coordinator (MDSC) 1 to assist him. During an interview on 6/14/2023, at 1:30 p.m., with MDSC 1, MCSC 1 stated he submitted the medical records to LR 1 on 6/12/2023 via email. During an interview on 6/14/2023, at 2 p.m., with Medical Records Supervisor (MRS) 1, MRS 1 stated if a resident was discharged , the facility had 5 working days to submit medical records upon written request. During an interview on 6/14/2023, at 2:23 p.m., with MRA 1, MRA 1 stated he received the request for Resident 1's records from Rep 1 on 5/17/2023. MRA 1 stated his previous supervisor, Medical Records Supervisor (MRS) 2 was assigned to the matter but resigned without notice on 5/26/23. MRA 1 stated when MRS 2 resigned there was no endorsement of Rep 1's request for medical records. During an interview on 6/14/2023, at 4 p.m., with the Director of Nursing (DON), the DON stated MRS 2 recently resigned 5/2023. The DON stated there should have been a contingency plan in the interim for medical record requests because it was the residents' rights to have access to their records. During a record review of the document titled Patient Request for Access to Protected Health Information, dated 5/10/2023, the document indicated Rep 1 requested Resident 1's physician's orders, medication administration records, and progress notes from 2016 to 11/25/2023. During a record review of the facilities policies and procedures (P&P), titled Requests for access to PHI (personal health information), revision date 6/11/2022, the P&P indicated, the facility will provide the resident representee with a copy of the personal health information (PHI) upon 15 days of receiving the written request.

Apr 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the license staff did not monitor potassium (an essential mineral in the body) levels in t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the license staff did not monitor potassium (an essential mineral in the body) levels in the blood for one of three sampled residents (Resident 1), as indicated in the care plan interventions. This deficient practice resulted in Resident 1 requiring hospitalization in a general acute care hospital (GACH) for hyperkalemia (high potassium levels in the blood). Findings: During a review of Resident 1's Face sheet (admission record), the face sheet indicated Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 1's diagnoses included Pneumonia (infection in the lungs), diabetes ([DM]-abnormalblood sugar), and hypertension ([HTN] high blood pressure). During a review of Resident 1's history and physical (H&P) dated 8/6/2022, 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 standardized care assessment and screening tool), dated 11/24/2022, the MDS indicated Resident 1's cognitive skills (thought process) was moderately impaired. The MDS indicated Resident 1 could understand and be understood by others. The MDS indicated Resident 1 required extensive assistance from one to two persons with activities such as dressing, toilet use, personal hygiene, transfer (moving between surfaces to and from bed, chair, and wheelchair) and bed mobility (how the resident moves from lying to turning side to side). The MDS indicated Resident 1 was always incontinent of bowel and bladder. The DS also indicated Resident 1 was dependent on a wheelchair for mobility. During a review of Resident 1's physician order dated 7/7/2022, the physician order indicated Dyazide (medication that treats high blood pressure) capsule 37.5-25 milligrams ([mg] unit of measurement), once a day for high blood pressure. During a review of Resident 1's care plan for potassium dated 12/3/2021, the care plan indicated Resident 1 was at risk for altered potassium levels due to laxative use and the use of Dyazide. Resident 1's care plan interventions indicated to follow protocol for labs as ordered. During a review of Resident 1's care plan for adverse effects from black box medication (high alert medications that can cause serious safety risks) Dyazide, dated 6/17/2021, the care plan indicated hyperkalemia (high potassium levels in the blood) can occur and is more likely in residents with renal (kidney) impairment, diabetes, and in the elderly or severely ill. Resident 1's care plan interventions indicated to monitor for potential risks and effects, and alert medical doctor (MD) when indicated. During a review of Resident 1's change in condition (COC) report dated 11/24/2022, the COC indicated during the morning assessment, Resident 1 was weak, unable to feed himself, refused to eat breakfast, was slow to respond, sleepy, and confused. The COC indicated Resident 1 was noted with low blood pressure and Resident 1 was transferred to a GACH for altered mental status (confusion), and generalized body weakness. During a review of Resident 1's GACH emergency department (ED) physician progress notes dated 11/24/2022, the physician progress notes indicated Resident 1 had severe metabolic acidosis (a buildup of acid in the body), significant anemia (low red blood cells), acute kidney injury (a condition in which the kidneys suddenly stop filtering waste) with hyperkalemia. During a review of Resident 1's potassium laboratory results from GACH dated 11/24/2022, the lab results indicated Resident 1's potassium level upon admission was 5.6 (normal range is 3.5-5.0) milliequivalents per liter ([mEq/L] unit of measurement). During an interview on 4/27/2023 at 11:03 a.m. with License Vocational Nurse (LVN) 1, LVN 1 stated, the importance of a care plan was to monitor a resident's condition and come up with interventions. LVN 1 stated it was important to follow the care plan interventions to improve the quality of life in a resident. LVN 1 stated if the care plan interventions were not followed, the resident was at risk for life threatening conditions. LVN 1 stated she was unsure why Resident 1's potassium level was not being monitored and she did not know Dyazide placed Resident 1 at risk for high potassium levels. During a concurrent interview and record review with the Assistant Director of Nursing (ADON) on 4/27/2023 at 12:25 p.m., Resident 1's care plans for potassium and adverse effects from black box warning medication was reviewed. The ADON stated if care plan interventions were not followed, the patient could suffer a life-threatening condition. The ADON stated Resident 1's potassium blood levels should have been monitored at least once a month or as needed due to Resident 1's increased risk for altered potassium levels. During a review of the facility's undated policies and procedures (P&P) titled Laboratory Tests , the P&P indicated unless a specific date for laboratory tests is ordered, laboratory tests will be completed by month's end.

Apr 2023 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and procedure (P&P) for out on a pass (OOP- a t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow their policy and procedure (P&P) for out on a pass (OOP- a temporary pass to leave the facility), by not providing a sign in/sign out book at the nurse's station for two of three residents (Residents 1 and 2). This deficient practice had the potential to place Resident 1 and Resident 2 at risk for harm and jeopardize the resident's health. Findings: During a review of Resident 1's admission record (Face sheet), the face sheet indicated Resident 1 was admitted on [DATE] with a diagnosis that included seizures (abnormal electrical activity in the brain), opioid dependence (physical dependence on opioid), and end stage renal disease (ESRD-Kidney failure). During a review of Resident 1's history and physician (H&P), dated 3/24/2023, 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 standardized care assessment and care screening tool), dated 2/10/2023, the MDS indicated Resident 1's cognitive skills (thought process) was intact and could understand and be understood by others. The MDS indicated Resident 1 required limited assistance with one person assist with activities such as dressing, and personal hygiene. The MDS indicated Resident 1 was independent with activities such as eating, toilet use, bed mobility, and transfer (moving between surfaces to and from bed, chair, and wheelchair). The MDS indicated Resident 1 was dependent on a wheelchair for mobility. During a review of Resident 1's physician orders dated 1/27/2023, the physician orders indicated Resident 1 may go OOP daily for 3-4 hours. During a review of Resident 1's care plan OOP with an initiation date of 7/19/2022, the OOP interventions indicated resident will be instructed to inform charge nurse when leaving the facility and to complete and sign the OOP booklet indicating date, time and destination. During an interview on 4/6/2023 at 1:20 p.m. with Resident 1, Resident 1 stated he did not sign a log sheet that indicated what time he left the facility, when he returned, or the destination. Resident 1 stated when he leaves OOP he informs the nurses that he is leaving. During a review of Resident 2's admission record (Face sheet), the face sheet indicated Resident 2 was admitted on [DATE] with a diagnosis that included paraplegia (paralysis of the lower body), anemia (lack of red blood cells), and muscle spasms of back (involuntary contractions of muscles). During a review of Resident 2's history and physician (H&P), dated 8/25/2022, the H&P indicated Resident 2 had the mental capacity to understand and make medical decisions. During a review of Resident 2's MDS dated [DATE], the MDS indicated Resident 2's cognitive skills (thought process) was intact and could understand and be understood by others. The MDS indicated Resident 2 required limited assistance with one person assist with activities such as dressing, and personal hygiene. The MDS indicated Resident 2 was independent with activities such as eating, toilet use, bed mobility, and transfer (moving between surfaces to and from bed, chair, and wheelchair). The MDS indicated Resident 2 was dependent on a wheelchair for mobility. During a review of Resident 2's physician orders dated 1/27/2023, the physician's orders stated Resident 2 may go OOP daily for 3-4 hours. During an interview on 4/6/2023 at 2:00 p.m. with Resident 2, Resident 2 stated he did not sign a log sheet that indicated what time he left the facility, when he returned, or the destination. Resident 2 the nurses have never asked him to sign in and out of the facility. During an interview on 4/6/2023 at 1:51 p.m. with license vocational nurse 1 (LVN 1), LVN 1 stated when residents leave OOP, she documented on the nursing progress notes (NPN) the time and date the resident left and the time and date the resident returned. LVN 1 stated she was not familiar with the OOP policy that indicated a book must be kept at the nurse's station where residents leaving OOP sign in and sign out. During an interview on 4/6/2023 at 1:57 p.m. with LVN 2, LVN 2 stated when a resident leaves OOP, she documented on the NPN the time and date the resident left and the time and date the resident returned. LVN 2 stated she was not informed that that the OOP policy indicated a book must be kept at the nurse's station where residents leaving OOP sign in and sign out. During a concurrent interview and record review with the director of nursing (DON), the facility's P&P for OOP was reviewed. The DON stated the facility did not keep a binder available to residents who have orders to go OOP to sign in and sign out. The DON stated he was unaware the policy indicated a binder must be kept at the nurse's station for residents who leave OOP. The DON stated it was important to keep a current log of all residents who leave OOP for safety purposes so that staff are able to keep track of the resident's outings, the time the residents leave the facility, and the time the residents returned. During a review of the facility's undated P&P titled Out on a Pass , the P&P indicated residents/responsible party will be asked to sign out-on-pass book at nurses' station to indicated date, time, and destination of out-on-pass.

Apr 2023 1 deficiency 1 Harm

SERIOUS (G) 📢 Someone Reported This

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

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to inspect residents' bedrails routinely per the bed manufacturer's r...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to inspect residents' bedrails routinely per the bed manufacturer's recommendations to prevent one of three sampled residents (Resident 1), from falling from the bed to the floor during care. As a result, Certified Nursing Assistant (CNA) 2, while providing care to Resident 1, turned the resident toward her (CNA 2), the side rail broke, and Resident 1 fell to the floor and sustained a fracture (broken bone) to her left femur (long bone in the upper leg). Findings: During a review of Resident 1's Face sheet (admission Record), the face sheet indicated Resident 1 was admitted to the facility on [DATE]. Resident 1's diagnoses included obstructive pulmonary disease ([COPD] a disease that causes airflow blockage and breathing-related problems), hemiplegia (paralysis of one side of the body) and hemiparesis (muscle weakness) following cerebral infarction (brain injury caused by the interruption of blood flow to part of the brain) affecting left nondominant side, and osteoarthritis (a disorder that happens when the cartilage in the joints breaks down over time, causing pain during movement). During a review of Resident 1's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 9/22/2022, the MDS indicated Resident 1 was rarely able to understand or be understood by others. The MDS indicated Resident 1 required a one person assist with bed mobility, locomotion (movement between locations), dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident 1 was a two person assist with transfers from bed to chair or chair to a standing position. During a review of Resident 1's Fall Risk assessment dated [DATE], the fall assessment indicated Resident 1 was at high risk for falls. During a review of Resident 1's History & Physical (H&P) dated 10/11/2022, the H&P indicated Resident 1 did not have the capacity to understand and make decisions. During a review of Resident 1's Care Plan titled Resident is at risk for falls/injury dated 7/22/2019, the care plan intervention indicated the facility was to provide safety instructions to Resident 1 regarding transfers and activities of daily living when appropriate. During a review of Resident 1's Interdisciplinary team ([IDT], a team of clinicians from different disciplines, working together for the resident's benefit) notes dated 10/22/2022, at 4:01 p.m., the IDT indicated per Resident 1's doctor, Resident 1 was at risk for pathological (caused by disease) fracture related to demineralization of the bone (loss of minerals from a person's bones that makes them more prone to fracture) or possible inflammation (swelling) of the bone due to osteoarthritis. During a review of Resident 1's Radiology ([x-ray] series of tests that take pictures or images of parts of the body) Report dated 10/22/2022, the radiology report indicated Resident 1 had an acute left subcapital neck (fracture line that extends through the junction of the head and neck of femur) fracture. During a review of Resident 1's Change of Condition (COC), dated 10/22/2022 at 6:55 a.m., the COC indicated on 10/22/2022, at 5:55 a.m., CNA 2 was rendering care to Resident 1 when CNA 2 turned Resident 1 towards herself, Resident 1 slid from the bed. The COC indicated CNA 2 was unable to break the fall due to Resident 1's weight and the resident fell on her left side. During a review pf Resident 1's Incident Report dated 10/23/2022, the incident report indicated Resident 1 had a witnessed fall with injury. The incident report indicated CNA 2 provided care to Resident 1 when the accident occurred, and CNA 2 attempted to hold and prevent Resident 1 from falling but was unsuccessful. During a review of Resident 1's General Acute Care Hospital (GACH) consultation report, dated 10/24/2022, the GACH report indicated Resident 1 was not a candidate for surgical intervention for the fractured femur. The GACH report indicated Resident 1 was monitored for pain and referred to physical therapy (field of medicine that improves mobility, restores function, reduces pain, and prevents further injury by using a variety of methods, including exercises, and stretches) for evaluation and treatment. During a telephone interview on 12/28/2022 at 7:40 a.m., with a CNA 2, CNA 2 stated on 10/22/2022 at 5:55 a.m., during morning care, CNA 2 told Resident 1 to hold on to the bed rail for support and to turn to her right side towards the window and away from CNA 2. CNA 2 stated she (CNA 2) continued to clean Resident 1 and placed the chuck (bed pads that protected beds and other surfaces from bodily fluids) underneath Resident 1's buttock, the right-side bedrail went down and caused Resident 1 to roll off the bed to her left side. CNA 2 stated she observed the bedrail was broken. During a concurrent interview and record review on 12/29/2022 at 10:53 a.m., with the Maintenance Supervisor (MS), the facility's maintenance logs dated January 2022 to December 2022 were reviewed. The logs did not indicate residents bed rails were cleaned and checked. The MS stated he did not routinely check bedrails because bed rails were usually up. The MS stated bedrails were only checked if something was wrong with the bedrails. The MS stated he fixed Resident 1's bedrail after he was notified by CNA 2 the day Resident 1 fell approximately two months ago. The MS stated on 10/2022, after Resident 1's fall, CNA 2 notified him (MS) Resident 1's bed rail was not locking properly, and the bedrail would fall when pressure was put on the bed rail. The MS stated he observed the right side of Resident 1's bedrails was not locking because the black lock latch underneath the bedrail was not attached properly. The MS stated the bedrail latch was displaced and made the bedrail malfunction when a lot of pressure was placed on the bedrail. The MS stated he did not have the owner's manual for the bed or bedrails and did not know how often the bed rails should be checked. During an email correspondence from a representative (Rep) of the Resident 1's bed manufacturer dated 12/30/2022 at 8:53 a.m., the email indicated residents' bedrails were not designed to support residents with lifting themselves in bed or as a support to get in and out of bed. The bedrails could be used for slight adjustments or movements but never for the sole purpose of support or movement because it could cause the bedrails to break. The email indicated for residents requiring extra support, trapeze bars (a gymnastic or acrobatic apparatus consisting of a short horizontal bar suspended by two parallel ropes) should be used. The email also indicated bedrails were to keep residents from falling out of bed and the nuts, bolts and screws should be checked often to make sure everything was tight and secured. During a review of an undated manufacturer's manual for residents' beds, the manual indicated to check monthly that all screws were tight and not loosened and inspect monthly for signs of cracking, frame, or any deterioration. The manual indicated regular maintenance of bed and accessories were required to ensure proper operation. The manual also indicated casters (set of small wheels fixed to the legs or base of a heavy piece of furniture so that it could be moved easily) and axle bolts (screws) were to be checked for tightness. During a telephone interview on 2/8/2023 at 11:44 a.m., with the MS, the MS stated it was important to perform maintenance on residents' beds and accessories for safety and to prevent accidents. The MS stated he should have followed the manufacturer's manual for safety checks. The MS stated he only had basic knowledge on how to maintain residents' beds and accessories. During an interview on 2/8/2023 at 4:58 p.m., with the Director of Nursing (DON), the DON stated bedrails were considered an assistive device during incontinent care because a resident could hold on to the bedrail for support. The DON stated if the manufacturer's recommendations were not followed, it could cause residents to have accidents such as falls and fractures. The DON stated it was very important to perform maintenance on residents' beds including bedrails according to the manufacturer's manual for residents' safety. During a telephone interview on 2/9/2023 at 7:24 a.m., with the Director of Rehabilitation (DOR), the DOR stated before Resident 1's fracture she had full Range of Motion ([ROM] movement at a given joint in a specific direction) to her left and right hip that consisted of bending the hips more than 90 degrees (unit of measurement) and rotating her hips. The DOR stated after Resident 1's accident on 10/22/2022, Resident 1 did not have full ROM to the left hip compared to her right hip. The DOR stated he did not expect Resident 1 to have full ROM to her left hip anytime soon because the resident's left hip was broken and unstable. The DOR stated Resident 1 was at risk for loss of ROM and contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to her left hip because Resident 1 was not ambulatory and not able to perform full ROM due to the fracture. The DOR stated the benefits of full ROM to joints was to prevent contractures. During a review of the facility's undated policy and procedures (P&P) titled Pathological/spontaneous Fractures- Reducing Risks, the P&P indicated a pathological fracture occurred when a bone breaks in an area weakened by another disease process. The P&P indicated reducing risks included two- people or lift transfer/re- positioning as needed. During a review of the facility's undated P&P titled Promoting Safety, Reducing Falls, the P&P indicated by simply focusing on fall preventions, caregivers can enhance the quality of life for residents, promote their independence, maintain their highest practical level of functioning. The P&P indicated the caregivers should inspect assistive devices routinely to make sure they are in good repair and working order with no missing or loose parts. During a review of the facility's undated P&P titled Equipment, the P&P indicated the facility will provide equipment for care of residents in the amount necessary to meet anticipated needs of the resident. The P&P indicated other equipment will be provided on a dedicated- patient basis. The P&P further indicated the equipment will be clean, maintained, and replaced as needed.

Apr 2023 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Treatment Nurse (TN 1) changed gloves and perfo...

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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 Treatment Nurse (TN 1) changed gloves and performed hand hygiene (cleaning hands by handwashing or using alcohol-based hand sanitizer) after removing soiled dressings and prior to applying clean dressings for two of four residents (Resident 1 and 3) during wound care. This deficient practice had the potential to result in cross contamination (transfer of harmful bacteria from one place to another), wound infection and a delay in wound healing for Residents 1 and 3. Findings: During a review of Resident 1 ' s Face Sheet (admission Record), the Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] and re admitted on [DATE] with diagnoses including respiratory failure (lungs could not get enough oxygen into the blood), traumatic subarachnoid hemorrhage (bleeding in the space between the brain and tissue covering the brain), metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood). During a review of Residents 1 ' s Minimum Data Set ([MDS], a standardized assessment and care screening tool) dated 3/13/23, the MDS indicated Resident 1 had severely impaired cognitive (thought process) skills for daily decision making and was totally dependent on staff for activities of daily living (ADL) such as bed mobility, transfer (how resident moves between surfaces including to or from bed), walking, eating, personal hygiene and toileting. During an observation of Resident 1 ' s wound care on 4/7/2023 at 9:46 a.m., in the resident ' s room, TN 1 was observed donning (putting on) gloves, removed soiled dressing from Resident 1 sacro coccyx (area around the lower back and tailbone) wound then proceeded to cleanse the wound with normal saline ([NS], a mixture of sodium chloride and water.), applied Santyl ointment (medicine that removes dead tissue from wounds so they can start to heal) with a gauze and covered the wound with an abdominal pad ([ABD], gauze pads used to absorb discharges from heavily draining wounds) without changing gloves nor performing hand hygiene. During an observation of Resident 3 ' s wound care on 4/7/2023 at 10:20 am., in Resident ' s 3 room TN 1 was observed donning gloves, removed Resident ' s 3 adult brief and soiled dressing from the resident ' s sacro coccyx wound then proceeded to cleanse the wound with NS, apply Santyl ointment, collagen pellets (absorbent topical dressing), and covered the wound with clean ABD pad without changing gloves nor performing hand hygiene. During an interview on 4/7/2023 at 1:00pm. with TN 1, TN 1 stated, she should have changed her gloves and performed hand hygiene after removing soiled dressings and prior to applying clean dressings for Residents 1 and 3, however she did not. TN 1 also stated, staff must change gloves and wash hands after removing old dressing and prior to applying clean dressings to prevent cross contamination and to keep the wounds clean. During an interview on 4/7/2023 at 1:30 p.m. with Infection Preventionist (IP), IP stated, when conducting wound dressing changes, nurses needed to remove dirty gloves, perform hand hygiene, apply new gloves, and proceed with applying clean dressing to residents. IP also stated, not following this practice could lead to wound infection, sepsis (life threatening complication of an infection), hospitalization, and death. During a review of the facility ' s policy and procedure (P&P) titled, Treatment Procedures for Different Wounds sites, undated, the P&P indicated, the facility ' s licensed staff should wash hands and put on clean gloves, remove old dressing(s) from one site only, wash hands and re-glove, apply ointments etc. if ordered and place clean dressing in place as indicated.

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected 1 resident

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

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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 their policy and procedure (P&P) titled, Resident Rights-Accommodation of Needs,' by failing to ensure: 1. Certified Nurse Assistants (CNAs) did not lay Residents 1 and 2 flat on the shower bed during their shower 2. CNAs did not spray water on the faces of Residents 1 and 3 when showering the residents. 3. CNAs were in-serviced upon hire and regularly on the use of shower beds and chairs. These deficient practices caused Resident 1 to have nightmares about drowning, and Residents 1 and 3 to refuse taking showers. It also had the potential to cause Residents 2 and 3 to decline having showers. Findings During a review of Resident 1's admission Record (face sheet), dated 3/3/2023, the face sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (a progressive disease where the immune system damages the protective covering of nerves, causing symptoms including vision loss, pain, fatigue, and impaired speech and coordination), anxiety disorder (an intense, excessive, and persistent worry and fear about everyday situations), and paraplegia (paralysis of the legs and lower body). During a review of Resident 1's Minimum Data Set ([MDS]), a standardized assessment and care screening tool, dated 1/5/2023, the MDS indicated Resident 1 was able to understand and be understood by others. The MDS indicated Resident 1 was totally dependent on staff for all activities of daily living (ADLs) like bathing, eating, and turning in bed. During an interview with Resident 1 on 3/2/2023 at 12:31 p.m., Resident 1 stated CNA 2 used a shower bed instead of a shower chair to shower Resident 1. Resident 1 stated she was placed flat on the shower bed and water was going up her nose. Resident 1 stated she felt like she was drowning. Resident 1 also stated she had nightmares that she was drowning for a couple nights after showering on the shower bed. Resident 1 stated she dreaded the next shower. Resident 1 stated no one explained why she needed a shower bed for showers. According to Resident 1 she was forced to use the shower bed. During a review of Resident 1's social service note (SSN), dated 2/23/2023, the SSN indicated Resident 1 had demanded to be put in a shower chair instead of a shower bed. The note indicated Resident 1 was agitated after the DSD explained the risks of the shower chair. The SSN indicated Resident 1 was not open to reviewing other options provided by the DSD. During a review of Resident 2's face sheet, dated 3/3/2023, the face sheet indicated Resident 2 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including transient ischemic attack (a temporary period of symptoms like those of a stroke caused by a temporary blockage of blood flow to the brain), muscle weakness (decreased strength in muscles), and pleural effusion (a buildup of fluid around the lungs). During a review of Resident 2's H&P, dated 10/26/2022, the H&P indicated Resident 2 was able to make decisions for ADLs. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 was able to understand and be understood by others. The MDS indicated Resident 2 was totally dependent on staff for bathing, toileting, and personal hygiene. During an interview with Resident 2 on 3/2/2023 at 1:54 p.m., Resident 2 stated she used a shower bed for showers. Resident 2 stated CNAs always place her completely flat on the shower bed during showers. Resident 2 stated she was unaware of any other positions for showering. During a review of Resident 3's face sheet, dated 3/3/2023, Resident 3 was admitted to the facility on [DATE] with diagnoses including paraplegia, polyneuropathy (malfunction of many peripheral nerves throughout the body), and urinary incontinence (loss of bladder control). During a review of Resident 3's H&P, dated 3/12/2022, the H&P indicated Resident 3 had the capacity to understand and make decisions. During a review of Resident 3's MDS, dated [DATE], the MDS indicated Resident 3 was able to understand and be understood by others. The MDS indicated Resident 3 required some physical help for bathing, toileting, and personally hygiene. During an interview with Resident 3 on 3/2/2023 at 2:26 p.m., Resident 3 stated she received a bed bath because she had a bad experience when a CNA sprayed water on her face during shower. Resident 3 stated after CNA sprayed water on her face, she refused having a shower since then and has only been having bed baths. During an interview with CNA 1 on 3/2/2023 at 2:09 p.m., CNA 1 stated the use of a shower chair, or a shower bed depended on each resident's condition. CNA 1 stated if a resident was not able to stay sitting up or was a fall risk, then CNAs would use a shower bed. CNA 1 stated when the resident used the shower chair, the resident sat up and when the resident used the shower bed, the resident was flat. During an interview with Licensed Vocational Nurse (LVN) 1 on 3/2/2023 at 2:17 p.m., LVN 1 stated the shower bed was always flat and staff could give residents a bed bath if residents feared using the shower bed. LVN 1 stated the head of the shower bed was fixed and could not be raised or lowered. During an interview with the Director of Staff Development (DSD) on 3/2/2023 at 2:42 p.m., the DSD stated using the shower bed or a shower chair was based on the safety of the resident and staff. The DSD stated the head of the shower bed was adjustable with a pad and water was supposed to be sprayed from the neck down. The DSD stated he advised the CNAs to put pillows to elevate the head of shower beds and not to have residents' shower beds completely flat because water could go up a resident's nose. The DSD stated if the water went up the resident's nose, that resident could choke, or the resident might think he/she was drowning. The DSD stated CNAs were trained on the use of the equipment upon hire. The DSD stated he did not remember the last time he did an in-service on shower beds and chairs. During a telephone interview with CNA 2 on 3/3/2023 at 3:14 p.m., CNA 2 stated when each time she used a shower bed to bathe residents, residents were placed completely flat on the bed. CNA 2 stated she tried to position the head of the shower towards the resident's body and away from face. CNA 2 stated sometimes water sprays hit the resident's face. CNA 2 also stated that she had never been in-serviced on the use of a shower bed. During a review of the facility's policy and procedure (P&P) titled, Resident Rights-Accommodation of Needs, dated 1/1/2012, the P&P indicated facility staff interacted with residents in a way that accommodated the physical or sensory limitations of each resident and maintained each resident's dignity. The P&P indicated staff attitude and behavior were directed towards assisting residents in maintaining independence, dignity and well-being to the extent possible according to residents' wishes.

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

Deficiency F0774 (Tag F0774)

Could have caused harm · This affected 1 resident

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was taken to Interventional Radiology ([IR] process used to diagnose and treat diseases within the body) appointment. This deficient practice had the potential to Resident 1's cancer (disease caused by an uncontrolled division of abnormal cells in a part of the body) to worsen or spread. Findings: During a review of Residents 1's Face Sheet (admission record), the face sheet indicated Resident 1 was originally admitted to the facility on [DATE], with diagnoses including a history of malignant neoplasm of larynx (cancer that forms in tissues of the throat that contains the vocal cords and used for breathing, swallowing, and talking), and aphonia (loss of voice.) During a review of Residents 1's Minimum Data Set ([MDS] a standardized care assessment and screening tool) dated 12/14/2022, the MDS indicated Resident 1 had the ability to understand and be understood by others. The MDS indicated Resident 1 required setup help for bed mobility, transfers, walking in room, locomotion (moving from place to place), dressing, eating, toilet use and personal hygiene. During an interview with Resident 1 on 1/25/2023 at 12:30 p.m., Resident 1 since September 2022, he had not gone to any IR appointments because the facility kept canceling and reschedule the appointments. Resident 1 stated he needed to go to his appointment to get treatment for his cancer and was worried he was not getting treatment because of facility's inability to provide him transportation. Resident also stated that the facility cancelled his appointment in September, October, November, and December. According to Resident 1, in January one of his friends had to take him to the appointment. During a concurrent interview and record review with Licensed Vocational Nurse (LVN 1) on 1/25/2023 at 2:54 p.m., of Resident 1's Order Summary Report dated 9/23/2022, the report indicated Resident 1 had an appointment on 9/27/2023 at 10:00 a.m. at a General Acute Care Hospital (GACH), and transportation was to be arranged by the Social Services. LVN 1 stated she did not know if Resident 1 was taken to his appointment. LVN 1 stated if Resident 1 was taken to the appointment, then the nurses would have put it in the notes. LVN 1 stated there were no notes indicating that Resident 1 was taken to his appointment. LVN 1 stated the social services was supposed to arrange for transportation for the resident. LVN 1 stated it was important to take Resident 1 to his IR appointments to treat his cancer and prevent from spreading to other parts of the resident's body. During an interview with the Social Services Director (SSD) and the Social Services (SS) on 1/25/2023 at 3:44 p.m., the SSD stated Resident 1 had not had any appointments in a while. The SS stated no appointments were pending or missed for Resident 1. The SSD stated the facility did not know what happened to Resident 1's appointment in September because Resident 1 was not on their log and there were no notes indicating the resident had an appointment. A review of the facility's policy and procedure (P&P) titled Resident Rights, with a revised date of 1/1/2012, indicated the Facility made every effort to assist each resident in exercising his/her rights by providing the services including transportation to community activities, through the Activity or Social Service Departments. A review of the facility's undated P&P titled Resident Requested/Non-Physician-Ordered Out-Of -Facility Appointments indicated the social services would assist residents with transportation arrangements as needed.

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to follow its policy and procedure on reporting an alleged abuse to the California Department of Public Health (CDPH) within 2 hours for one o...

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Based on interview and record review, the facility failed to follow its policy and procedure on reporting an alleged abuse to the California Department of Public Health (CDPH) within 2 hours for one of three sampled residents (Resident 1), who alleged to have been socked (hit forcefully) on the face. This deficiency practice resulted in the delayed investigation by the CDPH and had the potential to result in neglect to other residents. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was admitted to facility on 12/16/2022, with diagnoses including encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition [such as viral infection or toxins in the blood]), muscle weakness, type 2 diabetes ([DM] abnormal blood sugar). Resident 1's History and Physical (H&P), 12/17/22, was able to make decisions for activities of daily living. During a review of Resident 1's Minimum Data Set ([MDS], a comprehensive standardized assessment and care screening tool) dated 12/23/2022, the MDS indicated Resident 1 was sometimes able to understand and be understood by others. The MDS indicated Resident 1 required a one-person physical assist for bed mobility, dressing, toilet use, eating and personal hygiene. The MDS indicated Resident required a two-person physical assist transferring to or from as bed, hair, wheelchair or standing position. During a review of Resident 1's Progress Notes dated 1/20/2022 and timed at 3:30 p.m., the Licensed Vocational Nurse (LVN) 1 indicated on 1/19/2023 at 2:45 p.m., the SW informed LVN 1 that FM 1 1 wanted resident to be discharged home on 1/20/2023. The progress notes indicated FM 1 stated Resident 1 had a bruise on her face and was afraid about the type of care Resident 1 was receiving at the facility. The progress notes indicated the Assistant Director of Nursing (ADON) was made aware, and Resident 1's physician agreed for Resident 1 to be discharged home on 1/20/2023, per family's request. During an interview on 1/20/2023 at 10:55 a.m., a family member (FM) 1, stated on 1/19/2023 she notified the facility's social worker (SW) on that Resident 1, was hit on the left eye by a staff member. FM 1 stated the SW told FM 1 the facility investigated the alleged abuse and that no male nurse was assigned to Resident 1 on 1/18/2023. FM 1 also stated the incident happened between 1/18/2023 2:00 p.m., and 1/19/2023 10:00 a.m. During an interview on 1/20/2023 at 2:39 p.m., LVN 1 stated Resident 1's family alleged the resident was abused on 1/19/2023. LVN 1 stated she reported it to the ADON and the ADON provided the Resident 1's doctor's number to LVN 1 to notify the doctor for discharge orders Resident 1's family's request. LVN 1 stated the SW told her Resident 1's family did not feel the facility was safe for the resident after the alleged abuse incident. Resident 1, to be in the facility any longer. The LVN 1 further stated the SW asked her to call the doctor per resident family's request due to bruising to Resident 1's face and safety. During an interview on 1/20/2023 at 2:51 p.m., the SW stated on 1/19/2023 she was in Resident 1's room with FM 1. The SW stated Resident 1 told FM 1 that she had a bruise under her eye, but the SW did not see any bruise on the resident's face. The SW stated FM 1 never raised her voice or insinuated any abuse or concern of safety regarding the bruise the family potentially saw. During an interview on 1/20/2023 at 3:20 p.m., the ADON stated Resident 1's family wanted to take the resident home for financial reasons. The ADON stated on 1/19/2023, Resident 1's family did not complain of any bruising to the resident's face. The ADON stated on the morning of 1/20/2023 the SW notified the ADO that FM 1 alleged a bruise to Resident 1's left eye. The ADON stated she did not notify the Administrator (ADM). The ADON further stated the importance to report abuse and alleged abuse was to keep resident's safe. During an interview on 1/20/2023, at 4:07 p.m., the ADM stated all abuse or alleged abuse incidents were reported within two to the CDPH. The ADM stated all staff members were mandated reporters. During a review of the facility's undated P&P titled, Reporting , the P&P indicated the facility's Administrator and/or designee shall be responsible for reporting any reasonable suspicion of a crime against a resident and or all alleged and substantiated violations to the state agency and all other agencies as required. The P&P indicated the facility shall report the incident by notifying the CDPH and local enforcement entities no later than two hours of the knowledge of the allegation, if the events that caused the allegation involved abuse or resulted in serious bodily injury

Jan 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician of changes in condition for one of three sampl...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician of changes in condition for one of three sampled residents (Resident 1) who had persistent complaints of chills (shivering), painful urination, cloudy urine and a positive laboratory (lab) result of urinary tract infection ([UTI], kidney or bladder infection). This deficient practice resulted in a delay of treatment and had the potential to result in worsening of Resident 1 ' s medical condition. Findings: During a review Resident 1 ' s admission Record (Face Sheet), the admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including paraplegia (paralysis of the lower body and legs), urine retention (difficulty emptying the bladder) and sepsis (life threatening complication of an infection). During a review of Resident 1 ' s History and Physical (H&P) dated 8/25/2022, the H&P indicated Resident 1 had the capacity to understand and make decisions. During a review of Resident 1 ' s Minimum Data Set ([MDS], a comprehensive standardized assessment and care-screening tool) dated 8/30/2022, the MDS indicated Resident 1 needed supervision to limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) from staff for activities of daily living (ADL ' s) such as transfers (how resident moves between surfaces), dressing, toilet use, and personal hygiene. During a concurrent interview and record review of Resident 1 ' s Change in Condition/Interact Assessment form dated 11/6/2022, with Licensed Vocational Nurse (LVN 1), on 12/30/2022 at 3:59 p.m., the COC form indicated Resident 1 had complaints of pain when urinating, chills and cloudy urine. LVN 1 stated, the resident ' s physician was notified and a urine analysis with culture (lab tests to check for bacteria and diagnose infection) stat (immediately) was ordered. During a review of Resident 1 ' s Licensed Nurse Record (COC) dated 11/7/2022, 11/8/2022 and 11/9/2022, the records indicated the resident continued to have complaints of chills, pain and cloudy urine when urinating. During a review of Resident 1 ' s Lab Results Report dated 11/19/2022, the reported indicated the resident's urine sample collected on 11/15/2022 was positive for UTI on 11/19/2022. During a review of Resident 1 ' s physician ' s order dated 11/22/2022, the order indicated the resident was prescribed Levaquin (medication to treat infection) tablet 500 mg (milligrams) by mouth every day for 10 days to treat the resident ' s UTI. During an interview on 12/30/2022 at 5:01 p.m. with Assistant Director of Nursing (ADON), the ADON stated the staff should have notified Resident 1's physician of the resident's lab results on 11/9/2022 because Resident 1 continued to have signs and symptoms of UTI and the resident's urine sample had not been completed as ordered. The ADON stated it was important to contact the physician to discuss other options and interventions needed for the resident. The ADON also stated the facility missed following up the on Resident 1 ' s lab result and notifying the physician of the UTI on 11/19/2022. The ADON stated it was important to notify the physician of the positive lab result so antibiotic could be started to treat the infection, avoid the risk of sepsis and other complications to Resident 1. During a review of the facility ' s undated Policy and Procedure (P&P) titled, Change of Condition, the P&P indicated the facility should ensure proper assessment and follow-through for any resident with a change in condition. During a review of the facility ' s undated P&P titled, Laboratory Tests, the P&P indicated the facility would notify the physician of abnormal lab results in a timely manner.

CONCERN (D) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure medication administration was completely and accurately docu...

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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 medication administration was completely and accurately documented for one of three sampled residents (Resident 1). This deficient practice had the potential to negatively impact the delivery of services and medication administration error for Resident 1. Findings: During a review of Resident ' s 1 admission Record (Face Sheet), the record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including paraplegia (paralysis of the lower body and legs), polyneuropathy (malfunction of many nerves throughout the body), muscle spasm (involuntary and uncontrollable contraction of the muscle), and sepsis (life threatening complication of an infection). During a review of Resident 1 ' s History and Physical (H&P) dated 8/25/2022, the H&P indicated Resident 1 had the capacity to understand and make decision. During a review of Resident 1 ' s Minimum Data Set ([MDS], a comprehensive standardized assessment and care-screening tool) dated 8/30/2022, the MDS indicated Resident 1 needed supervision to limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight bearing assistance) from staff for activities of daily living (ADL ' s) such as transfers (how resident moves between surfaces), dressing, toilet use, and personal hygiene. During a review of Resident 1 ' s physician Order Summary Report dated 11/29/2022, the report indicated Resident 1 will receive Gabapentin (medication to treat nerve pain) 900 milligrams ([mg] unit of measurement) three times a day for the treatment of peripheral neuropathy (weakness, numbness and pain from nerve damage usually in hands and feet). During a review of Resident 1 ' s Medication Administration Record (MAR) dated 10/2022 and 11/2022, the MAR indicated Resident 1 did not receive the 1 p.m. doses of gabaentine for 10/9/2022, 11/15/2022 and 11/26/2022. During a review of Resident 1 ' s Licensed Nursing Notes, the notes indicated administration for Gabapentin 1 p.m. doses were documented late as follows: 10/9/2022 administration documented on 12/22/2022 at 1:31 p.m. 11/15/2022 administration documented on 1/4/2023 at 8:51 a.m. 11/26/2022 administration documented on 11/30/2022 at 6:06 p.m. During an interview on 1/4/2023 at 11:35 a.m. with the Assistant Director of Nursing (ADON), the ADON stated documentation of medication given to residents should be documented immediately after administration and late entries should not exceed 7 days. The ADON stated it was important to document in a timely manner to indicate care was provided and to ensure accuracy. During a review of the facility ' s undated policy and procedure (P&P) titled, Late Entries, the P&P indicated late entries should be completed during the time period for which the person making the entry had complete recall for the event/observations being documented and should not exceed a seven-day period unless there was an explanation/approval by both the DON and Administrator.

Feb 2022 22 deficiencies

CONCERN (D)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain dignity, comfort, and self-worth to four of ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain dignity, comfort, and self-worth to four of thirty-four sampled residents (Residents 108, 163, 104 and 422) by failing to ensure: 1. Staff responded to call lights in a timely manner for residents 108, 163, 104 and 422. 2. DSD investigated and reported to Director of Nursing (DON) and Administrator (ADM) that a male Certified Nursing Assistant 1 (CNA1) was sleeping and talking on the phone in Resident 104 and 163's room during the 7-11 p.m., shift. These deficient practices led to residents having feelings of sadness, anger, discomfort, frustration, abandonment, and ignored resulting in Resident 422 breaking down in tears. Findings: 1. During a review of Residents 108's admission record, the admission record indicated the resident was admitted to the facility on [DATE], with diagnosis including type 2 diabetes mellitus (high blood sugar) and hyperlipidemia (high cholesterol) During a review of Resident 108's history and physical H/P dated 1/10/2021, the H/P indicated Resident 108, had the capacity to understand and make decisions. During a review of Resident 108's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 12/20/2021, the MDS indicated Resident 108 had the ability to make himself understood and understood others. The MDS indicated Resident 108 required one-person assist for bed mobility, transfer, locomotion (moving from place to place), dressing, toilet use, personal hygiene, and set up from staff for eating. During a review of Resident 108's Care plan titled Self-care Deficits, Needs Total Assistance in Activities of Daily Living (ADLs), dated 1/11/2022, the care plan's interventions indicated assist with ADLS as needed, provide incontinent care as needed, call light within reach and attend to needs promptly. During a review of Residents 163's admission record, the admission record indicated Resident 163 was admitted to the facility on [DATE], with diagnosis including type 2 diabetes and functional quadriplegia (not able to move arms and legs). During a review of Resident 163's H/P dated 11/8/2020, the H/P indicated Resident 163, was able to make decision for activities of daily living. During a review of Resident 163's MDS, dated [DATE], the MDS indicated Resident 163 had the ability to understand and be understood by others. The MDS indicated Resident 163 required one-person assist for bed mobility, transfer, dressing, toilet use, personal hygiene, and eating. During a review of Resident 163's Care plan titled Assistance in Activities of Daily Living (ADLs)/Self-care Deficit, dated 1/18/2022, the care plan's interventions indicated assist with toileting needs, provide incontinent care, provide a safe environment, maintain privacy and respect the resident. During an interview with Resident 163 on 2/7/2022, at 12:08 p.m., Resident 163 stated that CNA1 did not respond to the resident 163's call light all the time. Resident 163 stated it made her feel very uncomfortable and sad. During a review of Residents 104's admission record, the admission record indicated Resident 104 was admitted to the facility on [DATE], with diagnosis including muscle weakness and difficulty walking. During a review of Resident 104's H/P dated 1/14/2022, the H/P indicated Resident 104, had the capacity to understand and make decisions. During a review of Resident 104's MDS, dated [DATE], the MDS indicated Resident 104 had the ability to understand and be understood others. The MDS indicated Resident 104 required a one-person assist for bed mobility, dressing, toilet use, personal hygiene, and eating. The MDS indicated Resident 104 required a two-person assist for transfers. During a review of Resident 104's Care plan titled Assistance in Activities of Daily Living (ADLs)/Self-care Deficit, dated 12/29/2021, the care plan's interventions indicated assist with toileting needs and/or provide incontinent care after incontinent episodes, provide a safe environment, maintain privacy and respect the resident. During an observation in Resident 104's room on 2/7/2022, the following were observed: 1.At 11:54a.m., Resident 104's room smelled of urine. 2. At 11:54 a.m., Resident 104 was observed pressing her call light at 12:00 p.m., and at 12:13 p.m. 3. CNA 1 and CNA 4 entered Resident 104's room at 12:13 p.m.and but did not help Resident 104. 4. At 12:18 p.m., CNA 2 entered Resident 104's room, CNA 2 removed Resident 104's gown and walked out of the resident's room without providing incontinent care to Resident 104. 5. At 12:23 p.m. CNA 2 was observed entering Resident 104's room, and exited the room, without providing care to the resident. During a review of Resident 422's admission record dated 2/2/22, the admission record indicated, Resident 422 was admitted with diagnoses not limited to acute respiratory failure (a condition that develops when the lungs cannot remove carbon dioxide from the blood) with hypoxia ( a below normal level of oxygen in the blood), chronic obstructive pulmonary disease a group of diseases that cause airflow blockage and breathing related problems) with (acute) exacerbation ( an increase in the severity of a problem), heart failure ( a progressive heart disease that affects pumping action of the heart muscles) and acute kidney failure (an abrupt reduction in the kidneys ability to filter waste products) . During a review of Resident 422's H/P dated 2/2/22, the H/P indicated, resident 422 had the capacity to understand and make decisions. During a review of Resident's 422 care plan dated 2/3/22, the care plan indicated, Resident 422 had an alteration in elimination patterns related to bowel and bladder and is always incontinent. The care plan indicated interventions to monitor for episodes of incontinence, change brief promptly when soiled/soaked, keep clean, dry and odor free, monitor incontinence episodes and frequency and always treat the resident with respect and dignity. During an interview with Resident 108 on 2/7/2022, at 11:15 a.m., Resident 108 stated that CNA1 did not respond to the call lights all night. Resident 108 stated feeling furious and ignored. 2. During an interview with Resident 163 on 2/7/2022, at 12:08 p.m., Resident 163 stated that CNA 1 did not respond to call lights all the time. Resident 163 stated it made her feel very uncomfortable. During an observation and interview on 2/07/22, at 1:13 p.m., Resident 422 was still in bed lying in urine and had not been attended to or cleaned. When asked how do feel when you must wait for staff to come clean you Resident 422 began to cry uncontrollably and stated she feels ashamed, embarrassed, humiliated, and further stated she removes her own wet diaper if staff do not come assist her in a timely manner. During an observation and interview on 2/07/22 at 2:44 p.m. with Resident 422, Resident 422 was resting quietly in bed cleaned, dried and the linen and sheets were changed. Resident 422 stated she had been lying in urine for over an hour prior to being cleaned. During an interview on 2/07/22 at 2:49 p.m. with CNA 7, CNA 7 stated she makes rounds in the mornings to check if residents' needs are met. CNA stated the last time she checked on Resident 422 was at 2:00 p.m. During an observation and interview on 2/10/22 at 8:25 a.m. with Resident 422 at Resident 422's bedside, Resident 422 pressed the call light for assistance. Resident 422 stated she already urinated three times. Resident 422 was lying in bed, and her diaper, linen, sheets, and incontinent (involuntary loss of urine) pad were wet from urine. Resident 422 stated she had been lying in urine for over 30 minutes. During an observation on 2/10/22 at 8:43 a.m. Certified Nursing assistant 10 (CNA 10) knocked on the door entered the room to assist Resident 422 incontinence care. 2. During an interview with Resident 163 on 2/7/2022, at 12:08 p.m., Resident 163 stated CNA1 slept in the room during nighttime and that he made would make phone calls. Resident 163 stated CNA1 was very loud while being on the phone during the nighttime and he would disturb her sleep. Resident 163 stated she had asked him to stop disturbing her sleep, but he did not stop. Resident 163 stated she reported the incident to LVN8 since it had been happening on a regular basis. Resident 163 stated CNA1 was sleeping in the room and talking on the phone last night. During an interview with Resident 104 and 163 on 2/8/2022, at 7:58 a.m., Resident 104 stated CNA1 disturbs their sleep because he talks very loudly during the night, and they are not able to sleep. Her roommate Resident 163 has asked him to leave the room, but he does not leave. Resident 104 and 163 stated CNA1 was sleeping in the room last night again. Resident 104 stated CNA1 works double shifts. Resident 163 stated he is in the facility from 11:00 p.m. to 7:00 p.m. and then 7:00 a.m. to 3:00 p.m. During an interview with CNA2 on 2/8/2022, at 10:28 a.m., CNA2 stated she was not assigned to the resident. She assisted Resident 104 after lunch. CNA2 stated if she had been soiled for several hours, she wouldn't be happy. CNA2 stated sitting in urine for a prolonged time could cause infection and skin breakdown. During an interview with DON on 2/8/2022, at 10:39 a.m., DON stated, staff was supposed to respond to call lights as soon as possible, if the light is on for more than five minutes it was excessive. If the resident was soiled, they had to be cleaned regardless of the time, especially if they had been sitting in urine for several hours. Being sitting in urine has the potential to develop urinary tract infection, skin breakdown and their dignity would be affected. During an interview with LVN 8 on 2/10/2022, at 11:06 a.m., LVN 8 stated, Resident 163 reported CNA1 sleeping in the room and talking loudly at nighttime on Saturday 2/5/2022 and she reported it to DSD on 2/6/2022.

CONCERN (D)

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

Deficiency F0552 (Tag F0552)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident and/or responsible party ([RP] designated perso...

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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 and/or responsible party ([RP] designated person who makes medical decision on behalf of the resident, when the resident is unable to do so) were informed in advance, of the risks and benefits of psychotherapeutic medication (a drug that changes brain function and results in alterations in perception, mood, consciousness, or behavior) for one of 34 sampled residents (Resident 367). This deficient practice violated the resident and/or RP's right to make an informed decision regarding the use of psychotherapeutic medications. Findings: During a review of the admission Record for Resident 367, the admission record indicated Resident 367 was admitted on [DATE] with the diagnosis of schizophrenia (a disorder characterized by thoughts that seem out of touch with reality and affects a person's ability to think, feel, and behave clearly) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily functioning). During a review of Resident 367's Care Plan, undated, the care plan indicated Resident 367 was on multiple medications. The care plan interventions included to inform and explain to family members/significant others and resident the risks and benefits of multiple medications. During a review of Resident 367's Medication Administration Record (MAR), dated 2/1/2022 to 2/28/2022, the MAR indicated Resident 367 received Risperdal 2 milligram ([mg] unit of measurement) tablets for treatment of schizophrenia on 2/6/2022 at 9:00 a.m., 2/6/2022 at 5:00 p.m., 2/7/2022 at 9:00 a.m., and on 2/8/2022 at 5:00 p.m. The MAR indicated Resident 367 received Trazadone HCl 50 mg tablets for treatment of depression on 2/6/2022 at 8:00 p.m., and on 2/8/2022 at 8:00 p.m. During an interview on 2/10/2022, at 9:31 a.m., with the Director of Nursing (DON), DON stated the attending physician was responsible for obtaining informed consents for the administration of psychotherapeutic medications from the resident or RP. DON stated the facility may get a verbal confirmation from the physician to verify the informed consent was done. DON stated the facility was responsible for documenting the informed consent was completed by the attending physician. During an interview on 2/10/2022, at 11:02 a.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated the process followed, for a newly admitted resident prescribed psychotherapeutic medications, was to clarify with the ordering physician that an informed consent was done. RNS 1 stated the admitting nurse must contact the RP to verify if they were aware of the resident's medication regimen. The RNS 1 stated the informed consent should be documented and placed in the resident's medical record. During an interview on 2/10/22, at 11:15 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she had medicated Resident 367 with Risperdal and Trazadone. LVN 2 stated an informed consent was required prior to administering psychotherapeutic medications to a resident. During a concurrent interview and record review on 2/10/2022, at 11:18 a.m., with the RNS 1, RNS 1 stated there were no signed informed consent for Risperdal and Trazadone in Resident 367's chart. The RNS 1 stated the informed consent form in Resident 367's chart was blank. The RNS 1 stated there was no documentation in the Resident 367's electronic chart indicating the informed consent was obtained from Resident 367 and/or RP. The RNS 1 stated the admitting nurse should have verified there was an informed consent for Risperdal and Trazadone. The RNS 1 stated the admitting nurse should have called the family to verify the informed consent for Risperdal and Trazadone was done. The RNS 1 stated it was important to ensure the informed consent was done prior to the administration of Risperdal and Trazadone it was the right of Resident 367 and the RP to be informed of the resident's medication regimen. During a review of the facility's policy titled Psychotherapeutic Medications, undated, the policy indicated informed consent would be obtained from physicians prior to administering psychotherapeutic drugs to residents. During a review of the facility's policy titled Informed Consent, undated, the policy indicated the facility should a patient was given informed consent before initiating the administration of psychotherapeutic drugs. The policy indicated an informed consent should have been prepared and acknowledged by the attending physician indicating the attending physician had disclosed the appropriate information prior to obtaining the informed consent. The policy also indicated the informed consent should be kept in the resident's clinical record.

CONCERN (D)

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

Deficiency F0553 (Tag F0553)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to involve the Responsible party ([RP] person who makes ...

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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 involve the Responsible party ([RP] person who makes medical decisions for a resident, who could not make decisions for themselves) for one of one sampled resident (Resident 70), in care plan meetings to discuss Resident 70' s treatment for Schizophrenia (chronic and severe mental disorder that affects how a person thinks, feels, and behaves). This deficient practice violated Resident 70 RP ' s right to be an active participant in Resident 70 ' s care planning process. Findings: During a review of Resident 70 ' s admission Record (facesheet), the face sheet indicated Resident 70 was admitted to the facility on [DATE]. Resident 70 ' s diagnoses included schizophrenia, anxiety (excessive worry and fear about everyday situations) and convulsions (stiffness and uncontrollable jerky movements of the body). A review of Resident 70's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 12/6/2021, indicated Resident 70 was completely dependent on staff for activities of daily living (dressing and toileting), moving from his bed to wheelchair or chair, locomotion (how resident moves from one location to another) on and off unit (how resident moves to and returns from areas outside his room, e.g dining areas, activity room, patio). A review of Resident 70's History and Physical (H&P), dated 11/30/2021, indicated Resident 70 did not have the capacity (ability) to understand and make decisions. During a review of Resident 70 's Clinical physicians order (CPO), dated 11/29/2021, the CPO indicated Resident 70 was prescribed the following antipsychotic medications (drugs used to treat mental disorders): Seroquel tablet 50 milligrams ([mg] unit of measurement) by mouth daily, and Risperdal 3 mg tablets by mouth two times a day. During a review of Resident 70 ' s care plan (CP), untitled, revised on 12/18/2021, the CP indicated Resident 70 was on multiple medications, and at risk for ill effects from multiple drug use. The interventions included inform and explain to family members/significant others and resident of the risks and benefits of multiple medications. During a review of Resident 70 ' s CP, untitled, revised on 12/18/2021, the CP indicated Resident 70 was on Seroquel (a medication to treat Schizophrenia). The interventions included involve the family in care if possible/available and encourage resident to discuss interest/concerns. During a review of Resident 70 ' s CP, untitled, revised on 12/18/2021, the CP indicated Resident 70 is on Risperdal (a medication to treat Schizophrenia). The interventions included involve the family in care if possible/available and encourage resident to discuss interest/concerns. During an interview on 2/9/2022, at 3:00 p.m., with Registered Nurse Supervisor (RNS) 2, RNS 2 stated that if a resident did not have capacity to make his or her own decisions, a resident presentative or RP must be involved in the care planning. RN 2 stated an Interdisciplinary team meeting (IDT-meetings involving resident's care team) involves including a resident's RP in the planning process. During a concurrent interview and record review on 2/10/2022, at 8:25 a.m., with RNS 1, RNS 1 stated Resident 70 the Interdisciplinary team meeting behavior management committee/psychotherapeutic drug review Record ([IDT] care plan meeting on antipsychotics), dated 12/13/2021 indicated Resident 70 ' s RP was not present. RNS 1 stated Resident 70 ' s RP did not take part in the scheduling of the IDT. RNS 1 stated the RP was not updated on what was discussed in the IDT meeting. RNS 1 stated because Resident 70 ' s RP was not part of the meeting, Resident 70 ' s RP could not make informed decisions regarding Resident 70's care. RNS 1 stated she did not call the RP to provide updates on the IDT meeting. During an interview on 2/10/2022, at 11:27 a.m., with Resident 70 ' s RP, RP stated she was not aware the resident was receiving medication to treat schizophrenia. RP stated she has not talked to Resident 70 ' s doctor or psychiatrist. RP stated she was not involved in the resident's plan of care. RP stated feeling very stressed and upset. During a review of the facility' s policy and procedure (P&P) titled Resident ' s Rights, undated, the P&P indicated residents or if the resident was unable to make medical decisions for themselves, a surrogate decision maker will be given information regarding that resident's rights to make decisions concerning medical care. During a review of the facility ' s P&P titled the Resident' s Care Plan, undated, the P&P indicated the following: It was the responsibility of the Licensed Nurse to ensure that the plan of care is initiated and evaluated.

CONCERN (D)

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

Deficiency F0554 (Tag F0554)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that one resident (Resident 66) did not self-a...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that one resident (Resident 66) did not self-administer medications without an interdisciplinary team (IDT - a team of professionals responsible for planning and coordinating a resident's care) assessment and physician order indicating it was clinically appropriate for him to do so. This deficient practice increased the risk that Residents 66 could have administered medications incorrectly, resulting in doses that were higher or lower than intended, or exposed other residents to medications not intended for them which could have resulted in a negative impact to their overall health and well-being. Findings: During a review of Resident 66's admission Record (a document containing diagnostic and demographic resident information), dated 2/8/22, the admission Record indicated he was admitted to the facility on [DATE] with diagnoses including osteoporosis (a medical condition causing bones to weaken and break more easily). During a review of Resident 66's Order Summary Report (a comprehensive list of current physician orders), dated 2/8/22, the order report indicated his attending physician prescribed calcitonin (a medication used to treat osteoporosis) nasal spray solution to administer one spray in alternating nostrils one time a day on 5/4/21. During an observation on 2/8/22 at 9:32 AM, the Licensed Vocational Nurse (LVN 1) was observed passing the calcitonin nasal inhaler to Resident 66 during his medication administration. Resident 66 was observed administering the nasal inhaler himself while LVN 1 watched nearby. During a review of Resident 66's physician order for calcitonin, the order indicated that the calcitonin should be clinician administered. During an interview on 2/8/22 at 9:41 AM with LVN 1, LVN 1 stated clinician administered means that the nurse must administer the medication to the resident directly. LVN 1 stated she gave the medication to the resident for him to self-administer while she watched and thus failed to administer the medication to the resident directly as required by the physician order. LVN 1 stated for residents to self-administer medications, they need approval first to ensure it will be safe and effective for them to do so. LVN 1 stated there is a chance they could administer too much or too little medication or with an ineffective technique which could lead to medical problems. During a review of Resident 66's Self-Administration of Drugs Assessment, dated 3/4/21, the assessment indicated the IDT did not feel Resident 66 was safe to self-administer medications. During a review of the facility's policy Self-Administration of Medications, dated April 2008, the policy indicated Residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team had determined that the practice would be safe for the resident and other residents of the facility.

CONCERN (D)

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

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record, the facility failed to provide one of one sample resident (Resident 14) a wheelchai...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record, the facility failed to provide one of one sample resident (Resident 14) a wheelchair to enable him go to the activity room for approximately 7 days. This deficient practice caused Resident 14 to feel upset and had the potential to cause feelings of isolation. Findings: During a review of Resident 14's admission Record (facesheet), the face sheet indicated Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 14's diagnoses included anemia (Lack of healthy red blood cells [RBCs- are essential to carry oxygen to all parts of the body]), diabetes mellitus type 2 (high blood sugar), paraplegia (inability to move the lower half of body, unable to move legs and feet) and neuropathy (group of diseases resulting from damaged or malfunctioning of nerves that causes weakness, numbness and pain in hands and feet). A review of Resident 14's Minimum Data Set ([MDS] a standardized resident assessment and care screening tool), dated 1/24/2022, indicated the resident could understand and be understood by others. The MDS indicated Resident 14 required assistance from staff for activities of daily living (dressing and toileting),moving from his bed to wheelchair or chair, locomotion (how resident moves between locations in his room ) on and off the unit. During a review of Resident 14's inventory list, dated 9/4/2021, the inventory list indicated Resident 14 had 1 wheelchair. During a review of Resident 14's care plan (CP), titled Anemia, undated, the CP indicated Resident 14 will attend activities of his choice. During a review of Resident 14's care plan (CP), titled Self-Care Deficit , undated, the interventions indicated Resident 14 will be encouraged do to as much as possible to increase independence and will be provided with an assistive device (device that aids a person in completing a task that they otherwise won't be able to perform such as a wheelchair) for activities of daily living (ADL). During a concurrent interview and observation on 2/7/2022, at 12:18 p.m., in Resident 14's room, Resident 14 was observed sitting up in bed. Resident 14 stated he would like to participate in activities in the activity room but he did not have his wheelchair. Resident 14 stated he asked the MDS Nurse (MDS) 2 a week ago for his wheelchair but still has not be given the wheelchair. During a concurrent interview and observation on 2/8/2022, at 9:00 a.m., with Licensed Vocational Nurse (LVN) 10, in Resident 14's room, LVN was observed changing a bandage on Resident 14's left foot. When LVN 10 asked Resident 14 how he was doing, Resident 14 stated he would like to go to the activity room but could not because he did not have his wheelchair. LVN 10 stated Resident 14 used to have a wheelchair in his room but she did not know where it was. Resident 14 stated he felt upset that he did not have his wheelchair and could not go outside his room. During an interview on 2/9/2022, at 11:36p.m., with Social Services Director (SSD), SSD stated residents' belongings were documented on an inventory list upon admission. SSD stated when a resident is looking for a specific belonging, the staff communicates via word of mouth to search for the item. SSD stated there is no tracking system to document if the requested item has been located and provided to the resident. A complaint log of the item is generated only when social services complete their investigation of the item in question and deems it missing and reimbursed by the facility. During an interview on 2/9/2022, at 3:17p.m., with MDS nurse, MDS stated Resident 14 asked for his wheelchair about a week ago the presence of the Rehabilitation Director (RD) and the Assistant Director of Nursing (ADON). MDS nurse stated, she thought the RD and ADON would take care of it. During an interview on 2/9/2022, at 3:24 p.m., with ADON, ADON stated she was aware Resident 14 had asked for his wheelchair a week ago. ADON stated social services assistant (SSA) had Resident 14's wheelchair. ADON stated she did not follow up with SSA to confirm that Resident 14 received his wheelchair. During an interview on 2/9/2022, at 3:30 p.m., with SSA, SSA stated he had taken the wheelchair out of Resident 14's room approximately 4 weeks ago and put it in the storage room. SSD stated he was not aware Resident 14 wanted his wheelchair in his room. SSA stated it was the resident's right to have his belongings in the room.

CONCERN (D)

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

PASARR Coordination (Tag F0644)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow up with the status of a Pre-admission Screening and 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 with the status of a Pre-admission Screening and Resident Review ([PASRR] a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) level II (a comprehensive evaluation by the appropriate state-designated authority determines whether the individual has a Mental Disorder (MD), Intellectual Disability (ID), or a related condition, determines the appropriate setting for the individual and recommends what, if any, specialized services and/or rehabilitative services the individual needs) and integrate the level of care into a plan of care for one of one sampled resident (Resident 91). This deficient practice had the potential for Resident 91 not to receive appropriate care and services. Findings: During a review of Resident 91's admission Record, the admission record indicated Resident 91 was admitted to the facility on [DATE] with diagnoses including, schizophrenia (severe mental disorder that affects how a person thinks, feels, and behaves) and depression (a mood disorder that causes persistent feelings of sadness and loss of interest). During a review of Resident 91's History and Physical (H&P) dated 9/22/2021, the H&P indicated Resident 91 had a fluctuating capacity to understand and make decisions. During a review of Resident 91's Minimum Data Set ([MDS] a standardized assessment and care screening tool), dated 12/24/2021, the MDS indicated Resident 91 had the ability to understand and be understood. The MDS indicated Resident 91 required supervision for bed mobility, eating, and toilet use. The MDS indicated Resident 91 required a one-person's physical assistance with transfers, dressing, and personal hygiene. During a review of Resident 91's PASRR level 1, dated 9/20/2021, the PASRR level 1 evaluation indicated Resident 91 was positive, and required a higher a level referral for evaluation to ensure the resident received adequate services in the facility. During an interview on 2/10/2022, at 9:40 a.m., with the Director of Nursing (DON), DON stated the PASRR system was automatic and if a resident required a level II evaluation, the system triggered a referral for a level II PASRR evaluation to be done. The DON stated the Department of Mental Health was responsible for completing level II PASRR evaluations. The DON stated he had not followed up on Resident 91's PASRR level II evaluations. The DON stated it was important to follow up on PASRR level II referrals to ensure residents received the appropriate care and services, depending on their individual needs. During a review of the facility policy titled PASRR Completion, dated 3/15/2016, the policy indicated the facility would complete a PASRR for all residents on admission and refer those with MI or ID to the State. The policy indicated all recommendations must be followed up with documentation in the clinical record and care planned as indicated/needed.

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the care plan for one of one sampled reside...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the care plan for one of one sampled residents (Resident 70) to involve Resident 70's RP in care plan meetings to discuss his treatment for Schizophrenia (chronic and severe mental disorder that affects how a person thinks, feels, and behaves). This deficient practice violated Resident 70 RP's right to be an active participant in his care. Findings: During a review of Resident 70's admission Record (facesheet), the face sheet indicated Resident 70 was admitted to the facility on [DATE]. Resident 70's diagnoses included schizophrenia (chronic and severe mental disorder that affects how a person thinks, feels, and behaves), anxiety (intense, excessive, and persistent worry and fear about everyday situations) and convulsions (stiffness and then uncontrollable jerky movements of the body). A review of Resident 70's Minimum Data Set ([MDS], a standardized resident assessment and care screening tool), dated 12/6/2021, indicated Resident 70 was completely dependent on staff for activities of daily living (dressing and toileting), moving from his bed to wheelchair or chair, moving on and off the unit. A review of Resident 70's History and Physical (H&P) dated 11/30/2021, indicated Resident 70 did not have the capacity (ability) to understand and make decisions. During a review of Resident 70's care plan (CP), untitled, revised on 12/18/2021, the CP indicated Resident 70 was on multiple medications, and at risk for ill effects from multiple drug use. The interventions indicated to inform and explain to family members/significant others and resident risks and benefits of multiple medications. During a review of Resident 70's care plan (CP), untitled, revised on 12/18/2021, the CP indicated Resident 70 was on Seroquel (a medication to treat Schizophrenia). The interventions indicated to involve the family in care if possible/available and encourage resident to discuss interest/concerns. During a review of Resident 70's care plan (CP), untitled, revised on 12/18/2021, the CP indicated Resident 70 was on Risperdal (a medication to treat Schizophrenia). The interventions indicated to involve the family in care if possible/available and encourage resident to discuss interest/concerns. During an interview on 2/9/2022, at 3:00 p.m., with Registered Nurse Supervisor (RNS) 2, RNS 2 stated if a resident did not have the capacity to make their own decisions, a resident presentative or responsible party (RP) must be involved in the care planning. During a concurrent interview and record review of Resident 70's Interdisciplinary team ([IDT] group of health care professional working together towards a common goal for the resident) Meeting Behavior Management Committee -Psychotherapeutic Drug review Record on 2/10/2022, at 8:25 a.m., with RNS 1, RNS 1 stated the record indicated Resident 70's RP was not included in the IDT scheduling and meeting. RNS 1 stated the RP was not updated on what was discussed in the IDT meeting. RNS 1 stated because Resident 70's RP was not part of the meeting, RP could not make informed decisions regarding Resident 70's care. During an interview on 2/10/2022, at 11:27 a.m., with Resident 70 ' s RP, RP stated she was not aware the resident was receiving medication to treat schizophrenia. RP stated she has not talked to Resident 70 ' s doctor or psychiatrist. RP stated she was not involved in the resident's plan of care. RP stated feeling very stressed and upset. During a review of the facility 's policy and procedure (P&P) titled Resident's Rights, undated, the P&P indicated the following: As part of the admission process, the patient or if the patient is incapacitated, the patient's surrogate decision maker will be given information regarding an individual's rights to make decisions concerning medical care. Such information shall be consistent with the promulgated and or required by the California Department of Health Services. During a review of the facility 's policy and procedure (P&P) titled Resident's Care Plan, undated, the P&P indicated was the responsibility of the Licensed Nurse to ensure resident's plan of care was initiated and evaluated.

CONCERN (D)

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

Deficiency F0658 (Tag F0658)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a physician's order to consult a psychiatri...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement a physician's order to consult a psychiatrist for one of one sampled residents (Resident 70), who had a diagnosis of Schizophrenia (serious mental disorder that affects how a person thinks, feels, and behaves).' This deficient practice had the potential to delay the needed assessment, care and services for Resident 70. Findings: During a review of Resident 70's admission Record (facesheet), the face sheet indicated Resident 70 was admitted to the facility on [DATE]. Resident 70's diagnoses included schizophrenia (chronic and severe mental disorder that affects how a person thinks, feels, and behaves), anxiety (intense, excessive, and persistent worry and fear about everyday situations) and convulsions (stiffness and then uncontrollable jerky movements of the body) A review of Resident 70's Minimum Data Set ([MDS], a standardized resident assessment and care screening tool), dated 12/6/2021, indicated Resident 70 was completely dependent on staff for activities of daily living (dressing and toileting), moving from his bed to wheelchair or chair, moving on and off the unit. A review of Resident 70's History and Physical (H&P) dated 11/30/2021, indicated Resident 70 did not have the capacity (ability) to understand and make decisions. During a review of Resident 70's Clinical Physicians Order (CPO), dated 11/29/2021, the CPO indicated Seroquel tablet 50 milligrams ([mg]unit of measurement) by mouth daily and Risperdal tablet 3 mg by mouth two times a day. During a concurrent interview and record review of Resident 70's facesheet and physicians' order, on 2/10/2022, at 8:20 a.m., with Registered Nurse Supervisor (RNS) 1, RNS 1 stated Resident 70's physician orders indicated Psychiatrist consultation with treatment and follow up as indicated. RNS 1 stated, the licensed nurse was responsible to carry out the order by calling the psychiatrist. During a concurrent interview and record review of Resident 70's Interdisciplinary team ([IDT] group of health care professional working together towards a common goal for the resident) Meeting Behavior Management Committee -Psychotherapeutic Drug review Record on 2/10/2022, at 8:25 a.m., with RNS 1, RNS 1 stated the record indicated a psychiatric follow up was to be completed on 12/13/2021, but the consult to Resident 70's psychiatrist had not been completed. RNS 1 stated the facility's failure to notify the psychiatrist, caused Resident 70 not to receive the proper psychiatric assessment and may have had a delay in care. During an interview on 2/10/2022, at 9:05 a.m., with Resident 70's psychiatrist, (Psych MD), Psych MD stated that Resident 70 was not on his list of residents to care for. Psych MD stated he had not been called by the facility to consult on Resident 70. A review of the Facility's policy and procedure (P&P) titled, Notification of Physician, undated, indicated, the Licensed Nurse will note and carry out physician's orders.

CONCERN (D)

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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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

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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 thirty-four sampled residents (Resident 108, 163, and 104) were kept clean and free of odors by providing incontinent care. This deficient practice caused residents to feel sad, angry, uncomfortable, frustrated, and abandoned. Findings: a. During a review of Resident 108's admission record, the admission record indicated Resident 108 was admitted to the facility on [DATE], with diagnosis including type 2 diabetes mellitus (high blood sugar) and hyperlipidemia (high cholesterol). During a review of Resident 108's history and physical (H/P) dated 1/10/2021, the H/P indicated Resident 108, had the capacity to understand and make decisions. During a review of Resident 108's Minimum Data Set ([MDS], a standardized assessment and care screening tool), dated 12/20/2021, the MDS indicated Resident 108 had the ability to understand and be understood by others. The MDS indicated Resident 108 required one-person assist for bed mobility, transfer, locomotion (moving from place to place), dressing, toilet use, personal hygiene, and set up from staff for eating. During a review of Resident 108's Care plan titled Self-care Deficits, Needs Total Assistance in Activities of Daily Living (ADLs), dated 1/11/2022, the care plan's interventions indicated assist with ADLS as needed, provide incontinent care as needed, call light within reach and attend to needs promptly. During an interview with Resident 108 on 2/7/2022, at 11:15 a.m., Resident 108 stated Certified Nursing Assistant (CNA)1 did not respond to Resident 108's call light all night, when the resident called to be cleaned. Resident 108 stated she felt furious and ignored. b. During a review of Residents 163's admission record, the admission record indicated Resident 163 was admitted to the facility on [DATE], with diagnosis including type 2 diabetes and functional quadriplegia (not able to move arms and legs). During a review of Resident 163's H/P dated 11/8/2020, the H/P indicated Resident 163, was able to make decision for activities of daily living. During a review of Resident 163's MDS, dated [DATE], the MDS indicated Resident 163 had the ability to understand and be understood by others. The MDS indicated Resident 163 required one-person assist for bed mobility, transfer, dressing, toilet use, personal hygiene, and eating. During a review of Resident 163's Care plan titled Assistance in Activities of Daily Living (ADLs)/Self-care Deficit, dated 1/18/2022, the care plan's interventions indicated assist with toileting needs, provide incontinent care, provide a safe environment, maintain privacy and respect the resident. During an interview with Resident 163 on 2/7/2022, at 12:08 p.m., Resident 163 stated that CNA1 did not respond to the resident 163's call light all the time. Resident 163 stated it made her feel very uncomfortable and sad. c. During a review of Residents 104's admission record, the admission record indicated Resident 104 was admitted to the facility on [DATE], with diagnosis including muscle weakness and difficulty walking. During a review of Resident 104's H/P dated 1/14/2022, the H/P indicated Resident 104, had the capacity to understand and make decisions. During a review of Resident 104's MDS, dated [DATE], the MDS indicated Resident 104 had the ability to understand and be understood others. The MDS indicated Resident 104 required a one-person assist for bed mobility, dressing, toilet use, personal hygiene, and eating. The MDS indicated Resident 104 required a two-person assist for transfers. During a review of Resident 104's Care plan titled Assistance in Activities of Daily Living (ADLs)/Self-care Deficit, dated 12/29/2021, the care plan's interventions indicated assist with toileting needs and/or provide incontinent care after incontinent episodes, provide a safe environment, maintain privacy and respect the resident. During an observation in Resident 104's room on 2/7/2022, the following were observed: 1.At 11:54a.m., Resident 104's room smelled of urine. 2. At 11:54 a.m., Resident 104 was observed pressing her call light at 12:00 p.m., and at 12:13 p.m. 3. CNA 1 and CNA 4 entered Resident 104's room at 12:13 p.m.and but did not help Resident 104. 4. At 12:18 p.m., CNA 2 entered Resident 104's room, CNA 2 removed Resident 104's gown and walked out of the resident's room without providing incontinent care to Resident 104. 5. At 12:23 p.m. CNA 2 was observed entering Resident 104's room, and exited the room, without providing care to the resident. During an interview with Resident 104 on 2/7/2022, at 1: 20 p.m., in Resident 104's room, Resident 104 stated that the last time she had incontinent care was at 5:00 a.m., on 2/7/2022. Resident 104 stated each time she used her call light, the call light turned off within 2 minutes and no one responded or came to provide her care. Resident 104 stated staying in urine made her feel sad, frustrated, and abandoned. CNA 2 said she would only provide Resident 104's incontinent care after lunch. Resident 104 stated she felt uncomfortable and sad. During an interview with CNA 2 on 2/8/2022, at 10:28 a.m., CNA 2 stated she was not assigned to the Resident 104. CNA 2 stated she assisted Resident 104 after lunch. CNA 2 stated sitting in urine for a prolonged time could cause infection and skin breakdown. During an interview with the Director of Nursing (DON) on 2/8/2022, at 10:39 a.m., DON stated, staff was supposed to respond to call lights as soon as possible. DON stated if the light is on for more than five minutes it was excessive and unacceptable. DON stated if a resident was soiled, the staff had to clean the resident regardless of the time, especially if they had been sitting in urine for several hours. The DON added that sitting in urine could cause urinary tract infection, skin breakdown as well as affect the resident's dignity. During a review of the facility's policy and procedures (P/P) titled Job Description Certified Nursing Assistant dated 1/27/2022, indicated, CNAs essential duties and responsibilities were to keep incontinent residents clean, dry, free of odor, and appropriately clothed. During a review of the facility's P/P titled Incontinent Care undated, indicated incontinent residents will be kept clean, dry, and free of odor. The P/P indicated residents will be protected from skin breakdown. During a review of the facility's P/P titled Early Morning Care (Early A.M. Care) undated, the P/P indicated early morning care will be provided by the night shift including assisting a resident to the bathroom, bedside commode, or bed pan as well as assisting residents with toilet activities as needed and before breakfast. During a review of the facility's P/P titled A.M. Care, undated indicated A.M. care included providing toileting or incontinent care as needed.

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility failed to ensure an accurate assessment was conducted for one reside...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, facility failed to ensure an accurate assessment was conducted for one resident out of 33 sampled residents (Resident 139). Resident 139 did not have an assessment documented on 2/5/2022. This deficient practice had the potential to result in Resident's 139 delay in necessary care and treatment. Findings: During a review of Resident 139's admission record (face-sheet) indicated Resident 139 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses of dependence of renal dialysis (The process of removing waste products and excess fluid from the body. Dialysis is necessary when the kidneys are not able to adequately filter the blood), and 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). During a review of the Minimum Data Set (MDS, a standardized assessment and care planning tool), for Resident 76 dated 12/10/2021, indicated Resident 139's cognitive skills for daily decision making was intact and required supervision to limited assistance from staff for activities of daily living. During a review of Resident 139's Licensed Nurse Record (Daily Note) indicated that an assessment for 2/5/2022 was not performed. Day shift, evening shift, and night shift nurses did not document that they performed an assessment on resident 139. On 2/10/2022 at 11:22 a.m., during an interview with registered nurse (RN) supervisor 1, Supervisor 1 stated that if there's no documentation of an assessment on file that means that it was not done. Supervisor 1 stated she could not find any assessment performed on Resident 139 for the date of 2/5/2022. Supervisor 1 stated that it looks like no one took care of resident 139 on 2/5/2022 because there's no charted assessment. Supervisor 1 stated that it's important to perform an assessment on residents to provide care. On 2/10/2022 at 12:48 p.m., during an interview with assistant director of nursing (ADON), ADON stated that she could not find any documentation for the date of 2/5/2022. ADON stated she wasn't sure what happened that day and that why no one charted. ADON asked medical records to help her locate any documentation for Resident 139 assessments for 2/5/2022 and they did not find any assessment. ADON stated that no assessments were performed for resident 139 on 2/5/2022. During a review of undated facility policy and procedure (P&P) titled Licensed Nursing Notes, indicated that daily notes are to be written for each Medicare-covered resident. The content is to include specific skilled care provided and skilled assessment performed as outlined in the Medicare Guideline Worksheet for the individual resident.

CONCERN (D)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an environment that was free from hazard for t...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure an environment that was free from hazard for two of 33 sampled residents (Resident 76, Resident 368), and ensure they did not store cigarette lighters in their rooms. This deficient practice had the potential to cause fire and injury to Residents 76, Resident 368, and other residents, staff, and visitors in the facility. Findings: a. During a review of Resident 76's admission record (face-sheet), the Facesheet indicated Resident 76 was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident 76's diagnoses included chronic obstructive pulmonary disease (a lung disease that causes obstructed airflow from the lungs), and hemiplegia (loss of strength/paralysis of one side of the body) and hemiparesis (slight weakness on one side of the body) affecting the left side. During a review of the Minimum Data Set ([MDS], a standardized assessment and care planning tool), dated 12/10/2021, the MDS indicated Resident 76 had intact cognitive skills for daily decision making and required supervision by staff for activities of daily living. During a review of Resident 76's care plan for smoking dated 12/18/2021, the care plan indicated Resident 76 needed supervision while smoking, may not have access to matches and lighters and staff would provide assistance with the use of matches and lighters when smoking. On 2/7/2022 at 1:03 p.m., during an interview and observation in Resident 76's room, Resident 76 was sitting up on his wheelchair with a crossbody bag containing a pack of Marlboro cigarettes and a lighter. Resident 76 stated he smoked out on the patio after breakfast, after 1:00 p.m., and at 6:00 p.m. after dinner. Resident 76 stated he carried his cigarettes and lighter with him. On 2/8/2022 at 10:26 a.m., during an observation and interview in the smoking patio, activity assistant (AA )1 stated she was supervising 16 residents smoke to make sure the residents did not share cigarettes [sic]. However, residents were observed lighting up their own cigarettes, sharing cigarettes, and picking up used cigarettes off the floor to smoke. On 2/9/2022 at 3:42 p.m., during an interview in the patio, social services assistant (SSA) stated residents could keep cigarettes and lighters in their possession. SSA stated the facility allowed residents to keep cigarette lighters in their room. b. During a review of the admission record for Resident 368, the admission record indicated Resident 368 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included fracture of the neck of the left femur (broken top part of the leg bone, just below the ball and socket joint), fracture of the fourth cervical vertebra (fracture of the neck), and hypertension (high blood pressure). During a review of Resident 368's, history and physical (H&P) dated 1/18/2022, the H&P indicated Resident 368 had the capacity to understand and make decisions. During a review of Resident 368's Minimum Data Set ([MDS], a standardized resident assessment and care screening tool), dated 1/25/2022, the MDS indicated Resident 368 had the ability to understand and be understood. The MDS further indicated Resident 368 required one-person physical assistance for bed mobility, transfers from the bed to the wheelchair and standing, dressing, toilet use, personal hygiene and required set-up help for eating only. During a review Resident 368's care plan for smoking, dated 1/26/2022, the care plan indicated Resident 368 was a smoker. The care plan's interventions indicated Resident 368 may not have access to matches and lighters and staff would provide assistance with the use of matches and lighters, when Resident 368 smoked. On 2/8/2011 at 10:15 a.m., during an observation, Resident 368 was sitting in his wheelchair on the patio. He took out a cigarette and a lighter out of his bag. He lit the cigarette and proceeded to smoke. Resident 368 was also observed lighting a cigarette for another resident. During a concurrent interview and observation on 2/9/2022, at 1:35 p.m., with Resident 368 in his room, Resident 368 was observed with a lighter. Resident 368 stated he kept the lighter with him in a bag. Resident 368 stated he lit his cigarettes on his own whenever he smoked in the patio. On 2/9/2022 at 1:46 p.m., during an observation and interview in the patio, Resident 368 who was sitting in a wheelchair was observed removing a cigarette and lighter from his bag. Resident 368 lit the cigarette and started to smoke. Resident 368 stated the facility allowed him to keep his lighter. On 2/10/2022 at 10:29 a.m., during an interview with the DON in the hallway, DON stated residents could have cigarettes in their possession but not lighters. DON stated, You never know when a resident could be watching television and want to smoke in their room. DON stated cigarettes were to be lit by patio staff only. During a record review of the facility's undated policy and procedure (P&P) titled, Smoking, the P&P indicated the facility would comply with local, state, and federal smoking regulations to ensure the safety of residents. During review of the State Operation Manual (SOM), dated 11/22/2017, the SOM indicated the facility must ensure precautions were taken for the resident's individual safety, as well as the safety of others in the facility. The SOM indicated such precautions included supervising residents whose care plans indicated a need for assisted and supervised smoking and limiting the accessibility of matches and lighters by residents who needed supervision when smoking for safety reasons.

CONCERN (D)

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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review the facility failed to provide incontinence (loss of control of urine) care for one of four sampled residents (Resident 422) in a timely manner by lea...

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Based on observation, interview and record review the facility failed to provide incontinence (loss of control of urine) care for one of four sampled residents (Resident 422) in a timely manner by leaving Resident 422 in urine for over an hour. This deficient practice had the potential to result in skin problems such as redness, rashes, and inflammation. Finding: During a review of Resident 422's admission Record the admission Record indicated, Resident 422 was admitted o the facility on 2/2/22, with diagnoses including chronic obstructive pulmonary disease ([COPD] a respiratory disease that causes difficulty breathing), and heart failure (when the heart does not pump like it normally does) During a review of Resident 422's History and Physical dated 2/2/22, the History and Physical indicated, Resident 422 had the capacity to understand and make decisions. During an observation on 2/07/22 at 12:29 p.m. Resident 422 was lying in bed, pressing the call light, wearing a urine-soaked diaper and her bed linen had dried yellow stains. During an observation and interview on 2/07/22 at 1:13 p.m. Resident 422 was still in bed lying in urine and had not been attended to or cleaned. Resident 422 began to cry uncontrollably and stated she felt ashamed, embarrassed, humiliated because staff leave her in wet diapers. Resident 422 stated sometimes, she had to remove her own wet diaper when staff don't assist her on time. During an observation and interview on 2/07/22 at 2:44 p.m., Resident 422 was resting quietly in bed cleaned, dried and the linen and sheets were changed. Resident 422 stated she had been lying in urine for over an hour prior to being cleaned. During an observation and interview on 2/10/22 at 8:25 a.m., at Resident 422's bedside, Resident 422 was lying in bed, and her diaper, sheets, and incontinence pad were wet from urine. Resident 422 stated she already urinated three times. Resident 422 stated she had been lying in urine for over 30 minutes. During a review of Resident's 422 Care Plan dated 2/3/22, the Care Plan indicated, Resident 422 had an alteration in elimination patterns related to bowel and bladder and is always incontinent. The Care Plan's interventions indicated to monitor for episodes of incontinence, change brief promptly when soiled/soaked, keep clean, dry and odor free, monitor incontinence episodes and frequency and always treat the resident with respect and dignity. During a review of the facility's policy titled Incontinence Care undated, the policy indicated, the objective was to keep incontinent residents clean, dry, and free of odors and to prevent skin breakdown. During a review of the facility's policy titled Resident's Rights: Purpose & Policies (undated), the policy indicated, the facility shall treat each resident with consideration, respect, and full recognition of his/her dignity and individuality. The policy indicated the facility shall provide service to each resident with respect, courtesy and consideration of resident's needs and feelings.

CONCERN (D)

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility licensed staff failed to ensure residents who received dialysis ...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility licensed staff failed to ensure residents who received dialysis (the process of removing waste products and excess fluid from the body using a machine when the kidneys are not able to do so) was assessed after dialysis treatment and this assessment was documented in the Dialysis Communication Records for one of 1 sampled resident (Resident139). This deficient practice had the potential for unidentified complications after dialysis treatment such as swelling, pain, bleeding and bruising. Findings: A review of Resident 139's admission record (face-sheet) indicated Resident 139 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses of dependence of renal dialysis (The process of removing waste products and excess fluid from the body. Dialysis is necessary when the kidneys are not able to adequately filter the blood), and 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). A review of the Minimum Data Set (MDS, a standardized assessment and care planning tool), for Resident 76 dated 12/10/2021, indicated Resident 76's cognitive skills for daily decision making was intact and required supervision to limited assistance from staff for activities of daily living. On 2/7/2022 at 11:21 a.m., during an interview and observation, Resident 139 was sitting on a wheelchair in the hallway, and she stated she is a dialysis patient and gets her dialysis on Saturday, Thursday, and Saturday. Resident 139 stated she gets her dialysis through a permcath (used for short term dialysis or until a permanent dialysis fistula can be created. The permacath consists of a soft silicon catheter which has 2 internal channels or lumen, one with a red cap and one with a blue cap) located on her right upper chest. A review of Resident 139's Dialysis Communication Records indicated resident's pre dialysis and post dialysis assessments were inaccurately performed, under the following sections: 1. On 1/11/2022 at 6:00p.m., access site (left upper arm) was not assessed for a bruit and a thrill for post dialysis. 2. On 1/18/2022 at 9:00 a.m., facility did not inquire about resident 139's pre dialysis weight and post dialysis weight. 3. On 1/21/2022 at 6:00 p.m., facility did not inquire about resident 139's post dialysis weight. 4. On 2/3/2022 at 8:00 a.m., right chest permacath was inaccurately assessed for a bruit and a thrill. 5. On 2/8/2022 at 9:00am and at 3:00p.m., right chest permacath was inaccurately assessed for a bruit and a thrill. On 2/10/2022 at 10:21 a.m., during an interview with DON, DON stated that the nurse is responsible to make sure the Dialysis Communication Record form is filled out. DON stated that the nurses are responsible for the pre dialysis assessment section and the post dialysis assessment section. DON stated that nurses must accurately assess graft site according to type of graft, either a permacath or an AV (arteriovenous) fistula (abnormal connection between an artery and a vein in which blood flows directly from an artery into a vein, bypassing some capillaries). On 2/10/2022 at 11:32 a.m., during an interview, registered nurse (RN) supervisor 1 stated that unaddressed entries on Dialysis Communication Record mean that the assessment was not performed. Supervisor 1 stated that checking for the presence of a bruit or a thrill is not part of the assessment when a resident has a permacath. Supervisor stated that it is important to know the resident's pre dialysis weight and post dialysis weight to prevent fluid overload. On 2/9/2022 at 1:19 p.m., during an interview with licensed vocational nurse 2 (LVN 2), LVN 2 stated that she assesses dialysis residents when they return from dialysis. LVN 2 stated that it was her mistake stating on assessment paper that she checked for a bruit and a thrill when a resident has a permacath. A review of undated facility policy and procedure (P&P) titled Care of Resident receiving Renal Dialysis, indicated that the Dialysis Communication Record must be completed during dialysis days and to send form with resident to be filled out by dialysis nurse. Facility nurse must complete the pre dialysis and post dialysis assessment by addressing the access site (central line, shunt, graft site), and document if there is a bruit or a thrill.

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, the facility failed to accurately account for the use of four doses of controlled substances (medications with a high potential for abuse) for three...

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Based on observation, interview, and record review, the facility failed to accurately account for the use of four doses of controlled substances (medications with a high potential for abuse) for three residents (Residents 19, 93, and 568) in two of seven inspected medication carts (Station 2 Medication Cart and Station 5 Medication Cart). This deficient practice increased the risk that Residents 19, 93, and 568 could have received too much or too little medication due to lack of documentation possibly resulting in serious health complications requiring hospitalization. Findings: During an interview and concurrent observation of Station 2 Medication Cart, on 2/7/22 at 2:38 PM, with Licensed Vocational Nurse 1 (LVN 1), the following discrepancy was found between the Controlled Drug Record (a log signed by the nurse with the date and time each time a controlled substance is given to a resident) and the medication card (a bubble pack from the dispensing pharmacy labeled with the resident's information that contains the individual doses of the medication): 1. Resident 93's Controlled Drug Record for hydrocodone/APAP (a medication used to treat pain) 5/325 milligrams (mg - a unit of measure for mass) indicated there were fourteen doses left, however, the medication cards only contained thirteen doses. LVN 1 stated she administered the missing dose of hydrocodone/APAP 5/325 mg to Resident 93 earlier that day but failed to sign for the dose in the Controlled Drug Record. LVN 1 stated it is the facility's policy to sign for each dose of controlled substances removed from the bubble pack on the Controlled Drug Record immediately once given to a resident. LVN 1 stated it is important to immediately sign for each dose of controlled substances to ensure they are not stolen or misused. LVN 1 stated it is also important to ensure there is accurate documentation of what was given to the resident to ensure they are not given too much medication. LVN 1 stated if the use of controlled substances is not documented properly, there is a chance that the resident may be given too much of the medication which could lead to health complications. During an interview and concurrent observation of the Station 5 Medication Cart, on 2/9/22 at 11:35 AM, with LVN 5, the following discrepancies were found between the Controlled Drug Record and the medication card): 1. Resident 568's Controlled Drug Record for oxycodone (a medication used to treat pain) 10 mg indicated there were 57 doses left, however, the medication cards only contained 56 doses. 2. Resident 19's Controlled Drug Record for Suboxone (a medication used to treat pain) 2 mg/ 0.5mg indicated there were 29 doses left, however, the medication box only contained 27 doses. LVN 3 stated she administered the missing dose of oxycodone to Resident 568 and one missing dose of Suboxone to Resident 19 earlier today and forgot to sign the Controlled Drug Record. LVN 3 stated the nurse on the 3-11 PM shift yesterday administered the other missing dose of Suboxone to Resident 19 at 5 PM and failed to sign for it. LVN 3 stated that the nurse coming off at 11-7 AM shift this morning was not available to reconcile the narcotics with her. LVN 3 stated she understands the importance of signing the narcotic log after each dose is removed to ensure accountability of the controlled medications and to ensure that residents don't accidentally receive too much medication which could lead to health complications. During a review of the facility's policy Controlled Medications, dated August 2014, the policy indicated When a controlled medication is administered, the licensed nurse administering the medication should immediately enter the following information on the accountability record and the medication administration record . Signature of the nurse administering the dose on the accountability record at the time the mediation is removed from the supply .

CONCERN (D)

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

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

Based on interview and record review, the facility failed to ensure a resident was free from unnecessary drugs for one of 34 sampled residents (Resident 113) by failing to adequately monitor for the c...

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Based on interview and record review, the facility failed to ensure a resident was free from unnecessary drugs for one of 34 sampled residents (Resident 113) by failing to adequately monitor for the continue need for heparin (used to prevent blood from clotting in the heart or blood vessels). This deficient practice resulted in prolonged use of heparin and had the potential to lead to adverse reactions including bleeding easily and bruising. Findings During a review of the facilities resident Face sheet (admission record) dated 9/17/21, the Face sheet indicated, Resident 113 was admitted to the facility with diagnoses that included a stage 4 pressure ulcer (injuries to the skin and underlying tissue resulting from prolonged pressure on the skin) of the sacral ( lower part of the back) area, dysphasia (difficulty in swallowing food or liquid) type 2 diabetes mellitus (insufficient production of insulin, causing high blood sugar), chronic embolism ( an obstruction in a blood vessel due to a blood clot or other foreign matter that gets stuck while traveling through the bloodstream) and thrombosis (occurs when blood clots block the blood vessels) of both legs and transient ischemic attack (occurs when the blood supply to part of the brain is briefly interrupted). During a review of Resident 113's Medication Administration Record (MAR) dated 12/1/21 to 12/31/2021, the MAR indicated, Resident 113 had received Heparin 5000 units subcutaneously (beneath, or under, all the layers of the skin) once a day for deep vein thrombosis (DVT) since 9/17/21. During a review of Resident 113's Order Summary Report dated 2/9/22, the Order Summary Report indicated, Resident 113 received Heparin 5000 units subcutaneously once a day for DVT since 9/17/21. During a review of Resident 113's Consultant Pharmacist's Medication Regimen Review dated 1/1/22 to 1/14/22, the Consultant Pharmacist Medication Regimen Review indicated, Resident 113 had used Heparin 5000 units subcutaneously once day for DVT since 9/17/21. The Consultant Pharmacist's Medication Regimen Review also indicated, to please verify duration of therapy for use of this medication, consider oral replacement, if possible or please document rationale for continuing with this medication at this time. During a review of the facility's Note to Attending Physician/Prescriber dated 1/14/22, the Note to Attending Physician/ Prescriber indicated, no response from the Physician regarding Resident 113's recommendations for Heparin 500 units subcutaneously once a day for DVT. During an interview on 2/10/22 at 9:55 a.m. with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated, Resident 133 had been receiving Heparin 5000 units subcutaneously once a day for DVT. During an interview on 2/10/22 at 10:33 a.m. with Assistant Director of Nursing (ADON), the ADON stated, the process for notifying the Physician of the Consultant Pharmacist's Medication Regimen Review is for the licensed staff to call the doctor and inform the doctor of the recommendation from the pharmacist, licensed staff will follow the orders given by the doctor and document the conversation with the doctor in the medical records. The ADON agreed that she did not document in Resident 113's medical record that the doctor was informed of the Consultant Pharmacist's Medication Regimen Review, and if the doctor is not informed of the Consultant Pharmacist's Medication Regimen Review regarding Heparin 5000 units subcutaneously once a day for DVT the resident is at risk for bleeding. During a record review of the policy titled Skilled Nursing Pharmacy, (undated), the Skilled Nursing Pharmacy policy indicated, the facility is responsible for documenting the follow-through of each monthly consultant pharmacist report. It is not required that the center agree with the pharmacist's recommendation, but follow-through is required. The Director of Nursing is responsible for ensuring proper follow

CONCERN (D)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure licensed staff did not: 1. Administer blood pr...

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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 licensed staff did not: 1. Administer blood pressure medication with hold parameters (conditions for administration indicated in the physician order based on vital sign measurements) for heart rate to two residents (Residents 66 and 567) without first checking the heart rate. 2. Administer 97 doses of expired insulin (a medication used to control high blood sugar) to one resident (Resident 136.) These deficient practices increased the risk that Resident 66, 136, and 567 could have experienced adverse effects (potentially harmful side effects) related to medication administration errors which could have resulted in medical complications possibly leading to hospitalization or death. Findings: During an observation of the medication administration for Resident 567 on [DATE] at 9:03 AM, LVN 1 was observed administering carvedilol (a medication used to treat high blood pressure) 12.5 mg to Resident 567 without first checking the resident's heart rate. Resident 567 was observed taking the medication by mouth with water. During a review of Resident 567's admission Record dated [DATE], the record indicated he was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses that included hypertension (high blood pressure). During a review of Resident 567's Order Summary Report, dated [DATE], the report indicated on [DATE] the attending physician prescribed carvedilol 12.5mg by mouth twice daily for hypertension with instructions to hold (not administer) for a heart rate less than 60 beats per minute. During an observation of medication administration for Resident 66 on [DATE] at 9:32 AM, LVN 1 was observed administering lisinopril (a medication used to treat high blood pressure) 20 mg to Resident 66 without first checking his heart rate. Resident 66 was observed taking the lisinopril by mouth with water. During a review of Resident 66's admission record, dated [DATE], the admission record indicated he was admitted to the facility on [DATE], with diagnoses that included osteoporosis (a medical condition causing bones to weaken and break more easily) and hypertension. During a review of Resident 66's Order Summary Report (a comprehensive list of current physician orders), dated [DATE], the order report indicated his attending physician prescribed lisinopril 20 mg by mouth every day with instructions to hold for a heart rate less than 60 beats per minute. During an interview on [DATE] at 9:41 AM with LVN 1, LVN 1 stated she failed to check the heart rate prior to administering carvedilol to Resident 567 and lisinopril to Resident 66. LVN stated that Resident 567 refused to have his heart rate checked and, instead of administering the carvedilol, she should have held it until she was able to measure the heart rate to ensure it was safe to give. LVN 1 stated she failed to remember to check Resident 66's heart rate prior to administering lisinopril. LVN 1 stated that it is important to check the heart rate prior to giving blood pressure medicine, because it can lower the heart rate to unsafe levels. LVN stated that if she doesn't check the heart rate first, there is a chance that the medications could drop the resident's heart rate too low which could lead to fainting or falls with an injury. During a concurrent observation and interview on [DATE] at 2:33 PM of the Sub-Acute Medication Cart 2 with LVN 4, two Admelog (a type of insulin) pens for Resident 136 were found stored at room temperature in the medication cart. One Admelog pen was labeled with an open date of [DATE] and the other was not labeled with an open date. LVN 4 stated the Admelog pen for Resident 136 opened on [DATE] expired 28 days after opening on [DATE]. LVN 4 stated and she did not receive the new undated pen for him until [DATE]. LVN 4 stated she administered a dose to Resident 136 today from the undated pen but failed to remove the expired pen from the cart and failed to record an open date on the new pen. LVN 4 stated it appears that from [DATE] to [DATE], the resident received many doses of the expired Admelog from multiple licensed staff. LVN 4 stated that if insulin is expired, it may not work to control blood sugar levels and could cause medical complications like coma, leading to hospitalization or death. During a review of Resident 136's admission record, the record indicated he was readmitted to the facility on [DATE], with diagnoses that included Type 1 diabetes mellitus (a medication condition characterized by the inability to control blood sugar levels without insulin injections). During a review of Resident 136's Order Summary Report, dated [DATE], the report indicated on [DATE], Resident 136's attending physician prescribed Admelog insulin to inject subcutaneously (under the skin) every six hours based on a sliding scale (dosage depends on blood sugar readings taken simultaneously). During a review of Resident 136's Medication Administration Record (MAR - a record of all medications administered to a resident), for January and February 2022, the MAR indicated Resident 136 received 97 doses of Admelog between [DATE] and [DATE]. During a review of the facility's policy Medication Administration-General Guidelines, dated [DATE], the policy indicated Medications are administered in accordance with written orders of the attending physician. During a review of the facility's policy Medication Storage in the Facility, dated [DATE], the policy indicated Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . Outdated, contaminated, or deteriorated medications . are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists.

CONCERN (E)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' medical records were updated to show documentatio...

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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 the advance directive ([AD] legal document of a resident's wishes regarding medical treatment) were discussed and written information was provided to the resident and/or responsible party ([RP] individual responsible for making medical decisions for a resident) for 5 of 20 sampled residents (Resident 70, 110, 367, 138, 578). This deficient practice violated the residents' and/RP's right to be fully informed of the option to formulate their AD and had the potential to cause conflict with the residents'/RP's wishes regarding health care. Findings: A. During a review of Resident 70's admission Record (facesheet), the face sheet indicated Resident 70 was admitted to the facility on [DATE]. Resident 70's diagnoses included schizophrenia (chronic and severe mental disorder that affects how a person thinks, feels, and behaves), anxiety (intense, excessive, and persistent worry and fear about everyday situations) and convulsions (stiffness and then uncontrollable jerky movements of the body). A review of Resident 70's Minimum Data Set ([MDS], a standardized resident assessment and care screening tool), dated 12/6/2021, indicated Resident 70 was completely dependent on staff for activities of daily living (dressing and toileting), moving from his bed to wheelchair or chair, moving on and off the unit. A review of Resident 70's History and Physical (H&P) dated 11/30/2021, indicated Resident 70 did not have the capacity (ability) to understand and make decisions. During an interview on 2/9/2022, at 3:00 p.m., with Registered Nurse Supervisor (RNS) 2, RNS 2 stated if a resident does not have capacity to make their own decisions, the RP must be informed and involved in the resident's decision-making process. RNS 2 stated the Social Services Director (SSD) was responsible for notifying residents' RPs to arrange a meeting and ensure the completion of the residents' AD. During an interview on 2/10/2022, at 2:13 p.m., with Resident 70's RP, RP stated she did not receive information from the facility regarding the resident. RP stated, I do not know what an AD is. During a concurrent interview and record review of Resident 70's AD form dated 11/3/2021, on 2/11/2022, at 9:00 a.m., with SSD, SSD stated the AD form did not have the physician's dated signature. The SSD stated Resident 70 was not capable of making care decisions and there was no indication that the resident's RP was informed of the AD. physician's dated signature was missing B(i). During a review of Resident 110's admission Record (face sheet), the face sheet indicated Resident 110 was originally admitted on [DATE] and readmitted on [DATE] with diagnosis including epilepsy (a disorder in which nerve cell activity in the brain are disturbed, causing seizures (a person experiences abnormal behavior, symptoms, and sensations, sometimes including loss of consciousness) and dementia (a condition characterized by impairment of brain functions, such as memory loss and judgement). During a review of Resident 110's MDS dated [DATE], the MDS indicated Resident 110 was usually able to be understood and understand others. The MDS indicated Resident 110 required a one-person assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS indicated Resident 110 required set-up only for eating. During a review of Resident 110's Care Plan, dated 1/6/2022, the care plan indicated the intervention for the AD was to be clearly labeled in the resident's chart. During a phone interview with Resident 110's RP on 2/10/2022, at 11:46 a.m., the RP stated he did not recall receiving any information from the facility or any discussion with the facility regarding the AD for Resident 110. B(ii). During a review of Resident 367's facesheet, the face sheet indicated Resident 367 was admitted to the facility on [DATE] with the diagnosis including schizophrenia (a disorder characterized by thoughts that seem out of touch with reality and affects a person's ability to think, feel, and behave clearly) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily functioning). During a review of the Licensed Nurse Record (Daily Note), dated 2/6/2022, the daily note indicated Resident 367 had fluctuating capacity to make decisions. The daily note indicated Resident 367 was able to make her needs known. The daily note indicated Resident 367 required supervision for ambulation, bathing, eating, and personal hygiene. B(iii) During a review of Resident 138's face sheet, the face sheet indicated Resident 138 was admitted on [DATE] with diagnosis including subarachnoid hemorrhage (bleeding in the space between the brain and the tissue covering the brain), dependence on ventilator (a machine that provides mechanical breaths to a patient who is unable to breathe on their own), and cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area). During a review of Resident 138's H&P, dated 12/30/2021, the H&P indicated Resident 138 did not have the capacity to understand and make decisions During a review of Resident 138's MDS, dated [DATE], the MDS indicated Resident 138 ability to make decisions was severely impaired. The MDS indicated Resident 138 was totally dependent on staff and required two-person assistance for bed mobility and transfers. The MDS indicated Resident 138 required a one-person assistance for eating, toilet use, dressing, bathing, and personal hygiene. During a concurrent interview and record review of Resident 110 and 367's charts, on 2/10/2022, at 2:10 p.m., with SSD, the SSD stated she did not have AD acknowledgements form for Residents 110 and 367. The SSD stated Residents 110, 367, and 138 AD forms were incomplete. C. During a review of Residents 578's facesheet,the facesheet indicated the resident was admitted to the facility on [DATE], with diagnosis including multiple fractures (breaks in bone), and motor-vehicle accident (car accident). During a review of Resident 578's H&P dated 1/10/2021, the H&P indicated Resident 578, did not have the capacity to understand and make decisions. During a review of Resident 578's MDS dated [DATE], the MDS indicated Resident 108 rarely/never had the ability to make himself understood and understand others. The MDS indicated Resident 578 required one-person assist for bed mobility, transfer, locomotion (moving from place to place), dressing, toilet use, personal hygiene, eating, and two-person assist for bed mobility. During an interview on 2/10/2022, at 9:50 a.m., with Resident 578's RP, RP stated she did not receive information from the facility regarding the resident's AD, and did not know what an AD was. During a review of the Advance Directive Acknowledgement for Resident 578, undated, the document was missing representatives' signature, physician signature and date. Document stated Resident 578 had executed an advance directive but there was no advance directive in chart. During an interview with SSD on 2/10/2022 at 2:35 p.m., SSD stated she did not have any AD for Resident 578. During a review of the facility 's policy and procedure (P&P) titled Resident's Rights, undated, the P&P indicated as soon as reasonably possible, during the admission process, an inquiry should be directed to the adult patient or, if the patient was incapacitated, to the patient's surrogate decision-maker as to whether or not the patient had completed an advanced directive. The P&P indicated if the patient was incapacitated, the patient's surrogate decision maker would be given information regarding an individual's rights to make decisions concerning medical care. The P&P indicated the patient's medical record must reflect whether the patient had completed an advance directive and should reflect written information was provided to the person signing the admission documents.

CONCERN (E)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than f...

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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 that its medication error rate was less than five percent (%). Four medication errors out of 27 total opportunities contributed to an overall medication error rate of 14.81 % affecting three of eight residents observed for medication administration (Residents 30, 66, and 567.) The deficient practice of failing to administer medications in accordance with the attending physician's orders increased the risk that Residents 30, 66, and 567 may have experienced health complications related to incorrect medication administration which could have negatively impacted her health and well-being. Findings: a. During an observation of the medication administration for Resident 30 on 2/8/22 at 8:33 AM, Licensed Vocational Nurse (LVN 1) was observed administering benztropine (a medication used for movement disorders) 0.5 milligrams (mg - a unit of measure for mass), docusate sodium (a stool softener) 100 mg, lamotrigine (a mood stabilizer) 100 mg, multivitamin with minerals (a vitamin supplement), and risperidone (a medication used to treat mental illness) 1 mg to Resident 30. Resident 30 was observed taking all five medications by mouth with juice. During an interview with LVN 1 on 2/8/22 at 8:38 AM, LVN 1 stated she administered five total medications to Resident 30. During a review of Resident 30's admission record (a document containing resident diagnostic and demographic information), dated 2/8/22, the record indicated she was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included anxiety disorder (a mental disorder characterized by worrisome thoughts strong enough to interfere with daily activities). During a review of Resident 30's Order Summary Report (a comprehensive list of current physician orders), dated 2/8/22, the report indicated on 11/7/21 the attending physician prescribed clonazepam (a medication used to treat anxiety) 0.25 mg to be administered by mouth twice daily for anxiety scheduled at 9:00 AM and 5:00 PM. LVN 1 failed to administer Resident 30's clonazepam. b. During an observation of the medication administration for Resident 567 on 2/8/22 at 9:03 AM, LVN 1 was observed administering carvedilol (a medication used to treat high blood pressure) 12.5 mg to Resident 567 without first checking the resident's heart rate. Resident 567 was observed taking the medication by mouth with water. During a review of Resident 567's admission Record dated 2/8/22, the record indicated he was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included hypertension (high blood pressure). During a review of Resident 567's Order Summary Report, dated 2/8/22, the report indicated on 2/2/22 the attending physician prescribed carvedilol 12.5mg by mouth twice daily for hypertension with instructions to hold (not administer) for a heart rate less than 60 beats per minute. c. During an observation of the medication administration for Resident 66 on 2/8/22 at 9:32 AM, LVN 1 was observed passing the calcitonin nasal inhaler (a medication used to treat bone weakness) to Resident 66 during his medication administration. Resident 66 was observed administering the nasal inhaler himself while LVN 1 watched nearby. LVN 1 was also observed administering lisinopril (a medication used to treat high blood pressure) 20 mg to Resident 66 without first checking his heart rate. Resident 66 was observed taking the lisinopril by mouth with water. During a review of Resident 66's admission Record, dated 2/8/22, the admission record indicated he was admitted to the facility on [DATE] with diagnoses that included osteoporosis (a medical condition causing bones to weaken and break more easily) and hypertension. During a review of Resident 66's Order Summary Report (a comprehensive list of current physician orders), dated 2/8/22, the order report indicated his attending physician prescribed calcitonin (a medication used to treat osteoporosis) nasal spray solution to administer one spray in alternating nostrils one time a day on 5/4/21 and lisinopril 20 mg by mouth every day with instructions to hold for a heart rate less than 60 beats per minute. During a review of Resident 66's physician order for calcitonin, the order indicated that the calcitonin should be clinician administered. During an interview on 2/8/22 at 9:41 AM with LVN 1, LVN 1 stated she failed to check the heart rate prior to administering carvedilol to Resident 567 and lisinopril to Resident 66. LVN stated that Resident 567 refused to have his heart rate checked and, instead of administering the carvedilol, she should have held it until she was able to measure the heart rate to ensure it was safe to give. LVN 1 stated she failed to remember to check Resident 66's heart rate prior to administering lisinopril. LVN 1 stated that it is important to check the HR prior to giving blood pressure medicine because it can lower the heart rate to unsafe levels. LVN stated that if she doesn't check the heart rate first, there is a chance that the medications could drop the resident's heart rate too low which could lead to fainting or falls with an injury. LVN 1 stated Resident 66's order for calcitonin was intended to be clinician administered which means that the nurse must administer the medication to the resident directly. LVN 1 stated she gave the medication to the resident for him to self-administer while she watched and thus failed to administer the medication to the resident directly as required by the physician order. LVN 1 stated for residents to self-administer medications, they need approval first to ensure it will be safe and effective for them to do so. LVN 1 stated there is a chance they could administer too much or too little medication or with an ineffective technique which could lead to medical problems. During an interview on 2/8/22 at 10:53 AM with LVN 1, LVN 1 stated that she failed to administer Resident 30's clonazepam this morning because she overlooked it on the list of the resident's orders. LVN stated that Resident 30 takes clonazepam for anxiety related panic attacks which if go untreated, can diminish her quality of life. During a review of the facility's policy Medication Administration-General Guidelines, dated October 2017, the policy indicated Medications are administered in accordance with written orders of the attending physician. During a review of Resident 66's Self-Administration of Drugs Assessment, dated 3/4/21, the assessment indicated the IDT did not feel Resident 66 was safe to self-administer medications. During a review of the facility's policy Self-Administration of Medications, dated April 2008, the policy indicated Residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team had determined that the practice would be safe for the resident and other residents of the facility.

CONCERN (E)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to follow lunch menu and standardized recipes when: 1. [NAME] 1 used a small scoop to serve food resulting in Residents on puree...

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Based on observation, interview, and record review, the facility failed to follow lunch menu and standardized recipes when: 1. [NAME] 1 used a small scoop to serve food resulting in Residents on puree diet and residents on mechanical soft diet receiving less protein. 2. [NAME] 1 served boiled green beans for the renal diet instead of seasoned green beans per recipe and made garlic parmesan spinach without measuring the portion of cheese needed. 3. [NAME] 1 did not have a replacement for the beef patty for vegetarian diet for the lunch. Two residents on vegetarian diet did not receive vegetarian protein equivalent with their meal. This deficient practice had the potential to affect nutrient adequacy of 16 residents on puree diet, 33 residents on mechanical soft diet and two residents on vegetarian diet and decreased food intake for residents who consumed spinach and green beans on 2/7/21 lunch meal service. Findings: 1. A review of the facility's lunch menu on 2/7/22, indicated that the following items would be served: Southern style beef patty (puree diet: use #6 scoop providing 5 1/3 ounces (oz.) of protein, mechanical soft diet: use #8 scoop providing 4 ounces (oz.) of protein), mashed potatoes ½ cup or pasta ½ cup for renal diet, garlic parmesan spinach ½ cup or seasoned green bean ½ cup for renal diet, wheat roll, margarine, ambrosia pudding 1/3 cup or mandarin oranges with coconut ½ cup for renal diet, and milk. During an observation of the tray line service for lunch on 2/7/22 at 12:00PM, for residents who were on a puree diet, the cook served pureed beef patty using #8 scoop size yielding (4oz) instead of (5 1/3oz). For residents who were on a mechanical soft minced/moist diet, the cook served ground beef patty using #10 scoop size yielding (3 ¼ oz.) instead of (4 oz.) During an interview with [NAME] (Cook1) on 2/7/22 at 12:20PM, she stated that she had the correct scoops out following the menu, but she made a mistake and used the smaller scoops to serve food. During the same observation and interview Dietary Supervisor (DS), DS verified that the small size scoop was used and stated she will provide an in-service to review the menu and the scoop sizes with staff. A review of the facility policy titled Menu (revised 2019) indicated, The standard menu will ensure nutritional adequacy of all diets, offer a variety of food in adequate amounts at each meal, and a standardized food production. 2. During an observation and interview with Cook1 on 2/7/22 at 12:00PM, the cook made spinach in the steamer and stated she will transfer the steamed spinach from the steamer to a large tray and onto the steam/hot holding table. She then stated she will mix the cheese and the melted butter pointing to the melted butter in a pot on top of the range. During the same observation, Cook1 transferred the cooked spinach to a large tray and added two # 6 (5 1/3 oz) scoops of parmesan cheese to the tray, and then added melted butter and continued adding until she was satisfied with consistency and amount of butter. Cook1 did not verify how much cheese the recipe required for spinach and didn't measure the butter. She stirred the mixture that was on the holding table and then started serving. A review of recipe for Garlic Parmesan Spinach indicated for 120 servings add 3 ¾ cups of (15 oz) of parmesan cheese. During the same observation cook2 served boiled green beans in a pot of water on the range. Cook2 stated the boiled green beans is an alternative vegetable for the renal diet. A review of the recipe for seasoned green beans indicated the directions for cooking is to drain green beans well, combine all ingredients (margarine, seasonings such as basil, rosemary or seasoning of choice, salt) and heat to serving temperatures. 3. A review of the facility's lunch menu on 2/7/22, indicated the following items would be served: Southern style beef patty, mashed potatoes ½ cup, garlic parmesan spinach ½ cup, creamy gravy, wheat roll, margarine, ambrosia pudding 1/3 cup and milk. During a tray line observation for lunch service on 2/7/22 at 12:15PM, an observation of a random resident diet order indicated vegetarian and no egg products. A vegetarian is a person who does not eat meat products. The cook served mashed potatoes ½ cup, garlic parmesan Spinach ½ cup with gravy, margarine, wheat bread and milk. There was no menu written for a vegetarian diet. During a concurrent interview and review of the lunch menu on 2/7/22 at 12:20PM, Cook1 stated there are two residents on a vegetarian diet. She added that she doesn't have anything vegetarian to serve instead of the beef patty, so she served only mashed potatoes and spinach. She stated that she usually has something else ready for vegetarian diets, but she made a mistake today and didn't prepare. She agreed that the residents on vegetarian diet did not get protein and received less food. During an interview with Registered Dietitian (RD) on 2/8/22 at 10:30AM, RD stated that the cook's spreadsheet (which includes the menu items, different diets and the portion sized served during lunch) doesn't indicate a vegetarian option, but the facility has a policy for vegetarian diets and the replacements for the meat or protein. He also stated that he will in-service the cooks regarding the vegetarian diet and other protein options. A review of facility policy titled Vegetarian and Vegan Diet (dated 2020) indicated, The Academy of Nutrition recognizes that well planned vegetarian and vegan diets are consistent with good nutritional status. A careful diet history is needed to ensure health food practices and the correct type of vegetarian.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Several food items were not dat...

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Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: 1. Several food items were not dated, labeled in the walk-in refrigerator (liquid egg, nectar thickened milk) 2. Several food items were leftover in the walk-in refrigerator past the three-day left-over timeframe. (Ten old ham and cheese sandwiches, liquid egg, and nectar thickened milk). 3. The Juice machine was covered with dried juice, the juice dispensing gun had red colored dried juice on it, the nozzle and the drip tray had juice in it and some dried juice, and one gnat (small fly) was flying around the drip tray. 4. Ice machine ice deflector (inner plastic cover in the ice storage bin) and the ice scoop and holder were dirty with white stains and streaks. 5. One Dietary aide (DA 1) did not wear facial hair restraints (beard Cover) in the kitchen. 6. Two cooks (Cook 1 and [NAME] 2) used the same glove that touched serving utensils, and cooking equipment to place bread on food during lunch observation. These failures had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness for 139 out of 180 medically compromised residents who received food from the kitchen. Findings: 1. During an observation in the kitchen on 2/7/22, at 8:45 AM there were 10 ham and cheese sandwiches stored in a large plastic container in the walk-in refrigerator with a date of 2/3/22. During a concurrent interview with [NAME] 1 (Cook1), she stated the sandwiches are for residents' snacks. She also stated that we keep leftovers for 3 days and these are old. [NAME] 1 discarded the sandwiches. During the same observation there was a medium size plastic container with liquid egg that was seasoned for French toast with no date stored in the walk-in refrigerator. There was a tray with six cups of nectar thickened milk (nectar thick milk has slightly more body than thin milk but still can pour easily). Two cups had no preparation date, one cup had preparation date of 2/5/22 and three cups had preparation dates of 2/6/22. During a concurrent interview, Cook1 stated the liquid egg for French toast was not from today and we never keep leftover liquid egg. Cook1 discarded the liquid egg. Cook1 also added that thickened milk prepared in advance should be dated. She added that these are old, and we didn't use them. [NAME] 1 discarded the cups with the thick milk. A review of facility policy titled Refrigerator/Freezer Storage (revised 2019) indicated, Leftover food or unused portions of packaged foods should be covered, dated and labeled to ensure they will used first. Leftovers will be covered, dated, labeled and discarded within 72 hours. 2. During an observation in the kitchen on 2/7/22 at 9:00 AM, the side of the juice machine had red stains and sticky dried juice. The juice dispensing gun and nozzle was dirty with dried sticky juices and the juice drip tray had juice in it and dried juice. There was one gnat flying on the counter next to the juice dispensing gun and drip tray. During a concurrent interview with Cook1, she stated that it is the responsibility of staff to clean and wipe outside of the juice machine. Cook1 looked inside the juice dispensing gun and stated this should be soaked in soap water and cleaned. She removed for cleaning. [NAME] 1 agreed that juices can attract pests such as gnats. During an interview with Dietary Supervisor (DS) on 2/7/22 at 11:00AM, she stated kitchen staff are assigned to clean the juice machine following manufactures instructions. DS stated she will provide Inservice on cleaning the juice machine and will monitor the daily cleaning of the machine. A review of the manufactures instruction for cleaning the juice machine, indicated to wipe down the machine and counter with a clean cloth and simple green detergent. Dip the dispensing gun in warm water and clean the entire head with a brush. Use dish soap and clean water. Instructions also indicted to remove the drip tray and clean with warm water and dish soap. 3. During an observation of the facility's ice machine located in the kitchen on 2/7/22 at 9:30AM, a clean paper towel swipe of the ice storage bin ceiling and corners of the bin produced some black color residue. The residue was located around the ice storage bin door hinges and behind the inner plastic cover inside the bin where ice drops. The ice scoop was also covered with white color stains. During a concurrent interview with Cook1, she stated dietary staff clean the ice machine bin following the instructions. She agreed that the corners should be cleaned better. Cook1 stated the ice scoop doesn't look clean. She removed the ice scoop and took it to ware washing area. During an interview with Dietary Supervisor (DS) on 2/7/22 at 11:00AM, she stated that the ice machine is cleaned once a month and she would make sure to clean behind the inner plastic cover inside the bin. 4. During an observation in the kitchen on 2/7/22 at 11:30AM Dietary Aide 1 (DA1) was wearing an N95 mask in the food preparation and service area. His facial hair was not covered with a beard cover. DA1 had a full beard. During a concurrent interview with DS and DA1, DS stated that we do have beard covers but we stopped using since we started wearing 95. DS continue that DA1 should wear a beard cover over his 95 mask. DS also stated she will provide Inservice regarding hair covers. A review of Food Code 2017 indicates Food Employees shall wear hair restrains such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens and unwrapped single service and single use articles. During a lunch service observation on 2/7/22 at 12:00 PM [NAME] 1 and [NAME] 2 were placing bread on top of the beef patty with gloved hands. [NAME] 1 was serving plates, touching serving utensils, Cook1 went to the steamer and opened the door touching the handle to remove the vegetables. Cook1 returned with the vegetables, opened a container of cheese and preprepared the vegetables for lunch. After she was done, she did not change gloves and wash her hands, but she continued to serve bread with the same gloves. Cook 2 also was wearing gloves as she left to get bread and cheese and make grilled cheese sandwiches. [NAME] 2 touched the knobs of the range and cooking utensils, after she was done, and continued serving bread with the same gloves. During a concurrent interview with Cook1 and [NAME] 2, [NAME] 1 sated she should use a utensil to serve bread. During an interview with DS on 2/7/22 at 12:05PM, DS stated that Cook1 and [NAME] 2 should use utensil to serve bread. She added that she will provide in service on hand hygiene and glove use. A review of 2017 U.S. Food and Drug Administration Food Code, notes that pathogens can be transferred to food from utensils that have been stored on surfaces which have not been cleaned and sanitized. Food that comes into contact directly or indirectly with surfaces that are not clean and sanitized is liable to such contaminations. The handles of utensils are particularly susceptible to contamination. The food Code defines gloves as a Utensil and therefore gloves must meet the applicable requirements related to utensils.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement their infection prevention and control polic...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement their infection prevention and control policies for the following: 1.Nursing staff failed to donn (to put on) appropriate Personal Protective Equipment (commonly referred to as PPE is equipment worn to minimize exposure to hazards that cause serious workplace injuries and illness, PPE includes items such as gloves, gowns and safety glasses), for Resident 422 who is on transmission based precautions (implemented for residents with documented or suspected diagnoses where contact with the resident, their body fluids, or their environment presents a substantial transmission risk) for Covid-19 (a contagious disease caused by severe acute respiratory syndrome coronavirus 2). 2.License staff failed to monitor and document oxygen saturation (Levels of oxygen in your blood), temperature, and respiratory rate (breaths taken per minute), every four (4) hours, for two (2) of two (2) residents who are positive for Coronavirus disease (Covid 19-a respiratory disease causing severe illness and is easily spread from person to person) as indicated per physician orders. 3.Certified Nurse Assistant (CNA) 1, was observed not wearing gown, not wearing appropriate N95 mask (protective mask that covers the mouth and nose to protect against airborne diseases) she was fit tested for, and not sanitizing hands when entering Resident 19's room who is in the yellow zone (designated are for exposed Covid-19 Residents) 4.In the yellow zone, multiple staff were observed providing patient care without donning and doffing (removing) PPE and not performing hand hygiene before and after patient care. These deficient practices had the potential to further spread Covid-19 causing severe illness affecting the residents health and possibly require hospitalization. Findings: 1. During a review of Resident 422's admission Record dated 2/2/22, the admission Record indicated, Resident 422 was admitted with diagnoses not limited to acute respiratory failure (a condition that develops when the lungs cannot remove carbon dioxide from the blood) with hypoxia ( a below normal level of oxygen in the blood), chronic obstructive pulmonary disease a group of diseases that cause airflow blockage and breathing related problems) with (acute) exacerbation ( an increase in the severity of a problem), heart failure ( a progressive heart disease that affects pumping action of the heart muscles) and acute kidney failure (an abrupt reduction in the kidneys ability to filter waste products) . During a review of Resident 422's History and Physical dated 2/2/22, the History and Physical indicated, resident 422 had the capacity to understand and make decisions. During an observation on 2/10/22 at 8:43 a.m. Certified Nursing Assistant 10 (CNA 10) knocked on the door of Resident and entered the room of Resident 422 in the yellow zone not wearing a gown. CNA 10 was holding a gown in her hand and began to put on the gown on inside of the Resident's room. During an observation on 02/10/22 at 08:50 a.m. Respiratory Therapist 2 (RT 2) the entered room with gown in gloves on. During an observation on 0/10/22 at 8:56 a.m. Licensed vocational Nurse 10 (LVN 10) entered Resident 422's room without a gown, then abruptly left the room when she saw a surveyor. During an interview on 2/10/22 at 9:13 a.m. with CNA 10, CNA 10 stated she had training on gowning and total care. When asked what the process is prior to entering a resident's room on contact precautions, CNA 10 stated she puts on a gown, washes hands, and applies gloves prior to entering a resident's room. During an interview on 2/10/22 at 10:26 a.m. with Licensed Vocational Nurse 11 (LVN 11) stated, prior to entering a resident's room staff should knock on the resident's door introduce self, explain procedures, and care, and put on a gown and gloves prior to entering a resident's room. LVN 11 further stated staff need to where gowns for residents placed in contact isolation because a resident could develop covid or any infection from the staff since the facility has an outbreak. During a review of the policy titled Infection Control (undated), the Infection Control Policy indicated for residents on Contact Precautions gowns and gloves are to be worn when providing care or working with environmental surfaces. 2. During a review of Resident 64's admission record (facesheet), dated 2/10/2022, the facesheet indicated, Resident 64 has a history of dementia (impairment of memory and judgement), osteoarthritis (the wearing down of the protective tissues of the bone), cardiac arrhythmia (irregular heartbeat), anemia (lack of red blood cells), and repeated falls. During a review of Resident 57's facesheet, dated on 2/9/2022, the facesheet indicated Resident 57 has a history of fracture of the right femur (a crack in the thigh bone), hypertension (high blood pressure), and hyperlipidemia (high levels of fats in the blood) During a review of Resident 64's history and physical (H&P), dated 1/23/2021, the H&P indicated, Resident 64 has the capacity to understand and make decisions During a review of Resident 57's H&P, dated 8/24/2021, the H&P indicated Resident 57 has the capacity to under and make decisions. During a review of Resident 64's Minimum Data Set (MDS-a standardized care screening and assessment tool) dated on 11/31/2021 indicated Resident 64's speech, hearing and vision was intact. Resident 64's cognitive skills (thought process) was intact and has the ability to understand others and is easily understood. Resident 64 is independent with supervision with activities of daily living (ADLs-basic self-care activities) in the areas of bed mobility, eating, toilet use bathing, and personal hygiene. During a review of Resident 57's MDS dated on 11/30/2021 indicated Resident 57's speech, hearing and vision was intact. Resident 57's cognitive skills (thought process) was intact and has the ability to understand others and is easily understood. Resident 57 is totally dependent (unable to perform activities independently) with one (1) to two (2) person assist with ADLs in the areas of bed mobility, eating, toilet use, bathing and personal hygiene. During a review of Resident 64's order summary report dated on 2/9/2022 indicated Resident 64 has physician orders to monitor for signs and symptoms of Covid-19 and document temperature, respiratory rate, and oxygen saturation every four (4) hours. During a review of Resident 57's order summary report dated on 2/10/2022 indicated Resident 57 has physician orders to monitor for signs and symptoms of Covid-19 and document temperature, respiratory rate, and oxygen saturation every four (4) hours. During a review of Resident 64's medical administration record (MAR) dated on 2/9/2022 indicated Resident 64 was not monitored for signs and symptoms of Covid-19 every 4 hours for the following dates: 1. 2/2/2022 2. 2/3/2022 3. 2/4/2022 4. 2/6/2022 5. 2/7/2022 6. 2/8/2022 During a review of Resident 57's medical administration record (MAR) dated on 2/9/2022 indicated Resident 57 was not monitored for signs and symptoms of Covid-19 every 4 hours for the following dates: 1. 2/2/2022 2. 2/3/2022 3. 2/4/2022 4. 2/6/2022 5. 2/7/2022 6. 2/8/2022 7. 2/9/2022 During a review of Resident 64's laboratory results dated on 2/9/2022 indicated Resident 64 has a positive Covid-19 result During a review of Resident 57's interdisciplinary team meeting notes dated on 1/28/2022 indicated Resident 57 tested positive for Covid on 1/25/2022 and result was received on 1/27/2022. Resident 57 will be placed on droplet, contact isolation precaution, and will quarantine for fourteen (14) days. During a concurrent interview and record review with Infection Preventionist (IP) on 2/9/2022 at 3:33 p.m., the facilities Covid-19 Mitigation Plan Policy (facilities plan of action for Covid-19) was reviewed. IP stated that she had little involvement in the facilities Covid-19 Mitigation Plan, but she has reviewed the policy and has made suggestions. IP stated that all residents who are in the red zone (area where Covid-19 positive residents are placed) should have their oxygen levels, respiratory rate and temperature monitored and documented every 4 hours. IP stated even if the Covid-19 Mitigation Plan policy does disclose that residents should be monitored every 4 hours it is a standard physicians orders and it should be followed. During an interview with IP on 2/10/2022 at 11:43 a.m., IP stated it is important to monitor and document the oxygen levels, temperature, and respiratory rate for the residents in the red zone because a lot of the residents have underlying diseases and their health could deteriorate quickly. If the license nurses are not monitoring and documenting their findings for the residents, the resident's health could become unstable and turn out to be a big cascade of events, or possibly death. IP stated, it is not acceptable that nursing staff is not monitoring and documenting their findings for the residents in the red zone. 3. A review of Residents 19's admission record, indicated the resident was admitted to the facility on [DATE], with diagnosis including depressive disorder and hyperlipidemia (high cholesterol) During a review of Resident 's H/P dated 1/21/2022, indicated Resident 19, had the capacity to understand and make decisions. During a review of Resident 19's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 12/20/2021, the MDS indicated Resident 19 had the ability to make himself understood and understood others. During a concurrent observation on 2/7/2022 at 12:13 p.m., CNA1 entered room [ROOM NUMBER]A in the yellow zone and was within three feet of resident without gown. CNA1 was wearing a green N95mask below his nose. During an observation on 2/7/2022 at 12:13 p.m., CNA4 entered room [ROOM NUMBER]A in the yellow zone and was within three feet of resident without gown dropping off a brown bag. During an observation on 2/7/2022 at 12:15 p.m., SSD entered room [ROOM NUMBER]A in the yellow zone and was within three feet of resident without gown. SSD started handling brown bag next to resident. During an observation on 2/7/2022 at 12:18 p.m., CNA2 entered room [ROOM NUMBER] bed in the yellow zone and was within three feet of residents in the room without gown. CNA2 started wearing a gown once next to the bed of resident. At 12:23 p.m. CNA2 went into the room without wearing gown. During an interview with Resident 19 on 2/7/2022 at 12:42 p.m., Resident stated staff did not wear gowns nor gloves when entering his room and provide care. During an observation on 2/7/2022 at 12:18 p.m., CNA1 was feeding a resident in room [ROOM NUMBER]A with a green N95 below his nose. During a concurrent observation and interview on 2/7/2022 at 3:46 p.m., CNA3 was observed entering a room in the yellow zone without gown and without gloves. CNA3 was bringing lunch at the bedside table to room [ROOM NUMBER]A. CNA3 stated he was supposed to wear gown, mask and eye protection while being six feet within residents. CNA3 stated he needed to wear proper protective equipment to protect himself and others, he stated without proper protection he could contaminate those around him. During an interview on 2/8/2022 at 10:28 p.m., CNA2 stated she did not know what PPE was. CNA2 could not state the importance of wearing PPE. During a concurrent observation and interview on 2/9/2022 at 8:06 a.m., observed CNA6 delivering a food tray to resident 19 did not wear gown, did not performed hand hygiene after exiting room. CNA6 stated he was supposed to wear a gown and sanitized hands when entering and exiting room, but it was difficult to wear gowns when they were not readily available. CNA6 stated that not wearing proper PPE and not sanitizing hands could increase the spread of COVID to other residents, staff, and community. During a concurrent observation and interview on 2/9/2022 at 1:44 p.m., IP stated eye protective equipment, gown, gloves and N95 mask should be always worn when staff is within 6 feet of residents. IP stated it was important to have PPE readily available for staff to maintain compliance. During a walkthrough of facility rooms 111, 112, 110, 109, 108, 106,106, 14, 131, 140 128, 127, 124, 123, 120, 3, 2, 117, 38, 37, 33, 35, 34, 32, 26, 31, 30,24, 29, 28, 22 and 17 did not have clean PPE containers readily available for staff. IP stated staff had to wear N95 mask that they were fit tested for, in the facility. IP stated it was important to wear N95 per OSHA (California Division of Occupational Safety and Health) guidance's. Currently they only had the white N95 masks for staff. IP stated she had 41 residents confirmed positive covid and for that week there were 6 new cases. IP stated not complying with proper PPE usage and hand hygiene could increase the transmission of COVID-19 to other residents, staff, and community. IP stated COVID-19 virus was very dangerous, and it could lead to hospitalizations and death. During a concurrent interview and record review of N95 Respirator Fit Test Record with IP, on 2/9/2022 at 3:34 p.m., CNA1 did not have an N95 fit testing done. IP stated not being fit tested can transmit or catch COVID-19 virus. 4. A review of Resident 121's admission record (face-sheet) indicated Resident 121 was admitted to the facility on [DATE] and re-admitted on [DATE], with diagnoses of failure to thrive (syndrome of weight loss, decreased appetite and poor nutrition, and inactivity, often accompanied by dehydration, depressive symptoms, and impaired immune function), and Pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) of sacral region. A review of Minimum Data Set (MDS, a standardized assessment and care planning tool), for Resident 121 dated 1/3/2022, indicated Resident 121's cognitive skills for daily decision making were not intact and required total dependance care assistance from staff for activities of daily living. ON 2/7/2022 at 10:46 a.m. during an observation in the yellow zone hallway, observed certified nurse attendant 7 (CNA 7) enter room [ROOM NUMBER] and room [ROOM NUMBER] in the yellow zone, did not perform hand hygiene and did not put any PPE's on. On 2/7/2022 at 10:49 a.m., during an observation in the yellow zone hallway, observed LVN 11, treatment nurse exit room [ROOM NUMBER] wearing a yellow gown, gloves, mask, shield and did not perform hand hygiene. LVN 11 grabbed her treatment cart and proceeded to enter room [ROOM NUMBER]. LVN 11 entered room [ROOM NUMBER] wearing the same Personal protective equipment (PPE) from room [ROOM NUMBER]. There were no PPE signs on the door for room [ROOM NUMBER]. On 2/7/2022 at 11:00 a.m., during an observation and interview in room [ROOM NUMBER], LVN 11 was providing skin care on resident 121's sacral decubiti's ulcer and proceeded to change resident's diaper and grabbed a new diaper without removing dirty gloves. LVN 11 treated decubiti's ulcer on the left side of the back of resident 121 and continued with fastening diaper, repositioning resident, touching linen, and bed rails without removing used gloves. Treatment nurse stated that she was supposed to change gloves after providing skin care, but she did not bring enough gloves into the room and because she was nervous. LVN 11 exited room [ROOM NUMBER] without performing had hygiene. On 2/7/2022 at 11:12 a.m., during an interview with charge nurse (LVN 2), LVN 2 stated that staff should wear a gown, mask, shield, and gloves before entering a yellow zone room. LVN 2 stated that PPE's cart should be readily available outside each room. LVN 2 stated that she did not know why there wasn't any carts outside room [ROOM NUMBER], 102, and 103. On 2/8/2022 at 10:11 a.m., during an observation and interview, Housekeeper 1 entered room [ROOM NUMBER] without performing hand hygiene and exited room without performing hand hygiene. Housekeeping stated she understands the importance of PPE's is to protect the resident's and herself but did not know that hand hygiene was part of the protection. On 2/9/2022 at 10:00 a.m., during an observation in the yellow zone hallway, CNA 8 was wearing PPE's and exited room [ROOM NUMBER] and walked to room [ROOM NUMBER] to get the soiled linen cart and the clean linen cart and took it to room [ROOM NUMBER]'s doorway and reentered room [ROOM NUMBER]. CNA 8 came out of room [ROOM NUMBER] wearing PPE's, opened clean linen cart and grabbed some clean linen while wearing gloves. CNA 8 was wearing a mask that the facility does not offer to staff but CNA 8 said he was fit tested for it. On 2/10/2022 at 9:19 a.m., during an observation in the yellow zone hallway, CNA 8 exited room [ROOM NUMBER] wearing a yellow gown, mask, face shield, and gloves. He walked outside of room to get soiled linen cart and went back into room [ROOM NUMBER].

CONCERN (F)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected most or all residents

Based on observation, interview, and record review the facility failed to: 1. Ensure unopened insulin (a medication used to control high blood sugar) was stored in the refrigerator per the manufacture...

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Based on observation, interview, and record review the facility failed to: 1. Ensure unopened insulin (a medication used to control high blood sugar) was stored in the refrigerator per the manufacturer's requirements in seven (7) out of seven (7) medication carts (Station 1 Cart, Station 2 Cart, Station 1 & 2 Extender Cart, Station 3 Cart, Sub-Acute Cart 1, Sub-Acute Cart 2, Station 5 Cart) affecting residents 10, 56, 60, 68, 76, 77, 82, 119, 132, 136, 150, 152, 163, and 569. 2. Ensure liquid medications requiring refrigeration were stored in the refrigerator per the manufacturers or pharmacy's requirements in two out of seven medication carts (Station 1 Medication Cart and Sub-Acute Medication Cart 2) affecting residents 13 and 74. 3. Remove expired insulin from the cart in two of seven medication carts (Station 1 Medication Cart and Sub-Acute Medication Cart 2.) affecting Residents 12 and 136. These deficient practices of failing to store or label medications per the manufacturer's requirements and remove expired medications from the medication carts increased the risk that Residents 10, 12, 13, 56, 60, 68, 74, 76, 77, 82, 119, 132, 136, 150, 152, 163, and 569 could have received medication that had become ineffective or toxic due to improper storage or labeling possibly leading to health complications resulting in hospitalization or death. Findings: During a concurrent interview and observation on 2/7/22 at 2:15 PM of the Station 1 Medication Cart with Licensed Vocational Nurse (LVN 5), the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications: 1. One Lantus Solostar (a type of insulin) and one Admelog Solostar (a type of insulin) pen for Resident 12 were found labeled with an open date of 1/2/22. Per the manufacturer's product labeling, Lantus Solostar and Admelog insulin pens should be discarded 28 days after opening. 2. One unopened insulin lispro Kwikpen (a type of insulin) for Resident 150 was found not labeled with an open date and stored at room temperature. Per the manufacturer's product labeling, unopened insulin lispro Kwikpens should be stored in the refrigerator. 3. One unopened vial of Humalog (a type of insulin) insulin for Resident 68 was found not labeled with an open date and stored at room temperature. Per the manufacturer's product labeling, unopened vials of Humalog insulin should be stored in the refrigerator. 4. One bottle of compounded (custom made by the pharmacy) metoprolol (a mediation used to treat high blood pressure) 10 milligrams (mg - a unit of measure for mass) per milliliter (ml - a unit of measure for volume) suspension was found stored at room temperature. Per the pharmacy labeling on the bottle, metoprolol 10 mg/ml suspension should be stored in the refrigerator. LVN 5 stated that insulin must be stored in the refrigerator if it is unopened. LVN 5 stated that once opened or stored at room temperature it would only be good for around 28 days and must be labeled with an open date. LVN 5 stated that medications must be stored in the refrigerator if specified by the pharmacy or they may not be safe to administer to residents. LVN 5 stated that if insulin is not stored properly, there is a risk that it may not be effective at controlling blood sugar levels when administered with residents. LVN 5 stated that if insulin is ineffective at controlling blood sugar levels, it is possible that the residents may experience health complications possibly leading to hospitalization or death. During a concurrent observation and interview on 2/7/22 at 2:30 PM of the Station 1 & 2 Extender Cart with LVN 5, the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications: 1. One unopened Humulin 70/30 (a type of insulin) Kwikpen for Resident 82 was found not labeled with an open date and stored at room temperature. Per the manufacturer's product labeling, unopened Humulin 70/30 Kwikpens should be stored in the refrigerator. During a concurrent observation and interview on 2/7/22 at 2:38 PM of the Station 2 Medication Cart with LVN 1 the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications: 1. One unopened Novolog Flexpen (a type of insulin) for Resident 132 was found not labeled with an open date and stored at room temperature. Per the manufacturer's product labeling, unopened Novolog Flexpen should be stored in the refrigerator. 2. One unopened Insulin Aspart Flexpen (a type of insulin) for Resident 82 was found not labeled with an open date and stored at room temperature. Per the manufacturer's product labeling, unopened Insulin Aspart Flexpen should be stored in the refrigerator. 3. One unopened lispro Kwikpen (a type of insulin) and one unopened vial of Novolin R (a type of insulin) for Resident 76 was found not labeled with an open date and stored at room temperature. Per the manufacturer's product labeling, unopened lispro Kwikpens and vials of Novolin R should be stored in the refrigerator. 4. One unopened vial of Humulin R (a type of insulin) for Resident 10 was found not labeled with an open date and stored at room temperature. Per the manufacturer's product labeling, unopened vials of Humulin R should be stored in the refrigerator. 5. Two unopened vials of Humulin R for Resident 77 were found not labeled with an open date and stored at room temperature. Per the manufacturer's product labeling, unopened vials of Humulin R should be stored in the refrigerator. 6. One unopened vial of Humulin R for Resident 56 was found not labeled with an open date and stored at room temperature. Per the manufacturer's product labeling, unopened vials of Humulin R should be stored in the refrigerator. 7. One unopened vial of Novolin R for Resident 82 was found not labeled with an open date and stored at room temperature. Per the manufacturer's product labeling, unopened vials of Novolin R should be stored in the refrigerator. 8. One unopened vial of Humulin R for Resident 119 was found not labeled with an open date and stored at room temperature. Per the manufacturer's product labeling, unopened vials of Humulin R should be stored in the refrigerator. LVN 1 stated that insulin is supposed to be stored in the refrigerator if it is unopened otherwise it might not work when the resident needs it. LVN 1 stated that there is a chance that the residents could suffer from impaired blood sugar if their insulin doesn't work as expected. During a concurrent interview and observation on 2/8/22 at 2:33 PM of the Sub-Acute Medication Cart 2 with LVN 4 the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications: 1. One Admelog Solostar pen for Resident 136 was found with an open date of 12/12/21. Per the manufacturer's product labeling, Admelog Solostar insulin pens should be discarded 28 days after opening. 2. One unopened Admelog Solostar pen for Resident 136 was found not labeled with an open date and stored at room temperature. Per the manufacturer's product labeling, unopened Admelog Solostar pens should be stored in the refrigerator. 3. One bottle of gabapentin (a medication used to treat nerve pain) 250 mg/5ml solution for Resident 13 was found stored at room temperature. Per the manufacturer's product labeling, gabapentin 250 mg/5ml solution should be stored in the refrigerator. LVN 4 stated the Admelog pen for Resident 136 was opened on 12/12/21 and expired 28 days after opening on 1/9/22. LVN 4 stated she did not receive the new undated pen for him until 2/7/22. LVN 4 stated she administered a dose to Resident 136 today from the undated pen but failed to remove the expired pen from the cart and failed to record an open date on the new pen. LVN 4 stated it appears that from 1/9/22 to 2/7/22, the resident received many doses of expired Admelog from multiple licensed staff. LVN 4 stated if insulin is expired, it may not work to control blood sugar levels and could cause medical complications like coma, leading to hospitalization or death. LVN 4 stated she administered the gabapentin solution to Resident 13 around 2:00 PM today and put it back in the cart intending to return it to the refrigerator later. LVN 4 stated that she should have returned it directly to the refrigerator after administering it to the resident to ensure it was not forgotten. LVN 4 stated that using medications that have not been stored at the correct temperature could cause them to be ineffective resulting in possible medical complications to the residents. During a concurrent interview and observation on 2/9/22 at 11:35 AM of the Station 5 Medication Cart with LVN 3, the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications: 1. One unopened vial of Novolin R for Resident 163 was found not labeled with an open date and stored at room temperature. Per the manufacturer's product labeling, unopened vials of Novolin R should be stored in the refrigerator. LVN 3 stated unopened vials of insulin are to be kept in the refrigerator. LVN 5 stated if insulin is not stored properly, it may not work to adequately control blood sugar which could lead to medical complications for residents. During a concurrent interview and observation on 2/9/22 at 12:10 PM of the Sub-Acute Medication Cart 1 with LVN 6, the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications: 1. One unopened vial of Humulin R for Resident 569 was found not labeled with an open date and stored at room temperature. Per the manufacturer's product labeling, unopened vials of Humulin R should be stored in the refrigerator. LVN 6 stated she took the vial of Humulin R for Resident 569 out of the refrigerator because she was about to check the resident's blood sugar and wanted to have it ready to administer it if necessary. LVN 6 stated it should have stayed in the refrigerator until she confirmed she needed to administer it. LVN 6 stated that unopened insulin must stay refrigerated to ensure it works properly when given. LVN 6 stated that giving insulin that doesn't work properly may lead to medical complications due to poor blood sugar control. During a concurrent interview and observation on 2/9/22 at 1:31 PM of the Station 3 Medication Cart (red zone cart) with LVN 7, the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications: 1. One unopened vial of Humulin R for Resident 152 was found not labeled with an open date and stored at room temperature. Per the manufacturer's product labeling, unopened vials of Humulin R should be stored in the refrigerator. LVN 7 stated that the Humulin R should be stored in the refrigerator since it is unopened. LVN 7 stated that if insulin is not stored properly, it might not work correctly for the resident to control blood sugar. LVN 7 stated that if blood sugar levels are out of control, the resident may experience medical complications leading to hospitalization. During a review of the facility's policy Medication Storage in the Facility, dated April 2008, the policy indicated Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . Medications requiring 'refrigeration' or 'temperatures between 2C (36F) and 8C (46F)' are kept in a refrigerator with a thermometer to allow temperature monitoring . Outdated, contaminated, or deteriorated medications . are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists.

LONGWOOD MANOR CONV.HOSPITAL

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LONGWOOD MANOR CONV.HOSPITAL

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