What is MONTEBELLO CARE CENTER's CMS rating?

MONTEBELLO CARE CENTER has a one-star overall rating from CMS (Centers for Medicare & Medicaid Services), based on health inspections, staffing levels, and quality measures.

Does MONTEBELLO CARE CENTER have any serious inspection findings?

Yes, MONTEBELLO CARE CENTER has 2 Immediate Jeopardy citations on record, which represent the most serious type of deficiency. The facility has 70 total deficiencies from recent inspections.

What are the staffing levels at MONTEBELLO CARE CENTER?

MONTEBELLO CARE CENTER has a three-star staffing rating from CMS with 0.34 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 MONTEBELLO CARE CENTER located?

MONTEBELLO CARE CENTER is located in MONTEBELLO, CA. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does MONTEBELLO CARE CENTER have?

MONTEBELLO CARE CENTER has 99 certified beds.

Who owns MONTEBELLO CARE CENTER?

MONTEBELLO CARE CENTER is a for profit - limited liability company facility and is part of the GENESIS HEALTHCARE chain.

Is MONTEBELLO CARE CENTER safe?

MONTEBELLO CARE CENTER has documented safety concerns including 2 immediate jeopardy citations. Families should ask about corrective actions taken.

Do nurses at MONTEBELLO CARE CENTER stick around?

MONTEBELLO CARE CENTER has low staff turnover at 28%, which means caregivers stay longer and know residents better.

Was MONTEBELLO CARE CENTER ever fined?

Yes, MONTEBELLO CARE CENTER has been fined $28,592 by federal regulators. Fines are issued for serious violations of Medicare and Medicaid requirements.

Is MONTEBELLO CARE CENTER on any federal watch list?

No, MONTEBELLO CARE CENTER 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 MONTEBELLO CARE CENTER?

Medicare inspectors have found 70 deficiencies at MONTEBELLO CARE CENTER: 2 critical, 1 serious, 66 moderate, 1 minor. Each deficiency represents a violation of federal nursing home requirements.

What questions should families ask when visiting MONTEBELLO CARE CENTER?

Families visiting MONTEBELLO CARE CENTER should ask about how serious violations have been addressed. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does MONTEBELLO CARE CENTER compare to other nursing homes?

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

MONTEBELLO CARE CENTER

Name: MONTEBELLO CARE CENTER
Address: 1035 W BEVERLY BLVD, MONTEBELLO, CA, 90640, US
Telephone: (323) 724-1315
Rating: 1.0

1035 W BEVERLY BLVD, MONTEBELLO, CA 90640 · (323) 724-1315

For profit - Limited Liability company 99 Beds GENESIS HEALTHCARE Data: November 2025 2 Immediate Jeopardy citations

Trust Grade

9/100

#1069 of 1155 in CA

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MONTEBELLO CARE CENTER nursing home in MONTEBELLO, CA - Photo 1 of 4

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MONTEBELLO CARE CENTER nursing home in MONTEBELLO, CA - Photo 2 of 4

Photo by Cynthia Martinez

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Last Inspection: April 2025

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

Overview

Montebello Care Center has a Trust Grade of F, indicating significant concerns about the quality of care provided. Ranked #1069 out of 1155 facilities in California, it falls in the bottom half of nursing homes in the state, and at #324 out of 369 in Los Angeles County, only a few local options are worse. The facility’s trend is stable with 22 issues reported in both 2024 and 2025, but this stability does not indicate improvement. Staffing is rated average with a turnover rate of 28%, which is better than the California average, and there is average RN coverage, meaning they have enough registered nurses to help monitor residents effectively. However, the facility has faced serious issues, including a critical incident where a resident was physically abused by another resident, and a serious error where medications meant for one resident were given to another, resulting in adverse effects that required hospitalization. While staffing levels seem acceptable, the serious deficiencies raise significant concerns about the overall quality of care.

Trust Score: F
In California: #1069/1155
Safety Record: High Risk
Inspections: Holding Steady
Staff Stability: 28% annual turnover. Excellent stability, 20 points below California's 48% average. Staff who stay learn residents' needs.
Penalties: $28,592 in fines. Lower than most California facilities. Relatively clean record.
Skilled Nurses: Each resident gets only 20 minutes of Registered Nurse (RN) attention daily — below average for California. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 70 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★★☆☆

3.0

Staff Levels

★★★★☆

4.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 22 issues

2025: 22 issues

The Good

4-Star Quality Measures · Strong clinical quality outcomes
Low Staff Turnover (28%) · Staff stability means consistent care
Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record
Staff turnover is low (28%)
20 points below California average of 48%

Facility shows strength in quality measures, staff retention, fire safety.

The Bad

1-Star Overall Rating

Below California average (3.1)

Significant quality concerns identified by CMS

Federal Fines: $28,592

Below median ($33,413)

Moderate penalties - review what triggered them

Chain: GENESIS HEALTHCARE

Part of a multi-facility chain

Ask about local staffing decisions and management

The Ugly 70 deficiencies on record

2 life-threatening 1 actual harm

Jul 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 6) received treatment and care in accordance with professional standards of practice (guidelines and expectations that define competent and ethical conduct within specific profession) by failing to complete medication reconciliation (the process of verifying and updating a patient's medication list during the transition from hospital to home or another care setting) of Resident 6's Discharge Medication List from General Acute Care Hospital (GACH 2) to administer the resident's Terazosin (a medication used in men to treat symptoms of benign prostatic hyperplasia [BPH-also known as an enlarged prostate], which include difficulty urinating, painful urination, and urinary frequency and urgency) once a day to start on 1/28/2025 at 9 PM. This failure could lead to worsening of the Resident 6's BPH and hospitalization.Findings: During a review of Resident 6's admission Record, the admission Record indicated the facility admitted Resident 6 on 1/28/2025, with diagnoses including but not limited to urinary retention (the inability to completely or partially empty the bladder) and BPH. During a review of Resident 6's Minimum Data Set (MDS-a resident assessment tool), dated 1/31/2025, it indicated Resident 6 had intact cognitive skills (ability to think, understand and reason) for daily decision making. The MDS also indicated Resident 6 required set up or clean up assistance (Helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) with eating, oral and personal hygiene. The MDS indicated Resident 6 also required substantial or maximal assistance (Helper lifts or holds trunk or limbs and provides more than half the effort) with shower/bathing self and upper body dressing and dependent (Helper does all the effort. Resident does none of the effort to complete the activity or the assistance of two or more helpers is required for the resident to complete the activity) with toileting hygiene, lower body dressing, and putting on/taking off footwear. During a concurrent interview and record review on 7/17/2025 at 5:14 PM with the Director of Nursing (DON), the External Facility Discharge Medication List from General Acute Care Hospital (GACH 2) dated 1/26/2025, Resident 6's Medication Administration Record (MAR) from the facility dated January 2025, and Resident 6's Order Summary Report from the facility dated1/28/2025 to 4/30/2025 were reviewed. The External Facility Discharge Medication List from GACH 2 dated 1/26/2025 indicated terazosin 5 mg (milligram-a unit of mass or weight equal to one thousandth of a gram) orally once a day, next dose on 1/28/2025 at 9 PM. Resident 6's MAR and Order Summary Report for January 2025 to April 2025, did not indicate there was an order for terazosin nor it was given to Resident 6 from 1/28/2025 to 4/24/2025 The DON stated the terazosin order that was in Resident 6's External Facility Discharge Medication List from GACH 2 was not reconciled in the physician's order when the resident was admitted at the facility on 1/28/2025. The DON stated that since it was not reconciled, it would not be in the order summary and MAR and Resident 6 did not receive the terazosin during the resident's stay in the facility from 1/28/2025 to 4/24/2025. During an interview on 7/17/20265 at 5:25 PM with the DON, the DON stated, Resident 6's missing medication that was not reconciled from the discharge medication list was not acceptable as it will affect the residents' health and safety and residents are put at risk for experiencing complications for not having received the medications. Resident 6's BPH symptoms could end up getting worse and affect Resident 6's overall health. The DON stated RN 1 could not explain why the terazosin order was not reconciled in Resident 6's Order Summary. The DON stated there were 87 doses of Terazosin that was not given to Resident 6, from 1/28/2025 to 4/24/2025 because the resident's discharge medication list for GACH 2 was not reconciled correctly. During a concurrent interview and record review on 7/18/2025 at 10 AM with Resident 6's attending physician (MD), the External Facility Discharge Medication List from GACH 2 was reviewed. The discharge medication list from GACH 2 reflected order for terazosin to give once a day. The MD validated that terazosin was not reconciled and was not given to Resident 6 during the resident's stay in the facility from 1/28/2025 to 4/24/2025. The MD stated the terazosin was for Resident 6's BPH and resident did not receive this medication. During a review of the facility's Policy and Procedure (P&P), titled Reconciliation of Medication on Admission, revised 1/5/2025, the P&P indicated the purpose of the P&P is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. The P&P also indicated, medication reconciliation reduces medication errors and enhances resident safety by ensuring that the medications the resident needs and has been taking continue to be administered without interruption, in the correct dosages and routes, during the admission/transfer process. In addition, the P&P indicated, medication reconciliation helps to ensure that medications, routes and dosages have been accurately communicated to the Attending Physician and care team. The P&P indicated steps includes: Verify and clarify medication list with the physician Transcribe verified orders to point click care (PCC-a cloud-based healthcare technology platform that focuses on connecting care providers, services, and financial operations within the senior care and long-term care sectors) under physician orders

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to prevent accidents to one of four (Resident 1) sampled residents who was identified at risk for falls and had a history of falls in accordance with the facility's policy and procedure (P&P) titled, Fall Management by failing to:1. Ensure adequate supervision of Resident 1 was provided to prevent accidents and injury on 7/16/2025.2. Create a comprehensive resident - centered care plan (a care plan developed and implemented to meet his or her preferences and goals, and addressed the resident's medical, physical, mental, and psychosocial needs) for Resident 1's long term care plan with focus on Resident 1's risk for fall/injury which includes intervention to supervise the resident every hour from 4/1/2025 to 7/16/2025. This deficient practice resulted in Resident 1 found on the floor near the Nurse's Station and the resident lying on her right side next to her on 7/16/2025 at 4:45 AM. Resident 1 was noted to have a small skin tear on the right temple (the area on the side of the head, just above the cheekbone and below the hairline) with minimal bleeding.Findings: During a review of Resident 1's admission Record, the admission Record, the admission Record indicated Resident 1 was initially admitted on [DATE] and was readmitted on [DATE] with diagnoses that included unspecified dementia (a brain disorder that results in memory loss, poor judgment, and confusion), muscle weakness, and history of falling. During a review of Resident 1's Minimum Data Set (MDS-a resident assessment tool), dated 6/19/2025, the MDS indicated Resident 1 was assessed having severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 1 required substantial/maximal assistance (helper does more than half the effort) with eating, oral/personal hygiene, and upper/lower body dressing. Resident 1 was dependent (helper does all of the effort, resident does none of the effort to complete the activity) with roll left and right, sit to lying, lying to sitting on side of bed, and chair/bed-to-chair transfer. During a review of Resident 1's Nursing Documentation Evaluation, dated 3/23/2025, the Nursing Documentation Evaluation form indicated Resident 1's Fall Risk factor included disorientation, confusion, and visual impairment. Resident 1's Nursing Documentation Evaluation form indicated fall risk indicators were identified for Resident 1. During a review of Resident 1's Interdisciplinary Care Conference (IDT- a meeting where healthcare professionals from different disciplines collaborate to develop or review a resident's care plan), dated 7/16/2025, the IDT indicated, on 7/16/2025 at 4:45 AM, Resident is observed on right side lying position next to her wheelchair. A small skin tear is noted to the right temple with minimal bleeding observed. During an interview, on 7/18/2025, at 11:27 AM, with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 1 was at risk for falls because the resident always tried to jump and move out of bed. CNA 1 stated CNA 1 did not know if Resident 1 had a history of falls in the facility. During an interview, on 7/18/2025, at 12:04 PM, with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated he was assigned to Resident 1 the morning of 7/16/2025 when Resident 1 had a fall. LVN 1 stated Resident 1 was a fall risk and had a history of falls. LVN 1 stated, at around 4 AM, on 7/16/2025, Resident 1 woke up and was restless and anxious in bed. LVN 1 stated CNA 2 placed Resident 1 on the resident wheelchair and wheeled Resident 1 to the Nurse's Station. LVN 1 stated, at around 4:45 AM, LVN 1 was notified by Housekeeping 1 (HSK 1) that HSK 1 found Resident 1 on the floor in the Nurse's Station. LVN 1 stated Resident 1 was found lying on her right side in the Nurse's Station. LVN 1 stated Resident 1 had discoloration and skin tear on the resident's right temporal area. During an interview, on 7/18/2025, at 12:24 PM, with HSK 1, HSK 1 stated, on 7/16/2025 at around 4:30 AM, HSK 1 passed by the Nurse's Station to get the broom and saw Resident 1 sitting on her wheelchair with CNA 2 and when she returned back to the Nurse's Station, she observed Resident 1 leaning towards the right side of the resident wheelchair and did not see CNA 2 or other facility staff at the Nurse's Station. HSK 1 stated HSK 1 informed LVN 1 to check on Resident 1 because the resident could fall and when HSK1 returned to the Nurse's Station, HSK1 found Resident 1 on the floor. HSK 1 stated Resident 1 was alone in the Nurse's Station when HSK1 found Resident 1 on the floor. During a concurrent interview and record review, on 7/18/2025, at 1:01 PM, with the Director of Nursing (DON), Resident 1's long term care plan with focus on Resident 1's risk for falls with risk factors including the resident's physical behavior observed by staff of scooting (sliding in a sitting position) from her low bed onto the fall mat, revised on 3/23/2025, was reviewed. The DON stated Resident 1's care plan intervention for resident safety check every hour for proper positioning, and to address and anticipate resident's needs was cancelled on 3/23/2025. During the same concurrent interview and record review, on 7/18/2025, at 1:01 PM, with the DON, Resident 1's long term care plan with focus on Resident 1's risk for fall/injury dated 4/1/2025 was reviewed. The DON stated Resident 1 has fallen in the facility at least three times from 7/30/2024 to 1/28/2025 and that is the reason why Resident 1 cannot be left unsupervised especially when the resident is in the wheelchair. The DON stated Resident 1 had a behavior of scooting and swinging her legs. The DON stated, at approximately 4:30 AM, on 7/16/2025, HKS 1 walked by the Nurse's Station and observed Resident 1 leaning towards the right side while sitting in the wheelchair at the Nurse's Station. The DON stated CNA 2 should not have left Resident 1 unsupervised on 7/16/2025. The DON stated Resident 1 sustained a skin tear on the resident's right temple. The DON stated facility staff should monitor Resident 1's safety every hour due to the resident's history of falls. The DON stated Resident 1's long term care plan with a focus on Resident 1's risk for fall/injury, dated 4/1/2025, did not include monitoring Resident 1's safety every hour and it should be included. The DON also stated, monitoring of Resident 1's safety every hour was included in Resident 1's previous care plan for at risk for fall that was cancelled on 3/23/2025 and it should have been carried over/ added in Resident 1's care plan for risk for fall/injury. The DON stated there was no intervention in Resident 1's fall care plan for her scooting behavior. The DON stated Resident 1's care plan for risk for fall/injury was not and should have been resident-centered given Resident 1's history of falls and scooting behavior. During an interview, on 7/18/2025, at 2:36 PM, with Physical Therapist 1 (PT 1), PT 1 stated Resident 1 was not cognitively intact and had a history of restlessness. PT 1 stated Resident 1 was dependent with chair repositioning PT 1 stated supervision by facility staff was necessary for Resident 1 while she was on her wheelchair. During a review of the facility's P&P titled, Fall Management, dated 5/26/2021, the P&P indicated the purpose of the policy is to reduce risk for falls and minimize the actual occurrence of falls. The P&P indicated, under the procedure, the following:1. Identify patient's fall risk by reviewing the Nursing Documentation.2. Develop individualized plan of care.3. Review and revise care plan as indicated.4. If patient falls: update care plan to reflect new interventions. During a review of the facility's P&P, titled, Care Plan Comprehensive, dated 8/25/2021, the P&P indicated the following: An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident. Each resident's comprehensive care plan is designed to:o Build on the Resident's individualized needs, strengths, preferenceso Identify the professional services that are responsible for each element of careo Reflect currently recognized professional standards of practice for problem areas and conditions Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. When possible, interventions address the underlying source(s) of the problem area(s), rather than addressing only symptoms or triggers. The Interdisciplinary Team is responsible for evaluation and updating care plans when there has been a significant change in the residents' condition, when the desired outcome is not met, when the resident has been readmitted to the facility from a hospital stay, and at least quarterly.

Jun 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

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one (1) of 2 sampled residents (Resident 1) who was unable to carry out Activities of Daily Living (ADL - activities such as bathing, dressing and toileting a person performs daily) was provided care and services to maintain good grooming and personal hygiene. This deficient practice resulted in Resident 1's fingernails being untrimmed with sharp edges which potentially resulted in the pea size bruise on the inner corner of the resident's left eye and scratches measuring 1/4 to 1 inch to the resident's right forehead. Findings: During a review of Resident 1's admission Record, the admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included autistic disorder (a complex developmental condition involving persistent challenges with social communication, restricted interests and repetitive behavior) and dementia (a progressive state of decline in mental abilities). During a review of Resident 1's Minimum Data Set (MDS- a resident assessment tool), dated 5/17/2025, the MDS indicated Resident 1 had severe impairment in cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 1 was dependent (helper does all the effort) with toileting, shower, lower body dressing and putting on/taking off footwear. The MDS further indicated Resident 1 required substantial/maximal assistance (helper does more than half the effort) with eating, oral and personal hygiene and upper body dressing. During an observation on 6/27/2025 at 12:17 PM, Resident 1 was observed with a pea size bruise on the inner corner of the left eye and scratches on the resident's right forehead measuring approximately 1/4 to 1 inch. Resident 1 was also observed with untrimmed fingernails on both the resident's left and right hands with some sharp edges. During an interview with Certified Nursing Assistant 1 (CNA 1) on 6/27/2025 at 12:24 PM, CNA 1 also stated nail care was part of the CAN's job responsibilities and Resident 1's fingernails should be assessed daily to ensure the resident's fingernails are clean and trimmed. During an interview on 6/27/2025 at 1:50 PM, the Licensed Vocational Nurse 1 (LVN 1) stated Resident 1's fingernails should have been assessed and trimmed to ensure the resident would not continue injuring himself from the scratching. LVN 1 also stated Resident 1's fingernails should have been care planned so the problem of having long fingernails can get fixed. During an interview on 6/27/2025 at 2:20 PM, CNA 2 stated, part of the residents' skin assessment was checking the fingernails on the residents' hands and trimming them to prevent sharp edges and scratches. f. During a concurrent interview and review of Resident 1's Care Plan and the facility's Policy and Procedure (P&P) with the Director of Nursing (DON) on 6/27/2025 at 3:10 PM, the DON confirmed, the facility did not have a Care Plan on the Resident 1's behavior of scratching self and no care plan to address fingernail care. The DON stated, Care Plans serves as a guide for patient centered goals and intervention and without a care plan on scratching behavior and nail care, Resident 1 is at risk for skin injuries from untrimmed nails. The DON also confirmed the facility did not have a P&P specific to nail care but stated the ADL policy under subcategory of hygiene was a blanket statement that should include nail care. The DON also stated the CNAs should be checking the residents' nails to make sure they are clean and trimmed to prevent skin injuries. During a review of the facility's P&P titled, Activities of Daily Living, Supporting, revised March 2018, indicated that appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene.

May 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop/implement comprehensive care plan for Resident 1's Foley catheter care which was order physician on [DATE]. This failure had the potential to negatively affect the provisions of care and services for Residents 1 and had the potential to place Resident 1 at risk for left buttock pressure ulcer wound become worse, cause urine blockage, and risk of urinary tract infection. Findings: During a review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included fracture of unspecified part of neck of left femur (a break in the bone at the base of the left thigh bone, specifically in the neck region, but the exact location of the fracture within that area isn't specified. It's a hip fracture), presence of left artificial hip joint (a person has undergone a hip replacement surgery on the left side of their body, where the natural hip joint has been replaced with a prosthetic implant) and unspecified fall (descend freely by the force of gravity where the specific cause or circumstances are not known or documented). During a review of the Minimum Data Set (MDS- a resident assessment tool) dated [DATE], indicated Resident 1 had severely impaired (never/ rarely made decisions) for cognitive skills (the mental processes that allow people to think, learn, and solve problems) for daily decision making. Resident 1 is dependent, (helper does all of the effort) with the eating, oral hygiene and personal hygiene, toileting, upper and lower body dressing, change of position, and transfer, shower/bathe self. During a review of the Resident 1's Medication Administration Record (MAR) for the month of [DATE], the MAR indicated D/C Foley catheter monitoring: Monitor urine output q shift (every shift) monitor urine output every shift started on [DATE] which started from [DATE] to [DATE] for D/C Foley catheter. During a review of the Resident 1's Order Summary Report for the month of [DATE], the report indicated physician's order for indwelling catheter: Indwelling Catheter. Foley catheter size:16 FR balloon size:10 CC (a fluid measuring unit) change for blockage, leaking, pulled out, excessive sedimentation. Change catheter drainage bag as needed and every change of indwelling catheter. as needed for urinary retention start date on [DATE]. During a review of the Resident 1's Care Plan Report (CPR) for the month of [DATE], there was no care plan developed or implemented for the Foley catheter care. During a concurrent interview and record review on [DATE] at 12:56 PM with LVN 2, LVN 2 stated there was no care plan has been developed to monitor resident's urine output for Foley catheter discharge. Nursing supervisor and charge nurse should have developed the care plan for Foley catheter care when Resident 1 admitted to the facility and update or revised plan of care when there is a change in resident's condition and when there is a new order from physician. During an interview on [DATE] at 2:36 PM with medical record (MR), MR confirmed that there was no care plan for the [DATE] Foley catheter monitor and discharge foley catheter urine output monitoring for Resident 1. MR stated nurses should have developed the plan of care every time there is a new physician order or change of resident's condition to update the nursing interventions and provide better care and the appropriate monitoring of Resident 1's foley catheter care and urine output monitoring for discontinue of foley catheter. During a concurrent interview and record review on [DATE] at 4:49 PM, with the Director of Nurses (DON), DON stated nurses should have implemented a comprehensive care plan for Resident 1 to reflect the update interventions of monitoring. During a record review of the facility's policy and procedure titled, Care Plan Comprehensive, effective date [DATE], the policy indicated: The facility's interdisciplinary team, in coordination with the resident and/or his/her family or representative, must develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, physical, and mental and psychosocial needs that are identified in the comprehensive assessment. 1. Each resident' s comprehensive care plan is designed to: a. Incorporate identified problem areas. b. Incorporate risk and contributing factors associated with identified problems. c. Build on the resident's individualized needs, strengths, preferences. d. Reflect treatment goals, timetables, and objectives in measurable outcomes. e. Identify the professional services that are responsible for each element of care. f. Aid in preventing or reducing declines in the resident's functional status and/or functional levels. 2. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. 3. The resident's comprehensive care plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS). 4. Assessments of residents are ongoing and care plans are reviewed and revised as information about the resident and the resident 's condition change. 5. The interdisciplinary Team is responsible for evaluation and updating of care plans: a. When there has been a significant change in the resident's condition. b. When the desired outcome is not met. c. When the resident has been readmitted to the facility from a hospital stay; and at least quarterly.

CONCERN (D) 📢 Someone Reported This

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

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure concise, and accurate document what happened on 4/17/2025 on Weekly Summary Documentation for one (1) of two (2) sampled residents (Resident 1). This deficient practice had the potential to cause delay of precaution and care for pressure ulcer and potentially cause worsening of wounds. Findings: During a review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included fracture of unspecified part of neck of left femur (a break in the bone at the base of the left thigh bone, specifically in the neck region, but the exact location of the fracture within that area isn't specified. It's a hip fracture), presence of left artificial hip joint (a person has undergone a hip replacement surgery on the left side of their body, where the natural hip joint has been replaced with a prosthetic implant) and unspecified fall (descend freely by the force of gravity where the specific cause or circumstances are not known or documented). During a review of the Minimum Data Set (MDS- a mandated resident assessment tool) dated 4/7/2025, indicated Resident 1 had severely impaired (never/ rarely made decisions) for cognitive skills (the mental processes that allow people to think, learn, and solve problems) for daily decision making. Resident 1 is dependent, (helper does all of the effort) with the eating, oral hygiene and personal hygiene, toile personal hygiene, toileting, upper and lower body dressing, change of position, and transfer, shower/bathe self. During a review of the Change in Condition Evaluation (CCE) dated 4/13/2025 indicated Resident 1 had a new onset Grade 2 or higher pressure ulcer/injury, or progression of pressure ulcer/injury despite interventions at site # 32 left buttock with pressure injury stage 3 size 2 x 2 cm. Site # 49 for right heel DTI 4 x 5 cm, and site # 50 for left heel DTI 2 x 2 cm, family and physician had been notified, and signed by Unit Manager Registered Nurse (RN). During a review of the Resident 1's Treatment Administration Record (TAR) for the month of April 2025, the TAR indicated a wound treatment L heel DTI: Betadine swab sticks external swab 10 % (Povidone-lodine) apply to left heel topically every day shift for DEEP TISSUE INJURY for 21 days paint with betadine, cover with gauze, and wrap with kerlex roll which started from 4/14/2025 to 4/30/2025. R heel DTI: Betadine swab sticks external swab 10 % (Povidone-lodine) apply to right heel topically every day shift for DEEP TISSUE INJURY for 21 days paint with betadine, cover with gauze, and wrap with kerlex roll which started from 4/14/2025 to 4/24/2025. Left Buttock pressure injury stage 2, cleanse with normal saline (NS), pat dry, cover with form dressing every day for 21 days which started from 4/14/2025 to 4/17/2025. During a review of the Weekly Summary Documentation (WSD) dated 4/17/2025, section p for skin integrity indicated Resident 1 has no skin issues and signed by LVN 1. During a review of the Weekly Wound Assessment (WWA) provided by wound care doctor dated 4/17/2025 indicated left heel wound size is L:5 cm x W: 6 cm x D: UTD (Unstageable Full Thickness Skin or Tissue Loss - Depth Unknown), right heel wound size is L: 4 cm x W: 4 cm x D: UTD, left buttock wound size is L: 3 cm x W: 3 cm x D: 0.4 cm. During a telephone interview on 5/16/2025 at 12:26 PM with LVN 1, LVN 1 stated she did her assessment on the WSD dated 4/17/2025, but she had checked section p of skin integrity by mistake to indicate Resident 1 has no skin issues. LVN 1 stated she should have marked section p to indicate Resident 1 has skin problems to ensure documentation accuracy, and nurses can provide treatment and skin monitoring to prevent Resident 1's skin integrity worsening. During a concurrent interview and record review on 5/16/2025 at 3:13 PM with DON, DON stated WSD date 4/17/2025 was not consistent with what skin condition/ wound Resident 1 had in accordance with the wound care doctor's weekly wound assessment and TAR. DON stated nurses should have to ensure documentation accuracy in order to provide monitoring and prevent worsening of Resident 1's skin integrity and wounds on her left, right heel and left buttock area. DON stated precise documentation ensure consistent communication and provide a high-level overview of the week's progress for all residents' care. During a review of the facility's Policy and Procedure (P&P) titled Nursing Documentation, dated 6/27/2022, indicated, I. PURPOSE To communicate patient's status and provide complete, comprehensive, and accessible accounting of care and monitoring provided. II. POLICY Nursing documentation will follow the guidelines of good communication and be concise, clear, pertinent, and accurate based on the resident's/patient's (hereinafter patient) condition, situation, and complexity. Ill. PROCEDURE a. Documentation includes information about the patient's status, nursing assessment and interventions, expected outcomes, evaluation of the patient's outcomes, and responses to nursing care. b. Timely entry of documentation must occur as soon as possible after the provision of care and in confom1ance with time frames for completion as outlined by other policies and procedures. c. The patient's record specifies what nursing interventions were performed by whom, when, and where.

Apr 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

Incontinence Care (Tag F0690)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide the appropriate care and services for one (1) of two (2) sampled residents (Resident 1) who was admitted with indwelling catheter (a tube that helps drain urine from the bladder [organ inside the body that stores urine] through a drainage tube [indwelling catheter tube] into a drainage collection bag) by failing to monitor Resident 1 for signs and symptoms of urinary tract infection (UTI, an infection in the bladder/urinary tract) in accordance with the care plan and facility policy on catheter care. This deficient practice had the potential to result in the delay of treatment and care in the event Resident 1 develops a catheter associated urinary tract infection (germs enter the urinary tract through the urinary catheter and cause infection) which could result in harm, hospitalization, and death. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] with diagnoses which included urine retention (a condition in which you cannot empty all the urine from your bladder), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) on the right side, and muscle weakness. During a review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 1/31/2025, the MDS indicated Resident 1 had intact cognitive skills (ability to think, understand, and reason) for daily decision making. The MDS indicated Resident 1 dependent (helper does all of the effort, resident does none of the effort to complete the activity) in toileting hygiene, lower body dressing, and putting on/ taking off footwear. The MDS also indicated Resident 1 needed substantial/ maximal assistance (helper does more than half the effort. helper lifts, holds trunk or limbs, and provides more than half the effort) in shower/ bathe self, upper body dressing, roll left and right, sit to lying, lying to sitting on side of the bed and tub/ shower transfer. The MDS indicated Resident 1 was admitted to the facility with Indwelling catheter. During a review of Resident 1's the Physician's Order (PO), dated 1/28/2025, the PO indicated indwelling catheter: Foley catheter (type of urinary indwelling catheter) Size: 16 French unit (Fr, a unit of measurement for the catheter's diameter) Balloon Size: 10 cubic centimeters (cc- unit of measurement). Change for blockage leaking, pulled out, excessive sedimentation. Change catheter drainage bag as needed and with every change of indwelling catheter, as needed for urinary retention. During a review of Resident 1's Care Plan (CP) for Indwelling Catheter due to urinary retention and diagnosis of benign prostatic hyperplasia (BPH, also known as an enlarged prostate, is a noncancerous condition in which the prostate gland becomes larger than normal), dated 2/1/2025, the staff interventions indicated were to: Monitor for signs and symptoms of infection and report to physician Monitor urine for sediment, cloudy, odor, blood and amount Report to physician promptly if the urine contains any sediment, or blood, is cloudy or odorous, or if the resident has a fever During a review of Resident 1's Care Plan (CP) for Indwelling Catheter dated 2/3/2025, the staff interventions indicated were to: Monitor and document intake and output as per facility policy. Monitor for signs and symptoms (s/s) of discomfort on urination and frequency. Monitor/document for pain/discomfort due to catheter. Monitor/record/report to MD (doctor) for s/s of urinary tract infection (UTI- an infection in the bladder/urinary tract): pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, and altered mental status, change in behavior, change in eating patterns. During a review of Resident 1's Care Plan (CP) for sediments in resident's urine dated 4/1/2025, the e staff interventions indicated were to: Foley catheter care daily as or [NAME]. Irrigate Foley catheter with NS 100 ml as needed if heavy sedimentation. MD and family notified. Observation for S/S of UTI: fever, chills, hematuria (blood in the urine), dysuria (difficulty of urinating) and notify MD if noted. Observation for urinary retention every shift. During a concurrent observation and interview on 4/22/2025 at 9:16 AM with the Director of Nursing (DON) inside the Rehabilitation Room, Resident 1 was observed sitting on his wheelchair. Resident 1 had white colored sediments in half of the length of his indwelling catheter tubing. The DON stated Resident 1 had moderate amount of white colored sediments his indwelling catheter tubing. The DON stated the sediments will need to be flushed to prevent clogging in the indwelling catheter tubing. During an interview on 4/22/2025 at 10:23 AM with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated Resident 1 was very alert and complains about his indwelling catheter all the time. CNA 1 stated Resident 1 complaints of pain in the bladder area. During a concurrent interview and record review on 4/22/2025 at 10:58AM with Director of Staff Development (DSD), the Nurses' Progress Notes dated 4/1/2025 to 4/22/2025 were reviewed. DSD stated, she did not document anything in Resident 1's progress notes on 4/7/2025 because there was nothing wrong with Resident 1's indwelling catheter. DSD stated she did not document anything because Resident 1's urine was clear and had no sediments. DSD added Resident 1 did not complain of any pain during her shift. DSD also stated, she should have documented that Resident's indwelling catheter was monitored. During an interview on 4/22/2025 at 11:18 AM with Licensed Vocational Nurse (LVN 1), LVN 1 stated, I did not look if his (Resident 1) indwelling catheter tubing had sediments. LVN 1 stated Resident 1 had bladder discomfort sometimes. During an interview on 4/22/2025 at 11:33AM with LVN 2, LVN 2 stated the licensed nurse needs to monitor signs and symptoms of UTI for a resident with a foley catheter. LVN 2 stated the licensed nurse needs to document in the nurses' notes whether the resident has signs and symptoms of UTI or not. LVN stated if it was not documented, that means the resident was not monitored for it. During a concurrent interview and record review on 4/22/2025 at 1:33PM with the DON, the Change of Condition (COC) Evaluation, dated 4/1/2025, was reviewed. COC Evaluation indicated Resident 1 had sediments in his urine. The DON stated the licensed staff should have documentation for Resident 1's urine clarity for the sediments in his urine for 72 hours every shift. During a concurrent interview and record review on 4/22/2025 at 1:39 PM with the DON, the Daily Documentation, dated 4/1/2025 to 4/4/2025, was reviewed. The DON stated the Daily Documentation did not reflect any monitoring of Resident 1's urine for sediments on 4/2/2025 (7am -3pm) shift, 4/3/2025 (7am -3pm) shift, and 4/4/2025 (3pm-11pm) shift. During a concurrent interview and record review on 4/22/2025 at 1:52PM with the DON, the Change of Condition (COC) Evaluation, dated 4/8/2025 was reviewed. The DON stated COC Evaluation indicated Resident 1 had pinkish colored urine and lower abdominal pain. The DON stated the licensed staff should have a documentation for Resident 1's pinkish colored urine and lower abdominal pain in the 3pm-11pm shift because this was a COC. During a concurrent interview and record review on 4/22/2025 at 1:54 PM with the DON, the Daily Documentation, dated 4/9/2025 to 4/11/2025 and COC policy were reviewed. The DON stated the Daily Documentation did not reflect any monitoring of the following: 1. Resident 1's pinkish colored urine and lower abdominal pain on 4/9/2025 (7am -3pm shift), 4/10/2025 (7am -3pm shift) shift and 4/11/2025 all shifts. 2. Resident 1's sediments and hematuria. The DON stated the licensed staff were not documenting and addressing Resident 1's COC. The DON stated the facility did not and should have a policy on COC to include the need to document COC every shift for 72 hours. During a concurrent interview and record view on 4/22/2025 at 2:03 PM with the DON, the Care plan for indwelling catheter dated 2/3/2025 was reviewed. The DON stated the licensed staff were inconsistent in following Resident 1's care plan interventions. The DON stated it was important to monitor Resident 1 for signs and symptoms of UTI to prevent risk for complications such as bladder discomfort. During a concurrent interview and record view on 4/22/2025 at 2:45 PM with DON, the facility's policy and procedure titled, Catheter Care, was reviewed. The P&P indicated to check the urine for unusual appearance (i.e., color, blood, etc.). Observe the resident for signs and symptoms of urinary tract infection and urinary retention. Check the urine for color and clarity. DON stated the licensed staff did not follow the policy for Catheter care, they are not doing proper documentation on Resident 1's catheter monitoring. During a review of the undated facility's policy and procedure titled, Catheter Care, the P&P indicated to observe the resident's urine level for noticeable increases or decreases. If the level stays the same or increases rapidly. Check the urine for unusual appearance (i.e., color, blood, etc.). Observe the resident for signs and symptoms of urinary tract infection and urinary retention. Check the urine for color and clarity. Documentation: The following information should be recorded in the resident's medical record; Character of urine such as color (straw-colored, dark, or red), clarity (cloudy, solid particles, or blood), and odor.

Apr 2025 16 deficiencies

CONCERN (D)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accommodate the needs of one (1) of 21 sampled residents (Resident 9) in accordance with the facility policy by failing to ensure: 1. Resident 9's call light (device used by residents to call staff for assistance) was within reach. 2. Resident 9 was provided a touch pad call light (device used by residents to call staff for assistance with a gentle touch) appropriate for the resident's condition/needs. This deficient practice has the potential to delay in the provision of Resident 9's necessary care and services, which could negatively affect the overall condition of the resident. Findings: During a review of Resident 9's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the diagnoses of ptosis (drooping of the eyelid) of left eyelid, cataract (lens of eyes becomes opaque [not letting light through] resulting in blurred vision) of both eyes, and muscle weakness. During a review of Resident 9's Minimum Data Set (MDS - a resident assessment tool), dated 2/28/2025, the MDS indicated resident was severely impaired with cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 9 was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) in toileting hygiene, shower/bath self and putting on/taking off footwear. Resident 9 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with upper body dressing, lower body dressing and personal hygiene. The MDS also indicated Resident 9 was always incontinent with both urine and bowel. During a review of Resident 9's Care Plan with focus on Risk for falls/injury, revised 12/23/2024, the Care Plan indicated staff intervention to place the call light within reach. During an observation on 4/1/2025 at 8:34 AM in Resident 9's room, Resident 9 was observed with a standard push button call light. Resident was also observed asking for water when Certified Nursing Assistant 2 (CNA 2) stated Resident 9 is blind and would require assistance to get things because she cannot see. During a concurrent observation and interview on 4/2/2025 at 1:57 PM, Resident 9's call light was observed in the middle of the bed. Resident 9 was observed in her wheelchair, on the side toward the foot of the bed, and against the wall. Registered Nurse 3 (RN 3) stated the call light was not within reach of the resident and the call light is not appropriate for Resident 9's needs. RN 3 also stated Resident 9 is blind and would not know where or how to use the call light. During an interview on 4/2/2025 at 2:29 PM, the Director of Nursing (DON) stated the call light should always be within reach of the resident. The DON also stated a resident who is blind should have a pad call light in order to ask for assistance. During a review of the facility's Policy and Procedure (P&P) titled, Answering the Call Light, revised 9/2022, the P&P indicated to ensure the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. During a review of the facility's P&P titled, Resident Call System, dated 9/2022, the P&P indicated if the resident has a disability that prevents him/her from making use of the call system, an alternative means of communication that is usable for the resident is provided and documented in the care plan.

CONCERN (D)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure accurate assessment of resident's functional ability for personal hygiene on the Minimum Data Set (MDS, a resident assessment tool) for one (1) of 1 sampled resident (Resident 9) as indicated on the facility policy. This deficient practice had the potential for the facility to not develop and implement a resident centered care plan for Resident 9 to receive care and services to maximize or improve Resident 9's functional ability in personal hygiene. Findings: During a review of Resident 9's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following diagnoses of osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage), contracture (a stiffening/shortening at any joint, that reduces the joint's range of motion), muscle weakness, and dementia (a progressive state of decline in mental abilities). During a review of Resident 9's MDS, dated [DATE], the MDS indicated resident was severely impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. The MDS also indicated Resident 9 required partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with oral hygiene and personal hygiene. Resident also required substantial/maximal assistance (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with upper body dressing and lower body dressing while was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting hygiene, shower bath self and putting on/taking off footwear. During a review of Resident 9's Interdisciplinary (a group of health care professionals with various areas of expertise who work together toward the goals of their clients) Care Conference, dated 2/24/2025, indicated Resident 9 required substantial/maximal assistance with personal hygiene. During a review of Resident 9's MDS, dated [DATE], the MDS indicated resident was severely impaired with cognitive skills for daily decision making. The MDS also indicated Resident 9 was dependent with toileting hygiene, shower/bath self and putting on/taking off footwear. Resident 9 required substantial/maximal assistance with upper body dressing, lower body dressing and personal hygiene. During an observation on 4/3/2025 at 10:25 AM, Certified Nursing Assistant 2 (CNA 2) was observed providing Activities of Daily Living (ADL) care to Resident 9. CNA 2 was observed wiping Resident 9's face with maximal assistance from the resident. During an interview on 4/4/2025 at 11:20 AM, the Director of Nursing (DON) stated Resident 9's MDS, dated [DATE], was inaccurately assessed since Resident 9 has always required substantial/maximal assistance for personal hygiene. During an interview on 4/4/2025 at 11:50 AM, CNA 4 stated Resident 9 has required maximal assistance with personal hygiene for a year and it has not changed. During a concurrent record review of Resident 9's MDS, dated [DATE] and 2/28/2025, and interview on 4/4/2025 at 11:53 AM, the DON and MDS Nurse stated Resident 9's functional ability for personal hygiene was inaccurately assessed on 11/30/24 since it indicated partial/moderate assistance instead of substantial/maximal assistance. The DON and MDS Nurse also stated the MDS, dated [DATE], should have been substantial/maximal assistance and not partial/moderate assistance. The DON and MDS stated it is important to have an accurate MDS because it can affect the residents plan of care. During a review of the facility's Policy and Procedure (P&P) titled, MDS Completion and Submission Timeframes, revised July 2017, the P&P indicated the assessment coordinator, or designee is responsible for ensuring that resident assessments are submitted to CMS in accordance with current federal and state guidelines.

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a care plan for two of 21 sampled residents (Residents 28 and 86) in accordance with the facility policy by failing to ensure a care plan reflected: 1. Resident 28's smoking and refusal to wear a smoker's apron (prevents burns in clothing and keep hot ashes from burning the skin) while smoking. This deficient practice had the potential to place Resident 28 at risk for injury, accidents, and harm. 2. Resident 86's fluid restriction as indicated on the physician's order, dated 3/1/2025. This failure had the potential to place Resident 86 at risk for fluid overload (too much fluid in the body which can raise the blood pressure and force the heart to work harder), edema (swelling caused by too much fluid trapped in the body's tissues), and dehydration (a dangerously loss of body fluid caused by illness, sweating, or inadequate intake). Findings: 1. During a review of Resident 28's admission Record, the admission Record indicated the resident was originally admitted on [DATE] and was readmitted on [DATE] with the diagnoses of dementia (a progressive state of decline in mental abilities) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). During a review of Resident 28's Minimum Data Set (MDS, a resident assessment tool), dated 1/13/2025, the MDS indicated the resident was severely impaired with cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 28 was dependent with lower body dressing and putting on/taking off footwear. Resident 28 required substantial/maximal assistance (Helper does less than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.) with toileting hygiene and shower/bathe self. During an observation in the smoking area on 4/2/2025 at 9:44 AM with the admission Assistant (AA), Resident 28 was observed refusing to put on a smoker's apron while smoking. During a concurrent record review of Resident 28's Care Plans, dated 10/17/2024 to 3/5/2025, and interview on 4/3/2025 at 11:28 AM, Director of Nursing (DON) stated the resident does not and should have a plan of care for smoking to address and implement the needs of the resident while smoking such as the use of protective apron to keep the resident safe and prevent accidents. During an interview on 4/4/2025 at 11AM, Activities Director (AD) stated when he would supervise Resident 28, the resident would always refuse to put on a smoker's apron while smoking. During a review of the facility's Policy and Procedure (P&P) titled, Smoking Policy, revised 8/2022, the P&P indicated any smoking related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 2. During a review of Resident 86's admission Record, the admission record indicated Resident 86 was admitted to the facility on [DATE], with diagnoses that included stage 4 chronic kidney disease ( the kidneys are moderately or severely damaged and are not properly filtering waste from the blood), type 2 diabetes (a chronic condition where the body does not use insulin [hormone that helps sugar from food enter cells for energy] effectively or does not produce enough insulin, leading to high blood sugar levels), and acute systolic heart failure, (a sudden and life-threatening condition where the heart's left ventricle struggles to contract and pump blood effectively, leading to reduced blood flow to the body). During a review of the Minimum Data Set (MDS, resident assessment tool), dated 2/10/2025, the MDS indicated Resident 86 had modified independence (some difficulty in new situations) for cognitive skills for daily decision making. Resident 86 need partial or moderate assistance (helper does less than half the effort) with eating, oral, toilet, personal hygiene, upper and lower body dressing, change of position, and transfer. During a review of Resident 86's Physician Orders, dated 3/1/2025, the physician's order indicated Resident 86's fluid restriction of 1200 milliliters (ml, units of measurement) per 24 hours as follows: - Nursing 600 ml: 300 ml for 7AM -3PM (AM shift), 200 ml for 3PM to 11 PM (PM shift), and 100 ml for 11PM to 7AM. (NOC shift) - Dietary 600 ml (for meals): 360 ml for breakfast, 120 ml for lunch and 120 ml for dinner. During a concurrent review of Resident 86's care plan and interview on 4/2/2025 at 12:58 PM with Licensed Vocational Nurse 1(LVN1), LVN 1 stated that there was no care plan to reflect the fluid restriction ordered on 3/1/2025 for Resident 86. During a concurrent review of Resident 86's care plan and interview on 4/2/2025 at 2:26 PM with medical records staff (MR), MR stated there was no care plan for the fluid restriction order on 3/1/2025 for Resident 86. MR stated nurses should have developed the plan of care every time there is a new physician order or change of resident's condition to update the nursing interventions and provide better care to prevent resident from getting fluid overload which could lead to hospitalization. During a concurrent interview and record review on 4/2/2025 at 2:59 PM, with the Director of Nurses (DON), the DON stated nurses should have implemented a comprehensive care plan for Resident 86's to reflect the interventions to monitor fluid restriction for Resident 86 to prevent fluid overload, edema, dehydration, chest pain, heart attack or other complications which could harm Resident 86. During a record review of the facility's P&P titled, Comprehensive Care Plan, effective 8/25/2021, the policy indicated: The facility's interdisciplinary team, in coordination with the resident and/or his/her family or representative, must develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, physical, and mental and psychosocial needs that are identified in the comprehensive assessment. 1. Each resident' s comprehensive care plan is designed to: a. Incorporate identified problem areas. b. Incorporate risk and contributing factors associated with identified problems. c. Build on the resident's individualized needs, strengths, preferences. d. Reflect treatment goals, timetables, and objectives in measurable outcomes. e. Identify the professional services that are responsible for each element of care. f. Aid in preventing or reducing declines in the resident's functional status and/or functional levels. 2. Care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes . 4. Assessments of residents are ongoing and care plans are reviewed and revised as information about the resident and the resident 's condition change. 5. The interdisciplinary Team is responsible for evaluation and updating of care plans: a. When there has been a significant change in the resident's condition. b. When the desired outcome is not met. c. When the resident has been readmitted to the facility from a hospital stay; and at least quarterly. During a record review of the facility's P&P titled, Dialysis Care, effective 8/25/2021, the policy indicated the Care Plan, The Interdisciplinary Team (IDT) will ensure that the resident's Care Plan includes documentation of the resident's renal condition and necessary precautions (e.g. fluid restrictions lab draws ., observe for signs and symptoms of infection, etc.). The resident's Care Plan will be updated as needed.

CONCERN (D)

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

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to set the low air loss mattress (LALM, pressure relieving mattress that operates using a blower based pump that is designed to circulate a constant flow of air through the mattress, commonly used to heal pressure ulcers [wound that occurs as a result of prolonged pressure on a specific area of the body]) at the correct setting for one (1) of six (6) sampled resident's (Resident 51) in accordance with the facility's policy and procedure (P&P) titled, Skin Integrity Management and physician's order. This deficient practice had the potential to result in Resident 51's pressure ulcers to worsen. Findings: During a review of Resident 51's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included pressure ulcer Stage 4 (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) of sacral region (lower back), and diabetes mellitus (DM a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 51's Minimum Data Set (MDS, resident assessment screening tool), dated 2/28/2025, indicated the resident had severe impairment of cognitive (capable of remembering, learning new things, concentrating, or making decisions that affect everyday life) skills for daily decision making. Resident 51 was dependent (staff does all the effort in tasks, resident does no effort in task, assistance of two or more helpers is sometimes required to complete a task) on staff for eating, hygiene (oral and physical), toileting, showering, upper/lower body dressing and putting on/taking off footwear. The MDS indicated Resident 51 was admitted with 1 pressure Ulcer Stage 4 and five (5) unstageable pressure ulcers (a full-thickness pressure injury where the base of the ulcer is obscured by dead skin or a dark, dry scab, making it impossible to determine the depth of the tissue damage). The MDS indicated Resident 51 required pressure ulcer care. During a review of Resident 51's Weight Summary, dated 3/25/2025, the Weight Summary indicated Resident 51 weighed 94 lbs (pounds; unit of measurement for weight). During a review of Resident 51's Care Plan titled, Sacro-coccyx (lower end of the spinal area at the base of the spine), pressure ulcer Stage 4, dated 2/7/2025, the care plan indicated staff interventions were to monitor treatment effectives or ineffectiveness, treatment as ordered, and weekly evaluation. During a review of Resident 1's Order Summary Report, dated 3/4/2025, the order summary indicated, Resident 51 was ordered a LALM, and it was to be set based on Resident 51's weight. During a concurrent observation and interview on 4/1/2025 at 9:53 AM with Licensed Vocational Nurse 3 (LVN3), Resident 51's LALM setting was observed set at 160 lbs. During a concurrent record review and interview on 4/1/2025 at 9:58 AM with LVN 3, Resident 51's weight summary was reviewed. The weight summary indicated Resident 51 weighed 94 lbs on 3/25/2025. LVN 3 stated, On 3/25/25 Resident 51 weighed 94 lbs. The purpose of the LALM is to prevent further skin breakdown. If it's set higher than the patient's weight the bed becomes too hard, and it defeats the purpose of the mattress. This can make the patient's wounds worsen. During a concurrent interview and record review on 4/3/2025 at 10:40 AM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Skin Integrity Management, dated 5/26/2021 was reviewed. The P&P indicated: 1. The purpose of the P&P is to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment and promote healing of all wounds. 2. Nursing staff will observe for any sign of potential or active pressure injury daily while providing nursing care. 3. Implement pressure ulcer prevention for identified risk factors. DON stated, The purpose of the LALM is to relieve the pressure of a resident on bony areas. If the LALM is set higher than the resident's weight, it adds more pressure and the surface becomes harder. A harder surface can be a factor in worsening the condition of wounds.

CONCERN (D)

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

Tube Feeding (Tag F0693)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to label the enteral feeding (form of nutrition that is directly delivered into the digestive system (a group of organs that work together to digest and absorb nutrients from the food eaten) as a liquid) for one (1) of two (2) sampled resident's (Resident 80) in compliance with the facility's Enteral Feeding policy and procedure. Findings: During a review of Resident 80's admission Record, the admission record indicated Resident 80 was admitted on [DATE] with diagnosis that included malnutrition (poor nutrition), muscle weakness, and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 80's Minimum Data Set (MDS, resident assessment tool) dated 3/13/2025, the MDS indicated the resident had an intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 80 required substantial/maximal assistance (helper does more than half the effort) for putting on/taking off footwear and partial/moderate assistance (helper does less than half the effort) for oral hygiene, toileting hygiene, showering, upper/lower body dressing. Resident 80 required set up or clean up assistance (helper sets up or cleans up) for eating and personal hygiene. During a review of Resident 80's Order Summary Report (OSR), dated 3/20/2025, the OSR indicated enteral feeding of Glucerna (a type of enteral feeding) due to failure to thrive (failure to gain weight). During a review of Resident 80's Care Plan (CP) titled, Resident requires tube feeding related to severe malnutrition, initiated on 12/12/2024, the CP indicated the goal was for Resident 80 to maintain adequate nutritional status and stable weight. Staff interventions included were to have the registered dietitian (a credentialed healthcare professional with specialized knowledge and training in nutrition and diet) monitor caloric intake, estimate needs and make recommendations for changes to tube feeding as needed and to administer tube feeding as ordered. During an observation on 4/1/2025 at 11:35 AM in Resident 80's room, Resident 80 was observed lying in bed. Resident 80's enteral feeding attached to the resident's gastrostomy tube was infusing but it did not have a label to indicate the feeding rate, date, and time hung. During a concurrent observation and interview on 4/1/2025 at 9:11 AM in Resident 80's room with Licensed Vocational Nurse 2 (LVN 2), Resident 80's enteral feeding was observed infusing but the tube feeding was unlabeled. LVN 2 stated, the enteral feeding is not labeled, it should be labeled. During a concurrent interview and record review on 4/4/2025 at 12:10 PM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Enteral Feeding, dated 5/26/2021 was reviewed. The P&P indicated: 1. The purpose of the P&P is to administer tube feeding. 2. Procedure: label the formula with date and time hung. The DON stated, it's important to label the enteral feeding to make sure the correct resident is receiving the correct formula and the correct rate of feed. The feeding rate determines the nutrition and calories the resident is receiving. It's important to make sure the resident is receiving the correct amount of calories and nutrition. If they are not receiving the correct amount of nutrition, they may lose weight and nutritional status. It puts the resident at risk of worsening health condition.

CONCERN (D)

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

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to accurately monitor the fluid intake for one of one sampled resident (Resident 86) who was on fluid restrictions, as indicated on the physician's order. This deficient practice had the potential to place Resident 86 at risk for fluid overload (too much fluid in the body which can raise the blood pressure and force the heart to work harder), edema (swelling caused by too much fluid trapped in the body's tissues), and dehydration (a dangerously loss of body fluid caused by illness, sweating, or inadequate intake). Findings: During a review of Resident 86's admission Record, the admission record indicated Resident 86 was admitted to the facility on [DATE], with diagnoses that included stage 4 chronic kidney disease ( the kidneys are moderately or severely damaged and are not properly filtering waste from the blood), type 2 diabetes (a chronic condition where the body does not use insulin [hormone that helps sugar from food enter cells for energy] effectively or does not produce enough insulin, leading to high blood sugar levels), and acute systolic heart failure, (a sudden and life-threatening condition where the heart's left ventricle struggles to contract and pump blood effectively, leading to reduced blood flow to the body). During a review of the Minimum Data Set (MDS, resident assessment tool), dated 2/10/2025, the MDS indicated Resident 86 had modified independence (some difficulty in new situations) for cognitive skills for daily decision making. Resident 86 need partial or moderate assistance (helper does less than half the effort) with eating, oral, toilet, personal hygiene, upper and lower body dressing, change of position, and transfer. During a review of Resident 86's Physician Orders, dated 3/1/2025, the physician's order indicated Resident 86's fluid restriction of 1200 milliliters (ml, units of measurement) per 24 hours as follows: - Nursing 600 ml: 300 ml for 7AM -3PM (AM shift), 200 ml for 3PM to 11 PM (PM shift), and 100 ml for 11PM to 7AM. (NOC shift) - Dietary 600 ml (for meals): 360 ml for breakfast, 120 ml for lunch and 120 ml for dinner. During an observation on 4/2/2025 at 12:33 PM in Resident 86's room, observed Resident 86 was drinking coffee besides the milk for his lunch. Resident 86 stated that Certified Nursing Assistant (CNA1) gave him the coffee. During an interview on 4/2/2025 at 12:40 PM with, CNA 1 confirmed that she gave the coffee to Resident 86 and stated it was 240 ml. CNA1 stated she knows Resident 86 was on fluid restriction. CNA1 stated she should not have given the 240 ml cup of coffee to the resident which can cause harm or adverse effects to his health because resident is on fluid restriction. During an interview on 4/2/2025 at 12:58 PM, Licensed Vocational Nurse 1 (LVN1) stated the LVNs put a check mark in the medication administration record (MAR) that Resident 86 is on fluid restriction, but the resident's actual amount of fluid intake is not recorded. During an interview on 4/2/2025 at 1:26 PM with medical record staff (MR), MR confirmed that there was no fluid intake recorded for each shift for Resident 86. During a concurrent interview and record review on 4/2/2025 at 1:45 PM, with the Director of Nursing (DON), the DON stated CNA1 should not have given Resident 86 coffee without verifying with LVN or RN supervisor. The DON stated nurses should have recorded Resident 86's actual amount of fluid intake to ensure implementation of Resident 86's fluid restriction in accordance with the physician's order to prevent fluid overload, edema, dehydration, chest pain, heart attack or other complications which could harm Resident 86. During a review of the facility's Policy and Procedure (P&P) titled, Dialysis Care, effective 8/25/2021, the P&P indicated, Fluid Restrictions: a. Dialysis residents are given fluid based on the fluid restriction as ordered by the physician. b. The Nursing and Dietary Staff will carefully organize the division and distribution of fluid. During a review of the facility's undated P&P titled, Encouraging and Restricting Fluids, indicated the following: General Guidelines: 1. Follow specific instructions concerning fluid intake or restrictions. 2. Be accurate when recording fluid intake. 3. Record fluid intake on the intake side of the intake and output record. Record fluid intake in ml. 4. Substitute other liquids (i.e., tea, broth, soda, gelatin, milk, ice cream, etc.) as permitted by the resident's diet. 5. When a resident has been placed on restricted fluids, remove the water pitcher and cup from the room. If the resident refuses to have the water pitcher removed, notify the supervisor and in turn, the physician. Documentation: The following information should be recorded in the resident's medical record: 1. Any evidence of dehydration such as weight loss, confusion, drowsiness, dry skin, etc. 2. The amount (in ml) of fluids consumed by the resident during the shift. 3. The type of liquid consumed (i.e., tea, milk, coffee, soup, etc.).

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures to ensure administering of all drugs and biologicals to meet the needs of one (1) of five (5) sampled residents (Resident 149) in accordance with the facility's policy and procedure (P&P) by failing to completely administer two (2) medications mixed in water to Resident 149. This deficient practice resulted to Resident 149 not receiving the full amount of 2 medications as prescribed by the physician, which could affect the resident's well-being. Findings: During a review of Resident 149's admission Record, the admission record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the diagnoses of urinary tract infection (UTI, an infection in the bladder/urinary tract) 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 149's Minimum Data Set (MDS, a resident assessment tool), dated 3/28/2025, the MDS indicated the resident was severely impaired with cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 149 was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) with 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 149 was on a feeding tube. During a review of Resident 149's Order Summary, the Order Summary indicated the following: 1. Acetazolamide (a medication for fluid retention [buildup of fluid in the body]) tablet 250 milligrams (mg-a unit of measurement). Give 1 tablet via gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) tube (G-tube) one time a day for edema. 2. Oyster Shell Calcium/ Vitamin D (a medication to prevent or treat a calcium deficiency) tablet 500-200 mg- unit. Give 1 tablet via G-tube one time a day for supplementation. During an observation on 4/2/2025 at 8:17 AM, Licensed Vocational Nurse 5 (LVN 5) was observed preparing all medications for Resident 149 and was observed using the same G-tube syringe to mix all the individually crushed medications. LVN 5 administered Acetazolamide and Oyster Shell Calcium/ Vitamin D separately to Resident 149 via G-tube. The two medications were not completely administered to Resident 149 due to residue left in the medication cup. During an interview on 4/2/2025 at 8:45 AM, LVN 5 stated there was still 70% of the Oyster Shell Calcium and 50% of the Acetazolamide left in the medication cup, which was not administered to Resident 149. LVN 5 stated Resident 149 did not get all her medications as ordered which can cause harm to the resident. During an interview on 4/4/2025 at 12pm, Director of Nursing (DON) stated that LVN 5 did not follow doctor's orders since the 2 medications were not entirely administered to Resident 149. During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, revised 4/2019, the P&P indicated medications are administered in accordance with prescriber's orders. The P&P also indicated medication administration is determined by the resident need and benefit that includes preventing potential medication interactions.

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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to conduct a monthly Medication/Drug Regimen Review (MRR, a monthly thorough evaluation by the consulting pharmacist of a resident's medication regimen, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication) in the month of 2/2025 for one (1) of five (5) sampled residents (Resident 47) in accordance with the facility's Medication Regimen Reviews policy and procedure (P&P). This deficient practice had the potential to cause Resident 47 to receive unnecessary medication and to potentially have adverse reactions (harmful effects) from medications. Findings: During a review of Resident 47's admission Record, the admission record indicated Resident 47 was admitted on [DATE] with diagnosis that included cerebral infarction (loss of blood flow to a part of the brain), unspecified psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality),and diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 47's Minimum Data Set (MDS, resident assessment tool), dated 11/1/2024, the MDS indicated the resident had intact cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 47 required substantial/maximal assistance (helper does more than half the effort) for toileting hygiene, showering, lower body dressing and putting on footwear. The MDS indicated Resident 47 required partial/moderate assistance (helper does less than half the effort) for upper body dressing. The MDS indicated Resident 47 required set up or clean up assistance (helper sets up or cleans up) for oral hygiene and personal hygiene. The MDS indicated Resident 47 was independent (resident completes the activity by self) for eating. During a concurrent interview and record review on 4/3/2025 at 7:48 AM with the Director of Nursing (DON), the facility's MRR for 2/1/2025 to 2/28/2025 records were reviewed. The MRR records indicated there was no documented evidence of Resident 47's medications reviewed on the MRR. The DON stated, The resident's (Resident 47) name is not in the MRR list for February 2025. She did not have an MRR done that month. The purpose of the MRR is to ensure necessary dose reduction are done if necessary. It also screens for unnecessary medications. The residents are at risk for adverse effects if the MRR is not done for them. During an interview on 4/4/2025 at 11:51 AM with the facility's Pharmacy Consultant (PC), PC stated, If the resident's name does not appear in the MRR list, the MRR wasn't done. The purpose of the MRR is to discontinue unnecessary medications, check if there are any drug interactions, and adjust medication doses. It is for the patient's safety. During a review of the facility's P&P titled, Medication Regimen Reviews, revised 5/2019, the P&P indicated: 1. The Consultant Pharmacist reviews the medication regimen of each resident at least monthly. 2. The Consultant Pharmacist performs a MRR for every resident in the facility receiving medication. 3. MRR are done upon admission and at least monthly. 4. The goal of the MRR is to promote positive outcomes while minimizing adverse consequences and potential risks associated with medication. 5. Copies of medication regimen review reports, including physician responses, are maintained as part of the permanent medical record.

CONCERN (D)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure its medication error rate was less than five (5) percent (%). There were two (2) medications errors (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order/ manufacturer's specifications / accepted professional standards and principles) out of 25 opportunities (observed administered medications) for error, which yielded a facility medication rate of eight (8) % for one of five (5) sampled residents (Resident 149) observed during medication administration. This deficient practice had the potential for harm to Resident 149 due to the resident not receiving the full amount of each medication as prescribed by the physician. Findings: During a review of Resident 149's admission Record, the admission record indicated the resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the diagnoses of urinary tract infection (UTI, an infection in the bladder/urinary tract) 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 149's Minimum Data Set (MDS, a resident assessment tool), dated 3/28/2025, the MDS indicated the resident was severely impaired with cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 149 was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) with 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 149 was on a feeding tube. During a review of Resident 149's Order Summary, the Order Summary indicated the following: 1. Acetazolamide (a medication for fluid retention [buildup of fluid in the body) tablet 250 milligrams (mg-a unit of measurement). Give 1 tablet via gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) tube (G-tube) one time a day for edema. 2. Oyster Shell Calcium/ Vitamin D (a medication to prevent or treat a calcium deficiency) tablet 500-200 mg- unit. Give 1 tablet via G-tube one time a day for supplementation. During an observation on 4/2/2025 at 8:17 AM, Licensed Vocational Nurse 5 (LVN 5) was observed preparing all medications for Resident 149 and was observed using the same G-tube syringe to mix all the individually crushed medications. LVN 5 administered Acetazolamide and Oyster Shell Calcium/ Vitamin D separately to Resident 149 via G-tube. The two medications were not completely administered to Resident 149 due to residue left in the medication cup. During an interview on 4/2/2025 at 8:45 AM, LVN 5 stated there was still 70% of the Oyster Shell Calcium and 50% of the Acetazolamide left in the medication cup, which was not administered to Resident 149. LVN 5 stated Resident 149 did not get all her medications as ordered which can cause harm to the resident. During an interview on 4/4/2025 at 12pm, Director of Nursing (DON) stated that LVN 5 did not follow doctor's orders since the 2 medications were not entirely administered to Resident 149. During a review of the facility's Policy and Procedure (P&P) titled, Administering Medications, revised 4/2019, the P&P indicated medications are administered in accordance with prescriber's orders. The P&P also indicated medication administration is determined by the resident need and benefit that includes preventing potential medication interactions.

CONCERN (D)

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

Garbage Disposal (Tag F0814)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to properly contain waste and cover two (2) of 2 large trash bins with lids as indicated on the facility policy. This deficient practice had the potential to attract vermin (animals that are believed to be harmful, carry diseases such as rodents, parasitic worms, or insects), pests (any living thing that has a negative effect on humans), and wildlife (undomesticated animal species) that could potentially infiltrate the facility, affect the resident care areas, and pose a disease threat to the residents and staff of the facility. Findings: During initial visit on 4/01/2025 at 8:01 AM, observed two large trash bins in the facility parking lot area with open lids and there was also visible trash on the floor surrounding the parking lot area. During an observation and interview with Dietary Staff 1 (DS1) on 4/01/2025 at 8:03 AM, DS1 confirmed both trash bins were open and not covered with a lid. DS1 stated the trash bins are picked up weekly but the trash lids should be closed to prevent any type of contamination or pest infestation (a situation where a large number of unwanted pests, such as insects, rodents [any of various small mammals with large, sharp front teeth, such as mice and rats, or other organisms, invade and establish themselves in a particular area]). During an observation of the same trash bins in the facility parking lot area on 4/02/2025 at 7:32 AM, observed the 2 trash bins to be overfilled with trash bags and the lids were not closed. During an interview with the Director of Nursing (DON) on 4/03/2025 at 2 PM, the DON stated the trash bin lids should be closed at all times because if the trash bin lids are open, it can attract vermin or other animals. The DON also stated it's not sanitary to have open trash lids near the resident's activity room which is located inside the facility near the parking lot area where the trash bins are located. During an interview with Maintenance Supervisor (MS) on 4/03/2025 at 2:10 PM, MS stated the trash bins are emptied by a private company but there is not an exact time of when they get picked up. MS stated the trash lids should remain closed at all times for sanitary purposes. Per MS, Central supply, the kitchen and housekeeping staff are responsible for throwing out the trash. MS stated, If any staff throws out the trash and leaves the trash bins lids open, it can attract rodents like mice and also cockroaches. It's not sanitary to leave the lids open or to have trash on the floor in the surrounding areas. During an interview with Infection Preventionist (IP) nurse on 4/03/25 at 2:20 PM, IP stated trash bins should always be covered with a lid to prevent any type of rodents being attracted to the facility area. IP stated, It is not sanitary and also, it's not acceptable for staff to leave the trash bin lids open. During a review of the facilities Policy & Procedure (P&P) titled, Sanitization, revised on 11/2022, the P&P indicated . 14. Garbage and refuse containers are in good condition, without leaks, and waste is properly contained in dumpsters/compactors with lids (or otherwise covered). 15. Areas used for garbage disposal are free from odors and waste fats and maintained to prevent pests. During a review of the facilities undated P&Ps titled, Food-Related Garbage and Reuse Disposal, the P&P indicated Food-related garbage and refuse are disposed of in accordance with current state laws 2. All garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or no in continuous use . 5. Garbage and refuse containing food wastes will be stored in a manner that is inaccessible to pests . 7. Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter.

CONCERN (E)

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

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 70's admission Record, the admission Record indicated resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses of disorder of kidney (filtrates waste and makes urine) and ureter (duct where the urine passes from the kidney to the bladder) and dehydration. During a review of Resident 70's MDS, dated [DATE], the MDS indicated the resident was severely impaired (never/rarely make decisions) with cognitive skills for daily decision making. The MDS also indicated Resident 70 was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the 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 70 had an indwelling catheter (tube that drains urine from the bladder to a drainage bag). During an observation on 4/1/2025 at 8:24 AM, Resident 70's urine collection bag was noted without a privacy bag. During a concurrent observation and interview on 4/2/2025 at 1:55 PM, Registered Nurse 3 (RN 3) stated, It is not okay for the urine collection bag to be exposed because that is the resident's dignity. During an interview on 4/2/2025 at 2:36 PM, the Director of Nursing (DON) stated there should be a privacy bag for the urine collection bag to maintain resident's dignity. During a review of the facilities Policy and Procedure (P&P) titled, Quality of life-Dignity, revised 2/2020, the P&P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem.11. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents. For example: a. Helping the resident to keep urinary catheter bag covered Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced dignity and respect in full recognition of the individuality for two (2) of three (3) sampled Residents (Residents 70 and 198) by failing to ensure the residents' urinary collection bag (a medical device used to collect urine that is drained from the bladder, typically via a urinary catheter [a thin, flexible tube {usually made of silicone or plastic} inserted into the bladder to drain urine]) was covered with a privacy bag. This deficient practice violated Resident 70 and 198's right for privacy and had the potential to affect the residents' self-esteem, self-worth, sense of independence, and psychosocial well-being (an individual's mental, emotional, and social health, encompassing aspects like happiness, life satisfaction, self-esteem, social functioning, and a sense of purpose, all of which are interconnected and influence overall functionality). Findings: 1. During a review of the admission Record, the admission Record indicated Resident 198 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included but not limited to end stage renal disease (the kidney is no longer able to perform its main functions, which are to filter the blood to remove any waste and to balance fluids within the body) and chronic kidney disease (a condition where the kidneys are damaged and do not function as well as they should, leading to a gradual loss of kidney function- the ability of the kidneys to perform their vital tasks, which include filtering blood, removing waste and excess fluid, and maintaining a balance of electrolytes and other substances in the body). During a review of Resident 198's Order Summary, dated 3/20/2025, the Order Summary indicated, indwelling catheter: Foley catheter (a type of indwelling urinary catheter, which is a flexible tube inserted through the urethra {or sometimes directly into the bladder through a small incision} to drain urine) French (FR) 16 [NAME] size: 10 cubic centimeters (cc- a unit of volume in the metric system, representing the space occupied by a cube that measures 1 centimeter on each side) change for blockage, leaking, pulled out, excessive sedimentation. Change catheter drainage bag as needed and with every change of indwelling catheter. As needed for Urinary retention. During a review of Resident 198's Minimum Data Set (MDS- a resident assessment tool), dated 3/22/2025, the MDS indicated Resident 198 was moderately impaired with cognitive (the ability to understand and make decisions) skills for daily decision making. Resident 198 needed partial/moderate assistance (helper does less than half the effort) from the staff for the activities of daily living such as toileting, showers and upper and lower body dressing and needed supervision (helper provides verbal cues and resident completes activity) for eating, oral and personal hygiene. During a review of Resident 198's Care Plan initiated on 3/23/2025, the care plan indicated Resident 198 requires indwelling Foley catheter due to urinary retention (the inability to completely empty the bladder when urinating) with Dx (diagnosis) of BPH (Benign prostatic hyperplasia, a condition that causes the prostate gland which produces a fluid that is part of semen to grow larger than normal]). Staff interventions indicated were to provide privacy and comfort and provide a privacy bag. During observation in Resident 198's room on 4/01/25 at 9:07 AM, observed Resident 198 resting in bed. Resident 198's Foley catheter bag was noted to be hanging on the right side of the bed not covered with privacy bag. During an interview with Licensed Vocational Nurse 3 (LVN3) on 4/01/2025 at 9:15 AM, LVN3 stated Resident 198's Foley catheter bag was on the floor and was not covered with a privacy bag. LVN3 stated, the urine bag should be covered with a privacy bag to promote respect and dignity for the resident. During an interview with Registered Nurse 3 (RN3) on 4/01/2025 at 9:20 AM, RN3 stated it is per facility policy to make sure to have all foley catheter bags covered to promote residents' privacy. During an interview with the Director of Nursing (DON) on 4/04/25 at 11:56 AM, the DON stated Resident 198 does use a wheelchair to mobilize and the foley catheter is placed on the side of Resident 198's wheelchair and there must be a privacy bag covering the foley catheter bag for residents' dignity.

CONCERN (E)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of the admission Record, the admission Record indicated Resident 198 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included but not limited to type 2 diabetes mellitus (DM-a disease in which the blood glucose, or blood sugar, levels are too high), other lack of coordination (a medical condition, often called ataxia, characterized by a loss of muscle coordination, leading to clumsy or jerky movements, unsteady gait, and difficulty with balance and fine motor skills), end stage renal disease (the kidney is no longer able to perform its main functions, which are to filter the blood to remove any waste and to balance fluids within the body),and chronic kidney disease ( a condition where the kidneys are damaged and don't function as well as they should, leading to a gradual loss of kidney function) and dysphagia (trouble swallowing). During a review of Resident 198's MDS, dated [DATE], the MDS indicated Resident 198 had moderate impairment with cognitive skills for daily decision making. Resident 198 needed partial/moderate assistance (from the staff for the activities of daily living such as toileting, showers and upper and lower body dressing and needed supervision (helper provides verbal cues and resident completes activity) for eating, oral and personal hygiene. During the initial observation and interview of Resident 198 on 4/01/2025 at 9:15 AM, observed Resident 198 resting in bed watching TV with the bedside table within reach. A medication cup with medication tablets was observed on the bedside table next to Resident 198's breakfast tray. Resident 198 stated, The nurse gave me Tums (used to treat symptoms caused by too much stomach acid such as heartburn, upset stomach, or indigestion) to help me with my heartburn, the nurse left them on the table for me to take when I am ready. During observation, interview and record review with Licensed Vocational Nurse 4 (LVN4) on 4/01/2025 at 9:16 AM, LVN4 confirmed that there was medication left on Resident 198's bedside table. LVN4 stated the medication should not have been left on bedside table even though it is an over the counter (medication that can be sold directly to people without a prescription) because it was still considered medication. LVN 4 stated, Leaving medicine at bedside is not something a licensed nurse should do. I did my rounds quickly this morning when I began my shift, it was a mistake on my part not to check. The medicine should not have been left at bedside because it can cause harm to the patient and to others. For example, his roommates may take the medication or the resident could hoard (accumulate or collect) them and take them all at once causing an overdose (take more than the recommended amount of something, often a medicine or drug) or cause an allergic reaction (a reaction that can range from mild, like itching or sneezing, to severe, like anaphylaxis [difficulty breathing], which is a life-threatening condition). If the medicine is left at bedside, anyone could grab it and if taken it can also be considered a medication error. During an interview with Registered Nurse (RN3) on 4/01/2025 at 9:23 AM, RN3 stated it was unacceptable to leave medication at residents' bedside which could cause potential harm to the residents. During an interview and record review with Director of Nursing (DON) on 4/04/25 at 11:56 AM, the DON stated medication should not be left at residents' bedside because it could have potentially caused harm to Resident 198. Based on observation, interview, and record review, the facility failed to provide an environment free from accident (any unexpected or unintentional incident, which results or may result in injury or illness to a resident) hazards for two of two sampled residents (Residents 81 and 198) when: 1. A razor blade was found on the floor in Resident 81's room. This failure had the potential to cause injury to Resident 81. 2. Medication was observed left unattended at Resident 198's bedside table. This deficient practice had the potential for Resident 198 or other residents to get hold of the medication and if ingested (swallowed), had the potential for complications. Findings: 1. During a review of Resident 81's admission Record, the admission record indicated Resident 81 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE], with diagnoses that included acute on chronic systolic heart failure, (sudden and life-threatening condition, a pre-existing, long-term condition, where the heart's left ventricle struggles to contract and pump blood effectively, leading to reduced blood flow to the body), other abnormalities of gait and mobility, (deviations from the normal pattern of walking or movement, often caused by neurological, musculoskeletal, or other medical conditions, impacting balance, coordination, and overall mobility), and chronic kidney disease (kidneys are moderately to severely damaged, waste products build up in the blood, potentially leading to serious complications). During a review of the Minimum Data Set (MDS- a resident assessment tool), dated 1/16/2025, indicated Resident 81 was severely impaired with cognitive skills (the mental processes that allow people to think, learn, and solve problems) for daily decision making. Resident 81 needed partial or moderate assistance, (helper does less than half the effort) with the eating, oral hygiene and personal hygiene. Resident 81 was dependent, (helper does all of the effort) with the toilet, upper and lower body dressing, change of position, and transfer. During an observation on 4/3/2025 at 11:06 AM in Resident 81's room, observed an unused razor blade on the floor by Resident 81's bed. During a concurrent observation and interview on 4/3/2025 at 11:15 AM with Infection Preventionist Nurse (IPN) in Resident 81's room, IPN verified that there was an unused razor blade on the floor. IPN stated that unattended razor blade can cause injury to resident inside the room and staff who is working with the resident. IPN stated razor blades are not allowed inside the resident's room. IPN stated that it was probably from the (CNA) Certified Nurse Assistant who helped resident to shave in the morning. During an interview on 4/3/2025 at 12:08 PM with Registered Nurse Supervisor 1(RN1), RN 1 stated the razor blade was not supposed to be on the floor or anywhere inside the resident's room. RN 1 stated only staff have access of the storage room where the razor blades were stored. RN1 stated residents cannot keep any razor blade by themselves due to risk for injury. RN1 stated nursing aid may use it to shave the resident in the morning. RN1 stated unattended razor blade inside resident's room can injure residents accidentally. During a record review of the facility's undated policy and procedure titled, Hazardous Areas, Devices and Equipment, the policy indicated: 1. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to: a. Equipment and devices that are left unattended. b. sharp objects that are accessible to vulnerable residents.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure safe provision of pharmaceutical services as indicated in the facility policy by failing to: 1. Remove and discard one expired insulin (medication used to regulate blood sugar levels) Humulin R (short-acting insulin) vial, three expired suppositories (medications inserted into the rectum), one expired topical ointment (medication or cream applied directly to the skin), and two expired enemas (liquid to help relieve constipation [infrequent or difficult bowel movements]) from the medication cart. 2. Remove and discard eye drops according to label 3. Store insulin Lispro (short-acting insulin) and insulin Lantus (long-acting insulin) in the refrigerator. 4. Remove and discard three expired Vitamin D bottles from the medication storage room. These deficient practices increased the risk of the residents to be administered medications that have become ineffective or toxic which could result in adverse reactions (any unexpected or dangerous reaction to a drug). Findings: During a concurrent observation of Medication Cart 2 and interview of Licensed Vocational Nurse 6 (LVN 6) on [DATE] at 12:39 PM, the following medications were found stored in a manner contrary to the manufacturer's requirements, and were expired and not discarded in accordance with the facility's policy and procedure: 1. Three expired Bisacodyl (medication to treat constipation) suppositories with expiration date of 2/2024. 2. Latanoprost (medication to treat increased pressure in the eye) eye drops with an open date of [DATE] and a label which indicated to discard unused portion after 28 days from opening. 3. Dorzolamide and timolol (medication to treat increased pressure in the eye) with an open date of [DATE] and a label which indicated to discard unused portion after 28 days. 4. Triamcinolone Acetonide (topical medication to relieve skin conditions) ointment with a used by date of [DATE]. 5. Unopened Insulin/ Lispro with a label that indicated to refrigerate until used and once in use, store at room temperature. 6. One enema with an expiration date of 5/2024. LVN 6 stated the suppositories are expired and should be discarded. LVN 6 also stated the eye drops should be discarded within 28 days according to the label. LVN 6 stated the topical ointment was expired and should be discarded. LVN 6 also stated the enema was expired and should be discarded as well. LVN 6 stated the unopened insulin should have been kept in the refrigerator until use. LVN 6 stated the medications that were expired and/or not properly stored may not be as potent and can cause harm to the residents. During a concurrent observation of Medication Cart 1 and interview with LVN 7 on [DATE] at 1:06 PM, the following medications were found either stored in a manner contrary to the manufacturer's requirements, and were expired and not discarded in accordance with the facility's policy and procedure: 1. Insulin Humulin (R) with an open date of [DATE]. 2. Unopened Insulin Lantus Solostar with a label which indicated to refrigerate until used and once in use, store at room temperature. 3. One enema with an expiration date of 1/2025 LVN 7 stated unopened insulin should be in the refrigerator until used and should be used within 28 days and discarded after 28 days. LVN 7 also stated the expired enema should be discarded. LVN 7 stated the medications that were not properly stored or expired may not be as potent and can cause harm to the residents. During a concurrent observation and interview with LVN 2 on [DATE] at 1:22PM in the Medication Storage room [ROOM NUMBER], two Vitamin E 180 milligrams (mg, unit of measurement) bottles were found with expiration date of 1/2025. LVN 2 stated the medications should have been discarded. LVN 2 also stated the expired medication may not be as potent and may cause harm to the residents. During an interview on [DATE] at 12 PM, the Director of Nursing (DON) stated medications should be stored properly and discarded according to manufacturer's instructions. The DON stated multi dose vials should be used within 28 days and then discarded. The DON stated insulin should be kept in the refrigerator until used. The DON added the medications that were expired should not be in the medication cart/medication storage room and should be discarded. During a review of the facility's undated Policy and Procedure (P&P) titled, Medication Labeling and Storage, the P&P indicated if the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. The P&P also indicated the medication label includes but not limited to expiration date. The P&P indicated medications for external use are clearly marked as such and are stored separately from other medications. The P&P also indicated multi-dose vials that have been opened or accessed (needle punctured) are dated and discarded within 28 days. In addition, the P&P indicated medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurse's station or other secured location.

CONCERN (E)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide menus and nutritional adequacy for three (3) of 3 sampled residents (Residents 198, 84, and 35) in the food care area by failing to: 1. Provide Residents 198, Resident 84 and Resident 35 with a facility meal menu in advance 2. Follow the menu as written for Resident 198 on large and double portion (A large portion refers to a quantity that is bigger than average or standard, while double portion implies a quantity that is twice as large as the original or a standard amount) diets and were served incorrect amounts of food. These deficient practices had the potential to result in weight loss due to inadequate calories in residents who did not receive the correct amount or food items of their choices of their preference. Findings: 1. During a review of the admission Record, the admission Record indicated Resident 198 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included but not limited to type 2 diabetes mellitus (DM-a disease in which your blood glucose, or blood sugar, levels are too high), other lack of coordination (a medical condition, often called ataxia, characterized by a loss of muscle coordination, leading to clumsy or jerky movements, unsteady gait, and difficulty with balance and fine motor skills), end stage renal disease (the kidney is no longer able to perform its main functions, which are to filter the blood to remove any waste and to balance fluids within the body), and chronic kidney disease (is a condition where the kidneys are damaged and don't function as well as they should, leading to a gradual loss of kidney function). During a review of Resident 198's Minimum Data Set (MDS- a resident assessment tool), dated 3/22/2025, the MDS indicated Resident 198 had the mental capacity to understand and make medical decisions. Resident 198 needed partial/moderate assistance (helper does less than half the effort) from the staff for the activities of daily living such as toileting, showers and upper and lower body dressing and needed supervision (helper provides verbal cues and resident completes activity) for eating, oral and personal hygiene. During a review of Resident 198's Care Plan initiated on 3/23/2025, the care plan indicated Resident 198 is at nutritional risk, interventions indicated to provide diet education to resident, honor food preferences within meal plan, monitor for changes in nutritional status (unplanned weight loss) and report to food and nutrition/physician as indicated, monitor intake at all meals, offer alternate choices as needed and alert dietician and physician to any decline in intake. During a review of Resident 198's Order Summary dated 3/28/2025, the Order Summary indicated, carbohydrate controlled (a type of food that provides the body with energy, often called carbs. They are found in foods like bread, fruits, vegetables, and other plant-based item), renal diet (a specialized eating plan designed for people with kidney disease such as lean chicken, turkey, fish, apples, lettuce, wild rice, unsalted popcorn, fresh herbs and spices), soft and bite-sized texture, thin consistency (liquid or watery). Fortified diet (a diet that includes foods with extra nutrients added that wouldn't naturally be present. These added nutrients are usually vitamins and minerals, and the goal is to enhance the nutritional value of the food and benefit health) for all meals with double portion for all meals. During a review of the facility's breakfast menu for 4/1/2025, the following items will be served: scrambled eggs with chorizo and flour tortilla. During initial observation of Resident 198 on 4/1/2025 at 9:07 AM, Resident 198 was resting in bed watching TV. Observed Resident 198's breakfast tray to be on top of bedside table containing, scrambled eggs and flour tortilla, a serving of 4-ounce (oz, unit of measurement) apple sauce and a cup of apple juice. Resident 198 stated, they brought me this breakfast since 7:00 AM, I asked for oatmeal, it is now passed 9:00 AM, it has been more than two hours, and I still have not received my oatmeal. My stomach hurts, my stomach is empty. I cannot even take my medicine because I refuse to take them on an empty stomach. The nurse keeps coming to give me my meds, she keeps asking why she cannot give them to me. I tell her how am I supposed to take them on an empty stomach? Resident 198 also stated, if he knew he was not going to get his oatmeal, he would have called his son to bring him some chilaquiles, that way he would have had breakfast and been able to take his morning meds. During concurrent observation of Resident 198's breakfast tray on 4/01/2025 at 9:10 AM, observed Resident 198's breakfast/ meal ticket to indicate Double portion breakfast, pureed bread, scramble egg portion, 4 oz apple juice, and ¾ cup of fortified oatmeal. During an observation of License Vocational Nurse (LVN4) on 4/01/2025 at 9:15 AM, observed LVN4 walk into Resident 198's room to manually check the resident's blood pressure. LVN4 informed Resident 198 that LVN4 would be giving Resident 198 the resident's morning medication. Resident 198 informed LVN4 that the resident still had not received the resident's oatmeal and had not had breakfast. Resident 198 told LVN4 I am still waiting for my oatmeal; it has been over two hours. I have an empty stomach; I cannot take my meds. During concurrent observation of Resident 198 on 4/01/25 at 9:31 AM, Observed Dietary Staff (DS1) to visit Resident 198 asking if there was something wrong with his breakfast. Observed Resident 198 tell DS1 about the oatmeal request two hours ago and still did not have oatmeal. DS1 told Resident 198 if he was sure he did not have oatmeal on his tray when he received it in the morning. Resident 198 told DS1, I did not get my oatmeal, that is the reason I have not touched my breakfast, and I am still on an empty stomach, meaning I can't take my morning meds. I would like some oatmeal please. Observed DS1 tell Resident 198 the kitchen did have oatmeal, but it would take a bit to cook it and provide it for him. During an interview with DS1 on 4/01/25 at 9:32 AM, DS1 confirmed Resident 198 should have been served oatmeal but would double check with the Certified Nursing Assistant (CNA) if it was true that Resident 198 did not receive any oatmeal on his tray this morning for breakfast even though Resident 198 stated multiple times, he did not get oatmeal. DS 1 stated, Resident 198 should not have to wait two hours for a serving of oatmeal especially since it was ordered on his meal ticket. DS 1 stated, On the breakfast ticket it does say he should have double portions and a serving of oatmeal. We can make some for him, but it will take a bit since it's already been two hours from breakfast. 2. During a review of the Resident 84's admission Record, the admission Record indicated Resident 84 was admitted to the facility on [DATE] with diagnoses that included but not limited to type 2 diabetes mellitus, unspecified fracture of unspecified lumbar vertebra (where the specific bone or injury is not clearly identified or specified of any of the five bones in the back of the human body), subsequent encounter for fracture with routine healing (receiving ongoing care during the healing or recovery phase), muscle weakness, and hyperlipidemia (having too many fats in the blood). During a review of Resident 84's Minimum Data Set (MDS- a resident assessment tool), dated 1/31/2025, the MDS indicated Resident 84 had the mental capacity to understand and make medical decisions. Resident 84 was dependent (helper does all the effort, resident does none of the effort to complete the activity) from the staff for the activities of daily living (ADLs) such as toileting, lower body dressing and putting on/taking off footwear and required substantial/maximal assistance (helper does more than half the effort) for showers and upper body dressing and needed setup or clean-up assistance (helper sets up or cleans up and resident completes activity) for eating, oral and personal hygiene. During a review of Resident 84's Care Plan initiated on 2/01/2025 indicated Resident 84 has nutritional problem or potential nutritional problem related to diet restrictions (limitations or on food consumption, often for reasons of health, religious beliefs, or personal preference), interventions indicated to provide, serve diet as ordered, and monitor intake and record every meal. Also, Registered Dietitian to evaluate and make diet change recommendations as needed. During a review of Resident 84's Care Plan initiated on 2/06/2025 indicated Resident 84 is at nutritional risk due to increased needs for wound healing. Interventions indicated to provide diet education to resident, evaluate for proper consistency diet, honor food preferences within meal plan, monitor meal consumption, monitor weights as ordered and provide diet as ordered. During a review of Resident 84's Order Summary dated 3/01/2025, the Order Summary indicated, carbohydrate controlled (A carb-controlled meal might include a specific amount of carbohydrates, such as a slice of bread or a cup of pasta, alongside other foods like protein and vegetables to help manage sugar levels), renal diet (, regular texture (a surface characteristic or appearance that exhibits a predictable and repeating pattern or arrangement), thin consistency (a dietary modification that allows for regular, unthickened liquids). Fortified diet (a diet in which certain nutrients have been added to foods to increase their nutritional value) for all meals with double portion for all meals. During initial observation and interview with Resident 84 on 4/01/2025 at 9:35 AM, Resident 84 stated, I do not like the food; I do not go to activities it is too hard to go on the wheelchair, it is too hard to mobilize myself to go to the activity room. During concurrent observation and interview with Resident 84 on 4/01/2025 at 12:52 PM, observed Resident 84 resting in bed. Resident 84 stated he had not had lunch yet and was very hungry. Resident 84 stated, it is late, and I do not even know what they will serve me for lunch. I never get a food menu; I just have the staff come and drop off the tray. Most of the time I do not even eat the food because they pour gravy all over the meals and I just cannot eat that. I wish I knew what meals were being served that way I could tell my brother to bring me food from home instead. During an interview with Resident 84 on 4/02/2025 at 10:37 AM, Resident 84 stated that since he was admitted at the facility, he never gets a menu and does not know what is for lunch or other meals on a daily basis. Per Resident 84 the CNAs do not tell him what the lunch is either, he just gets served the meals and it makes him feel like he is in jail. Resident 84 stated it makes him sad and depressed and stated, I have never been in jail, but I feel like this is worse. Resident 84 stated, at home I was well taken care of. I had hardboiled eggs or eggs over easy in the morning, here I have asked for eggs and all I get is scrambled all the time. Resident 84 stated he will mostly just take a couple of bites of the food but not eat even 25% of what the tray of food has because he does not like it and is never offered a substitution or supplement. Resident 84 stated, the CNA just comes and removes the tray without asking why I did not eat anything. Resident 84 stated he is always hungry. 3. During a review of Resident 35's admission Record, the admission Record indicated Resident 35 was admitted to the facility on [DATE] with diagnoses that included but not limited to diabetes mellitus with diabetic neuropathy (nerve damage that can occur in people with diabetes), type 2 diabetes with hyperglycemia (a person has diabetes and their blood sugar levels are excessively high), partial traumatic transmetacarpal amputation of left hand (the partial loss of a finger or fingers due to a traumatic injury, occurring between the finger and the hand), acquired absence of right leg below the knee (the right leg, from the knee joint down, is missing, and this absence was acquired through a process like surgery or trauma, rather than being present at birth), acquired absence of left leg above the knee. During a review of Resident 35's MDS, dated [DATE], the MDS indicated Resident 35 had the mental capacity to understand and make medical decisions. Resident 35 needed supervision or touching assistance (helper provides verbal cues and/or touching steadying and/or contact guard assistance as resident competes activity) from the staff for the activities of daily living such as showers and lower body dressing and needed set up or clean-up assistance (helper sets up or clean up, resident completes activity) for upper body dressing, toileting and personal hygiene. The MDS also indicated Resident 35 was independent (resident completes the activity by themselves with no assistance from a helper) for eating and oral hygiene. During a review of Resident 35's Care Plan initiated 4/04/2023 indicated Resident 35 is at risk for altered nutrition and hydration status related to DM with neuropathy on therapeutic diet. Interventions indicated to honor food preferences within meal plan, monitor intakes of all meals, offer alternate choices as needed, alert dietitian and physician to any decline in intake. During observation and interview of the facilities activity room in the presence of Activity Assistant Staff (AAS1) on 4/01/2025 at 12:56 PM, observed the activity room to be empty and staff finishing up collecting chairs and tables from lunch time and putting them away. AAS1 stated the residents that can ambulate or be transferred to the activity room for lunch usually eat their meals inside the activity room at 12:00 PM. AAS1 stated not all residents are able to eat in the activity room during mealtimes because some are bedbound (confined to bed, can't move out of bed) or just do not want to eat their meal in the activity room and prefer to eat in their rooms. AAS1 stated that there is a menu that is placed right outside the activity room door for the residents to see. During interview with the Director of Nursing (DON) on 4/01/2025 at 12:58 PM, the DON stated usually the lunch is served from 12:00 PM to 1:00PM. Per DON, the residents that eat in the activity room usually eat first, at 12:00 PM, and the residents that eat in their rooms get served later. Per DON the residents that eat in their rooms are the ones that prefer to stay in their rooms or are bedbound and cannot go to activity room for meals. The DON confirmed the practice in the was facility to serve the residents in the dining room first and then an hour later serve the residents inside their rooms. During an observation and interview with Resident 35 on 4/01/2025 at 1:05 PM, observed Resident 35 to be sitting on his wheelchair next to side table with lunch tray. Observed Resident 35 with furrowed brows, a glare in his eyes and flared nostrils. Observed Resident 35's diet on meal ticket to indicate it was carbohydrate controlled renal and the lunch tray to contain a plate with a serving size (approximately 3x3inches in size) of vegetable quiche, a small bowl with salsa salad ½ cup,1 dinner roll, 1 margarine,1 chocolate ice cream, graham crackers -2 packet (pkt), coffee 6 oz, milk 4oz. Resident 35 stated, this is the food we get? It is ridiculous and it makes me lose my appetite! During concurrent observation and interview with Resident 35 on 4/01/2025 at 1:18 PM, observed Resident 35's lunch tray to be untouched. Observed CNA1 bring Resident 35 a turkey sandwich and handed it to Resident 35 as a substitution for the resident's lunch. Resident 35 stated he might as well eat the dry turkey sandwich he was provided because he was hungry and did not eat his lunch because it did not look appetizing, and it was such a small serving it made the resident so upset. Resident 35 stated, I would eat the lunch if they would serve me a good meal. I cannot even begin to tell you how awful these meals have been. I am so tired of it. The worse part is that I do not even have a menu so I can at least know what the meals are going to be. They say they have a substitution menu, but it is very limited to about 3 different options, for example a cold turkey sandwich, which is basically what I always have to order since I do not eat the meals. Things would be different if I had a menu with the different meal options. At least that way I would know ahead of time if I should order a substitution. I am always hungry. The meals I do eat is because I am very hungry, but I can honestly tell you, I do not enjoy the food. During a concurrent interview with Resident 35 on 4/02/2024 at 10:06 AM, Resident 35 stated he did not know what he was getting for lunch but was not very hopeful of getting something good. Resident 35 stated, I eat not because the food taste good but because I am starving and I know that if I do not eat that meal, I won't eat at all. During a concurrent interview with DS1 on 4/02/2025 at 10:30 AM, DS1 stated I print out the meal tickets from the computer, their preferences come out on the ticket automatically, this is how we know what meals to serve each resident. The residents have substitution options if they do not like the meals they were served, but they have to give us a two (2) hour in advance notice so we can prepare their substitution. DS1 stated the facility did print out a menu for the month of all the meals the residents were going to be served. DS1 stated, The menu is posted by the activity room and at the front of the facility by the lobby, if there is a last-minute request the residents can ask as well for a substitution. During a concurrent interview with DS1 on 4/03/2025 at 8:33 AM, DS1 confirmed the copy of the menu is posted in the front of the facility and also near the activity room near the kitchen. DS1 confirmed they did not in fact pass out menus to each resident but that the CNAs would inform the residents what the meal was for the day. DS1 stated there is a copy of the meal substitutions with items as cheese quesadillas, deli sandwiches, bean and cheese burrito or tamales and residents were asked to request items at least 2 hours before the meal service. During an interview with Registered Dietitian (RD) on 4/03/25 at 11:54 AM, RD stated the residents are not provided with their own copies of the menu for the month but that the menus are posted near the activity room area and in the front of the facility for the residents to see. RD stated it was not acceptable not to have the menu information for all the residents including the ones that were bedbound or did not leave their rooms. RD stated if a resident is bed bound or does not attend the activity room, they would not be able see the menu. During a concurrent interview with RD on 4/03/2025 at 12:01PM, RD stated that if a resident is not eating the food because they do not like the meals, it can affect the resident's weight, wound healing and possibly the resident will refuse medications because they are on an empty stomach, causing other underlying medical conditions to worsen. RD stated the residents are provided with meal substitution, but it would be hard for the residents to make a meal substitution request if they did not have a menu giving them the information of the daily meals. During a review of the facilities Policy & Procedure titled, Resident Food Preferences, revised 7/2017 indicated, The dietary manager will complete a dietary profile for residents to reflect current food preferences and nutritional needs upon admission, readmission, quarterly, annually or as needed. 1. The Dietary Manager will meet with the resident .to review the following: d. Discuss the resident's food preferences e. The weekly men and location of the posted menu 2. The Dietary Manager will provide residents with meals consistent with their preferences, as indicated on their tray card (diet tray card-printed cards used in facilities like hospitals and nursing homes to provide detailed information about a patient or resident's specific meal requirements)). a. If a preferred item is not available, a suitable substitute should be provided. During a review of the facilities Policy & Procedure titled, Quality of life-Dignity, revised 2/2020 indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to follow proper food storage handling practices in accordance with its policy and procedure (P&P) by failing to label and discard expired food items stored in the facility's kitchen refrigerators, freezers, and dry storage by failing to ensure: 1. 17 pre-filled orange juice cups and two (2) orange juice pitchers inside refrigerator 3 were labeled with a use by or expiration date. 2. Conventional oven temperature was accurate since its oven knobs have no temperature settings. 3. 18 Large metal baking trays were free of grease build-up 4. Two (2) large food pans were free from dents. 5. One (1) blender used in the preparation of mechanical soft diet (foods that are easy to chew and swallow, requiring minimal chewing, and includes foods that are cooked, shredded, blended, chopped, or ground to a soft consistency stand was clean and free from scratches and cracks. 6. The dishwasher machine was free from dirt, corrosion (the gradual breakdown or eating away of a material, especially metals, due to a reaction with its environment like air, water, or chemicals), and calcification (the formation of calcium deposits or hardened material (like scale) on internal or external surfaces, which can lead to reduced performance, malfunction, or even failure). These deficient practices have the potential to result in pathogen (germ) exposure to 88 residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead hospitalization. Findings: 1.During initial kitchen observation on 4/01/2025 at 7:50 AM, observed inside Refrigerator 3, 17 pre-filled orange juice cups and 2 orange juice pitchers which were not labeled to indicate a use by or expiration date. During a concurrent kitchen observation and interview with Dietary Staff (DS2) on 4/01/2025 at 7:52 AM, DS2 stated the pre-filled orange juice cups and orange juice pitchers were not and should have been labeled with a use by or an expiration date. DS2 stated, this way, staff would know when food items are expiring and when not to serve to the residents. DS2 stated residents could get sick from their stomach and could have vomiting or diarrhea if given expired food, which has a potential to cause harm. 2. During a concurrent kitchen observation and interview with DS2 on 4/03/2025 at 7:33 AM, observed ten (10) all the knobs on the conventional oven did not have settings for the temperature. DS2 stated she guesses the temperature setting when cooking using the oven because the settings have been erased over time. Per DS2, If the food is not cooked to correct temperature of at least 165 degrees, like for example if the chicken is cooked and it's raw and it's served to a resident, it can make the resident sick from their stomach and potentially cause harm. During a concurrent observation and interview with DS1 on 4/03/2025 at 7:35 AM, in the kitchen, DS1 stated, We do not know the temperature of the oven, the knob has no settings printed on there. It was difficult to guess, maybe the food does not heat or cook properly and that can be dangerous for the residents if the food does not cook properly. The gas department checked the kitchen, and they did state it wasn't heating to what it should be, so they raised the temperature, and it seems like now it's overheating, possibly overcooking the food. If the cook is not careful to check while it's being cooked and the food is overcooked and served to the residents, the residents might complain that it's too hard to eat or too tough to chew, causing the residents to not eat the food and potentially weight loss, causing the resident potential harm because they need to eat the food to stay healthy. 3. and 4. During a concurrent kitchen observation and interview with DS1 on 4/03/25 at 7:38 AM, observed multiple eighteen (18) metal baking trays piled up on top of each other. The edges were visibly crusted with dry caked grease. Also observed two large metal food pans stored under the stove to be old and dented. Per DS1, using trays inside the oven with dry caked on grease could potentially be a fire hazard. 5. During a concurrent kitchen observation and interview with DS1 on 4/03/25 at 7:40 AM, observed plastic blender used for mechanical soft diet have small cracks at the bottom. The blender stand was dirty, dusty, and DS1 stated it was a new blender but since it was made out of plastic, it looked so old. DS1 stated it was important for the blender used for the residents pureed diet to be in good condition to make sure the food will be pureed perfectly for the residents' meals. 6. During a concurrent kitchen observation and interview with DS1 on 4/03/25 at 7:43 AM, observed the dishwashing machine to have visible calcification (the build-up of calcium deposits, often salts of calcium, within the machine's components. This hardening process can lead to various issues, including reduced functionality, increased maintenance needs, and potential damage), corrosion and discoloration. DS1 stated the same dishwashing machine has been in the facility for a very long time, since before he began to work there. DS1 stated that the dishwashing machine gets serviced once a year and it's tested by dishwasher staff three (3) times a day, once before every meal, breakfast, lunch, and dinner. DS1 stated the machine was recently serviced by a technician only to replace some bolts but that it would it be advisable to consult a qualified technician for any further repairs or maintenance regarding the corrosion since per the warning label, it could be a potential for electrical hazards. During an interview with DS3 on 4/03/2025 at 8:00am, DS3 stated that if the dishwashing machine is not working properly due to the corrosion, it can also lead to reduced performance, malfunction, or even failure of the machine causing the dishes to not be washed or sanitized properly. DS3 stated if the dishwasher is not sanitizing dishes properly, there is a risk of leaving behind food particles (bits of food left on dishes) behind and bacteria (microscopic living organisms that have only one cell. Most bacteria are not harmful, but certain types can make people sick), which potentially could spread germs to the residents causing them to get sick from their stomach and experience nausea, vomiting or diarrhea. During a review of the facility's P&P titled, Food Receiving and Storage, revised 7/2014, the P&P indicated, Food shall be received and stored in a manner that complies with safe food handling practices 7. Refrigerated foods are labeled and dated. During a review of the facility's P&P titled, Sanitization, revised 11/2022, indicated, The food service area is maintained in a clean and sanitary manner . 2. All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use of proper cleaning .12. Plastic ware, China and glassware that cannot be sanitized or are hazardous because of chips, cracks or loss of glaze are discarded. Damaged or broken equipment that cannot be repaired is discarded. During a review of the facility's P&P titled, Preventing Foodborne Illness-Food Handling, revised 7/2014 indicated, Food will be stored, prepared, handled, and served so that the risk of foodborne illness is minimized . This facility recognizes that the critical factors implicated in foodborne illness are: . b. Inadequate cooking and improper holding temperatures c. Contaminated equipment

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. During a review of Resident 248's admission Record, the admission record indicated Resident 248 was admitted to the facility on [DATE] with diagnosis that included chronic obstructive pulmonary disease (COPD, a progressive lung disease characterized by persistent airflow limitation and difficulty breathing due to narrowed or damaged airways). During a review of the MDS, dated [DATE], indicated Resident 248 had modified independence (some difficulty in new situations) for cognitive skills for daily decision making. Resident 284 need partial or moderate assistance with the eating, oral hygiene and personal hygiene. Resident 284 was dependent with the toilet, upper and lower body dressing, change of position, and transfer. During a review of Resident 284's Physician Orders, dated 3/14/2025, the physician's orders indicated the following: 1. Oxygen at 2 liters per minute (2L/min) via nasal canular (NC, a device that delivers extra oxygen through a tube and into the nose continuously) to keep oxygen level above 92%. 2. Ipratropium-albuterol solution 0.5-2.5 (3) milligrams (mg, a unit of measurement) /3 milliliters (ml, a unit of measure for the capacity of an item) inhale orally three times a day for asthma. During an observation on 4/1/2025 at 9:28 AM in Resident 284's room, observed Resident 284's breathing treatment mask and nasal cannula laying on top of an undated and unlabeled plastic bag on top of the night. During an observation on 4/3/2025 at 10:41 AM in Resident 284's room, observed Resident 284's breathing treatment mask and nasal cannula laying on top of an undated and unlabeled plastic bag on top of the night. During an interview on 4/3/2025 at 11:05 AM with Licensed Vocational Nurse (LVN1), LVN 1 stated that the breathing treatment mask and nasal cannula were supposed to be inside a clean bag labeled with a date and resident's name on it to prevent infection and cross contamination. During an interview on 4/2/2025 at 11:14 AM with Infection Preventionist Nurse (IP), IP nurse confirmed that the breathing treatment mask and nasal cannula were supposed to be stored in a clean, dated and named bag to prevent infection, cross contamination. During a review of the Facility's Policy and Procedure (P&P) titled, Standard Precautions, revised September 2022, the P&P indicated hand hygiene is performed with alcohol-based hand rub (ABHR) or soap and water: 1. Before and after contact with the resident 2. Before moving from work on a soiled body site to a clean body site on the same resident 3. After contact with items in the resident's room 4. And after removing gloves The P&P also indicated standard precautions apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. The P&P also indicated resident-care equipment soiled with blood, body fluids, secretions, and excretions are handled in a manner that prevents skin and mucous membrane exposure, contamination of clothing, and transfer of microorganisms to other residents and environments. During a review of the Facility's P&P titled, Handwashing/Hand Hygiene, dated 9/18/2023, the P&P indicated to consider hand hygiene the primary means to prevent the spread of infection. The P&P also indicated the use of ABHR before and after contact with the resident, after contact with blood/body fluids, or after contact with objects in the resident's room. The P&P indicated single use disposable gloves when in contact with blood or body fluids and gloves does not replace hand washing/hand hygiene. 3. During a review of the admission Record, the admission Record indicated Resident 198 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included but not limited to type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing), other lack of coordination (a medical condition, often called ataxia, characterized by a loss of muscle coordination, leading to clumsy or jerky movements, unsteady gait, and difficulty with balance and fine motor skills), end stage renal disease (the kidney is no longer able to perform its main functions, which are to filter the blood to remove any waste and to balance fluids within the body), chronic kidney disease (is a condition where the kidneys are damaged and don't function as well as they should, leading to a gradual loss of kidney function). During a review of Resident 198's MDS, dated [DATE], the MDS indicated Resident 198 was moderately impaired with cognitive skills for daily decision making. Resident 198 needed partial/moderate assistance (helper does less than half the effort) from the staff for the activities of daily living such as toileting, showers and upper and lower body dressing and needed supervision (helper provides verbal cues and resident completes activity) for eating, oral and personal hygiene. During a review of Resident 198's Order Summary, dated 3/20/2025, the Order Summary indicated, indwelling catheter: Foley catheter (a type of indwelling urinary catheter, which is a flexible tube inserted through the urethra {or sometimes directly into the bladder through a small incision} to drain urine) French (FR) 16 balloon size: 10 cubic centimeters (cc- a unit of volume in the metric system, representing the space occupied by a cube that measures 1 centimeter on each side) change for blockage, leaking, pulled out, excessive sedimentation. Change catheter drainage bag as needed and with every change of indwelling catheter as needed for Urinary retention (the inability to completely empty the bladder when urinating). During a review of Resident 198's Care Plan initiated on 3/23/2025, the care plan indicated Resident 198 requires indwelling Foley catheter due to urinary retention with Dx (diagnosis) of BPH (Benign prostatic hyperplasia, a condition that causes the prostate gland which produces a fluid that is part of semen to grow larger than normal]). Staff intervention included was to keep foley catheter (a type of indwelling urinary catheter, to collect urine drained from the bladder) off the floor During observation in Resident 198's room on 4/01/25 at 9:07 AM, observed Resident 198 resting in bed, with the Foley catheter bag (a collection bag that attaches to a Foley catheter) noted to be on the right side of the bed touching the floor. During an interview with Licensed Vocational Nurse 3 (LVN3) on 4/01/2025 at 9:15 AM, LVN3 confirmed Resident 198's Foley catheter bag was on the floor and was not covered with a privacy bag. LVN3 stated, the urine bag should not be touching the floor to prevent any type of bacteria from entering the bag possibly causing infection to the resident. During an interview with Registered Nurse 3 (RN3) on 4/01/2025 at 9:20 AM, RN3 stated it's per facility policy to make sure all foley catheters are off the floor to prevent any type of infection to the resident. During an interview with the Director of Nursing (DON) on 4/04/25 at 11:56 AM, the DON stated Resident 198 uses a wheelchair to mobilize and the foley catheter is placed on side of wheelchair and the staff must make sure it's not touching the floor to prevent any type of bacteria introduced into the catheter or to prevent backflow (urine flowing backwards from the drainage bag or tubing into the bladder, potentially leading to infection). Based on observation, interview, and record review, the facility failed to follow infection control practices according to facility's policy and procedure for four (4) of five (5) sampled residents (Residents 70, 9, 198, and 248) by failing to ensure: 1. Facility staff doff (take off) Personal Protective Equipment (PPE, protective clothing, goggles, or other garments to prevent or minimize exposure to and spread of infection or illness) and perform hand hygiene (cleaning hands to prevent germs) after providing peri-care (cleaning the genitals and anal area) and during wound care for Resident 70. 2. Facility staff did not touch Resident 9's straw after touching another resident's surface. Facility staff also failed to doff PPE and perform hand hygiene after providing peri-care for Resident 9. 3. Resident 198's indwelling urinary catheter was not touching the floor. 4. Resident 248's respiratory treatment mask and nasal cannular (NC) were stored inside a clean bag with the resident's name and date to prevent equipment contamination and infection. These deficient practices have the potential to spread infection to staff and residents. Findings: 1. During a review of Resident 70's admission Record, the admission Record indicated resident was originally admitted to the facility on [DATE] and was readmitted on [DATE] with the diagnoses of sepsis (a life-threatening blood infection), cellulitis (a skin infection that causes swelling and redness), and dementia (a progressive state of decline in mental abilities). During a review of Resident 70's Minimum Data Set (MDS, a resident assessment tool), dated 1/31/2025, the MDS indicated the resident was severely impaired (never/rarely make decisions) with cognitive (the ability to understand and make decisions) skills for daily decision making. The MDS also indicated Resident 70 was dependent (Helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the 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 70 had an indwelling catheter (tube that drains urine from the bladder to a drainage bag) and was always incontinent with bowel. During a review of Resident 70's Care Plan with focus on Patient at risk for Multidrug-resistant Organisms (MDRO, bacteria that are resistant to three or more classes of antimicrobial drugs) colonization (presence of microorganisms in a host that multiplies without interaction between host and organism), revised 3/12/2025, the Care Plan indicated enhanced standard precaution (EBP - gown and glove use during high contact care activities) to use gown and gloves when performing high contact activities such as changing briefs or assisting with toileting. During a concurrent observation and interview on 4/3/2025 at 9:28 AM in Resident 70's room (EBP), Certified Nursing Assistant 2 (CNA 2) was observed not wearing a gown and was providing incontinent care (cleaning the residents perineal [genital and anal area] area of urine and feces) to Resident 70. After providing incontinent care, CNA 2 was observed using the same gloves, touching resident's hands and bed side rail. CNA 2 stated she did not and should have worn a gown when providing care to Resident 70. CNA2 also stated she did not and should have taken off her gloves and performed hand hygiene prior to touching the resident's hands and surfaces. During a review of Resident 70's physician orders, dated 3/14/2025, the physician orders indicated to apply collagenase powder (medication to improve the functionality of cells) to sacrococcyx (tail bone area) topically every day for pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) for 30 days. Cleanse with normal saline (mixture of sodium chloride and water), pat dry and apply to affected area with calcium alginate (topical cream for wounds) and cover with super absorbent dressing. During an observation and interview on 4/3/2025 at 9:50 AM, Treatment Nurse 1 (TN 1) was observed performing wound care for Resident 70. TN 1 was observed with gloves on. TN 1 removed Resident 70's dirty dressing off and with the same gloves, continued with treatment application and applied a clean dressing over the wound. TN 1 stated she did not and should have changed her gloves and performed hand hygiene prior to continuing Resident 70's wound treatment and prior to applying the dressing. During an interview on 4/3/2025 at 11:07 AM, IPN stated gloves should be one time use. IPN also stated the treatment nurse should change gloves and perform hand hygiene prior to continuing treatment and applying the clean dressing. 2. During a review of Resident 9's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the diagnoses of urinary tract infection (UTI - an infection in the bladder/urinary tract), and dementia. During a review of Resident 9's MDS, dated [DATE], the MDS indicated resident was severely impaired with cognitive skills for daily decision making. The MDS also indicated Resident 9 was dependent with toileting hygiene, shower/bath self and putting on/taking off footwear. Resident 9 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with upper body dressing, lower body dressing and personal hygiene. The MDS also indicated Resident 9 was always incontinent with both urine and bowel. During a concurrent observation and interview on 4/1/2025 at 8:34 AM, CNA 2 was observed touching Resident 9's roommate's surfaces and proceeded to grabbing Resident 9's cup while touching the straw. CNA 2 stated she should have performed hand hygiene in between resident care because that can spread infection. During an interview on 4/2/2025 at 2:25 PM, IPN stated the CNA should have changed gloves and performed hand hygiene in between resident care to prevent the spread of infection. During a concurrent observation and interview on 4/3/2025 at 10:25 AM, CNA 2 was observed with gloves while providing incontinent care to Resident 9. CNA 2 was observed with the same gloves, touching resident's hand and bed side rail after providing incontinent care to Resident 9. CNA stated she was supposed to change her gloves and perform hand hygiene prior to touching the resident's hands and surfaces to prevent the spread of infection. During an interview on 4/3/2025 at 11:07 AM, the Infection Prevention Nurse (IPN) stated the CNA should put on a gown prior to entering an EBP room. IPN also stated the CNA should have doff the gloves and perform hand hygiene prior to touching the resident's hand and surfaces because that can spread infection.

Aug 2024 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide nutritional care services for one of two sampled residents (Resident 1) who is experiencing impaired nutrition by: a. Failing to ensure Resident 1's primary physician and Registered Dietician (RD) were notified regarding Resident 1's change of condition (COC, a sudden, clinically important deviation from a patient's baseline in physical, cognitive, behavioral, of functional domains) of weight loss of six (6) pounds (lbs., unit of measurement) noted on 7/3/2024. b. Failing to ensure Resident 1's primary physician and RD were notified regarding Resident 1's meal intake of 50% or less noted on 7/3/2024, 7/5/2024, 7/6/2024, 7/7/2024, 7/8/2024 and 7/9/2024 (total of 6 days). c. Failing to initiate a resident centered care plan and provide interventions to address Resident 1's weight loss noted on 7/3/2024 and poor meal intake that was noted on 7/3/2024 to 7/9/2024. These deficient practices placed Resident 1 at risk for further weight loss. In addition, this led to Resident 1 experiencing general weakness and poor meal intake of 0- 50% noted on 7/10/2024. Resident 1 was sent to General Acute Hospital (GACH) and was diagnosed with dehydration (a dangerous loss of body fluid caused by illness, sweating, or inadequate intake), anorexia (an eating disorder causing people to obsess about weight and what they eat), and general weakness, and resident is at risk for malnutrition (occurs when the body doesn't get enough nutrients). Findings: During a review of Resident 1's admission Record indicated Resident 1 was originally admitted by the facility on 10/31/2016 and was readmitted on [DATE] with the following diagnoses of dehydration and diabetes (a group of diseases that result in too much sugar in the blood). During a review of Resident 1's History and Physical (H&P), dated 7/18/2024, indicated Resident 1 has fluctuating capacity to understand and make decisions. During a review of Resident 1's Minimum Data Set (MDS; a standardized care screening and assessment tool), dated 8/23/2024, indicated resident is severely impaired in cognitive (the functions your brain uses to think, pay attention, process information, and remember things) skills for daily decision making. The MDS also indicated resident is dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity) with eating, oral hygiene, toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. During a review of Resident 1's Weight and Vitals Summary, dated 6/5/2024, indicated resident's weight was 165 lbs. During a review of Resident 1's Weight and Vitals Summary, dated 7/3/2024, indicated resident's weight was 159 lbs. During a review of Resident 1's Meal intake dated 6/30/2024-7/15/2024, indicated on: 1. 7/3/2024 ate 50% of her lunch and dinner. 2. 7/5/2024 ate 50% of her breakfast and lunch. 3. 7/6/2024 ate 0% her breakfast and lunch. 4. 7/7/2024 at 50% of her breakfast and 25% of her dinner 5. 7/8/2024 Refused her breakfast and lunch and ate 50% of her dinner. 6. 7/9/2024 ate 25% of her breakfast and lunch and refused her dinner. During a review of Resident 1's COC Evaluation, dated 7/10/2024, indicated resident is having functional decline, general weakness poor meal intake of 0-50%. The COC Evaluation also indicated resident was chewing food and spitting it out. During a review of Resident 1's GACH's Emergency Department Record, dated 7/10/2024, indicated admitting diagnosis of dehydration, anorexia, and general weakness and resident is at risk for malnutrition. During an interview on 8/29/2024 at 1:50 PM, Registered Dietician stated she was not made aware of Resident 1's weight loss on 7/3/2024. During an interview on 8/29/2024 at 2:12 PM, Assistant Director of Nursing (ADON) stated the Registered Dietician (RD) was not made aware of Resident 1's weight loss on 7/3/2024 and should have been informed. During a concurrent record review of Resident 1's medical records and interview on 8/30/2024 at 10:26 AM, ADON stated on 7/10/2024, Resident 1's primary physician was made aware of Resident 1's weight loss of 6 lbs. taken on 7/3/2024. The ADON stated, Resident 1's primary physician should have been informed of the resident's COC of weight loss noted on 7/3/2024 as soon as possible but the primary physician was not made aware until 7/10/2024 and it was too late that Resident 1 needed to be sent to GACH. During the same concurrent interview with ADON on 8/30/2024 at 10:26 AM and record review of Resident 1's meal intake from 6/30/2024 to 7/15/2024, ADON stated if the resident was eating 50% or less the Certified Nursing Assistant (CNA) should inform the charge nurse and the charge nurse should inform the resident's primary physician and RD. ADON stated, Resident 1 had 50 % or less meal intake on 7/3/2024, 7/5/2024, 7/6/2024, 7/7/2024, 7/8/2024 and 7/9/2024. ADON stated, there was no documented evidence that Resident 1's primary physician and/ or RD was notified regarding resident's meal intake of 50% or below. During a concurrent record review of Resident 1's Care Plans, dated 7/3/2024- 7/10/2024, and interview on 8/30/2024 at 11 AM, the Director of Nursing (DON) stated the facility did not create a resident centered care plan but should have a care plan to address Resident 1's poor meal intake that was noted on 7/3/2024 and poor meal intake noted on 7/3/2024, 7/5/2024, 7/6/2024, 7/7/2024, 7/8/2024 and 7/9/2024. During the same concurrent record review of Resident 1's medical records, dated 7/3/2024-7/9/2024, and interview on 8/30/2024 at 11 AM, the DON stated there was no documented evidence that Resident 1's primary physician and RD was made aware of Resident 1's weight loss on 7/3/2024. The DON stated a if a resident was eating 50% or less for two meals including weight loss of 6 lbs. within a span of 28 days, it is considered COC and should be included the facility's policy for Change of Condition. The DON also stated a COC should have been done between the dates from 7/3/2024 to 7/9/2024 when Resident 1 was noted to be eating 50% or less of two meals and weight loss of 6 lbs. on 7/3/2024. During an interview on 8/30/2024 at 11:30 AM, the DON stated Resident 1's care plan, dated 7/3/2024- 7/9/2024, did not include goals or interventions to address Resident 1's weight loss of 6 lbs. on 7/3/2024 and no care plan initiated for Resident 1's poor meal intake noted from 7/3/2024 to 7/9/2024 which can put the resident at risk for nutritional deficiency or malnutrition. The DON also stated there was no Interdisciplinary Team (IDT; brings together knowledge form different health care disciplines to help residents receive the care they need) meeting conducted regarding Resident 1's weight loss on 7/3/2024 and poor meal intake that was noted from 7/3/2024 until 7/9/2024. During an interview on 8/30/2024 at 12:40 PM, Certified Nursing Assistant 2 (CNA 2) stated she will only report to the licensed nurse if the resident was eating 25% or less. During an interview on 8/30/2024 at 12:50 PM, CNA 1 stated she will only report to the licensed nurse if the resident was eating 25% or less. During an interview on 8/30/2024 at 2:20 PM, primary physician stated she was made aware of Resident 1's poor meal intake when she gave an order for the resident to go to the hospital on 7/10/2024 and was not made aware from 7/3/2024 to 7/9/2024. During a review of the facility's Policy and Procedure (P&P) Charting and Documentation, revised July 2017, indicated changes in resident's condition is to be documented in the resident's medical record. The policy also indicated documentation will include the assessment data or any unusual findings and whether the resident refused the procedure/treatment. During a review of the facility's P&P titled Weight Management, dated 8/25/2021, indicated the facility IDT collaborates for determining the need for initiation or discontinuation of weights other than weekly or ordered by physician. The P&P also indicated that RD will be responsible for determining the desirable weight range or usual body weight range. During a review of the facility's P&P titled Notification of Change in Condition, dated 8/25/2021, indicated to ensure physicians are informed of changes in the resident's condition. During a review of the facility's P&P titled Interdisciplinary Team Care Plan, dated 8/25/2021, indicated the care plan is based on the resident's assessment and developed by an interdisciplinary Team to meet the needs of the resident. During a review of the facility's P&P Care Plan Comprehensive, dated 8/25/2021, indicated an individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental, and psychosocial (having to do with the mental, emotional, social, and spiritual effects of a disease) needs shall be developed for each resident. The policy also indicated each resident's comprehensive care plan is designed but not limited to incorporate identified problem areas and incorporate risk and contributing factors associated with identified problems.

Aug 2024 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Safe Environment (Tag F0921)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to maintain a sanitary environment by failing to prevent the accumulation of dust and lint, and dispose dead cockroaches found in the facility's laundry room. This deficient practice had a high potential to encourage pest activity and infection. Findings: During a concurrent observation of the facility's laundry room and interview with maintenance assistant (MA) on 8/1/2024 at 10:58 AM, two cockroach traps were observed behind the two dryer machines. The surrounding area where the cockroach traps were located was observed dusty and with lint accumulation. MA stated that these cockroach traps appear old. MA stated the cockroach traps were covered with lint. MA stated that one cockroach trap had six (6) dead insects and the other cockroach trap had five (5) dead insects. MA stated, These insects are not cockroaches, these are American water bugs. MA stated he did not know when these cockroach traps were placed in the laundry room. MA verified that these cockroach traps were not dated. MA stated that he did not know when to dispose the dead insects and when to change the traps. During an interview with laundry staff 1 (LS 1) on 8/1/2024 at 3:20 PM, LS 1 stated, I had seen cockroach traps in the laundry room, behind the dryer machines, with dead cockroaches in it for few days now. LS 1 stated that she did not know when or who needs to discard the cockroach trap with the dead cockroach in it. LS 1 added that cockroaches are dirty and should not be in the facility. During an interview with Infection Preventionist Nurse (IPN) on 8/1/2024 at 3:30 PM, IPN stated that having a dead or alive cockroach was unsanitary. IPN stated that cockroaches could potentially go into the clean linen carts, which were distributed throughout the facility and can cause residents to get sick. During an interview with the Assistant Administrator (AA) on 8/1/2024 at 4 PM, AA stated cockroach traps were placed by pest control company to monitor cockroach activity in the laundry room. AA stated that facility was not given instructions when to dispose the cockroach traps with dead cockroaches. AA was unable to provide documented evidence when the cockroach traps were placed in the laundry room. AA stated, All I know is the pest control company wanted to monitor cockroach activity by monthly basis, and that is when pest control will determine the treatment for the area. During a concurrent record review of the facility's Policy and Procedure (P&P) titled, Pest Control, revised in May 2008, and interview with the Director of Nursing (DON) on 8/1/2024 at 4:30 PM, the DON verified P&P did not indicate when to change and dispose cockroach traps. The DON stated instructions onto when to dispose cockroach traps should be included in the P&P. The DON stated that cockroaches can carry disease-causing germs and can get residents sick that can lead to hospitalization. A review of facility's Environmental Services Operations Manual, titled Environmental Services Employees, revised in 9/5/2017, indicated to make sure all equipment is kept clean or it could be a breeding ground for germs.

May 2024 1 deficiency

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based an observation, interview, and record review, the facility staff failed to ensure one of four sampled residents (Resident 4) was free of accident hazards by leaving an unattended bottle of cleaning solution in the shower and failing to supervise Resident 4 who had a history of wandering (when a resident roams around and becomes lost or confused about his/her location). This deficient practice resulted in Resident 4 to gain access to the bottle of cleaning solution on 5/2/24 and was observed holding the bottle tilted towards the resident's mouth. This failure also had the potential for other residents to have access to the bottle of cleaning solution and risk for ingesting the cleaning solution, which could lead to harm and hospitalization. Findings: A review of Resident 4's admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses that included hypercalcemia (a condition in which the calcium level in the blood becomes too high), dementia (a brain disorder that results in memory loss, poor judgment, and confusion), and dysphagia (difficulty or discomfort in swallowing). A review of Resident 4's History and Physical Examination (H&P), dated 3/14/2024 indicated Resident 4 did not have the capacity to understand and make decisions. A review of Resident 4's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 2/7/2024, indicated Resident 4 was assessed having severely impaired cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making and required partial moderate assistance (helper does less than half the effort) with toileting hygiene, shower/bathe self, sit to lying, sit to stand, wheel 50 feet (ft- unit of measurement) with two turns (the ability to wheel at least 50 feet and make two turns once seated in wheelchair/scooter), and wheel 150 feet (the ability to wheel at least 150 feet in a corridor or similar space once seated in wheelchair/scooter). A review of Resident 4's Care Plan, revised on 2/6/2024, indicated Resident 4 was observed at risk for physical behaviors: wandering. The care plan indicated Resident 4's risk factors included impaired cognition secondary to dementia and impaired safety awareness/safety judgement. Resident 4's care plan interventions indicated to redirect resident to resident care areas when indicated. A review of Resident 4's Change in Condition Evaluation form, dated 5/2/2024, indicated Resident 4 was witnessed by Certified Nursing Assistant (CNA) holding a bottle of cleaning solution in Station 2 shower room. The COC also indicated; Resident 4 was also witnessed spitting something out. The COC further indicated, Registered Nurse (RN) did the assessment and called Poison Control Center. The COC indicated RN was directed by the Poison Control Center to provide resident with water or milk and Resident 4 refused water did drink the milk. During an interview with Housekeeping Supervisor (HKS), on 5/15/2024, at 11:19 AM, HKS stated cleaning solutions are stored and locked in the housekeeping carts after use. HKS stated housekeeping staff are not allowed to leave any cleaning solutions or chemicals in the bathrooms or showers and/ or other areas that can be accessed by the residents. HKS stated on 5/2/2024 Housekeeper (HK 1) left a bottle of cleaning solution in Shower 2. HKS stated in the evening of 5/2/2024, Resident 4 was found by CNA 1 and CNA 2 inside Shower 2 holding a bottle of Toilet Bowl Cleaner (cleaning solution). HKS stated she was told that Resident 4 drank and spit out the cleaning solution. HKS stated Resident 4 likes to wander around Station 2. During an observation in Resident 4's room on 5/15/2024 at 12:14 PM, Resident 4 was observed seated on the wheelchair about to be assisted for lunch by the facility staff. Resident mumbled and was not able respond to any questions asked. During an interview with Licensed Vocational Nurse (LVN 1), on 5/15/2024, at 12:38 PM, LVN 1 stated CNA 2 found Resident 4 in Shower 2 on 5/2/2024 at around 8:30 PM holding a bottle of cleaning solution. LVN 1 stated she was informed by CNA 2 that Resident 4 had a bottle of cleaning solution tilted towards Resident 4's mouth when she found her. LVN 1 stated CNA 2 saw Resident 4 spit something out of her mouth after Resident 4 was found. LVN 1 stated Resident 4 gets restless and wanders around the facility and needs to be redirected when the resident wanders. LVN 1 stated the Shower 2 door is usually left open. LVN 1 stated housekeeping staff store bottles of cleaning solutions in the housekeeping cart of in the locked closet. LVN 1 stated housekeeping staff is not allowed to leave any bottles of cleaning solution in the bathrooms or showers. LVN 1 stated residents can have a bad reaction and get sick from ingesting cleaning solution. During an interview with CNA 1, on 5/15/2024, at 1:08 PM, CNA 1 stated, on 5/2/2024, at approximately 8:45 PM, CNA 1 and CNA 2 were getting ready to prepare Resident 4 for bed and found Resident 4 inside Shower 2. CNA 1 stated she was walking behind CNA 2 when CNA 2 found Resident 4 inside Shower 2 holding a bottle of cleaning solution tilted and pointing towards the resident's mouth. CNA 1 stated CNA 2 pulled Resident 4's wheelchair back and immediately checked Resident 4's mouth for any cleaning solution. CNA 1 stated the bottle of cleaning solution was left inside Shower 2. CNA 1 stated Resident 4 can get sick from drinking cleaning solution. CNA 1 stated Resident 4 needs to be supervised for her safety because she tends to wander into different rooms in the facility. During an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), on 5/15/2024, at 1:32 PM, the DON stated she was notified on 5/2/2024 at approximately 10 PM the Resident 4 was seen holding a bottle of cleaning solution inside Shower 2. The DON stated CNA 2 saw Resident 4 spitting after Resident 4 was found. The DON stated Resident 4 possibly wheeled herself into Shower 2 which is located across Resident 4's room. The DON stated Shower 2 door did not have a lock. The DON stated that based on the facility's investigation, a housekeeping staff left the bottle of cleaning solution in Shower 2. During the same interview with the DON and ADON, on 5/15/2024, at 1:32 PM, the DON stated housekeeping staff is not allowed to leave any cleaning solution around the facility. The DON stated cleaning solutions should be placed in the locked closet or inside the locked housekeeping cart to prevent residents having and access to the cleaning solutions and from accidentally ingesting the cleaning solution. The DON stated if the cleaning solution is ingested it can cause accidental poisoning, potential harm, a change in condition, and possible hospitalization for the resident. The DON stated, on 5/2/2024, the facility staff did not monitor Resident 4's location in the facility and provide redirection when the resident wheeled herself inside Shower 2. A review of the facility's P&P, titled, Storage Areas, Maintenance, revised on 12/2009, indicated, Maintenance storage areas shall be maintained in a clean and safe manner. A review of the facility's P&P, titled, Safety and Supervision of Residents, revised on 7/2017, indicated the following: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.

Apr 2024 19 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

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility staff failed to ensure one (1) of 22 sampled residents (Resident 18) was cared for in a dignified way by failing to sit and be at eye level while feeding Resident 18 on 4/22/2024. This failure had the potential to negatively affect Resident 18's dignity and self-worth. Findings: A review of Resident 18's admission Record, indicated Resident 18 was admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including, but not limited to Parkinson's disease (a condition that causes nerve damage in the brain that affects, speech and movement) and dementia (the loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that it interferes with a person's daily life and activities). A review of Resident 18's Physician's Orders, dated 3/30/2023, indicated the resident should receive a regular dysphagia (difficulty swallowing foods or liquids) puree (a smooth, creamy substance) texture, thick liquids- nectar consistency (a liquid slightly thicker than water) double portions as ordered. A review of Resident 18's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 3/21/2024, indicated Resident 18 was severely impaired with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. Resident 18 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is requires for the resident to complete the activity) on staff to help with feeding. During a concurrent observation and interview on 4/22/2024 at 12:27 PM with Certified Nursing Assistant 1 (CNA1) and Infection Preventionist Nurse (IPN) in Resident 18's room, CNA 1 was standing and leaning in front of Resident 18, while feeding the resident in a wheelchair. IPN stated it is important to sit while feeding the resident to make sure nothing is being pushed down the resident's mouth and to be at eye level. During an interview on 4/25/2024 at 8:22 AM with Restorative Nursing Assistant (RNA), RNA stated staff should sit down while feeding the resident to provide dignity. During an interview on 4/25/2024 at 10:52 AM with the Director of Nursing (DON), the DON stated the resident should be fed at eye level to show respect and dignity. A review of the facility's Policy and Procedure titled, Quality of Life-Dignity, revised in February 2020, indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self-worth and self-esteem. and Residents are treated with dignity and respect at all times.

CONCERN (D)

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

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of five (5) sampled Residents (Resident 107) was given information to formulate an advance directive (written statement of a resident's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the resident be unable to communicate them to the doctor). This deficient practice had the potential to cause conflict in carrying out the Resident 107's wishes for medical treatment and health care decisions. Findings: A review of Resident 107 admission Record indicated resident was admitted on [DATE] with the following diagnoses of arthritis (joint inflammation) and sciatica (pain, weakness, numbness, or tingling in the leg). A review of Resident 107's History and Physical (H&P), dated 4/5/2024, indicated resident has the capacity to understand and make decisions. A review of Resident 107's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 4/8/2024, indicated resident had an intact cognitive (ability to understand and make decision) skills for daily decision making. MDS also indicated Resident 107 required set up or clean up assistance (helper sets up or cleans up; resident completes the activity. Helper assists only prior to or following the activity) with eating, oral hygiene, toileting hygiene and personal hygiene. Resident 107 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with shower/bathe self and upper body dressing. During a record review on 4/23/2024 at 12:07 PM, there was no advance directive noted in the chart. Resident 107's Physician Orders for Life Sustaining Treatment (POLST, form is a written medical order form a physician that give people more control over their own care by specifying the types of medical treatment they want during serious illness) was noted with advance directive box unchecked. During a concurrent interview and record review of Resident 107 POLST on 4/24/2024 at 11:41 AM, Administrator (ADM) and Assistant Administrator (AADM) stated the Social Services Director (SSD) was not supposed to put a check mark on the No Advance Directive box on Section D. ADM also stated SSD needs to confirm if the resident has an advance directive or not before adding the check mark; and if not, the SSD should provide the resident an option to formulate an advance directive. ADM also stated it should be done at the time of admission. ADM stated there was no documented evidence that the resident was given an option to formulate an advance directive. A review of the facility's Policy and Procedure titled, Advanced Directive, dated 3/23/2022, indicated at the time of admission, admission staff or designee will inquire about the existence of an Advance Directive. Policy also indicated the facility will honor resident's Advance Directive and will provide information but if no Advance Directive exist then the facility provides the resident with an opportunity to complete one.

CONCERN (D)

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

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the resident's physician/ medical doctor (MD) when there was a delay in discharging one (1) of 22 sampled residents (Resident 108) to home from 3/8/2024 to 3/9/2024. This deficient practice had the potential to result in an unsafe discharge. Findings: A review of Resident 108's admission Record indicated Resident 108 was admitted to the facility on [DATE], with diagnoses of generalized osteoarthritis (the cartilage within a joint begin to break down and the underlying bone begins to change causing reduced function and disability), syncope (fainting) and collapse, and history of falling. A review of the Resident 108's Physician Order Summary Report, dated 2/29/2024, indicated Resident 108's last covered day (LCD, the last day insurance company pays for in full or in part) on 3/7/2024 and discharge home on 3/8/2024. A review of Resident 108's Minimum Data Set (MDS, a comprehensive standardized assessment and screening tool), dated 3/1/2024, indicated Resident 108's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were intact. The MDS indicated Resident 108 required partial/moderate assistance (helper does less than half the effort) with shower/bathe, lower body dressing, chair/bed-chair transfer, toilet transfer, and walking ten feet. A review of Resident 108's Change of Condition (COC, tool used by health care professionals when communicating about critical changes in a resident's status), dated 3/7/2024, indicated Resident 108 was found in kneeling position next to foot of bed on right side. Resident 108 stated she tried to go to the restroom by herself and lost footing. A review of Resident 108's Nursing Notes, dated 3/8/2024, indicated to discharge Resident 108 home on 3/9/2024, Saturday. A review of Resident 108's Nursing Notes, dated 3/9/2024, indicated Resident 108 was discharged home. A review of Resident 108's Physician Progress Notes (PPN), dated 3/9/2024, indicated the Medical Doctor (MD) came to see Resident 108 but was Resident 108 was discharged today (3/9/2024). MD was not able to see the resident. PPN indicated MD had to check Resident 108's records since MD was notified Resident 108 had a fall on 3/7/2024 at 5:30 AM and was waiting for X-Ray (an imaging study that takes pictures of bones and soft tissues) reports after the fall. During an interview on 4/25/2024 at 3:19 PM with Registered Nurse 1 (RN 1), RN 1 stated when residents' insurance had a last covered day, the doctor would be notified of the LCD, and the doctor would order for the resident to be discharged at a later date. RN 1 stated if a resident was not discharged home on the day of the discharge in accordance with the physician's order, the nurse need to notify the MD. RN 1 stated an order for discharge would be obtained if the resident were to be discharged on a different day. During a concurrent interview and record review of Resident 108's medical records on 4/25/2024 at 3:24 PM with RN 2, RN 2 stated MD ordered for Resident 108 to be discharged on 3/8/2024. RN 2 stated Resident 108 was not discharged on 3/8/2024. RN 2 stated Resident 108 was discharged on 3/9/2024, which was not what the MD had ordered. During a concurrent interview and record review of Resident 108's medical records on 4/25/2024 at 3:56 PM with the Director of Nursing (DON), the DON stated Resident 108 was discharged from the facility on 3/9/2024. The DON stated Resident 108 had an order to be discharged on 3/8/2024 which was placed on 2/29/2024. The DON stated the doctor needed to be notified and an order received to discharge Resident 108 on 3/9/2024. The DON stated, according to the COC report, Resident 108 had a fall on 3/7/2024 (two days prior to being discharged ) and according to the PPN, it did not seem that MD was aware that Resident 108 was discharged home when the MD came to the facility on 3/9/2024. A review of the facility's Policy and Procedure titled, Notification of Change in Condition, dated 8/25/2021, indicated physicians are informed of changes in the resident's condition. The facility must immediately consult with the resident's physician and/or Nurse Practitioner (NP) where there is a decision to discharge the resident from the center. When making notification of above, the facility must ensure that all pertinent information is available and provided upon request to the physician and/or NP. A review of the facility's Policy and Procedure titled, Transfer and Discharge, dated 3/23/2022, indicated the Interdisciplinary Team (IDT, group of healthcare professionals from diverse fields who work in a coordinated manner toward a common goal for the resident) and the Attending Physician will determine that the resident may be appropriate for discharge.

CONCERN (D)

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

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise the care plan for (one) 1 of 22 residents (Resident 77) who had multiple falls. This deficient practice has the potential for Resident 77 to have further falls, which could result in harm, hospitalization, and death. Findings: A review of Resident 77's admission Record, indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of muscle weakness and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities. A review of Resident 77's History and Physical, dated 10/11/2023, indicated resident does not have the capacity to understand and make decisions. A review of Resident 77 Minimum Data Set (MDS; a standardized assessment and care screening tool), dated 2/8/2024, indicated resident is severely impaired (never/rarely made decisions) with cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making. MDS indicated resident required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with eating, oral hygiene, and personal hygiene. Resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with upper and lower body dressing. Resident 77 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) toileting hygiene, shower/bathe self and putting on/taking off footwear. A review of Resident 77's Situation, Background, Assessment and Recommendation (SBAR, a structured communication framework that can help teams share information about the condition of the resident) Communication Form, dated 2/8/2023, indicated resident had a fall. A review of Resident 77's Interdisciplinary Team (IDT, a group of healthcare professionals from complementary fields who work in tandem to treat a resident) fall, dated 3/1/2023, indicated resident had a fall incident on 2/28/2023 when resident was trying to get up by himself from his wheelchair. A review of Resident 77's IDT fall, dated 5/22/2023, indicated resident had a fall incident on 5/19/2023 when resident was laying on the floor at the right side of the bed. A review of Resident 77's IDT fall, dated 6/12/2023, indicated resident had a fall incident on 6/8/2023 when resident was laying on the fall mat on the right side of the bed. A review of Resident 77's Progress Notes, dated 7/10/2023 at 7:03 PM, indicated resident had a COC for falls when resident was found on the floor on the left side of the bed. A review of Resident 77's Progress Notes, dated 8/10/2023 at 4:30 PM, indicated resident had a COC for falls when resident tried to stand up from his wheelchair. A review of Resident 77's Change of Condition (COC, a sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral or functional domains), dated 1/13/2024, indicated resident fell from his wheelchair in the hallway. A review of Resident 77's COC, dated 4/18/2024, indicated had a fall when resident slid off the wheelchair in the hallway. During a concurrent interview and record review on 4/24/2024 at 12:49 PM of Resident 77's Care Plan, dated 10/03/2023 with the Director of Nursing (DON), the DON stated the care plan indicated Resident is at risk for falls/injury. Staff interventions included were the following: 1. Assess for changes in medical status, pain status, mental status, and report to Medical Doctor (MD) as indicated 2. Bed in low position 3. Collaborate with family and explore residents' bedtime routine at home. Offer and assist patient with toileting at bedtime. 4. Constantly remind resident to use call light for help and assistance 5. Monitor vital signs including orthostatic blood pressure as needed and report to MD. 6. Physical Therapy evaluation and treatment as indicated, re-evaluation of proper wheelchair positioning 7. Toileting schedule. After meal and bedtime. 8. Utilize bilateral floor mats when resident in bed for safety. The DON stated there was not and should have a structured monitoring/ supervision intervention in the care plan to help prevent further falls. The DON also stated Resident 77 should have monitoring/ supervision at least every 2 hours to prevent further falls. During a concurrent interview and record review on 4/24/2024 at 12:49 PM of Resident 77's Care Plan, dated 4/18/2024 with DON, the DON stated the care plan indicated Resident is at risk for falls/injury. Staff interventions included were the following: 1. Medical Doctor and responsible party were notified 2. Monitor vital signs and report abnormalities to MD. 3. Observe for changes in mental status and significant changes in condition 4. Perform body assessment to assess for any injury 5. Perform initial neurological assessment (an assessment of the nerve cells and motor responses to determine if the nervous system [system that carries messages from to and from the brain] is impaired), then times 72hrs per policy. 6. PT evaluation and treatment as indicated, re-evaluation of proper wheelchair positioning. The DON stated there was not and should have a structured monitoring/ supervision intervention in the care plan to help prevent further falls. The DON also stated Resident 77 should have monitoring/ supervision at least every 2 hours to prevent further falls. During an interview on 4/24/2024 at 1:15 PM, Licensed Vocational Nurse 1 (LVN 1) stated no one was at the nursing station to supervise Resident 77 who was near the area at the time of fall on 1/13/2024 and 4/18/2024. During a concurrent record review of Resident 77's COC, SBAR, and Progress notes dated 2/8/2023, 2/28/2023, 5/19/2023, 6/8/2023, 7/10/2023 and 8/10/2023 and interview with the DON on 4/25/24 at 9:39 AM, the DON stated that all these fall incidents of Resident 77 were as a result of not being supervised. The DON stated Resident 77 should have been supervised to prevent falls. During an interview on 4/25/2024 at 3:30 PM, the DON stated Supervision is being close/next to the resident. The DON stated Structured Monitoring means checking/assessing the resident every 2 hours. During a concurrent record review of Resident 77's Care Plans and interview on 4/25/2024 at 1:58 PM, the DON stated the care plan does not and should have been directed to help prevent further falls. The DON stated Resident 77's care plan dates were changed when the resident fell, but the interventions were not revised. The DON stated the care plan should have been revised and should have been individualized to prevent further falls. During an interview on 4/25/24 at 3:40 PM, Administrator (ADM) stated structured monitoring should be in the policy. A review of the facility's Policy and Procedure titled, Comprehensive Person-Centered Care Plans, revised 3/2022, indicated assessment of residents are ongoing and care plans are revised as information about the residents and the resident's condition change.

CONCERN (D)

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

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to clean one of one sampled resident (Resident 36) face and gown after having breakfast. This deficient practice resulted in not meeting the resident ' s needs and had the potential for compromised dignity. Findings: A review of Resident 36 ' s admission record indicated resident was initially admitted on [DATE] and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing) following cerebral infarction (occurs as a result of disrupted blood flow to the brain), hemiplegia (complete paralysis) and hemiparesis (partial weakness) following cerebral infarction affecting the left side of the body, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 36 ' s Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 4/9/2024, indicated Resident 36 had difficulty communicating some words or finishing thoughts but is able if prompted or given time and had severely impaired cognitive skills (ability to think, understand, learn, and remember) for daily decision making. The MDS indicated that resident required set-up or clean-up assistance (helper sets up or cleans up; resident completes activity. Helper assists only prior to or following the activity) for eating and oral hygiene; substantial/maximal assistance (helper does more than half the effort) for toileting hygiene, bathing, lower body dressing, transfers (moving from one surface to another); partial/moderate assistance (helper does less than half the effort) for personal hygiene and upper body dressing. A review of Resident 36 ' s History and Physical (H&P), dated 4/15/2024, indicated resident has fluctuating capacity to understand and make decisions. A review of Resident 36 ' s Care Plan, titled Resident assistance, date initiated 4/15/2024 by Registered Nurse (RN), indicated resident is dependent for activities of daily living (ADL) care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, and toileting. During an observation on 4/22/2024 at 9:56 AM, Resident 36 is lying in bed asleep and observed with food crumbs on the resident ' s gown and around the resident ' s mouth. In addition, Resident 6 was noted to have drool marks on the left side of the resident ' s mouth, and gown has wet mark at the chest area. During a concurrent interview and record review of resident ' s MDS dated [DATE] on 4/24/2024 at 8:51 AM, with the Director of Staff Development (DSD), DSD stated, MDS indicated Resident 36 need partial to moderate assistance when eating, oral hygiene and personal hygiene. DSD also stated whitish and yellowish stains on the resident ' s gown and face is not okay because it affects the resident ' s dignity, that the CNA should be changing the gown and wiping the face of the resident. During an interview on 4/24/2024 at 10:48 AM with the Director of Nursing (DON), the DON stated it is not okay that the resident has food crumbs on his face and gown, and this was important to maintain the resident ' s dignity. The DON also stated the CNA should have provided hygiene care and changed Resident 36 with a new gown to ensure we are providing the resident ' s needs A review of the facility ' s Policy and Procedures (P&P), titled Activities of Daily Living (ADLs), Supporting, revised 3/2018, the P&P indicated residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. The P&P indicated interpretation and implementation included: Residents will be provided with care, treatment, and services to ensure that their ADLs do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care). A review of the facility ' s P&P titled, Quality of Life-Dignity, revised February 2020, indicated each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, feeling of self worth and self esteem.

CONCERN (D)

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

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement the care plan to insert an indwelling foley catheter (a hollow tube inserted though the urethra [a tube through which urine leaves the body] into the urinary bladder to collect and drain urine) for wound management for one of 22 sampled Residents (Resident 39). This deficient practice had the potential for Resident 39's wound to get worse. Findings: A review of Resident 39's admission Record indicated resident was admitted on [DATE] with the following diagnoses of pressure ulcer (PU, localized skin and soft tissue injuries that form as a result of prolonged pressure and shear, usually exerted over bony prominences) and muscle weakness. A review of Resident 39's History and Physical (H&P), dated 1/13/2024, indicated resident has the capacity to understand and make decisions. A review of Resident 39's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 1/11/2024, indicated resident was moderately impaired with cognitive (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making. MDS also indicated Resident 39 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with upper body dressing and putting/on taking off footwear. MDS indicated Resident 39 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or hold trunk or limbs and provides more than half the effort) with shower/bathe self and lower body dressing but was dependent (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, including wiping the opening but not managing equipment) with toileting hygiene. A review of Resident 39's Change of Condition (COC, a sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral or functional domains), dated 4/14/2024, indicated a skin tear to the penile shaft with slight redness noted. A review of Resident 39's Progress Notes, dated 4/14/2024 at 2:17 PM, indicated per physician, to change Resident 39's condom catheter (collection device that fits like a condom to collect and drain urine) to an indwelling foley catheter for 1 week until skin issue is resolved. A review of Resident 39's Care Plan with focus on, Skin Tear to Penile Shaft, dated 4/14/2024, indicated to discontinue (D/C) condom catheter and place foley catheter for 1 week until skin tear is healed. A review of Resident 39's Wound Assessment form, dated 4/18/2024, indicated open wound at the base of the penis with a length of 1.5 centimeters (cm, unit of measure), width of 4.5 cm and depth of 0.1 cm. During an observation in Resident 39's room and interview on 4/24/2024 at 9:52 AM, Resident 39 was observed with a penile wound that was pinkish red in color with skin peeling around it. Resident 39's was observed with a condom catheter. During a concurrent record review of Resident 39's care plan on Skin tear to penile shaft, dated 4/14/2024 and interview on 4/24/2024 at 10:21 AM, Treatment Nurse 1 (TN 1) stated Resident 39 still has penile wound and should have a foley catheter until wound heals. TN 1 also stated the care plan was not and should be implemented to prevent resident's wound from getting worse. A review of the facility's policy and procedure titled Comprehensive Person Centered Care Plan, dated 3/2022, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary respiratory care services for one (1) of 1 sampled resident (Resident 17) for respiratory care area by failing to ensure Resident 17's nasal cannula (NC, device used to deliver supplemental oxygen placed directly on a resident's nostril) tubing was changed weekly per facility's policy. This deficient practice had the potential for Resident 17 to develop a respiratory infection. Findings: A review of Resident 17's admission Record indicated Resident 17 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of pleural effusion (fluid buildup in the space between the lung and the chest wall), hypertensive heart (heart problems caused by high blood pressure) and chronic kidney disease (gradual loss of kidney damage where kidneys cannot filter the blood the way they should) with heart failure (a lifelong condition in which the heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen) and with end stage renal disease (the final, permanent stage of chronic kidney disease where kidney has declined and can no longer function on their own), and hypoxemia (an abnormally low concentration of oxygen in the blood). A review of Resident 17's Minimum Data Set (MDS, a standardized assessment and care planning tool), dated 3/6/2024, indicated Resident 17's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were severely impaired. The MDS indicated Resident 17 required supervision or touch assistance for toileting hygiene, shower/bathe self, lower body dressing and chair/bed-to-chair transfer. The MDS also indicated Resident 17 received oxygen therapy. A review of Resident 17's Physician's order, dated 1/30/2024, indicated oxygen at two (2) to four (4) liters per minute (LPM, volume of oxygen supplied over a period of time) via nasal cannula as needed to keep oxygen saturation (SpO2, measures how much oxygen is carried by the hemoglobin [Hgb, a protein in red blood cells that carries oxygen to the body's organs and tissues and transports carbon dioxide from the resident's organs and tissues back to the lungs] in the blood or how well a resident is breathing) equal to or greater than 92% as needed. A review Resident 17's Oxygen Saturation Summary indicated Resident 17 received oxygen via nasal cannula on the following dates: - 3/27/2024, 3/28/2024, 3/29/2024, 3/30/2024, 3/31/2024, 4/1/2024, 4/2/2024, 4/3/2024, 4/6/2024, 4/7/2024, 4/8/2024, 4/9/2024, 4/12/2024, 4/13/2024, 4/14/2024, 4/15/2024, 4/18/2024, 4/19/2024, 4/20/2024, 4/21/2024, 4/23/2024. During an observation on 4/22/2024 at 9:40 AM in Resident 17's room, Resident 17 was sitting in her wheelchair and not receiving oxygen therapy. The back of Resident 17's wheelchair had a nasal cannula tube attached to the oxygen tank. The nasal cannula tubing was not dated. During a concurrent observation and interview on 4/23/2024 at 4:18 PM with Resident 17 in her room, Resident 17 was sitting on her wheelchair. Resident 17 stated she had used her nasal cannula to receive oxygen earlier today. The nasal cannula tubing connected to the oxygen tank was not dated. The end of the nasal cannula tubing containing the prongs were placed inside of a clear bag. The bag containing the nasal cannula was dated 3/27/2024 (27 days prior to observation date 4/23/2024). During a concurrent observation and interview on 4/23/2024 at 4:21 PM with Licensed Vocational Nurse 3 (LVN 3), LVN 3 stated oxygen tubing was supposed to be labeled with the first date the oxygen tubing was used. LVN 3 stated there was no date on Resident 17's oxygen tubing. LVN 3 stated the bag containing Resident 17's tubing was dated on 3/27/2024. LVN 3 stated the oxygen tubing should be labeled upon using and changed regularly for infection control. LVN 3 stated if the oxygen tubing was not changed regularly, the tubing could harbor bacteria because of the moisture and cause an infection. During an interview on 4/24/2024 at 5:25 PM with the Infection Prevention Nurse (IPN), the IPN stated the oxygen tubing should be labeled to know when the tubing was last changed. The IPN stated the oxygen tubing should be changed once a week. The IPN stated if the oxygen tubing being used by the resident was undated, it could already be old and dirty. The IPN stated the bacteria from the tubing could expose the resident to an infection. During an interview on 4/25/2024 at 10:52 AM with the Director of Nursing (DON), the DON stated the oxygen tubing should be dated to ensure the oxygen tubing was being replaced weekly. The DON stated the use of an oxygen tubing longer than a week could create cross contamination and put the resident at risk for an infection. During a follow up interview on 4/25/2024 at 6:28 PM with the DON, the DON stated the facility did not have a policy which indicated to date the oxygen tubing to ensure it was changed every seven (7) days. The DON stated there should be a policy for dating the oxygen tubing since it was the best standard of practice to change the oxygen tubing every 7 days. A review of the facility's undated Policy and Procedure titled, Changing of Nasal Cannula/Oxygen Tubing, indicated it is the policy of the facility to change the nasal cannula and oxygen tubing weekly and as needed if the nasal cannula is visibly soiled or damaged. Setup bags are dated and placed with each nasal cannula to prevent the nasal cannula from touching the floor when not being used.

CONCERN (D)

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

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure for one of seven sampled residents (Residents 48) was free from significant medication error (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications [not recommendations] regarding the preparation and administration of the medication or biological; or accepted professional standards and principles) by failing to check blood sugar and administer insulin (medicine to lower the level of glucose [type of sugar] in the body) before meals in accordance with the physician's order. On 4/24/2024, Resident 48's blood sugar was checked after the insulin was administered and after the resident already consumed a portion of his lunch meal. This deficient practice had the potential for the resident to experience unwanted side effects of the medication including drowsiness, trouble breathing, hypoglycemia (low blood sugar), mental changes, and jeopardizing Resident 48's health and safety. Findings: A review of Resident 48's admission Record indicated Resident 48 was originally admitted on [DATE] with diagnoses that included type 2 diabetes (abnormal blood sugar), muscle weakness, and dementia ((long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). A review of Resident 48's Minimum Data Set (MDS, a standardized assessment and care screening tool) dated 3/29/2024, indicated Resident 48 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding through thought and the senses) and required supervision with eating and personal hygiene. The MDS indicated, Resident 48 required partial/moderate assistance (helper does more than half the effort) with oral hygiene, upper body dressing. It also indicated that Resident 48 required substantial assistance (helper does more than effort) with toileting hygiene and shower and was dependent with lower body dressing and lower body dressing. A review of Resident 48's Medication Review Report (MRR), dated 3/27/2024, indicated an order on 3/26/2024 to administer insulin Lispro (a fast-acting insulin used to control high blood sugar) per sliding scale (the increasing administration of the pre?meal insulin dose based on the blood sugar level before the meal), subcutaneously (SQ, method of giving a medication in the fatty layer of tissue just under the skin) before meals and at bedtime for diabetes. The MRR indicated sliding scale: For blood sugar less than 70 milligram per deciliter (mg/dL, unit of measurement), follow hypoglycemia protocol and call Doctor. For blood sugar of 0 mg/dL - 199 mg/dL, give 0 units of insulin. 200 mg/dL to 249 mg/dL = give one unit of insulin 250 mg/dL to 299 mg/dL = give two units of insulin 300 mg/dL to 349 mg/dL = give three units of insulin 350 mg/dL to 399 mg/dL = give four units of insulin 400 mg/dL to 449 mg/dL = give five units of insulin 450 mg/dL to 999 mg/dL = give six units of insulin and call the doctor During a medication pass observation on 4/24/2024 at 12:03 PM with Assistant Director of Nursing (ADON) and Licensed Vocational Nurse (LVN) 7, ADON stated Resident 48 is due for blood sugar check and insulin administration per sliding scale due at 11:30 AM. During a concurrent observation of the dining room and interview with LVN 7 on 4/24/2024 at 12:05 PM, LVN 7 stated, Resident 48 already started his lunch meal, and already consumed a small portion of his plate. During a medication pass observation on 4/24/2024 at 12:07 PM with ADON and LVN 7, ADON and LVN 7 checked Resident 48's blood sugar with result of 245 mg/dL ADON stated per the physician's order, Resident 48 should receive 1 unit of insulin Lispro. ADON added, the blood sugar result of 245 mg/dL was not reliable since it was checked after the fact that Resident 48 already ate. During an interview on 4/24/2024 at 5 PM with LVN 3, she stated, prior to giving insulin, licensed nurse should have checked Resident 48's blood sugar to see if resident would need to be administered insulin Lispro in accordance with the physician's order. LVN 3 added, checking blood sugar level, and administering the ordered insulin is important to prevent resident from developing hyperglycemia after eating. During a concurrent interview on 4/25/2024 at11:35 AM with ADON, ADON stated, it was important to administer medication as ordered to get full benefit of the medication and to prevent complications of inconsistent timing of medication administration. ADON stated, Resident 48's blood sugar check and insulin order are to control his blood sugar, and if it was not given timely, Resident 48 can develop uncontrolled high blood sugar and can cause complications such as death. A review of the facility's policy and procedure titled Administering Medications, revised in April 2019, indicated medications are administered in a safe and timely manner, and as prescribed. It also indicated that medications are administered in accordance with prescriber orders, including any required time frame. Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: a. Enhancing optimal therapeutic effect of the medication. b. Preventing potential medication or food interactions.

CONCERN (D)

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

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices for three out of 22 sampled residents (Resident 18, 41 and 78) by failing to accurately document the administration of antibiotic (medicine to treat infection) and narcotics (drug or controlled substance that affects the mood or behavior and if consumed for nonmedical purposes or not prescribed by the doctor can cause serious harm) count in the narcotic drug record (narcotic count sheet is a document used to document and track the administration of controlled substance to ensure accurate dispensing and administration of medications, as well as to provide a record of how much of a controlled substance has been used and when). This deficient practice had the potential to negatively impact the delivery of services. Findings: 1. A review of Resident 18 admission Record indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnosis of anxiety (feeling of fear, dread, and uneasiness) and dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities). A review of Resident 18 Minimum Data Set (MDS; a standardized care screening and assessment tool), dated 3/21/2024, indicated resident severely impaired in cognitive skills for daily decision making. The MDS also indicated resident is dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity). A review of Resident 18's Physician Orders, dated 2/24/2023, indicated Ativan/ lorazepam (medication for anxiety) tablet 0.5 milligrams (mg, unit of measure) give 0.25 mg (half tablet) by mouth at bedtime for anxiety as manifested by physical aggression towards staff. A review of Resident 18's Physician Orders, dated 4/24/2024, indicated amoxicillin (medication for infection) oral tablet 500 mg, give 500 mg by mouth two times a day for wound infection for 7 days until finished. During an observation of the Medication Cart A (Med Cart A), interview, and record review of Resident 18's narcotic drug record for amoxicillin undated, on 4/25/2024 at 10:05 AM, the narcotic drug record indicated refill date on 4/24/2024 (date facility received from the facility's pharmacy) with total of 14 tablets. In addition, it indicated last tablet taken out was signed on 4/24/2024 at 4 PM under tablet number 14. Observed Resident 18's amoxicillin bubble pack (packaging in which a product is sealed between a cardboard backing and clear plastic cover), the bubble pack showed 12 tablets left. Assistant Director of Nursing (ADON) stated, the narcotic drug record for Resident 18's amoxicillin was incorrect, it did not indicate the number 13 tablet was taken out from Resident 18's amoxicillin bubble pack and the drug narcotic drug record should indicate the date, time, and signature of the nurse who took out the number 13 tablet and gave it to the resident this morning. During the same observation of the Med Cart A, interview, and record review of Resident 18's narcotic drug record for lorazepam undated, on 4/25/2024 at 10:05 AM, the narcotic drug record indicated refill date on 4/19/2024 with total of 14 tablets of 0.25 mg tablets. In addition, it indicated licensed nurse's signed under tablet #11 (meaning there 10 tablet left) on 4/25/2024 at 8 AM. Observed Resident 18's bubble pack for lorazepam 0.25 mg tablet with 11 tablet (0.25 mg tablets) left. ADON stated, the narcotic drug record for Resident 18's lorazepam was incorrect because it indicated there's 10 tablets left but there were really 11 tablets of lorazepam left in the bubble pack. ADON also stated, the licensed nurse who signed the narcotic drug record under tablet #11 made a mistake by signing under the lorazepam narcotic drug record instead of writing it under Resident 18's narcotic drug record. During an interview the Assistant Director of Nursing (ADON) on 4/25/2024 at 11 AM, the ADON stated he did an investigation of the discrepancy of Resident 18's lorazepam and amoxicillin narcotic drug record and the ADON found out that the licensed nurse (did not identify) who administered the amoxicillin to Resident 18 on 4/25/2024 at 8 AM, mistakenly signed under the lorazepam tablet #11. 2. A review of Resident 41 admission Record indicated resident is originally admitted on [DATE] and was readmitted on [DATE] with the following diagnosis of chronic pain syndrome and major depression (a group of conditions associated with the elevation or lowering of a person's mood) A review of Resident 41's MDS, dated [DATE], indicated resident had intact cognitive skills for daily decision making. The MDS also indicated resident required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene, shower/bathe self, lower body dressing and putting on/taking off footwear. A review of Resident 41's physician orders, dated 4/18/2024, indicated nitrofurantoin mono MCR/macrobid (medication for infection) oral capsule 100 mg, give 1 capsule by mouth two times a day for urinary tract infection (UTI, infection in the urinary tract system) for 7 days. During an observation of Med Cart B, interview, and record review on 4/25/2024 at 10:27 AM, observed Resident 41's medication nitrofurantoin mono MCR 100 mg bubble packet was empty. Licensed Vocational Nurse 5 (LVN 5) stated narcotic drug record for Resident 41's medication indicated there is supposed to be one medication left. LVN 5 stated she gave the nitrofurantoin medication to Resident 41 but she forgot to sign it off in Resident 41's nitrofurantoin mono MCR narcotic drug record. 3. A review of Resident 78 admission Record indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnosis of amputation (loss or removal of a body part such as a finger, toe, hand, foot, arm, or leg) of left lower extremity and muscle weakness. A review of Resident 78's H&P, dated 2/29/2024, indicated resident does not have the capacity to understand and make decisions. A review of Resident 78's MDS, dated [DATE], indicated resident is moderately impaired in cognitive skills for daily decision making. The MDS also indicated resident requires partial/moderate assistance with toileting hygiene, upper body dressing, lower body dressing and putting on/taking off footwear. The MDS indicates resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with shower/bathe self. A review of Resident 78's physician orders, dated 1/31/2024, indicated morphine sulfate oral tablet (medication for pain) 15 mg, give 1 tablet by mouth every 12 hours for pain management. During an observation, interview, and record review on 4/25/2024 at 10:29 AM on Med Cart B, Observed Resident 78's medication morphine immediate release (IR) 15 mg bubble packet contained 8 tablets. LVN 5 stated narcotic drug record for Resident 78's medication indicated there is nine (9) tablets of morphine IR left in the bubble pack. LVN 5 stated she gave the morphine IR medication to Resident 78 but she forgot to sign it off in Resident 78's morphine IR narcotic drug record. During an interview on 4/25/2024 at 11 AM, Assistant Director of Nursing (ADON) stated it is not okay that the narcotic count record was not signed. During an interview on 4/25/2024 at 4:16 PM, ADON stated if the narcotic count in the narcotic drug records is off, it is not okay because we are not taking into account if there is a missing narcotic medication and if it falls in the wrong hand, it can cause harm to the residents and it is illegal. A review of the facility's policy and procedure titled Controlled Substances, revised November 2022, indicated controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow up.

CONCERN (D)

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

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of 22 sampled resident's (Resident 80) call light was within reach. This failure had the potential to result in Resident 80's not receiving assistance when needed from facility staff. Findings: A review of Resident 80's admission Record indicated Resident 80 was admitted to the facility on [DATE] with the diagnoses including but not limited to hemiplegia (an inability to move one side of body) and hemiparesis (an inability to move the arm, leg and sometimes face on one side of the body) following a cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue) affecting left non-dominant side. A review of Resident 80's Minimum Data Set (MDS, a comprehensive assessment and care screening tool), dated 4/06/2024, the MDS indicated Resident 80 had an impairment on one side of upper and lower extremity and required moderate to maximal assistance from staff for activities of daily living (ADLs, toileting hygiene, shower/bathe, upper and lower body dressing, and personal hygiene). During a concurrent observation in Resident 80's room and interview on 4/22/2024 at 9:58 AM, with Resident 80 and Licensed Vocational Nurse 4 (LVN 4), Resident 80 was observed lying in bed and the call light was on the floor, on the left side of the bed. Resident 80 stated he is unable to reach the call light in case he needs assistance from the staff. LVN 4 stated the call light is on the floor and it should be within reach of the resident at all times. During an interview on 4/25/2024 at 10:52 AM with the Director of Nursing (DON), the DON stated the call light should be placed within reach of the resident while in bed for easy access. The DON stated the call light should not be on the floor because the resident may need assistance with toileting, hygiene, repositioning and in case of an emergency. A review of the facility's Policy and Procedure (P&P) titled, Answering the Call Light, dated September 2022, indicated to ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.

CONCERN (E)

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

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings: 1.b. A review of Resident 24's admission Record indicated Resident 24 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included history of fall, history of transient ischemic attack (a temporary disruption in the blood supply to part of the brain), generalized muscle weakness, and other lack of coordination. During a review of Resident 24's Minimum Data Set (MDS- a comprehensive assessment and screening tool) dated 2/20/2024, the MDS indicated Resident 24 was unable to follow commands, and required maximum assistance with the toilet, personal hygiene, change of position and transfer. A review of Resident 24's care plan titled At risk for falls, injury related due to fall related to impaired safety judgment, impaired gait and mobility weakness dated 10/25/2021, revised on 02/20/2024, indicated Resident 24 required assist with transfer and mobility as needed (PRN) and Resident 24 also required monitoring of fall. The care plan indicated interventions included Certified Nurse Assistant (CNA) to remind resident to use call light when attempting to ambulate or transfer, CNA will make sure Resident 24's call light is placed within reach while in bed or proximity to the bed. During a concurrent interview and observation on 4/22/2024 at 8:00 AM, in the Resident 24's room, Resident 24 was observed resting in bed and tried to get up to her right-side of the bed and she was asking for help and there was no CNA present. During the observation, Resident 24's call light device was out of the resident's reach and was placed on the floor near the middle of the headboard closed to the wall. Resident 24 stated she was not able to find her call light device. Resident 24 stated she needed help to get up from her bed. During an interview on 4/22/2024 at 08:03 AM with CNA 6 (assigned to Resident 24 on 4/22/2024 during the 7 AM to 3 PM), CNA6 stated the call light should have been placed on Resident 24's bed close to the resident for easy reach, so that the resident is able to get service in a timely manner. CNA 6 also stated this way, Resident 24 can be prevented from having another fall. During an interview on 4/22/2024 at 10:31 AM with Licensed Vocational Nurse (LVN) 8, LVN 8 stated the call light should have been on Resident 24's bed close to the resident for easy reach. LVN 8 stated it is important to ensure the call light was withing the resident's reach so that Resident 24 can get service in a timely manner and can prevent resident from another fall incident. During a review of the facility's policy and procedure titled Answering the call light revised September 2022, indicated each resident is provided with a means to call staff directly for assistance from his/her bed and the purpose of the call system is to ensure timely responses to the resident's requests and needs. The policy also indicated, ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower, bathing facility and from the floor. Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for two of 22 sample residents (Resident 94 and 24). This deficient practice had the potential for a delay in necessary care and services for Resident 94 and 24. Findings: 1. A review of Resident 94's admission Record indicated resident was admitted on [DATE] with the following diagnosis of hemiplegia (paralysis on one side of the body) affecting the right dominant side and muscle weakness. A review of Resident 94's History and Physical (H&P), dated 3/9/2024, indicated resident does not have the capacity to understand and make decisions. A review of Resident 94's Minimum Data Set (MDS), dated [DATE], indicated resident is moderately impaired in cognitive skills (ability to understand and make decision) for daily decision making. The MDS also indicated resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or hold trunk or limbs and provides more than half the effort) with eating, oral hygiene, and personal hygiene. Resident 94's is dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) with toileting hygiene, shower/bath self, upper body dressing, lower body dressing and putting on/taking off footwear. A review of Resident 94's Occupational Therapy (OT) Evaluation, dated 3/6/2024, indicated resident's right elbow/ forearm can flex up to 45 degrees, right shoulder flex 0 degrees, and right wrist flex 0 degrees. OT evaluation also indicated resident's right upper extremity strength is impaired. During an observation on 4/22/2024 at 11:40 AM, Resident 94 was observed with a call light placed on the bed beside of the resident's right shoulder. During an interview on 4/24/2024 at 8:14 AM, Director of Staff Development (DSD) stated resident is unable to move her right arm since admission. During an interview on 4/24/2024 at 8:27 AM, Physical Therapy (PT) stated Resident 94's right elbow can only move 45 degrees actively (the space in which you move a part of your body by using your muscles). During an interview on 4/24/2024 at 8:39 AM, DSD stated the call light is not within Resident 94's reach and it is too high for the resident to reach. DSD also stated it is not okay because the resident is unable to use the call light to call facility staff in case of an emergency. During an interview on 4/29/2024 at 10:45 AM, the Director of Nursing (DON) stated it is not okay for the call light to not be within Resident 94's reach because the facility needs to make sure the resident's needs are promptly met or if the resident were to have an emergency. A review of the facility's Policy and Procedure titled Answering the Call Light, revised 9/2022, indicated to ensure that the call light is accessible to the resident when in bed, from the toilet, form the shower or bathing facility and from the floor.

CONCERN (E)

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

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 31 did not have an accurate assessment for restorative nursing program (a program that helps residents maintain any progress made during therapy treatments, enabling them to achieve their highest practicable level of functioning) received. These deficient practices have the potential for the facility to not develop and implement an individualized care plan, which could negatively affect Resident 77 and 31's overall wellbeing. Findings: 2. A review of Resident 31's admission Record indicated Resident 31 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of abnormal posture, contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the right knee, and contracture of the left knee. A review of Resident 31's MDS, dated [DATE], indicated Resident 31's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were intact. The MDS indicated Resident 31 was dependent (helper does all the effort) toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, sit to lying, lying to sitting on bed, chair/bed-to-chair transfer, and tub/shower transfer. The MDS indicated Resident 31 had a functional limitation in range of motion on both lower extremities (LEs - hip, knee, ankle, and foot). The MDS indicated Resident 31 did not receive restorative nursing care. A review of Resident 31's Medication Review Report are as follows: a. Order dated 8/4/2024, Restorative Nurse Aide (RNA) order, passive range of motion (PROM, the range that can be achieved by external means such as another person or a device) on bilateral upper extremities (BUE - both arms from shoulder to hands) every day seven (7) times per week as tolerated. a. Order dated 2/21/2024, RNA PROM exercise on head and neck motion as tolerated five (5) times per week. b. Order dated 8/8/2023, RNA PROM exercise on both LEs as tolerated every date 5 times per week. c. Order dated 8/8/2023, RNA to apply cervical soft collar (a device used to support the neck and spine and limit neck movement) up to four (4) hours as tolerated 5 times per week. d. Order dated 8/8/2023, RNA to perform skin inspection on both LEs before and after orthotic (an artificial support brace for the limbs or spine) use, to report to charge nurse of any change in condition. A review of Resident 31's RNA Record for March and April 2024, indicated as follows: - BUE PROM every day 7 times per week as tolerated. - PROM on bilateral lower extremities (BLE - hips, knees, ankles, and feet) exercises as tolerated 5 times per week. - To apply bilateral LE Ankle Foot Orthosis (AFO, a brace that provides support to the foot and ankle) up to 4 hours as tolerated 5 times per week. - To perform skin inspection on BLE before and after orthotic use. - To perform PROM exercises head/neck as tolerated 5 times per week. - To apply cervical soft collar up to 4 hours as tolerated 5 times per week. A review of Resident 31's Care Plan, dated 8/8/2023, indicated Resident 31 was at risk to decline in lower extremity joint mobility and further develop contracture due to immobility. Staff interventions were to have the RNA apply bilateral LE AFO up to 4 hours or as tolerated every day 5 times per week, and the RNA to perform skin inspection on both LEs before and after orthotic use. A review of Resident 31's Care Plan, revised 1/15/2024, indicated Resident 31 was at risk for decreased ability to perform activities of daily living (ADLs - bathing grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting) related to: impaired balance, limited mobility, Parkinson's (progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement), hyperlipidemia (a condition in which there are high levels of fat particles in the blood), depression (severe feelings on sadness and hopelessness), and psychosis (a mental disorder characterized by a disconnection from reality). Staff interventions included were for RNA to perform PROM to both LE 5 times per week as tolerated, RNA for PROM to BUE 7 times per week as tolerated, RNA for PROM BUE and BLE, RNA to apply AFO on BLE, RNA to apply AFO to BLE for 4 hours every day 5 times per week, RNA to apply cervical collar up to 4 hours as tolerated 5 times per week, and RNA to perform PROM exercises of head and neck as tolerated 5 times per week. During an observation on 4/22/2024 at 4:41 PM in the dining room, Resident 31 was sitting in her wheelchair with her head tilted to the left side. During an interview on 4/25/2024 at 8:14 AM with Resident 31, Resident 31 stated she received RNA services daily. During a concurrent interview and record review of Resident 31's RNA Record on 4/25/2024 at 8:22 AM with RNA 1, RNA 1 stated Resident 31 received RNA services and did not refuse RNA services. RNA 1 stated RNA services provided to Resident 31 took about 15 to 20 minutes. RNA 1 stated Resident 31 used AFOs on both sides of the LE and the AFOs were left on for 4 hours as tolerated. RNA 1 also stated Resident 31 had a cervical collar ordered for 4 hours as tolerated. During a concurrent interview and record review of Resident 31's MDS on 4/25/2024 at 11:52 AM with the MDS Coordinator (MDSC), the MDSC stated she had not completed the Restorative Nursing Program Section for Resident 31 who received RNA services. The MDSC stated the RNA section of the MDS did not and should have reflected the RNA services the resident received. A review of the facility's Policy and Procedure titled, Resident Assessments, revised 10/2023, indicated information in the MDS assessments will consistently reflect information in the progress notes, plans of care and resident observations/interviews. A review of the Centers for Medicare and Medicaid Services' Long-Term Facility Assessment Instrument 3.0 User's Manual, dated 10/2023, indicated to code the time for activities provided by restorative nursing staff for range of motion (passive - movement performed without voluntary muscle contraction), range of motion (active - self movement of a joint by contracting your muscles), and splint or brace assistance. Based on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment and care screening tool) accurately reflected the status of two (2) of 2 sampled residents (Residents 77 and 31) by failing to: 1. Resident 77 did not have an accurate assessment for falls. 2. Resident 31 did not have an accurate assessment for restorative nursing program (a program that helps residents maintain any progress made during therapy treatments, enabling them to achieve their highest practicable level of functioning) received. This deficient practice had the potential for the facility to not develop and implement an individualized care plan, which could negatively affect Resident 77 and 31's overall well-being. Findings: 1. A review of Resident 77's admission Record, indicated resident was originally admitted on [DATE] with the following diagnoses of muscle weakness and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). A review of Resident 77's History and Physical, dated 10/11/2023, indicated resident does not have the capacity to understand and make decisions. A review of Resident 77's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/8/2024, indicated resident is severely impaired (never/rarely made decisions) with cognitive (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making. MDS indicated resident required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with eating, oral hygiene, and personal hygiene. Resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with upper and lower body dressing. Resident 77 was dependent (helper does all of the effort. Resident does none of the effort to complete the activity or the assistance of 2 or more helpers is required for the resident to complete the activity) toileting hygiene, shower/bathe self and putting on/taking off footwear. A review of Resident 77's Interdisciplinary Team (IDT, a group of healthcare professionals from complementary fields who work in tandem to treat a patient) fall, dated 6/12/2023, indicated resident had a fall incident on 6/8/2023. A review of Resident 77's Progress Notes, dated 7/10/2023, timed at 7:03 PM, indicated resident had a Change of Condition (COC, a sudden clinically deviation from a resident's baseline in physical, cognitive, behavioral, or functional domains) for falls. During a concurrent record review of Resident 77's MDS, dated [DATE] and interview with the Director of Nursing (DON) on 4/25/2024 at 12:32 PM, the DON stated the MDS did not and should have accurately reflected Resident 77's fall of two or more falls since reentry on 5/28/2023 in accordance with the MDS. The DON also stated it was important that the MDS was accurate because this can affect the residents plan of care. A review of the facility's Policy and Procedure titled, Resident Assessments, revised 10/2023, indicated information in the MDS assessments will consistently reflect information in the progress notes, plans of care and resident observations/ interviews.

CONCERN (E)

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of Resident 82's admission Record indicated Resident 82 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of lack of coordination, abnormalities of gait (a manner of walking or moving on foot) and mobility, history of falling, and dementia (progressive brain disorder that slowly destroys memory and thinking skills). A review of Resident 82's Minimum Data Set (MDS- a standardized assessment and care planning tool), dated 3/11/2024, indicated Resident 82's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decision making were moderately impaired. The MDS indicated Resident 82 required substantial/maximal assistance (helper does more than half the effort) for shower/bathe self, lower body dressing, sit to stand, chair/bed-to-chair transfer, and tub/shower transfer. There were no incidents of fall as indicated on the MDS. A review of Resident 82's Nursing Documentation Evaluation, dated 12/10/2023, indicated Resident 82's fall risk factors included a history of falls in the last six (6) months, disorientated/confused, poor safety judgement impaired balance, and an unsteady gait. A review of Resident 82's Care Plan, dated 4/1/2024, indicated Resident 82 was found on the floor near his bed in a side lying position. Staff interventions included were to anticipate the resident's needs, keep the environment clutter free, and place a fall mat on the left side of the bed. A review of Resident 82's Care Plan, revised on 4/1/2024, indicated Resident 82 was at risk for fall/injury with risk factors of muscle weakness, impaired mobility, impaired vision, poor safety judgement/awareness, narcotic pain medication, cardiac medication, aspirin medication, and medical diagnosis of dementia, hypertension (chronic elevated blood pressure), and anemia (lowered ability of blood to carry oxygen resulting in feeling tired and shortness of breath). Staff interventions included were to assess for changes, in medical status, pain status, mental status and report to medical doctor as indicated, bed in low position, and a fall mat to the left side of the bed. A review of a facility form titled, Interdisciplinary (IDT, involving two or more academic, scientific, or artistic disciplines) Fall, dated 4/2/2024, indicated Resident 82 was observed in left side position next to his bed with an abrasion to the left shoulder. Resident 82's risk factors included poor safety judgement/awareness, impaired cognition, impaired balance, impaired functional mobility, and lack of coordination. Interventions recommended by the Interdisciplinary Team (IDT, group of healthcare professionals from diverse fields who work in a coordinated manner toward a common goal for the resident) were to apply initial treatment to the abrasion on the left shoulder, utilize a fall mat to the left side of the bed when in bed, and provide a regular mattress for the resident. During an observation on 4/22/2024 at 10:09 AM in Resident 82's room, Resident 82 was lying on his back in bed. Resident 82's body was angled diagonally in bed with his right boot (a medical device worn during treatment and recovery of a variety of foot injuries) touching the wall on the right side of the bed. Resident 82's head was partially off on the left side of the bed mattress between the head of the bed and the grab bar. There was no fall mat on the left side of Resident 82's bed. Resident 82's fall mat was folded and was placed leaning onto the privacy curtain which was touching and against the bottom part of Resident 82's roommate bed. During a concurrent observation and interview on 4/22/2024 at 10:13 AM with Licensed Vocational Nurse 4 (LVN 4), LVN 4 stated Resident 82 was resting on his back, angled in bed, and his head was partially on the bed and the rest of his head was partially off the bed. LVN 4 stated Resident 82 tended to move around a lot and was at risk for fall. LVN 4 stated he needed to get another staff to reposition the resident. LVN 4 stated Resident 82's fall mat was not properly placed on the floor. LVN 4 stated the mat was folded up and placed against the curtain. LVN 4 stated the fall mat was to prevent injury in the event Resident 82 had a fall. During an interview on 4/25/2024 at 9:36 AM with LVN 2, LVN 2 stated Resident 82 was at risk for falls. LVN 2 stated Resident 82 recently had a fall on 4/1/2024 and had a history of falling. LVN 2 stated since Resident 82 was found lying on the floor laying on his life side the IDT implemented the use of a floor mat on the left side. LVN 2 stated the fall mat should be placed on the left side of Resident 82's bed in case he fell. LVN 2 stated Resident 82 liked to move around a lot which placed him at risk for falls. Based on observation, interview, and record review, the facility did not provide the necessary care and services for (two) 2 of (three) 3 residents (Residents 77 and 82) who were at risk for falls by failing to: 1. Modify the fall/injury care plan for Resident 77 after episodes of multiple falls. Facility also failed to provide supervision to Resident 77. 2. Ensure Resident 82's floor mat was placed on the floor as indicated on the care plan. This deficient practice had the potential for injury to Resident 82 in an event of a fall. This deficient practice has the potential for Resident 77 and 82 to have further falls which could result to harm, hospitalization, and/or death. Findings: 1. A review of Resident 77's admission Record indicated resident was originally admitted on [DATE] and was readmitted on [DATE] with the following diagnoses of muscle weakness and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities. A review of Resident 77's History and Physical, dated 10/11/2023, indicated resident does not have the capacity to understand and make decisions. A review of Resident 77's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/8/2024, indicated resident is severely impaired (never/rarely made decisions) with cognitive (a mental action or process of acquiring knowledge and understanding through thought, experience and senses) skills for daily decision making. MDS indicated resident required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with eating, oral hygiene and personal hygiene. Resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with upper and lower body dressing. Resident is was dependent (helper does all of the effort. Resident does none of the effort to complete the activity or needs the assistance of 2 or more helpers is required for the resident to complete the activity) toileting hygiene, shower/bathe self and putting on/taking off footwear. The MDS indicated Resident 77 had an episode of fall. A review of Resident 77's Nursing Documentation Evaluation, dated 2/1/2023, indicated resident was at risk for falls with risk factors of poor safety judgement, impaired balance, required assistant for toileting, unsteady gait and taking psychotropic medications (drug taken to exert an effect on the chemical makeup of the brain and nervous system. Medications used to treat mental illnesses). A review of Resident 77's Situation, Background, Assessment and Recommendation (SBAR, a structured communication framework that can help teams share information about the condition of the resident) Communication Form, dated 2/8/2023, indicated resident had a fall. A review of Resident 77's Interdisciplinary Team (IDT; a group of healthcare professionals from complementary fields who work in tandem to treat a resident) fall, dated 3/1/2023, indicated resident had a fall incident on 2/28/2023 when resident was trying to get up by himself from his wheelchair. A review of Resident 77's IDT fall, dated 5/22/2023, indicated resident had a fall incident on 5/19/2023 when resident was laying on the floor at the right side of the bed. A review of Resident 77's IDT fall, dated 6/12/2023, indicated resident had a fall incident on 6/8/2023 when resident was laying on the fall mat on the right side of the bed. A review of Resident 77's Progress Notes, dated 7/10/2023 at 7:03 PM, indicated resident had a COC for falls when resident was found on the floor on the left side of the bed. A review of Resident 77's Progress Notes, dated 8/10/2023 at 4:30 PM, indicated resident had a COC for falls when resident tried to stand up from his wheelchair. A review of Resident 77's Change of Condition (COC, a sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral or functional domains), dated 1/13/2024, indicated resident fell from his wheelchair in the hallway. A review of Resident 77's COC, dated 4/18/2024, indicated had a fall when resident slid off the wheelchair in the hallway. During an observation on 4/22/2024 at 12:34 PM in Resident 77's room, Resident 77 was observed sitting in a wheelchair with a fall risk band. During a concurrent interview and record review on 4/24/2024 at 12:49 PM of Resident 77's Care Plan, the DON stated there was not and should have a structured monitoring/ supervision intervention in the care plan to help prevent further falls. The DON also stated Resident 77 should have monitoring/ supervision at least every 2 hours to prevent further falls. During an interview on 4/24/2024 at 1:15 PM, Licensed Vocational Nurse 1 (LVN 1) stated no one was at the nursing station to supervise Resident 77 who was near the area at the time of fall on 1/13/2024 and 4/18/2024. LVN1 stated Resident 77 was not supervised and should have been supervised. During a concurrent record review of Resident 77's COC, SBAR, and Progress notes dated 2/8/2023, 2/28/2023, 5/19/2023, 6/8/2023, 7/10/2023 and 8/10/2023 and interview with the DON on 4/25/24 at 9:39 AM, the DON stated that all these fall incidents of Resident 77 were as a result of not being supervised. The DON stated Resident 77 should have been supervised to prevent falls. During a concurrent record review of Resident 77's Care Plans and interview on 4/25/2024 at 1:58 PM, the DON stated the fall care plans do not and should have been directed to help prevent further falls. The DON stated Resident 77's care plan dates were changed when the resident fell, but the interventions were not revised. The DON stated the care plan should have been revised and should have been individualized to prevent further falls. During an interview on 4/25/2024 at 3:30 PM, the DON stated Supervision is being close/next to the resident. The DON stated Structured Monitoring means checking/assessing the resident every 2 hours. During an interview on 4/25/24 at 3:40 PM, Administrator (ADM) stated structured monitoring should be in the policy. A review of the facility's Policy and Procedure titled, Fall Management, dated 5/26/2021, indicated to communicate patients fall risk status to caregivers, develop individualized plan of care and to review and revise care plan as indicated. A review of the facility's Policy and Procedure titled, Comprehensive Person-Centered Care Plans, revised 3/2022, indicated assessment of residents are ongoing and care plans are revised as information about the residents and the resident's condition change.

CONCERN (E)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of two (2) of seven (7) sampled residents (Resident 16 and 48) as indicated on the facility policy by: a. During a Medication Pass observation, Licensed Vocational Nurse 7 (LVN 7) failed to administer Resident 16's medications within 60 minutes of scheduled time of 9 AM on 4/24/2024. This deficient practice had the potential for Resident 16's health and well-being to be negatively impacted due to unintended consequences, such as decreased effectiveness of the medications and adverse reactions (an unwanted effect caused by the administration of a drug) from the medications. b. During a Medication Pass observation, LVN 7 failed to check Resident 48's blood glucose (blood sugar, main sugar found in the blood) and administer insulin (medicine to lower the level of glucose [type of sugar] in the body) before lunch meal on 4/24/2024. This deficient practice had the potential for Resident 48's diabetes not to be effectively managed which could result place the resident at risk for hypoglycemia (low blood sugar), hospitalization, and death. Findings: a. A review of Resident 16's admission Record indicated Resident 16 was originally admitted on [DATE] and readmitted on [DATE], with diagnoses that included asthma (a condition in which a resident's airways become narrow which makes it difficult to breathe), dysphagia (difficulty swallowing), and hypertension (high blood pressure). A review of Resident 16's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/20/2024, indicated Resident 16 had moderately impaired (decisions poor; cues/supervision required) cognitive skills (mental action or process of acquiring knowledge and understanding through thought and the senses) for daily decision making. The MDS indicated Resident 16 required supervision with eating. MDS indicated Resident 16 required partial/moderate assistance (helper does more than half the effort) with oral hygiene and personal hygiene. It also indicated that Resident 16 required substantial assistance (helper does more than effort) with toileting hygiene and upper body dressing. Resident 16 was dependent with shower, lower body dressing and putting on/taking off footwear. A review of Resident 48's Physician's order, dated 3/27/2024, indicated the following orders: Advair Diskus (used to prevent asthma attacks) 250 micrograms (mcg, unit of measurement), one (1) inhalation every 12 hours for Asthma, ordered on 3/18/2024. Ascorbic Acid tablet 500 milligrams (mg, unit of measurement), 1 tablet by mouth once a day, ordered on 3/18/2024. Colace (stool softener) capsule 100 mg, 2 (two) capsules by mouth, 2 times a day for constipation (a problem with passing stool), ordered on 3/18/2024. Enoxaparin sodium solution (blood thinner) injection (act of administering a liquid, especially a drug, into a person's body using a needle and a syringe), inject 30 mg subcutaneously (beneath, or under, all the layers of the skin) once a day to prevent blood clotting, ordered on 3/18/2024. Irbesartan (medication to treat high blood pressure) 150 mg tablet, 1 tablet by mouth once a day for hypertension, ordered on 3/23/2024. Isosorbide Mononitrate (used to prevent angina [chest pain]) extended release 30 mg, 1 tablet by mouth once a day for hypertension, ordered on 3/23/2024. Lactulose solution (used to treat constipation) 10 grams (gm, unit of measurement)/15 milliliters (ml, unit of measurement), 10 gm by mouth once a day for constipation, hold if loose stool, ordered on 3/18/2024. Lorazepam (used to treat anxiety [a feeling of fear, dread, and uneasiness]) oral tablet 1 mg, 1 tablet by mouth 2 times a day for anxiety manifested by physical restlessness and inability to relax, ordered on 3/23/2024. Ferrous sulfate (an iron supplement used to treat or prevent low blood levels of iron) 325 mg, 1 tablet by mouth once a day for supplement. During a concurrent record review of Resident 16's physician's orders and observation of the medication administration for Resident 16 on 4/24/2024, at 10:30 AM, Assistant Director of Nursing (ADON) and LVN 7 were preparing Resident 16's medications. The ADON and LVN 7 stated that the following medications were Resident 16's scheduled medications for 9 AM: Advair Diskus Ascorbic Acid tablet 500 mg, 1 tablet Enoxaparin sodium solution injection Irbesartan 150 mg tablet, 1 tablet Isosorbide Mononitrate extended release 30 mg, 1 tablet Lactulose solution 10 gm/15 ml Lorazepam oral tablet 1 mg, 1 tablet Ferrous sulfate tablet 325 mg, 1 tablet Colace capsule 100 mg, 2 (two) capsules During an interview with LVN 7 at 4/24/2024 at 10:45 AM, LVN 7 verified that she administered Resident 16's 9 AM medication late because she gave them after 10 AM. She stated that medications can be administered one hour before or after the scheduled time. LVN 7 stated, If medications were not administered on time, for example blood pressure medications, it can affect the blood pressure of the residents which can cause a change in the residents' condition. b. A review of Resident 48's admission Record indicated Resident 48 was originally admitted on [DATE] with diagnoses that included type 2 diabetes (abnormal blood sugar), muscle weakness, and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). A review of Resident 48's MDS, dated [DATE], indicated Resident 48 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding through thought and the senses) for daily decision making and required supervision with eating and personal hygiene. The MDS indicated, Resident 48 required partial/moderate assistance (helper does more than half the effort) with oral hygiene, upper body dressing. It also indicated that Resident 48 required substantial assistance (helper does more than effort) with toileting hygiene and shower and was dependent with lower body dressing and lower body dressing. A review of Resident 48's Physician's order, dated 3/27/2024, indicated an order on 3/26/2024 to administer insulin Lispro (a fast-acting insulin used to control high blood sugar) per sliding scale (the increasing administration of the pre?meal insulin dose based on the blood sugar level before the meal), subcutaneously (SQ, method of giving a medication in the fatty layer of tissue just under the skin) before meals and at bedtime for diabetes. The MRR indicated sliding scale as follows: For blood sugar less than 70 milligram per deciliter (mg/dL, unit of measurement), follow hypoglycemia protocol and call Doctor. For blood sugar of 0 mg/dL to 199 mg/dL, give 0 units of insulin. 200 mg/dL to 249 mg/dL = give 1 unit of insulin 250 mg/dL to 299 mg/dL = give 2 units of insulin 300 mg/dL to 349 mg/dL = give three (3) units of insulin 350 mg/dL to 399 mg/dL = give four (4) units of insulin 400 mg/dL to 449 mg/dL = give five (5) units of insulin 450 mg/dL to 999 mg/dL = give six (6) units of insulin and call the doctor During an interview on 4/24/2024 at 12:03 PM, ADON stated Resident 48 was due for blood sugar check and insulin administration per sliding scale at 11:30 AM. During a concurrent observation in the dining room and interview with LVN 7 on 4/24/2024 at 12:05 PM, LVN 7 stated, Resident 48 had already started eating and had consumed a small portion of his lunch plate. During a concurrent interview and medication pass observation on 4/24/2024 at 12:07 PM, ADON and LVN 7 checked Resident 48's blood sugar. Resident 48's blood sugar result was 245 mg/dL. The ADON stated per the physician's order, Resident 48 should receive 1 unit of insulin Lispro. The ADON added that Resident 48's blood sugar result of 245 was not reliable since it was checked after Resident 48 had already eaten. During an interview on 4/24/2024 at 5 PM with LVN 3, she stated, prior to giving insulin, licensed nurse should have checked Resident 48's blood sugar to see if resident would need to be administered insulin Lispro in accordance with the physician's order. LVN 3 added, checking the blood sugar level and administering the ordered insulin was important to prevent resident from developing hyperglycemia after eating. During an interview on 4/25/2024 at 11:35 AM, the ADON stated that it was important to administer medication as ordered to get the full benefit of the medication and to prevent complications of inconsistent timing of medication administration. The ADON stated, Resident 48's blood sugar check and insulin order were to control the resident's blood sugar, and if it was not given timely, Resident 48 can develop uncontrolled high blood sugar and can cause complications such as death. A review of facility's Policy and Procedure titled, Administering Medications, revised in April 2019, indicated medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

CONCERN (E)

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

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five (5) percent (%). 10 medication errors out of 33 total opportunities for error, to yield an overall medication error rate of 30.3 % for two (2) of seven (7) residents observed for medication administration (Residents 16 and 48). The medication errors were as follows: 1. During a Medication Pass observation, Licensed Vocational Nurse 7 (LVN 7) failed to administer Resident 16's medications within 60 minutes of scheduled time of 9 AM on 4/24/2024. 2. During a Medication Pass observation, LVN 7 failed to check Resident 48's blood glucose (blood sugar, main sugar found in the blood) and administer insulin (medicine to lower the level of glucose [type of sugar] in the body) before lunch meal on 4/24/2024. These deficient practices had the potential to result in Resident 16 and 48 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents health and well-being to be negatively impacted. Findings: 1. A review of Resident 16's admission Record indicated Resident 16 was originally admitted on [DATE] and readmitted on [DATE], with diagnoses that included asthma (a condition in which a resident's airways become narrow which makes it difficult to breathe), dysphagia (difficulty swallowing), and hypertension (high blood pressure). A review of Resident 16's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 2/20/2024, indicated Resident 16 had moderately impaired (decisions poor; cues/supervision required) cognitive skills (mental action or process of acquiring knowledge and understanding through thought and the senses) for daily decision making. The MDS indicated Resident 16 required supervision with eating. MDS indicated Resident 16 required partial/moderate assistance (helper does more than half the effort) with oral hygiene and personal hygiene. It also indicated that Resident 16 required substantial assistance (helper does more than effort) with toileting hygiene and upper body dressing. Resident 16 was dependent with shower, lower body dressing and putting on/taking off footwear. A review of Resident 48's Physician's order, dated 3/27/2024, indicated the following orders: Advair Diskus (used to prevent asthma attacks) 250 micrograms (mcg, unit of measurement), one (1) inhalation every 12 hours for Asthma, ordered on 3/18/2024. Ascorbic Acid tablet 500 milligrams (mg, unit of measurement), 1 tablet by mouth once a day, ordered on 3/18/2024. Colace (stool softener) capsule 100 mg, 2 (two) capsules by mouth, 2 times a day for constipation (a problem with passing stool), ordered on 3/18/2024. Enoxaparin sodium solution (blood thinner) injection (act of administering a liquid, especially a drug, into a person's body using a needle and a syringe), inject 30 mg subcutaneously (beneath, or under, all the layers of the skin) once a day to prevent blood clotting, ordered on 3/18/2024. Irbesartan (medication to treat high blood pressure) 150 mg tablet, 1 tablet by mouth once a day for hypertension, ordered on 3/23/2024. Isosorbide Mononitrate (used to prevent angina [chest pain]) extended release 30 mg, 1 tablet by mouth once a day for hypertension, ordered on 3/23/2024. Lactulose solution (used to treat constipation) 10 grams (gm, unit of measurement)/15 milliliters (ml, unit of measurement), 10 gm by mouth once a day for constipation, hold if loose stool, ordered on 3/18/2024. Lorazepam (used to treat anxiety [a feeling of fear, dread, and uneasiness]) oral tablet 1 mg, 1 tablet by mouth 2 times a day for anxiety manifested by physical restlessness and inability to relax, ordered on 3/23/2024. Ferrous sulfate (an iron supplement used to treat or prevent low blood levels of iron) 325 mg, 1 tablet by mouth once a day for supplement. During a concurrent record review of Resident 16's physician's orders and observation of the medication administration for Resident 16 on 4/24/2024, at 10:30 AM with Assistant Director of Nursing (ADON), LVN 7 was observed administering Resident 16's medications. The ADON and LVN 7 stated that the following medications were Resident 16's scheduled medications for 9 AM: Advair Diskus Ascorbic Acid tablet 500 mg, 1 tablet Enoxaparin sodium solution injection Irbesartan 150 mg tablet, 1 tablet Isosorbide Mononitrate extended release 30 mg, 1 tablet Lactulose solution 10 gm/15 ml Lorazepam oral tablet 1 mg, 1 tablet Ferrous sulfate tablet 325 mg, 1 tablet Colace capsule 100 mg, 2 (two) capsules During an interview with LVN 7 at 4/24/2024 at 10:45 AM, LVN 7 verified that she administered Resident 16's 9 AM medication late because she gave them after 10 AM. She stated that medications can be administered one hour before or after the scheduled time. LVN 7 stated, If medications were not administered on time, for example blood pressure medications, it can affect the blood pressure of the residents which can cause a change in the residents' condition. 2. A review of Resident 48's admission Record indicated Resident 48 was originally admitted on [DATE] with diagnoses that included type 2 diabetes (abnormal blood sugar), muscle weakness, and dementia (long term and often gradual decrease in the ability to think and remember severe enough to affect a person's daily functioning). A review of Resident 48's MDS, dated [DATE], indicated Resident 48 had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding through thought and the senses) for daily decision making and required supervision with eating and personal hygiene. The MDS indicated, Resident 48 required partial/moderate assistance (helper does more than half the effort) with oral hygiene, upper body dressing. It also indicated that Resident 48 required substantial assistance (helper does more than effort) with toileting hygiene and shower and was dependent with lower body dressing and lower body dressing. A review of Resident 48's Physician's order, dated 3/27/2024, indicated an order on 3/26/2024 to administer insulin Lispro (a fast-acting insulin used to control high blood sugar) per sliding scale (the increasing administration of the pre?meal insulin dose based on the blood sugar level before the meal), subcutaneously (SQ, method of giving a medication in the fatty layer of tissue just under the skin) before meals and at bedtime for diabetes. The Physician's order indicated sliding scale as follows: For blood sugar less than 70 milligram per deciliter (mg/dL, unit of measurement), follow hypoglycemia protocol and call Doctor. For blood sugar of 0 mg/dL to 199 mg/dL, give 0 units of insulin. 200 mg/dL to 249 mg/dL = give 1 unit of insulin 250 mg/dL to 299 mg/dL = give 2 units of insulin 300 mg/dL to 349 mg/dL = give three (3) units of insulin 350 mg/dL to 399 mg/dL = give four (4) units of insulin 400 mg/dL to 449 mg/dL = give five (5) units of insulin 450 mg/dL to 999 mg/dL = give six (6) units of insulin and call the doctor During an interview on 4/24/2024 at 12:03 PM, ADON stated Resident 48 was due for blood sugar check and insulin administration per sliding scale at 11:30 AM. During a concurrent observation in the dining room and interview with LVN 7 on 4/24/2024 at 12:05 PM, LVN 7 stated, Resident 48 had already started eating and had consumed a small portion of his lunch plate. During a concurrent interview and medication pass observation on 4/24/2024 at 12:07 PM, ADON and LVN 7 checked Resident 48's blood sugar. Resident 48's blood sugar result was 245 mg/dL. The ADON stated per the physician's order, Resident 48 should receive 1 unit of insulin Lispro. The ADON added that Resident 48's blood sugar result of 245 was not reliable since it was checked after Resident 48 had already eaten. During an interview on 4/24/2024 at 5 PM with LVN 3, she stated, prior to giving insulin, licensed nurse should have checked Resident 48's blood sugar to see if resident would need to be administered insulin Lispro in accordance with the physician's order. LVN 3 added, checking the blood sugar level and administering the ordered insulin was important to prevent resident from developing hyperglycemia after eating. During an interview on 4/25/2024 at 11:35 AM, the ADON stated that it was important to administer medication as ordered to get the full benefit of the medication and to prevent complications of inconsistent timing of medication administration. The ADON stated, Resident 48's blood sugar check and insulin order were to control the resident's blood sugar, and if it was not given timely, Resident 48 can develop uncontrolled high blood sugar and can cause complications such as death. A review of the facility's Policy and Procedure titled, Administering Medications, revised in April 2019, indicated medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). A review of the facility's Policy and Procedure titled, Job Description for Long Term Care Facilities, Licensed Vocational Nurse, revised in May 2022, it indicated duties and responsibilities to administer medications within the scope of practice and according to practitioner orders.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to label foods in the kitchen with item name, 'use by' date (the last date recommended for the use of the product) and failed to discard expired food as indicated in the facility's policy and procedure. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever and can lead to other serious medical complications and hospitalization. Findings: During a concurrent observation in the facility kitchen and interview on 4/22/2024 at 8:02 AM with the Accounts Manager (ACM), the kitchen was observed with food items not labeled to indicate the food item names and use by date. The ACM stated all food items were supposed to be labeled with food item name, use by date, and food must be discarded when expired. ACM stated. the following were found in the kitchen's refrigerators and/or freezer: a. Open bag of fries not labeled with item name, date opened, and used by date. b. Open bag of chicken tenders not labeled with item name, date opened and used by date. c. Clear bag of hash browns not labeled with item name and used by date. d. Two packs of raw meat not labeled with item name and used by date. e. A metal container of beans with used by date of 4/20/2024. f. A zip lock bag containing deli turkey with used by date of 4/20/2024. g. An open loaf of bread with no used by date. During the same interview on 4/22/2024 at 8:02 AM with the ACM, ACM stated all expired food items such as the beans and deli turkey should have been thrown away. ACM stated the food items fries, chicken tenders, hashbrowns, raw meat and loaf bread only had the received date. The ACM stated the food items should have been labeled with the item name along with a used by date to know when the food items were going be expired. During a follow up interview on 4/22/2024 at 8:24 AM with the ACM, ACM stated items should be labeled with the expiration date/ used by date to know when food items will expire. ACM stated the importance of having an expiration date of food items was to prevent serving expired food to the residents. During an interview on 4/25/2024 at 12:33 PM with the Registered Dietician (RD) Consultant, RD Consultant stated there was no policy for discarding food items. The RD Consultant stated the facility followed Food and Drug Administration (FDA) guidelines for discarding food. A review of the facility's policy and procedure titled. Food Storage: Cold Foods, revised 4/2018, indicated all foods will be stored, wrapped, or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. A review of the 2022 FDA Food Code U.S. Food and Drug Administration, 3-501.18 titled, Ready-to-Eat, Time/Temperature Control for Safety Food, Disposition, indicated time/temperature control safety refrigerated foods must be consumed, sold, or discarded by the expiration date. https://www.fda.gov/media/164194/download?attachment

CONCERN (E)

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

Safe Environment (Tag F0921)

Could have caused harm · This affected multiple residents

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Based on observation and interview, the facility failed to maintain a safe environment by failing to fix the broken tile around two uncovered sewer drains on the floor, in the hallway, causing the floor to be uneven. This deficient practice had the potential for residents, visitors, and staff to be placed at risk for fall and injury. Findings: During a concurrent observation at the hallway where the rehabilitation room was located and hallway infront of the kitchen and activity/dining room and interview with the Maintenance Director (MED) on 4/25/24 at 8:25 AM, the MED stated there was an uncovered sewer drain, in each area, about four (4) inches in circumference with a broken tile around the hole. MED stated all the sewer drains were supposed to be covered and the broken tile was supposed to be fixed to prevent residents, visitors, and staff from falling. MED stated housekeeping usually checks the floors and the maintenance department is responsible for repairs. MED stated he did not receive any reports for floor repairing. During an interview on 4/25/24 at 8:27 AM, in front of the rehabilitation room, Housekeeping Supervisor (HS) stated Housekeeping cleaned the hallway last night and have reported the two uncovered sewer drains and broken tile to the maintenance department so it can be fixed. HS stated, Somebody might fall due to the two uncovered sewer drains and one broken tile. A review of the facility's Policy and Procedure (P&P) titled, Maintenance Service, Physical Environment, revised on December/2009, indicated the maintenance service shall be provided to all areas of the building, grounds, and equipment. I. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: b. Maintaining the building in good repair and free from hazards. h. maintaining the grounds, sidewalks, parking lots etc., in good order. i. Providing routinely scheduled maintenance service to all areas. J. Others that may become necessary or appropriate.

CONCERN (F)

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

Infection Control (Tag F0880)

Could have caused harm · This affected most or all residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a concurrent interview and record review on 4/25/24 at 9:40 A.M. with the Maintenance Director (MED), the MED stated he never used any toolkit to test the water for water management of Legionella for this facility since 2018. MED stated he did not monitor the cold-water temperature. MED stated he only conducted visual inspection of water heaters and lines and took temperature of hot water from randomly picked residents' rooms. MED stated he entered all the temperatures data to TELS (a building management platform designed for Senior Living with integrated Asset Management, Life Safety, and Maintenance solutions.) MED stated the TELS only recorded inspection data from Monday to Friday and has no data recording for Saturday and Sunday. MED added TELS does not have recording for the heaters and line inspection. MED stated he has no other paperwork to record the monitoring data besides TELS. MED stated hot water monitoring was conducted from Monday to Saturday, but there was no monitoring of hot water temperature, heaters, line inspection on Sundays. MED stated it was important to perform daily water monitor to prevent water contamination. MED added that it was important to test the water to ensure safe and sanitary water to prevent residents from getting sick. During an interview on 4/24/24 at 1:18 P.M. with the Infection Preventionist (IP), the IP stated, I know there is a water management policy in the infection control. IP stated MED knows how to take care of it and the maintenance department is responsible for water management of the infection control program. During a concurrent interview and record review on 4/25/24 at 10:03 A.M. with the Administrator (ADM), the ADM stated the facility did not use any toolkit to test the water. ADM stated the water management monitoring was not performed daily as it was described in the policy. ADM stated any data that was not logged into TELS, was not done. ADM stated it was important for the team to follow instructions to maintain proper water and stop legionella. During an interview on 4/25/24 at 4:35 P.M. with Dietary Manager (DM) and Registered Dietitian (RD), both DM and RD stated the blue water filter system in the kitchen under the sink is to supply drinking water for the whole facility's residents, visitors, and staff. During a review of the facility's Policy and Procedure (P&P) titled, Water Management, Legionella Plan, dated 1/1/2023, indicated the facility promotes proactive steps to establish healthy, infection-free environments for their residents, staff, and visitors. When residents contract Legionnaires' disease, it is often the result of exposure to inadequately managed building water systems, which can be prevented. It also indicated for the Facility to: I. Establish a water management program team. II. Describe the building water systems. III. Identify areas where Legionella could grow and spread. IV. Decide control measures and monitoring. V. Establish ways to intervene when control limits are not met. VI. Ensure the program is running as designed and is effective. A review of the Centers for Disease Control and Prevention (CDC) toolkit titled, Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, dated 6/24/2021, indicated control measures and limits should be established for each control point. There is a need to monitor to ensure the control measures are performing as designed. Control limits, in which a chemical or physical parameter must be maintained, should include a minimum and a maximum value. Examples of chemical and physical control measures and limits to reduce the risk of Legionella growth: Water quality should be measured throughout the system to ensure that changes that may lead to Legionella growth (such as a drop in chlorine levels) are not occurring. Water heaters should be maintained at appropriate temperatures. Decorative fountains should be kept free of debris and visible biofilm. Disinfectant and other chemical levels in cooling towers and hot tubs should be continuously maintained and regularly monitored. Surfaces with any visible biofilm (i.e., slime) should be cleaned. Based on observation, interview, and record review, the facility failed to observe infection control measures as indicated on the facility policy when facility staff failed to: 1. Wear Personal Protective Equipment (PPE, protective clothing such as gown, gloves, goggles, mask) when entering an Enhanced Standard Precaution (reducing transmission of organisms through health provider with the use of gown and gloves when caring for the resident) room. This deficient practice has the potential to spread infection to other residents. 2. Ensure the Legionella (a type of bacteria spread through small droplets of water that can cause legionellosis [Legionnaires' Disease, a serious and potentially deadly lung infection]) Water Management Program policy and procedure was fully implemented. This deficient practice had the potential to result in the infection (a process when a microorganism, such as bacteria, fungi, or a virus, enters a person's body and causes harm) and a spread waterborne illness in the facility. Findings: 1. A review of Resident 39's admission Record indicated resident was admitted on [DATE] with the following diagnoses of pressure ulcer (PU, localized skin and soft tissue injuries that form as a result of prolonged pressure and shear, usually exerted over bony prominences) and muscle weakness. A review of Resident 39's History and Physical (H&P), dated 1/13/2024, indicated resident has the capacity to understand and make decisions. A review of Resident 39's Minimum Data Set (MDS, a standardized care screening and assessment tool), dated 1/11/2024, indicated resident was moderately impaired with cognitive (mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) skills for daily decision making. MDS also indicated Resident 39 required partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with upper body dressing and putting/on taking off footwear. MDS indicated Resident 39 required substantial/maximal assistance (helper does more than half the effort. Helper lifts or hold trunk or limbs and provides more than half the effort) with shower/bathe self and lower body dressing but was dependent (the ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy, including wiping the opening but not managing equipment) with toileting hygiene.MDS indicated resident had a catheter (indwelling catheter, a hollow tube inserted though the urethra [a tube through which urine leaves the body] into the urinary bladder to collect and drain urine). During a concurrent observation in Resident 39's room and interview on 4/24/2024 at 10:06 AM, Certified Nursing Assistant 1 (CNA 1) was observed with only gloves on while providing care to Resident 39. CNA 1 stated she did not but should have put on a gown to prevent the spread of infection to other residents. During an interview on 4/24/2024 at 10:52 AM, Infection Preventionist Nurse (IPN) stated, CNAs need to wear gown and gloves while providing close contact care (eating, changing, bathing) in enhanced standard precaution rooms. A review of the facility's Policy and Procedure titled, Infection Prevention and Control Program, revised 10/2018, indicated those with potential direct exposure to blood or body fluids are trained in and required to use appropriate precautions and personal protective equipment. Policy also indicated it is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

MINOR (B)

Minor Issue - procedural, no safety impact

Staffing Information (Tag F0732)

Minor procedural issue · This affected multiple residents

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Based on observation, interview and record review, the facility failed to ensure staffing information (list of total number of staff and the actual hours worked by the staff) was posted and placed in a visible and prominent place on 4/22/2024. As a result, the total number of staff was not readily accessible to residents and visitors. Findings: During an observation, on 4/22/2024 at 7:45 AM, no visible daily staffing information posting was found at the facility lobby. During a concurrent observation of the nursing posting on the wall near the lobby and interview with Director of Staff Development (DSD), on 4/24/2024 at 11:15 AM, DSD stated On 4/22/2024, 4/23/2024 and 4/24/2024, she did not post the number of licensed nurses (Registered Nurse [RN] and Licensed Vocational Nurse [LVN]) and the number of unlicensed nursing personnel (Certified Nurse Assistants [CNA]) directly responsible for resident care. DSD stated she cannot recall the exact date when she stopped posting the number of Directly responsible for resident care (means that individuals are responsible for residents' total care or some aspect of the residents' care including, but not limited to, assisting with activities of daily living [ADLs], giving medications, supervising care given by CNAs, and performing nursing assessments to admit residents or notify physicians of changes of condition). During an interview, on 4/24/2024 at 11:30 AM with the Director of Nursing (DON), she stated that she did not know that the facility was not posting the shift staffing information that consist of the census, the total number of RN, LVN and CNA's working each shift. The DON added this posting should be easily seen and read by residents, visitors, and staff and that it is important to post the staffing information so residents and visitors would know that the facility is staffed with the required number of nurses to deliver care to the residents in accordance with the regulations. A review of the facility's policy and procedure titled Posting Direct Care Daily Staffing Numbers, revised August 2022, policy indicated facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents.

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

Safe Environment (Tag F0921)

Could have caused harm · This affected 1 resident

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Based on observation, interview and record review, the facility failed to ensure a safe and functional environment for residents, staff, and the public, due to an unapproved repair project, and non-compliance with the State building codes. This deficient practice of has the potential to have negative effects to the safety, welfare and health of the residents, staff, and the public. Findings: On 9/7/23, at 1:30 pm, a complaint investigation was initiated regarding the facility's unapproved repair project at the facility. The administrator-in-training (AIT) was informed of the visit and called for the maintenance supervisor. During a general observation with the maintenance supervisor, at 2:00 pm, two washing machines were observed in the laundry room. One washing machine was shiny and new, and the other washing machine was not shiny and old. During an interview, at 2:20 pm, the maintenance supervisor stated that the new washing machine was installed about 3 or 4 months ago because one of the two old washing machines stopped working. The maintenance supervisor added that the facility received an emergency authorization letter from HCAI to replace the inoperable washing machine (HCAI is the Department of Health Care Access and Information which is the State agency that reviews and approves plans for construction, repairs, renovations, and remodeling made to buildings to comply with State codes.) During an interview, at 2:45 pm, the AIT stated that the facility's corporate maintenance director had the documentation, including the HCAI building permit, regarding the new washing machine project. The AIT stated that she would have the corporate maintenance director email her the documents and she would forward that email to this Department, by today. During a record review, on 9/8/23, at 1:00 pm, the HCAI construction advisory report (dated 9/6/23), stated that the building permit was pending. During an interview, on 9/8/23, at 2:30 pm, the AIT stated that she had an emergency authorization letter from HCAI for the washing machine project (dated 8/29/23) and another HACI document for the washing machine project. During a record review of these two HCAI documents, it was indicated that HCAI had given the facility authorization to install the new washing machine, due to an emergency situation and that an application for a building permit for the washing machine project was submitted. The documents did not indicate that a permit was obtained. During an interview, at 2:45 pm, the AIT stated she was not aware that these two documents were not the building permit requested for the washing machine project.

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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Based on interview and record review, the facility failed to ensure the Change of Shift Narcotics (drug that produces analgesia [pain relief], narcosis [state of stupor or sleep], and addiction [physical dependence on the drug]) Reconciliation Records contained two Licensed Nurses' signatures for one (1) of four (4) medication carts (Station 1 Cart1) in accordance with the facility's policy and procedure. This deficient practice had the potential for the diversion (illegal distribution or abuse of prescription drugs or their use for unintended purposes) of controlled substance (medications with a likelihood for physical and mental dependence.) medications. Findings: On 8/29/23 at 10:54 AM, a review of the facility's Station 1 Cart 1's Change of Shift Narcotics Reconciliation Records titled, Narcotic Log, for the month of July 2023, indicated missing Licensed Nurse's signature on the following dates: 1. Outgoing (going off duty-leaving the shift) Licensed Nurse on 7/28/23 who worked the 7 AM to 3 PM (day) shift. 2. Outgoing Licensed Nurse on 7/30/23 who worked day shift. During a concurrent record review of the Narcotic log and interview with License Vocational Nurse 1 (LVN 1) on 8/29/23 at 10:55 AM, LVN 1 stated there were missing signatures of the outgoing licensed nurses on 7/28/23 and 7/30/23. LVN1 stated incoming (starting the shift) and outgoing Licensed Nurses count the controlled medications together. LVN 1 stated both Licensed Nurses should sign the Narcotic log after they counted the controlled medications to verify that the count was accurate. LVN 1 stated it was very important to have two Licensed Nurses' signature on the Narcotic Log to know who conducted the count and to prevent the loss of the controlled drugs. During a concurrent record review of the Narcotic log and interview with the Director of Nursing (DON) on 8/29/23 at 10:58 AM, the DON stated the facility required two Licensed Nurses to sign and document accurately on the log to ensure the count of controlled medications was done and there were no missing medications. A review of the facility's policy and procedure titled, Routine Reconciliation of Controlled Substances, dated 1/1/22, indicated that when conducting the reconciliation, one nurse should perform the actual count while the second nurse records. Both nurses should sign the reconciliation worksheet.

Aug 2023 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0800 (Tag F0800)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a nourishing, well-balanced diet and dietary needs and choices for 87 of 89 residents when: 1. Second (2nd) menu options were not prepared for lunch on 8/30/2023 due to food items were not purchased 2. There were no available fresh fruits and vegetables on 8/30/2023. 3. Menu and standardized recipes were not followed on 8/30/2023 due to unavailable food supplies such as sausages, powdered onions and powdered garlic. 4. Available food supplies were limited to one (1) day at hand. 5. 20 menu substitution from 8/4/2023 to 8/29/2023, 1 menu substitution for 8/30/2023, four (4) menu substitution for 8/31/2023 were made due to food items not purchased. 6. Insufficient silverwares for residents use in lunch service on 8/30/2023. These deficient practices placed the residents on regular (diet with no restrictions) and therapeutic diets (meal plan that controls certain foods and nutrients) at risk of potential decreased nutrient intake causing unintentional weight loss (weight loss without trying). Findings: 1. A review of Resident 1 ' s admission Record indicated the facility initially admitted the resident on 5/26/2021 with diagnoses that included essential (primary) hypertension (HTN, high blood pressure), hyperlipidemia (high levels of fats in the blood), and age-related osteoporosis (a condition that weakens the bones). A review of Resident 1 ' s Minimum Data Sheet (MDS-a standard assessment tool that measures health status), dated 6/1/2021, indicated the resident was cognitively (a mental process that take place in the brain, including thinking, attention, language, learning, memory and perception) intact. The MDS indicated that Resident 1 needed supervision and set up only when eating. A review of Resident 1 ' s Physician diet order, dated 8/9/2023, indicated Resident 1 ' s diet was Renal diet (diet that is limited in protein, sodium, potassium and phosphorus), regular texture consistency (no restriction). During an interview with Resident 1 on 8/30/2023 at 10:26 a.m., Resident 1 stated, I don ' t really like the food and I don ' t eat a lot of what they cook. Resident 1 stated that the facility served a lot of rice, chicken, mixed vegetables and that there were no variety. Resident 1 stated that she requested sandwiches instead of the regular meal tray. During a review of the facilities document titled, Diet Guide Sheet, for Wednesday lunch, dated 8/30/2023, indicated menu has two options for Regular, Large portions, Small portions, Consistent Carbohydrate diet (CCD, diet for people with high blood sugar), 2 grams Sodium Diet (diet provided for people with HTN), CCD 2 grams Sodium Diet, CCD Renal Diet, Renal Diet (diet provided for people with Kidney problems), Therapeutic Lifestyle Changes (TLC) Diet (diet provided for people with heart disease). a. The following foods will be served to Option 1: Regular, Large portion, small portions, CCD, 2 grams Sodium, CCD 2 grams Sodium, CCD Renal Diet, Renal diet, TLC diet: - Open-faced Roast Pork Sandwich - Herbed [NAME] Beans - Mashed Potatoes - Dinner Roll - Lemon Cake with Lemon icing b. The following foods will be served to Option 2: Regular, Large portion, small portions, Consistent Carbohydrate diets: - Salisbury Steak - Brussels Sprouts - Buttered Noodles - Dinner Roll - Lemon Cake with Lemon Icing The following foods will be served to Option 2: 2 grams sodium, CCD 2 grams sodium, CCD Renal, Renal, TLC - Low salt (LS) Salisbury Steak - Brussels Sprouts - Buttered Noodles - Dinner Roll - Lemon Cake with Lemon Icing During a concurrent observation in tray line (area to assemble resident meals) and interview with the Dietary Supervisor (DS) on 8/30/2023 at 11:55 a.m., there were no Salisbury steak, buttered noodles and Brussels Sprouts prepared. DS stated that buttered noodles were not available and that mashed potatoes were being given as an alternative. During an interview with [NAME] 1 on 8/30/2023 at 1:05 p.m., [NAME] 1 stated, I did not cook buttered noodles because there were no butter and noodles available in the kitchen. During an interview with the DS on 8/30/2023 at 3:44 p.m., DS stated, Buttered noodles were not prepared for today as mashed potatoes were in stock. DS stated that they received the wrong noodles from the supplier. DS stated the second menu options were not prepared as none of the residents requested for it. A review of facility invoices from dairy vendor invoice number WEB153220, dated 8/28/2023, indicated there was no butter ordered. A review of the facility invoices from food vendor invoice number 645792484, dated 8/28/2023, indicated elbow macaroni was ordered and there were no Salisbury steak and Brussels sprouts ordered. A review of the facility ' s policy and procedure (P&P) titled, Menus, revised 9/2017, indicated menus will be planned in advance to meet nutritional needs of the residents in accordance with established national guidelines. Menus will be developed to meet the criteria through the use of an approved menu planning guide. The P&P indicated menus will periodically be presented for resident review, including the resident council menu review meetings, or other review board as indicated by the center. The menu will identify the primary meal, the alternate meal, and any always offered food and beverage items. 2. A review of Resident 2 ' s admission Record indicated the facility initially admitted the resident on 7/23/2022 and was re-admitted on [DATE] with diagnoses that included dysphagia (difficulty swallowing), mild protein-calorie malnutrition (condition due inadequate intake of protein and calories), and essential (primary) HTN. A review of Resident 2 ' s MDS, dated [DATE], indicated the resident was cognitively intact. The MDS indicated that Resident 2 ' s needed supervision and set up only when eating. A review of Resident 2 ' s Physician diet order, dated 2/24/2023, indicated Resident 2 ' s diet was Regular diet (diet with no restrictions), regular texture consistency (no restriction). During an interview with Resident 2 on 8/30/2023 at 10:34 a.m., Resident 2 stated that he preferred more fresh mixed fruits and fresh vegetables. Resident 2 stated he informed the nurses however, there were no fresh fruits and vegetables available in the kitchen. Resident 2 stated that the kitchen served a lot of peas as a vegetable and there were no varieties. Resident 2 stated that there was a daily menu posted on the wall. Resident 2 stated, Sometimes they follow the menu, sometimes not. I don ' t know what the issue was. During a kitchen tour observation on 8/30/2023 at 10:45 a.m., there were no fresh fruits and vegetables observed in the refrigerators. During an interview with the DS on 8/30/2023 at 3:44 p.m., DS stated, frozen fruits and vegetables are served to the residents. DS stated, We do not serve fresh fruits and vegetables. During an interview with the Kitchen District Manager 2 (DM2) on 8/30/2023 at 4:19 p.m., DM 2 stated she does not know why fresh fruits and vegetables were not served or included in the menu. 3. A review of Resident 3 ' s admission Record indicated the facility initially admitted the resident on 9/29/2022 and was re-admitted on [DATE] with diagnoses that included type 2 diabetes mellitus (DM2, increase of blood sugar levels), mixed hyperlipidemia, and essential HTN. A review of Resident 3 ' s MDS dated [DATE], indicated the resident was cognitively intact. The MDS indicated that Resident 3 ' s needed supervision and set up only when eating. A review of Resident 3 ' s Physician diet order, dated 4/26/2023, indicated Resident 3 ' s diet was Regular diet, regular texture consistency. During an interview with Resident 3 on 8/30/2023 at 10:40 a.m., Resident 3 stated that there were no variety and there were inadequate amounts of breakfast food served from the kitchen. Resident 3 stated the food served for breakfast were mostly beans, once sliced of wheat bread, 2 scrambled eggs and juice. Resident 3 stated food has no flavor at all and that the kitchen mostly served chopped up beans and carrots with no seasonings. During an interview with [NAME] 1 on 8/30/2023 at 1:05 p.m., [NAME] 1 stated, We do not go by the books anymore for standardized recipes. We haven ' t been following the menu books anymore because we have been substituting everything. [NAME] 1 stated that the kitchen run out of food and offered what was available to the residents. [NAME] 1 stated they run out of spices to use as indicated in the standardized recipe and ended up using spices that were available on the shelves to flavor the food. [NAME] 1 stated that the possible outcome of not following a standardized recipe was a change in flavor resulting to resident not liking and not eating the food. [NAME] 1 stated resident could lose weight and get sick. During an interview with [NAME] 2 on 8/30/2023 at 1:31 p.m., [NAME] 2 stated, The kitchen run out of food items and were mostly tomatoes and condiments such as garlic powder, onion powder and paprika. [NAME] 2 stated that she just added dill or black pepper to flavor the food, so the residents would not complain. [NAME] 2 stated that there were no garlic powder and fresh onions for the beef Mexican casserole preparation for today ' s (8/30/2023) dinner. During an interview with Certified Nursing Assistant 1 (CNA1) on 8/30/2023 at 1:59 p.m., CNA1 stated there were 2 residents (unnamed) complained that they did not like the food. CNA1 stated she offered alternative foods and went to the kitchen to request it. CNA1 stated there were times that kitchen staff would state to come back at a certain time. CNA1 stated, Sometimes they do not have the food. CNA1 also stated there were times when residents would get annoyed because they always get served with eggs at breakfast. CNA1 stated she went to the kitchen and the kitchen staff would not replace the food item and was told That is all we have. CNA1 stated the kitchen run out of food like milk, juices, and sugar, but did know the frequency, but heard from the kitchen staff that it was quite often. CNA1 stated residents can starve, lose weight and get weaker as the immune system goes down as a possible outcome of not eating food. During a review of facility corporate undated recipe titled, Beef, Mexican Casserole, not dated indicated ingredients included, onion yellow, fresh and spice, garlic powder. A review of facility invoices from dairy vendor invoice number WEB153220, dated 8/28/2023, indicated fresh yellow onions were not ordered. A review of the facility invoices from food vendor invoice number 645792484, dated 8/28/2023, indicated there were no spice garlic powder ordered. A review of the facility ' s P&P titled, Menus, revised 9/2017, indicated, Menu cycle will include standardized recipes. (6) It also indicated menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal. 4. During a kitchen tour observation in the storage areas on 8/30/2023 at 10:45 a.m., the storage shelves were observed with the following: a. Walk-in Refrigerator 2 contained: 1 tub of shredded American cheese, 2 packet of American cheese, 1 tub of shredded Mexican cheese, 1 tub of sliced single served cheese, 1 cartoon of liquid whole egg, few pieces of butter, 1 tub of mustard, ¼ tub of canned sliced peaches, ¼ tub canned pineapple, and 1 tub of yellow cake mix. b. Reach-in Freezer contained: 5 plastic of frozen corn, 2 boxes of opened frozen dinner roll, 1 box of opened turkey patties, 1 plastic of tater tots, 1 box of opened cinnamon sweet roll frozen dough, and 1 box of frozen southern style biscuit dough. c. Refrigerator 3 contained: 2 boxes of honey thick juice, 1 bottle of orange juice, 23 cups of portioned orange juices, 1 tray of orange and apple juice portioned in cups. d. Refrigerator 4 contained: 4 pieces of peach puree, 2 oz of prepared juices. e. Dry storage area contained: 12 boxes of toasted oats, 5 cans of diced tomatoes, 4 cans of tropical fruit salad, 3 cans of tomato ketchup, 1 can beef stew, pouches o lemon drink, 1 pouch of lime gelatin, 1 pc mustard, 2 cans grape jelly, 2 plastic of elbow macaroni, 8 boxes of lasagna noodles, and corn starch boxes. During an interview with Dietary Aide 1 (DA1) on 8/30/2023 at 11:00 a.m., DA 1 stated the last delivery was on Monday 8/28/2023. DA1 stated that all the storage were inside the kitchen and there were no other storage areas for food. During an interview with [NAME] 1 on 8/30/2023 at 11:03 a.m., [NAME] 1 stated the storage areas including dry storage (storeroom of canned and dry goods/food), freezer and refrigerator were empty. [NAME] 1 stated the staff has been dealing with this insufficient food supplies since the new District Manager 1 (DM1) took over the kitchen for 2-3 months. During an interview with the DS on 8/30/2023 at 11:09 a.m., DS stated he is the person responsible for ordering food and paper supplies and was overseen by DM2 and DM1. DS stated that last food delivery was on Monday (8/28/2023). DS stated the schedule for ordering was bi-weekly (2 times a week). DS stated he ordered every Friday for Monday delivery for four days ' worth of food, then Wednesday for Thursday delivery for three days ' worth of food. DS stated he has 1 day worth of food supply at hand for tomorrow ' s use. DS stated the policy for ordering food was 3-4 days food supply, however, DS stated he was uncertain of the exact policy and would check with the DM1. During an interview with the DS on 8/30/2023 at 11:49 a.m., DS stated that 1 day food supply at hand was acceptable as there was an order coming in tomorrow. DS stated if the food item was not available, he would get it from the sister facilities. During an interview with [NAME] 1 on 8/30/2023 at 1:05 p.m., [NAME] 1 stated that there were budget cuts which was the reason why DS was just ordering the exact amount of food per order. [NAME] 1 stated shelves were always empty and oil, bread, butter, seasonings were always out of stock because DS does not order enough. [NAME] 1 stated that the kitchen would run out of milk and would use powdered milk. [NAME] 1 stated she told the DM2 that residents were complaining that they were given chicken four times a week. During an interview with the Licensed Vocational Nurse 1 (LVN1) on 8/30/2023 at 1:15 p.m., LVN stated the facility has current limitations when it comes to low stocks of food as there had been budget cuts. LVN 1 stated the Director of Nursing (DON) was aware that the kitchen run out of food and there were missing food items. During a concurrent kitchen tour observation and interview with DON and Assistant Administrator (AADM) on 8/30/2023 at 3:13 p.m., the DON stated that the food supply at hand was not meeting the regulatory requirement based on State regulations AADM stated there were not enough perishable foods like eggs and milk available at hand in the kitchen. AADM stated that there were no fresh fruits and vegetables. DON stated not having sufficient food supply could result to not meeting the resident ' s menu and impact the quality of nutrition residents were receiving that could lead to weight loss, weight variance and psychosocial harm. During an interview with DM1 on 8/30/2023 at 4:19 p.m., DM1 stated they order food and supplies twice a week for Monday and Thursday deliveries. Thursday orders were good until the next Monday and Monday delivery will be good until Thursday. DM1 stated that the facility ordered food for 3 days following the menu including emergency supply. DM1 stated their current process was not compliant with the regulation of 1-week staple food and 2 days of perishable food at hand. DM1 stated this should not count the disaster food supplies as it followed a different menu. 5. A review of Facility Menu titled, Week-At-A- Glance, dated 8/30/2023, indicated Regular diet dinner menu will have the following: - Mexican Beef Casserole - Seasoned Whole Kernel Corn - Cornbread - Tropical Fruit Salad A review of the Facility Menu titled, Week-At-A- Glance, dated 8/30/2023, indicated Regular diet have the following: Breakfast: - Buttermilk Pancakes - Sausage Patty Lunch: - Crispy Baked Chicken - Sauteed spinach - Macaroni and Cheese - Dinner Roll/Bread Pudding parfait - Pumpkin Pie Dinner: - Smothered Patty/Philly cheese steak (CCD diets) - Mixed Vegetables - French Fries - Pineapple tidbits During a concurrent kitchen tour observation and interview with the DS on 8/30/2023 at 11:29 p.m., corn bread, sausage patty, chicken, pumpkin pie, Philly cheese steak were not available in the kitchen. DS stated corn bread will be substituted with dinner roll, kernel corn will be substituted with peas, sausage patty will be substituted with eggs, chicken will be substituted with ground meat, pumpkin pie will be substituted with yellow cake and Philly cheese steak will be substituted with smothered steak hamburger patty as the delivery did not come in. DS stated that the reason why there were a lot of substitution was there were times the food were damaged and had to be returned. During an interview with DM2 on 8/30/2023 at 4:19 p.m., DM2 stated, menu substitution happened due to shortage of food from the supplier. DM2 stated that the possible outcome of too many substitutions could result to residents complaining. DM2 stated menu substitution were not meeting nutritional facts (information on the calorie, protein, fats, vitamins and minerals food content ) and was not equivalent for the food substituted. DM2 stated residents might not eat the substitution. A review of the Facility Menu Substitution log, dated 8/4/2023 to 8/30/2023, indicated the following: a. 20 menu substitution from 8/4/2023 to 8/29/2023 b. 1 menu substitution for 8/30/2023. Dinner substitution for corn bread and kernel corn were not indicated in the form. c. 8/31/2023 substitution for sausage patty, chicken, pumpkin pie and Philly cheese steak were not indicated in the menu substitution log. A review of the facility invoices from food vendor invoice number 645792484, dated 8/28/2023, indicated there were no orders for corn bread mix, sausage patties, pumpkin pies, and Philly cheese steak. There was an order of 1 case 41 pounds of boneless chicken thighs. A review of facility ' s P&P titled, Menus, revised 9/2017, indicated a menu substitution log will be maintained in file. 6. During an interview with Resident 3 on 8/30/2023 at 10:40 a.m., Resident 3 stated, the kitchen does not give silverwares to eat with. Resident 3 stated, We use fork for oatmeal. Resident 3 stated there were no silverwares on the trays every day. During a concurrent tray line observation and interview with DS and DM1 on 8/30/2023 at 12:11 p.m., some trays for station 2 cart did not have spoon and some trays did not have forks. DS stated, We are waiting for the forks and spoon to be pulled out of there resident ' s room for breakfast. DM1 stated they were waiting for the spoon and forks from the residents ' trays this morning. DM1 stated, Spoon and forks will be given in the residents ' trays as soon as we get the silverwares back. DM1 stated he already instructed DS to order more spoons and forks. During an interview with DS on 8/30/2023 at 3:44 p.m., DS stated that he does not know how much silverwares they keep on stock as a Periodic Automatic Replacement (PAR, inventory to keep at hand for the needs and demands of the residents). DS stated, We run out of silverwares just for today.

Aug 2023 1 deficiency

CONCERN (E) 📢 Someone Reported This

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

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

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure there is a functioning call system (call light, device used by a patient to signal his or her need for assistance from professional staff. It typically consists of a remote control at the bedside)at the resident ' s bedside for three (3) of five (5) sampled residents (Resident 1, 3, and 4) in accordance with the facility's Policy and Procedure. This deficient practice had the potential for Resident 1, 3, and 4 not being able to call the facility's staff for help or assistance especially during an emergency. Findings: A review of Resident 1's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included history of fall and displaced fracture (the bone snaps into two or more parts and moves so that the two ends are not lined up straight) of the left lower leg. A review of Resident 1's History and Physical (H&P), dated 8/3/23 and signed by Resident 1's attending physician (MD), indicated Resident 1 had the capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS, a standardized resident assessment care screening tool) dated 8/8/23, indicated Resident 1 had an intact cognitive (able to understand and make decision) status and required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transfer, dressing, toilet use and personal hygiene. A review of Resident 3's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included muscle weakness and abnormalities of gait (pattern of walking) and mobility. A review of Resident 3 ' s MDS dated [DATE], indicated Resident 3 had severely impaired cognitive status and required extensive assistance with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. A review of Resident 3's H&P dated 10/2023 and signed by Resident 3's attending physician (MD), indicated Resident 3 does not have the capacity to understand and make decisions. A review of Resident 4's admission Record indicated the resident was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnosis of dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems) A review of Resident 4 ' s MDS dated [DATE], indicated Resident 4 had severely impaired cognitive status and required extensive assistance with bed mobility, transfer, dressing, eating, toilet use, and personal hygiene. During a concurrent observation and interview on 8/15/23 at 10:35 am, Resident 1 ' s call light was observed not functioning. Resident 1 stated, he had told the staff (unable to remember who) a couple of weeks ago that his call light was not working. During a concurrent observation in Resident 1 ' s room and interview on 8/15/23 at 10:50 am, Licensed Vocational Nurse (LVN 2) 2 confirmed Resident 1 ' s call lights was nonfunctional. LVN 2 stated, call lights must be working so Resident 1 would be able to call facility staff and relay his needs to the staff and prevent another fall. During a concurrent observation and interview on 8/15/23 at 11:15 am, the call lights of Resident 3 and Resident 4 were confirmed by LVN 1 as nonfunctional. LVN 1 stated, it is important to have a working call light so residents can use it to call facility staff when they need assistance and/ or help. During an interview on 8/15/23 at 11:35 am, the Certified Nursing Assistant 1 (CNA 1) stated, a functioning call light are necessary for the safety of the residents so they could call the staff in case of any emergencies. During an interview on 8/15/23 at 1:05 pm, LVN 3 stated, call lights are one of the ways the resident asks for help and if the call lights are not functioning it could result to delay of care. LVN 3 also stated, the residents might try to do things on their own which could result to injuries and/ or falls. During an interview on 8/15/23 at 1:30 pm, CNA 2 stated Resident 1 sometimes screams for help, so CNA 2 thought the resident was confused and forgets to use his call light. CNA 2 stated now she realized Resident 1 had to scream for help because the call light was not working. CNA 2 further stated, the residents should have a functioning call system to prevent accidents and to call if they needed something so they will be able to provide for those needs. CNA 2 further stated, it is the staff ' s responsibility to make sure the residents call lights are working. During an interview on 8/15/23 at 3:15 pm, the Director of Nursing (DON) stated they did not have a policy for call lights. The DON also stated guideline should be in place for call lights to assist staff in addressing and assisting resident in a timely manner. During the same interview on 8/15/23 at 3:15 pm, the DON stated that a non-working call lights is a safety concern for the residents and call lights should always be in good working condition to make sure the residents are able to get their needs addressed by the staff promptly and timely. A review of the facility ' s policy and procedure titled, Residents Rights, revised 12/2021, indicated that the Federal and State laws guarantee certain basic rights to all residents of the facility which included the resident ' s rights to communication with and access to people and services inside the facility. A review of the facility ' s undated policy and procedure titled, Maintenance Services, indicated that the maintenance department is responsible for always maintaining the buildings equipment in a safe and operable manner.

Jun 2023 2 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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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 resident specific care plan was developed on locomotion (how resident moves between locations) for one (1) of two (2) sampled residents (Resident 1) as indicated on the Minimum Data Set (MDS, a standardized assessment and care-screening tool) and the facility ' s care plan policy. This deficient practice has the potential to not provide specific intervention for the resident ' s care which could lead to deterioration in functional ability, falls and injury. Findings: A review of Resident 1's admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems) and history of falling. A review of Resident 1's History and Physical (H&P), dated 6/22/23, indicated Resident 1 does not have the capacity to understand and make decisions. A review of Resident 1's MDS, dated [DATE], indicated the resident had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding). The MDS also indicated Resident 1 required extensive assistance (resident involved in activity, staff provide weight bearing support) using one-person physical assist with bed mobility, transfer, locomotion on and off unit, dressing, toilet use, and personal hygiene. A review of Resident 1 ' s Care Plan, initiated 5/4/23, indicated Resident 1 was at risk for decreased ability to perform Activities of Daily Living (ADL). The staff interventions included were to provide Resident 1 extensive assistance with bed mobility, transfer, toileting, dressing, personal hygiene, and bathing. The care plan did not indicate nursing interventions related to locomotion. During an interview on 6/23/23 at 10:15 AM, Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 required assistance with transfers from bed to wheelchair and with locomotion. During an interview on 6/23/23 at 2:19 PM, CNA 2 stated Resident 1 was at risk for fall and required assistance with ADL. During a concurrent record review of Resident 1 ' s care plan and interview on 6/23/23 at 3 PM, LVN 1 stated Resident 1 had a care plan for ADLs but did not have one indicated for locomotion. LVN 1 stated care plans are necessary and are used as a guide for nurses on what specific care interventions to provide to the residents. During an interview on 6/23/23 at 4:50 PM, the DON stated that Resident 1 ' s fall would have been prevented if the care plan were initiated and implemented based on Resident 1 ' s MDS ADL assessment. A review of the facility ' s policy and procedure titled, Care Planning - Interdisciplinary Team, dated 8/25/21, indicated the facility interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. The policy also indicated that the comprehensive care plan for each resident is developed within seven (7) days of the comprehensive assessment. A review of the facility ' s policy and procedure titled, Care Planning - Interdisciplinary Team, dated 8/25/21, indicated the facility interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident. The policy also indicated that the comprehensive care plan for each resident is developed within seven (7) days of the comprehensive assessment.

CONCERN (D) 📢 Someone Reported This

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

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

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide supervision for one (1) of two (2) sampled residents (Resident 1) who was assessed as high risk for falls by not closely monitoring residents ' location and not keeping the resident within staff ' s visual range as indicated on the care plan. This deficient practice resulted to a repeated fall on 6/7/23 and had the potential to result in fall reoccurrence and injury. Findings: A review of Resident 1's admission Record indicated the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems) and history of falling. A review of Resident 1's MDS, dated [DATE], indicated the resident had severely impaired cognitive skills (mental action or process of acquiring knowledge and understanding). The MDS also indicated Resident 1 required extensive assistance (resident involved in activity, staff provide weight bearing support) using one-person physical assist with bed mobility, transfer, locomotion on and off unit, dressing, toilet use, and personal hygiene. A review of Resident 1 ' s Care Plan, initiated on 6/4/23 and revised on 6/9/23, indicated Resident 1 had an actual fall on 6/4/23 when she attempted to grab a room door and fell forward from her seat. The care plan also indicated Resident 1 had another fall on 6/7/23 near the employee lounge and Station 2, which resulted to right hand pain and discoloration. The care plan interventions included were to conduct frequent visual checks, keep Resident 1 within staff ' s visual range, and to redirect Resident 1 to resident care area for visual monitoring. A review of Resident 1 ' s Nursing Documentation Evaluation, dated 6/5/23, included history of falls within six months, poor safety judgement, impaired balance, required assistance for toileting, and unsteady gait as fall risk factors. A review of the facility ' s form titled, Task List Report for Certified Nursing Assistant (CNA), dated 6/5/23, included keeping Resident 1 within the staff ' s visual range for monitoring by redirecting Resident 1 to resident care areas for visual monitoring. During an interview on 6/23/23 at 3:20 PM, the Director of Nursing (DON) stated the CNAs were made aware of Resident 1 ' s task list report which was for Resident 1 to be kept within the staff ' s visual range for monitoring. The DON stated, this meant that Resident 1 should be in a resident care area where she is visible to the staff. The DON also stated during Resident 1 ' s second incident of fall, Resident 1 was not within staff ' s visual range since the CNA and 2 LVN ' s were all in other residents ' rooms. During an interview on 6/23/23 at 3:40 PM, Resident 3 stated there were no staff around when she saw Resident 1 came by from another station with her wheelchair. Resident 3 stated, I saw Resident 1 try to grab a paper from the floor and then fell over on her right side in front of where she was. During an interview on 6/23/23 at 4:50 PM, the DON stated that Resident 1 ' s fall on 6/4/23 and 6/7/23 would have been prevented if the care plan interventions were implemented. The DON stated Resident 1 should have received extensive assistance during locomotion as indicated on the MDS. A review of the facility ' s policy and procedure titled, Fall Management, dated 5/26/21, indicated its purpose was to reduce risk for falls and minimize the actual occurrence of falls. The policy also indicated those patients determined to be at risk for falls will receive appropriate interventions to reduce risk and minimize injury.

May 2023 2 deficiencies 2 IJ

CRITICAL (J) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Free from Abuse/Neglect (Tag F0600)

Someone could have died · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) free from physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish). Resident 2, who had behavioral issues, hit Resident 1 on the face and head on [DATE] in Resident 1 and 2's room. The facility did not identify, assess, and implement interventions to address Resident 2's behavior, mood, and cognitive (the ability to clearly think, learn, and remember) status prior to Resident 2 hitting Resident 1 on the face. In addition, the facility failed to protect Resident 1 when Resident 3 reported to Licensed Vocational Nurse 2 (LVN 2) about Resident 2's behavioral issues and requested for Resident 2 to be transferred to another room on several occasions prior to [DATE]. Residents 1, 2, and 3 remained in the same room up to [DATE]. These deficient practices resulted in Resident 1 to experience physical abuse. Resident 1 was found unconscious on [DATE] at 7 AM, 6.5 hours after the resident was hit on the face and head by Resident 2. Resident 1 was then transferred to the General Acute Care Hospital (GACH) via 911 (a number to contact emergency services) was called. According to GACH records, Resident 1 had a large right subdural hematoma (collection of blood outside the brain) measuring up to 3.7 centimeters (cm, unit of measurement) and was comatose (state of deep unconsciousness for a prolonged period) upon arrival to the GACH. Resident 1 died on [DATE] in the GACH with diagnoses that included large subdural hemorrhage (a pool of blood between the brain and its outermost covering), neurogenic shock (a life-threatening medical condition in which there is insufficient blood flow throughout the body), and brain death (permanent, irreversible, and complete loss of brain function). This deficient practice also placed Resident 3 and other resident in the facility at risk of being physically abused by Resident 2. On [DATE] at 8:03 PM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Assistant Administrator (AADM), Director of Nursing (DON), Director of Staff Development (DSD), and Medical Records Director (MRD) regarding the facility's failure to: 1. Protect Resident 1's rights to be free from physical abuse when Resident 2, who had behavioral issues, hit Resident 1 on the face and head during a resident-to-resident altercation (confrontation or aggression that may result in injury) that happened on [DATE] in Resident 1 and 2's room. 2. Prevent Resident 2 from physically abusing Resident 1, who was assessed as needing extensive assistance in bed mobility and unable to walk, when the facility did not identify, assess, and implement interventions to address Resident 2's behavior, mood, and cognitive status that could place other residents at risk for abuse. 3. Identify and implement intervention when Resident 3 reported to LVN 2 about Resident 2's behavioral issues and request for Resident 2 to be transferred to another room, prior to [DATE]. In addition, Resident 1, 2, and 3 remained in the same room up to [DATE] that led to Resident 1 and 2's altercation on [DATE]. On [DATE] at 7:24 om, the IJ was removed after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practices). The surveyor verified and confirmed the implementation of the Plan of Action (POA) while onsite by observation, interview, and record review. The IJ was removed in the presence of the AADM, and DON. The acceptable IJ Removal Plan included the following: a. Resident 1 was discharged to acute hospital via 911 on [DATE] for further evaluation. b. The DON/Quality Assurance (QA) Educator initiated the following: - In-service and skills competency validation initiated on [DATE] by DON or designee to Licensed Nurses regarding timely neurological assessment (to check the mental status, reflexes [automatic action the body does in response to anything that can trigger a physical or behavioral change], and movement to evaluate the brain and nervous system [transmits signals between the brain and the rest of the body]) to include checking of patterns of speech, speech clarity, gag reflex (occurs in the back of the mouth and triggered when the body wants to protect itself from swallowing something), facial drooping (loss of motor control on one side of the face resulting in muscle weakness on one side of the mouth with inability to smile symmetrically [exact match]), and eye opening, verbal, and motor responses using Glasgow Coma scale (GCS, used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma residents). On [DATE], QA Educator initiated the skills competency validation of Licensed Nurses regarding timely neurological assessment and completion of Neurological evaluation flow sheet. - In-service on timely physician (MD) notification and documentation of reasons for refusals of neurological assessment and /or abnormal findings. c. The DON reviewed residents with change of condition (COC) necessitating neurological assessment such as unwitnessed fall and resident to resident altercation in the last 30 days. The DON and MRD identified seven (7) residents that were on neurological assessment status post fall incident with incomplete documentation/assessment. Identified Licensed Nurses who did not complete the neurologic assessment were given one to one (1:1) in-service regarding the importance of neurological assessment. The Licensed Nurses completed the COC documentation, updated the care plans, and placed residents on every shift monitoring for 72 hours. These residents have the potential to be affected by the deficient practice. There were no resident-to-resident altercations that have occurred in the last 30 days. d. The Interdisciplinary Team (IDT, means a group of professional and direct care staff that have primary responsibility for the development of a plan for the care and treatment of a patient) will review any COC during the Clinical Meeting (team members review and discuss information and make recommendations that are relevant to the patient's needs) from Monday to Friday. e. Any COC requiring neurological assessment will be evaluated by the DON or designee for timeliness and compliance with facility's policy pertaining to neurological assessment. f. The MRD will complete a neurological assessment audit, COC audits for documentation of MD notification and reasons for resident refusals and report findings to DON /designee for immediate corrective action. daily, from Monday to Friday. g. Neurological assessment skills competency will be provided by the DON/designee during Licensed Nurses' orientation and will be validated annually and as needed. h. On [DATE], Neurological Evaluation Flowsheet was revised based on Neurological Assessment Policy provided during survey. The DON/QA Educator will initiate education, training, and skills competency on the revised Neurological Flow Sheet to Licensed Nurses starting on [DATE]. The DON/designee will complete the education, training, and skills validation of Licensed Nurses till 100 percent (%) completion is achieved. The DON/designee will evaluate the effectiveness of skills validation weekly through return demonstration for four (4) weeks. Newly hired Licensed Nurses will receive the same education, training, and skills validation and these will be included in the Licensed Nurses' annual skills competency. i. This process will be monitored by completing the following tasks: -The QA committee will continue to review the alleged deficient practice monthly or as often as deemed necessary based on observed trends and patterns of Neurological Evaluation Flowsheet completion, COC audits and compliance. - The QA committee will make recommendations to extend if deemed necessary based on patterns. j. Resident 1 was discharged to acute hospital on [DATE] via 911 for further evaluation. k. Resident 2 was discharged to acute hospital on [DATE] for further psychiatric (branch of medicine concerned with the study, diagnosis, and treatment of mental illness) evaluation. l. Resident 3 was interviewed by AADM and MRD on [DATE]. AADM and MRD conducted a Person Centered Interview and Rounding Worksheet. Resident 3 did not express any concerns at this time. m. Staff were in-serviced by DSD, QA Educator and /or DON on [DATE] and [DATE] regarding the following: m.1. Abuse reporting and investigation with an emphasis on roommate compatibility and a thorough investigation of alleged abuse. QA Educator will conduct a follow up education and training skills competency validation pertaining to Abuse reporting and investigation to staff. m.2. Roommate compatibility and timely response to residents' concerns and/or request for room change. m.3. Any change in residents' behavior will be addressed immediately by licensed nurse by initiating a change of condition, escalation of care plan interventions, involvement of psychiatrist, psychologist (person who specializes in the study of the mind and behavior), attending physician, appropriate room placement and medication regimen review. Any allegation of abuse will be investigated immediately and reported within two hours to California Department of Public Health (CDPH), Ombudsman (official who is usually appointed by the government to investigate complaints and attempt to resolve them) and law enforcement. n. Employees that are currently on vacation (17 employees identified) or on leave, will be educated by the DSD and/or Designee regarding the above topics prior to the start of their next shift. o. MD was notified by AADM on [DATE] regarding facility receiving an IJ. Medical Director stated to keep him informed regarding the facility's plan of correction. p. An emergency QAA Committee meeting was conducted on [DATE] with Medical Director, AADM, DON, Activities Director, Medical Records Director, RN Supervisor and Clinical Support. q. Person Centered Interview and Rounding Worksheets were conducted on [DATE] and [DATE] by Department Managers (Activity Director, admission Director, Marketing, Dietary Manager, Business office assistant, Central Supply, Social Service Assistant) with 69 interviewable residents as identified based on Resident Responses Analyzer generated from the facility's computer system regarding roommate compatibility to ensure in house residents were compatible with one another in their current rooms. No concerns were identified during the Person-Centered Interview and Rounding Worksheets. Department Managers will continue to conduct Person Centered Interview and Rounding Worksheet daily from Monday through Friday to identify and address any issues related to roommate compatibility. On weekends, Activity Assistant, Manager of the Day, and Licensed Nurses will conduct Person Centered Interview and Rounding Worksheet. Licensed Nurses will observe and document residents' condition with recent room change every shift for 72 hours and will initiate a COC. Licensed Nurse will include COC on the progress note if indicated. If not indicated, Licensed Nurse will complete a Room Transfer/New Roommate Change form. r. An audit on the most recent room transfer/room change in the last seven (7) days was completed on [DATE] and there were no issues/concerns reported. s. On [DATE], all interviewable residents were queried (asked) by Social Services Assistant, Central Supply, and Dietary Supervisor regarding any recently witnessed or experienced altercations with other residents and no residents expressed any concerns at this time. t. On [DATE], IDT identified and reviewed residents with psychiatric diagnosis, including dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and Alzheimer's disease (type of dementia) and residents who were on monitoring for behavioral manifestations that may potentially affect others to ensure that appropriate care plan was implemented. IDT identified 10 residents that exhibited verbal and physical behaviors that may potentially affect others. IDT care conference was initiated on [DATE] to address behavioral problems and collaborate with psychiatrist, psychologist, and attending physician for further evaluation and treatment. Psychiatrist scheduled to conduct evaluation on [DATE] on the 10 residents identified. u. All allegations of abuse will be thoroughly investigated by the facility Abuse Coordinator. Room compatibility and any request for room change will be discussed by the IDT members Monday through Friday during stand-up meeting. Licensed Nurses will monitor, and document appropriateness of room change every shift for the next 72 hours. The DON/designee initiated an in-service to Licensed Nurses on [DATE] regarding the use of Person centered interview and Rounding Worksheet. The DON/designee will continue to in-service until completed. v. The AADM initiated an in-service on [DATE] regarding the use of Person Centered Interview and Rounding Worksheet to the department managers. w. Potential new admissions will be reviewed by the DON/Designee and will collaborate with IDT prior to admission for appropriate room placement and roommate compatibility. Department Managers will meet with assigned residents daily from Monday to Friday. Assigned Licensed Nurses, Manager of the day, and Activity assistant will conduct Person Centered Interview and Rounding Worksheet on weekends. Any signs of incompatibility will be addressed immediately for corrective action. x. This process will be monitored by completing the following tasks: The QA committee will continue to review the alleged deficient practice monthly and/or as deemed necessary for further recommendations and corrective actions until no issues are identified. The QA committee will make recommendations to extend if deemed necessary based on findings, patterns and trends reported. Findings: On [DATE], an unannounced abbreviated survey was conducted at the facility to conduct an investigation of a facility reported incident about resident- to- resident abuse. A review of Resident 1's admission Record indicated an initial admission to the facility on [DATE] and readmission on [DATE]. Resident 1's diagnoses included end stage renal disease (a medical condition in which a resident's kidneys stop functioning on a permanent basis leading to the need for a regular course of long-term dialysis [a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly] or a kidney transplant to maintain life), dependence on renal dialysis, generalized muscle weakness and abnormalities of gait and mobility. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated [DATE], indicated Resident 1 was independent with cognitive (the ability to clearly think, learn, and remember) skills for daily decision making. Resident 1 was totally dependent (full staff performance) with one person for bed mobility, transfer, dressing, toilet use and personal hygiene. A review of Resident 2's admission Record indicated an initial admission to the facility on [DATE] and readmission on [DATE]. Resident 2's diagnoses included dementia, without behavioral disturbance, psychotic disturbance (severe mental disorders that cause abnormal thinking and perceptions), mood disturbance (feelings of distress or sadness) and anxiety (feeling of fear, dread, and uneasiness). A review of Resident 2's MDS, dated [DATE], indicated Resident 2 was severely impaired with cognitive skills for daily decision making. Resident 2 was totally dependent with one- person assist for bed mobility, transfer, dressing, toilet use and personal hygiene. A review of Resident 3's admission Record indicated admission to the facility on [DATE]. Resident 3's diagnoses included right above knee amputation and muscle weakness. A review of Resident 3's MDS's dated [DATE], indicated Resident 3 had an intact cognitive skill for daily decision making. Resident 3 required limited assistance (staff provide guided maneuvering) with one-person assist for bed mobility, transfer, dressing, and toilet use and personal hygiene. A review of Resident 1's Nurses' Note, dated [DATE] at 1:30 AM, indicated Resident 1 was in bed when Resident 2 came up to him and tried to take his jacket. Resident 1 refused so Resident 2 hit him on the left side of his face. Licensed Vocational Nurse 1 (LVN 1) indicated neurological check (assess an individual's neurological functions, motor and sensory response, and level of consciousness) was started. A review of Resident 2's Nurses' Note, dated [DATE] entered at 4:06 AM, Resident 2 went up to Resident 1, and tried to take his jacket but Resident 1 resisted so Resident 2 hit him on the left side of his face. A review of Resident 1's Nurses' Note, dated [DATE], entered at 7 AM, Registered Nurse 1 (RN 1) indicated that Resident 1 was found unresponsive, respiration even and unlabored. Resident 1's oxygen saturation (amount of oxygen that's circulating in the blood) at 87% (normal level is between 95% and 100%), on room air. 911 was called and was transferred to GACH. During a concurrent interview with RN 2 and review of Resident 1's medical records on [DATE] at 5:20 PM, RN 2 verified that there was no behavior monitoring and interventions done to address Resident 2's behavior prior to the altercation between Resident 1 and 2 on [DATE]. RN 2 stated Resident 2 should have been moved out of the room and be placed in a single room after the altercation, to protect Resident 1 and prevent another resident- to- resident altercation. During an interview on [DATE], at 11:07 AM, the DSD stated, Resident 2 was very confused and would sometimes enter other residents' rooms and needs to be redirected back to his room. During an interview on [DATE], at 3:25 PM, LVN 1 stated on [DATE] at 1:30 AM one of the CNAs (unable to recall who) told him Resident 1 told CNA about the hitting. LVN 1 stated, she went into Resident 1's room and Resident 1 told her Resident 2 hit him on the head and face with Resident 2's right hand. During an interview on [DATE], at 3:29 PM, Resident 4 (witness of Resident 2's aggressive behavior) stated on [DATE] (five days prior to the altercation between Resident 1 and 2) Resident 2 had previously pushed Resident 3 with clenched hands. Resident 4 stated Resident 3 grabbed his grabber reacher (a tool that works as an extension of the arm) to block Resident 2. Resident 4 stated, he and Resident 3 were aware Resident 2 was unstable and could snap any time. Resident 4 stated Resident 3 notified the facility staff that Resident 2 was unstable, but facility staff did not listen and did not do anything. During an interview on [DATE], at 4:28 PM, Certified Nurse Assistant 1 (CNA 1) stated Resident 1 had redness on the left side of his face by the temple (located on the side of the head behind the eye between the forehead and the ear) area. CNA 1 stated on [DATE], approximately at 5:30 AM, CNA1 noticed something was off with Resident 1 and that Resident 1 was in a deep sleep. CNA1 stated she patted Resident 1 on his chest but was not arousable, so she called LVN1 who assessed Resident 1. CNA1 stated Resident 1 continued to have redness on the left side of his face. CNA1 stated LVN1 was aware of Resident 1's facial redness. During an interview on [DATE], at 6:08 PM, LVN3 stated Resident 2 was confused and required supervision. LVN3 stated Resident 2 would enter other residents' rooms and needed to be redirected back to his room. LVN3 stated on [DATE], two days prior to the altercation between Residents 1 and 2, Resident 2 entered an unnamed resident's room trying to take the residents wheelchair. LVN3 stated Resident 3 would complain about Resident 2 going through Resident 3's belongings. LVN3 stated she had informed the DON on more than one (1) occasion about Resident 2's behavior of wandering into another resident's room and going through other resident's belongings but the DON did not want to move Resident 2. A record review Resident 1's untitled GACH records, dated [DATE], indicated Resident 1 had a large right subdural hematoma measuring up to 3.7 cm and was comatose upon arrival to the GACH. A record review of Resident 1's untitled GACH records, dated [DATE], indicated Resident 1 died on [DATE] with diagnoses that included large subdural hemorrhage, neurogenic shock, and brain death. A review of the facility's policies and procedures titled, Abuse Prohibition and Procedure, dated [DATE], indicated if the suspected abuse is resident to resident, the resident who has in any way threatened or attacked another will be removed from the setting or situation and an investigation will be completed. The policy also indicated the facility is responsible for identifying residents who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation.

CRITICAL (J) 📢 Someone Reported This

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

Immediate Jeopardy (IJ) - the most serious Medicare violation

Deficiency F0658 (Tag F0658)

Someone could have died · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide treatment and services for one of two sampled Residents (Resident 1), after being hit on the face and head, in accordance with current professional standard of practice by failing to: 1. Conduct a neurological assessment (to check the mental status, reflexes [automatic action the body does in response to anything that can trigger a physical or behavioral change], and movement to evaluate the brain and nervous system [transmits signals between the brain and the rest of the body]) to include checking of patterns of speech, speech clarity, gag reflex (occurs in the back of the mouth and triggered when the body wants to protect itself from swallowing something), facial drooping (loss of motor control on one side of the face resulting in muscle weakness on one side of the mouth with inability to smile symmetrically [exact match]), and eye opening, verbal, and motor responses using Glasgow Coma scale (GCS, used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma residents) on [DATE] in accordance with the facility's policy on Neurological Assessment. 2. Identify changes in Resident 1's neurological status. 3. Document Resident 1's reason/s for refusing Neurological assessment on [DATE] at 4:30 AM and 5AM and interventions taken by facility staff after refusal. These deficient practices resulted in Resident 1 being found unconscious on [DATE] at 7 AM, 6.5 hours after the resident was hit on the face and head by Resident 2, with an oxygen saturation (level of oxygen in the blood) of 87% (normal level 90-100%). Resident 1 was then transferred to the General Acute Care Hospital (GACH) via 911 (a number to contact emergency services) was called. According to GACH records, Resident 1's pupils were fixed and pinpoint upon arrival to the GACH. Resident 1 had a large right subdural hematoma (collection of blood outside the brain) measuring up to 3.7 centimeters (cm, unit of measurement), and was comatose (state of deep unconsciousness for a prolonged period). Resident 1 expired on [DATE] in the GACH with diagnoses that included large subdural hemorrhage (a pool of blood between the brain and its outermost covering.), neurogenic shock (a life-threatening medical condition in which there is insufficient blood flow throughout the body), and brain death (permanent, irreversible, and complete loss of brain function). On [DATE] at 8:06 PM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified in the presence of the facility's Assistant Administrator (AADM), Director of Nursing (DON), Director of Staff Development (DSD), and Medical Records Director (MRD) regarding the facility's failure to: 1. Conduct Neurological assessment to include checking of patterns of speech, speech clarity, gag reflex, facial drooping, and eye opening, verbal, and motor responses using Glasgow Coma scale on [DATE] initiated at 1:30 AM in accordance with the facility's policy on Neurological Assessment. 2. Conduct neurological assessment on [DATE] from 5:30 AM to 7AM to identify changes in Resident 1's neurological status. 3. Document Resident 1's reason/s for refusing Neurological assessment on [DATE] at 4:30 AM and 5AM and interventions taken after refusal. On [DATE] at 7:24 PM, the IJ was removed after the facility submitted an acceptable IJ Removal Plan (interventions to correct the deficient practices). The surveyor verified and confirmed the implementation of the Plan of Action (POA) while onsite by observation, interview, and record review. The IJ was removed in the presence of the AADM, and DON. The acceptable IJ Removal Plan included the following: a. Resident 1 was discharged to acute hospital via 911 on [DATE] for further evaluation. b. DON/Quality Assurance (QA) Educator initiated the following: - In-service and skills competency validation initiated on [DATE] by DON or designee to Licensed Nurses regarding timely neurological assessment, to include checking of patterns of speech, speech clarity, gag reflux, facial drooping, and eye opening, verbal, and motor responses using Glasgow Coma scale. On [DATE], QA Educator initiated the skills competency validation of Licensed Nurses regarding timely neurological assessment and completion of Neurological Evaluation Flowsheet. - In-service on timely physician (MD) notification and documentation of reasons for refusals of neurological assessment and /or abnormal findings. c. The DON reviewed residents with change of condition (COC) necessitating neurological assessment such as unwitnessed fall and resident to resident altercation (confrontation or aggression that may result in injury) in the last 30 days. The DON and MRD identified seven (7) residents that were on neurological assessment status post fall incident with incomplete documentation/assessment. Identified Licensed Nurses who did not complete the neurologic assessment were given one to one (1:1) in-service regarding the importance of neurological assessment. The Licensed Nurses completed the COC documentation, updated the care plans, and placed residents on every shift monitoring for 72 hours. These residents have the potential to be affected by the deficient practice. There were no resident-to-resident altercations that have occurred in the last 30 days. d. The Interdisciplinary Team (IDT, a group of professional and direct care staff that have primary responsibility for the development of a plan for the care and treatment of a resident) will review any COC during the Clinical Meeting (team members review and discuss information and make recommendations that are relevant to the resident's needs) from Monday to Friday. e. Any COC requiring neurological assessment will be evaluated by the DON or designee for timeliness and compliance with facility's policy pertaining to neurological assessment. f. The MRD will complete a neurological assessment audit, COC audits for documentation of MD notification and reasons for resident refusals and report findings to DON /designee for immediate corrective action. daily, from Monday to Friday. g. Neurological assessment skills competency will be provided by the DON/designee during Licensed Nurses' orientation and will be validated annually and as needed. h. On [DATE], the Neurological Evaluation Flowsheet was revised based on Neurological Assessment Policy provided during survey. The DON/QA Educator will initiate education, training, and skills competency on the revised Neurological Evaluation Flowsheet to Licensed Nurses starting on [DATE]. The DON/designee will complete the education, training and skills validation of Licensed Nurses till 100 percent (%) completion is achieved. The DON/designee will evaluate the effectiveness of skills validation weekly through return demonstration for four (4) weeks. Newly hired Licensed Nurses will receive the same education, training and skills validation and these will be included in the Licensed Nurses' annual skills competency. i. This process will be monitored by completing the following tasks: -The QA committee will continue to review the alleged deficient practice monthly or as often as deemed necessary based on observed trends and patterns of neurological flowsheet completion, COC audits and compliance. - The QA committee will make recommendations to extend if deemed necessary based on patterns. Findings: A review of Resident 1's admission Record indicated an initial admission to the facility on [DATE] and readmission on [DATE]. Resident 1's diagnoses included end stage renal disease (a medical condition in which a resident's kidneys stop functioning on a permanent basis leading to the need for a regular course of long-term dialysis [a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly] or a kidney transplant to maintain life), dependence on renal dialysis, generalized muscle weakness and abnormalities of gait and mobility. A review of Resident 1's Minimum Data Set (MDS, a standardized assessment and care planning screening tool), dated [DATE], indicated Resident 1 was independent with cognitive (the ability to clearly think, learn, and remember) skills for daily decision making. Resident 1 was totally dependent (full staff performance) with one person for bed mobility, transfer, dressing, toilet use and personal hygiene. A review of Resident 1's Nurse's Note, dated [DATE], timed at 1:30 AM, indicated Resident 2 hit Resident 1's left side of the face. A neurological assessment was initiated by LVN 1. A review of Resident 1's Neurological Evaluation Flowsheet indicated a neurological assessment was completed for Resident 1 on [DATE] at 1:30 AM, 1:45 AM, 2AM, 2:15 AM, 2:30 AM, 2:45 AM, 3AM, 3:15 AM, 3:30 AM, and 4AM. At 4:30 AM and 5AM, it was documented that Resident 1 refused the neurological assessment. The Neurological Evaluation Flowsheets did not include an assessment for patterns of speech, speech clarity, gag reflex, facial drooping, and GCS, as indicated on the facility policy. A review of Resident 1's Nurses' Note, dated [DATE], timed at 8:55 AM, indicated Registered Nurse 1 (RN 1) found Resident 1 unresponsive with oxygen saturation at 87% at 7AM. 911 was called and Resident 1 was transferred to GACH. During a concurrent interview with Licensed Vocational Nurse 5 (LVN 5) and record review of the Neurological Evaluation Flowsheet on [DATE] at 3:15 PM, LVN 5 verified that the Neurological Evaluation Flowsheet for Resident 1 indicated that there was no neurological assessment conducted on [DATE] from 5:30 AM to 6:30 AM. LVN 5 stated that it should have been done every 30 mins as indicated on the flowsheet. LVN 5 added it was important to follow the instructions on the frequency of assessment as indicated on the Neurological Evaluation Flowsheet form to ensure whether the resident needs emergency medical treatment after a head injury. During a concurrent interview with RN1 and record review of Resident 1's Neurological Evaluation Flowsheet on [DATE] at 4:10 PM, RN 1 validated that Resident 1 did not have a neurological assessment at 5:30 AM to 6:30 AM. The last vital signs obtained for Resident 1 were at 4AM. RN 1 stated it was important to check and follow time intervals indicated in the Neurological Evaluation Flowsheet to assess if there was a change in Resident 1's condition. RN1 stated a neurological assessment must be conducted to monitor any head injury, bleeding, or swelling to the brain or any change in a resident's level of consciousness. During a concurrent interview with RN 2 and record review of Resident 1's Order Summary Report on [DATE] at 5:20 PM, RN 2 verified that there was no order for a neurological assessment to be conducted for Resident 1. RN 2 stated a physician order should have been obtained based on the facility policy on Neurological Assessment. RN 2 also verified that Resident 1 refused the neurological assessment on [DATE] at 4:30 AM and 5AM as indicated on the flowsheet. RN 2 stated LVN 1 should have notified MD when Resident 1 refused the assessment. During an interview with the DSD on [DATE], at 10:58 AM, the DSD stated neurological assessment or neuro check was conducted to assess if residents were alert and oriented after a head injury. The DSD stated neuro check should include assessing resident's pattern of speech, speech clarity, gag reflex, facial drooping, and use of GCS, which are in accordance with the facility policy. The DSD stated when a resident refuses a neuro check, intervention included was to call for another nurse to conduct the assessment. The DSD stated the reason for resident's refusal and any additional interventions taken by the staff should be documented on the Resident's clinical record. During an interview on [DATE], at 11:23 AM, LVN 4 stated on [DATE] at 7AM, LVN 4 found Resident 1 unresponsive. LVN 4 stated Resident 1 did not regain consciousness and was transported via 911 to GACH. LVN 4 stated when a resident refuses neuro check, the LN should document the refusal and implement other interventions such as explaining to the resident why the assessment needs to be conducted and to have another nurse assist and perform the neuro check. During a concurrent interview with RN 2 and record review of Resident 1's Neurological Evaluation Flowsheet on [DATE], at 1:14 PM, RN2 stated, Resident 1 was on neurocheck due to an abuse allegation of being hit on the face by Resident 2. RN2 stated a neuro check was done using the Neurological Evaluation Flowsheet to assess level of consciousness and orientation of the resident. RN2 stated there was no indication on the flowsheet to assess facial drooping. RN2 stated the neurological assessment performed was only based on the specific information on the flowsheet. RN2 stated the Neurological Evaluation Flowsheet did not indicate other assessments such as gag reflex and utilization of the GCS, so they were not done. During a concurrent interview with RN 2 and record review of Resident 1's Nurses Progress Notes on [DATE], at 1:29 PM, RN2 stated there were no interventions done and documented to address Resident 1's refusal for neuro check. During a telephone interview on [DATE], at 3:25 PM, LVN 1 stated that she started Resident 1's neuro check after it was reported that Resident 1 was hit on the face. LVN 1 stated, she checked Resident 1's pupil reaction, hand grip, and if able to respond to questions. LVN 1 further stated, Resident 1 refused neuro check because he asked me to stop and was getting tired and sleepy. A review of the facility's policy titled, Neurological assessment, revised 10/2010 indicated the purpose of this procedure was to provide guidelines for a neurological assessment: General Guidelines included: 1. Neurological assessments are indicated: a. Upon physician order. b. Following an unwitnessed fall. c. Following a fall or other accident/injury involving head trauma. d. or when indicated by resident's condition. 2. When assessing neurological status, always include frequent vital signs. Particular attention should be paid to widening pulse pressure (difference between systolic and diastolic pressures [represents the force that the heart generates each time it contracts]). This may be indicative of increasing intracranial pressure (ICP, growing pressure inside the skull when there is brain injury). 3. Any change in vital signs or /neurological status in a previously stable resident should be reported to the physician immediately. Steps in the Procedure 1. Perform neurological checks with the frequency as ordered or per falls protocol. 2. Determine resident's orientation to time, place and person. 3. Observe resident's patterns of speech and speech clarity. 4. Take temperature, pulse, respirations, blood pressure. 5. Check pupil reaction: 6. Determine motor ability: 7. Have resident move all extremities. 8. Ask resident to squeeze your fingers. Note strength bilaterally. 9. Have resident plantar and dorsiflex. Note strength bilaterally. Ask resident if he/she has any numbness or tingling in legs/feet/toes and document accordingly. 10. Determine sensation in extremities. Rub resident's arms at the same time to see if resident has decreased sensation in either arm. Check sensation in lower extremities also and document accordingly. 11. Check gag reflex with tongue depressor, if safe for resident. 12. Have the resident smile to determine if there is any facial drooping and document accordingly. 13. Check eye opening, verbal, and motor responses using the Glasgow Coma Scale. Record observations. Documentation: The following information should be recorded in the resident's medical record: 1. The date and time the procedure was performed. 2. The name and title of the individual(s) who performed the procedure. 3. All assessment data obtained during the procedure. 4. How the resident tolerated the procedure. 5. If the resident refused the procedure, the reason(s) why and the intervention taken. 6. The signature and title of the person recording the data. Reporting 1. Notify the physician of any change in a resident's neurological status. 2. Notify the supervisor if the resident refuses the procedure. 3. Report other information in accordance with facility policy and professional standards of practice.

May 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

Accident Prevention (Tag F0689)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide adequate supervision and assistive device to prevent accidents for one of two sampled residents (Resident 1) by failing to provide a functional wander guard (a monitoring device used to help ensure safety for residents. Safety then depends upon the ensuring the alarm is activated and staff respond to the alarm when a resident attempts to leave a safe area or certain distance from an exit door) to prevent elopement (leaving a facility without notice or without the facility staff knowledge) and to monitor functionality of the wander guard system per manufactures guidelines. This deficient practice resulted to Resident 1 leaving the facility unsupervised on 3/24/23 and 3/25/23 which can lead into serious injury and/ or death of the resident. Findings: A review of Resident 1's Face Sheet indicated Resident 1 was originally admitted to the facility on [DATE] with a readmission date of 3/15/23 with diagnoses of congenital malformation of brain (a group of brain defects or disorders that develop in the womb and are present at birth), dementia (a term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) without behavioral disturbances, psychotic disturbances, mood disturbances, anxiety. A review of Resident 1's History and Physical (H and P) dated 3/21/23 indicated the resident had fluctuating capacity to understand and make decisions. A review of Resident 1's Minimum Data Set (MDS- a care area screening and assessment tool) dated 3/22/23, indicated the Resident 1 had severe cognitive impairment (ability to think and make decisions). The MDS indicated Resident 1 required supervision (oversight, encouragement, or cueing) with set up for bed mobility, transfers, locomotion, and eating. Resident 1 required limited assistance (resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight bearing assistance) with one-person physical assist for dressing and personal hygiene. A review of Resident 1's Physician Order dated 3/22/23 indicated Resident 1 may use wander guard for safety due to poor safety awareness, monitor for placement and function every shift. A review of Resident 1's Care Plan for Elopement risk/Wandering episode, dated 03/22/2023, indicated Resident 1' will not attempt to leave the facility without accompanied until next review. The care plan indicated the following interventions: a. Charge nurses monitor for placement and functioning of wander guard every shift. b. Notified MD, apply wander guar alarm to right arm as order A review of Resident 1's Care Plan for Resident has actual elopement, dated 3/24/23, indicated Resident 1 has made one or more attempts to leave facility during this stay-Poor cognition due to dementia. The care plan included the intervention to utilize and monitor wander guard per protocol. A review of the facility's five (5)- day follow up report dated 3/28/23, indicated an investigation to the elopement determined Resident 1 was able to elope from the facility once through a manually key activated system door on 3/24/23 and then elope for the second time on 3/25/23 through the lobby entrance or exit. During an interview with the Director of Nursing (DON) on 4/11/23 at 10:47 AM, The DON stated the wander guard system, was located at the facility's front door and side door. The DON stated facility Maintenance supervisor (MS)1 was responsible for testing the functionality of the wander guard system. The DON stated Resident 1 had eloped from facility on two separate occasion the first on 3/24/23 and then again on 3/25/23. The DON stated both times Resident 1 eloped from facility he was wearing a wander guard bracelet but was not sure if it was functional. During an interview with Regional Maintenance Supervisor (RMS) on 4/11/23 at 2:37 PM, RMS 1 stated he will come to facility and complete a walk though check of the wander guard system with facility MS 1. RMS 1 stated MS 1 will hold a wander guard bracelet used for testing the door system on hand and walk through the doors. RMS 1 stated that is the only way he has observed MS 1 testing door wander guard system. RMS 1 stated he has never observed MS 1 placing the wander guard on foot or above head. RMS 1 stated he was not aware of the manufacturer's guideline of Maintenance nine (9)- point test (process of testing the functionality of the wander guard system) for testing wander guard system. RMS 1 stated the manufacturer's guideline for the maintenance 9- point test was not followed by MS 1 when testing for the functionality of the wander guard system. During a telephone interview with MS 1 on 4/17/23, MS 1 stated the wander guard system, was located at the facility's front door (Door 1) and side door (Door 2). MS 1 stated he is responsible for testing the wander guard system in the facility by using a tester wander guard tag and passing through Door 1 and Door 2. MS 1 stated he did not measure the distance from the wander guard tag from the wander guard transmitter alarm every time he conducted the test. MS 1 stated he measured the distance from the wander guard system over a year ago and relies on memory when completing his weekly checks of the wander guard alarm system. MS 1 stated he will hold wander guard bracelet on hand and walk through the doors where the wander guard transmitter alarm was placed when testing. MS 1 stated he only holds wander guard bracelet on hand and did not place it in foot or hold up in the air when completing the required maintenance testing of the wander guard system. A review of the wander guard manufacturer's Touch Pad Exit Controller Administrator Guide- Maintenance 9-Point test dated July 2018, indicated to perform a 9-point test in the following procedure: a. Activate a test transmitter b. Stand four (4) feet away from the door c. Following the 9- point check test cycle, hold the transmitter up to the first position. d. Both receivers should pick up the transmitter, but you must have at least one receiver picking up the transmitter and it be indicated on the exit controller. e. Remove the transmitter from the alarm area f. Reset the alarm on the exit controller g. Repeat until all 9 check points have registered successfully h. When done, return the volume level to the customer's settings if they were changed during the testing i. Repeat process for all doors. A review of facility policy titled Maintenance Service with a revision date of December 2009, indicated the Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.

Mar 2023 13 deficiencies

CONCERN (D)

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

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to provide privacy for one of one sampled resident (Resident 11) when the curtain was not fully drawn during resident care, in accordance with the facility policy and procedure. This failure had the potential to affect Resident 11's psychosocial well-being. Findings: A review of Residents 11's admission Records indicated the facility admitted Resident 11 on 5/25/22 with diagnoses including muscle weakness, abnormalities of gait and mobility and dementia (loss of intellectual functioning). A review of the Minimum Data Set (MDS, standardized care and screening tool), dated 22/23/23, indicated Resident 11 was moderately impaired with cognitive (processes of thinking and reasoning) skills for daily decision making. Resident 11 required extensive (resident involved in activity, staff provide weight bearing support) two-person physical assistance with bed mobility, transfer, and one person assist on dressing, toilet use, personal hygiene, and bathing. During observation in Resident 11's room and interview on 3/22/23 at 10:52 AM, Resident 11 was in bed while being cleaned and changed by Certified Nursing Assistant 5 (CNA 5). There were three resident beds occupying Resident 11's room, with a curtain in between each bed. Resident 11's bed was in the middle of the other 2 beds. Resident 11's curtain was observed halfway closed, which left Resident 11 without a full privacy while being changed by CNA 5. During an interview on 3/22/23 at 10:55 AM, Resident 11 stated she wanted the curtain closed all the time when being changed. CNA 5 stated it was important to close the resident's curtain all the way to maintain privacy. CNA 5 stated, Resident 11 need not be exposed, curtain needs to be fully closed. During an interview on 3/22/23 at 11:05 AM, Licensed Vocational Nurse (LVN 5) stated Curtains should be closed all the way to cover the bed to provide privacy to resident. The resident will feel bad. During an interview on 3/23/23 at 10:04 AM, the Director of Nursing (DON) stated curtains should be closed properly for the residents to have full privacy. A review of the facility's policy and procedure titled, Confidentiality of Information and Personal Privacy, revised 10/2017, indicated the facility will strive to protect the resident's privacy regarding his or her personal care.

CONCERN (D) 📢 Someone Reported This

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

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

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its policy and procedure to ensure an allegation of verbal abuse (willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) was reported to the State Licensing Agency (SA) and local law enforcement, within two (2) hours for two of three residents (Resident 30 and Resident 41) after facility staff witnessed Resident 41 called Resident 30 fat ass: and threatened the resident that she will kill her. This deficient practice had the potential to place Resident 30 at risk for further abuse and resulted in a delay in the investigation for the abuse allegation. Findings: A review of Resident 30's admission record (Face sheet), indicated Resident 30 was admitted on [DATE] with a diagnosis that included congestive heart failure (CHF, a condition in which the heart does not pump blood as well as it should), type 2 diabetes mellitus (DM, a condition that affect the way the body processes blood sugar), and morbid obesity (excessive amount of body fat). A review of Resident 30's Minimum Data Set (MDS, a standardized care assessment and care screening tool), dated 10/14/22, the MDS indicated Resident 30's cognitive skills (thought process) was intact and could understand and be understood by others. The MDS indicated Resident 30 required total dependence of staff assistance for bed mobility, transfer (moving between surfaces to and from bed, chair, wheelchair), dressing, eating, personal hygiene and toileting. A review of Resident 30's history and physical (H&P), dated 1/19/23, indicated Resident 30 have the capacity for complex medical decisions. A review of Resident 30's change in condition (COC) dated 3/13/23 entered at 1:31 PM, the COC indicated Resident 30 was in psychological distress because Resident 41 was socially inappropriate and had inappropriate verbal behavior towards Resident 30 on 3/13/23 between 10 AM to 11 AM. COC indicated, Resident 30 stated, she did not like what Resident 41 said to her and would be letting her family know. Resident 30 was also asked if she wanted to talk about it, but resident declined. During a review of Resident 30's nurses progress notes (NPN) dated 3/13/23 entered at 1:56 PM, the NPN indicated facility called the local Police Department ([PD] 1:56 PM, more than 2 hours from the verbal abuse incident) to report verbal altercation between Resident 30 and another resident (Resident 40). During a review of Resident 41's admission record (Face sheet), the face sheet indicated Resident 41 was initially admitted on [DATE] and re-admitted on [DATE] with a diagnosis that included Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination), seizures , major depressive disorder (a mood disorder causing severe symptoms that may affect daily activities, such as sleeping and eating) and dementia. During a review of Resident 41's MDS, dated [DATE], the MDS indicated Resident 41's cognitive skills was intact, and he could understand and be understood by others. The MDS indicated Resident 41 required one physical help with activities such as bed mobility, transfer (moving between surfaces to and from bed, chair, wheelchair), dressing, toilet use, and personal hygiene. During a review of Resident 41's H&P, dated 3/14/23, the H&P indicated Resident 41 does not have the capacity to understand and make decisions. During a review of Resident 41's change in condition (COC) notes dated 3/13/23 entered at 11:39 AM, the COC notes indicated Resident 41 had a behavioral change as describe by episode of inappropriate verbal behavior towards other resident (Resident 30) in the activity room on 3/13/23 between 10 AM to 11 AM . The COC notes indicated RN 3 went to the activity room and witnessed Resident 41 was exhibiting socially inappropriate verbal behavior towards Resident 30. During a review of Resident 41's social service notes (SSN) dated 3/13/23 at 7:32 PM, the SSN indicated SSD was notified by Activity Director (AD) about resident to resident incident between Resident 41 and Resident 30 on 3/13/23 at around past 10:00 AM. During an interview with the Administrator (ADM) on 3/22/23 at 11:00 AM, the ADM stated he got the verbal report from SSD on 3/13/23 after 10 AM (unable to remember exact time) about the resident-to-resident altercation between Resident 30 and Resident 41 on 3/13/23. The ADM stated the incident should have been reported within two hours to CDPH, Ombudsman and local PD, but he did not report on time. The ADM verified that he reported the incident by fax to CDPH on 3/13/23 at 4:05 PM and to Ombudsman on 3/13/23 at 5:25 PM. The ADM stated he did not call the SA, Ombudsman, and local police department to report the allegation of abuse between Resident 30 and Resident 41 because did not know there was a 2-hour time frame to report verbal abuse. During an interview with Resident 41 on 3/22/23 at 12 PM, Resident 41 stated she did not want to talk about the incident that happened with Resident 30. During a concurrent interview and observation on 3/22/23 at 12:27 PM with Resident 30 in the dining area, Resident 30 stated she did not want to talk about the past incident with Resident 41 (verbal abuse). During an interview with SSD 3/24/23 at 11:27 AM, SSD stated after AD reported to him the incident on 3/13/23, SSD unable to remember the exact time, SSD only remembers that it was between 10:00 AM to 11:00 AM. During a review of the facility's abuse in-service, preventing, reporting violations from 1/26/23 to 3/23/21, the Abuse in- service sign in sheet indicated SSD and ADM did not attended/ completed the training on 1/26/23, 3/13/23 and 3/23/23. During a review of the facility's policies and procedures (P&P) titled Abuse prohibition and procedure dated 2/23/21, the P&P indicated Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the designee will perform the following, that includes: -Report allegations involving abuse (physical, verbal, sexual, [NAME]) not later than two hours after the allegation is made.

CONCERN (D)

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

Deficiency F0625 (Tag F0625)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written notice of bed-hold (holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) policy during a transfer to the general acute care hospital (GACH) for one of two of sampled residents (Resident 4), in accordance with the facility policy. This deficient practice violated the resident or resident's representative's rights to make informed decisions and receive information of their rights to have the bed hold and return to the facility upon transfer to acute hospital. Findings: A review of the admission Record indicated Resident 4 was initially admitted to the facility on [DATE] and was readmitted on [DATE], with diagnoses of hemiplegia (a condition caused by brain damage or spinal cord injury that leads to paralysis [loss of motor function in one or more muscles] on one side of the body) and hemiparesis (weakness of one entire side of the body) following cerebral infarction (disrupted blood flow to the brain due to problems with the blood vessels that supply it) affecting right dominant side, aphasia (an impairment of language, affecting the production or comprehension of speech and the ability to read or write), and unspecified bilateral hearing loss (hearing loss in both ears). A review of Resident 4's Minimum Data Set (MDS, a comprehensive assessment and care screening tool), dated 2/24/23, indicated Resident 4's cognitive skills (skills and knowledge involve the ability to acquire factual information) for daily decision-making skills were moderately impaired (decisions poor; cues/supervision required). The MDS also indicated Resident 4 required extensive assistance (resident involved in activity, staff provide weight-bearing support) and one person physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture), dressing, eating, toilet use, and personal hygiene (how resident maintains personal hygiene, including combing hair, brushing teeth, shaving, washing/drying face and hands). During a concurrent interview and record review on 3/23/23 at 8:34 AM, the Registered Nurse 2 (RN 2) stated she was not sure if a bed hold needed to be completed when a resident was transferred to GACH. RN 2 stated licensed nurses do not need the residents to sign a bed hold. RN 2 stated Resident 4 did not have a bed hold when Resident 4 was transferred to GACH. RN 2 stated the nurse was supposed to put an order for a bed hold when Resident 4 was transferred to GACH. RN 2 stated the nurse did not put in an order for a bed hold for Resident 4. RN 2 stated there was no documentation for the bed hold or notification of Resident 4's family member regarding the bed hold. RN 2 stated Resident 4 was transferred to GACH on 2/11/23 and returned to the facility on 2/17/23. RN 2 stated Resident 4 did not return to the same room when he was readmitted to the facility. During an interview on 3/23/23 at 9:28 AM, Resident 4's family member 1 (FM 1) stated Resident 4 was in a different room prior to being transferred to the hospital. FM 1 stated Resident 4 was very comfortable in his previous room. FM 1 stated she really liked his previous room because FM 1 was familiar and liked the nurses who took care of Resident 4. FM 1 stated the nurses did not notify her regarding the bed hold. FM 1 stated when Resident 4 returned from GACH, the facility placed Resident 4 in a new room. During an interview on 3/23/23 at 9:54 AM, the Director of Nursing (DON) stated when the resident was transferred to GACH, the nurses should have asked the family if they wanted to hold the bed until the resident returned. The DON stated she was not sure how long a bed hold consent was valid for. The DON stated the nurses should have obtained a bed hold order for seven (7) days when the Resident 4 was transferred to GACH. The DON stated when Resident 4 was transferred to GACH and returned to the facility, the facility should had respected the resident's home and respected the resident's wish to return to his room. During an interview on 3/24/23 at 11:07 AM, the Licensed Vocational Nurse 4 (LVN 4) stated bed holds are available for 7 days. LVN 4 stated she was not aware of what documentation was needed for a bed hold. LVN 4 stated she did not know who was responsible for completing a bed hold. A review of the facility's policy and procedure titled, Bed-Holds and Returns, revised 3/1/22, indicated all residents/representatives are provided written information regarding the facility bed-hold polices addressing holding or reserving a residents' bed during periods of absence. Residents are provided written information at the time of transfer (or, if the transfer was an emergency, within 24 hours).

CONCERN (D)

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

Comprehensive Care Plan (Tag F0656)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review the facility failed to develop and implement a care plan for the use of Tramadol Hydrochloride (HCl oral tablet 50 milligrams (MG, unit of measurement) for one (1) of 22 sampled residents (Resident 69) in accordance with the facility policy and procedure. This failure had the potential for harm as care plans guide the daily care provided by staff to assist residents to meet their goals and address their unique needs. Findings: A review of Residents 69's admission Records indicated the facility admitted Resident 69 on 5/21/22 with diagnoses including hypertension (high blood pressure), diabetes mellitus (high sugar levels) and acute kidney failure (kidneys suddenly become unable to filter waste products from the blood). A review of the Minimum Data Set (MDS, standardized care and screening tool), dated 2/23/23, indicated Resident 69 had intact cognition (processes of thinking and reasoning). A review of Medication Review Report, dated 2/25/23, indicated Tramadol HCl oral tablet 50 MG 1 tablet by mouth every six (6) hours as needed for moderate to severe pain. During an observation in Resident 69's room and interview on 3/21/23 at 10:31 AM, Resident 69 was in bed talking on the phone. Resident 69 denied pain. During a concurrent interview and record review on 3/23/23 2:51 PM, Licensed Vocational Nurse 5 (LVN 5) verified that there was no care plan for Tramadol HCL 50 MG. LVN 5 stated a resident centered care plan should be developed for a new physician's order to monitor the effectiveness of the medication. During a concurrent interview and record review on 3/23/23 3:12 PM, Director of Nursing (DON) verified Resident 69 did not have a care plan for Tramadol used for pain. The DON stated it was important to develop a care plan for resident with pain to know if the pain medication was effective and was being managed. A review of the facility's policy and procedure titled, Using the Care Plan, revised 8/2006, indicated care plan should be used in developing the residents daily care routines and will be available to staff personnel who have responsibility for providing care or services to the resident.

CONCERN (D)

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

Deficiency F0676 (Tag F0676)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 29) had a communication board (a sheet of symbols, pictures, or photos that a person can point to, to communicate with those around them) at the bedside in a language the resident could understand. This failure had the potential to cause avoidable harm to Resident 29 and the resident's needs not being met by the facility staff. Findings: A review of Resident 29's admission Record indicated admitting diagnoses of second-degree atrioventricular block (a potentially life-threatening heart rhythm disorder that causes the heart to beat more slowly than it should), paroxysmal atrial fibrillation (rapid, erratic heart rate), abnormalities of gait (walking pattern) and mobility, lack of coordination, and history of falling. A review of Resident 29's Minimum Data Set (a standardized assessment and care-screening/care-planning tool) dated 12/29/22, indicated Resident 29 had moderately impaired cognition (intellectual functions, such as thinking, remembering, and reasoning), and required extensive, one-person, and two-plus person physical assistance from staff for movement in bed, transferring between surfaces, toileting, and performing personal hygiene. A review of Resident 29's care plan dated 11/3/22 indicated, the resident has impaired communication as evidenced by primary language spoken is different from and with limited understanding of the primary language used in the facility and further indicated, Resident/patient will use alternative method of communication, using simple communication and picture or communication board (written in the Resident 29's primary language) as needed daily. During an observation in Resident 29's room on 3/22/23 at 10:27 AM, Resident 29 was observed in bed watching a news channel in her primary language spoken. Resident 29 also had various reading material at her bedside written in the resident's primary spoken language. There was no communication observed in the resident's room or near the resident's bedside table to assist Resident 29 to communicate with facility staff. During a concurrent observation in Resident 29's room and interview on 3/22/23 at 10:28 AM, when asked how staff communicate with Resident 29, Certified Nursing Assistant (CNA) 1 stated, Usually we use the communication board for translation. CNA 1 verified there was no communication board in Resident 29's room. During an observation in Resident 29's room on 3/23/23 at 8:32 AM, observed Resident 29 in bed reading a book written in resident's primary language spoken while a news channel in resident's primary language spoken played in the background. There was no communication board observed on the bedside table or posted on the wall in the resident's room. During a concurrent observation and interview in Resident 29's room on 3/23/23 at 8:41 AM, Licensed Vocational Nurse (LVN) 3 stated when family is unavailable to translate, There is a communication board that is written in the resident's (Resident 29's) native language and stated it should be in the resident's room. LVN 3 verified Resident 29 did not have a communication board in the room and stated, Resident 29 needs a new one. During a concurrent observation and interview in Resident 29's room on 3/23/23 at 8:45 AM, LVN 4 stated they were assigned to provide care for Resident 29 that day (3/23/23) and verified there was no communication board in the room. When asked why it was important to be able to communicate with residents in a language they can understand, LVN 4 stated We are not able to address what they need. Like if resident (Resident 29) had pain, we would not know and we would not be able to treat it. During an observation in Resident 29's room on 3/23/23 at 11:58 AM, observed two communication boards on Resident 29's bedside table. One communication board had all symbols and photos described in the primary language used in the facility, and the other communication board had all symbols and photos described in the primary language spoken in the facility and with translations that were not Resident 29's primary language spoken. During a concurrent observation and interview in Resident 29's room on 3/23/23 at 12:01 PM, the Director of Nursing (DON) stated a communication board is used for residents who do not speak the primary language used in the facility and the communication board is supposed to be at the resident's bedside. The DON verified Resident 29's primary language is not the primary language spoken in the facility and stated Resident 29's family translates in the morning and afternoon. The DON further stated there were no staff who spoke Resident 29's primary language in the evening, and a communication board should have been used. The DON reviewed the two communication boards at the resident's bedside and verified they were not appropriate for Resident 29 as they were not in a language Resident 29 can speak or understand. The DON stated, the resident's needs might not be addressed. A review of facility policy and procedure (P&P) titled Translation and/or Interpretation of Facility Services, dated November 2020, indicated the purpose of the P&P was to ensure that [residents] with limited English proficiency shall have meaningful access to information and services provided by the facility. The document further indicated family members and friends shall not be relied upon to provide interpretation services and in order to provide meaningful access to services provided by [the] facility, translation and/or interpretation must be provided in a way that is culturally relevant and appropriate to the individual.

CONCERN (D)

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

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 18) received oxygen therapy at the flow rate ordered by the physician and failed to ensure the oxygen humidifier (bottle with sterile water that helps to prevent sore, dry, and/or bloody nose associated with oxygen use) bottle was changed every 24 hours in accordance with the facility's policy and procedure. This failure had the potential to cause harm to Resident 18 due to low blood oxygen levels and respiratory distress and/or failure and respiratory infection. Findings: A review of Resident 18's admission Record indicated admitting diagnoses of acute pulmonary edema (an abnormal buildup of fluid in the lungs, which can be caused by heart conditions or pneumonia [lung inflammation caused by bacterial or viral infection]) and acute respiratory failure with hypoxia (when the respiratory system cannot adequately provide oxygen to the body, resulting in not enough oxygen in the bloodstream). A review of Resident 18's Minimum Data Set (a standardized assessment and care-screening/care-planning tool) dated 3/8/23 indicated Resident 18 had severely impaired cognition (loss of intellectual functions, such as thinking, remembering, and reasoning), and required extensive, one-person, and two-plus person physical assistance from staff for various activities of daily living (e.g., movement in bed, transferring between surfaces, and performing personal hygiene). A review of Resident 18's physician orders dated 2/3/23 indicated Resident 18 was to receive oxygen therapy at three (3) LPM continuously to maintain oxygen saturation [at] 94% and above every shift for hypoxia. 1. During an observation in Resident 18's room, on 3/21/23 at 9:16 AM, observed Resident 18's oxygen cannula (a flexible tube with two prongs that deliver oxygen directly into the nostrils) connected to an oxygen concentrator (a machine that pulls in the air around you and filters out the nitrogen) at the bedside, and the attached oxygen humidifier bottle was dated 3/15/23. During an observation, on 3/21/23 at 4:17 PM, observed that the oxygen humidifier bottle attached to Resident 18's oxygen concentrator was dated 3/15/23 (same as the morning observation). During a concurrent observation and interview in Resident 18's room on 3/21/23 at 4:28 PM, the Director of Nursing (DON) verified the oxygen humidifier bottle attached to Resident 18's oxygen concentrator was labeled with date opened on 3/15/23. The DON stated the facility policy was to change the oxygen humidifier bottle on a weekly basis. During an observation in Resident 18's room, on 3/24/2023 at 12:04 PM, observed Resident 18 with an oxygen nasal cannula connected to the oxygen concentrator at the bedside. The oxygen humidifier bottle connected to the oxygen concentrator was dated 3/22/23. During a concurrent observation and interview in Resident 18's room on 3/24/23 at 12:26 PM, Licensed Vocational Nurse (LVN 4) verified the oxygen humidifier bottle was dated 3/22/23. LVN 4 stated the facility policy was to change the oxygen humidifier bottle daily. During an interview on 3/24/23 at 2 PM with the Infection Preventionist (IP), the IP stated the facility's policy is to change the oxygen humidifier bottle 24 hours after opening. The IP further stated the purpose of changing the humidifier bottle 24 hours after opening is to prevent bacterial growth inside the bottle and to prevent bacteria in the bottle to be transmitted to the resident and cause an infection. During an interview on 3/24/23 at 2:04 PM with the DON, the DON verified the facility's undated policy titled Departmental (Respiratory Therapy) - Prevention of Infection, provided by the IP, was the current facility policy, and stated they were unaware that the humidifier bottles needed to be changed 24 hours after opening. When asked of the risk to the resident if the humidifier bottle is not changed 24 hours after opening, the DON stated the resident can develop a respiratory infection. A review of undated facility policy and procedure titled Departmental (Respiratory Therapy) - Prevention of Infection indicated staff are to Mark [oxygen humidifier bottle] with date and initials upon opening and discard after twenty-four (24) hours. 2. During an observation in Resident 18's room on 3/23/23 at 6:27 AM, Resident 18's was observed in bed with oxygen cannula connected to an oxygen concentrator at the bedside. The oxygen concentrator indicated Resident 18 was receiving oxygen at a flow rate (the amount of oxygen gas being delivered) of two (2) liters per minute (LPM). During a concurrent observation and interview in Resident 18's room on 3/23/23 at 6:35 AM, Registered Nurse (RN) 1 stated licensed staff (e.g., licensed vocational nurses [LVN] and RNs) are responsible for administering oxygen, and to check physician orders prior to administration of oxygen to ensure the resident receives the correct amount. RN stated, Resident 18's oxygen flow rate is at 2 LPM. During a concurrent interview with RN 1 on 3/23/23 at 6:40 AM and review of Resident 18's physician order dated 2/3/23, RN 1 verified Resident 18 had physician orders to receive oxygen via nasal cannula at a continuous rate of 3 LPM. RN 1 stated, Resident 18 was receiving oxygen at a rate of 2 LPM which was different from the physician's order. RN 1 stated it was important to ensure to follow the physician's order for the oxygen flow rate is that it placed Resident 18 at risk for oxygen desaturation (decrease in the amount of oxygen in the blood), hypoxia, and altered level of consciousness (decreased wakefulness, alertness, or ability to understand or react to the surrounding environment). During an interview on 3/23/23 at 1:56 PM with the Director of Nursing (DON), the DON verified licensed staff are responsible for administration of oxygen and monitoring oxygen administration and equipment. The DON further stated that if the physician orders indicated a specific flow rate to be administered continuously, it meant the flow rate cannot be adjusted without notifying the physician and obtaining a new physician order. The DON stated it was important to follow the physician's order for the oxygen flow rate to ensure Resident 18 received the amount of oxygen needed because if Resident 18 received the oxygen less than the ordered amount, resident could suffer from signs of decreased oxygen saturation (the amount of oxygen carried by red blood cells) and shortness of breath. During an observation in Resident 18's room on 3/24/23 at 11:49 AM, observed Resident 18 in bed wearing an oxygen cannula connected to the oxygen concentrator at the bedside. The oxygen concentrator indicated Resident 18 was receiving oxygen at a flow rate of 2.5 LPM. During a concurrent observation and interview in Resident 18's room on 3/24/23 at 12:04 PM, LVN 4 verified Resident 18 was receiving oxygen at a flow rate of 2.5 LPM and that the physician's order indicated a continuous flow rate of 3 LPM. LVN 4 could not state why the flow rate was not at 3 LPM as ordered by the physician. LVN 4 stated, Resident 18's oxygen saturation could go down and resident could be in respiratory distress if resident did not receive the correct oxygen flow rate as ordered by the physician. A review of undated facility's policy and procedure titled Oxygen Administration indicated staff are to verify that there is a physician's order for oxygen administration and review the physician's orders for oxygen administration.

CONCERN (D)

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

Pharmacy Services (Tag F0755)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to properly administer antibiotic intravenously ([IV] administered into a vein) per doctor's order for treatment of wound infection for one of one sampled resident (Resident 233). This deficient practice had resulted to Resident 233 receiving antibiotic intravenously on a slower rate than prescribed order and had the potential for ineffective treatment for resident's infection. Findings: A review of the admission Record indicated that Resident 233 was readmitted to the facility on [DATE] with diagnoses that included generalized muscle weakness, abscess (collection of pus in the skin) of left foot and diabetes mellitus ([DM] disorder that is characterized by high blood sugar, insulin resistance, and relative lack of insulin) . A review of the Minimum Data Set (standardized assessment and care screening tool), dated 2/23/23, indicated Resident 233's cognitive skills (thought process) was intact and could understand and be understood by others. Resident 233 required supervision with bed mobility, eating, locomotion and toilet. Resident 233 limited assistance from staff for all other activities of daily living (ADL) including transfer, walk in room, dressing, and personal hygiene. A review of Resident 233's physician's order, dated 3/10/23, indicated Ceftriaxone sodium (used to treat certain infections caused by bacteria) solution 2 grams. Use 2 grams IV every 24 hours for left foot abscess for 14 days. On 3/23/23 at 9:15 AM, Resident 233 was observed in bed who engaged in minimal conversation. Resident 233 was observed with ongoing intravenous medication that's being infused by gravity (medication is put in a bag that hangs on a pole, and the pressure of gravity delivers the medication into the IV line). Ceftriaxone sodium solution 2 grams 50 milliliters ([ml] unit of measurement) bag observed with more than half the volume of the container. On 3/23/23 at 9:20 AM, during interview, Registered Nurse 2 (RN 2) stated, she started the IV antibiotic infusion to Rresident 233 at 9 AM. RN 2 stated, she regulated the IV tubing set (used to connect the medication to the needle inserted into the patient) to be administered at 10 drops per minute. RN 2 stated, the IV bag of Ceftriaxone indicated transfusion time of 30 minutes. On 3/23/23 at 9:30 AM, during a follow up observation of the IV antibiotic infusion (Ceftriaxone) in Resident 233's room, IV antibiotic of Ceftriaxone sodium solution 2 grams 50 ml bag is not emptied yet, and still infusing at 10 drops per minute. On 3/23/23 at 9:43 AM, during a concurrent observation in Resident 233's room and interview with RN 2, IV antibiotic of Ceftriaxone sodium solution 2 grams 50 milliliters bag is almost empty, and still infusing at 10 drops per minute. RN 2 stated that the infusion will finish soon. IV antibiotic of Ceftriaxone sodium solution 2 grams 50 milliliter bag was emptied at 9:45 AM. RN 2 stated that she frequently checked the infusion and there were no instances that the infusion stopped throughout the infusion time so there should not be reason for the Ceftriaxone to infuse for more than 30 minutes. On 3/23/23 at 12:10 PM, during an interview with the director of nursing (DON), the DON stated RN should follow the doctor's order for Resident 233's IV antibiotic of Ceftriaxone sodium solution 2 grams 50 milliliter bag, that to be infused in 30 minutes. The DON stated it should have infused at 17 drops per minute, instead of 10 drops per minute. DON stated that RN 2 should have asked another RN or her to verify the drip rate to be delivered if she was not sure of how many drops per minute to give. The DON stated the importance of following doctor's order is not to cause adverse effects to the resident. DON stated that she will educate RN 2 regarding proper calculation of drips to be regulated when IV pump machine is not being used. A review of the facility's policy and procedure (P&P), revised April 2019, titled, Administering medications, indicated medications are administered in accordance with prescribe orders, including any required time frame.

CONCERN (D)

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

Deficiency F0919 (Tag F0919)

Could have caused harm · This affected 1 resident

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Based on observation, interview, and record review, the facility failed to have functioning call lights (a device used by residents to call or signal his or her need for assistance from the facility staff) for one of one sampled resident (Resident 11). This failure had the potential to result in a delay in response time and resident's needs not met. Findings: During a review of the admission Record indicated the facility admitted Resident 11 on 5/25/22 with diagnosis including muscle weakness, abnormalities of gait and mobility and dementia (brain disease causing confusion). During a review of the Minimum Data Set (MDS, standardized care and screening tool), dated 2/23/23, indicated Resident 11 was oriented to place, time, and location. The MDS indicated the resident has moderately impaired cognitive skills (ability to understand and make decisions). The MDS indicated Resident 11 required a two-person physical assistance with bed mobility, transfer, one person assistance on dressing, toilet use, personal hygiene, and bathing. During observation and interview, on 3/22/23 10:52 AM, observed Certified Nursing Assistant (CNA 5) cleaning and changing Resident 11 clothes on bed with the curtain halfway closed. Observed CNA 5 pressing the call lights to call the nurse (not speficied) and the call light did not swithced on. CNA 5 stated the call light was not working. CNA 5 stated the importance for call lights to work for staff to be able to attend to residents needs when residents call for help. During an interview on 3/22/23 10: 55 AM, the Maintenance Director (MD) stated he should change the call light that was not functioning. During an interview on 3/22/23 11:05 AM Licensed Vocational Nurse (LVN 5) stated the call lights should be working so they could attend to the resident's needs. During an interview on 3/23/23 10:04 AM the Director of Nursing (DON) stated when identified call lights were not working, the facility should respond to it as soon as possible. The DON stated they have the binder called Maintenance Log accessible. The DON stated the residents' needs were not met promptly if call lights were non-functioning. During a review of the policy and procedure titled Answering Call Light revised September 2022, indicated be sure that the call light is plugged in and functioning at all times. Report all defective call lights to the nurse supervisor promptly.

CONCERN (E)

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

Deficiency F0726 (Tag F0726)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Cross reference with F755 Based on observation, interview and record review, the facility failed to ensure three of three registered nurses (RN) had the competency skills to care for a resident with intravenous (IV, fluid or medications administered directly into a resident's vein) antibiotic (ATB, medicines that fight bacterial infections) infusion for two of two sampled residents (Resident 233 and Resident 234). This deficient practice had potential for medication error (the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order) and potential harm to residents due to complication of incorrect medication given. Findings: 1. A review of the admission Record indicated that Resident 233 was readmitted to the facility on [DATE] with diagnoses that included generalized muscle weakness, abscess (collection of pus in the skin) of left foot and diabetes mellitus([DM] disorder that is characterized by high blood sugar, insulin resistance, and relative lack of insulin). A review of the Minimum Data Set (standardized assessment and care screening tool), dated 2/23/23, indicated Resident 233's cognitive skills (thought process) was intact and could understand and be understood by others. Resident 233 required supervision with bed mobility, eating, locomotion and toilet. Resident 233 limited assistance from staff for all other activities of daily living (ADL) including transfer, walk in room, dressing, and personal hygiene. A review of Resident 233's physician's order, dated 3/10/23, indicated ceftriaxone sodium (used to treat certain infections caused by bacteria) solution 2 grams. Use 2 grams IV every 24 hours for left foot abscess for 14 days. 2. A review of the admission Record indicated that Resident 234 was admitted to the facility on [DATE] with diagnoses that included generalized muscle weakness, bacteremia (the presence of bacteria in the bloodstream), cyst of kidney (round pouches of fluid that form on or in the kidneys). A review of the Minimum Data Set (standardized assessment and care screening tool), dated 2/23/23, indicated Resident 234's cognitive skills (thought process) was intact and could understand and be understood by others. Resident 234 required supervision with eating. Resident 233 required limited assistance from staff for all other activities of daily living (ADL) including bed mobility, transfer, walk in corridor, locomotion, dressing, toilet use and personal hygiene. A review of Resident 234's physician's order, dated 3/7/23, indicated cefazolin sodium (is an antibiotic used to treat a wide variety of bacterial infections) injection reconstituted 2 grams (GM). Use 2 gram intravenously every eight hours for bacteremia infected renal (kidney) cyst until 4/3/23. On 3/23/23 at 11:34 AM, during an interview, RN 2 verbalized, she knows how to calculate the drops per minute when administering intravenous infusion through gravity. RN 2 stated, infusing medication without following the physician's order is bad for the residents. RN 2 unable to elaborate what would be the bad effect when intravenous infusion is being infused slowly or faster than the physician's order. On 3/23/2 at 11:40 AM, during an interview with Director of nursing (DON) in the presence of RN 1 and RN 2, the DON verbalized she knows how to calculate the drip rate of intravenous infusion if it needs to be given by gravity. DON, RN 1, and RN 2 manually calculated the drip rate for Resident 234's IV ATB order of cefazolin sodium injection reconstituted 2 GM and was scheduled to be given today (3/23/23 at 3 PM). The DON, RN 1 and RN 2 verbalized their answer of six drops per minute and observed them calculating in paper. The DON explained how the calculations should be and came up with 6 drops per minute. During an interview, on 3/23/23 at 2:44 PM, the facility's consultant pharmacist (Pharm 1), stated, the IV infusion time for the ceftriaxone and cefazolin sodium was labeled in the medication (IV bag), and calculating drip rate should be the RN's responsibility. Pharm 1 verbalized, for Resident 233's ceftriaxone the infusion time is to run in 30 minutes, and it should be administered at 17 drops per minute. Pharm 1 stated, Resident 234's cefazolin sodium, the 100 milliliter (mL, unit of measurement) IV bag should be infused in 1 hour. Pharm 1 stated, the facility should have called the pharmacy to verify the infusion rate. During an observation of medication pass for Resident 234 on 3/23/23 at 3:30 PM, RN 2 was about to start an IV infusion of cefazolin sodium by gravity for Resident 234 using an IV tubing regulator (use to regulate the flow of IV fluid from the infusion set) at 17 mL per hour, RN 2 verbalized, she is setting the regulator at 17 drops per minute because that is the right calculation for the drops per minute for infusion of cefazolin sodium according to Pharm 1. Surveyor informed RN 2 that the IV drip regulator was labeled as mL given per hour and not the drip rate. RN 2 stated, she made a mistake and thought the 17 in the IV tubing regulator meant the drip rate and should have set it to 100 mL per hour (17 drops per minute). RN 2 verbalized the importance of infusing the medication at the ordered infusion time, to avoid having bad affects such as palpitations, RN 2 unable to verbalize adverse effects for infusing slower than the ordered infusion time. A review of the facility's job description titled Registered Nurse, with revised date of 6/16/17, indicated RN performs nursing functions and provides care within the scope of practice; administers medications and perform treatments per physician orders.

CONCERN (E)

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

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to follow the facility's policy and procedure on storage and disposal of medications for two of three medication storage rooms. There were five (5) boxes of heparin lock flush (used to flush [clean out] an intravenous [IV, administered into a vein] catheter [flexible tube inserted through a narrow opening into a body cavity] during the administration of medications or IV , which helps prevent blockage in the tube) solution syringes with an expiration date of 3/31/22 in Medication Storage 1 while one (1) box of heparin lock flush solution syringes with an expiration date of 8/31/22 was found in Medication Storage 3. This deficient practice had the potential for residents to be exposed to adverse side effects of heparin lock flush solution such as signs of an allergic reaction, like rash, itching, severe dizziness and trouble breathing in the event that it was used. Findings: On 3/23/23 at 11:50 AM, during a concurrent medication storage room observation and interview with Director of Nursing (DON), 1 box with 30 heparin lock flush syringes was found in Medication Storage 3. The DON verbalized that the box of heparin lock flush syringe shouldn't be there because it was already expired. The DON removed the expired box of heparin lock flush from medication storage 3 and verbalized that she will discard the expired heparin lock flushes in the pharmaceutical waste container (container that is suitable for used, almost empty, unused, or expired medications and pharmaceuticals). On 3/23/23 at 11:57 AM, during a concurrent medication storage room observation and interview with DON, 5 boxes of heparin lock flush syringe were found in Medication Storage 1. 4 boxes are unopened with 30 syringes each box, and 1 opened box with 25 syringes. The DON verbalized that the boxes of heparin lock flush syringe shouldn't be there because they were already expired. The DON verbalized that the facility's pharmacy comes every month to check their medication storage rooms. During an interview with Assistant Director of Nursing (ADON) on 3/24/23, ADON verbalized that he does not have an idea how the expired boxes of heparin lock flush syringe solutions were still in the medication storage rooms. The ADON verbalized the importance of administering heparin lock flush based on manufacturers instruction, of which to not administer after expiration date. A review of the facility's undated policy and procedure (P&P) titled, Storage of Medication, indicated discontinued, outdated, or deteriorated biologicals are returned to the dispensing pharmacy or destroyed.

CONCERN (E)

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

Menu Adequacy (Tag F0803)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to follow menu as written, in accordance with the facility policy and procedure. These deficient practice had the potential to result in meal dissatisfaction and decreased nutritional intake, which could result in weight loss. Findings: According to the facility lunch menu, on 3/21/23, the following items would be served: pork loin three (3) ounces (oz -unit of measurement) or alternative one (1) cheese quesadilla (3 oz cheese filling), honey roasted carrots one half cup, au gratin potatoes one half cup, dinner roll/bread, margarine, butterscotch pudding, coffee, or tea. During an observation and interview of the lunch service, on 3/21/23 at 11:55 AM, [NAME] 2 was making quesadilla using six (6) inches flour tortilla and shredded mozzarella cheese. [NAME] 2 was using a large spoon and filling half of the large scoop with cheese, stuffing it inside the tortilla then grilling the tortillas in a pan. During an interview, [NAME] 2 stated the quesadilla was for residents who asked for an alternative to the pork entrée. [NAME] 2 stated that she would serve two (2) quesadillas per resident. During the same observation and interview, [NAME] 2 only served 1 quesadilla to the residents. During an interview and review of recipe with [NAME] 2 on 3/21/23 at 12:50 PM, [NAME] 2 stated she had the recipe for the quesadilla, but she was not following it. [NAME] 2 said that she did not use the 3 oz scoop and she used a large spoon. [NAME] 2 stated she did not know how many ounces of cheese she was putting inside the tortillas and stated some tortillas got more and some tortillas got less cheese inside them. [NAME] 2 stated she should use the scoop so that every quesadilla received the same portion of the cheese and the right portion. [NAME] 2 stated she used less cheese. During a review of the cheese quesadilla recipe, it indicated to use a #10 scoop yielding (3oz) of the cheese mix in the center of the tortilla. The recipe indicated 1 quesadilla will provide 16 grams (unit of measurement) of protein. During a review of the nutrition facts on the packaging of the shredded Mozzarella cheese used for the cheese quesadillas indicated one forth cup (28 gram or 1 oz) provides 6 gram of protein. A review of facility policy titled, Menus, revised 9/2017, indicated menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guidelines.

CONCERN (E)

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

Food Safety (Tag F0812)

Could have caused harm · This affected multiple residents

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Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage practices in the kitchen when: 1. Nutritional supplements labeled store frozen with manufacturers instruction to use within 14 days of thawing, were not monitored for the date they were thawed to ensure expired shakes were discarded after this timeframe. Nine (9) individual cartons of vanilla shake, 9 individual cartons of apple cranberry flavored shakes were stored in the refrigerator with no thaw date. There was one (1) box of vanilla flavored nutrition shakes and 1 box of apple cranberry flavored nutrition shakes stored in the walk-in refrigerator with no thaw date. 2. Several food items such as a small pan of soup, cooked ground beef and cheese quesadilla stored in the walk-in in refrigerator had an incorrect preparation and used by dates. 3. Ready to eat ham was stored on the same shelf and next to raw pork and fish. 4. Ground beef that was already thawed and soft to touch had the wrong thaw date. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness. Findings: 1. During observation in the kitchen on 3/21/23 at 8:10 AM, there was 1 tray with 9 vanilla flavored high calorie nutritional shakes and 3 apple cranberry nutrition supplements stored in the refrigerator with no date. There was another tray of individual cartons of vanilla and apple cranberry flavored shakes stored in the walk-in refrigerator with no thaw date. During the same observation there was 1 unopened box of vanilla flavored shake and 1 box of apple cranberry flavored nutrition shakes stored on the top shelf in the walk-in refrigerator with no thaw date. During a concurrent observation and interview with Dietary Supervisor (DS), DS stated that the shakes were delivered frozen then it was stored in refrigerator to thaw. DS did not know when the shakes were out of the freezer. DS said the shakes run out within a couple of day and stated after thawing and was good for one week. During the same observation and review of manufactures instruction on box indicated, store frozen and when thawed stored in refrigerator for 14 days. DS stated these products go bad and these don't have dates to know when they were out of the freezer. 2. During a concurrent observation and interview on 3/21/23 at 8:10 AM, there was a small pan of soup dated, 3/23 with a use by date of 3/25, previously cooked ground beef dated 3/23 with a use by date of 3/25 and 1 previously cooked cheese quesadilla dated 3/23 with a use by date of 3/25 stored in the walk-in refrigerator. DS stated the dates indicated preparation day and when to discard day. DS stated they were mislabeled and were left over from the day before. DS agreed that dates were wrong and did not know when they were prepared. DS said she would discard the mislabeled food. During the same observation on 3/21/23 at 8:10 AM, there was ready to eat ham defrosting on same shelf as raw pork and raw tilapia (a type of fish) stored in the walk-in refrigerator. There was a small log of ground beef thawing on bottom shelf that was already thawed and soft to touch, with a date of 3/23/23 and use by 3/27/23. During interview with DS, she stated that ready to eat products should not be stored next to raw meat to prevent cross contamination of ready to eat food. DS also stated the ground beef was thawed and it was removed from freezer yesterday. DS stated it should be cooked today or discarded. A review of facility's policy, titled Food Storage: Cold Foods, revised 4/2018, indicated, All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. A review of the 2022 U.S. Food and Drug Administration Food Code, code:3-501.17 titled Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, indicated, refrigerated, ready-to-eat, time/ Temperature Control for Safety Food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

CONCERN (E)

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed for two of three sampled residents (Resident 18 and 53) when: 1. Oxygen therapy (colorless gas necessary for life) equipment was stored while not in use and humidifier bottle (bottle with sterile water that helps to prevent sore, dry, and/or bloody nose associated with oxygen use) was changed 24 hours after opening, for Resident 18. 2. Indwelling catheter (soft plastic tube to drain urine) collection bag was not in direct contact on the floor for Resident 53. These failures had the potential to cause infection to Resident 18 and Resident 53. Findings: 1. A review of Resident 18's admission Record indicated the resident was admitted to the facility on [DATE], with diagnoses that included acute pulmonary edema (an abnormal buildup of fluid in the lungs, which can be caused by heart conditions or pneumonia [lung inflammation caused by bacterial or viral infection]) and acute respiratory failure with hypoxia (when the respiratory system cannot adequately provide oxygen to the body, resulting in not enough oxygen in the bloodstream). A review of Resident 18's Minimum Data Set (MDS, a standardized assessment and care-screening tool) dated 3/8/23 indicated Resident 18 had severely impaired cognition (loss of intellectual functions, such as thinking, remembering, and reasoning), and required extensive, one-person, and two-plus person physical assistance from staff for various activities of daily living (e.g., movement in bed, transferring between surfaces, and performing personal hygiene). During an observation in Resident 18's room, on 3/21/23 at 9:16 AM, Resident 18's oxygen cannula (a flexible tube with two prongs that deliver oxygen directly into the nostrils) was observed draped on the bed, without any barrier between the oxygen cannula's prongs (the part of the tubing that is placed in the nostrils) and Resident 18's bed. The oxygen cannula was connected to an oxygen concentrator (a machine that pulls in the air around you and filters out the nitrogen) at the bedside, which had an attached humidifier bottle, dated 3/15/23. During an observation, on 3/21/23 at 4:17 PM, Resident 18 was observed in their room, sitting in a wheelchair, and wearing an oxygen cannula that was connected to an oxygen tank on the back of the wheelchair. Further observation showed that the oxygen cannula connected to the oxygen concentrator was still in direct contact with Resident 18's bed and not stored in a storage bag. The humidifier bottle was still dated 3/15/23. During a concurrent observation and interview in Resident 18's room, on 3/21/23 at 4:28 PM, the Director of Nursing (DON) stated the oxygen cannula connected to the oxygen concentrator was in direct contact with Resident 18's bed and was not stored in a storage bag. The DON stated the humidifier bottle was dated 3/15/22 which means the date of open or first use. The DON stated the facility policy was to change the humidifier bottle on a weekly basis and oxygen cannulas should be stored in an oxygen storage bag while not in use. The DON stated the oxygen cannula could be exposed to potentially harmful pathogens if left exposed, which was an infection risk to the resident. During an observation in Resident 18's room, on 3/24/2023 at 12:04 PM, observed Resident 18 wearing an oxygen cannula connected to the oxygen concentrator at the bedside. The humidifier bottle connected to the oxygen concentrator was dated 3/22/23. During a concurrent observation and interview in Resident 18's room on 3/24/23 at 12:26 PM, Licensed Vocational Nurse (LVN 4) verified the humidifier bottle was dated 3/22/23. LVN 4 stated the facility policy was to change the humidifier daily. During an interview on 3/24/23 at 2 PM with the Infection Preventionist (IP), the IP stated the facility policy was to change the humidifier bottle 24 hours after opening. The IP further stated the purpose of changing the humidifier bottle 24 hours after opening was to prevent bacterial growth inside the bottle. When asked of the risk to the resident if the humidifier bottle was not changed 24 hours after opening, the IP stated bacteria in the bottle could be transmitted to the resident and cause an infection. During an interview on 3/24/23 at 2:04 PM with the DON, the DON stated the facility policy provided by the IP was the current policy and stated they were unaware that the humidifier bottles needed to be changed 24 hours after opening. When asked of the risk to the resident if the humidifier bottle was not changed 24 hours after opening, the DON stated the resident could develop a respiratory (lung) infection. A review of undated facility policy and procedure titled Departmental (Respiratory Therapy) - Prevention of Infection indicated the following: a. Keep the oxygen cannula and tubing .in a plastic bag when not in use b. Mark bottle with date and initials upon opening and discard after twenty-four (24) hours 2. A review of Resident 53's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses that included hydronephrosis (swelling of a kidney due to a build-up of urine), neuromuscular dysfunction of bladder (when a person lacks bladder control due to brain, spinal cord, or nerve problems), and dementia (a group of thinking and social symptoms that interferes with daily functioning). A review of Resident 53's MDS dated [DATE] indicated Resident 53 had moderately impaired cognition, and required extensive, one-person, and two-plus person physical assistance from staff for various activities of daily living (e.g., movement in bed, transferring between surfaces, and performing personal hygiene). During an observation in Resident 53's room on 3/22/23 at 8:53 AM, indwelling catheter collection bag (a drainage bag, connected to a tube in the bladder, which collects urine) was observed hanging from Resident 53's bed and was in direct contact on the floor, without any barrier in place. During a concurrent observation and interview in Resident 53's room on 3/22/23 at 8:58 AM with CNA 2, CNA 2 stated the indwelling catheter collection bag was touching the floor. CNA 2 stated, When the bed is low, I put the indwelling catheter collection bag in a basin (a wide-open container, often used for holding liquid), to prevent direct contact with the floor and CNA 2 stated, there was no basin. During an interview on 3/22/23 at 9:04 AM with LVN 3, LVN 3 stated, the collection (indwelling catheter collection bag) bag can not be touching the floor, and further stated the indwelling catheter collection bag should never touch the floor because it is not sanitary and can cause a urinary tract infection (infections that happen bacteria invade and grow in the urinary tract [the kidneys, bladder, ureters, and urethra]). During an interview on 3/23/23 at 11:27 AM with the DON, the DON stated the indwelling catheter collection bag should never touch the floor and if the bed is in a low position, there should be a barrier between the collection bag and the floor. The DON stated the facility used basins as barriers because the floor is dirty. When asked of the risk to the resident if the indwelling catheter collection bag was in contact with the floor, the DON stated the bag could encounter pathogens (bacteria or microorganisms that can cause disease) on the floor, which can cause a urinary tract infection in the resident. A review of facility policy and procedure titled Urinary Tract Infections (Catheter-Associated), Guidelines for Preventing, dated April 2017, indicated the purpose of the policy is to provide guidelines for the prevention of catheter-associated urinary tract infections and indicated do not place the [indwelling catheter collection bag] on the floor.

Mar 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

Deficiency F0760 (Tag F0760)

A resident was harmed · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of four sampled residents (Resident 1) was free from significant medication error (one or more observed or identified preparation or administration of medications ordered by a physician causing the resident discomfort or jeopardizes his or her health and safety). On 2/26/23, the licensed nurse (RN1) did not properly check and identify the resident prior to administering medications. RN1 erroneously administered eight (8) medications to Resident 1 belonging to Resident 2. This deficient practice resulted in Resident 1 to experience adverse effects that included nausea, vomiting, dizziness, and malaise (feeling of being unwell and feeling tired). Resident 1 was transferred to the General Acute Care Hospital (GACH) due to the adverse reactions to the medications. Findings: A review of Resident 1 ' s admission record indicated the resident was readmitted to the facility on [DATE], with diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (Muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (stroke, damage to the brain due to interruption of blood supply) affecting the left side and type 2 diabetes mellitus (DM, a chronic condition that affects the way the body processes blood sugar). A review of Resident 1 ' s Minimum Data Set (MDS – a comprehensive assessment and care-screening tool) dated 1/5/23, indicated resident was assessed to have severe impairment with cognitive skills (ability to understand and make decisions). The MDS also indicated Resident 1 required limited assistance from one facility staff when eating and extensive assistance from one facility staff during dressing and personal hygiene. A review of Resident 1 ' s eINTERACT Change in Condition Evaluation form (COC form) dated 2/26/23 entered at 2:01 PM, indicated, Resident 1 had change of condition of vomiting, body weakness and severe frontal lobe (forehead, front part of the brain. It controls high level cognitive skills and primary motor function [activity or movement of the body]) headache. A review of Resident 1 ' s progress notes (general) dated 2/26/23 entered at 2:48 PM, indicated, Resident 1 was taken to the GACH via 911 at 2:27 PM due to nausea, vomiting and chills. A review of Residents 1 ' s care plan (documentation of information that easily described the services, care and support being given to the patient), dated 2/26/23 indicated Resident 1 had episodes of vomiting, body malaise, and severe headache secondary to medication error. A review of Resident 1 ' s untitled GACH record dated 2/26/23, indicated the resident was seen by the GACH doctor on 2/26/23 at 2:31 PM. The GACH record indicated, the resident was sent to their Emergency Department (ED) from the facility due to dizziness with onset of 30 minutes prior to arrival. The GACH record also indicated, Resident 1 received her regular dose of medication for hypertension (elevated blood pressure) earlier that day, but then was accidentally given another resident ' s medication for hypertension. A review of Resident 1 ' s progress notes (IDT, interdisciplinary team [team consist of doctors, licensed nurses, social services and/ or dietary supervisor) dated 2/28/23 entered at 8:36 PM, indicated, Resident 1 received medications that belonged to another resident. A review of Resident 2 ' s admission record indicated the resident was readmitted at the facility on 11/18/22, with diagnoses that included type 2 DM, hydronephrosis (excess water in the kidney due to back up of urine) with renal (kidney) and ureteral calculous obstruction (blockage in one or both tubes that carry urine from kidneys to the bladder). A review or Resident 2 ' s medication review report dated 3/2/203, indicated the following medication order: 1. metformin hydrochloride (Metformin HCL, medication for DM) tablet give 500 (mg, unit of measurement) by mouth two (2) times a day with meals 2. sacubitril – valsartan (Entresto, medication for hypertension for patients with kidney disease) 24- 26 mg give 1 tablet by mouth two times a day for hypertension 3. metoprolol tartrate (medication for high blood pressure) tablet give 2.5 mg by mouth two times a day 4. aspirin (reduce risk of serious problems like heart attacks and strokes) oral tablet give 325 milligrams (mg, unit of measurement) one time a day 5. ascorbic acid (vital to body ' s healing process) oral tablet give 500 mg two times a day 6. calcium with vitamin D (supplement for bone, nervous system, musculoskeletal, and immune system) oral tablet 500 mg, give 1 tablet by mouth one time a day 7. docusate sodium (Colace, treats occasional constipation) tablet, give 100 mg by mouth two times a day 8. multi-vitamin (dietary supplement containing all or most of the vitamins that may not be readily available in the diet) oral tablet give one tablet by mouth During an interview with Resident 1 on 3/1/23 at 12:54 PM, the resident stated on 2/26/23 between 11:00 AM to 11:30 AM (unable to recall specific time), Registered Nurse 1 (RN 1) was giving medications that she did not know what medications to the resident. The resident stated she told RN 1 more than once that she was already given medications in the morning. Resident 1 stated, RN 1 did not respond to the resident ' s comment and continued to administer the crushed medications in her mouth. Resident 1 stated, on the same date (2/26/23) after a few minutes after RN 1 gave her the unknown medications, Resident 1 began to feel dizzy, shaky, vomiting, headache, eyes felt heavy, and cold. Resident 1 also stated, Licensed Vocational Nurse 1 (LVN 1) told her on the same day she would be transferred to the GACH. During an interview with certified nurse assistant (CNA 1) on 3/1/23 at 1:20 PM, CNA 1 stated on 2/26/23 sometime prior to 12:30 PM Resident 1 informed CNA 1 that the resident was feeling dizzy, had a headache, and that the resident ' s head felt heavy. CNA 1 stated, Resident 1 would not stop vomiting. During an interview with the Director of Nursing (DON) on 3/1/23 at 2:05 PM, the DON stated RN 1 did not identify Resident 1 by checking the resident ' s photo from the electronic medication administration record (eMar) and did not check the resident ' s wrist band to verify name, date of birth , and room number prior to administering all eight (8) medications that belonged to Resident 2. The DON stated the medication error was discovered when LVN 1 witnessed RN 1 giving Resident 1 medications with a spoon on 2/26/23, between 11AM to 11:10AM. During the same interview with the DON on 3/1/23 at 2:10 PM, the DON also stated the medications given to Resident 1 in error on 2/26/23 that included sacubitril – valsartan which can cause some stomach upset and metformin could have led the resident to experience vomiting, body weakness and headache due to hypoglycemia (low blood sugar level) requiring the resident to be transferred to the GACH on the same day. During a concurrent review of Resident 2 ' s eMAR for the month for February 2023 and interview with the DON, the DON stated RN 1 admitted to her that RN 1 administered the 8 medications of Resident 2 to Resident 1 on 2/26/23 in error. The DON stated, according to Resident 2 ' s eMAR, the 8 medications were: 1. Metformin HCL tablet 500 mg by mouth 2. sacubitril – valsartan 24- 26 mg by mouth 3. metoprolol tartrate tablet give 2.5 mg by mouth 4. aspirin oral tablet give 325 milligrams mg by mouth 5. ascorbic acid oral tablet give 500 mg by mouth 6. calcium with vitamin D oral tablet 500 mg tablet by mouth 7. docusate sodium 100 mg tablet by mouth 8. multi-vitamin oral tablet give one tablet by mouth During an interview with Registered Nurse Supervisor (RNS) on 3/1/23 at 2:50 PM, RNS stated on 2/26/23 (unable to recall time) RN 1 approached him and asked who Resident 2 was. RNS informed RN 1, the resident was the lady on my left. RNS stated shortly after, LVN 1 approached him questioning as to why RN1 gave medications to Resident 1. RNS stated he attempted to talk to RN 1 to verify medications given to the resident, but RN 1 walked away from him. RNS stated shortly after RN 1 allegedly administered Resident 1 medications, the resident started having adverse reactions (undesired effect of the drug). During a telephone interview with RN 1 on 3/1/23 at 3:12 PM, RN 1 stated, on 2/26/23 during the morning shift (unable to recall specific time) RN 1 stated, she asked RNS Who Resident 2 was and RN 2 replied, it was the resident on my left. RN 1 stated she thought RNS gestured pointing to Resident 1. RN 1 then stated she prepared 8 medications (metformin, sacubitril – valsartan, metoprolol, aspirin, ascorbic acid, calcium with vitamin D, Colace, and multivitamins) by crushing them and spoon fed them to Resident 1 around 11am-11:10am. RN1 stated RNS informed her she had administered the wrong medications to the wrong resident shortly after she administered Resident 2 ' s medications. RN 1 stated, she did not identify Resident 1 properly prior administering the resident medications by checking the resident ' s wrist band, by photo identification (ID), resident self-identification, or using other staff to verify and identify the actual resident. A review of the facility policy and procedure (P&P) titled, Resident Identification System, revised December 2007, indicated a resident identification system is used to help facility personnel provide medical and nursing care which include: 1. The facility has adopted a photo and/ or wristband identification system to help assure that medication and treatments are administered to the right resident. 2. The photo identification or wristband identification is used by nursing service personnel when administering medications and treatments. A review of the facility ' s P&P titled, California Long Term Care (LTC) Facility ' s Pharmacy Services and Procedures Manual, revised on 4/1/22, indicated prior to administration of medication, facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: facility staff should verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident. The P&P indicated during medication administration, facility staff should take all measures required by facility policy and applicable law including identify the resident per facility policy.

Nov 2022 3 deficiencies

CONCERN (D) 📢 Someone Reported This

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

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

Deficiency F0883 (Tag F0883)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide influenza and/or pneumococcal immunizations as consistent with professional standards and current guidance for two of five residents (Resident 2 and Resident 3). This deficient practice had the potential to violate the resident ' s rights to make an informed decision and track residents who require influenza and pneumococcal immunizations. Findings: A review of the admission record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD - airflow blockage and breathing-related problems) with acute exacerbation (sudden worsening of COPD), type 2 diabetes (impairment in the way the body regulates and uses sugar (glucose) as a fuel, and abnormalities with gait (a manner of walking) and mobility. A review of Resident 2 ' s Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 10/14/2022, indicated Resident 2 had cognitively intact (mental action or process of acquiring knowledge and understanding) skills for daily decision making. A review of the admission record indicated Resident 3 was admitted to the facility on [DATE], with diagnoses that included multiple sclerosis (a disease that impacts the brain, spinal cord and optic nerves which make up the central nervous system and controls everything we do), spinal stenosis (when the spaces in the spine narrow and create pressure on the spinal cord and nerve roots) and chronic osteomyelitis (inflammation or swelling that occurs in the bone). A review of Resident 3 ' s MDS dated [DATE], indicated Resident 3 had cognitively intact skills for daily decision making. During an interview on 11/21/2022 at 2:44 p.m., Resident 2 stated she had resided in the facility for over one year. Resident 2 stated when she was first admitted to the facility, the facility staff asked her if she wanted to receive the influenza and pneumococcal vaccines. Resident 2 stated the facility had not reoffered her the influenza and pneumococcal vaccines since admission. During a concurrent interview and record review of immunization forms on 11/21/2022 at 2:32 p.m. with the Infection Prevention Nurse (IP), IP stated consent forms for vaccinations should be done annually. IP stated the last time Resident 2 was offered a pneumococcal (a name for any infection caused by bacteria called Streptococcus pneumoniae, or pneumococcus) and influenza (flu) vaccine was on 7/8/2021. IP stated resident was not offered the pneumococcal or influenza vaccine this year. IP stated Resident 3 was last offered pneumococcal vaccine on 8/8/2018. IP stated Resident 3 was not offered the pneumococcal vaccine this year. IP stated she has clinic every Friday for vaccinations. IP stated she knows when vaccines are need by each resident. IP stated she was not aware the residents were not up to date with their vaccinations. IP stated in the past she used a log to tract the residents and their vaccines but has stopped using the log. During a concurrent interview and record review of immunization forms on 11/21/2022 at 3:06 p.m., IP stated if residents refused the vaccines, the IP would document the refusal and would reoffer the vaccine to the residents. IP stated there should be new consents for the influenza and pneumococcal forms for the year 2022. IP stated the consent forms were not done for this year. A review of the facility ' s policy and procedure titled, Influenza Immunization Program, revised 11/15/2021, indicated patients are to receive the appropriate influenza vaccine annually, unless the immunization is medically contraindicated, or the patient has already been immunized. The policy also indicated the process for the influenza (flu) program starts in early September to achieve the highest level of immunity during the peak of flu season. A review of the facility ' s policy and procedure titled, Pneumococcal Vaccination – Prevnar 15 or 20 (PCV15 or PCV 20) or Pneumovax (PPSV23), revised 3/4/2022, indicated all patients are to be provided the opportunity to receive the pneumococcal vaccine in adherence with current recommendations of the Advisory Committee on Immunizations Practices (ACIP) as set forth by the Centers for Disease Control and Prevention (CDC). Based on the patient ' s pneumococcal vaccination history, offer (unless the vaccination is medically contraindicated, or the patient has already been vaccinated) the appropriate vaccination following the recommended schedule. A review of the CDC Vaccines and Preventable Diseases titled, Pneumococcal Vaccination: Who and When to Vaccinate, revised 1/24/2022, indicated CDC recommends pneumococcal vaccination for all adults 65 years or older. For adults 65 years or older who have not previously received any pneumococcal vaccine, the CDC recommends one dose of PCV15 or PCV20.

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 F0887 (Tag F0887)

Could have caused harm · This affected 1 resident

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide COVID-19 vaccination as consistent with professional standards and current guidance for one of five residents (Resident 2). This deficient practice had the potential to violate the resident ' s rights to make an informed decision and track residents who require COVID-19 vaccination. Findings: A review of the admission record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD - airflow blockage and breathing-related problems) with acute exacerbation (sudden worsening of COPD), type 2 diabetes (impairment in the way the body regulates and uses sugar (glucose) as a fuel, and abnormalities with gait (a manner of walking) and mobility. A review of Resident 2 ' s Minimum Data Set (MDS - a comprehensive assessment and care screening tool) dated 10/14/2022, indicated Resident 2 had cognitively intact (mental action or process of acquiring knowledge and understanding) skills for daily decision making. During an interview on 11/21/2022 at 2:44 p.m., Resident 2 stated she had resided in the facility for over a year. Resident 2 stated when she was first admitted to the facility, the facility asked her if she wanted to receive the COVID-19 vaccine. Resident 2 stated the facility had not since reoffered her the COVID-19 vaccinationsince admission. During a concurrent interview and record review of immunization forms on 11/21/2022 at 2:32 p.m. with the Infection Prevention Nurse (IP), IP stated consent forms for vaccinations should be done annually. IP stated the last time Resident 2 was offered the COVID-19 vaccine was on 7/8/2021. IP stated resident was not offered the COVID-19 vaccine this year. IP stated she knows when vaccines are need by each resident. IP stated she was not aware the resident was not up to date with her COVID-19 vaccination. IP stated in the past she used a log to tract the residents and their vaccines but has stopped using the log. During a concurrent interview and record review of immunization forms on 11/21/2022 at 3:06 p.m., IP stated if residents refused the vaccines, the IP would document the refusal and would reoffer the vaccine to the resident. IP stated there should be a new consent for the COVID-19 form for the year 2022. IP stated the COVID-19 consent form was not done for this year and does not have a tracking log for residents who require COVID-19 vaccine. A review of the facility ' s policy and procedure titled, COVID-19 Management in Long Term Care (LTC), revised 10/6/2022, indicated the facility will provide a safe environment for residents and staff to prevent the development and transmission of COVID-19. A review of the of Quality, Safety and Oversight (QSO)-21-19- (Nursing Home) NH titled, COVID-19 Vaccine Immunization Requirements for Residents and Staff, dated 5/11/2021, indicated the facility must develop and implement policies and procedures to ensure when COVID-19 vaccine is available to facility each resident is offered the COVID-19 vaccine unless the immunization is medically contraindicated, or the resident has already been immunized. A review of the local Public Health Guidelines titled, Coronavirus Disease 2019: Guidelines for Preventing and Managing COVID-19 in Skilled Nursing Facilities, revised 9/29/22, indicated facilities should offer the vaccine/booster doses, provide education, host listening sessions including to persons who have previously declined.

CONCERN (E) 📢 Someone Reported This

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

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

Infection Control (Tag F0880)

Could have caused harm · This affected multiple residents

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure infection control practices were followed by failing to cohort (a group of people banded together or treated as a group) eight of eleven residents (Resident 1, 8, 9, 10, 11, 12, 13, and 15) based on policy and procedure, Centers for Disease Control and Prevention (CDC) guidelines and local Public Health Guidelines for cohorting. This deficient practice had the potential for transmission and infection of Coronavirus-19 (COVID-19, a respiratory illness that can spread from person to person) to residents, staff, and visitors. Findings: During an observation on 11/21/2022 at 1:20 p.m., Residents 1, 8, 9, 10, 11, 12, 13 and 15 resided in the Yellow Zone (isolation room for Covid-19 exposure). A review of Resident 1 ' s admission record indicated Resident 1 was admitted to the facility on [DATE]. A review of the census dated 11/21/2022 indicated Resident 1 resided in the Yellow Zone. A review of Resident 8 ' s admission record indicated Resident 8 was admitted to the facility on [DATE]. A review of the census dated 11/21/2022 indicated Resident 8 resided in the Yellow Zone. A review of Resident 9 ' s admission record indicated Resident 9 was admitted to the facility on [DATE]. A review of the census dated 11/21/2022 indicated Resident 9 resided in the Yellow Zone. A review of Resident 10 ' s admission record indicated Resident 10 was admitted to the facility on [DATE]. A review of the census dated 11/21/2022 indicated Resident 10 resided in the Yellow Zone. A review of Resident 11 ' s admission record indicated Resident 11 was admitted to the facility on [DATE]. A review of the census dated 11/21/2022 indicated Resident 11 resided in the Yellow Zone. A review of Resident 12 ' s admission record indicated Resident 12 was admitted to the facility on [DATE]. A review of the census dated 11/21/2022 indicated Resident 12 resided in the Yellow Zone. A review of Resident 13 ' s admission record indicated Resident 13 was admitted to the facility on [DATE]. A review of the census dated 11/21/2022 indicated Resident 13 resided in the Yellow Zone. A review of Resident 15 ' s admission record indicated Resident 15 was admitted to the facility on [DATE]. A review of the census dated 11/21/2022 indicated Resident 15 resided in the Yellow Zone. During an interview on 11/21/2022 at 2:32 p.m. with the Infection Prevention Nurse (IP), IP stated Resident 1 was cleared from the Red Zone (area where patients who are Covid-19 positive are for duration of isolation period) on 11/11/2022. IP stated Resident 1 ' s room was converted to a Yellow Zone room after being a Red Zone room. IP stated Resident 1 should be placed in a [NAME] Zone room (non Covid-19 unit) after isolation, but the facility did not have any rooms in the [NAME] Zone. IP stated there was no reason why Resident 1 should still be in the Yellow Zone. IP stated the local Public Health Guidance indicates that residents can be moved to the [NAME] Zone after their isolation period. During an interview on 11/21/2022 at 3:06 p.m., IP stated Resident 1 was admitted on [DATE] she was placed in the yellow zone room, she was in the Yellow Zone room for 22 days before she tested positive for Covid. IP stated once Resident 1 was cleared from Red Zone on 11/11/2022, Resident 1 remained in the Yellow Zone. IP stated there were a total of 11 residents in the Yellow Zone. IP stated the residents placed in the Yellow Zone were new admissions and not symptomatic. IP stated there were four new admissions placed in the Yellow Zone room for less than five days. IP stated all residents tested negative when admitted to the facility. IP stated seven of the 11 residents have been in the Yellow Zone for over 5 days. IP stated theses residents should be moved to the [NAME] Zone after being in the Yellow Zone for five days. A record review of the facility ' s testing schedule indicated all residents in the facility excluding Resident 1 tested negative for Covid through polymerase chain reaction (PCR, a diagnostic test that determines if you are infected by analyzing a sample to see if it contains genetic material from the virus) testing on 11/3/2022, 11/8/2022, 11/10/2022, 11/15/2022, and 11/17/2022. A review of the facility ' s policy and procedure titled, Covid-19 Management in LTC, revised 10/6/2022, indicated [NAME] Cohort are for residents who recovered from Covid, asymptomatic, and up to date with covid vaccines for admissions, readmissions, left facility greater than 24 hours. The policy also indicated Yellow Cohort are for residents who are symptomatic, close contacts with covid, and not up to date with covid vaccines for admissions, re-admissions, or left the facility for greater than 24 hours. A review of the local Public Health Guidelines titled, Coronavirus Disease 2019: Guidelines for Preventing and Managing COVID-19 in Skilled Nursing Facilities, revised 9/29/22, indicated new admissions, re-admissions, or left the facility greater than 24 hours and not up to date with Covid-19 vaccines (exception: asymptomatic residents who recently recovered from a prior Covid-19 infection within the last 90 days should be placed in the [NAME] Cohort). It also indicated the duration of quarantine of at least seven days from date of admission. Second PCR test collected on day five to seven should result negative before moving to [NAME] Cohort. A review of Centers for Disease Control and Prevention titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, revised 9/23/2022, indicated patients can be removed from Transmission-Based Precautions after day seven following exposure (count the day of exposure as day 0) if they do not develop symptoms and all viral testing as described for asymptomatic individuals following close contact is negative. It also indicated if viral testing is not performed, patients can be removed from Transmission-Based Precautions after day ten following the exposure (county the day of exposure as day 0) if they do not develop symptoms.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"What changes have you made since the serious inspection findings?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• 28% annual turnover. Excellent stability, 20 points below California's 48% average. Staff who stay learn residents' needs.

Concerns

• Multiple safety concerns identified: 2 life-threatening violation(s), 1 harm violation(s), $28,592 in fines. Review inspection reports carefully.
• 70 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
• $28,592 in fines. Higher than 94% of California facilities, suggesting repeated compliance issues.
• Grade F (9/100). Below average facility with significant concerns.

Bottom line: Trust Score of 9/100 indicates significant concerns. Thoroughly evaluate alternatives.

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About This Facility

What is Montebello's CMS Rating?

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

How is Montebello Staffed?

CMS rates MONTEBELLO CARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 28%, compared to the California average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Montebello?

State health inspectors documented 70 deficiencies at MONTEBELLO CARE CENTER during 2022 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, 66 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.

Who Owns and Operates Montebello?

MONTEBELLO CARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by GENESIS HEALTHCARE, a chain that manages multiple nursing homes. With 99 certified beds and approximately 90 residents (about 91% occupancy), it is a smaller facility located in MONTEBELLO, California.

How Does Montebello Compare to Other California Nursing Homes?

Compared to the 100 nursing homes in California, MONTEBELLO CARE CENTER's overall rating (1 stars) is below the state average of 3.1, staff turnover (28%) is significantly lower than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Montebello?

Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.

Is Montebello Safe?

Based on CMS inspection data, MONTEBELLO CARE CENTER has documented safety concerns. Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in California. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.

Do Nurses at Montebello Stick Around?

Staff at MONTEBELLO CARE CENTER tend to stick around. With a turnover rate of 28%, the facility is 18 percentage points below the California average of 46%. Low turnover is a positive sign. It means caregivers have time to learn each resident's needs, medications, and personal preferences. Consistent staff also notice subtle changes in a resident's condition more quickly. Registered Nurse turnover is also low at 22%, meaning experienced RNs are available to handle complex medical needs.

Was Montebello Ever Fined?

MONTEBELLO CARE CENTER has been fined $28,592 across 1 penalty action. This is below the California average of $33,365. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.

Is Montebello on Any Federal Watch List?

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

Facility Details

Beds: 99
Avg. Residents: 90
Occupancy: 91.7%
Ownership: For profit - Limited Liability company
Chain: GENESIS HEALTHCARE
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
Low Turnover: +3
2 Immediate Jeopardy citations: -24
1 Actual Harm citation: -5
70 Deficiencies: -10
Fines ($28,592): -5
Final Score: 9/100

Nearby Alternatives

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

View all in MONTEBELLO →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 055153